Health inspection·April 9, 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 NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interviews, review of facility investigation, and review of facility policy, the facility failed to ensure a resident was properly transferred from the bed to the wheelchair. This resulted in Actual Harm when Resident #04 was transferred without the use of a Hoyer (mechanical lift) by Certified Nursing Assistant (CNA) #200 and the resident sustained a left femoral head fracture requiring hospital admission and surgical repair. This affected one (#04) of three residents reviewed for accidents. The census was 169. Findings include: Review of Resident #04's medical record revealed an admission date of 02/07/05. Diagnoses listed included convulsions anxiety disorder, psychotic disorder, decreased mobility, and legal blindness. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 was severely cognitively impaired and had bilateral upper and lower extremity impairments. Review of a care plan dated revised 11/19/24 revealed Resident #04 is at risk for falls as evidenced by disease process, incontinence, medications, safety awareness, and being unaware of self-care needs or safety awareness. Resident #04 was dependent on staff for transfers. Resident #04 requires a Hoyer lift for transfers with two-person assistance. Review of Resident #04's physician orders revealed an order dated 03/27/23 for Hoyer lift transfers requiring two people. Review of progress notes revealed Resident #04 started displaying left hip pain on 02/18/25. Resident #04 was assessed by a nurse practitioner (NP) and X-radiation (X-ray) was ordered. Resident #04 was sent to the emergency room on [DATE]. Review of X-ray results dated 02/21/25 revealed irregularity of the left femoral neck is identified just beneath the femoral head. This may represent a non-displaced fracture. The fracture does not involve the articular surface. The femoral head is well seated within the acetabulum. Moderate degenerative changes are noted. Mild soft tissue swelling is noted. Review of hospital records revealed Resident #04 was admitted to the hospital on [DATE] with an impacted angulated left femoral neck fracture. Resident #04 required surgical repair on 02/22/25 and Page 1 of 3 365877 365877 04/09/2025 Riverside Nursing and Rehabilitation Center 1390 King Tree Drive Dayton, OH 45405

F 0689 was discharged on 02/25/25. Level of Harm - Actual harm Review of the facility's investigation dated 02/24/25 revealed staff members were interviewed about Resident #04's condition and the care they had provided. CNA #200 confessed during a phone interview with the Administrator on 02/25/25 to improperly transferring Resident #04 from the bed to wheelchair. CNA #200 reported lifting Resident #04 by going to the side of the bed and placing his arms under his legs and back and placing him into his wheelchair. CNA #200 had previously denied any concerns with care or transfers. Residents Affected - Few An interview with the Director of Nursing (DON) on 04/08/25 at 2:10 P.M. revealed during an investigation into Resident #04's left femur and hip fracture it was discovered that CNA #200 incorrectly transferred Resident #04 from his bed to his wheelchair. CNA #200 picked Resident #04 up like a baby and put him into his wheelchair. CNA #200 was aware that Resident #04 was a Hoyer lift transfer. An interview with the Administrator on 04/08/25 at 2:28 P.M. revealed CNA #200 confessed to improperly transferring Resident #04. CNA #200 had previously denied any care concerns when interviewed regarding Resident #04. Review of the facility's undated policy titled, Mechanical Lifts and Transfer revealed it is the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. Safety is a primary concern for our residents, staff and visitors. The use of mechanical lifts requires a competent and skilled user and requires the use of two (2) employees to perform the lift safely, for both resident and employees. As a result of the incident, the facility took the following actions to correct the deficient practice by 03/01/25: • CNA #200 was terminated from employment at the conclusion of the facilities investigation on 02/24/25. • All [NAME] unit residents were interviewed by the Administrator regarding any care concerns by 03/01/25 and no concerns were identified. • All nurses were educated by 03/01/25 by the DON on resident pain monitoring and pain assessment. • All nurses and CNA's were educated by the DON by 03/01/25 on resident transferring and repositioning. • Weekly audits were initiated on 03/01/25 by the DON for mechanical lift transfers and resident 365877 Page 2 of 3 365877 04/09/2025 Riverside Nursing and Rehabilitation Center 1390 King Tree Drive Dayton, OH 45405

F 0689 repositioning. Level of Harm - Actual harm • Residents Affected - Few Weekly interviews with residents were initiated on 03/01/25 and will be completed by the DON or designee. This deficiency represents non-compliance investigated under Complaint Number OH00163988. 365877 Page 3 of 3