Health inspection·January 9, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interviews, and policy review, the facility failed to provide adequate staff assistance when transferring a resident who required two persons assist with transfers resulting in a fall without injuries. This affected one (#58) out of the three residents reviewed for mechanical (hoyer) lift transfers. The facility census was 166. Findings included: Review of the medical record for Resident #58 revealed an admission date of 04/30/23 with medical diagnoses of chronic pain, chronic Hepatitis C, hyperlipidemia, and protein calorie malnutrition. Review of the medical record for Resident #58 revealed an Activities of Daily Living (ADL) self-care performance deficit care plan, dated 05/01/23, which indicated Resident #58 was dependent (helper does all the effort or two or more helpers assist) for chair/bed to chair transfers, for tub/shower transfers, and for rolling to left and right while in bed. Review of the ADL care plan revealed an intervention was initiated on 01/08/24 that resident required the use of the mechanical lift with two persons assist for transfers. Review of the at risk for falls care plan, dated 05/01/23, revealed Resident #58 was at risk for falls due to weakness, pain, bilateral lower extremity contracture's, and impaired safety awareness. The fall care plan revealed an intervention was initiated on 12/26/23 that staff are to transfer resident to wheelchair from shower bed and then to bed. Review of the medical record for Resident #58 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #58 was cognitively intact and was dependent upon staff for toilet hygiene, bed mobility, transfers, and bathing. Review of the MDS did not reveal any documentation to support Resident #58 sustained any falls. Review of the medical record for Resident #58 revealed a nurse's progress note, dated 12/26/23 at 8:47 P.M., which stated the nurse was notified by a State Tested Nursing Assistant (STNA) that when she was transferring Resident #58 from shower bed to his bed Resident #58 slid to the floor. The note stated upon entering the room, Resident #58 was observed on top of the shower mattress on the floor beside his bed, was alert and oriented, and no injuries were noted. The note continued to state Resident #58 was assisted back to bed via hoyer lift and four staff assistance, physician notified, and neurological checks were started. Review of the medical record for Resident #58 revealed a physician order, dated 12/27/23, to ensure all device wheels are locked and an order dated, 01/08/24, that resident required hoyer lift with two persons assist for transfers: transfer resident from wheelchair after showers and then to bed. (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 3 Event ID: 365877 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 365877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Nursing and Rehabilitation Center 1390 King Tree Drive Dayton, OH 45405 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)