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 Page 1 of 5 366289 366289 07/06/2023 Concordia at Sumner 970 Sumner Parkway Copley, OH 44321

F 0677 Level of Harm - Minimal harm or potential for actual harm why she didn't lock the brakes on the mechanical lift when lowering resident #6 into his electric wheelchair as required. Interview on 07/05/23 at 3:15 P.M. with Director of Nursing (DON) revealed residents are assessed for the level of transfer assistance required on admission and quarterly. Residents Affected - Few Interview on 07/06/23 at 8:05 A.M. with DON confirmed mechanical lifts are required to have the brakes locked. Review of the manufacturer's guide for Maxi Move (electric mechanical lift) revised 03/2020 revealed on page six the policy on the number of staff members required for patient transfer. Stated lifts are designed for safe usage with one caregiver. However, there are circumstances such as combativeness, obesity, contracture etc. of the individual that may dictate the need for a two-person transfer. It is the responsibility of each facility or medical professional to determine if a one or two-person transfer is more appropriate, based on the task, resident load, environment, capability, and skill level of the staff members. 2. Review of the medical record for Resident #12 revealed an admission date of 06/05/23 and diagnosis included nontraumatic intracerebral hemorrhage, unsteadiness on feet, lack of coordination, dysphagia, hypertension, chronic kidney disease, stage 3, and dysphagia. Review of the the initial Physical Therapy Evaluation for Resident #12 dated 06/06/23 revealed the resident required assist of one with the manual sit to stand (Sara Steady). Review of the plan of care, dated 06/08/23 revealed no evidence of the level of transfer assistance the resident required. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #12 required extensive with two plus assistance for transfers. Review of the progress notes dated 06/16/23 at 10:27 A.M. revealed Resident #12 had a witnessed fall with STNA #122 present to lower to floor using the manual sit to stand with only one assist. Progress notes further stated contributing factors to include two assist needed with resident due to right sided weakness. 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 9:14 A.M. revealed STNA #122 transfer Resident #12 using a manual sit to stand lift. It took STNA #122 numerous attempts to get the resident up from the sitting position to transfer. STNA #122 had to give the resident many cues to complete the transfer. Interview on 07/05/23 at 9:23 A.M. with STNA #122 confirmed Resident #12 should have been a two person assist with the manual sit to stand after pulling up the [NAME] on her computer. STNA #122 reported she doesn't usually check the [NAME] in the computer. Observation of the [NAME] with STNA #122 confirmed Resident #12 required two person assistance with transfers. Interview on 07/05/23 at 9:51 A.M. with Director of Nursing (DON) confirmed Resident #12 required a 366289 Page 2 of 5 366289 07/06/2023 Concordia at Sumner 970 Sumner Parkway Copley, OH 44321

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few manual sit to stand with two assist for transfers. DON reported Resident #12 had a fall on 06/16/23 with the manual sit to stand lift with one assist. DON reported the new intervention was two assist for sit to stand transfers. Review of the manufacturer's policy, Sara Steady, dated 12/2022, revealed on page 11 safety instructions, Warning: To avoid injury, a full clinical assessment of the patient's condition and suitability must be carried out by qualified personnel before attempting to use Sara Steady for rehabilitation activities. This deficiency represents non-compliance investigated under Complaint Number OH00140148. 366289 Page 3 of 5 366289 07/06/2023 Concordia at Sumner 970 Sumner Parkway Copley, OH 44321

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 observation, record review, and interview the facility failed to ensure Resident #6 was transferred safely and Resident #12's fall interventions were in place. This affected one Resident (Resident #6) out of two residents reviewed for accident hazards. 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 quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 required total dependence of two plus assistance for transfers. 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 why she didn't lock the brakes on the mechanical lift when lowering resident #6 into his electric wheelchair as required. Interview on 07/06/23 at 8:05 A.M. with DON confirmed mechanical lifts are required to have the brakes locked. 2. Review of the medical record for Resident #12 revealed an admission date of 06/05/23 and diagnosis included nontraumatic intracerebral hemorrhage, unsteadiness on feet, lack of coordination, dysphagia, hypertension, chronic kidney disease, stage 3, and dysphagia. Review of the the initial Physical Therapy Evaluation for Resident #12 dated 06/06/23 revealed the resident required assist of one with the manual sit to stand (Sara Steady). Review of the plan of care, dated 06/08/23 revealed no evidence of the level of transfer assistance the resident required. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #12 required extensive with two plus assistance for transfers. Review of the progress notes dated 06/16/23 at 10:27 A.M. revealed Resident #12 had a witnessed fall with STNA #122 present to lower to floor using the manual sit to stand with only one assist. Progress notes further stated contributing factors to include two assist needed with resident due to right sided weakness. 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 366289 Page 4 of 5 366289 07/06/2023 Concordia at Sumner 970 Sumner Parkway Copley, OH 44321

F 0689 provided in-service to staff on the use of mechanical lifts. Level of Harm - Minimal harm or potential for actual harm Observation on 07/05/23 at 9:14 A.M. revealed STNA #122 transfer Resident #12 using a manual sit to stand lift. It took STNA #122 numerous attempts to get the resident up from the sitting position to transfer. STNA #122 had to give the resident many cues to complete the transfer. Residents Affected - Few Interview on 07/05/23 at 9:23 A.M. with STNA #122 confirmed Resident #12 should have been a two person assist with the manual sit to stand after pulling up the [NAME] on her computer. STNA #122 reported she doesn't usually check the [NAME] in the computer. Observation of the [NAME] with STNA #122 confirmed Resident #12 required two person assistance with transfers. Interview on 07/05/23 at 9:51 A.M. with Director of Nursing (DON) confirmed Resident #12 required a manual sit to stand with two assist for transfers. DON reported Resident #12 had a fall on 06/16/23 with the manual sit to stand lift with one assist. DON reported the new intervention was two assist for sit to stand transfers. Review of the manufacturer's policy, Sara Steady, dated 12/2022, revealed on page 11 safety instructions, Warning: To avoid injury, a full clinical assessment of the patient's condition and suitability must be carried out by qualified personnel before attempting to use Sara Steady for rehabilitation activities. This deficiency represents non-compliance investigated under Complaint Number OH00140148. 366289 Page 5 of 5