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 Page 1 of 4 366162 366162 12/18/2023 Lutheran Home 1036 South Perry Street Napoleon, OH 43545

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few how the lift tipped, possibly the legs were not completely opened to ensure a stable base. Both STNAs were agency. The agencies were all alerted to ensure STNAs received education on the use of mechanical lifts. Review of a typed statement from the Administrator after talking with agency STNA #145 revealed Resident #48 was almost over to the recliner when the lift tipped onto resident. Review of the policy titled, Mechanical Lift dated May 2023, revealed one step to include widen the legs of the lift and raise the resident to a level high enough to perform a safe transfer. Once the resident is raised, close the legs of the lift, and carefully move the lift to transfer the resident to the desired location such as a chair. Lower the lift to properly position the resident. This deficiency represents non-compliance investigated under Complaint Number OH00149183. 366162 Page 2 of 4 366162 12/18/2023 Lutheran Home 1036 South Perry Street Napoleon, OH 43545

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, review of facility resident list, staff interview and policy review, the facility failed to ensure medications were properly stored when a medication cart was left with a drawer open, the cart unlocked, and unattended. This had the potential to affect two residents (#33 and #34) identified as being independently mobile and confused. The facility census was 48. Findings include: Observation and interview on 12/14/23 at 7:39 A.M., the medication cart was unlocked, the top drawer was open, medications were visible and no staff was in attendance. Licensed Practical Nurse (LPN) #100 exited the room of Resident #37 and verified the cart was unattended and unlocked. Review of a facility identified list revealed two residents (#33 and #34) are independently mobile and have confusion. Review of the policy titled Security of Medication Cart dated 04/12 revealed the medication cart is to be locked when out of view of the nurse. 366162 Page 3 of 4 366162 12/18/2023 Lutheran Home 1036 South Perry Street Napoleon, OH 43545

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, review of facility resident list and review of policy, the facility failed to ensure the shared glucometer was disinfected between residents. The facility further failed to ensure the correct disinfecting solution was used to cleanse the glucometer. This had the potential to affect two residents (#36 and #37) identified as using the glucometer. The facility census was 48. Residents Affected - Few Findings include: Observation on 12/14/23 at 7:39 A.M., revealed Licensed Practical Nurse (LPN) #100 was carrying a glucometer when exiting the room of Resident #37. LPN #100 proceeded into the room of Resident #36 with the glucometer and proceeded to perform a fingerstick to obtain a blood glucose reading. LPN #100 had not disinfected the meter between residents. Interview with LPN #100, at the time of the observation verified not having disinfected the glucometer between resident use. Continued observation revealed LPN #100 was using an alcohol prep pad to clean the glucometer; after this surveyor questioned her about not cleaning the meter between residents and thought that was an acceptable cleanser. Review of a facility identified list revealed two residents (#36 and #37) utilize a glucometer. Review of the policy titled, Disinfecting Glucometer's and other reusable patient equipment dated May 2020 revealed the glucometer is to be cleansed between residents using sanitary wipe. 366162 Page 4 of 4