Health inspection·December 19, 2018

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a progress note, dated 02/14/17, revealed a care planning meeting was held with Resident #38, the resident's son, therapy, and the Assistant Director of Nursing. No other evidence of a care planning meeting held with the resident and/or the resident's family was found. Interview on 12/16/18 at 10:01 A.M., Resident #38 revealed she did not know what a care planning meeting was and had no memory of ever attending one. Resident #38 verified she was not offered an opportunity to attend a care planning meeting with the facilities interdisciplinary team. Interview on 12/18/18 at 10:44 A.M., Social Service Designee (SS) #325 revealed an invitation was mailed to resident's family offering a quarterly care planning meeting and a care planning meeting was held only when the family accepted the invitation to attend. SS #325 further revealed the resident were not invited to attend the care plan meeting. SS #325 verified Resident #38 was not invited to a care conference since his employment with the facility. Review of a facility policy titled, Resident/Family/Responsible Party Care Conference, dated 08/2006, revealed the purpose of a care planning meeting was to provide resident and families the opportunity to participate in the residents plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366426 If continuation sheet Page 2 of 14 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 366426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woods on French Creek Nursing & Rehab Center The 37845 Colorado Avenue Avon, OH 44011 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interviews, the facility failed to ensure resident's call lights were within reach. This affected three (#19, #31 and #45) of 67 residents observed for call light placement. The facility census was 67. Residents Affected - Few Findings include 1. Medical record review revealed Resident #45 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, dementia with behavioral disturbance, hemiplegia and hemiparesis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had cognitive impairment. Observation on 12/16/18 at 1:21 P.M. revealed Resident #45 was sitting in her wheelchair in her room. Further observation revealed Resident #45's call light was clipped to her bed and not within her reach. Interview on 12/16/18 at 01:23 PM with State Tested Nursing Assistant (STNA) #103 verified Resident #45's call light was not within her reach. 2. Medical record review revealed Resident #31 was admitted to the facility on [DATE]. Diagnoses included atrial fibrillation, schizoaffective disorder, hypertension, and muscle weakness. Review of the comprehensive Minimum Data Sets (MDS) assessment, dated 10/26/18, revealed the resident's cognition was severely impaired. Observation on 12/16/18 at 8:38 A.M., revealed Resident #31 was in her bed sleeping. Further observation revealed the resident's call light was lying in a chair located opposite of the head of the resident's bed and under a blanket that was also lying in the chair. Observation and interview on 12/16/18 at 9:00 A.M., State Tested Nursing Assistant (STNA) #103 revealed all resident's call lights were to be within the resident's reach while they were in bed so they would be able to call for assistance if needed. STNA #103 verified Resident #31's call light was lying in a chair located opposite of the head of the resident's bed and under a blanket. STNA #103 verified the resident was not able to reach the call light if she needed assistance. 3. Medical record review revealed Resident #19 admitted to the facility on [DATE]. Diagnoses included cerebral infarction, hemiplegia affecting the right side, aphasia, and difficulty walking. Review of the quarterly MDS assessment dated [DATE] revealed the resident's cognition was severely impaired. Observation on 12/16/18 at 8:43 A.M., revealed Resident #19 was in his bed sleeping. Further observation revealed the resident's call light was laying on the floor under the resident's bed. Observation and interview on 12/16/18 at 9:01 A.M., STNA #103 verified Resident #19's call light was lying on the floor, under his bed. STNA #103 verified the resident was not able to reach the call light if he needed assistance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366426 If continuation sheet Page 3 of 14 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 366426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woods on French Creek Nursing & Rehab Center The 37845 Colorado Avenue Avon, OH 44011 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 0558 Level of Harm - Minimal harm or potential for actual harm Interview on 12/17/18 at 3:55 P.M., the Director of Nursing revealed staff were supposed to ensure resident's call lights were placed with in their reach while in their beds to ensure residents would be able to ring for assistance if it was needed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366426 If continuation sheet Page 4 of 14 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 366426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woods on French Creek Nursing & Rehab Center The 37845 Colorado Avenue Avon, OH 44011 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interview, the facility failed to ensure the physician was informed of a resident's continuous refusal of care. This affected one (Resident #69) of three residents reviewed for nutrition. The facility census was 67. Findings include: Record review revealed Resident #69 was re-admitted to the facility on [DATE]. Diagnoses included cerebral