Inspection·November 25, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few the ground. The daughter yelled out audibly when the event occurred which alerted surrounding staff. Immediately nursing and therapy staff responded to the scene. Resident #63 was found on the ground lying on his left side in front of the facility with an empty wheelchair behind the resident. The wheelchair accessible van was present with the side door open, and the inclined ramp was down. Only the resident, Resident #63's daughter and the transportation driver were at the scene when first responders arrived. Immediate assessment of the resident resulted in Resident #63's complaints of back pain and first aid was provided to areas of skin impairment. Emergency Medical Services (EMS) quickly arrived on the scene and took over care. The resident was transferred onto a gurney by EMTs and taken to the hospital. The hospital completed multiple computerized tomography (CT) scans which confirmed Resident #63's history of a chronic subdural hematoma and the presence of an acute re-bleed.Additional review of the fall investigation dated 09/10/25 revealed staff witness statements, first-hand account by the Director of Nursing (DON) and verbal witness reports from the resident and his daughter were utilized for investigation and root cause analysis. Follow-up intervention and information included the van driver was immediately removed from the transport assignment. Statements were collected from witnesses. The van driver's past completed education was reviewed. Thereafter, the van driver and all other facility drivers were provided with new education on safe wheelchair transport. Upon Resident #63's return from the hospital, PT and OT were ordered for evaluation and treatment for safe transport. Therapy recommended to only use the bus for wheelchair transport needs and no longer use the wheelchair accessible van with the side ramp which was used during the incident.Review of the witness statement written 09/10/25 from Transportation Driver #204 stated she tried to take Resident #63 and the silver bars on the back of the wheelchair were too low and stopped the chair from going up. She turned the resident around and tried to pull him up. The resident leaned forward and fell out of the chair. He landed on his side.Review of the witness statement written 09/10/25 by the DON revealed the DONresponded to the outside front entrance of the facility on 9/10/25 after hearing someone yelling outside He fell! Oh my God. He fell. Resident #63 was noted laying on the concrete slightly on his left side. An empty wheelchair was behind him. The leg rests were on the bench to the left ofthe scene. Oxygen was on via nasal canula and connected to concentrator on back of the wheelchair. Resident #63's daughter standing to the resident's right side. Transport van with a right-side entry ramp was open behind the resident. Transportation Driver #204 was present and holding a cell phone. Multiple first responders arrived at the same time including employees from therapy, campus security and the front offices of the facility. On initial assessment Resident #63 was alert and responsive. Skin tears with active bleeding noted to left elbow and fingers on both hands. The charge nurse was notified. First aid supplies and vital signs equipment was obtained. Resident #63 complained of back pain from 'laying on the concrete'. The resident denied neck pain. Range of motion (ROM) was within normal limits. A towel for padding was placed under the resident's lower back for comfort. First aid to the skin tears was initiated. EMS responded while vital signs were being taken charge by the nurse, and EMS took over the assessment and treatment. Resident #63 was alert and oriented to person, place, and time, answering EMS responders' questions to time and place correctly. Resident #63 was transferred to the gurney by EMS and was taken to the emergency room (ER) for evaluation and treatment. Transfer paperwork was gathered and provided to EMS by the unit manager. Resident #63 remained alert and conversive through the interaction. The resident's daughter remained at the scene after Resident #63 was placed into the EMS ambulance. One to one was provided with the resident's daughter to offer support and obtain details of what she witnessed. The resident's daughter stated she saw her dad fall out of the wheelchair while the transporter was attempting to roll him in his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365581 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 365581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Living Breckenridge Village 36855 Ridge Rd Willoughby, OH 44094 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 wheelchair up the wheelchair ramp into the van. The resident's daughter stated Transportation Driver #204 first attempted to load the wheelchair into the van by approaching straight on and pushing him forward but the leg rests and metal pieces on the wheelchair prevented entry. The daughter stated Transportation Driver #204 then removed the wheelchair leg rests to try again. Resident #63's daughter stated the transporter then attempted to pull the resident backwards up the ramp and that is when he fell forward out of the wheelchair and she yelled out for help.Review