Inspection·February 26, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Telephone interview on 02/26/24 at 12:08 P.M. with Licensed Practical Nurse (LPN) #201 confirmed she completed the skin assessment on Resident #11 after he was found outside the facility on 01/11/24. LPN #201 did not see him outside, and could not remember who brought Resident #11 back into the facility. LPN #201 notified the physician and DON and completed a physical and mental assessment on Resident #11 who suffered no injuries from this incident. LPN #201 could not state how long Resident #11 was outside. Residents Affected - Few Interview on 02/26/24 at 4:29 P.M. with the DON revealed she did not know how long Resident #11 was outside on 01/11/24. The DON did not know who brought Resident #11 in from outside. The DON stated LPN #201 could be interviewed to determine who brought Resident #11 inside. The DON confirmed the facility did not investigate how Resident #11 got outside on 01/11/24, how long he was outside, where he was in the parking lot, or who brought him back into the facility. Review of the facility's policy titled Elopements and Wandering Residents, revised 12/18/23, revealed no guidance regarding investigating the cause or circumstances of the wandering or elopement incident. 2. Review of the current care plan for Resident #11 revealed he was at risk for falls with multiple interventions, including a fall mat, perimeter mattress, and low bed. Review of the incident log dated 12/01/23 through 02/18/24 revealed Resident #11 fell, resulting in a fracture on 01/17/24. Further review revealed Resident #11 fell and had no injuries on 12/04/23, 12/13/23, 01/09/24, 01/12/24, 01/22/24, 01/24/24, 01/28/24, 01/31/24, 02/04/24, 02/06/24, and 02/14/24. Review of the incident report dated 12/04/23 revealed Resident #11 was found face down on the floor between the chair and the bed. An intervention was developed to put a fall mat next to the bed and lower the bed to the floor. Review of a progress note dated 12/05/23 revealed the interdisciplinary team (IDT) reviewed incident and new intervention for low bed and mat at side. The incident report and progress note did not state whether Resident #11 was in the bed or the chair prior to the fall. Review of the incident report dated 12/13/23 at 9:30 P.M. revealed Resident #11 was found on the floor in front of his recliner. Resident #11 stated he was trying to get up to go to bed. An intervention was developed to place call for assistance signs. Review of a progress note dated 12/15/23 revealed the IDT reviewed and new intervention for call for assistance sign. The incident report and progress note did not indicate whether Resident #11 had his call light within reach at the time of the fall. Review of the incident report dated 01/12/24 revealed Resident #11 was seated on the floor next to his bed in a wet brief. Resident #11 stated he was trying to get up, but could provide no additional information. Review of a progress note dated 01/16/24 revealed the IDT reviewed and continue low bed with mat at side. The incident report and progress note did not include if the fall mat and low bed were in place at the time of the fall. Review of the incident report dated 01/17/24 revealed Resident #11 was found with his head on the floor in his doorway. Resident #11 was unable to provide details regarding the fall. Resident #11 was assessed to be oriented to person, place and time, but not to situation. The physical assessment revealed a skin tear to his left forearm. Resident #11 was brought to bed by three staff. Review of the progress notes dated 01/17/24 and 01/18/24 revealed Resident #11 was observed on 01/17/24 at 7:10 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365458 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 365458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Haven Health Care Senior Living & Rehab 1965 E Gypsy Lane Rd Bowling Green, OH 43402 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 P.M. with his head on the floor in his doorway. Resident #11 was assessed for injuries, including a skin tear to his left forearm. Resident #11 reported pain to his hip, and was transported to the local hospital by Emergency Medical Services (EMS). The incident report and progress note not show the facility investigated the cause of the fall, the whereabouts of the fall mat, or what Resident #11 was doing prior to the fall. Residents Affected - Few Review of the hospital records for Resident #11 dated 01/17/24 revealed Resident #11 was identified with a left hip fracture, but due to previous hardware already in the vicinity, no operation was performed. Interview on 02/26/24 at 3:04 P.M. with the DON regarding fall investigations revealed the facility discussed falls during an IDT meeting and reviewed the circumstances, developed interventions, and updated the care plan as needed. The DON stated the evidence of their investigation into each fall was an IDT note in each resident's record. Continued interview with the DON confirmed all fall investigations were verbal and no additional documentation regarding their investigation was available. Further interview with the DON and concurrent review of the incident report for the fall on 01/12/24 revealed Resident #11 was found seated on the floor next to his bed. The DON was unable to verify whether the fall mat was in place. The DON directed Assistant Director of Nursing (ADON) #501 to interview LPN #201, who documented the fall on 01/12/24 and was working in the facility during the interview, and have LPN #201 write a statement regarding whether Resident #11 was on the fall mat when LPN #201 observed him on 01/12/24. On 02/26/24 at approximately 3:25 P.M., ADON #501 provided a statement, handwritten by LPN #201, dated 02/26/24. Review of the statement revealed Resident #11 was found on the floor next to his bed on 01/12/24 at 6:10 P.M. Resident #11 was seated on a floormat, and had no injuries. Further interview on 02/26/24 at 3:40 P.M. with the DON regarding the fall incident report for Resident #11 dated 01/17/24 at 7:10 P.M., resulting in a fracture, revealed the facility could provide no evidence they investigated the cause of the fall, the whereabouts of the fall mat, or what Resident #11 was doing prior to the fall. Interview on 02/26/24 at 4:29 P.M. with the DON, and concurrent review of a fall incident report for Resident #11 dated 12/04/23 at 3:20 P.M. revealed Resident #11 was found between the bed and the chair. The intervention was implemented was a fall mat and low bed. Interview with the DON revealed she could not verify whether Resident #11 was in the bed or the chair prior to the fall. The DON stated she would have to follow up with the nurse who documented the fall to determine where Resident #11 was prior to the fall. Continued interview at that time with the DON, and concurrent review of the fall incident report for Resident #11 dated 12/13/23 revealed the new intervention was to hang call for assistance signs. The DON could not verify whether Resident #11 had his call light within reach at the time of the fall. The DON stated call lights should be in reach, and staff would only document by exception; therefore, she would expect the call light was within reach. Review of the facility policy titled Fall Guidelines, revised 05/11/23, revealed the IDT would seek to identify and document resident risk factors for falls. Additionally, a plan would be developed after the information was gathered regarding a fall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365458 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 365458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Haven Health Care Senior Living & Rehab 1965 E Gypsy Lane Rd Bowling Green, OH 43402 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 This deficiency represents non-compliance investigated under Complaint Number OH00150753. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365458 If continuation sheet Page 4 of 4