Health inspection·September 18, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few revealed CNA #407 and CNA #408 were transferring Resident #53 from the bed to a wheelchair. During the transfer, one of the Hoyer lift pad straps was not secured to the spreader bar. The unsecured strap caused the resident to slip from the sling and fall. Both CNAs provided written statements verifying the failure to secure the strap, which directly resulted in the fall and subsequent pelvic fracture. The Director of Nursing (DON) confirmed in an interview on 09/15/25 at 4:45 P.M. that the injury suffered by Resident #53 was caused by the improper securing of the Hoyer lift sling during a transfer on 09/03/25. Interview with Resident #53 on 09/16/25 at 1:33 P.M. verified the events of the fall and subsequent pelvic fracture. Resident #53 further expressed apprehension to be transferred in the Hoyer lift after the incident. Review of the manufacturer's instructions for the Hoyer lift utilized by the facility, copyright 2022, revealed to not move the patient if the sling was not properly connected to the hooks of the hanger bar. When the sling was elevated a few inches off of the stationary surface and before moving the patient, check again to make sure the sling was properly connected to the hooks of the hanger bar. If any attachments were not properly in place, lower the patient back onto the stationary surface and correct this problem; otherwise, injury or damage may occur. Review of the policy titled, Hoyer lift, dated 07/01/22, revealed the facility would utilize a Hoyer lift to assist a resident to move with increased independence and transfer with greater comfort, to feel physically more secure while preventing accidents, maintaining safety, and body alignment, promoting, supplementing, and/or enhancing the resident's function and/or safety. The deficient practice was corrected on 09/04/25 when the facility implemented the following corrective actions: On 09/03/25 at 10:32 A.M., Resident #53's family and nurse practitioner were called to notify of incident. On 09/03/25 at 10:34 A.M., the Hoyer lift and sling used in the incident with Resident #53 were removed from service. On 09/03/25 at 10:45 A.M., Resident #53 was transported to a local hospital for evaluation. On 09/03/25 at 10:47 A.M., the Director of Nursing (DON) provided immediate education and competency check with CNA #407 and CNA #408. Both staff members passed their competency checks. On 09/03/25 at 11:00 A.M., the Hoyer lift utilized in the incident was inspected by Maintenance Manager (MM) #315 and found to be in good working order. The Hoyer pad used in the transfer was also inspected and showed no signs of wear. On 09/03/25 at 11:00 A.M., the DON and designees began education for all direct care staff regarding use of mechanical lifts with special focus on checking straps prior to beginning to lift a resident. Competencies were performed with all CNAs employed at the facility. All education and competencies were completed by 11:00 A.M. on 09/04/25. On 09/03/25, MM #315 conducted an emergency audit of all Hoyer lifts and Hoyer pads in the facility for functionality and safety with no negative findings. On 09/03/25, the facility held an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting to discuss the incident. The facility implemented a policy beginning on 09/08/25 newly hired employees would be educated regarding mechanical lift use and must pass a mechanical lift competency prior to working with residents. The Administrator and the DON would continue to monitor compliance directly in the monthly Quality Assurance and Performance Improvement (QAPI) meetings for three months and then as needed for one year. Review of the incident and accident report from July, August, and September 2025 revealed no additional instances of resident accidents or injuries involving transfers with mechanical (Hoyer) lift devices. Interviews on 09/15/25 between 10:30 A.M. and 4:00 P.M. with Licensed Practical Nurse (LPN) #348, LPN #349, CNA #383, CNA #390, CNA #393 and CNA #397 all verified being provided education regarding use of a mechanical lift for resident transfers and were able to demonstrate knowledge from the training. Observation of a Hoyer lift transfer on 09/15/25 at 3:00 P.M. for Resident #67, performed by CNA #383 and CNA #390, revealed the staff members correctly and safely completed the transfer without incident. This deficiency (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365758 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 365758 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parma Care Center 5553 Broadview Rd Parma, OH 44134 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 represents non-compliance investigated under Master Complaint Number 2616144 and Complaint Number 2574416. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365758 If continuation sheet Page 3 of 3