infarction, type two diabetes mellitus, malignant neoplasm of larynx, tracheostomy status, muscle weakness and gastrostomy status. Review of the most recent nursing assessment, dated 12/18/18, revealed Resident #69 to have no cognitive impairment, needed staff assist for bed mobility, transfers, tube feeding, toileting, dressing, and ambulation. Review of the most recent physician orders revealed Resident #69 to have a current order for nothing by mouth (NPO) diet with enteral feed order of Diabetisource 250 milliliters (ml.) gravity feedings six times per day. Review of the nutrition assessment, dated 12/07/18 revealed Resident #69 had changes in weight and noted the resident had complaints of feeling full and at times refusing enteral nutrition. The assessment also revealed the resident and Certified Nurse Practitioner (CNP) were notified of the weight change,but evidence of notification of enteral feeding refusals. Review of progress notes from 12/01/18 to 12/16/18 revealed Resident #69 refused 1:00 A.M. enteral nutrition feedings on a continued basis. There was no evidence the physician and/or CNP was notified of the refusals. Interview with Diet Tech #180 on 12/17/18 at 5:30 P.M. revealed awareness that Resident #69 would refuse tube feed and that he also had a continuous feeding tube at one time and refused that as well. Diet Tech #180 revealed Resident #69 had complained he felt full and doesn't want all feedings. Interview on 12/18/18 at 5:50 P.M. with Registered Nurse (RN) #311 verified the resident's progress notes do not show any notation regarding notification made to the physician and/or CNP regarding Resident #69's refusals of enteral nutrition feedings at 1:00 A.M. Interview on 12/19/18 at 9:30 A.M. with Resident #69 revealed the resident had reported to the nursing staff regularly that he does not want the 1:00 A.M. tube feedings and feels this feeding was too much and he feels too full. Interview on 12/19/18 at 3:08 P.M. with Administrator revealed the facility does not have a policy regarding notification to physician or change of condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366426 If continuation sheet Page 5 of 14 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 366426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woods on French Creek Nursing & Rehab Center The 37845 Colorado Avenue Avon, OH 44011 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a self-reported incident (SRI), an employee statement, staff and resident interviews and review of facility policy, the facility failed to follow their abuse policy requirement to immediately report an allegation of misappropriation to the State Agency. This affected one (#60) of one resident reviewed for misappropriation. The facility census was 67. Residents Affected - Few Findings include Medical record review revealed Resident #60 was admitted to the facility on [DATE]. Diagnoses included cellulitis of the right lower limb, chronic kidney disease, type diabetes mellitus, kidney transplant and pancreas transplant. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 had impaired cognition. Review of a facility self-reported incident (SRI) dated 12/16/18 revealed on 12/14/18 Resident #60 realized his wallet was not in his duffle bag. Resident #60 reported the missing wallet to a nurse. The nurse reported the missing wallet to the Director of Nursing (DON). Review of an investigation statement dated 12/14/18 written by Licensed Practical Nurse (LPN) #201 revealed at approximately 8:30 P.M. Resident #60 informed her, someone took his wallet. LPN #201 also wrote Resident #60 reported his wallet was missing. Interview on 12/16/18 at 10:34 A.M., Resident #60 stated he was robbed on Friday, (12/14/18). Resident #60 revealed in the evening on 12/14/18 his wallet was gone. Resident #60 stated the only time he was out of his room was during therapy from around 11:00 A.M. to 12:00 P.M. Resident #60 said he notified a nurse his wallet was gone. Resident #60 heard the nurse on the phone tell her supervisor his wallet was gone. Resident #60 stated he stored his duffle bag in his closet. Resident #60 stated there was a drawer with a lock on his bedside table, but no one had given him a key. Resident #60 reported he was missing two credit cards, a driver's license and $200.00. In a follow up interview on 12/18/18 at 2:09 P.M. Resident #60 indicated he was missing $1200.00. Interview on 12/17/18 at 5:08 P.M. with the Administrator verified a Self-Reported Incident (SRI) was not filed until 12/16/18. The Administrator revealed the Director of Nursing notified him regarding Resident #60's missing wallet during the morning on 12/15/18. The Administrator revealed Resident #60's wallet was missing, and misappropriation was not suspected at the time. The Administrator also revealed the resident changed the amount of money that was in wallet. Further interview with the Administrator revealed on 12/16/18 a family member of Resident #60 confirmed she had given the resident $1000.00. The Administrator revealed the facility would provide Resident #60 with a key for the locked drawer on his bedside stand. Interview on 12/18/18 at 5:50 P.M. with Licensed Practical Nurse (LPN) #201 revealed on 12/14/18 around 8:30 P.M., Resident #60 notified her he could not find his wallet. LPN #201 revealed she could not remember if Resident #60 stated the wallet was missing or if someone took his wallet. LPN #201 further revealed in her witness statement she wrote Resident #60 indicated both the wallet was missing and someone took the wallet. LPN #201 revealed she notified the Director of Nursing (DON). LPN #201 revealed