Health inspection·October 15, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few 10:17 A.M. revealed Resident #10 had a history of a cardiovascular accident (stroke) presented to a local emergency department (ED) as a level 2 trauma after falling out of his wheelchair and striking his head when in transport as the vehicle came to a sudden stop. He denied loss of consciousness. Resident #10 was on blood thinners. He had an abrasion and slight swelling along his right eye. Resident #10 endorsed low back pain and right arm pain. All imaging tests were negative for acute fractures, however, Resident #10 was having significant lower back pain. He was admitted for pain control and ongoing monitoring. Review of the hospital Trauma Physician's progress notes, dated 08/25/25 at 8:34 P.M. revealed Resident #10 was in a wheelchair strapped to a van when it came to a sudden stop. The strap broke and he fell out of his chair and hit his head. Resident #10 complained of significant back pain and had an abrasion and slight swelling to the right side of his face. Computed tomography (CT) scan and x-ray imaging were negative but Resident #10 was being admitted to observation for pain control and physical and occupational therapy. The note referenced the resident was admitted with risk variables including coagulation defect, chronic fatigue and reduced mobility. Review of the nursing progress notes dated 08/25/25 revealed Resident #10 was out to a doctor's appointment. The notes revealed no indication of an accident or that Resident #10 was admitted to the hospital until 08/26/25 at 12:00 A.M. when the hospital called the floor nurse to verify the resident's information and the equipment he routinely used. Review of a summary of the incident dated 08/25/25, authored by the Administrator, revealed TS #101 had reported and described the incident to her. TS #101 stated the resident was utilizing his own wheelchair seatbelt, so the vehicle's seatbelt was not needed. The summary referenced following the incident, the Administrator provided re-education to all personnel qualified to drive the facility's van regarding proper utilization of Q'Straints (a fixed wheelchair securement system installed in the transport van) and seatbelt use. Review of a witness statement dated 08/28/25, authored by the Administrator, revealed the Administrator interviewed Resident #10 who stated he was buckled into his wheelchair with a seatbelt, but could not recall being strapped to the floor. He tipped forward with the wheelchair when a car cut TS #101 off and she had to slam on the brakes to avoid hitting another car. The statement concluded that the resident felt safe and well-cared for. The statement did not contain Resident #10's signature or initials. Review of Resident #10's progress notes revealed on 09/02/25, the resident complained of lower back and neck pain and was transferred to a local hospital by EMS. Review of Resident #10's Emergency Department Provider Notes, dated 09/02/25 at 3:36 P.M. revealed the resident was seen at a local hospital for a chief complaint of back and neck pain. Resident #10 reported he had a recent injury when his wheelchair was not secured correctly in a van, the driver slammed on the brakes, and his wheelchair went forward and landed on top of him. The note references Resident #10's family requested a repeat CT scan. Review of the imaging completed in the emergency department revealed a clinical impression of post-concussive syndrome, cervical (neck) pain, and chronic lower back pain. Resident #10 was discharged from the local hospital back to the facility on [DATE] at 5:20 P.M. During an interview on 10/07/25, at 2:00 P.M. the Administrator and the Interim Director of Nursing (DON) confirmed Resident #10 was being transported to an outside appointment on 08/25/25 in the facility van with (TS) #101 driving. During the transport, TS #101 had to slam on her brakes to avoid an accident. When she slammed on the brakes, Resident #10's electric wheelchair moved, and he and the chair moved forward, and the resident landed on the floor of the van directly behind the driver's seat. Resident #10 and his chair tipped over, landing him on his right side while still attached to his electric wheelchair when the van came to a complete stop. The police, firemen and emergency medical services (EMS) arrived, and Resident #10 was transported to a local hospital. A follow up interview on 10/07/25, at 2:30 P.M. with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 2 of 4 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 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 the Administrator stated Maintenance Director (MD) #123, TS #101, and Director of Activities #127 were trained to operate the bus. The Administrator stated the facility does not have any formal training policy or documentation confirming Maintenance Director (MD) #123, TS #101, and Director of Activities #127 were educated on the operation of the van and how to operate the van's lift and the four-point wheelchair securement system. The Administrator stated that MD #123 had demonstrated how to operate the van's systems including the chair lift and the four-point wheelchair securement system.During an interview on 10/07/25, at 3:25 P.M., MD #123 stated he had experience transporting residents to and from the facility for outside appointments. Prior to the incident on 8/25/25, he trained the two drivers from the facility but could not provide any documentation from the training