Health inspection·January 23, 2020

F 0609 Level of Harm - Minimal harm or potential for actual harm Interview on 01/22/20 at 4:00 P.M. with the Director of Nursing, (DON) revealed on 12/22/19, the resident was complaining of additional pain to his right leg and refusing to participate in therapy. An order was obtained for an x-ray from the physician due to the pain and swelling of his right leg. The result of the x-ray revealed a fractures of the distal tibia and proximal fibula. The DON confirmed there was no Self-Reported Incident sent to the State Survey Agency to report the injury of unknown origin. Residents Affected - Few Review of the facility's policy titled Abuse, Neglect Misappropriation and Crime Reporting, dated 11/04/19, revealed that an immediate investigation will take place and the proper authorities will be notified immediately. An injury of unknown origin must be reported within five days of the initial report. The policy identified an injury of unknown origin as the source was not observed by any person or could not be explained by the resident, is suspicious due to the extent of the injury, the location of the injury or the number of injuries. This deficiency substantiates Complaint Number OH00109319. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365974 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 365974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Living Quaker Heights 514 West High Street Waynesville, OH 45068 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on record review, review of the facility's policy and staff interview the facility failed to investigate a resident's injuries of unknown origin which involved a fractured tibia and fibula. This affected one (#58) of three residents reviewed for abuse. Residents Affected - Few Findings include: Review of the medical record for Resident #58 revealed an admission date of 07/24/18. Diagnoses included Parkinson's disease, congestive heart disease, depression, diabetes mellitus, cerebral vascular accident with right sided hemiplegia, chronic kidney disease and right knee prosthesis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/01/19, revealed the resident had intact cognition. He was totally dependent on one staff member for bed mobility, toileting and personal hygiene and required extensive assistance of one staff member for transfers. He used an electric wheelchair for mobility. Review of the plan of care, dated, 12/11/19, revealed the resident was in need of assistance with activities of daily living due to his right knee replacement. Interventions included to monitor for pain and intolerance during movement, physical and occupational therapy as ordered and extensive assistance of one persons for transfers. Review of the physical therapy (PT) documentation, dated 12/16/19, revealed the resident tolerated the session poorly this date with increased muscle guarding and poor participation due to report of increased pain stating he fell yesterday. Per nursing though, no fall was reported. The PT documentation, dated 12/18/19, revealed the resident complained of increase in pain, swelling and decreased movement in the right lower extremity. Review of the Occupational Therapy (OT) documentation, dated 12/17/19, revealed an increase in pain with transfer from bed to wheelchair, and nursing was notified. The resident stated he fell yesterday and his right ankle hurts. Review of the nursing documentation, dated 12/22/19 at 9:07 P.M., revealed the resident was complaining of pain while working with therapy. A physician order was received to obtain an x-ray due to swelling and pain. The results of the x-ray revealed a fracture of the distal tibia diaphysis and fracture of the proximal fibula. Interview on 01/22/20 at 4:00 P.M. with the Director of Nursing, (DON) revealed on 12/22/19, the resident was complaining of additional pain to his right leg and refusing to participate in therapy. An order was obtained for an x-ray from the physician due to the pain and swelling of his right leg. The result of the x-ray revealed a fractures of the distal tibia and proximal fibula. The DON confirmed the facility did not complete an investigation involving the injuries of unknown origin. Review of the facility's policy titled Abuse, Neglect Misappropriation and Crime Reporting, dated 11/04/19, revealed that an immediate investigation will take place and the proper authorities will be notified immediately. An injury of unknown origin must be reported within five days of the initial report. The policy identified an injury of unknown origin as the source was not observed by any person or could not be explained by the resident, is suspicious due to the extent of the injury, the location of the injury or the number of injuries. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365974 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 365974 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Living Quaker Heights 514 West High Street Waynesville, OH 45068 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 0610 This deficiency substantiates Complaint Number OH00109319. Level of Harm - Minimal harm or potential for actual harm . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365974 If continuation sheet Page 4 of 4