Health inspection·December 18, 2023

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, resident interview, staff interview, and review of policy, the facility failed to safely transfer a resident using a mechanical lift device. This directly affected one (#48) of three residents reviewed for assistance with transfers. The facility identified five additional residents (#14, #21, #41, #45, and #49) utilizing a mechanical lift devices. The facility census was 48. Findings include: Review of the medical record of Resident #48 revealed an admission date of 08/10/22. Diagnoses include chronic obstructive pulmonary disease, rheumatoid arthritis, type II diabetes mellitus, venous insufficiency, and neuromuscular dysfunction of bladder. Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #48 was cognitively intact and required extensive assistance for activities of daily living and transfers. Review of the care plan dated 08/19/22 revealed an intervention for falls to include the use of a stand-up lift. A second intervention dated 08/19/22 for basic needs revealed a mechanical lift to assist with transfers, type: total lift. Review of the progress note dated 11/22/23 at 6:53 A.M., revealed Resident #48 was being transferred to a reclining chair, by State Tested Nursing Assistants (STNA), using a mechanical lift device. Resident #48 was suspended over the recliner when the device tipped over onto Resident #48. An ice pack was applied, and pain medications administered. A second note at 11:13 A.M., revealed Resident #48 continued to have a knot on her forehead and remained alert with pupils equal, round, and reactive to light, hand grasp and pedal push equal. A note dated 11/24/23 at 6:33 A.M., revealed bruising noted to right forehead and below right eye with pain upon palpation or moving eyebrows. Interview on 12/18/23 at 9:00 A.M., with Resident #43 revealed she had fallen from the mechanical lift some time ago. Resident #43 stated she fell into her recliner and had a black eye and bruise on her forehead. Resident #48 stated the lift had not been used properly but didn't feel as if the staff had done it on purpose. Interview on 12/18/23 at 9:05 A.M., with Assistant Director of Nursing (ADON) #151 revealed Resident #48 was moved to a bigger room to safely use the mechanical lift. The lift went to tip and the aides tried to hold it. Both STNAs were adamant the legs were completely open, one STNA in front and one working the lift. The mechanical lift was pulled immediately from use and the maintenance staff inspected the lift and found nothing wrong. The investigation revealed no definite conclusion as to (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 4 Event ID: 366162 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 366162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Home 1036 South Perry Street Napoleon, OH 43545 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)