Ohman Family Living At Holly

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and review of facility policy, the facility failed to contain accurate information in medical records. This affected three residents (#132, #180 and #181) out of three residents reviewed for medical record accuracy. The facility census was 80.Findings include: 1. Review of the medical record for Resident #132 revealed an admission date of 12/08/25 and his diagnoses included acute respiratory failure with hypoxia (low oxygen level) and hypercapnia (increased carbon dioxide in the blood stream), sepsis, heart failure, tracheostomy (a surgical procedure that creates an opening in the neck and inserts a tube into the windpipe to help a patient breathe) and dependence on respiratory mechanical ventilator (a life-support treatment using a machine to assist or replace spontaneous breathing when a person cannot breathe adequately on their own).
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #132 had intact cognition and was dependent on activities of daily living (ADLs) including personal hygiene, rolling left and right and transfers. He had a tracheostomy and required an invasive mechanical ventilator. He also had oxygen and required suctioning.
Review of February 2026 Physician Orders and Respiratory Treatment Record (RTR) revealed the following:
Resident #132 had an order dated 12/08/25 for ventilator checks (a structured, documented evaluation of both the mechanical ventilator and the resident's response to the support) every six hours and as needed. The RTR was blank for the 5:00 A.M. check on 02/02/26, 02/03/26, 02/04/26, 02/05/26, 02/07/26, 02/11/26, 02/14/26, 02/15/26, 02/16/26, 02/17/26, 02/19/26, 02/21/26, 02/22/26, 02/24/26, 02/25/26, 02/27/26 and 02/28/26; for the 11:00 A.M. check on 02/04/26, 02/05/26, 02/09/26, 02/18/26, 02/19/26, 02/22/26 and 02/27/26; for the 5:00 P.M. check on 02/06/26, 02/08/26, 02/10/26, 02/22/26, 02/25/26 and 02/27/26; and for the 11:00 P.M. check on 02/01/26, 02/02/26, 02/10/26, 02/23/26, 02/24/26, 02/26/26 and 02/28/26.
Resident #132 had an order dated 12/08/25 to replace his oxygen nasal cannula, nebulizer mask, water bottle, and storage bag including marking the date and time on the items and checking the oxygen magnet on the door every Monday night, and the RTR was blank on 02/02/26 and 02/23/26.
Resident #132 had an order dated 12/08/25 for sodium chloride inhalation nebulizer solution (respiratory therapy aerosol treatment used to thin, loosen, and help clear thick mucus from the lungs) seven percent per four milliliters (ml) via tracheostomy two times a day for pneumonia. The RTR was blank on 02/09/26 for the A.M. dose and on 02/25/26 for the P.M. dose.
Resident #132 had an order dated 12/08/25 to assess his cuffed number six tracheostomy every shift. The RTR was blank on 02/09/26 for the A.M. shift, on 02/25/26 for the evening shift, and on 02/01/26, 02/02/26, 02/10/26, 02/23/26, 02/24/26, 02/26/26 and 02/28/26 for the night shift.
Resident #132 had an order dated 12/08/25 for budesonide inhalation suspension (steroid aerosol treatment) 0.5 milligrams (mg) per two ml via tracheostomy two times a day due to pneumonia. The RTR was blank on 02/09/26 for the A.M. dose and on 02/25/26 for the P.M. dose.
Resident #132 had an order dated 12/09/25 for ipratropium-albuterol solution (aerosol treatment) 0.5 mg per three ml via tracheostomy two times a day due to respiratory failure. The RTR was blank on 02/09/26 for the A.M. dose and on 02/25/26 for the P.M. dose.
Resident #132 had an order dated 12/09/25 for tracheostomy care twice daily and as needed. The RTR was blank on 02/08/26 and 02/09/26 for the A.M. and on 02/06/26, 02/08/26, 02/10/26, and 02/25/26 for the P.M.
Resident #132 had an order dated 12/09/25 to change his disposable tracheostomy inner cannula daily and as needed. The RTR was blank on 02/09/26 for the day shift.