the DON indicated she would notify the Administrator. Interview on 12/19/18 at 10:04 A.M. with the DON revealed she was notified on 12/14/18 sometime (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366426 If continuation sheet Page 6 of 14 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 366426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woods on French Creek Nursing & Rehab Center The 37845 Colorado Avenue Avon, OH 44011 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 0607 Level of Harm - Minimal harm or potential for actual harm after 8:00 P.M. of Resident #60's missing wallet. The DON revealed she notified the Administrator of the missing wallet on 12/15/18. Interview on 12/19/18 at 2:12 P.M. with the Administrator revealed the police and the facility had not yet completed their investigation. Residents Affected - Few Review of the policy for Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/21/16 revealed the facility would investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment or Misappropriation of Resident Property. The facility would immediately report all such allegations to the Ohio Department of Health. In cases where a crime was suspected, staff would also report the same to local law enforcement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366426 If continuation sheet Page 7 of 14 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 366426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woods on French Creek Nursing & Rehab Center The 37845 Colorado Avenue Avon, OH 44011 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a self-reported incident (SRI), an employee statement, staff and resident interviews and review of facility policy, the facility failed to immediately report an allegation of misappropriation to the State Agency. This affected one (#60) of one resident reviewed for misappropriation. The facility census was 67. Findings include Medical record review revealed Resident #60 was admitted to the facility on [DATE]. Diagnoses included cellulitis of the right lower limb, chronic kidney disease, type diabetes mellitus, kidney transplant and pancreas transplant. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 had impaired cognition. Review of a facility self-reported incident (SRI) dated 12/16/18 revealed on 12/14/18 Resident #60 realized his wallet was not in his duffle bag. Resident #60 reported the missing wallet to a nurse. The nurse reported the missing wallet to the Director of Nursing (DON). Review of an investigation statement dated 12/14/18 written by Licensed Practical Nurse (LPN) #201 revealed at approximately 8:30 P.M. Resident #60 informed her, someone took his wallet. LPN #201 also wrote Resident #60 reported his wallet was missing. Interview on 12/16/18 at 10:34 A.M., Resident #60 stated he was robbed on Friday, (12/14/18). Resident #60 revealed in the evening on 12/14/18 his wallet was gone. Resident #60 stated the only time he was out of his room was during therapy from around 11:00 A.M. to 12:00 P.M. Resident #60 said he notified a nurse his wallet was gone. Resident #60 heard the nurse on the phone tell her supervisor his wallet was gone. Resident #60 stated he stored his duffle bag in his closet. Resident #60 stated there was a drawer with a lock on his bedside table, but no one had given him a key. Resident #60 reported he was missing two credit cards, a driver's license and $200.00. In a follow up interview on 12/18/18 at 2:09 P.M. Resident #60 indicated he was missing $1200.00. Interview on 12/17/18 at 5:08 P.M. with the Administrator verified a Self-Reported Incident (SRI) was not filed until 12/16/18. The Administrator revealed the Director of Nursing notified him regarding Resident #60's missing wallet during the morning on 12/15/18. The Administrator revealed Resident #60's wallet was missing, and misappropriation was not suspected at the time. The Administrator also revealed the resident changed the amount of money that was in wallet. Further interview with the Administrator revealed on 12/16/18 a family member of Resident #60 confirmed she had given the resident $1000.00. The Administrator revealed the facility would provide Resident #60 with a key for the locked drawer on his bedside stand. Interview on 12/18/18 at 5:50 P.M. with Licensed Practical Nurse (LPN) #201 revealed on 12/14/18 around 8:30 P.M., Resident #60 notified her he could not find his wallet. LPN #201 revealed she could not remember if Resident #60 stated the wallet was missing or if someone took his wallet. LPN #201 further revealed in her witness statement she wrote Resident #60 indicated both the wallet was missing and someone took the wallet. LPN #201 revealed she notified the Director of Nursing (DON). LPN #201 revealed the DON indicated she would notify the Administrator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366426 If continuation sheet Page 8 of 14 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 366426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woods on French Creek Nursing & Rehab Center The 37845 Colorado Avenue Avon, OH 44011 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 12/19/18 at 10:04 A.M. with the DON revealed she was notified on 12/14/18 sometime after 8:00 P.M. of Resident #60's missing wallet. The DON revealed she notified the Administrator of the missing wallet on 12/15/18. Interview on 12/19/18 at 2:12 P.M. with the Administrator revealed the police and the facility had not yet completed their investigation. Review of the policy for Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/21/16 revealed the facility would investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment or Misappropriation of Resident Property. The facility would immediately report all such allegations to the Ohio Department of Health. In cases where a crime was suspected, staff would also report the same to local law enforcement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366426 If continuation sheet Page 9 of 14 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 366426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woods on French Creek Nursing & Rehab Center The 37845 Colorado Avenue Avon, OH 44011 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on record review, policy review and staff interview, the facility failed to ensure community outings were scheduled for residents in the facility. This affected five residents (#12, #15, #25, #42, and #50) who attended community outings. The facility census was 67. Residents Affected - Some Findings include: Review of facility's Activities calendars revealed an outing in November was scheduled for 11/13/18. No other outing was listed in that month. Further review of calendars revealed no outings to be scheduled for month of December. Interview with Resident #42 on 12/16/18 at 10:33 A.M. revealed outings to have been canceled by facility for winter months. Resident #42 reported that outing scheduled in November had been canceled due to a bus breaking down and was never re-scheduled. Interviews on 12/17/18 at 10:09 A.M. with residents, including Resident #15, #25, #42 and #59, who attended the Resident Council meeting, revealed concerns with the activities programs and lack of outings. Residents expressed feelings of being 'cooped up' and 'down' in facility during winter months. Interview on 12/17/18 at 11:10 A.M. with Activities Director (AD) #326 revealed outings were not scheduled for months of December, January, February and March. AD #326 reported that she made this decision due to staying healthy- not getting residents sick during the winter months and then start outings back up in the spring. She reported that there were several accessible vans through the company to use for back-ups if the facility van was not working. Review of the facility's list of residents who attend community outings regularly revealed Resident #12, #15, #25, #42, and #50 attend community outings regularly. Review of facility policy named Activity Department Policy/Procedure Manual revealed the policy of the Activity Department is responsible for planning and scheduling an Activity Program, consisting of stimulating and therapeutic activities, diverse in focus, and consistent with resident's wishes and needs. The procedure outlined the calendar will be implemented as written. When cancellations and changes are unavoidable they will be announced in the morning and afternoon. Changes and substitutes will be noted on the daily participation log. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366426 If continuation sheet Page 10 of 14 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 366426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woods on French Creek Nursing & Rehab Center The 37845 Colorado Avenue Avon, OH 44011 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 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the physicians wrote new orders for residents and progress notes at the time of their visits. This affected one resident (#31) of one resident reviewed for physician visits. The facility census was 67. Findings included: Medical record review revealed Resident #31 admitted to the facility on [DATE]. Diagnoses included muscle weakness, ataxic gait, schizoaffective disorder bipolar type, and depression. Review of Resident #31's nursing progress notes revealed on 12/10/18 at 6:00 P.M., the resident's alarm was sounding and staff found the resident face down on the floor next to her wheelchair. No injury was noted and neurological monitoring was initiated. Review of Resident #31's skin assessments revealed on 12/11/18, the resident had bruising under both eyes and to her forehead. Review of Resident #31's physician visits revealed on 12/12/18, the resident's was seen by the physician and noted to have black eyes after a fall with a closed head injury from a fall she suffered on 12/10/18. The resident was found to be at her baseline neurologically. The physician revealed staff were to continue to observe the resident for any neurological decline, strive to continue aggressive fall precautions, monitor high risk medications, and provide an ice pack to the resident's frontal hematoma as needed for comfort. Review of Resident #31's 12/2018 physician orders revealed an order dated 12/11/18 to monitor the discoloration to the resident's bilateral eyes and forehead and to discontinue when resolved. Further review revealed there was no order to apply an ice pack to her frontal hematoma as needed for comfort. Interview on 12/18/18 at 11:00 A.M., the Director of Nursing (DON) revealed Resident #31 suffered a fall in her room on 12/10/18 and bruising was noted under the resident's eyes and forehead on 12/11/18. The physician was notified and came to the facility on [DATE] to examine the resident. The DON revealed the physician did not write any new orders for the resident or write a physician progress note while at the facility on 12/12/18. The DON revealed the facility contacted the physician's office on 12/17/18 to obtain a progress note for the 12/12/18 visit. The DON verified the progress note stated to apply an ice pack to the resident's frontal hematoma as needed for comfort. The DON verified an order to apply the ice pack was never initiated because the facility was not aware of the order until they called and obtained the progress note on 12/17/18. