Health inspection·October 21, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few femoral metadiaphysis. The resident was then transferred to the emergency room and returned wearing a leg immobilizer and a recommendation for an orthopedic consultation. Interview with Certified Nursing Assistant (CNA) #568 on 10/16/25 at 4:12 P.M. revealed Resident #88 didn't have leg rests on her wheelchair on 08/30/25 and while pushing her back to her room from dinner her feet were dangling, her toes grazed the floor, and her left foot skidded under the wheelchair. CNA #568 also stated she tried to recline Resident #88's chair when the resident complained of pain in her left leg/knee. CNA #88 stated it was common knowledge among the CNAs that Resident #88 would not lift her feet while being transported and would often need reminded to do so. She was unaware of what Resident #88's care plan said with regard to transporting her in the wheelchair or whether or not she was supposed to have leg rests. Interview the CNA #564 on 10/16/25 at 5:02 P.M. revealed Resident #88 had a short chair, her feet always drug on the ground, and she needed to be leaned back while she was moving. CNA #564 also stated Resident #88's feet were always on the ground and indicated the resident needed to have leg rests (on the wheelchair) but didn't have them. CNA #564 also stated this was common knowledge among the CNAs. CNA #564 stated when she came in to work on 08/30/25, Resident #88 was in a lot of pain when the resident was assisted to bed and the nurse on duty gave her Tylenol (analgesic). CNA #564 stated the next morning, the resident was still in a lot of pain every time she moved her left leg. CNA #564 further stated Resident #88 would often drop her feet and stop the wheelchair from moving while being transported. CNA #564 stated she told everyone this resident needed leg rests, but she didn't have them until after her knee injury was confirmed on 08/31/25. Interview with Licensed Practical Nurse (LPN) #507 on 10/16/25 at 2:50 P.M. revealed on 08/30/25 Resident #88 was in her wheelchair when a CNA told her the resident was complaining of pain in her left leg. LPN #507 stated she assessed Resident #88's left leg at the time and gave her some Tylenol for pain. LPN #507 stated the resident was then sleeping soundly within an hour. LPN #507 stated it was not reported to her that the resident's foot dropped under her wheelchair while being propelled by staff (as a source/cause of the pain). Interview with LPN #527 on 10/16/25 at 3:22 P.M. revealed on 08/31/25, CNA #564 told the nurse that Resident #88's foot dropped under her wheelchair while being transported from dinner the during the previous shift. LPN #527 proceeded to assess for pain, notified the doctor and obtained an x-ray and sent the resident to the emergency room (ER) for evaluation. The resident returned to the facility the same day with a diagnosis of a fractured distal medial femoral metadiaphysis and a knee immobilizer. Review of the resident's progress note authored by LPN #507 dated 10/03/25 at 6:06 P.M. revealed appears Hoyer pad not positioned right under resident. Hoyer pad up too high on resident legs and resident buttocks slid out from pad and on to floor. Review of an additional progress note dated 10/04/25 at 2:44 A.M. authored by LPN #523 revealed the resident returned from the hospital with a soft cast on her right upper extremity and a sling was also noted. The note revealed a diagnosis of a closed fracture of right upper extremity and an order to follow up with an orthopedic surgeon as soon as possible. Review of the facility's fall investigation dated 10/03/25 revealed during hands on care two CNAs witnessed the resident sliding from the Hoyer lift sling to the floor. Prior to the fall Resident #88 was in bed. Hands on care was provided by a CNA for incontinence, and the Hoyer pad was placed under the resident by a CNA. Two CNAs were in the room and hooked the sling under the resident up to the Hoyer lift. CNA #578 opened the legs of the Hoyer and used the remote to lift the resident up from bed. CNA #571 guided the resident in the lift off of the bed. CNA #578 turned to get the chair positioned for resident placement. CNA #571 was moving the Hoyer to the chair when the resident slid out from the feet end of the Hoyer pad to the floor between the legs of the Hoyer. The CNAs witnessed the resident sliding feet first, then to her buttocks, and on to her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366281 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 366281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483 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 right side. When LPN #507 entered the room, she noted the resident laying on the floor between the opened Hoyer legs. Resident #88's legs were over one leg, and her shoulders were on the other leg of the Hoyer. The resident complained of pain in the right arm. Range of Motion (ROM) was completed to the resident's legs. A left leg with immobilizer was in place (from the incident that had occurred on 08/30/25), and ROM was at baseline. Right leg-ROM was within normal limits (WNL) at baseline. The resident's left arm ROM was WNL at baseline. Right arm ROM was not completed due to complaints of pain. The CNA stated the resident did not hit her head during the fall. Vital signs were obtained which included blood pressure:141/87, temperature: 98.1 degrees Fahrenheit (F) oxygen was 98 percent at three liters per nasal cannula, heart rate: 92, respirations:16. Resident #88's level of consciousness (LOC) assessment WNL at baseline. Resident #88 was alert and oriented to self with minimal speech, yes or no question answered. The floor was dry. No obstacles or devices to contribute, and the bed brakes locked. Resident #88 was continent during the incident. Resident #88 was wearing gripper socks. Lighting was adequate in the room. The nurse notified the physician of the incident and complaints of pain in the right arm. The physician ordered the resident be sent to the ER for evaluation. 