Health inspection·November 18, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few Resident #13. Review of the witness statement dated 07/26/25 by CNA #249 documented she was changing Resident #13 in bed at 10:55 A.M. and she rolled Resident #13 towards the window. Resident #13 grabbed the side rail and started shaking it which caused it to loosen up, and the side rail came off. Resident #13 fell out of bed onto her face. CNA #249 immediately ran to get the nurse. The nurse came into the room to look at Resident # 13, saw blood and called 911 immediately. Interview on 11/05/25 at 10:51 A.M., CNA #249 stated on the morning of 07/26/25 she provided incontinence care by herself and rolled Resident #13 away from her towards the window, on her left side, and she asked the resident to hold onto the side rail in the process. Resident #13 shook the left side rail with her hands during care. CNA #249 said the left side rail gave way, and Resident #13 fell off the bed landing on the floor face first. Resident #13 was screaming, and CNA #249 ran out of the room immediately, and called for the nurse. CNA #249 stated she was educated to check the side rails before using and get staff to assist with care. Interview on 11/13/25 at 11:43 A.M. with the DON stated she would educate an aid with one person assist who also was substantial maximal assistance, that included a confused resident with the following steps: at the bedside first make sure side rails are in position, educate resident on what you're doing, lower head of bed, elevate the bed at right height for proper body mechanics, stand on the side of the bed that she was closest to the bed rail, undress her bottoms including brief while on her back, ask the resident to assist in turning and grab the bed rail turning towards the aid, and stand there to have her roll towards the aid providing assistance in the turn with hands, protecting her head, and boney premises to provide incontinence care.Review of the facility policy titled Fall Management dated 10/17/2016 revealed the facility promoted programs geared to improving mobility, stamina, and reduce the risk of falls through a comprehensive, interdisciplinary process of assessment, care plan development, and implementation with ongoing monitoring and review. Management of falls, including residents, was to be assessed for injuries and vital signs and provided with prompt medical attention as needed. The deficient practice was corrected on 07/26/25 when the facility implemented the following corrective actions:- On 07/26/25 at 11:00 A.M., the DON called the Maintenance Director #251 to come in and examine the bed.- On 07/26/25 at 12:15 P.M., the DON, the Administrator, Assistant Director of Nursing (ADON) #225 and Maintenance Director #251 met to discuss the situation and the bed. Resident #13's bed was replaced due to the pins attaching the side rail being loose. Maintenance Director #251 provided his quarterly side rail and bed audits last completed on 07/14/25 and reported Resident #13's bed functioned properly.- On 07/26/25, Maintenance Director #251 completed a whole house audit of beds and there were no additional resident beds that needed replacement. - On 07/26/25, a Quality Assurance and Performance Improvement (QAPI) meeting was held to put a plan in place to correct the problem. The meeting consisted of the Administrator, the DON, ADON #225, and Maintenance Director #251.- On 07/26/25 at 12:45 P.M., the DON and ADON #225 provided education to all CNAs who were currently in the building and text messages went out to CNA staff who were not working. The education included checking the resident beds with side rails to ensure the pins were in proper position prior to care and additional competencies were reviewed including positioning of a resident during care.- On 07/26/25, the DON and ADON #225 revised Resident #13's care plan to reflect two-person assistance for all care. No other resident care plans required changes. - On 11/06/25, interview with CNA #249 stated she had been educated about having two people in the room, proper positioning, and to check the side rails before starting care to ensure they were attached.- On 11/06/25, two additional CNA's #301 and #230 reported they had training back in July related to positioning during care and checking side rails.- Review of the fall's documentation revealed there had been no current falls from the bed related to positioning or from the bed side (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366347 If continuation sheet Page 2 of 3 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 366347 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Veranda Gardens & Assisted Living 11784 Hamilton Avenue Cincinnati, OH 45231 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 rails falling off. - Review of the side rail audits dated from 07/26/25 through 08/31/25 revealed weekly audits were completed and there were no concerns identified. Side rail and bed audits continued quarterly thereafter.This deficiency represents non-compliance investigated under Complaint Number 2638584. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366347 If continuation sheet Page 3 of 3