Health inspection·June 14, 2023

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 medical record review, observation, staff interview and policy review the facility failed to ensure a safe transfer was performed. This affected one resident (#60) of three residents reviewed for transfers. The census was 75. Findings included: Medical record review for Resident #60 revealed an admission date of 03/09/23. Diagnoses included Parkinson's disease, coronary artery disease, and cerebrovascular accident. Review of the care plan for Resident #60 dated 03/10/23 revealed Resident #60 had an activity of daily living (ADL) self-care deficit as evidenced by the inability to care for self related to physical limitations. Interventions included to transfer with two-person assistance with the use of a gait belt. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #60 required extensive assistance of two-persons for bed mobility, transfers, and toilet use. Observation of a transfer for Resident #60 on 06/13/23 at 9:40 A.M. revealed the State Tested Nursing Assistant (STNA) #140 used her hands to pull on the resident's right arm and then used her other hand underneath the left arm to pull Resident #60 up in bed to a sitting position on the side of the bed. The STNA #140 placed her right and left hands under the resident's armpits, raised the resident up and placed her in the wheelchair. No other staff members were in the room at this time. Interview on 06/13/23 at 9:45 A.M., STNA #140 verified she should have used a two-person transfer and used a gait belt when she transferred Resident #60, but she was nervous. Interview with the Director of Nursing (DON) on 06/13/23 at 10:12 A.M., revealed gait belts should be used for transfers for the resident if the care plan says so. Interview with the Unit Manager (UM) #108 on 06/13/23 at 1:20 P.M., verified Resident #60 required two-person assistance for bed mobility and transfers. Review of the policy titled Gait Belts, undated revealed gait belts will be available for use during all standing pivot transfers and when ambulating a resident who requires contact guard or physical assist. Page 1 of 3 365576 365576 06/14/2023 Chillicothe Post Acute 1058 Columbus St Chillicothe, OH 45601

F 0689 This deficiency represents non-compliance investigated under Complaint Number OH00143090. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365576 Page 2 of 3 365576 06/14/2023 Chillicothe Post Acute 1058 Columbus St Chillicothe, OH 45601

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure infection prevention measures were followed during incontinence care to prevent potential infection. This affected one resident (#60) of one resident reviewed for incontinence care of 45 residents who were incontinent. The facility identified there were 45 residents who were incontinent. The census was 75. Findings included: Medical record review for Resident #60 revealed an admission date of 03/09/23. Diagnoses included Parkinson's disease, coronary artery disease, and cerebrovascular accident. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #60 required extensive assistance of two-persons for bed mobility, transfers, and toilet use. The resident was always incontinent of bowel and bladder. Observation on 06/13/23 at 9:30 A.M. revealed State Tested Nursing Aide (STNA) #140 provided peri-care for the resident. The STNA #140 washed her hands, donned gloves, wiped the front peri area of the resident. STNA #140 turned Resident #60 on to the right side and proceeded to clean the stool from the resident's bottom, she turned the resident further onto the right side which revealed more stool on the upper part of the buttocks the STNA had missed. STNA #140 stuck her right gloved hand into the stool. The STNA #140 continued cleaning the stool off of the resident. STNA #140 placed a clean adult brief on Resident #60, pulled the curtain back with both gloved hands, removed clean clothes out of the closet, placed clean pants on the resident, and placed her in the wheelchair. Once the STNA #140 had Resident #60 in her wheelchair the STNA removed the residents' shirt and placed a clean shirt on the resident. At no time was STNA #140 observed changing her gloves until she had the resident ready for the day. Interview with the STNA #140 on 06/13/23 at 9:45 A.M., verified she probably had stool on her gloved hands when she found more stool on the top portion of the buttocks. She said she should have changed her gloves and washed her hands before she dressed Resident #60 and helped her out of bed. She said this was not her practice at all, she was nervous with someone watching her. 365576 Page 3 of 3