Health inspection·April 21, 2025

F 0689 Level of Harm - Actual harm #60 had intact cognition. The assessment revealed Resident #60 required moderate to extensive (staff) assistance for all activities of daily living. Resident #60 was always incontinent of urine and occasionally incontinent of bowel. Resident #60 was identified as a fall risk due to taking anti-anxiety medications daily during the seven-day assessment reference period. Residents Affected - Few Review of a nursing progress note dated 03/10/25 at 5:47 A.M. revealed Resident #60's daughter put the call light on and was stating her mother was trying to take her clothes off and get out of bed. Resident #60 was asking about her grandmother. The note revealed the nurse educated Resident #60's daughter about terminal agitation, and the nurse was going to administer a dose of Ativan, but Resident #60 calmed down. Record review revealed no new safety or fall risk interventions were implemented or considered at this time. Review of a nursing progress note dated 03/10/25 at 9:41 P.M. revealed Resident #60's daughter walked into the resident's room and ran out screaming stating her mother was on the floor. The nurse entered the room, Resident #60's bed was in a high position, and she (the resident) was lying on the ground on her stomach with her head, shoulders, and arms under the bed. A small amount of blood was visualized on the floor next to Resident #60. Vital signs were assessed, and Resident #60 was reporting pain in her left arm and head. The hospice agency was notified, and an x-ray of the left shoulder was ordered. Emergency responders assisted to help Resident #60 back into bed. At the time of the incident, the resident's family made the decision not to send the resident to the emergency room. Review of the left shoulder x-ray dated 03/11/25 for Resident #60 revealed an acute displaced fracture of the left humorous metaphysis. Review of a facility unwitnessed fall investigation dated 03/10/25 revealed Resident #60's family (daughter) walked into her room and ran out stating her mother was on the floor. Resident #60 was found on the floor lying on her stomach with head shoulders and arms under the bed. Resident #60's bed was in a high position. A small amount of blood was on the floor next to the resident. Initial assessment of Resident #60 revealed she was oriented to person, situation, and place. Her predisposing factors included she had periods of confusion, was incontinent, a recent change in cognition, weakness, gait imbalance, and impaired memory. Review of a witness statement from Certified Nursing Assistant (CNA) #499, (no longer employed at the facility), revealed she changed Resident #60 a little after 8:00 P.M. (on 03/10/25) that day. Resident #60 was still urinating, so she informed her she would return. CNA #499 then went back to change her again, and she put the bed in the lowest position and put the resident's bed remote in the drawer of her bedside table. CNA #499 then went to care for other residents until she heard the nurse calling for her. (However, Resident #60's sister was in the room on 03/10/25 from 7:00 P.M. to 8:40 P.M. and stated no staff came into the room while she was visiting). Resident #60 was lying on the floor and due to her position, it was difficult to assess her. Resident #60's family was very upset with CNA #499, so the nurse had her stay in the hallway with her. Review of a statement from Nurse Manager #505 revealed she arrived on the unit on 03/10/25 at 9:57 P.M. Two nurses were in Resident #60's room attempting to assess her. The nurses informed her that the emergency medical services team was in route. Nurse Manager #505 then notified the hospice agency and the Director of Nursing (DON). Blood was coming from Resident #60 on the right side of her forehead and after the area was cleaned, a small laceration was discovered that eventually stopped bleeding. Resident #60's right cheek had some bruising as well, and she was complaining of left shoulder pain. Resident #60's family agreed to not send the resident out but an order for a left shoulder (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365904 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 365904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saint Joseph Care Center 2308 Reno Drive NE Louisville, OH 44641 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 x-ray was obtained and neurological checks were instituted. Level of Harm - Actual harm Interview on 04/17/25 at 9:40 A.M. with the Administrator revealed the facility had investigated Resident #60's fall. She reported prior to the fall, the aide had left Resident #60's bed in the lowest position (she was unsure of the time this occurred) and put the bed remote (used to raise and lower the bed) in the bedside drawer, which was a hospice recommendation. The Administrator revealed Resident #60 unfortunately experienced end of life psychosis and raised her bed because she preferred it that way and fell out. She reported the resident's daughter did find Resident #60 on the ground. The Administrator also revealed Resident #60 had some behaviors of removing all of her clothing and trying to walk. Resident #60 was not left alone after she was found on the ground and a staff member, and the daughter were present with her the whole time she was on the ground. Residents Affected - Few Interview on 04/17/25 at 10:25 A.M. with the Director of Nursing (DON) confirmed