Health inspection·September 2, 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** Based on medical record review, hospital record review, interview, observation, review of the mechanical lift instructions, and policy review, the facility failed to use appropriate slings for the mechanical lift and failed to maintain the mechanical lift per the manufacturer's instructions resulting in significant resident injury with mechanical lift transfers. Actual harm occurred on 07/20/25 when Resident #4, who required extensive assistance from two staff members and a mechanical lift with transfers, experienced a fall during a mechanical lift transfer when staff used the incorrect sling and the sling straps broke. The resident was transferred to the emergency room for evaluation and subsequently admitted to the surgical trauma intensive care unit overnight due to multiple rib fractures and a right occipital scalp contusion and hematoma. Additionally, an incident of actual harm occurred on 07/18/25 when Resident #1, who required extensive assistance from two staff members and the use of a mechanical lift with transfers, was transferred from her bed to her wheelchair and was struck in the forehead with the swivel bar of the mechanical lift after the transfer was completed. The resident sustained a laceration to the forehead requiring four staples. This affected two (Resident #1 and Resident #4) of three residents reviewed for falls. The facility census was 48. Findings include: 1. Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, diabetes mellitus, Parkinson's disease, kidney failure, congestive heart failure, syncope and collapse, and mild cognitive impairment.Review of the care plan, dated 07/21/25, revealed the resident had activities of daily living (ADL) self-care deficits related to general decline and collapse and was dependent upon staff for transfers with a mechanical lift. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/27/25, revealed the resident had intact cognition and required physical staff assistance for transfers and mobility. Review of a nursing progress note, dated 07/20/25 at 9:05 A.M., revealed Registered Nurse (RN) #70 was called into the room by a Certified Nursing Assistant (CNA) and observed Resident #4 on the floor, lying on his left side. The CNA (unidentified) stated while using the mechanical lift, the sling broke/ripped and the resident fell to the floor, on his left shoulder, head, neck, left ribs, and left hip. The resident stated it hurt to take a deep breath, and he was tearful. Nine-one one (911) was called. The physician and family were notified. The resident was transported to the Emergency Department (ED).Review of the Fall Investigation/Incident Report revealed on 07/20/25 at 9:05 A.M. revealed Resident #4 was being transferred into bed with a mechanical lift when suddenly the sling broke and the resident fell onto the floor, hitting the left side of his head, neck, ribs, shoulder and hip. The sling being used was not the appropriate mechanical lift sling and was a thin, hospital sling. The immediate intervention implemented was to ensure the correct sling is used. All thin, hospital slings were removed to ensure they would not be used again. Review of the After Visit Summary from the ED dated 07/20/25-07/21/25 revealed the resident was admitted to the Surgical Trauma Intensive Care Page 1 of 3 365988 365988 09/02/2025 Willow Brook Christian Home 55 Lazelle Rd Columbus, OH 43235

F 0689 Level of Harm - Actual harm Residents Affected - Few Unit (ICU) due to fracture of multiple ribs. Imaging tests included computed tomography (CT) of the cervical spine, chest, abdomen, pelvis, maxillofacial, and head, and x-rays of the chest, pelvis, and right knee. The resident sustained an acute mildly displaced fracture of the left sixth lateral rib. There were multiple additional remote bilateral rib fractures. Upon discharge back to the facility, the resident was prescribed oxycodone for pain control.Interview on 08/29/25 at 11:20 A.M. with Resident #4 revealed he fell from the Hoyer lift when the sling broke and he hit his head and broke his rib.Interview with CNA #72 on 08/29/25 at 1:18 P.M. revealed she and another CNA were transferring Resident #4 with the wrong type of sling when it broke during the transfer resulting in the resident falling (from the lift) and caused the resident to hit the floor. CNA #72 stated the sling was already beneath the resident (when they secured the sling to the mechanical/Hoyer lift) and they didn't change the sling to a correct one. Interview on 08/29/25 at 11:59 P.M. with the Assistant Director of Nursing (ADON) confirmed Resident #4 fell during a mechanical lift