Inspection·July 10, 2023

F 0689 all times as resident will tolerate and allow to support feet; and Dycem® (nonslip material) to seat to reduce risk of sliding out of chair, initiated 06/08/23. Level of Harm - Actual harm Residents Affected - Few Review of the hospital documentation dated 06/07/23 revealed the Resident #84 presented to the hospital following a fall out of his wheelchair. A Computed Tomography (CT) scan was performed which revealed Odontoid (toothlike projection from the second cervical vertebra on which the first vertebra pivots) fracture and bilateral First Cervical (C1) lamina fracture with minimal displacement. Review of the 06/07/23 fall investigation completed by the facility for Resident #84 revealed Resident #84 had been assisted by a team member from the dining room, in a wheelchair without foot pedals. Resident #84 planted his feet down and slid forward out of the wheelchair and onto the carpet. This resulted in a C1 fracture, the root cause was documented as being pushed without foot pedals. Review the Interdisciplinary Team (IDT) notes dated 06/08/23 at 10:37 A.M., revealed on 06/07/23, Resident #84 was being assisted by Administrator #15, from the dining room when Resident #84 planted his feet, stopping his wheelchair, sliding forward, and landed face down on the carpet. The fall was witnessed and Resident #84 was immediately assessed and after denying pain and answering questions appropriately, he was assisted onto his back. Resident #84 was not documented as complaining of pain, was observed talking and joking with staff prior to Emergency Medical Services (EMS) arrival. A large rug abrasion was noted to his forehead. Interventions upon return were to always have foot pedals as Resident #84 tolerated and a Dycem® will be applied to the seat of the wheelchair to reduce sliding. Review of all staff education dated 06/08/23, provided by the Director of Nursing, regarding wheelchair safety and propelling included educating staff residents were not to be transported without foot pedals at any time unless they have been care planned as such due to their refusal and safety education had been provided to them first. Review of the 06/11/23 progress note revealed Resident #84 returned to the facility around 9:00 P.M., with a C1 fracture and a neck collar to be always worn. Bruising to left elbow, skin tear to left ankle due to fall and abrasion to forehead were documented. Interview on 07/06/23 at 11:12 A.M., with Registered Nurse (RN) #10 revealed she was working on 06/07/23 when Resident #84 fell from his wheelchair. She stated he was being pushed by Administrator #15 in his wheelchair, without his foot pedals. Resident #84 fell, after he planted his feet during transport, which caused him to fall forward onto the carpet. Interview on 07/06/23 at 11:24 A.M., with Administrator #15 revealed on 06/07/23 Resident #84 went to lunch late and she attempted to assist him back to his room. She acknowledged he usually had foot pedals on his wheelchair, however, on that day he did not. She admitted it was completely my fault, she did not ensure the foot pedals were in place prior to transport. Resident #84 dropped his feet as she was assisting him down the hall, which caused him to fall from the wheelchair. Administrator #15 stated after the incident, therapy did a facility audit to identify the residents who required foot pedals, education was provided to the staff in general and she received one on one education from the Director of Nursing, Dycem® was also placed on Resident #84's wheelchair and his care plan was updated. Interview and observation on 07/06/23 at 12:29 P.M., revealed Resident #84 was observed in his room with cervical collar in place, sitting in his wheelchair with foot pedals present. Resident #84 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366245 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 366245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Glen Health Campus 2150 Montego Drive Springfield, OH 45503 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 unable to recall the exact events of his fall. Level of Harm - Actual harm Interview on 07/06/23 at 1:37 P.M., with Physical Therapist (PT) #16 revealed residents who could not self-propel in a wheelchair were identified by the therapy staff and the name list was provided to the facility to ensure pedals were in place. PT #16 stated Resident #84 had leg strength to self-propel for a short time up to around 30 feet upon discharge from therapy in April, but he required assistance from staff to and from the dining room to his room (111 feet) and for any outings, and appointments. Residents Affected - Few Review of the policy titled, Fall Management Program Guidelines revised 03/16/22 revealed the facility strives to maintain a hazard free environment, mitigate fall risk factors, and implement preventative measures. As a result of the incident, the facility took the following action to correct the deficient practice by 06/09/23. • On 06/08/23, one-on-one education for general safety measures when assisting residents while in wheelchairs and the use of adaptive equipment such as foot pedals and to review profiles and care plans for prevention of falls or injury provided for Administrator #15 by the Director of Nursing. • On 06/08/23, all staff in-service was provided on the use of adaptive equipment and wheelchair safety, by the administrative staff or designee. All staff signed as receiving the training via electronic signature or in person signature. • On 06/08/23, the Therapy department assessed all residents and identified 35 residents as requiring foot pedals for wheelchair transportation. • On 06/08/23, care plans for the identified residents utilizing foot pedals/rest were updated by the MDS nurse. • On 06/08/23, the Quality Assurance team met and discussed corrective action plan of in-service and audits for safely transporting resident with wheelchair pedals on. • On 06/09/23, audits of wheelchairs utilizing foot pedal/rest during transports were completed by the Administrator or designee and will continue for six weeks. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366245 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 366245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Glen Health Campus 2150 Montego Drive Springfield, OH 45503 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 Review of wheelchair audits revealed audits were completed on 06/09/23, 06/12/23, 06/15/23, 06/22/23, 06/28/23 and 07/05/23 revealed foot pedals were present on the wheelchairs of each of five random residents reviewed on those dates. Residents Affected - Few • Interview on 07/10/23 from 2:57 P.M. to 3:07 P.M., with Registered Nurse #10 and State Tested Nurse Aides (STNA) #18, #19 revealed each acknowledged they had received education on wheelchair safety and the use of foot pedals for residents who were not able to propel the wheelchair on their own. All staff was able to verbalize the procedure. This deficiency represents the non compliance investigated under Complaint Number OH00143687. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366245 If continuation sheet Page 4 of 4