Inspection·February 14, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 12, indicated the resident was a high fall risk. At approximately 5:00 A.M. Resident #107 fell from the bed when an aide was providing care. An assessment was completed. Vital signs were completed blood pressure was 127/81, pulse 64, oxygen saturation was 94% on room air, temperature was 97.8 degrees F, ROM was within normal limits, resident moved all extremities without pain, no visible injury was observed. The resident's bed moved when locked, a bed rail was not on the side where the resident fell. Maintenance was notified about the bed. The Wong-Baker FACES pain scale indicated zero, no pain. Interventions: keep items within reach, nonskid footwear, half siderail for bed mobility, maintenance to check the bed. Symptoms prior to fall: none noted. Interventions: keep items within reach, nonskid footwear, half siderail for bed mobility, maintenance to check the bed. The resident's family and physician were notified of the fall. Review of the Interdisciplinary Team (IDT) note on 12/15/23 at 10:18 A.M. revealed the IDT team met to review the fall on 12/15/23. While being assisted with toiletings needs, Resident #107 rolled out of bed onto floor. Resident #107 denied hitting his head. Risk factors included but were not limited to epilepsy, anxiety and bilateral below knee amputation (BKA). Immediate intervention: the resident was assisted back into bed with three-person assistance, evaluated by nurse, physician notified, and neurological checks were initiated. Locks on bed wheels were found not to be working properly. New intervention: a new bed and grab bars to both sides of bed. All parties were notified. Review of the Physician's Monthly Progress Note on 12/26/23 at 4:04 P.M. revealed Resident #107 was a new resident for the nurse practitioner (NP) at the facility. The musculoskeletal exam revealed no tenderness, normal ROM, and right lower leg edema (above the amputation). Interview on 02/08/24 at 10:42 A.M. the Director of Nursing (DON) and Administrator revealed that during care the aide turned Resident #107 toward the wall, the bed moved away from the wall, and he rolled off. The resident was immediately assessed. Staff got him back to bed. That was when they noticed the lock was broken on the bed. The facility got him a new bed and had grab bars put on both sides. During that time the resident never complained of pain or said anything that indicated he wasn't feeling okay. The resident never complained of pain after that, or we would have had x-rays done. We did a re-education with the state tested nurse aide (STNA) about making sure the bed was locked before doing care and about how the need to turn a resident toward yourself, not away. Interviews on 02/08/24 from 12:19 P.M. through 12:48 P.M. with Licensed Practical Nurse (LPN) #302, LPN #303, LPN #304, and STNA #304 revealed all had been trained in fall prevention and in what to do after a resident fell. All residents were assessed by a nurse after a fall. None of the staff interviewed had heard Resident #107 complain of any pain in the days after his fall. The deficient practice was corrected on 12/16/23 when the facility implemented the following corrective actions: • On 12/15/23 at 10:18 A.M. the IDT met to review Resident #107's fall. The interventions included a new bed and grab bars to both sides of bed. • On 12/15/24 at 7:09 A.M. the nurse assessed Resident #107 after the fall. The assessment at the time did not reveal any injuries. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365033 If continuation sheet Page 2 of 3 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 365033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarwood Plaza 12504 Cedar Road Cleveland Heights, OH 44106 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)

F 0689 • Level of Harm - Minimal harm or potential for actual harm On 12/15/23 Resident #107's plan of care (POC) and [NAME] were reviewed and updated. • Residents Affected - Few On 12/15/23 the physician ordered grab bars to both sides of bed to assist with turning and repositioning, transfers and to promote safety due to weakness. • Bed Safety Inspection Audits were held 12/15/23, 12/19/23, 12/26/23, 01/02/24, 01/09/24, 01/16/24, and 01/23/24. • On 12/16/23 a re-education was done with STNA#305 about making sure the bed was locked before doing care and about the need to turn a resident toward yourself, not away. This deficiency represents non-compliance investigated under Complaint Number OH00150400. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365033 If continuation sheet Page 3 of 3