Inspection·October 31, 2023

F 0689 Level of Harm - Actual harm Residents Affected - Few Review of the nursing orders administration note dated 09/23/23 timed 11:30 P.M. revealed Resident #48 was administered one tablet of Hydrocodone-Acetaminophen (Norco) orally 5-325 milligrams (mg) (an opioid pain medication) per complaints of left knee pain. Review of the nursing orders administration note dated 09/24/23 timed 6:05 A.M. revealed Resident #48 was administered one tablet of Norco orally 5-325 mg per complaints of left knee pain. Review of the nursing progress note dated 09/26/23 revealed Resident #48 refused a shower stating, I didn't want one because my leg is in too much pain. Review of the physician orders from September 2023 revealed Resident #48 was ordered Diclofenac Sodium Gel 1% (Voltaren gel) apply to left knee topically every day and every shift for pain for seven days. The order began 09/26/23. Review of the nursing progress note dated 09/28/23 revealed a new order was given for Tylenol 650 mg orally every four hours as needed for pain. Resident #24 stated that she felt more pain relief when taking the Tylenol than when she took the as needed Norco. Review of the NP progress note dated 09/29/23 authored by NP #5 revealed Resident #48 was visited and physical exam for left leg pain was completed. Resident #24 complained of acute pain from knee to ankle which started when being transferred over the weekend. Resident #24 was given Voltaren gel without relief. Resident #24 was unable to specify if calf pain, stated it all hurts. The plan indicated stat (immediate) x-ray of left knee and ankle, venous duplex (type of ultrasound used to measure blood flow) left leg and ibuprofen 600 mg twice a day for three days. Review of the radiology results report of the knee dated 09/29/23 revealed Resident #48 had an acute impacted fracture present at the proximal tibia without significant displacement and a nondisplaced proximal fibular fracture was present. The conclusion indicated an acute proximal tibia and fibular fracture. Review of the nursing progress note dated 09/29/23 timed 7:32 P.M. revealed Resident #48 had an x-ray of left knee due to chronic pain. The results showed an acute proximal tibia and fibular fracture. The NP was called and gave orders to send Resident #48 to the emergency room. The writer called an ambulance company, and they did not have anything available on this date and said to try back tomorrow. Another ambulance company was called, and they said to call back in three hours. The writer called the NP who indicated it would be okay to send Resident #48 to emergency room tomorrow. Review of the nursing progress note dated 09/29/23 timed 9:25 P.M. revealed Resident #48 stated the Norco was not effective for the pain. The nurse spoke to the on-call NP who gave orders to send Resident #48 to the emergency room via emergency medical services (911) for uncontrolled pain. Review of the nursing progress notes dated 09/29/23 timed 9:30 P.M. revealed the squad arrived to transport Resident #48 to emergency room. At 9:45 P.M. the squad left with Resident #48 and the nurse called report to hospital emergency room. Review of the transfer form assessment dated [DATE] timed 9:30 P.M. revealed Resident #48's pain level was an eight out of 10 to the left lower leg. Review of the injury incident report for Resident #48 dated 09/29/23 timed 7:00 P.M. authored by the Director of Nursing (DON) revealed Resident #48 reported increased pain to the left lower extremity. No noted bruising or swelling. An x-ray showed tibia and fibula fracture. Resident description: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366057 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 366057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Middleburg Heights Health & Rehabilitation Center 19530 Bagley Road Middleburg Heights, OH 44130 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 it started when [STNA #1] was putting me back to bed. My knee bent too much. Resident #48 reported a pain level of seven out of 10. Level of Harm - Actual harm Residents Affected - Few Review of the nursing progress note dated 09/30/23 timed 4:07 A.M. revealed the hospital emergency room called and Resident #48 would be returning. Resident #48 had a left proximal tibia and fibula fracture and would come back with an immobilizer on. Review of the nursing progress note dated 09/30/23 timed 11:17 A.M. revealed Resident #48 returned from the emergency room at 11:00 A.M. with a prescription for pain medication faxed to pharmacy and knee immobilizer on left knee. Review of the hospital emergency department discharge instructions dated 09/30/23 timed 12:44 A.M. revealed Resident #48 was diagnosed with a closed fracture of the left tibia and fibula. Resident #48 was ordered Percocet 5 mg-325 mg oral tablet by mouth every six hours for three days. Review