Health inspection·February 28, 2024

F 0689 transfers. She was always incontinent of bowel and bladder. Level of Harm - Actual harm Review of the Fall Risk assessment dated [DATE] and completed by Licensed Practical Nurse (LPN) #618 revealed Resident #63 was at high risk for falls as she was incontinent, non-ambulatory, and required assistance with transfers. Residents Affected - Few Review of the physician order dated 01/10/24 revealed Resident #63 had an order to have a low air loss mattress with bilateral bolsters every shift. Review of the Physical Therapy Evaluation and Plan of Treatment dated 01/17/24 and completed by Physical Therapist (PT) #611 revealed therapy would be provided 12 times from 01/17/24 to 02/13/24. The evaluation revealed currently Resident #63 required maximum assistance with bed mobility. Review of SRI tracking number 243669 dated 01/31/24 revealed the facility filed an SRI for neglect involving Resident #63 and Agency STNA #600. The SRI revealed Resident #63 came back from an appointment and needed immediate care as she was incontinent. While providing care, the resident turned the wrong way and fell out of bed. The facility unsubstantiated the SRI for neglect. Review of undated witness statement completed by Agency STNA #600 revealed she and another aide, Agency STNA #607, went to complete care in Resident #63's room. (Agency STNA #607 provided care to Resident #63's roommate in the bathroom). Agency STNA #600 completed care for Resident #63 as she had come back from a doctor's appointment and requested to be changed. She proceeded to gather her stuff to provide care and Resident #63 stated not to forget to put her bolsters back on when she was done. She told Resident #63 that she would not forget. Resident #63 stated the paramedics took them out of her bed. She proceeded to roll the linen on the bed and asked the resident to turn. She proceeded to turn and placed the linen underneath her. She told her not to roll anymore but she rolled again, and Agency STNA #600 tried to catch her as she leaped onto her bed but Resident #63 fell to the floor. She told the Agency STNA #607 who went to get the nurse. Review of the progress note dated 01/31/24 at 10:58 A.M. and completed by Nurse Practitioner (NP) #606 revealed Resident #63 was examined due to the fall and hematoma. Resident #63 had a tennis ball sized hematoma to her forehead due to a fall from her bed to the floor. She had a skin tear on her right arm. Her neurological checks were within normal limits but due to blood thinners NP #606 recommended the resident be sent to the hospital. Review of the nursing note dated 1/31/24 at 5:13 P.M. and completed by Registered Nurse (RN) #605 revealed Resident #63 rolled out of bed onto the floor when turned on her side during care. She hit her face on the carpet causing large hematoma to the middle of her forehead, bruising to the bridge of her nose, bleeding from her nose, and a skin tear to her right elbow. Her vital signs were stable, and she was alert and oriented with no loss of consciousness. NP #606 was notified, and Resident #63 was sent to the emergency room (ER). Review of the After Visit Summary dated 01/31/24 revealed ER Physician #601 evaluated Resident #63 due to fall from bed. She was diagnosed with neck injury, closed fracture to her nasal bone, closed nondisplaced fracture to her right wrist, contusion of her chest and abdominal wall, and a skin tear to her right elbow. She was provided with a splint to her right wrist and an ordered antibiotic therapy. She also was scheduled to have follow up consults with Facial/ Plastic Physician #602 and Orthopedic Physician #603. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Care Center 500 Community Drive Avon Lake, OH 44012 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 Review of the nursing note dated 01/31/24 at 7:30 P.M. and completed by RN #604 revealed Resident #63 came back from the emergency room and had facial bruising, right wrist wrapped due to fracture, skin tear to right elbow, severe swelling to her face, hematoma above her eyes, and her eyes were black and blue. Review of the nursing note dated 02/01/24 at 1:49 A.M. and completed by RN #604 revealed Resident #63's face was swollen to the point her right eye was swollen shut. Review of the Visual/ Bedside [NAME] Report as of 02/23/24 revealed Resident #63 was to have a low air loss mattress with bilateral bolsters. She required check and change every two hours and as needed. Interview on 02/23/24 at 8:52 A.M. with Agency STNA #607 revealed on 01/31/24 she was in Resident #63's bathroom during the incident with her roommate. She revealed Agency STNA #600 had gone in the room at the same time to provide Resident #63 incontinence care. (Agency STNA #600 was the only other staff member in the room providing Resident #63's care). While in the bathroom she heard a loud commotion, and Agency STNA #600 stated Resident #63 was on the floor. Agency STNA #607 went to get the nurse. Interview and observation on 02/23/24 at 9:26 A.M. revealed Resident #63 was lying on a low air loss mattress with bilateral bolsters and had a large hematoma to the center of her forehead, bruising covering almost her entire face of all different colors: yellow, brown, purple, and blue. She had a black splint on her right wrist. Resident #63 revealed when she went to the doctor's appointment, the paramedics removed the bolsters so that they could move her from the bed to the stretcher. When she returned, she told Agency STNA #600 to put her bumpers back on her bed before she changed her. Agency STNA #600 was in a big hurry and would not listen to her. Agency STNA #600 started changing her by pushing her over towards the doorway. Resident #63 told Agency STNA #600 to stop but she kept on pushing her until she fell out of bed onto the floor. Resident #63 fell on her face and broke her wrist. Observation on 02/23/24 at 10:47 A.M. of incontinence care for Resident #63 completed by Licensed Practical Nurse (LPN) #608, STNA #609, and Agency STNA #607 revealed Resident #63 was dependent on staff to assist in rolling her from side to side in bed to complete her incontinence care. She was on a low air loss mattress with bed bolsters. Interview on 02/23/24 at 12:27 P.M. with the Director of Nursing revealed Resident #63 had gone on an appointment on 01/31/24 and at that time the paramedics removed the bolsters because they were moving her from the bed to the cot. When Resident #63 returned from the appointment the bolsters were not put back on. She verified in Agency STNA #600's witness statement that Resident #63 had requested her bed bolsters be put on. She verified Agency STNA #600 provided care including rolling and incontinence care without the bed bolsters in place resulting in Resident #63 falling out of bed. Interview on 02/23/24 at 12:32 P.M. with Agency STNA #600 revealed Resident #63 had told her to put the bed bolsters back on when she got done with providing her incontinence care. She told Resident #63 that she would and that she would not forget. Agency STNA #600 then proceeded to raise the bed to her height and had Resident #63 roll towards the door because she needed a complete bed linen change. Resident #63 rolled fast right off the bed. Agency STNA #600 attempted to catch her but was unable, and she fell face down onto the floor. The other aide (STNA #607) was in the same room but in the bathroom providing care for Resident #63's roommate. STNA #607 went to get the nurse. Agency STNA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Care Center 500 Community Drive Avon Lake, OH 44012 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 #600 denied pushing Resident #63 stating, Resident #63 rolled on her own and did not require assistance. Agency STNA #600 was asked why she did not place the bolsters prior to providing care and she revealed because she was going to after she was done. Interview on 02/23/24 at 3:00 P.M. with Physical Therapy Assistant (PTA) #610 revealed she had provided Resident #63's therapy. Resident #63 required maximum assistance of one for bed mobility as she felt comfortable rolling her side to side by herself but with bed bolsters in place. If she was not positioned in the center of the bed and/or needed moved up in bed she would require two staff assist. Interview on 02/27/24 at 9:03 A.M. with RN #605 revealed she was assigned Resident #63's unit on 01/31/24. Staff had alerted her that Resident #63 had fallen out of bed. When RN #605 walked into her room Resident #63 was lying face down on the carpeted floor. They carefully rolled her over and she noticed a large hematoma to her front forehead, bruising already forming to her bridge of her nose, and her nose bleeding. NP #606 was in the facility, examined, and ordered her to go to the hospital for evaluation. Resident #63 stated Agency STNA #600 had rolled her right out of bed. RN #605 noticed after Resident #63 went to the hospital that she did not have her bed bolsters in place. RN #605 revealed Resident #63 had a doctor's appointment previously in the day and felt when she went to that appointment her bed bolsters were removed and not put back in place when Resident #63 returned. Interview on 02/27/24 at 9:38 A.M. with NP #606 revealed she was in the facility when Resident #63 fell out of bed. When NP #606 went to assess her, they had already gotten her back in bed. Resident #63 had tennis ball sized hematoma to her forehead and bruising already forming on her face. NP #606 was concerned because the resident was on blood thinners, so ordered her to be sent to the hospital for evaluation. Resident #63 was alert and stated that she told the aide to put her bolsters on before performing care, but that the aide did not listen to her. The aide then provided incontinence care, and she rolled her out of bed onto the floor. Interview on 02/27/24 at 9:57 A.M. with RN #604 revealed he was the nurse on duty 01/31/24 when Resident #63 returned from the hospital. He revealed she had a large hematoma to her forehead, bruising all over her face, her right eye was almost completely shut, right wrist fracture, and contusions to her abdominal and chest wall region. RN #604 revealed she had not talked about the incident, just that she was tired. Interview on 02/28/24 at 10:15 A.M. with the DON revealed the facility utilized many agency staff including nurses and STNAs. She was asked how agency staff were educated to prevent a similar incident. She stated, there was really no answer. There is really no answer like if they are here, I try but no I have nothing in place to ensure agency staff are educated prior to working especially regarding ensuring bed bolsters were in place and proper turning and repositioning during ADL care. She verified they had not figured out an effective training program to prevent another issue by agency staff. Review of the facility policy labeled, Fall Management and Incident Intervention Protocol, dated July 2022, revealed residents would be assessed as to their risk of sustaining a fall and interventions would be implemented to decrease the incidence of resident's incidents including falls ad to minimize the risk of injury. The policy revealed any interventions would be added to the resident plan of care and would be communicated to relevant nursing staff. This deficiency represents non-compliance investigated under Self-Reported Incident, Control Number (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Care Center 500 Community Drive Avon Lake, OH 44012 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 OH00150879. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 If continuation sheet Page 5 of 5