Inspection·March 7, 2024

F 0689 Level of Harm - Actual harm Residents Affected - Few Licensed Practical Nurse (LPN) #35 obtained an order from the Nurse Practitioner (NP) for a left shoulder stat (immediate) Xray. The order was placed, and Resident #28's daughter was made aware. The Director of Nursing (DON) was made aware. Review of Resident #28's progress note dated 02/27/24 at 4:07 P.M., revealed Resident #28's family requested Resident #28 be sent to the emergency room (ER) for evaluation and treatment of the shoulder. Emergency medical services (EMS) were called, and the appropriate paperwork was sent with the resident. Resident #28 was resting comfortably in her room while waiting for mobile Xray. Resident #28 was given Tylenol for pain and an order was obtained for as needed (PRN) pain medication. Review of Resident #28's progress note dated 02/27/24 at 10:35 P.M., revealed Resident #28 returned from the hospital with a diagnosis of closed fracture of the left shoulder. A sling was placed. The physician and DON were notified. Resident #28 denied pain and was resting. Review of Resident #28's hospital after visit summary dated 02/27/24, revealed Resident #28 was seen for a shoulder injury and had a diagnosis of closed fracture of left shoulder initial encounter. Further review of Resident #28's after visit summary, revealed Resident #28 complained of left shoulder pain after ambulating with an STNA at the facility. Resident #28 was getting up and the STNA assisted under her arm and Resident #28 felt a pop and pain. Resident #28 was administered Fentanyl citrate (narcotic pain medication) injectable syringe 50 micrograms (mcg) on 02/27/24 at 4:49 P.M. and Norco 5-325 milligrams (mgs) at 6:21 P.M. at the hospital. Review of STNA #500's investigation witness statement dated 02/28/24, revealed STNA #500 was assisting Resident #28 with getting out of bed for the day and to her wheelchair at approximately 10:30 A.M. STNA #500 was transferring Resident #28 out of bed by herself using a gait belt to stand and pivot her to her wheelchair. Resident #28's wheelchair was to the right side of the bed and the wheelchair locks were in the back of the wheelchair. When STNA #500 went to put the break down it must not have been all the way locked. When STNA #500 went to transfer Resident #28, the wheelchair slid backwards, and the resident started to slide down. STNA #500's gait belt slid upwards, and Resident #28 had her arms over STNA #500's arms. Due to the Resident #28's left sided weakness; the resident did not have much control over her left side. Resident #28's shoulder made contact with her wheelchair, and Resident #28 complained of pain in her left shoulder. After the resident was securely in her wheelchair, STNA #500 went to notify her nurse of the resident's complaint of pain. STNA #500 saw Physical Therapist (PT) #900 who was standing at the nurse's station and asked him to come see Resident #28. PT #900 came to look at her and evaluated her arm. PT #900 moved her arm in which she had some mild complaints of pain but not tearful, grimacing, or displaying any other symptoms of pain with movement. STNA #500 then took Resident #28 out to the nurse's station and notified LPN #35 who also evaluated Resident #28's arm. At no point was Resident #28 on the floor and STNA #500 would not have been able to get her off the floor by herself if she had fallen. STNA #500 would not have transferred her off the floor if she did fall and she would have immediately notified the nurse prior to moving her. Upon the nurse completing Resident #28's evaluation, the resident went to the dining room and ate lunch and stayed and played bingo. The interview was signed by STNA #500. Review of Resident #28's February 2024 Medication Administration Record (MAR) dated 02/28/24, revealed Resident #28 was ordered Norco oral tablet 5-325 mgs give on tablet by mouth every six hours PRN (as needed) for left shoulder pain for five days. Resident #28 received her PRN Norco oral tablet 5-325 mgs on 02/28/24 at 4:15 A.M. with a pain level of a five, on 02/28/24 at 12:21 P.M. with a pain level of a four, and on 02/29/24 at 8:20 P.M. with a pain level of a seven. There was no documentation on the MAR indicating that Resident #28 was administered Tylenol 325 mg on 02/27/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365187 If continuation sheet Page 2 of 5 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 365187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Xenia Health and Rehab 126 Wilson Drive Xenia, OH 45385 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 Review of the facility's February 2024 incident and accident log revealed Resident #28 fell on [DATE]. Level of Harm - Actual harm Review of Resident #28's March 2024 Medication Administration Record (MAR) revealed Resident #28 received her PRN Norco oral tablet 5-325 mgs on 03/01/24 at 5:55 P.M. with a pain level of a five, and on 