911 called and Emergency Medical Services (EMS) assisted the resident off the floor to the gurney and transported her to the local hospital. The resident's guardian and family were notified. Hospital visit- the resident had an x-ray of the humerus and right shoulder. X-ray results revealed fractures of the right elbow. Resident #88 returned to the facility with a sling and soft cast to the right arm and an order for ortho follow up. Tylenol was given for comfort and the circulation check was WNL to the right upper extremity. Interview with CNA #571 on 10/16/25 at 3:00 P.M. revealed she and CNA #578 started hooking Resident #88 up to the Hoyer sling and then switched places. CNA #571 stated she was going slow with the Hoyer lift toward the chair when all of a sudden, Resident #88 just dropped, and CNA #571 didn't know why. CNA #571 stated she thought she had the pad underneath her correctly. CNA #571 stated she raised the Hoyer over the bed and pulled the resident out and away from the bed and swung her toward the chair and she just slipped out. CNA #571 stated the other CNA got the nurse and checked her over. A couple of other nurses came to check her out, staff called 911, and the ambulance came to take her to the hospital. Interview with CNA #578 on 10/16/25 at 4:12 P.M. revealed on 10/03/25 she was assigned to other residents, but CNA #571 needed help with the Hoyer. She entered Resident #88's room when the resident was already in the Hoyer pad and hooked up to the Hoyer. CNA #571 started to raise the resident, and she was above her bed and was raised up. CNA #571 pulled the resident out and away from her bed a little. CNA #578 stated the right Hoyer leg was angled wrong, and she tried to fix it. CNA #571 started to turn the resident when the resident slid down and fell between the open legs of the Hoyer. CNA #578 ran to the nurse for help and ran back to help her and sat with the resident until the ambulance came and took the resident to the hospital. Interview with LPN #507 on 10/16/25 at 2:55 P.M. revealed on 10/03/25 when she arrived in Resident #88's room, the resident was lying on the floor between the open legs of the Hoyer. Resident #88's body was in the middle of the Hoyer legs, her shoulders were resting on one of the Hoyer legs, her head was being cradled by CNA #578, and her legs were over the other Hoyer leg. Resident #88's left leg was in an immobilizer from a previous injury. Resident #88 complained of pain when her right arm/shoulder were touched lightly, and the Hoyer pad on left side was not hooked. The Hoyer pad was not torn or frayed, it seemed to be in good condition for use, and the Hoyer clips were in place. LPN #507 stated another nurse called an ambulance, and the ambulance crew got the resident up off of the floor and took her to the hospital. LPN #507 further stated she didn't think the Hoyer pad was down far enough to support the resident's hips and buttocks because of the immobilizer on her leg. Interview with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366281 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 366281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Resident #88's granddaughter via telephone on 10/16/25 at 10:40 A.M. revealed her concerns that the Resident suffered two injuries at the facility in such a short time and she stated her hope that this doesn't happen to anyone else. Resident's granddaughter also stated her desire to advocate for the Resident who was cognitively impaired and couldn't speak on her own behalf. Review of the facility's policy titled Hoyer Lift - One Piece Sling with Straps revised November 2024 revealed Hoyer slings are to be placed half-way under the resident so the lower edge is slightly below the knees and the resident should be centered on the sling with the lower edge right behind the resident's knees. The deficient practice was corrected on 10/13/25 when the facility implemented the following corrective actions: The facility completed an audit to review all current facility residents to determine if leg rests were in place/available for residents that require assistance with wheelchair mobility. This quality assurance (QA) audit was completed on 09/01/25 by the facility QA nurse. Leg rests that were identified as needed through the audit were provided and this added to the Kardex /care plan by the facility MDS nurse by 09/05/25. On 09/02/25, a new order was obtained for Resident #88 to be up in a Broda chair (tilt-in-space positioning chair) with elevating leg rests. Her care plan was updated on 09/03/25 to reflect this change. An ad-hoc quality assurance and performance improvement (QAPI) meeting was held on 09/02/25 to review wheelchair transport on 08/30/25 for Resident #88. A plan of action was discussed and developed to include actions already taken by the facility. The medical director was also notified of the incident with Resident #88 by the facility DON on 09/02/25. Re-education was initiated with all CNA's on making sure leg rests are in place on wheelchairs for residents that require assistance with wheelchair mobility or determined to need leg rests for transport. The re-education was provided by the facility QA nurse and CNA supervisor and was started on 09/02/25 and completed by 10/12/25. Observation audits were initiated on 09/08/25 and were done by the facility QA nurse. Observation audits of 10 residents three times a week. Any issues identified during the audits will be immediately addressed with the individual responsible. Audits will be reviewed by the QAPI at the next three QAPI meetings. Immediate inspection of the Hoyer lift was completed by the charge nurse on 10/03/25, and no issues with the Hoyer lift were found. On 10/03/25, CNAs #578 and #571 were immediately in serviced by charge nurse on the Hoyer Lift policy. On 10/06/25, all Hoyer lifts and slings were inspected by the facility QA nurse with no issues noted. An ad-hoc QAPI meeting was held on 10/06/25 by the facility DON and QA nurse. The medical director was notified by the facility corporate nurse on 10/06/25. All clinical staff were educated on the Hoyer lift transfer policy by the QA Nurse and CNA supervisor. The education began on 10/03/25 and was completed by 10/13/23. All CNAs had a Hoyer lift competency completed by the facility QA nurse or CNA supervisor and follow up Hoyer lift Quiz. All residents that require a Hoyer lift trans-fer were assessed for appropriate size lift pad on 10/06/25 by the facility QA nurse. Hoyer lift observation audits were completed by the QA Nurse four times a week for four weeks. All observation audits will be reviewed by the QAPI committee at the next three QAPI meetings. This violation represents non-compliance investigated under Complaint Number 2640382. Event ID: Facility ID: 366281 If continuation sheet Page 4 of 4