Inspection·December 6, 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 record review and interviews, the facility failed to ensure residents were properly transferred using a mechanical lift. This affected one (#44) out of three residents reviewed for transfers. The facility census was 66. Findings include: Review of the medical record for Resident #44 revealed an admission date of 02/15/24. Diagnoses included other sequelae of cerebral infarction, human immunodeficiency virus disease, hemiplegia unspecified affecting left nondominant side, cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery, traumatic subdural hemorrhage without loss of consciousness sequela, nontraumatic subdural hemorrhage, osteomyelitis of vertebra lumbar region, epilepsy, hyperlipidemia, paroxysmal tachycardia, nonrheumatic tricuspid stenosis, major depressive disorder, anxiety disorder, opioid abuse with withdrawal, and unspecified viral hepatitis C without hepatic coma. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/01/24, revealed Resident #44 was cognitively intact. This resident was assessed to require setup assistance for eating, and oral hygiene, substantial/maximal assistance for toileting, bathing, lower body dressing, personal hygiene, and bed mobility, partial/moderate assistance for upper body dressing, and was dependent for transfers. Review of the plan of care initiated on 03/06/24 revealed Resident #44 was at risk for a decline in activities of daily living function related to need for assistance with activities of daily living, transfers, ambulation, and toileting due to depression, anxiety, epilepsy, hemiplegia, history of stroke, hypertension, hepatitis C, and pain. Interventions included allow time for rest breaks, encourage resident participation, report declines in function to physician, staff to anticipate needs and assist as needed, and therapy to evaluate and treat as needed. Review of the progress note dated 11/03/24 revealed Resident #44 had a possible fall from a Hoyer lift and both of her shoulders landed on the floor. The note indicated no injuries were noted. Review of the Post Fall Evaluation dated 11/03/24 revealed Resident #44 was being transferred with a Hoyer lift at the time of the fall. The evaluation noted a contributing factor was Certified Nursing Assistant (CNA) transferring the resident without assistance. Review of the facility investigation dated 11/03/24 revealed Resident #44 reported she had been dropped from the Hoyer lift to the floor where her shoulders touched the ground and was then lifted back up. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 365738 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365738 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ayden Healthcare of Fairfield 3801 Woodridge Boulevard Fairfield, OH 45014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)