of the Medication Administration Record (MAR) from September 2023 revealed Resident #48 received Norco 5-325 mg one tablet as needed for pain on 09/22/23 at 4:41 P.M., on 09/22/23 at 10:53 P.M. for a pain level of 10, on 09/23/23 at 10:11 A.M., 4:11 P.M. and 10:30 P.M., on 09/24/23 at 6:05 A.M., on 09/25/23 at 11:56 A.M., on 09/25/23 at 8:04 A.M. for a pain level of 10, on 09/26/23 at 10:19 A.M., on 09/27/23 at 4:00 P.M. and on 09/30/23 at 7:41 P.M. Resident #48 did not have Norco administered from 09/12/23 through 09/21/23. Review of the Treatment Administration Record (TAR) from September 2023 revealed Resident #48 had Voltaren gel applied twice a day to her left knee on 09/26/23, 09/27/23, 09/28/23 and 09/29/23. Review of the nursing progress note dated 10/02/23 timed 9:52 A.M. revealed Resident #48 was status post left tibia and fibula fracture. Resident had not complained of any pain. Resident remained on Percocet 5-325 mg every six hours for three days. Resident remained in an immobilizer. Review of the nurse practitioner progress note dated 10/02/23 authored by NP #5 revealed Resident #48 was seen for post emergency room visit and physical exam for tibia/fibula fracture. Repeat x-rays were ordered on 09/29/23 for continued pain to left lower leg. X-ray reports on 09/29/23 noted proximal tibia and fibula fracture to the left leg. Resident #48 was sent to the emergency room for evaluation and returned with immobilizer, Percocet and follow up with orthopedic physician. Resident #48 stated leg was feeling much better with immobilizer and Percocet. Rated pain a two out of 10 to left lower leg. Resident #48 was asked again to explain what happened during transfer on 09/22/23. Resident #48 stated she was transferring via Hoyer lift with aide and stated she bent left leg too far. Denied leg being twisted or hit on anything. The noted indicated NP #5 spoke with STNA #1 who said she pushed Resident #48's shin back slightly toward the resident so that she could move foot around Hoyer lift pole. STNA #1 heard a crack sound. Review of the pain assessment dated [DATE] revealed Resident #48 had a fracture to the tibia and fibula, was able to communicate and could articulate pain and had left lower extremity pain with movement. The pain was described as intermittent and sharp moderate pain. The pain interfered with the resident's physical activity. Percocet was changed from routine to as needed every eight hours for seven days. Review of the orthopedic physician note dated 10/05/23 revealed Resident #48 had a left tibia and fibula fracture. Resident #48 was ordered for left lower extremity to be non-weight bearing, brace (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366057 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 366057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Middleburg Heights Health & Rehabilitation Center 19530 Bagley Road Middleburg Heights, OH 44130 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 could be removed for bathing, monitor daily for skin integrity due to medical history and to follow up in three weeks. Level of Harm - Actual harm Residents Affected - Few Review of the MAR from October 2023 revealed Resident #48 was administered one tablet of Percocet 5-325 mg as needed on 10/02/23 at 9:33 P.M. for a pain scale of seven, on 10/03/23 at 7:03 A.M. for a pain scale of seven, on 10/04/23 at 12:19 A.M. for a pain scale of seven, on 10/04/23 at 7:49 P.M., on 10/05/23 at 9:05 A.M., on 10/06/23 at 8:05 A.M., on 10/08/23 at 12:52 A.M., on 10/09/23 at 5:50 A.M. and 2:13 P.M., on 10/23/23 at 2:59 P.M., on 10/24/23 at 12:34 P.M., on 10/25/23 at 7:46 P.M., on 10/29/23 at 1:00 P.M. and on 10/30/23 at 3:40 P.M. for a pain scale of seven. Review of nurse and STNA schedule from 09/22/23 revealed STNA #1 was assigned to care for Resident #48 from 7:00 A.M. to 7:00 P.M. Review of the witness statement dated 10/02/23 authored by STNA #1 revealed, while hoyering (mechanical lift) a resident alone, her legs ended up on opposite sides of hoyer lift. I then pulled hoyer pad back to get her positioned correctly to place in bed and got her into bed. Review of the witness statement dated 09/30/23 authored by the DON revealed the DON was in facility to interview Resident #48 after receiving notification of fracture to Resident #48's left tibia and fibula. Upon entering room, Resident #48 was in bed, watching television, talking on the phone. No signs or symptoms of acute distress, no objective signs, or symptoms of pain. Resident #48 stated that last week during a Hoyer transfer when STNA #1 was pulling her back, she hit her knee on the middle pole of the Hoyer. The DON inquired if a second STNA was present, and the resident said no. The DON also inquired if resident was in pain, resident stated that she was in pain and rated pain at a seven out of 10. Resident #48 denied swelling or bruising to her left