Health inspection·February 20, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure Resident #10 was transferred safely to prevent falls per the physician order. This finding affected one (Resident #10) of three residents reviewed for accident hazards. Findings include: Review of Resident #10's medical record revealed the resident was admitted on [DATE] with diagnoses including a non-displaced subtrachanteric fracture of the right femur (closed fracture with routine healing) dated 02/10/25 and a age-related current pathological fracture of the vertebrae with routine healing dated 11/02/23. Review of Resident #10's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition, was dependent for toileting and bathing. Review of Resident #10's fall investigation form dated 11/24/24 at 3:55 P.M. revealed the resident was assisted to the toilet and the resident fell to the bathroom floor. The Nurse Practitioner (NP) and brother were notified of the incident. Review of Resident #10's physician orders revealed an order dated 11/25/24 (discontinued 01/03/25) for 2-staff assist for all transfers and the resident was not to be alone in the bathroom. Review of Resident #10's fall care plans revealed an intervention dated 12/02/24 indicating the resident was not to be left alone while in the bathroom and an intervention dated 01/27/25 which indicated a mechanical sling lift due to leg weakness in and out of the bed with two assist in the spa and a grab bar and bedside commode in use. Review of Resident #10's fall investigation form dated 01/03/25 at 11:30 A.M. revealed the resident was toileted and his knees got weak, and he was lowered to the floor. The transfer orders were changed to a mechanical sling lift in and out of bed (Hoyer mechanical lift). (Occurred in the spa and the resident was on a sit-to-stand mechanical lift and his knees got weak and was lowered to the floor. The physician and family were notified). Review of Resident #10's physician orders dated 01/03/25 for transfers mechanical sling lift for transfers in and out of bed. Staff assist for toileting in the spa only with bedside commode and grab bars. Resident #10 was not to be left alone in the bathroom every shift. Page 1 of 2 365406 365406 02/20/2025 Pleasant View Health Care Center 401 Snyder Ave Barberton, OH 44203

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #10's fall investigation dated 01/06/25 at 5:32 A.M. revealed two certified nursing assistants (CNAs) were transferring the resident out of his bed to the shower chair to get a shower. The CNAs stated the resident did not bend his legs during the transfer, so they had to lower the resident to the floor for safety. The resident revealed his legs gave out trying to transfer. No complaints of pain or injuries. The resident was transferred into the shower chair. The resident's order was a 2-person assist in and out of bed but was recently changed to a mechanical sling lift in and out of bed. The CNAs were not aware of the recent change and were educated to verify orders due to possible changes. The physician and family were notified. Review of Resident #10's fall investigation dated 01/06/25 at 6:00 A.M. revealed the resident was in the spa after receiving a shower. With the assistance of two CNAs, the resident stood up at the grab bar to pull up his pants. While attempting to stand, the resident was not able to keep standing and the resident was lowered to the ground by the CNAs. The resident stated that his legs got tired while standing. The resident was transferred back into the shower chair from the floor. The resident had a recent downgrade in transfers to a mechanical sling lift in and out of bed but was a 2-person assist in the spa using a grab bar (no pivoting). The family and physician were notified. Interview on 02/20/25 at 9:44 A.M. with the Director of Nursing (DON) confirmed when Resident #10's was transferred from the bed to the shower chair on 01/06/25 at 5:32 A.M., staff were required to use a Hoyer mechanical lift and did not use the device, and the resident was unable to maintain his weight and was lowered to the floor. The DON confirmed when Resident #10 was transferred from the shower to stand at the grab bar in the shower (spa) room on 01/06/25 at 6:00 A.M., the CNAs stood the resident to pull up his pants and the resident was unable to hold his weight and was lowered to the floor. The DON confirmed the order was for the staff to only use the grab bar when toileting the resident and the resident was being dressed while standing in the bathroom, which was inappropriate. She confirmed staff were educated and the resident required the use of the Hoyer mechanical lift. Review of the Using a Mechanical Lifting Machine dated 09/2024 revealed at least two nursing assistants were needed to safely move a resident with a mechanical lift. This deficiency represents non-compliance investigated under Complaint Number OH00162322. 365406 Page 2 of 2