Health inspection·November 18, 2024

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. Based on medical record review, and staff interview, the facility failed to use the proper lift for resident transfers. This affected one (Resident #10) of three residents reviewed for lift transfers. The facility census was 81 residents. Findings include: Review of the medical record for Resident #10 revealed an admission date of 07/31/24 with diagnoses including cerebral infarction, hemiplegia/hemiparesis, edema, sepsis, dementia, and diabetes mellitus, and a discharge date of 11/10/24. Review of the care plan for Resident #10 dated 09/29/24 revealed the resident had an activities of daily living (ADL) self-care performance deficit related to history of cerebral vascular accident with hemiplegia with an intervention dated 10/02/24 to transfer with Hoyer lift with assist of two to transfer. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 10/07/24 revealed the resident had moderate to severe cognitive deficits and required extensive assistance with ADLs. Review of occupational therapy discharge summary for Resident #10 dated 10/10/24 revealed therapy recommended the resident be transferred with assistance of two staff using a Hoyer lift for safety. Review of nurse progress note for Resident #10 dated 11/02/24 revealed the Certified Nursing Assistant (CNA) was giving the resident a bed bath and noticed bruising to the resident's rib cage, under his armpits, and on the right wrist and reported the bruising to the nurse. Review of the facility investigation of the bruising observed for Resident #10 dated 11/04/24 revealed the resident did not know how he had obtained the bruises. Floor staff were interviewed and confirmed Resident #10 had not had any recent falls. The facility investigation revealed the bruising was caused from the resident being transferred by stand-up lift instead of the Hoyer lift as recommended by therapy and per the resident's plan of care. Interview on 11/18/24 at 11:45 A.M. with the Director of Nursing (DON) confirmed staff had been using the stand-up lift (instead of the Hoyer lift) to transfer Resident #10 and the pad was too tight. The DON further confirmed Resident #10 was on Eliquis (a blood thinning medication) which increased the resident's risk for bruising. Interview on 11/18/24 at 12:07 P.M. with Physical Therapy Manager (PTM) #40 confirmed therapy had Page 1 of 2 365733 365733 11/18/2024 Carecore at Margaret Hall 1960 Madison Road Cincinnati, OH 45206

F 0689 Level of Harm - Minimal harm or potential for actual harm recommended on 10/10/24 for staff to use the Hoyer lift for Resident #10's transfers as it was the safer option. This deficiency represents noncompliance investigated under Master Complaint number OH00159809 and Complaint Number OH00159808 and Complaint Number OH00159768. Residents Affected - Few 365733 Page 2 of 2