Health inspection·December 22, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few from the ER with no other new orders. Vitals were checked and recorded and neurological checks continued.Review of the eMAR Medication Administration Note dated 12/06/25 timed 9:08 A.M. revealed Resident #23 was administered Acetaminophen oral tablet 500 milligrams (mg) with instructions to give 1000 milligrams (mg) every eight hours as needed for mild pain related to chronic pain syndrome. Resident complained of generalized pain and left knee pain; 10 out of 10 on the pain scale.Review of the eMAR Medication Administration Note dated 12/06/25 timed 9:10 A.M. revealed Resident #23 was administered Cyclobenzaprine HCl (a muscle relaxant medication) oral tablet with instructions to give 10 mg orally every eight hours as needed for muscle spasms. Resident #23 complained of generalized pain and left knee pain; 10 out of 10 on the pain scale.Review of the nurse note dated 12/06/25 timed 7:00 P.M. revealed Resident #23's representative returned the call for notification of the resident's fall on 12/05/25. No concerns were voiced at this time.Review of the fall care plan revised on 12/06/25 revealed Resident #23 was at risk for falls related to behaviors: hoarding items in room, history of falls, medications, obesity, poor balances, psychoactive drug use with interventions which included: implement preventative fall interventions/devices and inspect Hoyer pad prior to use/transfer.Review of Resident #23's witness statement obtained via telephone by the Administrator dated 12/06/25 revealed Resident #23 was picked up from his chair to be put in bed and the strap broke. The resident's back hit the side of the bed and then buttock on the floor. The second time Resident #23 was lifted, the resident thought the strap broke again. Resident #23 did not see the staff switch the lift, but the staff did nothing different than any other time they assisted the resident. There were two aides (Certified Nursing Assistant (CNA) #72 and CNA #73) and the nurse came in after the first fall.Review of CNA #72's witness statement obtained via telephone by the Administrator dated 12/06/25 revealed CNA #72 was in the room with CNA #73 to lift Resident #23 into bed. CNA #73 removed the chair from the area and CNA #72 moved the lift in front of Resident #23's chair. The lift was in the proper position with the legs open and the sling loops on green and purple. As the staff were lifting him, the strap broke on the sling and Resident #23 fell. His back hit the edge of the bed and then his bottom landed on the floor. The nurse, RN #74, came in to assess the resident following the fall. At this time, CNA #72 obtained another pad to lift the resident. The staff were lifting the resident and the piston on the Hoyer gave out. The resident started to quickly drop to the floor again. The resident was not swaying or tipping and was equally balanced on both attempts. The resident had an injury on his forehead, nose and knee following the second fall. The staff were able to get him up on a third attempt using a different lift.Review of CNA #73's witness statement obtained via telephone by the Administrator dated 12/06/25 revealed CNA #73 was in the room with CNA #72 assisting Resident #23 to bed from his chair. CNA #73 was controlling the lift and CNA #72 was in the back. The first time the staff tried to lift him, the strap broke and was still attached to hooks of the lift. The aides got a second sling while the nurse was in the room with the resident. The aides tried to get the resident up from the floor and had to roll him to either side to get the new pad under him. The aides got the lift all the way down to pick him a second time. The resident was almost the same level as the bed and then the lift started to shake then the resident went down to the floor quickly. The aides called the nurse again to the room. The nurse checked the resident and the resident complained of pain in his left knee. The aides brought in a second lift, lowered the bed to the lowest position and assisted him to bed. Each time we attempted to lift the resident the legs were open and he was balanced. At no time did the resident sway, rock or tip while in lift.Observation on 12/22/25 at 8:40 A.M. revealed Resident #23 was lying in bed on his side then rolled to his back. Interview, during the observation, with Resident #23 revealed he had fallen twice during a mechanical lift (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366095 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 366095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glenwood Care and Rehabilitation 836 West 34th Street NW Canton, OH 44709 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 - Minimal harm or potential for actual harm Residents Affected - Few transfer from his chair to his bed when the strap broke twice. Resident #23 stated two staff members were assisting with the mechanical lift transfer when he fell. The first fall, Resident #23 fell back against the bed and landed on his buttocks. The second fall, Resident #23 fell on his face and was able to brace himself with his hands. Resident #23 stated the same mechanical lift was used during both transfers however a different mechanical lift pad was used on the second transfer. Resident #23 stated he was sent to the hospital and did not have