Health inspection·December 4, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm calls. The facility identified at the time of the resident's fall, Agency LPN #210 did not notify her, the on-coming staff, the resident's daughter or the physician of the resident's fall on 11/25/23. Interview on 12/04/23 at 4:13 P.M. with LPN #207 revealed she came on duty the following shift on 11/25/23 and had not been notified or made aware of the resident sustaining a fall on this date. Residents Affected - Few Interview on 12/04/23 at 4:18 P.M. with Registered Nurse (RN) #211 revealed she heard someone yelling when she got to the nursing station on 11/26/23. She stated Resident #80 had a history of yelling out at night and was aware he had been originally admitted with diagnosis of rib fracture. She was looking at his pain medications when Resident #80 stated he needed a medic. RN #211 reviewed the resident's progress notes which was when she discovered he had sustained a fall the prior day. She assessed him then called the physician obtaining orders for STAT x-rays or to send the resident to ER. The daughter arrived during this time period and was informed of the fall at that time. Interview on 12/04/23 at 4:53 P.M. with STNA #202 revealed she was not made aware on 11/25/23 of the resident's fall that had occurred on day shift. This deficiency represents non-compliance investigated under Complaint Number OH00148736. This deficiency is also an example of continued non-compliance from the survey dated 11/22/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366127 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 366127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodlands Health and Rehab Center 6831 North Chestnut Street Ravenna, OH 44266 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, hospital record review, facility policy review and interview the facility failed to provide adequate supervision and assistance to prevent a fall with injury for Resident #80. Following the fall, the facility failed to complete a comprehensive assessment, provide ongoing monitoring and physician notification to ensure the resident received timely medical treatment. Actual Harm occurred on 11/25/23 at 5:45 P.M. when Resident #80, who was cognitively impaired, at high risk for falls and with a history of recent falls, sustained a fall from the wheelchair in the lounge area following dinner, resulting in a left hip fracture. At the time of the fall, the facility identified the resident had wanted to go to bed and attempted to stand from the wheelchair independently (no staff were with the resident at the time of the incident). Staff failed to comprehensively assess the resident at the time of the fall and on 11/26/23 between 10:00 A.M. and 12:00 P.M. the resident's daughter requested the resident be transferred to the hospital due to increased pain. The resident was subsequently diagnosed with a left hip fracture requiring surgical intervention. This affected one resident (#80) of four residents reviewed for falls. The census was 76. Findings include: Review of the closed medical record for Resident #80 revealed an admission date of 11/14/23. On 11/26/23 the resident was discharged to the hospital. Resident #80 had diagnoses including repeated falls, type two diabetes mellitus, hypertension, weakness, cognitive communication deficit and fracture of rib on left side. Review of the physician's orders for November 2023 revealed an order for two (staff) to assist for all transfers, bed in low position, bell to wheelchair, encourage to be in common areas (initiated following falls that occurred on 11/21/23) and mat to side of bed. A fall risk assessment, dated 11/24/23 revealed the resident was at high risk for falls. Review of the Minimum Data Set (MDS) assessment, dated 11/26/23, revealed the resident had impaired cognition with a Brief Interview for Mental Status (BIMS) score of 7 out of 15. Review of a nurse's notes dated 11/25/23 at 6:19 P.M. revealed the nurse was passing medications when she heard a loud boom. Nursing assistants were collecting trays near resident when the resident fell. The resident was observed laying on his left side. The resident's vital signs were obtained, blood pressure was elevated at 183/104. The note indicated the resident indicated he was ready to lay down in bed and was assisted by two staff back into his wheelchair. The resident was assessed to have redness to the left shoulder with no other visible injuries noted. The resident was toileted and then put to bed. The nursing note documented, will continue to monitor. The next nursing note entry, dated 11/26/23 at 12:17 P.M. revealed Immediate discharge notice. bed hold notice and care plan sent with pt to hospital. Record review revealed the resident had been transferred to the emergency room on [DATE] at 12:00 P.M. The note indicated daughter in facility and updated on plan (for STAT x-ray orders to both extremities), daughter wished for resident to be sent outpatient to emergency room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366127 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 366127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodlands Health and Rehab Center 6831 North Chestnut Street Ravenna, OH 44266 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 The nursing note, dated 11/26/23 at 1:38 P.M. revealed Resident #80 presented with pain to the left upper and left lower extremities. The physician ordered an x-ray to both extremities STAT or to send the resident