Health inspection·December 5, 2023

F 0689 assist of two staff. Level of Harm - Actual harm Review of the nursing note dated 10/30/23 timed 12:26 P.M. revealed at 10:58 A.M., the nurse was told by an STNA that Resident #58 had fallen out of the Hoyer pad onto the floor during transfer. Resident #58 was observed lying face down on the floor with his upper abdomen and legs across the legs of the Hoyer lift. The Director of Nursing (DON) and Administrator were notified. The STNA stated Resident #58 hit his head on the nightstand. No bleeding was observed. The Nurse practitioner (NP) was notified at 11:01 A.M. of the fall and Emergency Medical Services (911) was called at 11:05 A.M. Red marks were observed across upper abdomen area and left knee. Resident #58 was lifted off the floor onto the emergency department gurney. Resident #58 left the facility at 11:15 A.M. Residents Affected - Few Review of an incident report dated 10/30/23 timed 11:00 A.M. revealed at 10:58 A.M., the nurse was told by a State Tested Nurse Aide (STNA) that Resident #58 had fallen out of the Hoyer pad onto the floor during transfer. Resident #58 was observed lying face down on the floor with his upper abdomen and legs across the legs of the Hoyer lift. The STNA stated Resident #58 hit his head on the nightstand. No bleeding was observed. Resident #58 was alert and oriented to person, situation, place and time. Resident #58 rated pain to his right cheek and right shoulder a 10 out of 10 (zero being no pain and 10 being severe). There were red marks to his upper abdomen and left knee. Review of the weights/vitals tab in the electronic medical record revealed Resident #58 rated his pain at a 10 out of 10 on 10/30/23 at 12:13 P.M. Review of the advanced pain and vitals only note dated 10/30/23 timed 12:28 P.M. revealed Resident #58 had vocal complaints of pain to his right anterior shoulder with a pain score of six out of 10. Review of the Emergency Medical Services (EMS) run report dated 10/30/23 revealed EMS were dispatched to the facility for a male who fell. Upon arrival, Resident #58 was lying on the base of the Hoyer lift next to his bed. Staff stated that resident fell from the lift pad. Resident #58 was lying prone and was complaining of right shoulder pain and pain on the right side of his face. Resident #58 was alert and oriented times four spheres (person, time, place and situation). Resident #58 was slightly lifted to move the Hoyer lift out from underneath him. Resident #58 was rolled onto his back on a sheet and lifted off the ground to the cot and secured. The EMS report indicated Resident #58 was on blood thinner medication and hit his face when he fell. Resident #58 had notable injuries and continued to complain of right shoulder pain when moved. Review of the hospital emergency physician note dated 10/30/23 revealed Resident #58 presented with a fall. Resident #58 was being lifted with new sling and Hoyer lift and resident fell out of sling landing on face and right shoulder. Resident #58, a [AGE] year old male, presented to the emergency room with chief complaint of face pain. Resident #58 reported that he was on a Hoyer lift where he was accidentally dropped. Resident #58 was able to move his right shoulder but did complain of some pain. X-rays were negative. The plan was to discharge the resident back to the nursing home. The diagnosis was closed head injury. Review of the nursing note dated 10/30/23 timed 7:02 P.M. revealed the nurse called the hospital emergency department for an update. Resident #58 would be coming back to the facility. The hospital nurse stated all x-rays were negative (head, right arm and shoulder). Review of the witness statement dated 10/30/23 authored by STNA #8 revealed, we got the sling hooked up on the Hoyer, raised Resident #58 up over the bed when I started to move the resident in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 2 of 7 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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 Hoyer. The other aide was walking around the bed to come to assist me and before she made it there, Resident #58 fell over to the right and slipped out of the side of the sling falling face down. Level of Harm - Actual harm Residents Affected - Few Review of the witness statement dated 10/30/23 authored by STNA #9 revealed, we got the sling hooked up on the Hoyer then raised Resident #58 up over the bed. The other aide then started to move Resident #58 in the Hoyer while I was walking around bed to assist her. Before I made it there, Resident #58 fell over to the right, slipped out the side of the sling falling face down. Review of the nursing note dated 10/31/23 timed 3:24 P.M. revealed Resident #58 had complaints of right shoulder pain. It was explained to Resident #58 the CT scan was negative. Resident #58 refused ice and heat. the NP was notified and new order received for Voltaren