of the witness statement written 09/10/25 from Business Office Coordinator (BOM) #214 revealed she heard a woman's scream, looked out the windows of the office, which she could see the outside area of the front door. I saw a man falling out of a wheelchair onto the ground. It appeared that he was being transferred into a vehicle from our transportation department. I responded immediately to the outside area of the front door. As I passed Receptionist #212, I asked her to call security. When I went through front doors to the outside area of the entrance, the elderly man was lying on his left side, his daughter was on his left side. Transportation Driver #204 was standing at the head of the resident about a foot behind. PT #215 was assessing the resident, when the DON and Admissions Coordinator #216 came out to assist. The DON went back into the building to obtain a vital signs machine. Resident #63 was asked if he hit his head, and he replied I don't think so but did state his back hurt. There was noticeable blood on the resident's left elbow, and fingers of left hand. The resident was rolled over to his back where a clearer assessment of his arm and hand could be seen. He had a large skin tear that from his elbow to approximately three to four inches up his arm. His fingers also had abrasions. When the DON returned to the scene along with Licensed Practical Nurse (LPN) #206, the DON further assessment was completed. Security Supervisor #217 was also was on the scene. Activities Director #203 was present consoling the daughter.Review of the witness statement written 09/10/25 from Receptionist #212 revealed she did not witness the actual incident.Review of the witness statement written 09/12/25 by PT #215 revealed she did not witness the event. She ran outside when she heard his daughter screaming. When she arrived, he was on the ground. The wheelchair was upright and off to side. She supported his head and assisted him to roll slightly off of his left arm that he reported hurt to be lying on. Resident #63 reported his arm felt better after he was able to get it out from under himself. Someone else brought pillows to support the resident's head. Once his head was supported, she returned to my resident indoors and let the others present take over.Review of the witness statement written09/15/25 by Certified Occupational Therapy Assistant (COTA) #213 revealed she did not witness the fall but heard the screams from the therapy gym. Resident #63 was on the ground next to the ramp, on his left side, alert and bleeding from the left forearm. Therapist, PT #215, was holding his head off the ground. Other people were around or on their way. She went back to therapy gym and got a pillow, a large bolster and a towel and brought them back to Resident #63. She placed the pillow under his head, others rolled Resident #63 onto his back and she placed the bolster under knees and the towel under his bleeding arm. Many people/nurses are around tending to him, so she retreated back to the therapy gym.Review of the witness statement written 09/15/25 from Activities Director #203 heard a loud scream and crash and ran out but did not witness the actual incident.Review of the hospital records for Resident #63's hospital stay from 09/10/25 to 09/13/25 revealed an acute re-bleed of the right frontoparietal subdural hematoma and the bilateral chronic subdural hematoma appeared slightly smaller than the prior exam eleven months ago with no significant global mass effect. Range of motion (ROM) was intact, and the right shoulder x-ray was negative. There was a left elbow skin tear with other superficial injuries.Interview on 11/17/25 at 11:53 A.M. with Resident #63 revealed on 09/10/25 the facility used a different van than usual and a different person loaded him onto the van. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365581 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 365581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Living Breckenridge Village 36855 Ridge Rd Willoughby, OH 44094 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 resident revealed usually the staff pushed him up the ramp face first, but at that time he was pulled up backwards and fell. The resident said he hit his head and scratched and bruised his arm, mostly the elbow. The fall also made his back hurt, so he was taken to the hospital.Interview on 11/17/25 at 2:21 P.M. with Activities Director #203 revealed she saw Resident #63's daughter upset when the bus driver pulled up. The resident's daughter told the driver they had been waiting for an hour. Activities Director #203 did not witness the incident.She was inside the facility when she heard a loud noise from outside. She then went outside and saw Resident #63 lying to the side of the ramp. The DON and another nurse came running out and assessed the resident. Interview on 11/17/25 at 2:45 P.M. with Transportation Driver #204 stated she tried to push Resident #63 up the ramp, but the footrests did not clear the top, so she turned him around and pulled him up backwards. She told the resident to lean back, but instead he leaned forward and rolled out of the wheelchair onto the ground beside the ramp.Interview on 11/17/25 at 3:44 P.M. with Licensed Practical Nurse (LPN) #206 revealed she was assigned to care for