Health inspection·June 14, 2023

F 0689 Level of Harm - Actual harm Residents Affected - Few assessed by the nurse. Resident #50 complained of pain to her left wrist. Resident #50 was sent to the emergency room for evaluation. Upon returning to the facility Resident #50 was found to have a fracture to the left distal radius with a new splint applied for immobilization. Review of the hospital discharge records 05/10/23 including orthopedic evaluation revealed a new left distal radius fracture after falling from a mechanical lift. A new splint for immobilization was applied. Hospital records indicated Resident #50 had a current weight of 452.3 pounds. Review of the facility fall investigation completed on 05/10/23 revealed Resident #50 was being transferred by a mechanical lift and two State Tested Nurse Aide (STNA) #133 and STNA #141. The lift tipped over causing Resident #50 to fall and the lift fell on the resident. Resident #50 was assessed, the physician notified and the resident was sent to the hospital. Review of the facility Root Cause Analysis of the fall incident dated 05/10/23 revealed staff members failed to use the correct size mechanical lift and also failed to widen the base of the lift which caused the lift to tip over during transfer of the resident. Interview with Resident #50 on 06/13/23 at 11:05 A.M. revealed last month during a mechanical lift transfer from bed to wheelchair with two staff members, the lift tipped over due to staff not widening the base of the lift and using the wrong size lift. Resident #50 indicated the lift tipped over causing her to fall to the ground and then the lift fell on top of her. She was sent to the hospital and found to have a fracture to the left wrist. Interview with STNA #133 on 06/14/23 at 2:00 P.M. revealed she was assisting another STNA in transferring Resident #50 using a mechanical lift and the base legs where not widened prior to lifting and moving the resident. Interview with the Administrator and Director of Nursing (DON) on 06/13/23 at 12:25 P.M. revealed Resident #50 suffered a fall during a mechanical lift transfer with two STNAs due to staff members using the wrong size mechanical lift and not widening the base of the mechanical lift. The fall resulted in a fracture to the resident's left distal radius. They indicated the 450-pound lift was utilized when the resident was determined to be 452 pounds at the hospital. They indicated staff should have used the 600-pound lift. Review of the undated facility policy titled Mechanical Lifts and Transfers indicated staff are to use the appropriate size lift and when transporting a resident from one location to another using a lift, the legs of the lift must remain in the maximum open position for optimum stability and safety while the lift is moving. Review of the undated mechanical lift manufacturer's guidelines indicated the following: Lifting the Patient When using an adjustable base lift, the legs must be in the maximum opened/locked position before lifting the patient. The deficient practice was corrected on 05/10/23, when the Administrator and DON provided staff education of mechanical lift procedures to 54 staff members and the facility implemented the following corrective measures: • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365862 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 365862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pines Healthcare Center 3015 17th Street NW Canton, OH 44708 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 On 05/10/23, Resident #50 was sent to the local emergency department for evaluation and treatment. Level of Harm - Actual harm • Residents Affected - Few On 05/10/23 a Root Cause Analysis was completed by the Administrator which determined staff failed to follow mechanical lift policy and procedure by using the incorrect size mechanical lift and not widening the base of the lift. • On 05/10/23 all medical staff including 38 STNA and 16 licensed nurses were educated on the mechanical lift policy and procedure. • On 05/10/23 all medical staff that were in the facility completed an in-person competency check with the DON. • On 05/10/23 medical staff not available in the facility completed an online mechanical lift training and policy review. • On 05/10/23 medical staff not available in the facility completed a verbal competency check with the DON. • On 05/10/23 maintenance staff completed an inspection of all mechanical lifts. • On 05/10/23 medical staff were educated to only use the 600 pound lift for Resident #50. • On 05/10/23 Resident #50's care plan was updated to indicate using only the 600 pound lift. • On 05/10/23 weekly audits were initiated for 30 days to include monitoring of staff members following the mechanical lift policy and procedures. No evidence of any incorrect mechanical lift use was observed during audits completed on 05/11/23, 05/19/23, 05/24/23, 06/02/23, 06/07/23 and 06/13/23. • There were no unsafe resident transfers from 05/10/23 to 06/14/23 (the time of the onsite complaint (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365862 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 365862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pines Healthcare Center 3015 17th Street NW Canton, OH 44708 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 investigation). Level of Harm - Actual harm This deficiency represents non-compliance investigated under Complaint Number OH00143330 and OH00143300. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365862 If continuation sheet Page 4 of 4