03/03/24 at 5:30 P.M. with a pain level of a five. Further review of the MAR dated 02/27/24, revealed Resident #28 was ordered Tramadol oral tablet 50 mg every six hours PRN for left shoulder pain. Resident #28 received her Tramadol 50 mgs on 03/06/24 at 10:13 P.M. with a pain level of an eight. Residents Affected - Few Interview with LPN #35 on 03/07/24 at 8:50 A.M., revealed she was at the facility passing medications in the morning on 02/27/24 when STNA #500 came up to her medication cart with Resident #28. LPN #35 reported STNA #500 informed her that she was getting Resident #28 dressed when she heard her shoulder pop. LPN #35 stated Resident #28 had pain in her shoulder and LPN #35 informed the physician and got an order for pain medication and an Xray. LPN #35 reported Resident #28 was sent out to the hospital because the Xray company did not come to the facility by 3:00 P.M. LPN #35 stated Resident #28 was up in her wheelchair and went to activities prior to going out to the hospital and the Tylenol that was given seemed to help Resident #28 with her pain. LPN #35 stated Resident #28 informed her after she returned from the hospital, that STNA #500 dropped her while transferring her without any assistance. LPN #35 also reported Resident #28 informed her that STNA #500 was not using a required Hoyer lift or gait belt at the time of the fall. LPN #35 stated Resident #28 required a Hoyer or mechanical lift and two-person assistance for transfers at the time of the incident. Interview with Resident #28 on 03/07/24 at 9:06 A.M., revealed she broke her left shoulder when a nurse dropped her on the floor. Resident #28 stated she could not remember the nurse's name but stated the incident occurred approximately four weeks ago around 10:00 A.M. Resident #28 stated the nurse was trying to transfer her from the bed to the wheelchair when she was dropped to the floor. Resident #28 stated the nurse was not using a Hoyer lift or gait belt and there were not any additional staff members present with the nurse at the time of the incident. Resident #28 reported the nurse tried to lift her again after the fall and she fell again, hitting her head. Resident #28 stated that she had terrible pain in her left shoulder after the incident and she was sent out to the hospital that night. Resident #28 reported she had always used a Hoyer lift with two-person assistance for transfers. Interview with the Administrator and Regional Registered Nurse (RN) #950 on 03/07/24 at 11:03 A.M., revealed Resident #28 fractured her left shoulder after STNA #500 transferred Resident #28 using one person assistance on 02/27/24. Regional RN #950 verified Resident #28 required a Hoyer lift with two-person assistance for transfers. Regional RN #950 also confirmed she was care planned to use a Hoyer lift with two-person assistance on 02/27/24. Attempted to call STNA #500 on 03/07/24 at 11:27 A.M. with no response. Interview with Regional RN #950 on 03/07/24 at 11:58 A.M. revealed she was not able to locate STNA #500's initial education on transfers provided upon hire. Interview with [NAME] President of Clinical Services (VPCS) #700 on 03/07/24 at 12:14 P.M. revealed VPCS #700 interviewed STNA #500 regarding the incident on 02/28/24. STNA #500 stated she went into Resident #28's room and was getting Resident #28 up for lunch. VPCS #700 reported STNA #500 told her she used a gait belt and went to transfer Resident #28 into her wheelchair when the wheelchair (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365187 If continuation sheet Page 3 of 5 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 365187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Xenia Health and Rehab 126 Wilson Drive Xenia, OH 45385 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 - Actual harm Residents Affected - Few moved backwards. VPCS #700 stated STNA #500 informed her that she pulled upon Resident #28 to put her into the wheelchair and Resident #28's left shoulder made contact with the wheelchair and she heard a pop. VPCS #700 reported Resident #28 stated she had pain after the transfer and STNA #500 asked PT #900 to come into the room to assess Resident #28. After PT #900 assessed Resident #28, STNA #500 told LPN #35 about the incident. VPCS #700 also stated she interviewed Resident #28 on 02/28/24 and Resident #28 stated that she was dropped on 02/27/24. Resident #28 stated an STNA with red hair which matched the description of STNA #500 who was transferring her from the bed to the wheelchair when she fell on the ground. VPCS #700 stated she asked Resident #28 how she got up and she stated STNA #500 used all her strength to get her up and in the wheelchair but then she later stated that someone with long blonde hair with white pants helped her get up. VPCS #700 reported Resident #28 stated she felt her arm crack at the time of the incident but later stated she heard a pop. Resident #28 told VPCS #700 that she