Resident #63 on that day (09/10/25). The resident had a dentist appointment, and his daughter was accompanying him. The resident went out to catch the transportation van, and that was the last time she saw him until the daughter came running up after the fall. LPN #206 went outside, and the resident was on the concrete. He was bleeding from his elbow and fingers. LPN #206 saw blood on Resident #63's head. The resident complained of pain on his bottom which he had landed on. The resident's daughter called EMS and they arrived quickly.Interview on 11/17/25 at 4:01 P.M. with the DON revealed on 09/10/25 she heard Resident #63's daughter yelling, He fell. He fell. The resident was lying on ground with the wheelchair behind him. Transportation Driver #204 was in front of the van calling someone. The DON assessed Resident #63 and found the resident was bleeding on his elbow, but not from his head. No open areas were seen on the resident's head. After more people responded, staff tried to bandage the resident's elbow. EMS arrived and took Resident #63 to the hospital. The resident's daughter and the driver reported the resident fell when he was pulled backwards up the ramp. Thereafter, Resident #63 was diagnosed with an area of acute rebleed from the CT scan, and skin injuries.Upon hire, all transportation driver complete training using a computer learning module entitled Lift and Securement Review.The deficient practice was corrected on 09/22/25 when the facility implemented the following corrective actions: -Transportation Driver #204 was immediately removed from the assignment by Transportation Supervisor #210 on 9/10/25 and suspended by Human Resources #207 on 09/12/25.-Beginning 09/11/25, the DON completed observational audits of safe wheelchair transport was completed by the transportation drivers and continued three times weekly for four weeks, and then weekly for three weeks.-On 09/12/25, the Administrator and Transportation Supervisor #210 reviewed additional education and action items. As a result, Transportation Driver #204 received education on safe wheelchair procedures on 9/12/25 by Transportation Supervisor #210 and was permanently removed from future healthcare center transports. All campus drivers were educated on safe wheelchair protocols by Transportation Supervisor #210 by 9/15/25. The results of this meeting and plans of correction were then reviewed with the facility Quality Committee on 9/16/25.-On 09/13/25, Resident #63 was evaluated by therapy services upon return from the hospital for safe transportation which resulted in recommendation to only use the bus for future transports and not to use the van with a side entrance ramp.-By 09/15/25, safe wheelchair education was completed with all facility drivers by Transportation Supervisor #210 which included repeating the computer learning module entitled Lift and Securement Review and additional training titled Transportation Department Wheelchair Procedures which included:1) Must evaluate the wheelchair for proper size for transport vehicle.2) Must push wheelchair in from behind! At all times! Prevent from falling forward.3) If you feel you cannot (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365581 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 365581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Living Breckenridge Village 36855 Ridge Rd Willoughby, OH 44094 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 accommodate safely, you must ask or call for help!4) Under no circumstances should a resident be facing forward on a slope without guidance!5) If process of transporting cannot be done in a safe manner, the driver has the right to refuse.6)The transporter needs to call the office for a final decision.-On 09/16/25, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the incident with the Interdisciplinary Team (IDT) and the Medical Director. The Administrator monitored compliance in a QAPI meeting monthly for three months and then on-going as needed.-On 09/17/25 and 10/02/25, Resident #63 had follow-up medical appointments.-On 09/22/25, a care conference and incident review was held with Resident #63's daughter and son-in-law with the DON, Administrator, and Executive Director.-Social services followed Resident #63 for psychosocial impact and offered support after returning from the hospital on [DATE]. -Resident #63's skin tear was followed by nursing staff and Wound Nurse #211 from Encore Wound Group weekly after return from the hospital on [DATE] and was healed on 10/09/25.-On 09/22/25 additional education was completed by Transportation Driver #204 using computer learning entitled Lift and Securement Review which was specific to the incident. Transportation driver #204 no longer transports facility residents. -Additional Driver education on Lift and Securement was then completed. Transportation Driver #204 was permanently removed from future transports for nursing home residents. Relias transcript of completed additional Relias training attached upon return from leave.-On 10/22/25, the Administrator reviewed results of the audits and investigation at the quarterly Quality Committee meeting.This deficiency represents non-compliance investigated under Complaint Number 2621195. Event ID: Facility ID: 365581 If continuation sheet Page 5 of 5