Resident #132 had an order dated 12/18/25 for oxygen at three liters per minute (LPM) via tracheostomy collar during the day, evening and night shift to maintain an oxygen saturation rate greater than 88 percent. The RTR was blank on 02/04/26, 02/05/26, 02/08/26 and 02/09/26 on the day shift, on 02/25/26 for the evening shift, and on 02/01/26, 02/02/26, 02/10/26, 02/23/26, 02/24/26, 02/26/26 and 02/28/26 for the night shift.
Resident #132 had an order dated 12/22/25 to change his tracheostomy collar set up every Monday on night shift. The RTR was blank on 02/02/26 and 02/23/26.
Resident #132 had an order for a cough assist (a non-invasive medical device designed to help residents with weak muscles or impaired lung function clear secretions from their airways) 30 times for five cycles two times a day. The RTR was blank on 02/09/26 for the A.M. and on 02/06/26, 02/08/26, 02/10/26 and 02/25/26 for the P.M.
Review of March 2026 Physician Orders and RTR revealed the following:
Resident #132 had an order dated 12/08/25 for ventilator checks every six hours and as needed. The RTR was blank for the 5:00 A.M. check on 03/01/26, 03/02/26, 03/03/26, 03/04/26, 03/05/26, 03/07/26, 03/09/26, 03/12/26 and 03/15/26; for the 11:00 A.M. check on 03/04/26 and 03/06/26; for the 5:00 P.M. check on 03/17/26; and for the 11:00 P.M. check on 03/01/26 and 03/08/26.
Resident #132 had an order dated 12/08/25 for sodium chloride inhalation nebulizer solution seven percent per four ml via tracheostomy two times a day for pneumonia. The RTR was blank on 03/05/26 and 03/13/26 for the P.M. dose.
Resident #132 had an order dated 12/08/25 to assess his cuffed number six tracheostomy every shift. The RTR was blank on 03/05/26 and 03/13/26 for the evening shift, and on 03/01/26 and 03/08/26 for the night shift.
Resident #132 had an order dated 12/09/25 for tracheostomy care twice daily and as needed. The RTR was blank on 03/05/26 and 03/13/26 for P.M.
Resident #132 had an order dated 12/09/25 for ipratropium-albuterol solution 0.5 mg per three ml via tracheostomy two times a day due to respiratory failure. The RTR was blank on 03/05/26 and 03/13/26 for the P.M. dose.
Resident #132 had an order dated 12/23/25 for a cough assist 30 times five cycles two times a day. The RTR was blank on 03/05/26 and 03/13/26 for P.M.
Resident #132 had an order dated 12/18/25 for oxygen at three liters via tracheostomy to maintain oxygen saturation level of 88 percent or greater and to check oxygen saturation level every evening and night shift. The RTR was blank on 03/05/26 and 03/13/26 for the evening shift and on 03/01/26 and 03/08/26 for the night shift.
Review of the care plan last revised 12/14/25 revealed Resident #132 required oxygen therapy, for his oxygen saturation rate to be monitored continuously and he was followed by Respiratory Therapy (RT). Interventions included administering medications as ordered, monitoring for respiratory distress and reporting to the physician as needed. Resident #132 had a tracheostomy, continuous oxygen saturation rate monitoring and he was followed by RT. Interventions included oxygen as prescribed, suctioning as needed, monitoring and checking respiratory rate, depth and quality every shift as ordered and documenting. Resident #132 was on a mechanical ventilator due to respiratory failure and stroke. He was dependent on staff for all his ventilator needs and he was followed by RT. Interventions included administering aerosols as ordered, assessing signs of hypoxia, monitoring oxygen saturation levels, and routine tracheostomy change as ordered. There was nothing in the care plan regarding ventilator checks every six hours.
2. Review of the closed medical record for Resident #181 revealed an admission date of 03/02/26 and discharge to the hospital on [DATE]. Her diagnoses included acute respiratory failure with hypoxia, heart failure, tracheostomy and dependence on a respiratory mechanical ventilator.
Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #181 was cognitively intact and dependent on ADLs including personal hygiene, rolling left and right and transfers. She had a tracheostomy and required an invasive mechanical ventilator. She also had oxygen and required suctioning.
Review of March 2026 Physician Orders and RTR revealed the following:
Resident #181 had an order dated 03/03/26 to have ventilator checks every six hours and as needed. The RTR was blank for 5:00 A.M. on 03/03/26, 03/04/26, 03/05/26, 03/07/26, 03/09/26 and 03/12/26, for 11:00 A.M. on 03/04/26 and 03/06/26, and for 11:00 P.M. on 03/08/26.
Resident #181 had an order dated 03/03/26 for albuterol sulfate nebulization solution 2.5 mg per three ml inhale orally per nebulizer two times a day for shortness of breath. The RTR was blank on 03/10/26 for the A.M. dose and on 03/05/26 for the P.M. dose.
Resident #181 had an order dated 03/03/26 for sodium chloride inhalation nebulization solution seven percent per four ml via tracheostomy two times a day due to thick secretions. The RTR was blank on 03/05/26 for the bedtime dose.
Resident #181 had orders dated 03/03/26 to assess her cuffed tracheostomy, size number seven, every shift and oxygen at one to 15 LPM to maintain an oxygen saturation rate of 88 percent or greater. The RTR was blank on 03/05/26 for the evening shift and on 03/08/26 for the night shift for both orders.
Review of the care plan dated 03/08/26 revealed Resident #181 had oxygen therapy related to acute and chronic respiratory failure with hypoxia and hypercapnia. She was followed by an RT at the facility. Interventions included administering medications as ordered by the physician and monitoring signs of respiratory distress. Resident #181 was ventilator dependent related to respiratory failure. Interventions included administering aerosol treatments as ordered, assessing for signs of hypoxia, maintaining ventilator settings as ordered, monitoring oxygen saturation levels while on mechanical ventilator every shift, monitoring and documenting to physician any signs of respiratory infection, and preventing accidental extubating by taping securely and checking every two hours. There was nothing in the care plan regarding ventilator checks every six hours. Resident #181 had a tracheostomy related to impaired breathing. Interventions included suctioning as needed, monitoring and documenting respiratory rate, depth, and quality every shift and giving oxygen as ordered.
3. Review of the closed medical record for Resident #180 revealed an admission date of 02/06/26 and discharge to the hospital on [DATE]. She was re-admitted to the facility on [DATE] and discharged back to the hospital on [DATE]. Her diagnoses included acute and chronic respiratory failure, congestive heart failure, type two diabetes mellitus, pneumonitis (inflammation of the lung), chronic obstructive pulmonary disease, interstitial (small spaces in the lungs) pulmonary disease, dysphagia (difficulty swallowing), myasthenia gravis (weakness in voluntary muscles), non-Hodgkin lymphoma (a cancer of the lymphatic system), dementia, and chronic kidney disease. The resident had a tracheostomy and dependence on a respiratory mechanical ventilator.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #180 had no cognitive impairment and was dependent on ADLs including personal hygiene, bathing, dressing, and substantial to dependent assistance with bed mobility and transferring. She had a tracheostomy, required an invasive mechanical ventilator, and oxygen therapy.
Review of February 2026 and March 2026 Physician Orders and RTR revealed the following:
Resident #180 had an order dated 02/06/26 to have ventilator checks every six hours and as needed. The order was discontinued on 02/19/26 after discharge, and a new identical order was initiated on 02/24/26 upon readmission to the facility. The RTR was blank on for the 5:00 A.M. check on 02/07/26, 02/11/26, 02/14/26, 02/15/26, 02/27/26, 02/28/26, 03/01/26, 03/02/26, 03/03/26, and 03/04/26; for the 11:00 A.M. check on 02/07/26, 02/08/26, 02/09/26, and 02/27/26; for the 5:00 P.M. check on 02/10/26, 02/25/26, and 02/27/26; and for the 11:00 P.M. check on 02/10/26, 02/26/26, and 02/28/26.