lower extremity over the past week. Treatment options were discussed and Resident #48 was agreeable to waiting for transfer as non-emergent transport was not available at this moment. Resident #48 stated that she wouldn't mind waiting if she could be given something stronger than Norco for pain as he did not feel that Norco was effective. The NP was called and indicated if Resident #48 was in that much pain, call 911 to transfer. Emergency Medical Services was notified and resident was sent to hospital emergency room. Interview on 10/24/23 at 12:40 P.M. with STNA #1 revealed around 4:00 P.M., STNA #1 used the mechanical lift without another staff member to transfer Resident #48 from her motorized wheelchair to bed after the resident returned from dialysis. Resident #48's left foot got caught on the mechanical lift middle bar, so STNA #1 had a hold of the resident/mechanical lift pad with one hand and used her other hand to move the resident's legs around the pole. STNA #1 stated she did not bend the resident's legs back. After the transfer to the bed, Resident #48 complained of being sore however that wasn't unusual for the resident to complain of pain as the resident tended to have leg pain. STNA #1 verified she operated the mechanical lift without another staff member present and verified a mechanical lift was supposed to be operated with two staff members when transferring a resident. Observation on 10/24/23 at 12:50 P.M. revealed Resident #48 was lying in a bariatric bed, feeding herself lunch and watching television. Interview, during the observation, with Resident #48 revealed STNA #1 used the mechanical lift to transfer her from her motorized wheelchair to bed. STNA #1 had Resident #48 in a funky position during the transfer and the resident's left leg get bent all the way back by the rectangle metal bar. Resident #48 explained that she had to be rolled during incontinence care and every day after the incident the pain worsened during rolling to complete incontinence care. Resident #48 rated her pain level ranging from five to nine out of 10 after the incident and stated her pain was pretty severe. Resident #48 stated one day she had to end dialysis early because (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366057 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 366057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Middleburg Heights Health & Rehabilitation Center 19530 Bagley Road Middleburg Heights, OH 44130 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 of being in too much pain after the incident. Resident #48 verified STNA #1 transferred her using the mechanical lift without another staff member present when the injury occurred. Level of Harm - Actual harm Residents Affected - Few Interview on 10/24/23 at 1:35 P.M. with RN #2 revealed the day Resident #48 was transferred back to bed via the mechanical lift with only STNA #1 present, Resident #48 stated, when I was getting into bed, I pulled a muscle in my knee. At the time, RN #2 wasn't aware that STNA #1 used the mechanical lift alone and that the transfer was incorrectly completed. Interview on 10/24/23 at 2:50 P.M. with the DON verified on 09/22/23 STNA #1 completed Resident #48's mechanical lift transfer without another staff member resulting in Resident #48 sustaining a left leg tibia and fibula fracture. The DON also revealed it was her expectation and the facility policy for two staff members to complete a resident mechanical lift transfer. Observation on 10/31/23 at 8:25 A.M. with the DON revealed Resident #48 was wearing a soft leg immobilizer on her left leg extending from above her left knee to above left ankle. Review of the facility's Hoyer lift/mechanical lift policy revised 04/16/23 revealed it was the facility's policy to provide appropriate use of mechanical lifts and to utilize two staff members. Review of the facility's Transferring Using a Mechanical Lift Machine policy dated 09/28/23 revealed at least two nursing assistants (or other licensed and trained staff) were needed to safely move a resident with a mechanical lift. Review of the 2018 mechanical lift user manual for Reliant 600 revealed it was recommended that two assistants be used for all lifting preparations and transferring to/from procedures. Review of the disciplinary written warning form dated 10/02/23 revealed STNA #1 was issued a written warning due to substandard job performance. On 09/22/23, STNA #1 transferred resident from power chair to bed. She did not follow facility policy and procedure of using two staff for all mechanical lift transfers. Resident subsequently sustained an injury to her left knee and reported increase in pain to the area. This deficiency represents non-compliance investigated during the investigation of Complaint number OH00147265. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366057 If continuation sheet Page 5 of 5