Gel (a topical medicated gel for muscle and joint pain) to the right shoulder every six hours for pain. Review of the late entry nursing note created 11/01/23, effective for 10/31/23 revealed an interdisciplinary team note indicating the fall on 10/30/23 was reviewed with an intervention for a new Hoyer sling. Review of the occupational therapy (OT) evaluation dated 11/01/23 revealed Resident #58 had a recent fall from Hoyer lift during staff transfer and now complained of right shoulder pain, decreased range of motion (ROM) and decreased functional use. Resident #58 reported pain of eight out of 10, was unable to operate joystick of wheelchair with right hand and had notable loss of ROM and strength in right upper extremity (RUE). Resident #58 referred to OT services to decrease pain in RUE and facilitate functional use of RUE and return to prior level of function. Review of the nurse practitioner (NP) progress note dated 11/01/23 revealed Resident #58 had a chief complaint of right shoulder pain. Resident #58 had a fall and was sent to the emergency department and x-rays were okay including scan to brain since on blood thinners. Resident #58 still complained of shoulder pain and was working with therapy despite pain medications ordered. He had no neurological changes and no vision changes or headaches from hitting head. Denied nausea and vomiting. Resident #58 appeared in mild moderate acute distress (shoulder pain). Unable to do good passive ROM to right shoulder due to pain. X-rays and scans were negative at hospital. On as needed pain medications. The note indicated Lidocaine patch (a medicated patch used to relieve the pain) to site would be added and if still pain working with therapy, could need further imaging like CT of shoulder. Review of the nursing note dated 11/03/23 timed 11:28 P.M. revealed the NP was in to see Resident #58. New order for Lidocaine patch 4% to right shoulder related to pain and discontinue Voltaren gel. Review of the nursing note dated 11/03/23 timed 11:31 P.M. revealed Lidocaine patch to be placed daily and removed at bedtime. Review of the nursing note dated 11/08/23 timed 9:48 A.M. revealed Resident #58 had complaints of pain to right shoulder post fall. New order per NP for x-ray to right shoulder. Review of the nursing note dated 11/09/23 timed 12:45 P.M. revealed x-ray of right shoulder done and sent to physician with no new orders. Impression: no acute fracture or dislocation. Review of the nursing note dated 11/15/23 timed 3:11 P.M. revealed the NP was in to see Resident #58 on this date. New order for CT scan with contrast of right shoulder related to pain to rule out (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 3 of 7 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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 rotator cuff tear status post fall. CT scan with contrast was scheduled for 11/28/23 at 12:00 P.M. Resident #58 had a pulmonary appointment on this same day. Per resident request, it was rescheduled. Level of Harm - Actual harm Residents Affected - Few Review of the late entry lab note created 11/29/23, effective for 11/28/23 timed 3:04 P.M. revealed Resident #58 was taken to CT scan at hospital. Returned from scan without incident. Awaiting report. Review of the CT right shoulder without intravenous (IV) contrast radiology result dated 11/29/23 revealed Resident #58 had subacute multifocal scapular fractures involving the acromion, coracoid and inferior tip. Review of the nursing note dated 11/30/23 timed 7:59 A.M. revealed CT results of right shoulder revealed subacute multifocal fracture of the scapula, in the acromion, coracoid, and inferior tip of the scapula with comminution. No fracture or dislocation elsewhere. The findings were discussed with Resident #58. Resident #58 stated he continued to have pain in right shoulder which worsened with movement. Rated pain as a seven out of 10. Resident #58 was willing to try Percocet (an oral narcotic pain medication) for pain. The NP was aware and was getting STAT (immediate) order for Percocet. The NP contacted a shoulder specialist for further evaluation and management. Review of the November 2023 physician orders revealed Resident #58 was ordered Percocet oral tablet 5-325 milligrams (mg) give one tablet by mouth every six hours as needed for right shoulder pain. The order started on 11/30/23. Review of the November 2023 Medication Administration Record (MAR) revealed Resident #58 was administered Percocet oral tablet on 11/30/23 at 9:11 A.M. for a pain of eight out of 10. Review of the December 2023 MAR revealed Resident #58 was administered Percocet oral tablet on the following dates and times with corresponding pain level: on 12/01/23 at 8:02 A.M. with a pain level of six, on 12/01/23 at 4:54 P.M. with a pain level of eight, on 12/02/23 at 5:00 A.M. with a pain level of eight, on 12/02/23 at 11:00 A.M. with a pain