transfer due to the night shift staff placing an incorrect, thin hospital sling under him. The day shift staff utilized the incorrect sling, and it broke during the transfer resulting in Resident #4 suffering fractured ribs. Review of the manufacturer's pamphlet titled, Electric Patient Lift, revealed specific slings are made for the Electric Patient Lifts. For the safety of the patient, do not intermix slings and patient lifts of different manufacturers.Review of the facility's policy titled, Safe Resident Handling/Transfers, revision date of 07/18/25, revealed it is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Guidelines include ensuring the sling designed for the lift is utilized with that specific lift and two staff members must be utilized when transferring residents with a mechanical lift.2. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, convulsions, mood disorder, heart failure, hemiplegia and hemiparesis, and a history of transient ischemic attack and cerebral infarction.Review of the care plan, dated 01/13/25, revealed the resident had activities of daily living (ADL) self-care deficits related to hemiparesis and was dependent upon staff for transfers with a mechanical lift. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/27/25, revealed the resident was rarely understood and required physical staff assistance for transfers and mobility. The assessment indicated there was impairment on one side of the upper extremities and impairment on both sides of the lower extremities. Review of the Fall Investigation/Incident Report revealed on 07/18/25 at 7:15 A.M. Resident #1 was injured from the Hoyer lift after being placed in a chair. The resident sustained a one to one and a half inch laceration on the top, left area of her head. The wound continued to bleed and 911 was called. Interview with Certified Nursing Assistant (CNA) #62 stated she was moving the mechanical lift away from the chair when the metal part made contact with the resident's head and caused the laceration. The resident received four staples in the ED. The immediate intervention implemented was to fit the mechanical lift cradle swing bar (swivel bar) with padding (as included with the lift as a main component of the assembly) to prevent further injury.Review of a nursing progress note, dated 07/18/25 at 10:16 A.M., revealed Resident #1 was injured this morning while getting out of bed via Hoyer lift and sustained a 1-1.5-inch laceration to the head. The wound was bleeding continuously, and the resident was sent to the emergency department (ED). The resident's daughter was notified. Review of the After Visit Summary from the ED dated 07/18/25 revealed the resident was seen due to a head injury and laceration of the scalp. Imaging tests included computed tomography (CT) of the cervical spine and head, and x-rays of the chest, right femur, 365988 Page 2 of 3 365988 09/02/2025 Willow Brook Christian Home 55 Lazelle Rd Columbus, OH 43235

F 0689 Level of Harm - Actual harm Residents Affected - Few right forearm, right hip with pelvis, right humerus, and right tibia fibula. The laceration was closed with four staples. Diphtheria, Tetanus Toxoid, and Acellular Pertussis immunization was administered.Interview with CNA #62 on 08/29/25 at 1:21 P.M. revealed she and CNA #68 transferred the resident from her bed to the wheelchair. At this point, CNA #68 left the room. While moving the mechanical lift away from the wheelchair, CNA #62 stated the metal edge of the cradle hit the resident in the head and she immediately started bleeding from the laceration. CNA #62 stated she applied a towel to the resident's head and called for the nurse. CNA #62 stated to prevent this from happening again she will always have two staff present until the mechanical lift is moved away from the resident. Interview on 08/29/25 at 1:32 P.M. with the Assistant Director of Nursing (ADON) confirmed Resident #1 was struck in the head with the cradle of the mechanical lift when CNA #62 was moving the mechanical lift away from the resident's wheelchair. The ADON stated the intervention put into place following the accident was for padding to be placed on the swing arm of the mechanical lift, as advised in the manufacturer's instructions.Observation on 08/29/25 at 1:45 P.M. of the mechanical lift revealed a swivel bar fabric protective cover that resembled the wrap illustrated in the Electric Lift Patient Manual.Review of the manufacturer's pamphlet titled, Electric Patient Lift, revealed the lift included a swivel bar protective covering as part of the main assembly components.This deficiency represents non-compliance investigated under Complaint Number 2566262. 365988 Page 3 of 3