Health inspection·January 29, 2024

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. Based on medical record review, observation, resident interview, staff interview and review of the facility policy, the facility failed to ensure residents were transferred in a safe manner and in accordance with the plan of care in order to prevent injury. This affected one (Resident #10) of three residents reviewed for assistance with activities of living (ADLs). The facility census was 68. Findings include: Review of the medical record for Resident #10 revealed an admission date of 06/26/21 with diagnoses included hemiplegia, cerebral infarction, aphasia, diabetes mellitus, osteoarthritis, intervertebral disc degeneration, major depressive disorder, and aftercare joint replacement surgery. Review of the physician order for Resident #10 dated 10/20/23 revealed the resident was a stand-pivot transfer with assistance of one staff using hemi-walker for transferring and could use a mechanical lift as needed every shift for transfers. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #10 dated 01/18/24 revealed the resident had moderate cognitive impairment, mobilized with an assistive device, and required the assistance of one staff with ADLs including transfers and showers. Review of the physician's order for Resident #10 dated 01/19/24 revealed the resident could independently transfer (stand pivot transfer) to the toilet but would call for help getting off the toilet and back to the wheelchair. Review of the shower sheet for Resident #10 dated 01/19/24 signed by State Tested Nursing Assistant (STNA) #100 revealed the resident's skin was intact with no bruising noted. Review of the shower sheet for Resident #10 dated 01/22/2024 signed by STNA #100 revealed the resident had a red bruise to the right arm. Interview on 01/24/24 at 4:20 P.M. with Registered Nurse (RN) #210 confirmed Resident #10 required the assistance of one staff with transfers, and staff should use a gait belt when transferring the resident to prevent injury. Review of the physician assessment for Resident #10 dated 01/25/24 revealed the resident was paralyzed to her right arm and had no pain sensation to the extremity. Resident #10 had a bruise observed to the right upper arm. Further review of the note revealed based on the location of the bruise it probably occurred while someone was helping the resident get off the toilet seat. Page 1 of 2 366392 366392 01/29/2024 Burbank Parke Care Center 14976 Burbank Road Burbank, OH 44214

F 0689 Level of Harm - Minimal harm or potential for actual harm Interview on 01/25/24 at 11:00 A.M. with Therapy Manager (TM) #250 confirmed staff should use a gait belt when assisting residents with stand and pivot transfers to prevent injuries. Observation on 01/25/24 at 3:15 P.M of Resident #10 revealed resident had a red and yellow bruised area to the medical aspect of the right upper arm. Residents Affected - Few Interview on 01/25/24 at 3:15 P.M. with Resident #10 confirmed on 01/19/24 sometime in the afternoon STNA #100 assisted the resident with a transfer from toilet to wheelchair. Resident #10 confirmed the STNA #100 did not transfer her with a gait belt but grabbed onto her right arm instead. Resident #10 confirmed it took three attempts for STNA #10 to successfully transfer her from the toilet to the wheelchair. Resident #10 further confirmed her right arm was paralyzed from a stroke and she had no pain to her arm. Resident #10 confirmed she believes the bruise to her right arm was caused when STNA #100 assisted her with transfer on 01/19/24. Interview on 01/25/24 at 4:20 P.M. of STNA #100 confirmed the facility policy was for aides to use a gait belt when transferring residents. STNA #100 confirmed on 01/19/24 sometime in the afternoon she assisted Resident #10 with a transfer from the toilet seat to wheelchair and it took three attempts before she was successfully able to transfer the resident. STNA #100 confirmed she did not use a gait belt when transferring Resident #10 on 01/19/24 but she grabbed onto the resident's right arm instead. STNA #100 further confirmed Resident #10 developed a bruise to her right arm which could have possibly occurred when grabbing the resident's arm during the transfer on 01/19/24. Review of the facility policy titled Safe Lifting and Movement of Residents dated July 2017 revealed the facility staff would promote the safety and well-being of staff and residents by use of appropriate techniques and devices to lift and move residents. This deficiency is an example of continued non-compliance from the survey dated 12/29/23. 366392 Page 2 of 2