level of eight, on 12/02/23 at 6:02 P.M. with a pain level of eight, on 12/03/23 at 9:53 A.M. with a pain level of nine and on 12/03/23 at 4:14 P.M. with a pain level of eight. Observation on 11/28/23 at 9:53 A.M. revealed Resident #58 was lying in bed. Resident #58 had a motorized wheelchair in his room. Interview, during the observation, with Resident #58 verified he was dropped from the mechanical lift to the floor during a transfer from his bed to his wheelchair. When Resident #58 was dropped, he landed on his right shoulder and was in a lot of pain. Resident #58 explained that the staff were using a new sling that crisscrossed and he slid out of the sling. STNA #8 and STNA #9 were the staff who transferred him that day. Resident #58 also stated since being dropped from the mechanical lift sling, he could not do therapy, lift weights and he tried to do ROM on his right shoulder and it didn't feel good. Interview on 11/28/23 at 10:45 A.M. with STNA #8 verified herself and STNA #9 were completing a mechanical lift transfer from Resident #58's bed to his wheelchair when Resident #58 slid out of the mechanical lift sling onto the floor. STNA #8 explained Resident #58 had a newer sling that crisscrossed at his legs which positioned the resident in a laidback position rather than sitting up. STNA #8 felt the sling was too big for Resident #58. STNA #8 revealed she was operating the mechanical lift, lifted Resident #58 approximately six inches away from the bed while STNA #9 was walking around the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 4 of 7 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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 bed (at the bottom of the bed). At that time, STNA #8 pulled Resident #58 back (while gripping the sling) towards her when Resident #58 slid out of the sling between the top and middle portion of the sling, hitting his head on the nightstand and falling face down on the floor. STNA #8 verified Resident #58 continued to complain of pain to his right shoulder. Residents Affected - Few Interview on 11/28/23 at 11:10 A.M. with STNA #9 verified herself and STNA #8 were completing a mechanical lift transfer from Resident #58's bed to his wheelchair when Resident #58 slid out of the mechanical lift sling onto the floor. STNA #9 explained the crisscross sling was used and all six hooks were hooked to the mechanical lift when STNA #8 used the mechanical lift to lift the resident off the bed while STNA #9 was walking around the bed when Resident #58 leaned to the right and slid out of the right side of the sling, between the top and middle portion of the sling, falling face down onto the floor. When the ambulance came and moved Resident #58, he yelled out in pain to his right shoulder. STNA #9 verified Resident #58 continued to complain of pain to his right shoulder. STNA #9 felt the newer crisscross sling was too big. During observation on 11/28/23 at 12:45 P.M. with STNA #8 and STNA #10, STNA #8 identified the mechanical lift on the hallway where Resident #58 resided as the mechanical lift that was used when Resident #58 slid out of the sling. It was a Joern's Hoyer HPL700 mechanical lift. There was a sticker on the boom or arm of the mechanical lift that read, Safety notice: not all slings are compatible with this lifting device. It is the policy of Joern's Healthcare to recommend that only Joern's slings be used with Joern's lifts. Interview on 11/28/23 at 3:00 P.M. with the Administrator, Director of Nursing (DON) and Regional Director of Clinical Services (RDCS) #21 revealed they were not aware the sling was not compatible with the mechanical lift that was used to transfer Resident #58 when he slid out of the sling. In addition, the Administrator, DON and RDCS #21 verified STNA #8 should have waited to lift Resident #58 off the bed until STNA #9 was nearby. Observation on 11/28/23 at 3:30 P.M. of the sling used when Resident #58 slid out of the sling (with the Administrator present) revealed Resident #58's first name was written in black permanent marker at the head of the back of the sling. The sling was manufactured by Direct Supply. The label attached to the sling stated, WARNING: this sling is intended ONLY for use with lifts indicated in the most recent version of Compatibility Guide. Never alter slings, exceed weight limit, or use this sling with any other make or model resident lift. Interview on 12/04/23 at 9:00 A.M. with the Administrator and [NAME] President of Clinical Operations #22 verified the Direct Supply sling was not listed in the most recent Direct Supply Compatibility Guide and verified the facility's policy stated to follow the manufacturer's guidelines for mechanical lifts and mechanical lift slings. Interview on 12/04/23 at 3:50 P.M. with Joern's Healthcare Customer Service for Product Support Representative (CSPSR) #23 revealed when the surveyor asked if a Direct