Health inspection·November 6, 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 review of the medical record, review of the facility investigation, and interview with staff the facility failed to safely transport Resident #57 in a wheelchair resulting in Resident #57 falling out of her wheelchair and hitting her head. This affected one resident (#57) of three residents reviewed for accidents/hazards. The facility census was 60. Findings include: Review of the medical record revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including pneumonia, pulmonary embolism, difficulty walking, lack of coordination, severe protein-calorie malnutrition, repeated falls, disorders of bone density, glaucoma, cerebral infarction, and weakness. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #57 had moderately impaired cognition and was dependent of staff for wheelchair transportation. Review of the progress note dated 10/10/23 at 1:45 P.M. revealed the nurse was called to the room and the nursing assistant reported when she was pushing the wheelchair from the restroom to the recliner Resident #57 started sliding down in the chair then fell out of the wheelchair and bumped her head on the floor. She had a skin tear on her forehead and there was a small amount of blood. Review of the facility incident report dated 10/10/23 at 1:45 P.M. revealed staff was exiting the bathroom with Resident #57 in the wheelchair when the resident started sliding forward in the wheelchair. The staff member attempted to get her arm around her to prevent her from falling out of the chair but was unsuccessful. Resident #57 slid from the chair to the floor. She received a skin tear to her forehead. A new intervention of Dycem (non-skid pad) in the wheelchair to promote safety. Review of the signed witness statement dated 10/10/23 revealed Hospitality Aide (HA) #221 was taking Resident #57 to her chair from the bathroom and she started sliding down in her chair then she sat up. HA #221 put her arm around her to break the fall but did not get to her fast enough. On 11/02/23 at 1:45 P.M. an interview with Regional Staff Coordinator #300 revealed HA #221 was a hospitality aide because she could not pass her skills test in class. She stated she was in the class scheduled 09/18/23 to 09/29/23 but missed 09/18/23 and had to make it up on 10/10/23. She was terminated on 10/10/23. She stated she should have had another aide with her when she took Resident #57 to the bathroom. She should not have been transporting her in the wheelchair herself. Page 1 of 2 365632 365632 11/06/2023 Majora Lane Ctr for Rehab & Nsg Care Inc 105 Majora Lane Millersburg, OH 44654

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/02/23 at 3:28 P.M. an interview with Regional Staff Coordinator #300 revealed she misspoke earlier and HA #221's class days were 09/19/23, 09/20/23, 09/21/23, 09/22/23, 09/25/23, 09/26/23, 09/27/23, 09/28/23, and her clinical days were 09/29/23 and 10/03/23. She stated she failed the clinical portion of the class and was going to work as a HA until she could take the class again however she was terminated before she could take the class again. She verified on 10/10/23 she was working as a HA and should not have been transporting Resident #57 to and from the bathroom. Review of the facility's job description for a hospitality aide dated 03/01/16 revealed no documentation of transporting residents in the wheelchair as in their job description. This deficiency represents non-compliance investigated under Complaint Number OH00147522 and OH00148041. 365632 Page 2 of 2