Health inspection·March 11, 2024

F 0689 Level of Harm - Actual harm revealed the resident had fallen out of Hoyer lift during transfer. Resident #30 had observed injuries including an abrasion to top of the scalp, unspecified injury to back of head, skin tear to right antecubital space, and an unspecified injury to right upper arm. Resident #30 was stuporous (responsive only to vigorous stimulation) following the incident. Residents Affected - Few Review of an EMS report for Resident #30 dated 02/21/24 revealed EMS arrived at the facility at 9:14 A.M. and the resident arrived at hospital at 9:32 A.M. Resident #30 was found lying supine on floor of his room, and facility staff reported the resident had fallen out of Hoyer lift while being transferred. The resident had an abrasion with bleeding to the forehead and right forearm and deformity of right upper arm and right elbow. Resident #30 was confused and unable to answer questions or recall what had happened. Review of the health status note for Resident #30 dated 02/21/24 revealed the resident was admitted to hospital. Review of the hospital record for Resident #30 dated 02/21/24 revealed the resident was transported to the hospital after sustaining a fall from a Hoyer lift at the facility in which he was dropped by the facility nursing staff. Upon arrival at the hospital Resident #30 complained of right arm pain and right sided frontal head pain. Resident #30 sustained injuries including the following: right frontal bone fracture extending into superior orbit, bilateral maxillary bone fractures, bilateral inferior orbital wall fractures with involvement of right nasal lacrimal duct, superficial skin tears of right side of the forehead, a large superficial skin tear of the right forearm. Review of the incident statement for Resident #30 dated 02/22/24 per State Tested Nursing Assistant (STNA) #803 revealed she was not the assigned caregiver for Resident #30 on 02/21/24 but she did assist STNA #804 with a transfer. Review of the statement revealed Resident #30 went forward out of Hoyer pad during the transfer, and STNA #803 notified Licensed Practical Nurse (LPN) #802. Review of the incident statement for Resident #30 dated 02/22/24 per STNA #804 revealed she was the assigned caregiver for Resident #30 on 02/21/24. Review of the statement revealed Resident #30 was being lifted into his Broda chair per the Hoyer lift when he fell out. Further review of the statement revealed Resident #30 rolled out of the Hoyer lift and onto the floor because he was contracted, and Resident Care Manager (RCM) #800 and LPN #802 were notified. Interview on 03/06/24 at 10:00 A.M. with LPN #802 confirmed on 02/21/24 STNA #803 notified her Resident #30 had fallen out of the Hoyer lift, and she and RCM #800 found the resident in his room lying on his right side bleeding profusely. Initially, LPN #802 was unable to confirm where the blood was coming from, but after further assessment she determined he was bleeding from his nose. LPN #802 asked RCM #800 to call 911. The resident had bruising on his right arm from shoulder to elbow, bruising on right knee, a skin tear on his right arm, and his right eye was swollen shut. LPN #802 confirmed there were no mechanical issues with the Hoyer lift or the Hoyer pad nor were there any environmental hazards present in the room at the time of the fall. Interview on 03/06/24 at 10:44 A.M. with STNA #803 confirmed on 02/21/24 she had assisted STNA #804 with a Hoyer lift transfer of Resident #30 from his bed to a Broda chair. STNA #803 indicated she was controlling the Hoyer lift and STNA #804 was guiding. STNA #803 indicated when she began to lower Resident #30 down into the chair, he fell forward out of the Hoyer sling, and she was unsure how or why the resident fell forward. STNA #803 confirmed after resident fell, she ran for help while STNA #804 stayed with the resident. STNA #803 confirmed there were no mechanical issues with the Hoyer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365870 If continuation sheet Page 2 of 3 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 365870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Judson Park 2181 Ambleside Rd Cleveland, OH 44106 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)

F 0689 lift or Hoyer sling nor were there any environmental hazards present in the room at the time of fall. Level of Harm - Actual harm Interview on 03/06/24 at 11:06 A.M. with STNA #804 confirmed on 02/21/24 she requested assistance from STNA #803 to transfer Resident #30 out of bed. STNA #804 confirmed she prepared Resident #30 on the Hoyer pad and brought in the Hoyer lift. STNA #804 confirmed Resident #30 had contractures of his legs and he resembled a ball. STNA #804 confirmed STNA #803 helped her hook up the straps to the Hoyer lift, and she was guiding while STNA #803 was operating the lift. STNA #804 confirmed she was unsure why Resident #30 fell out of the Hoyer sling. STNA #804 confirmed as soon as STNA #803 turned the Hoyer from over the bed Resident #30 fell forward. STNA #804 reported she stayed with Resident #30 while STNA #803 went to get help. STNA #804 confirmed Resident #30 was bleeding after the fall and she supported his head. STNA #804 confirmed there were no mechanical issues with the Hoyer lift or Hoyer sling nor were there any environmental hazards present in the room at the time of fall. Residents Affected - Few Interview on 03/06/24 at 12:22 P.M. with the [NAME] President (VP) of Health Services revealed the facility conducted an investigation regarding Resident #30's fall on 02/21/24. The VP of Health Services indicated the Hoyer lift used for the transfer for Resident #30 was checked (following the incident) with no equipment failure identified. The VP of Health Services revealed the facility was unsure if the size of the Hoyer lift sling was appropriate for the resident, and the facility had concluded the root cause of Resident #30's fall from Hoyer lift was user error. Interview on 03/06/24 at 12:42 P.M. with RCM #800 confirmed LPN #802 called her to Resident #30's room on 02/21/24 because STNA #803 and STNA #804 reported the resident had fallen during a Hoyer lift transfer. RCM #800 indicated she went to call 911 while LPN #802 assessed Resident #30. RCM #800 confirmed Resident #30 had a large bulge on right arm, a laceration to his elbow, and was bleeding from an unknown source. RCM #800 confirmed she waited on floor with Resident #30 until EMS arrived. Interview on 03/06/24 at 2:22 P.M. with the Director of Nursing (DON) confirmed the facility conducted an investigation regarding Resident #30's fall from the Hoyer lift on 02/21/24. The DON confirmed Resident #30 had contractures which caused him to be top heavy while being transported in a Hoyer sling. The DON confirmed she interviewed STNA #803 who confirmed Resident #30 was leaning forward in Hoyer sling during the transfer due to contractures. The DON questioned STNA #804 if she maintained hands on contact with Resident #30 while he was being transferred, and STNA #804 revealed she did not have hands on the resident but stated she was standing by while the resident was lifted in Hoyer lift. Interview with the DON confirmed the root cause of Resident #30's fall from the Hoyer lift was staff failed to recognize Resident #30 was top heavy due to contractures and failed to maintain hands on contact with the resident during the transfer. Review of facility policy titled Hoyer Lift Transfer dated 03/10/14 revealed one staff member should control the lift while the second staff member should oversee the positioning of the resident for safe transfer. When raising a resident, the staff member overseeing positioning must have their hands on the resident. Review of manufacturer's guidelines for the Hoyer lift dated 2011 revealed two assistants were recommended for all lifting, preparation, and transferring of residents. This deficiency represents non-compliance investigated under Complaint Number OH00151335. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365870 If continuation sheet Page 3 of 3