any broken bones and returned to the facility the same day.Observation on 12/22/25 at 11:15 A.M. with the Administrator revealed the mechanical lift (Serial #4A13020093), used to transfer Resident #23 when he fell twice on 12/05/25, was behind a locked door stored in the maintenance workroom. There was a lock applied to a cable preventing usage.Interview on 12/22/25 at 11:35 A.M. with CNA #72 revealed CNA #72 and CNA #73 attempted to transfer Resident #23 from his wheelchair to his bed when he fell twice from a mechanical lift. During the first fall, one of the bottom straps broke near the residents foot and Resident #23 hit the bed and then landed on his buttocks on the floor. CNA #72 reported CNA #72 and CNA #73 had inspected the straps prior to the transfer to ensure the straps were not frayed or torn. CNA #73 ran and got Registered Nurse (RN) #74 to assess the resident and obtain another mechanical lift pad. The staff rolled Resident #23 on to the other mechanical lift pad and used the same mechanical lift to lift the resident off the floor when the machine's hydraulics gave out and Resident #23 fell on his face. CNA #72 reported Resident #23 was approximately waist height when he fell from the mechanical lift during both falls.Interview on 12/22/25 at 12:00 P.M. with RN #74 revealed two CNA's were transferring Resident #23 from his wheelchair to the bed when one of the straps on mechanical lift pad broke. RN #74 assessed the resident and left the room to call the physician. The CNA's obtained another mechanical lift pad and was transferring the resident off the floor when the hydraulics went out on the mechanical lift causing the resident to fall again, hitting his head. Resident #23 reported he wasn't in too much pain.Interview on 12/22/25 at 3:05 P.M. with CNA #73 revealed Resident #23 fell twice during a mechanical lift transfer. The first time, one of the straps broke on the mechanical lift pad. During the second fall, CNA #73 wasn't sure what happened. CNA #73 stated Resident #23 had a bump on his head from the second fall.Review of the Drive Medical Electric Patient Lift Item #13240 manual revealed it was extremely important that the lift be inspected before each use.The deficient practice was corrected on 12/09/25 when the facility implemented the following corrective actions: - On 12/05/25 at 11:40 P.M., CNA #72 and CNA #73 removed the mechanical lift pad from the floor.- On 12/05/25 at 11:50 P.M., CNA #72 and CNA #73 removed the mechanical lift from the floor.- On 12/06/25, Maintenance Director #75 removed the malfunctioned mechanical lift from operation behind a locked door and locked the cords to prevent usage.On 12/06/25, the Administrator disposed of the mechanical lift pad with a broken strap into the garbage. On 12/06/25 at 10:30 A.M., an AD HOC Quality Assurance and Performance Improvement (QAPI) meeting was conducted with the Administrator, Maintenance Director #75, the Director of Nursing (DON), Assistant Director of Nursing (ADON) #76, Regional Nurse Consultant #77 and Regional Director of Operations #78.On 12/06/25, Maintenance Director #75 inspected all seven mechanical lifts for mobile lift safety without any negative findings.- On 12/06/25, Laundry/Housekeeping Director #79 educated all laundry staff on proper laundering of the mechanical lift pads and what to do if a mechanical lift pad was damaged.- By 12/08/25, the DON completed a mechanical lift competency evaluation with all nurses and CNA's without any negative findings.- By 12/09/25, the DON and ADON #76 educated all nurses and CNA's on inspecting the mechanical lift pad and proper mechanical lift techniques.- On the week of 12/07/25 and 12/14/25, Laundry/Housekeeping Director #79 audited all 23 mechanical lift pads for integrity without any negative findings. Maintenance Director (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366095 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 366095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glenwood Care and Rehabilitation 836 West 34th Street NW Canton, OH 44709 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 - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete #75 or the DON/designee would continue to inspect all mechanical lift pads five times weeks for two additional weeks.- On the week of 12/07/25 and 12/14/25, Maintenance Director #75 audited all mechanical lifts without any negative findings. Maintenance Director #75 would continue the audit for two additional weeks.- On the week of 12/07/25 and 12/14/25, the DON audited four nursing staff perform a mechanical lift transfer with inspecting the sling prior to use without any negative findings. The DON/designee would continue the audit for two additional weeks.- On 12/15/25, the Administrator ordered 10 new size large mechanical lift pads and six new extra-extra-large mechanical lift pads.- On 12/17/25, the Administrator audited and disposed of 12 mechanical lift pads in circulation and replaced the pads with 21 new mechanical lift pads.- On 12/22/25, CNA #70, CNA #71, CNA #72, CNA #73, and RN #74 were interviewed and verified mechanical lift and pad education and mechanical lift competency evaluation were completed after Resident #23's falls.This deficiency represents non-compliance investigated under Complaint Number 2690320. Event ID: Facility ID: 366095 If continuation sheet Page 4 of 4