Inspection·July 27, 2023

F 0689 911 was called, arrived, and transported Resident #70 to Metro Health Main Campus Emergency Room. Level of Harm - Actual harm Review of the facility incident file dated 04/20/23 revealed Resident #70 was being transported to dialysis when she had a fall in the facility van. Review of the file revealed Resident #70 remained alert until emergency medical services arrived. Review of the file revealed Resident #70 stated she was feeling tired and leaned forward too much. Review of the file revealed Resident #70 was transported to Metro Health campus emergency room. Residents Affected - Few Further review of the incident file revealed Staff Member (SM) #922 heard Resident #70 call out when he observed her laying face down on the ground. SM #922 revealed as he was slowing down the vehicle, Resident #70 slid out of the wheelchair. Review of the progress note dated 04/21/23 at 7:40 A.M. revealed Resident #70 was admitted to Metro Health hospital for a fall. Review of hospital documentation revealed Resident #70 came to the hospital after a fall and face laceration. The notes reflected the resident had a head trauma. Resident #70 was thrown forward in a braking patient transportation van. The resident had a sutured laceration at mid-forehead to right frontal scalp with no goiter. Hospital records further noted Resident #70 had been sent to Metro Health Hospital just over a week ago. Review of the documentation revealed Resident #70 was being transported to dialysis, was not appropriately strapped in, and suffered a severe injury with a forehead laceration. Resident #70 hurt her forehead with a metal object which then needed multiple stitches. The resident had a large forehead laceration closed with sutures with wound edges well approximated and no signs of infection. An additional hospital note revealed Resident #70 sustained injuries while in transport to dialysis. Resident #70 was in a wheelchair in the transport van, when the van came to a sudden stop, throwing Resident #70 from her wheelchair and causing her to hit her head. Resident #70 had a large laceration to her forehead. Review of the progress note revealed the resident was hospitalized until 05/03/23. Review of the weekly skin evaluation dated 05/04/23 revealed Resident #70 had a suture line, extending from mid forehead to hairline above right eyebrow. Suture line intact and well approximated with no drainage noted. Site without erythema, ecchymosis, induration, or increased warmth to peri wound area. Review of the progress note dated 05/05/23 at 3:56 P.M. revealed Resident #70 sutures were removed from her forehead on this date. Interview on 07/27/23 at 10:19 A.M. with Staff Member (SM) #849 verified Resident #70 had a fall in the transportation vehicle while being transported to dialysis and sustained an injury. Interview on 07/27/23 at 10:40 A.M. with SM #922 revealed he was the facility primary driver and was also a State Tested Nurse Assistant (STNA). SM #922 revealed he drove residents to their appointments and was also considered an escort due to his STNA status. SM #922 revealed on 04/20/23 he was transporting Resident #70 to her dialysis appointment, made a left hand turn off the highway, came to a stop, and heard her yell out. SM #922 revealed he looked behind him and Resident #70 was on her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366395 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 366395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks of Brecksville 8757 Brecksville Road Brecksville, OH 44141 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 knees and stomach area. SM #922 revealed he pulled over, put on his hazard lights, and called 911. SM #922 revealed emergency responders arrived in less than 10 minutes and transported the resident to the hospital. SM #922 revealed he did not know the logistics of what occurred or if she went over the strap that secured her in place. SM #922 revealed he was not aware of Resident #70 sustained any injuries. Residents Affected - Few Interview on 07/27/23 at 11:06 A.M. with the Administrator revealed SM #922 was transporting Resident #70 to her dialysis appointment and called 911 due to Resident #70 coming out of her wheelchair. The deficient practice was corrected on 05/18/23 when the facility completed the following corrective actions: · SM #922 was immediately suspended pending investigation and the van was taken out of service until inspection was complete. · An Ad Hoc QAPI meeting was held on 4/20/2023. · All residents requiring transport via the facility van for appointments were assessed . The Facility also reviewed the incident/accident log and there were no other issues related to falls when transporting residents in the facility van. · The Facility's compliance manager performed van inspection on 4/20/2023. · The facility re-educated SM #922 on proper securement of wheelchairs and residents in the facility van following the manufacture guidelines. Competency was completed with SM #922 and back-up driver. Drivers completed return demonstration competencies on proper securement of wheelchairs and residents in the facility van and van policy. · Future van drivers of this Facility will be trained in safe operation of the transportation van before being allowed to transport residents. Training will be done by Administrator or the Compliance Manager. · SM #922 completed a Safety Securement checklist with every resident transport and any negative finding was to be immediately communicated to the facility administrator and addressed immediately. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366395 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 366395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks of Brecksville 8757 Brecksville Road Brecksville, OH 44141 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 Future van drivers will be required to give the administrator the daily securement checklist at the end of each day. The securement checklist is completed by the van driver before/after each transportation with residents. The checklist was developed by the Manager of OSHA Compliance. Residents Affected - Few · The administrator/designee began completing visual audits of the securement of the resident and the safety securement checklist while residents are in the van and prior to being transported, to be done 3x weekly, audits will continue for up to 4 weeks. Audits will be verified by the facilities compliance manager. All audits will be brought to monthly QAPI. · The administrator/designee will review weekly the Facility vehicle inspection checklist with van driver. Administrator/designee has verified the proper working condition of the securement and the operations of the van. Any negative findings will be corrected immediately, if unable to correct immediately van will be placed out of service until correction is made. This deficiency represents non-compliance investigated under Complaint Number OH00144572. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366395 If continuation sheet Page 4 of 4