to the emergency room (ER) if not able to obtain STAT testing. The note indicated the resident's daughter was in the facility and wished for the resident to go to the ER. Residents Affected - Few Review of a facility Post Fall Huddle (PFH) Form revealed Resident #80 sustained a fall on 11/25/23 at 5:45 P.M. When asked what he was trying to do, go to? What happened? The resident said he was trying to go to bed. The root cause of the fall documented on the form revealed the fall occurred because the resident was ready to lay down. A statement from the nursing assistant who witnessed the fall on 11/25/23 revealed the resident was sitting a wheelchair in the television room doorway in front of the nurse's station (so staff could see him better). The resident was highly confused. While staff were gathering up supper trays from resident rooms and loading them into the caddy, this nursing assistant saw Resident #80 stand up from his wheelchair; he very quickly stumbled fell on his side on the floor landed on his shoulder and leg. The statement indicated the nursing assistant was not fast enough to catch him. The nursing assistant notified the nurse and then they sat the resident up on his butt on the floor. The resident was lifted with a gait belt onto his wheelchair and then assisted him to bed. Interview on 12/04/23 from 10:03 A.M. to 12:15 P.M. with Certified Nurse Practitioner (CNP) #216, Licensed Practical Nurse (LPN) #212, Certified Occupational Therapy Assistant (COTA) # 218, Physical Therapy Assistant #215, Registered Nurse (RN) #220 and State Tested Nursing Assistant (STNA) #205 revealed when a resident fell they got the nurse to do an assessment prior to moving the resident from the floor. CNP #216 stated she was not notified about Resident #80's fall because she did not work that weekend. Interview on 12/04/23 at 12:16 P.M. with STNA #250 revealed she took care of Resident #80 on 11/25/23 and 11/26/23. She stated (on 11/25/23) she had heard a commotion while she was in another resident's room. By the time she came out, another STNA and nurse were with Resident #80. She did not assist at that time. She stated it was the end of her shift. She stated the next morning, on 11/26/23, she went to change the resident around 8:00 A.M. and he screamed during care. She noted the resident had a bruise on his left arm. She got the agency nurse, LPN #211, who assessed the resident's arm and leg. LPN #211 told STNA #250 not to move the resident until she called the doctor. STNA #250 stated she saw the resident's daughter in the building she thought between 10:00 A.M. to 11:00 A.M. and the daughter spoke to nurse. The daughter requested the resident be sent out to the hospital. Interview on 12/04/23 at 3:53 P.M. with the Director of Nursing (DON) revealed she was on-call the weekend of the incident and received no phone calls on 11/25/23 related to a resident fall. She questioned her Assistant Director of Nursing (ADON) who also stated she did not received any phone calls. The facility identified at the time of the resident's fall, Agency LPN #210 did not notify her, the on-coming staff, the resident's daughter or the physician of the resident's fall on 11/25/23. Interview on 12/04/23 at 4:13 P.M. with LPN #207 revealed she came on duty the following shift on 11/25/23 and had not been notified or made aware of the resident sustaining a fall on this date. Interview on 12/04/23 at 4:18 P.M. with Registered Nurse (RN) #211 revealed she heard someone yelling when she got to the nursing station on 11/26/23. She stated Resident #80 had a history of yelling out at night and was aware he had been originally admitted with diagnosis of rib fracture. She was looking at his pain medications when Resident #80 stated he needed a medic. RN #211 reviewed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366127 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 366127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodlands Health and Rehab Center 6831 North Chestnut Street Ravenna, OH 44266 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 resident's progress notes which was when she discovered he had sustained a fall the prior day. She assessed him then called the physician obtaining orders for STAT x-rays or to send the resident to ER. The daughter arrived during this time period and was informed of the fall at that time. Interview on 12/04/23 at 4:53 P.M. with STNA #202 revealed she was not made aware on 11/25/23 of the resident's fall that had occurred on day shift. Interview on 12/04/23 at 5:02 P.M. with the DON revealed she would have expected the nurse to do a head-to-toe assessment every shift for 72 hours following the fall. The DON verified there was no assessment completed on 11/25/23 from 7:00 P.M. to 7:00 A.M. because staff were unaware the resident had sustained a fall. Review of the hospital record for Resident #80 for his stay from 11/26/23 through 12/01/23 revealed he was admitted from the emergency department on 11/26/23 and diagnosed with a left hip fracture. The resident underwent an intramedullary nailing for the left hip on 11/28/23 and was stable to be discharged to a nursing home on [DATE]. Review of facility policy titled Fall Prevention and Management Policy, dated 12/09/19, revealed the facility will assess residents at admission, quarterly, after a fall and as needed. This deficiency represents non-compliance investigated under Complaint Number OH00148736. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366127 If continuation sheet Page 5 of 5