Health inspection·June 12, 2023

F 0689 she was to be toileted AC, PC, HS and early AM, toilet at 7:00 A.M. every morning per the fall risk plan of care. A new intervention was initiated to place a sign on the resident's bathroom door to ask for assistance. Level of Harm - Actual harm Residents Affected - Few Interview on 06/12/23 at 1:19 P.M. with the Director of Nursing (DON) verified the fall investigation was not thorough and did not include if care planned interventions were in place at the time of the fall on 03/11/23. Review of the nurses note dated 03/16/23 at 11:10 A.M. stated Resident #38 was found by housekeeping staff on the floor on her left side in front of the heating unit. A purple bruise was noted above her left eye. The resident was assessed by nursing staff, and no injuries were noted. Neurological checks were initiated and within normal limits, pupils were equal and reactive, hand grasps were equal and strong, push pulls with feet were also equal and strong. The resident was assisted to the wheelchair by two staff. The resident stated she was trying to go around the side of the bed and lost her balance and fell. CNP #203 was notified with no new orders, and the residents POA was notified. The resident was taken to the nurse's station for observation and would be served lunch in the dining room today. Review of the fall investigation dated 03/16/23 did not indicate if the call light was within reach and/or if the call light was activated and did not indicate when Resident #38 was last toileted as she was to be toileted AC, PC, HS and early AM, toilet at 7:00 A.M. every morning per the fall risk plan of care. A new intervention was a referral to physical therapy (PT) and speech therapy (ST). Interview on 06/12/23 at 1:19 P.M. with the DON verified the fall investigation was not thorough and did not include if care planned interventions were in place at the time of the fall on 03/16/23. Review of the nurse's note dated 03/20/23 at 10:35 A.M. revealed Resident #38 was evaluated and picked up by PT for strengthening related to the fall on 03/16/23. Resident #38 also continued to work with ST for cognitive decline. Review of the nurse's note dated 03/22/23 at 3:17 P.M. revealed Resident #38 complained of left lower back and left upper hip pain. CNP #203 was notified and ordered an x-ray of lumbosacral (LS) spine, left hip, and left pelvis- two views. The resident's POA was present during the assessment and notified of the orders for the x-rays. Review of the nurse's note dated 03/25/23 at 11:10 A.M. (three days after the x-ray was ordered) revealed the x-ray results revealed an acute nondisplaced fracture of the inferior sacrum is not excluded. CNP #203 was notified and stated to continue to monitor for pain levels with no new orders. Resident #38's POA was notified and requested a consult for hospice. Review of the nurse's note dated 03/30/23 at 1:10 P.M. revealed Resident #38 was admitted to hospice today. Review of the significant change in status MDS assessment dated [DATE] revealed Resident #38 had severe cognitive impairment and now required minimal assistance of one staff for bed mobility and walking and limited two staff assistance for transfers. She was now frequently incontinent of bowel and bladder. Review of Resident #38's fall risk care plan dated 04/03/23 stated the resident had a potential (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366385 If continuation sheet Page 2 of 6 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 366385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury of Twinsburg 9928 Vail Drive Twinsburg, OH 44087 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 risk for falls related to decreased mobility, weakness, impaired safety awareness. Resident #38 was educated regarding wearing proper footwear during transfers/ambulation and utilize call light for assistance but was still impulsive despite one on one (1:1) education, Dycem (non-slip material) to the seat of the wheelchair, cue to assist and toilet AC, PC, HS and early AM, toileting every two hours, low bed, call light in reach, monitor for pattern of risk or tendency to fall. A fall assessment for significant change was completed on 04/04/23, and the resident was high risk. Review of the nurse's note dated 04/07/23 at 4:47 P.M. the laundry aide came to this nurse and stated, The aide is back there with resident on the floor, he is asking for a nurse. Upon entering, Resident #38 was lying on the floor, head lying beside armoire, under the window with feet pointed toward the floor. Resident #38 stated I was trying to come around here (the bed) and fell. The resident had a diagnosis of dementia and was alert and oriented times two. Pressure was enforced to the head wound, 911 was called, vital signs were obtained, and the resident was sent to the local emergency room. The resident's POA, the physician, and hospice were notified. Review of the nurse's note dated 04/07/23 at 9:45 P.M. revealed Resident #38 returned from the local emergency room with stitches (staples) in the back of her head. Review of the fall investigation dated 04/07/23 stated Resident #38 was incontinent at the time of the fall but did not indicate if the call light was within reach and/or if the call light was activated and did not indicate when the resident was last toileted as she was to be toileted AC, PC, HS and early AM, toilet at 7:00 A.M., every morning per the fall risk plan of care. The investigation also did not indicate what footwear the resident was wearing at the time of the fall or if Dycem was on the wheelchair. Interview on 06/12/23 at 1:19 P.M. with the DON verified the fall investigation was not thorough and did not include if care planned interventions were in place at