Resident #180 had an order dated 02/08/26 for albuterol sulfate nebulization (aerosol treatment) solution 2.5 mg per three ml via ventilator two times a day for respiratory failure. The order was discontinued on 02/19/26 after discharge, and a new order started on 02/24/26 for ipratropium-albuterol solution (aerosol treatment) 0.5-2.5 mg per three ml inhale orally three times a day for respiratory failure. The RTR was blank on 02/09/26 for the A.M. dose, on 02/27/26 and 03/04/26 at 1:00 P.M., and on 02/25/26 and 02/27/26 at 9:00 P.M.
Resident #180 had an order initiated on 02/06/26 for titration (adjustment of the level) of oxygen one to 15 LPM, to maintain peripheral capillary oxygen saturation (the percentage of oxygen-saturated hemoglobin in the blood) of 88 percent or greater every shift. The order was discontinued on 02/29/26 after discharge, and a new identical order started on 02/24/26 upon readmission to the facility. The RTR was blank on 02/09/26 and 02/27/26 for the day shift, on 02/25/26 for the evening shift, and on 02/10/26, 02/26/26, 02/28/26, and 03/01/26 for the night shift.
Review of the care plan dated 02/07/26 revealed Resident #180 had a tracheostomy and was ventilator dependent related to acute respiratory failure with hypoxia. Interventions included administering aerosol treatments as ordered, suctioning as necessary, and monitoring and documenting respiratory rate, depth, and quality every shift.
Interview on 03/17/26 at 11:14 A.M. with Assistant Director of Nursing (ADON) #200 and RT #307 revealed there was always an RT at the facility and the RT was to document on the RTR that the orders were completed, omitted, refused and/or any other reason the RT medication and/or treatment was not completed. They verified the blanks on the February and/or March 2026 RTRs for Residents #132, #180 and #181 and stated they felt the orders were completed but not documented accurately. They verified there was no other documentation that the RTs used including ventilator checks as they revealed the RTR was the only form utilized.
Interview on 03/17/26 at 2:06 P.M. with the Director of Nursing (DON) verified she had reviewed the RTRs for Residents #132, #180 and #181 for February and/or March 2026 and verified there were blanks including ventilator checks, aerosol treatments, tracheostomy assessments, and oxygen as ordered. She stated the facility had recently started the ventilator program and they were working out the issues including documentation. She felt the orders were completed but were not documented accurately. She revealed a medication error form should have been completed for any treatment and/or medication omitted and then the facility would investigate why the order was not documented as completed.
Interview on 03/17/26 at 2:20 P.M. with Director of RT #239 verified that she had noticed the blanks on the RTR for Residents #132, #180 and #181. She stated the RTs at the facility were just not used to documenting on the RTR and that she was just as guilty as she had not documented at times. She verified the RTR documentation was not accurate, but stated she believed the orders were completed just not documented.
Review of facility policy labeled, Medication Errors dated 01/30/20 revealed a medication error/omission report was to be completed immediately after an error was discovered to ensure proper resident follow up.
Review of facility policy labeled, Invasive Mechanical Ventilation dated 12/08/25 revealed the goals of mechanical ventilation was to sustain life, reduce morbidity and enhance quality of life. There was no reference in the policy regarding ventilator checks or the documentation of orders in the RTR.
