Health inspection·July 6, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure Resident #6 and Resident #12 who were dependent on staff assistance for activities of daily living (ADL) received proper assistance with transfers. This affected two residents (Resident #6 and Resident #12) out of four residents reviewed for ADL. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 01/05/22 with diagnosis of chronic kidney disease, abnormal posture, lack of coordination, unsteadiness on feet, acute kidney failure, morbid severe obesity, hypertension, and hypothyroidism. Review of the initial Physical Therapy Evaluation for Resident #6 done on 09/07/22 revealed to transfer the resident with mechanical lift and assist of one. Review of the physician orders dated 10/26/22 revealed Resident #6 orders included transfer/mobility with full body mechanical lift assist of one. Review of the plan of care, dated 12/09/22 for transfer and mobility revealed the resident required a full body mechanical lift assist of one. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 required total dependence of two plus assistance for transfers. Review of Resident #6's medical record revealed the plan of care and physician orders were not updated to reflect the residents most recent MDS on 06/04/23 assessment identifying the resident required two person assistance with transfers. There was no evidence the resident was assessed by therapy after the MDS identified the resident needing two person assistance. Interview on 07/03/23 at 11:46 A.M. with Therapy Director (TD) #144 revealed all residents are screened upon admission for transfer status by therapy department and as needed. TD #144 reported she provided in-service to staff on the use of mechanical lifts. Observation on 07/05/23 at 12:52 P.M. revealed State Tested Nursing Aide (STNA) #145 transfer the resident with the electric mechanical lift without locking the brakes when transferring Resident #6 into his electric wheelchair. During the transfer Resident #6 was leaning towards his left side. Interview on 07/05/23 at 1:03 P.M. with STNA #145 confirmed she did not lock the brakes on the mechanical lift as she should have. STNA #145 reported Resident #6 always leans to one side and that is (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 5 Event ID: 366289 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 366289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia at Sumner 970 Sumner Parkway Copley, OH 44321 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)