the time of the fall on 04/07/23. Review of the medical record revealed Resident #38's bed was moved against the wall on 04/08/23 at 9:10 A.M. Review of the nurse's notes dated 04/09/23 revealed the nurse heard Resident #38 yelling from inside her room. Upon entering the room, Resident #38 was found sitting on the floor on her bottom in front of her dresser. Her wheelchair was to the left side with the extra seat cushion on the floor next to the chair. Resident #38 was assessed for injury and vitals were obtained; no injuries were noted. Resident #38 was moved to the 300-hall dining room. Review of the fall investigation dated 04/09/23 stated Resident #38 was heard yelling from room, sitting on bottom on the floor on front of dresser, wheelchair at her side. The extra cushion for the wheelchair seat was beside her on the floor. The resident stated she was trying to get out of the wheelchair. Dycem was added as on immediate intervention. (Dycem was to be on the wheelchair before the fall per the 04/03/23 care plan). The resident was not incontinent. The fall investigation did not indicate if the call light was within reach and/or if the call light was activated and did not indicate when the resident was last toileted as she was to be toileted AC, PC, HS and early AM, toilet at 7:00 A.M. every morning and every two hours per the fall risk plan of care. The investigation also did not indicate what footwear the resident was wearing at the time of the fall. Interview on 06/12/23 at 1:19 P.M. with the DON verified the fall investigation was not thorough and did not include if care planned interventions were in place at the time of the fall on 04/09/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366385 If continuation sheet Page 3 of 6 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 366385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury of Twinsburg 9928 Vail Drive Twinsburg, OH 44087 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 Review of the nurse's note dated 04/14/23 at 6:51 P.M. stated the nurse and caregiver heard Resident #38 yelling out for help. Upon entering the room, the nurse observed the resident lying on her back on the floor in front of the bathroom door. Vital signs were obtained, and skin assessment performed with no injuries were noted. The resident complaint of back pain, and the as needed Tylenol (analgesic) was administered. CNP #204 was notified and advised to monitor. Hospice and the resident's POA were notified. The note included the resident was to be up in the 300-hall dining room for all meals. Review of the fall investigation dated 04/14/23 stated the nurse and aide heard Resident #38 yelling out for help. Upon entering Resident #38's room, she was observed by the nurse lying on her back on the floor in front of the bathroom door. Vital signs were obtained, and she was assessed for injuries; none were found. An immediate intervention of to be up in the 300-hall dining room for all meals was implemented. The resident was not incontinent. The fall investigation did not indicate if the call light was within reach and/or if the call light was activated and did not indicate when the resident was last toileted as she was to be toileted AC, PC, HS and early AM, toilet at 7:00 A.M. every morning and every two hours per the fall risk plan of care. The investigation also did not indicate what footwear the resident was wearing at the time of the fall. Interview on 06/12/23 at 1:19 P.M. with the DON verified the fall investigation was not thorough and did not include if care planned interventions were in place at the time of the fall on 04/14/23. 2. Review of the medical record for the Resident #50 revealed an admission date of 04/21/23 and a discharge date of 05/07/23. Diagnoses included kidney disease, osteoarthritis, dementia, and right femur fracture. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #50 had impaired cognition and required limited assistance of one staff for bed mobility, transfers, and ambulation. Review of the fall risk assessment dated [DATE] revealed Resident #50 was at moderate risk for falls. Review of the plan of care dated 04/21/23 revealed Resident #50 was at risk for falls due to deconditioning. Interventions included bed in lowest position, use and accessibility of call light, non-skid socks at all times when not wearing shoes, assisting and toileting each morning, afternoon, evening and as needed (prn), and ensure frequently used items within reach at all times. Review of physician orders for June 2023 identified orders for a low bed at all times unless providing personal care and assisting and toileting each morning, afternoon, evening prn. Review of the nurse's note dated 04/25/23 at 9:59 A.M. revealed Resident #50 was found on the floor on her right side. The nurse completed an assessment and reported Resident #50 had pain to the right buttock, hip, and leg. Review of the fall investigation dated 04/25/23 revealed Resident #50 was to be checked for incontinence at 11:00 P.M., 1:00 A.M., 3:00 A.M., 5:00 A.M. and 7:00 A.M. She was last incontinent and changed at 2:55 A.M. At 4:29 A.M., Resident #50 was witnessed on the floor by the STNA who notified the nurse immediately. The nurse observed Resident #50 lying on her bedroom floor on her right side. Resident #50 reported pain in her buttock, hip, and right leg. An assessment was completed, and the physician was notified. An order for an x-ray of the right hip and leg was obtained. Resident #50 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366385 If continuation sheet Page 4 of 6 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 366385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury of Twinsburg 9928 Vail Drive Twinsburg, OH 44087 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 noted to be clean and dry. The bed was placed against the wall with a fall mat to the exit side of the bed. The x-ray results reported at 1:58 P.M. revealed no fracture. During an assist in transferring Resident #50 at 2:00 P.M., the resident complained of pain and was not able to bear weight on her right leg. The physician ordered another x-ray which was reported at 7:00 P.M. to show a nondisplaced right hip fracture. The fall investigation revealed no documented evidence the bed was in the lowest position or Resident #50 was wearing non-skid socks at the time of the fall. Interview on 06/12/23 at 1:19 P.M. with the DON verified the fall investigation was not thorough and did not include if care planned interventions were in place at the time of the fall on 04/25/23. 