This deficiency represents non-compliance investigated under Complaint Number 2795617.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure timely incontinence care was provided to Resident #2. This affected one resident (#2) of three residents observed and reviewed for incontinence care. The facility census was 80.Findings include: Review of Resident #2's medical record revealed an admission date of 09/15/25. Diagnoses included spondylosis (an age-related degenerative condition) of the lumbar spine, diabetes, and high blood pressure.Review of the care plan dated 09/16/25 revealed Resident #2 had self care deficits related to weakness and limited mobility. Interventions included one staff participation with toileting. Resident #2 had bladder incontinence and required assistance with hygiene and transfers. Interventions included check resident as required for incontinence. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had intact cognition and was dependent with toileting. Resident #2 was identified to be frequently incontinent of both bowel and bladder. Observation on 01/28/26 at 10:50 A.M. revealed an electronic call light system at the nurses station that indicated Resident #2's call light had been active and unanswered for 35 minutes. Observation further revealed two staff members seated at the nursing station while the call light system was alarming. Observation and interview on 01/28/26 at 10:52 A.M. with Resident #2 revealed she had turned her call light on for assistance with toileting. During the interview at 11:02 A.M., Certified Nursing Assistant (CNA) #175 had entered the resident's room and stated she was on her way to lunch, but she had observed Resident #2's call light on for 45 minutes and wanted to check to see what Resident #2 needed. Resident #2 informed CNA #175 she needed toileting assistance and she had already been incontinent in her bed because she had waited so long. CNA #175 proceeded to assist Resident #2 into her wheelchair and assisted Resident #2 into the bathroom. CNA #175 had then proceeded to assist Resident #2 with personal hygiene and had changed Resident #2's bedding because it was soiled with urine.Interview on 01/28/26 at 11:25 A.M. with CNA #194 revealed she worked for agency and was not assigned to Resident #2, however she was present at the nurse's station and had heard the call system alarming, however had not answered the call light. At time of interview, Licensed Practical Nurse (LPN) #195 revealed she was the assigned nurse for Resident #2, however she was not aware of who the aide was for that assignment. LPN #195 further stated she was present at the nurses station and had heard the call light system, however she had assumed the aides would answer the light and if she was needed the aides would inform her. This deficiency represents non-compliance investigated under Complaint Number 2708882.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review and facility policy, the facility failed to ensure neutropenic guidelines and isolation were maintained for Resident #36 and the provider order was followed by staff to prevent the development and transmission of communicable diseases and infections to the immunocompromised resident. This affected one resident out of five reviewed for infection control. The census was 85.Review of the medical record for Resident #36 revealed an admission date of 10/27/25 with a diagnoses of Cauda Equina Syndrome (spinal cord injury of lower back), myeloblastic leukemia (a blood cancer), epileptic syndrome, diastolic heart failure, adult failure to thrive, depression, venous thrombosis and embolism (blood clots), and depression.Review of the physician's orders dated 10/27/25 revealed Resident #36 was ordered to have neutropenic transmission-based precautions due to being an immunocompromised resident with myeloblastic leukemia. Immunocompromised residents are at increased risk for numerous types of infections while receiving healthcare, specifically, fungal and bacterial infections. This included: signage outside of the room, wear N95 mask, shield, gloves and gown when entering the room. Removal of personal protective equipment (PPE) prior to leaving room and hand hygiene before and after entering room. Sanitize shared equipment between uses.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated Resident #36 was cognitively intact. The functional assessment revealed Resident #36 required maximum assistance with showering and personal hygiene and was dependent on staff for toileting and mobility using a manual wheelchair. Resident #36 was also incontinent of bowel and bladder.Observation on 12/08/25 10:36 A.M. of Resident #36 sitting comfortably in a chair in her room. PPE was hanging on the outside of the door for staff and included an ample supply of surgical masks, gowns, gloves, and hand sanitizer. No N95 masks were available for staff.Observation on 12/08/2025 1:10 P.M. revealed Resident #36 was outside of the room in the common area not wearing any mask and in close contact with other residents and staff.Observation on 12/08/25 at 2:11 P.M. of Licensed Practical Nurse (LPN) #413 entering Resident #36's room wearing a surgical mask only.Interview with LPN #413 on 12/08/25 at 2:20 P.M. revealed Resident #36 does not wear a mask outside of her room. LPN #413 also stated that staff do wear surgical masks when entering Resident #36's room but do not don all the PPE unless providing care to resident. LPN #413 also verified the provider order indicated