such as a check-off list or topics covered during training. MD #123 shared he showed them how to operate the van, its mechanics, and the four-point wheelchair securement system. MD #123 stated he had accompanied them on transports with residents during a two-week period. TS #101 was trained by MD #123. When the incident with Resident #10 occurred on 08/25/25, he accompanied the Administrator to the van that was in a parking lot. He met with TS #101 who confirmed she secured Resident #10's electric wheelchair with the four-point wheelchair securement system. He drove the van back to the facility and noted Resident #10's chair was on the right side of the van during the transport; the seat belt provided with and attached to the electric chair was cut by the EMS personnel. He tested all four of the QRT-360 retractors (that secured Resident #10's electric wheelchair to the van floor) and they were working properly. It was his belief that the shoulder and belt restraint was not being used in the van during transport and could have hit the red release lever during transport; when the van stopped abruptly it released the tension of the left restraint webbing, allowing the wheelchair to move forward. He could not confirm the wheelchair was attached to the floor when the incident occurred. He did not report the incident to a Q'Straint authorized dealer after he believed the red release button faulted, causing the chair to move forward. During an interview on 10/08/25, at 8:23 A.M., Resident #10 stated he was on his way to a doctor's visit on 08/25/25. A female staff member was driving when she slammed on the van brakes. He was in his wheelchair and went forward, close to the driver's seat, where his wheelchair tipped over. Resident #10 stated he landed on the floor on his right side where he hit his face, head and arms. Resident #10 said his wheelchair had not been strapped into the floor of the van before transport. An ambulance, police officer, and fire truck arrived at the scene. He was transported by EMS to a local hospital where he was admitted for a few days. During an interview on 10/08/25, at 8:51 A.M., TS #101 stated she was driving on 08/25/25 to take Resident #10 to an outside appointment. She escorted Resident #10 to the facility van. She dropped the van lift to the driveway to allow Resident #10 to drive himself onto the lift. She belted him onto the lift; his wheelchair was turned off. She turned on the lift's power to lift him to the van floor. Resident #10 turned on the power of his chair and parked his chair to the designated area in the back of the van to allow her to secure Resident #10 and his wheelchair to the floor prior to leaving. Resident #10's wheelchair has a designated area for each QRT-360 Retractor System (Q'Straint ) to hook onto. She secured each Q'Straint to the designated areas of the wheelchair, two in the back and two in the front of the wheelchair. Because Resident #10 had his wheelchair seatbelt fastened, she did not place the Shoulder Belt across Resident #10. While transporting Resident #10 to the appointment she had to slam on the brakes to avoid hitting the car in front of her who had suddenly slammed on their brakes. The van came to a sudden stop, jolting her and the resident. She was wearing a seatbelt and was not injured. However, the resident's wheelchair and the resident slid up in the van directly behind the driver seat, the wheelchair tipped, and Resident #10 and his wheelchair landed on the floor on his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365351 If continuation sheet Page 3 of 4 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 365351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Signature Healthcare of Galion 935 Rosewood Dr Galion, OH 44833 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 FORM CMS-2567 (02/99) Previous Versions Obsolete right side. TS #101 stated she called 911. The local police, fire department, and EMS arrived. EMS removed Resident #10 from his wheelchair by cutting his seatbelt and placed him onto a stretcher and transported him to a local hospital. TS #101 started the van and parked it in a local grocery store parking lot and called the facility's Administrator. She could not recall if the wheelchair was still locked to the van floor when she came to a stop and saw it in the van tipped over and close to her seat. Review of Resident #10's Quantum Q6 Edge H.D. Power Chair owner's manual dated 02/2020, page 27, revealed the Positioning Belt on the chair is designed for the operator's comfort. It is designed to support the operator so that he/she does not slide down or forward in the seat. The positioning belt is not designed for use as a restraining device. The manual has a warning label indicating: the positioning belt is not designed for use as a seatbelt in a motor vehicle. Review of the Use and Care Manual QRT-360 4-Point Wheelchair Securement System Complaint Shoulder and Pelvic Belt Restraint must go across occupant's shoulder and pelvis (lap) and not be worn twisted or held away from the occupant's body by wheelchair components. We recommend using both a pelvic and shoulder belt together and not individually since it will compromise the performance system. The system must be regularly inspected, cleaned and maintained. All damage and defects must be reported to a Q'Straint authorized dealer. This deficiency represents non-compliance investigated under Complaint Number 2635799. Event ID: Facility ID: 365351 If continuation sheet Page 4 of 4