3. Review of the medical record for Resident #5 revealed an admission date of 04/27/21 with diagnoses including bilateral above the knee amputation ([NAME]), cardiac pacemaker, atrial fibrillation, and heart failure. Review of the quarterly MDS assessment dated [DATE] revealed Resident #5 had moderate cognitive impairment, required extensive assistance of one staff for bed mobility, was dependent on two staff for transfers, was non-ambulatory, and always incontinent of bowel and bladder. Review of the fall risk assessment date 01/12/23 revealed Resident #5 was at high risk for falls. Review of the fall risk care plan for Resident #5 revealed interventions including bed to be in the lowest position at all times except during personal care (04/27/21), Dycem to the bottom of the cushion in the chair when out of bed (11/25/21), Dycem to the top of the cushion in the chair when out of bed (04/02/22), Broda (tilt-in-space positioning wheelchair) chair when out of bed (04/04/22), bed against the wall with fall mat to the exit side of the bed (04/12/23). Review of the nurse's note dated 03/07/23 at 5:15 A.M. revealed Resident #5 was found undressed on the floor mat lying next to the bed. No injuries were noted, and the resident denied any pain. The resident was on Warfarin (blood thinning medication). The physician and emergency contact were notified, and the physician ordered the resident be sent to the local emergency room for evaluation. The resident was sent out the hospital, and the bed was placed against the wall with a mattress to the open side of the floor to maintain safety. Review of the fall investigation dated 03/07/23 stated Resident #5 was observed lying on her back on the floor mat next to her bed by the State Tested Nurse Aide (STNA) answering the call light. The fall investigation did not indicate how long the call light had been on or if the bed was in the lowest position at the time of the fall. Interview on 06/12/23 at 1:19 P.M. with the DON verified the investigation was not thorough and did not include if all fall prevention interventions were in place at the time of the fall on 03/07/23. Review of the nurse's note dated 05/19/23 at 4:30 P.M. stated the nurse was called to the room by the STNA. Resident #5 was observed lying on her back on the floor next to her Broda chair. The call bell was within reach but not utilized. The resident denied pain and denied bumping her head. No injuries were noted. She was transferred back to bed with two staff assist. The bed was placed in the lowest position with the mat to the right of the bed and call bell within reach and the physician and the resident's son were notified. The resident stated, I did not fall, I slid out of the chair because I had something to do. Therapy to evaluate the resident. There was no documented evidence Dycem (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366385 If continuation sheet Page 5 of 6 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 366385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury of Twinsburg 9928 Vail Drive Twinsburg, OH 44087 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 was in place per the plan of care at the time the resident slid out of the Broda chair. Level of Harm - Actual harm Review of the fall investigation dated 05/19/23 stated Resident #5 was observed lying on her back on the floor next to her Broda chair. The call light was in reach and not utilized. The fall investigation did not indicate how long the call light had been on or if the bed was in the lowest position at the time of the fall. There was no documented evidence Dycem was in place per the plan of care at the time the resident slid out of the Broda chair. Residents Affected - Few Interview on 06/12/23 at 1:19 P.M. with the DON verified fall interventions were not in place at the time of Resident #5's fall on 05/19/23 and verified there was no documented evidence the Dycem was in place to the Broda chair at the time of the fall on 05/19/23. Review of the incident note dated 05/30/23 at 5:33 P.M. stated Resident #5 was observed lying on floor next to the bed. Resident #5 stated she got herself on the floor because she needed to be changed. No injuries were noted. Fall mat was not in place at the time of the fall. The STNA was disciplined for not maintaining fall interventions. Interview on 06/08/23 at 1:17 P.M. with Resident #5's POA/ friend revealed Resident #5 had fallen multiple times in a one-week period. Interview on 06/12/23 at 1:19 P.M. with the DON verified fall interventions were not in place at the time of Resident #5's fall on 05/30/23. Review of the facility policy titled Fall Prevention and Protocol Policy, dated 12/10/22, revealed fall interventions would be initiated as appropriate. This deficiency represents non-compliance investigated under Complaint Number OH00143246. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366385 If continuation sheet Page 6 of 6