anyone entering resident's room would wear an N95 mask, gown and gloves and perform hand hygiene upon entering and exiting the room, and the resident would wear a mask outside of her room.Interview with the Director of Nursing (DON) on 12/08/25 at 2:30 P.M. verified Resident #36's order and stated they have not been using N95 masks per the order. The DON also stated the provider should have been contacted after placing the order in October 2025 to change to surgical masks and not N95 masks.Interview with Resident #36 on 12/09/25 at 2:45 P.M. revealed she only wears a mask when in physical therapy and does not wear a mask in any other area of facility including common areas such as dining room and activities room.Review of Resident #36's labs dated 12/08/25 revealed a [NAME] Sedimentation Rate of 46 millimeters per hours (mm/hr.) (reference range 0-20 mm/hr.) which indicates chronic inflammation due to active leukemia.Review of the facility policy titled, Isolation: Transmission -Based Precautions, dated 01/04/25, revealed Reverse Isolation (Neutropenic) is for compromised residents and should include signage on door, protecting resident from everyone else; and in addition to standard precaution to wear a gown when coming into contact with resident; wear a mask when coming within six feet of resident; and place a mask on resident when outside of their room.Review of the Center for Disease Control (CDC) Guidelines for Infectious Disease, dated 2007, revealed for neutropenic precautions, healthcare staff typically wear gloves, gowns, and masks (surgical or N95), along with meticulous hand hygiene, to protect immunocompromised patients from germs by creating a barrier against blood, body fluids, and respiratory secretions, especially when entering the patient's room for direct care. Patients themselves often wear masks in public to protect their weakened immune systems from others' germs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, staff interview, policy review, and review of manufacturer's guidelines, the facility failed to ensure Resident #100 was transferred in a safe manner to prevent an injury during a mechanical (Hoyer) lift transfer.
Actual Harm occurred on 01/31/25 at approximately 6:49 P.M. when Resident #100, who was dependent on staff for transfers, was injured during a Hoyer lift transfer when staff did not ensure Resident #100 cleared the air mattress's bolsters on the edge of the bed. As a result, the Hoyer lift tipped and struck Resident #100 on the top of the head. Resident #100 was transported to the hospital and diagnosed with a concussion and laceration to the head which required six staples to close the lacerated wound. This affected one resident (#100) of three residents reviewed for safe transfers. The facility identified two additional residents who required the use of a Hoyer lift for transfers on the 500-hallway. The facility census was 90.
Findings include:
Review of the closed medical record for Resident #100 revealed a re-admission date of 01/23/25 with medical diagnoses including Parkinson's disease with dyskinesia, generalized muscle weakness, and chronic systolic heart failure. Resident #100 discharged from the facility on 02/09/25.
Review of Resident #100's care plan revised on 01/27/25 revealed the resident had an activities of daily living (ADL) self-care performance deficit related to Parkinson's weakness, limited mobility, and increased tremors. Listed interventions included transferring the resident using two staff participation using a Hoyer (mechanical) lift and a pressure relief mattress to bed to help reduce pressure on fragile skin. An additional care plan focus revealed Resident #100 was at risk for pressure ulcer development related to limited mobility and incontinence. A listed intervention included applying an air mattress to the resident's bed.
Review of Resident #100's Minimum Data Set (MDS) admission assessment dated [DATE] revealed the resident was cognitively intact. The assessment revealed Resident #100 was dependent on staff for transfers and required the use of a manual wheelchair.
Review of a progress note dated 01/31/25 at 6:49 P.M. revealed the nurse was notified by two Certified Nursing Assistants (CNAs) that as they were lifting Resident #100 with the Hoyer lift into his bed, the Hoyer lift tipped over, and the top-heavy part struck Resident #100 in the middle of his head, near his hairline and forehead. A large hematoma and bleeding were noted around the area. The physician was notified and gave an order to send Resident #100 out to a local emergency room (ED) for evaluation. A subsequent note timed 7:12 P.M. revealed Resident #100's family was notified of the injury and transfer to the local ED.
Review of a skin incident report dated 01/31/25 and timed 7:00 P.M. revealed Resident #100 obtained an injury during a Hoyer lift transfer. The report was prepared by Registered Nurse (RN) #224. RN #224 was notified by two (unnamed) CNAs that during a hoyer lift transfer, once Resident #100 was lowered into the bed, the Hoyer lift tipped over and struck Resident #100's head near his hairline. Resident #100 was bleeding and had a hematoma surrounding the area. Resident #100 was assessed to be at baseline mentation and alertness. The report listed Resident #100 as stating I got hit with the Hoyer lift as he was being transferred. Notifications were completed to the physician and Resident #100's family, and the resident was transferred to a local emergency department (ED) for treatment.
