Health inspection·August 4, 2025

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** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, staff interviews and facility policy review, the facility failed to ensure a safe transfer via mechanical lift (Hoyer) for Resident #45. This affected one (Resident #45) of three residents reviewed for falls/Hoyer transfers. The facility census was 44.Findings include:Review of the closed medical record for Resident #45 revealed an admission date of 12/07/22 with diagnoses including type two diabetes, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), anxiety disorder, failure to thrive, morbid obesity, and chronic kidney disease (CKD). Review of the physician's order dated 01/15/25 revealed an order for a Hoyer lift for transfers. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #45 was cognitively intact, was dependent on others for mobility and required extensive assistance/dependence with activities of daily living (ADL). Review of Resident #45's Fall Risk assessment dated [DATE] revealed the resident was at a moderate risk for falls, was completely incontinent, had a history of falls, was confined to a chair and was unable to independently come to a standing position. Review of the progress note dated 06/12/25 at 6:17 P.M. revealed Resident #45's nurse was notified that while two Certified Nursing Assistants (CNAs) #553 and #557 were getting the resident into bed with the Hoyer lift, the Hoyer tilted over sideways and fell. The resident then fell to the ground landing on her buttocks. Upon walking in the room, the nurse witnessed the resident sitting in the upright position on her buttocks in the Hoyer sling that was tilted over and lying on the ground. The nurse along with both CNAs and a second nurse adjusted the resident to a flat position on the ground to assess her. Upon assessment, Resident #45's vital signs included blood pressure 178/72, pulse 78, respirations 20, oxygen saturation was 94 percent on room air, temperature was 98.6 degrees Fahrenheit (F). The resident stated she had pain in her buttocks. After the assessment, staff got the resident up from the floor using the Hoyer and put her safely into the bed. The doctor was notified, and the Director of Nursing (DON) was notified. The physician ordered STAT (urgent) bilateral hip and pelvis x-rays. Review of the progress note dated 06/12/25 at 11:55 P.M. revealed Resident #45 complained of pain and was medicated with one tablet of Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams (mg) (opioid pain medication). Review of Resident #45's fall investigation revealed a statement on 06/12/25 signed by the DON stated CNA #553 was unable to remember if the legs on the Hoyer were open or closed when it tipped causing Resident #45's fall to the ground. Review of the progress note dated 06/13/25 at 3:57 A.M. revealed Resident #45 denied any pain or discomfort following her fall. Review of the progress note dated 06/13/25 at 1:39 P.M. revealed Resident #45 was sent to the emergency room for possible fracture post hip and pelvis x-ray and admitted to the hospital. Interview with the DON on 08/01/25 at 2:35 P.M. revealed audits and a plan of correction were conducted immediately following Resident #45's fall. An interview with the Administrator on 08/01/25 2:41 P.M. revealed her Page 1 of 2 365831 365831 08/04/2025 Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few statement that the Hoyer didn't tip all the way over and only partially tipped. She further stated the legs of the Hoyer were open partially but not all the way. Review of the policy entitled Lifting Machine, Using a Mechanical, dated July 2017, revealed staff were to make sure the lift was stable and locked. The deficient practice was corrected on 06/18/25 when the facility implemented the following corrective actions: On 06/13/25 at 5:20 P.M. when the Hoyer lift used to transfer Resident #45 was immediately removed from service pending maintenance department. On 6/13/25 beginning at 4:17 P.M. the DON assessed all Hoyer lift residents with no ill effects noted. On 6/14/25 at 7:00 A.M. the DON observed the weight capacity on the lift and ensured it was appropriate size for the resident that was transferred. The lift's weight capacity was noted to be appropriate for the resident's weight. The Hoyer lift was inspected on 06/14/25 at 8:30 A.M. by the facility Maintenance Director #547 and found to be in proper working order. On 6/14/25 at 8:30 A.M. the Maintenance Director #547 inspected all mechanical lifts to ensure they were in good repair and functioning appropriately. From 6/13/25 through 6/18/25 the DON completed Hoyer lift competency training and re-education with all licensed nursing staff and CNA staff. The facility planned to monitor its performance to make sure that solutions were sustained by having the DON or designee directly observing the nursing staff performing mechanical lift transfers three times weekly time four weeks, then as determined by the Quality Assurance and Performance Improvement (QAPI) committee. This deficiency represents noncompliance investigated under Complaint Number 1317076 (OH00167577). 365831 Page 2 of 2