did not receive any pain medication but later stated she was given Tylenol. VPCS #700 stated Resident #28 told her that she went to dining room for lunch but did not stay for activities because she was in too much pain, but activities staff told VPCS #700 that Resident #28 stayed for activities and did not appear in pain, but she was talking about the incident. VPCS #700 confirmed Resident #28's Tylenol received on 02/27/24 was not marked as given on the MAR. Telephone interview with PT #900 on 03/07/24 at 12:23 P.M., revealed he was at the nurse's station on 02/27/24 when STNA #500 stuck her head out of Resident #28's room and stated she needed PT #900 to come to Resident #28's room immediately. PT #900 stated STNA #500 told her that she was doing a transfer with Resident #28 when her shoulder popped, and the resident was complaining of a lot of pain. PT #900 reported Resident #28 was in her wheelchair when he entered the room. PT #900 stated he left the room and went back to the nurse's station and STNA #500 took Resident #28 out to the nurse's station and again stated Resident #28 was in a lot of pain. PT #900 stated Resident #28 had a lot of pain in her left arm and she reported her pain level was a nine out of ten which was not Resident #28's baseline. PT #900 reported LPN #35 offered Resident #28 Tylenol and PT #900 placed a blanket under the resident's elbow to assist with relieving Resident #28's pain. PT #900 stated Resident #28 was taken down to the dining room by staff and LPN #35 called the physician and an Xray was ordered. PT #900 reported he had not worked with Resident #28 in two months, and he was not sure what level of assistance she required on her care plan for transfers. Review of STNA #500's personnel file revealed STNA #500 was hired by the facility on 11/11/23. Further review of STNA #500's personnel file revealed no documentation that STNA #500 was educated on resident transfers upon hire. Review of the undated facility's safe resident handling and transfers policy revealed the facility will ensure that residents are handled and transferred safely to prevent or minimize risks for injury. The policy also stated resident lifting and transferring will be performed according to the resident's individual plan of care. As a result of the incident, the facility took the following actions to correct the deficient practice as of 03/01/24: • On 02/28/24, STNA #500 was educated on referring to the [NAME] (care plan) to verify the appropriate method and number of staff required to transfer a resident prior to transferring a resident and the safe handling and transfers policy by the DON. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365187 If continuation sheet Page 4 of 5 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 365187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Xenia Health and Rehab 126 Wilson Drive Xenia, OH 45385 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 - Actual harm On 02/28/24, all STNAs were educated on referring to the [NAME] to verify the appropriate method and number of staff required to transfer a resident prior to transferring a resident and the safe handling and transfers policy by the DON. Residents Affected - Few • On 02/28/24, the VPCS #700 completed a care plan transfer audit of all residents and their transfer status. No issues were discovered. • On 02/28/24, the facility-initiated audits on the appropriate number of staff used for transfers and the appropriate transfer method. The audits were to occur daily for 14 days and then three days per week for 14 days. Audits were completed 02/28/24, 02/29/24, 03/04/24 and 03/06/24 with no issues discovered. • On 02/28/23, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held regarding direct care staff not following the plan of care for transfers. The Administrator, Regional Director of Operations (RDO) #600, VPCS #700, the DON and Medical Director #860 were present at the meeting. • On 03/01/24, all nurses were educated on referring to the [NAME] to verify the appropriate method and number of staff required to transfer a resident prior to transferring a resident and the safe handling and transfers policy by VPCS #700. • On 03/07/24, a review of the Inservice records revealed all staff members were in-serviced referring to the [NAME] to verify the appropriate method and number of staff required to transfer a resident prior to transferring a resident and the safe handling and transfers policy. • A review of the audits of resident transfers completed on 02/28/24, 02/29/24, 03/04/24 and 03/06/24, revealed all transfers were completed using the appropriate level of assistance with no resident injuries noted. There were no other residents who sustained injuries from transfers. This deficiency represents non-compliance investigated under Complaint Number OH00151717. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365187 If continuation sheet Page 5 of 5