Review of an ED After Visit Summary (AVS) dated 01/31/25 revealed Resident #100 was seen in the ED after sustaining a head injury to his scalp. The note listed the resident had received six staples in his head to close the laceration. Listed diagnoses for the ED visit were listed as a head injury and concussion. Resident #100 received a dose of Tylenol (an over-the-counter analgesic) and a tetanus vaccination. Resident #100 returned to the facility in the early morning hours of 02/01/25.
Interview on 04/11/25 at 11:00 A.M. with the Director of Nursing (DON) revealed that the resident had previously been treated for moisture-associated skin damage (MASD) during a prior admission, so upon his re-admission on [DATE], an air mattress was placed on the resident's bed as a preventative measure. The DON stated after being made aware of Resident #100's Hoyer lift injury, she believed the air mattress contributed to the incident.
Interview on 04/11/25 at 4:22 P.M. with CNA #158 revealed her and Agency CNA #227 transferred Resident #100 on 01/31/25 when he sustained an injury from the Hoyer lift. CNA #158 reported the transfer went well until the lift got to the resident's bed. CNA #158 stated the mattress was too tall for the Hoyer lift to clear. The legs of the hoyer lift were open, CNA #158 stated she had control of the Hoyer lift, and Agency CNA #227 was guiding the resident. CNA #158 stated the legs of the Hoyer lift were open, Resident #100 was a taller and bigger man, and was unsure why or how the Hoyer lift tipped. CNA #158 stated she and Agency CNA #227 stopped the Hoyer lift from tipping completely.
Interview on 04/11/25 at 4:35 P.M. with RN #224 revealed she was on duty the night Resident #100 was injured during a Hoyer lift transfer. RN #224 reported she did not witness the transfer but was called to the room by an unspecified aide after the transfer and an injury occurred. RN #224 immediately responded to the resident's room and noticed an abrasion to the resident's forehead. She assessed the resident and determined Resident #100 needed to be evaluated at a local ED as he routinely took blood thinners.
Interview on 04/11/25 at 4:42 P.M. with Agency CNA #227 revealed she was caring for Resident #100 the night he sustained an injury during a Hoyer lift transfer. Agency CNA #227 and CNA #158 transferred Resident #100 from his wheelchair to his bed. On Resident #100's bed was an air mattress with bolsters (raised edges). Agency CNA #227 recalled the transfer went well until the Hoyer lifting Resident #100 did not clear the bolsters of the mattress. When turning and maneuvering the resident, the Hoyer lift tipped to the side, causing the top part of the Hoyer lift to hit Resident #100's head. Resident #100 started bleeding from where the Hoyer lift made contact with the resident's forehead. The two CNAs lowered Resident #100 into the bed and immediately summoned the nurse on duty.
A follow up interview on 04/14/25 with the DON revealed the facility investigated the incident and had attempted to recreate the incident. The DON reported she did a root cause analysis of the incident and determined the root cause of Resident #100's injury was a combination of the resident's weight (last recorded as 262 pounds), the resident not clearing the air mattress bolsters, and movement/positioning of Resident #100 while transferring the resident into bed. Following the incident, Resident #100's mattress was changed from an air mattress with bolsters to a regular pressure-reducing mattress per his request and for improvement of safe transfers between surfaces.
Review of the manufacturer's guidelines for the Hoyer lift, dated 2015, revealed the Hoyer lift's maximum capacity was 400 pounds (lbs). The guidelines contained a warning that lifters can tip over, and to keep base widened for stability.
Review of the policy Mechanical Lift: Hoyer Lift dated 11/20/24 revealed a mechanical lift is used to facilitate transfers of residents who are unable to bear weight. At least two (2) people are involved during transferring a resident with the lift. The procedure included ensuring the resident is safe and secure.
This deficiency represents non-compliance investigated under Complaint Number OH00162876.