Supply sling could be used on a Joern's Healthcare Hoyer lift, CSPSR #23 stated, I can't speak to that. CSPSR #23 stated he could only speak to the Joern's Healthcare Hoyer company only recommended genuine Joern's Hoyer lift slings manufactured by Joern's be used on Joern's Healthcare Hoyer lifts. CSPSR #23 explained that the Joern's Hoyer HPL500 was a standard mechanical lift whereas the Joern's Hoyer HPL700 was a bariatric mechanical lift. The company recommended that only bariatric slings manufactured by Joern's be used on the HPL700 lift. CSPSR #23 stated that Joern's bariatric lifts (such as HPL700) had a different spreader and different cradle and was engineered and built differently than a standard lift (such as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 5 of 7 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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 HPL500). Level of Harm - Actual harm Review of the Direct Supply invoice dated 10/03/23 revealed a Direct Supply Divided Leg Sling, Multi-Brand Compatible, size Large #GV249 was purchased. The sling was delivered on 10/05/23. Residents Affected - Few Review of the Direct Supply Multi-Brand Compatible Slings Owner Manual dated March 2021 revealed, this sling is intended ONLY for use with lifts indicated in the most recent version of the Compatibility Guide. Never alter slings, exceed the weight limit, or use this sling with any other make or model of resident lift. Review of the Direct Supply Sling Compatibility Guide dated November 2022 downloaded from the Direct Supply website on 11/28/23, revealed Joern's Hoyer HPL700 was not listed on the guide to be compatible with any Direct Supply sling. Review of the Joern's Hoyer HPL700 User Instruction Manual dated 2016 revealed, WARNING: HOYER RECOMMENDS THE USE OF GENUINE HOYER PARTS. Hoyer slings and lifts are not designed to be interchanged with other manufacturer's products. Using other manufacturer's products on Hoyer products is potentially unsafe and could result in serious injury to patient and/or caregiver. Review of the facility's Using a Mechanical Lifting Machine policy revised July 2017 revealed the purpose of the procedure was to establish the general principles of safe lifting using a mechanical lifting device. It was not a substitute for manufacturer's training or instructions. Before using a lifting device, assess the resident's current condition including: measure the resident for proper sling size and purpose, according to manufacturer's instructions. The deficient practice was corrected on 11/14/23 when the facility implemented the following corrective actions: • On 10/30/23, an investigation and root cause anaysis was completed by the Administrator, DON, Assistant Director of Nursings and RDCS #21. • On 10/30/23, the [NAME] President of Operations, [NAME] President of Clinical Operations, Quality Assurance Compliance Officer, and Regional Director of Operations were notified of Resident #58's fall from Hoyer lift sling. An abatement plan was discussed approved and put into action. • On 10/30/23, the sling utilized to transfer Resident #58 (Large #GV249 ) was taken out of serive and placed in storage. • On 10/30/23, The DON/designee audited all residents' fall care plans, care [NAME], and tasks for accuracy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 6 of 7 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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 10/30/23, The DON provided education to STNA #8 and STNA #9 regarding mechanical lift safety. The training including review of the facility mechanical lift policy and procedure, care giver safety tips, knowing the lift, checking resident condition before using lift, selecting resident sling size, preparing the environment, preparing the equipment, placing resident in sling, performing safety checks, lifting the resident, and lowering the resident. Residents Affected - Few • On 11/02/23, an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held to inform all interdisciplinary team members of details of occurrence, investigation process, and work completed. • Between 11/02/13 and 11/14/23 all nursing staff received training regarding mechanical lift competency. This one hour training included Hoyer/mechancal lift transferring, using the [NAME], transfers, falls, and pain. This training was confirmed as completed by in-service sign in sheets. • On 11/02/23, auditing was initiated regarding type of Hoyer/mechanical lift used and if residents were transferred per policy and procedure. Auditing to continue three times a week for four weeks and ongoing. Auditing to be completed by DON/designee. • Results of audits will be submitted to the QAPI committee for further review and recommendations. This deficiency represents non-compliance investigated under Complaint Number OH00148431. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 7 of 7