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 (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 04/09/2025 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)