Health inspection·September 16, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few discontinued 01/24/25. Review of the physician progress note dated 01/19/25 and authored by the Physician #500, revealed Resident #69 was assessed with a laceration on the leg. Physician #500 documented the staff notified him the prior day, but they did not know how the laceration happened. A photograph of the laceration was sent to him, and he thought it needed to be repaired. Resident #69 was sent to the ER where sutures were applied. The resident was assessed with leg swelling; skin was warm and dry with laceration and a wound present.Review of a nurse's progress noted dated 01/20/25 at 5:13 A.M. for Resident #69, revealed the nurse spoke with Resident #69's husband about the incident on 01/18/25 resulting in a laceration to right lower leg, the origin of the laceration, the education that was provided to staff to prevent further injury and the treatment being provided. Review of physician orders dated 01/20/25 for Resident #69, revealed the resident's bed frame was to be padded for safety, Tubi grips (elasticated tubular bandages to help with swelling/edema) were to be in place and wheelchair legs were to be removed prior to transfers. Review of physician orders dated 01/22/25 for Resident #69, revealed the resident was ordered to have the right lower leg cleansed with Hibiclens solution, bacitracin applied to the wound, covered with abdomen (ABD) pad, wrapped with Kerlix daily and monitor for signs and symptoms of infection. The order was discontinued on 02/02/25. Review of the facility's Concern Log dated 01/22/22, revealed Resident #69's family was concerned with the resident's transfer status which resulted in a skin tear. The resolution included therapy evaluating the resident's transfer status and transfer status changed to a Hoyer transfer. The wheelchair leg and bedframe were padded, and nursing staff competency was completed. The comments section on the concern log indicated the family was satisfied with the resolution. Review of a therapy note dated 02/04/25 for Resident #69, revealed the resident was evaluated due to a new onset of decrease in strength, transfers, range of motion, balance, functional activity tolerance, static and dynamic balance and increased need for assistance which placed the resident at risk for falls and further decline in function. The resident sustained a calf laceration on 01/18/25 and required 14 stitches. The stitches were removed on 02/03/25. The resident was consulted to improve strength and balance. The resident was assessed with strength, balance, activity intolerance and functional mobility deficits. The resident was unsteady with weight bearing activities in the stand-up lift, and it was painful. The resident has a decreased quality of life and recommended a Hoyer lift for transfers. Interview via phone on 09/11/25 at 11:56 A.M. with former CNA #750, revealed she transferred Resident #69 to the bed on 01/18/25 when the resident complained of pain. CNA #750 stated she looked at the resident's leg and it was bleeding, so she called for the nurse. CNA #750 stated the blood was dry and thought something happened earlier. She denied resident hitting her leg on anything.Interview via phone on 09/11/25 at 11:59 A.M. with CNA #700, stated she could not remember exactly what happened but stated they used a sit-to stand lift on Resident #69 and was not sure if the resident hit her leg on the bed frame or what happened. CNA #700 stated the blood on Resident #69's leg was still wet. CNA #700 stated the resident did not complain until they picked her legs up and put them on the bed. They told the nurse who immediately came to assess the resident. CNA #700 stated she had to review how to use the sit-to stand with the unit manager.Interview on 09/11/25 at 12:03 P.M. with the DON, revealed RDCO #600 was training her to become the DON at the time of the incident on 01/18/25 involving Resident #69. The DON's understanding was Resident #69 was being transferred via a sit-to-stand mechanical lift, when the resident complained of pain and the CNAs noticed blood on the resident's pants. The physician was consulted and wanted Resident #69 to be sent to the ER. The husband was upset, and the family came into the facility to discuss the incident. Therapy staff looked at the bed and the sit-to-stand mechanical lift after the incident and there was nothing sharp on the bed frame or the sit-to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365685 If continuation sheet Page 2 of 3 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 365685 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Neill Healthcare North Ridgeville 38600 Center Ridge Rd North Ridgeville, OH 44039 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete stand lift and thought it could be pressure causing edema to open. The DON stated Resident #69 had edema and the laceration could have been caused by the pressure against the equipment. The facility did training with all staff members on sit-to-stand lifts and the staff started using a Hoyer mechanical lift instead of a sit-to-stand and put pool noodles on the bedrails after the incident. The DON stated they did teach-back competency training with the CNAs and then did audits on other units for residents who used the sit-to-stand and found no issues. Interview on 09/11/25 at 2:11 P.M. with Licensed Practical Nurse (LPN) #220, revealed two CNAs were transferring Resident #69 from her wheelchair to the bed via a sit-to-stand mechanical lift. LPN #220 stated the CNAs took the leg rests off the wheelchair prior to transfer. LPN #220 stated when she assessed the resident the blood was still wet. LPN #220 stated after the resident went to the ER, they determined the resident's leg got scraped along the top of where the leg rest fits onto the wheelchair. LPN #220 did not recall any edema but stated the resident did not have her legs wrapped because that would have prevented the injury. LPN #220 stated she discussed this with RDCO #600 at the time of the incident.Interview on 09/15/25 at 12:32 P.M. with RDCO #600, revealed he investigated the incident involving Resident #69 then met with the family to discuss it. RDCO #600 stated he believed the laceration occurred while Resident #69 was in the sit-to-stand and described it as more of a crushing injury than any issues with edema or swelling.The deficient practice was corrected by 02/22/25 when the facility implemented the following corrective actions: On 01/18/25, the resident was sent to the ER for evaluation and returned with 14 sutures in her right lower leg. On 01/18/25, the facility conducted a comprehensive investigation of the incident causing the laceration to Resident #69. The investigation included collecting witness statements and interviewing staff and facility determined it was caused by an unsafe transfer using a sit-to-stand lift. On 01/19/25, Resident #69's transfer orders were reviewed and changed from a sit-to-stand to a Hoyer mechanical lift. On 01/20/25, Resident #69's bed and wheelchair were inspected for sharp edges. The bed rails were padded for safety, tubi grips on the resident were to be in place and the wheelchair legs were to be removed prior to transfers. On 01/20/25, CNA #700 and CNA #750 were educated on transfer and returned a competency demonstrating on how to properly use a sit-to-stand. On 01/20/25 started education and training all nursing staff on proper usage of the sit-to-stand mechanical lift. On 01/22/25, Resident #69 was assessed by wound nurse On 01/23/25, the facility conducted audits of all residents being transferred by a sit to-stand lift. The audits continued through 04/02/25 and no additional issues were discovered. On 02/04/25, the resident was assessed by the Therapy Department due to new onset of decrease in strength, range of motion, balance, and increased need for assistance which placed the resident at risk for falls and further decline in function. The resident was assessed with strength, balance, activity intolerance and functional mobility deficits. The resident was unsteady with weight bearing activities in the stand-up lift, and it was painful. The resident has a decreased quality of life and recommended a Hoyer lift for all transfers. On 02/22/25, the facility reviewed the incident log, and no current issues were identified with sit-to-stand.This deficiency represents non-compliance investigated under Complaint Number OH001357840. Event ID: Facility ID: 365685 If continuation sheet Page 3 of 3