there was only ever a fall risk assessment for Resident #60 on admission in the year 2020, and the facility never re-assessed the resident until 03/11/25 after she fell. She confirmed the family did not want to send the resident to the hospital, but she did receive an x-ray in the facility of her left shoulder, which showed a left humerus fracture (as a result of the fall). During the interview, the DON also confirmed Resident #60's fall prevention care interventions had not been updated since the resident's admission on [DATE] as noted above even though the resident was at risk for falls and demonstrated behaviors that increased her fall risk and safety needs prior to the fall with fracture that occurred on 03/10/25. A telephone interview on 04/17/25 at 11:18 A.M. with Resident #60's daughter revealed the resident's sister was the person who found the resident lying on the floor all bloody on 03/10/25. She reported her sister immediately called her, and she was at the facility within five minutes. Resident #60's daughter reported her mother had behaviors of trying to get out of bed and remove her clothing for a couple of nights prior to the incident, and at that time, hospice staff made a recommendation to keep the resident's bed in the lowest position. When she arrived at the facility, she reported that her mother was lying on her belly on the right side of the bed. There was blood all over the floor and the wall. She reported that the bedside table where the bed remote was placed in an open drawer was also on the right side of the bed next to Resident #60's head. Resident #60 had suffered a laceration to her head, and her daughter reported the next day her right eye was swollen shut. Resident #60's daughter also confirmed Resident #60 suffered a right shoulder and arm fracture due to the fall, but the family chose not to send the resident to the emergency room because her mother was terminal and not doing well. Resident #60's daughter reported they (the whole family) already knew the resident was nearing the end of her life but voiced concerns the resident had to suffer so much (as a result of the fall/fracture) before she passed away. A telephone interview on 04/17/25 at 3:65 P.M. with Resident #60's sister revealed she was at the facility on 03/10/25 from approximately 7:00 P.M. until 8:40 P.M. when she left. She reported during this visit, Resident #60 was in and out of consciousness, but was sleeping when she left. Resident #60's sister reported that no staff member came into the room during her visit on this date/time. She also reported the resident's bed was also raised in a high position when she was visiting which she stated surprised her because the (hospice) staff had left handwritten notes next to the resident's bed stating to leave the bed in the lowest position. Resident #60's sister reported she did not question staff about her bed being in the highest position because she was so distraught watching her sister go in and out of consciousness. Resident #60's sister reported she could not confirm where the bed remote was because she did not pay attention to that. Resident #60's sister reported after she left at 8:40 P.M., she did return to the facility at which time Resident #60 was lying on the ground (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365904 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 365904 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saint Joseph Care Center 2308 Reno Drive NE Louisville, OH 44641 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 her stomach on the right side of the bed complaining about her left shoulder and had a cut and bruises to the right side of her face. Level of Harm - Actual harm Residents Affected - Few A telephone interview on 04/21/25 at 8:45 A.M. with Licensed Practical Nurse (LPN) #506 revealed she was the nurse on duty on 03/10/25, the night Resident #60 fell. She reported she was two doors down passing medications to other residents when she saw Resident #60's family enter the resident's room. The resident's family then came out screaming the resident was on the floor. She reported Resident #60 was lying on her stomach half under the bed and half outside the bed. LPN #506 reported that when she went to assess Resident #60, the resident screamed, I fell and don't touch me, my arm is broken. LPN #506 confirmed the bed remote was on the floor next to Resident #60 at that time. LPN #506 reported she did not know how the bed ended up in the highest position but stated Resident #60 preferred it that way, but since Resident #60 was at the end of life and not always with it, staff decided to keep the bed in the lowest position. Review of the visitor sign-in logs from 03/10/25 revealed that Resident #60's sister signed in at 7:00 P.M. and signed out at 8:40 P.M. Review of the facility policy Falls and Fall Risk, Managing, revised March 2018, revealed based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident conditions that might contribute to the risk of falls include delirium and other cognitive impairment and medication side effects of medication. The staff with the input of the attending physician, would implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. This deficiency represents noncompliance investigated under Master Complaint Number OH00164791 and Complaint Number OH00164470. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365904 If continuation sheet Page 4 of 4