Health inspection·September 18, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a facility investigation, hospital documentation review, resident and staff interview, review of a mechanical lift manufacturer instructions document, policy review, and review of facility corrective action documentation, the facility failed to ensure residents who required staff assistance and use of a mechanical lift for transfers were safely transferred without injuries. Actual harm occurred to Resident #53 on 09/03/25 when two staff members were transferring the resident from the bed to a wheelchair; during the transfer, one of the mechanical (Hoyer) lift pad straps was not properly secured to the lift by the staff members which caused the resident to slip out of the sling and fall to the floor. Subsequently, Resident #53 complained of pain and was transported to the hospital where imaging revealed the resident sustained a fractured pelvis. Following the incident, Resident #53 voiced apprehension to be transferred in the mechanical (Hoyer) lift. This affected one (#53) of four residents reviewed for falls. The facility census was 76. Findings include: Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, post-traumatic stress disorder, and hemiplegia with hemiparesis following an unspecified cerebrovascular event affecting the left non-dominant side (resulting in weakness or paralysis on the left side of the body). Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #53 was dependent on staff for all activities of daily living (ADLs). Review of physician's orders dated 07/01/24 revealed Resident #53 required a mechanical (Hoyer) lift for all transfers. Review of the most recent fall risk assessment dated [DATE], as well as the seven prior fall risk assessments completed by the facility since the resident's admission, revealed Resident #53 was consistently identified as at high risk for falls. Review of the medical record revealed on 09/03/25 at approximately 10:30 A.M., a loud noise was heard by the charge nurse while seated at the nurse's station. Upon entering Resident #53's room, the nurse observed the resident lying on the floor adjacent to the bed. Two certified nurse aides (CNAs) were present. A wheelchair and Hoyer lift were nearby. Immediate assessment revealed no visible injuries to Resident #53; however, the resident verbalized slipping from the Hoyer lift sling and reported pain to the left elbow and left side of the face. The note revealed Resident #53 was maintained on the floor for safety until further evaluation. Emergency medical services (EMS), the facility Nurse Practitioner (NP), and the resident's family were notified. EMS subsequently transferred Resident #53 to a local hospital for evaluation. Review of hospital documentation dated 09/03/25 revealed Resident #53 was transferred to the hospital from the facility after a mechanical fall. The resident reported pain to the left side of the head, left elbow, and left hip. Further review of pelvis radiographs revealed Resident #53 had acute fractures of the superior and inferior rami (an arm or branch of a bone) on the left. Review of facility's investigation documents dated 09/03/25 Page 1 of 3 365758 365758 09/18/2025 Parma Care Center 5553 Broadview Rd Parma, OH 44134

F 0689 Level of Harm - Actual harm Residents Affected - Few revealed CNA #407 and CNA #408 were transferring Resident #53 from the bed to a wheelchair. During the transfer, one of the Hoyer lift pad straps was not secured to the spreader bar. The unsecured strap caused the resident to slip from the sling and fall. Both CNAs provided written statements verifying the failure to secure the strap, which directly resulted in the fall and subsequent pelvic fracture. The Director of Nursing (DON) confirmed in an interview on 09/15/25 at 4:45 P.M. that the injury suffered by Resident #53 was caused by the improper securing of the Hoyer lift sling during a transfer on 09/03/25. Interview with Resident #53 on 09/16/25 at 1:33 P.M. verified the events of the fall and subsequent pelvic fracture. Resident #53 further expressed apprehension to be transferred in the Hoyer lift after the incident. Review of the manufacturer's instructions for the Hoyer lift utilized by the facility, copyright 2022, revealed to not move the patient if the sling was not properly connected to the hooks of the hanger bar. When the sling was elevated a few inches off of the stationary surface and before moving the patient, check again to make sure the sling was properly connected to the hooks of the hanger bar. If any attachments were not properly in place, lower the patient back onto the stationary surface and correct this problem; otherwise, injury or damage may occur. Review of the policy titled, Hoyer lift, dated 07/01/22, revealed the facility would utilize a Hoyer lift to assist a resident to move with increased independence and transfer with greater comfort, to feel physically more secure while preventing accidents, maintaining safety, and body alignment, promoting, supplementing, and/or enhancing the resident's function and/or safety. The deficient practice was corrected on 09/04/25 when the facility implemented the following corrective actions: On 09/03/25 at 10:32 A.M., Resident #53's family and nurse practitioner were called to notify of incident. On 09/03/25 at 10:34 A.M., the Hoyer lift and sling used in the incident with Resident #53 were removed from service. On 09/03/25 at 10:45 A.M., Resident #53 was transported to a local hospital for evaluation. On 09/03/25 at 10:47 A.M., the Director of Nursing (DON) provided immediate education and competency check with CNA #407 and CNA #408. Both staff members passed their competency checks. On 09/03/25 at 11:00 A.M., the Hoyer lift utilized in the incident was inspected by Maintenance Manager (MM) #315 and found to be in good working order. The Hoyer pad used in the transfer was also inspected and showed no signs of wear. On 09/03/25 at 11:00 A.M., the DON and designees began education for all direct care staff regarding use of mechanical lifts with special focus on checking straps prior to beginning to lift a resident. Competencies were performed with all CNAs employed at the facility. All education and competencies were completed by 11:00 A.M. on 09/04/25. On 09/03/25, MM #315 conducted an emergency audit of all Hoyer lifts and Hoyer pads in the facility for functionality and safety with no negative findings. On 09/03/25, the facility held an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting to discuss the incident. The facility implemented a policy beginning on 09/08/25 newly hired employees would be educated regarding mechanical lift use and must pass a mechanical lift competency prior to working with residents. The Administrator and the DON would continue to monitor compliance directly in the monthly Quality Assurance and Performance Improvement (QAPI) meetings for three months and then as needed for one year. Review of the incident and accident report from July, August, and September 2025 revealed no additional instances of resident accidents or injuries involving transfers with mechanical (Hoyer) lift devices. Interviews on 09/15/25 between 10:30 A.M. and 4:00 P.M. with Licensed Practical Nurse (LPN) #348, LPN #349, CNA #383, CNA #390, CNA #393 and CNA #397 all verified being provided education regarding use of a mechanical lift for resident transfers and were able to demonstrate knowledge from the training. Observation of a Hoyer lift transfer on 09/15/25 at 3:00 P.M. for Resident #67, performed by CNA #383 and CNA #390, revealed the staff members correctly and safely completed the transfer without incident. This deficiency 365758 Page 2 of 3 365758 09/18/2025 Parma Care Center 5553 Broadview Rd Parma, OH 44134

F 0689 represents non-compliance investigated under Master Complaint Number 2616144 and Complaint Number 2574416. Level of Harm - Actual harm Residents Affected - Few 365758 Page 3 of 3