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366426 If continuation sheet Page 11 of 14 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 366426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woods on French Creek Nursing & Rehab Center The 37845 Colorado Avenue Avon, OH 44011 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and staff interview, the facility failed to ensure the posted daily staffing was updated daily. This had the potential to affect all 67 residents residing in the facility. Residents Affected - Many Findings include: Observation on 12/16/18 at 8:12 A.M., of the facility's posted daily staffing in the front lobby, revealed the posting was dated 12/14/18. No staff posting for 12/16/18 was observed. Interview on 12/16/18 at 8:24 A.M., Dietary Manager (DM) #304 verified the posted daily staffing was dated 12/14/18. DM #304 further verified there was not any staff posting for 12/16/18. Interview on 12/17/18 at 3:55 P.M., the Director of Nursing revealed nursing staff was responsible for making sure the posted daily staffing was changed daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366426 If continuation sheet Page 12 of 14 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 366426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woods on French Creek Nursing & Rehab Center The 37845 Colorado Avenue Avon, OH 44011 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure residents did not receive unnecessary opioid pain medication when they failed to assess and document the location of resident's pain. The facility further failed to attempt non-pharmacological interventions prior to the administration of as needed opioid pain medication. This affected one resident (#15) of five residents reviewed for unnecessary medications. The facility census was 67. Residents Affected - Few Findings include: Medical record review for Resident #15 revealed an admission date of 07/15/18. Diagnoses included chronic respiratory failure, chronic kidney disease, and obstructive sleep apnea. Review of Resident #15's physician orders revealed an order dated 12/01/18 for Norco (Opioid pain medication) 5-325 milligrams (mg.) one tablet every 12 hours as needed for pain. Review of the most recent plan of care revealed Resident #15 was at risk for pain or alteration in comfort related to restless leg syndrome, peripheral vascular disease, mobility impairments, arthropathy, and peptic ulcer disease. Interventions included to provide activities of diversion that the resident enjoys, encourage relaxation techniques (visualization, guided imagery, deep breathing), provide rest periods and/or reposition the resident for comfort, and provide a warm compress per orders. Review of Resident #15's Medication Administration Record (MAR) for 12/2018 revealed the resident was administered the as needed Norco eight times between 12/01/18 and 12/16/18. No documentation of the type and/or location of the resident's pain as well as any non-pharmacological interventions attempted, prior to the administration of the pain medication, for seven of the eight administrations was found on the MAR or in the resident's nursing progress notes. Interview on 12/18/18 at 10:09 A.M., the Director of Nursing (DON) revealed nurses were supposed to assess and document on the resident's MAR, the type/location of pain , severity of pain based on a numerical pain scale, and attempted non-pharmacological interventions to reduce pain prior to administering as needed opioid pain medications. The DON verified Resident #15 was administered eight doses of Norco between 12/01/18 and 12/16/18. The DON further verified there was no documentation of the type and/or location of the resident's pain as well as no documentation of any non-pharmacological interventions attempted, prior to the administration of the pain medication, for seven of the eight administrations on the resident's MAR or progress notes. Review of a facility policy titled, Pain Assessment and Management, dated 03/31/16, revealed resident's pain was to be assessed with the admission process and as needed thereafter. Residents were to be asked to describe his/her pain status including rating the pain on a numeric pain scale of zero to ten, and verbal descriptors such as mild, moderate, or severe/very severe. Further review revealed non-pharmacological methods to reduce pain in a resident may be implemented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366426 If continuation sheet Page 13 of 14 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 366426 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woods on French Creek Nursing & Rehab Center The 37845 Colorado Avenue Avon, OH 44011 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to identify target behavior appropriate of psychosis for use of antipsychotic medication. This affected one (Resident #47) of five residents reviewed for unnecessary medication and regimen review. The facility census was 67. Findings include: Record review revealed Resident #47 was admitted to the facility on [DATE]. Diagnoses included unspecified psychosis not due to a substance or known physiological condition, major depressive disorder, unspecified dementia without behavioral disturbance, anxiety disorder, low back pain, difficulty in walking, muscle weakness, and unsteadiness on feet. Review of most recent quarterly psychosocial assessment revealed Resident #47 to have clear speech, adequate hearing, understands others and was understood. Resident noted to be alert and oriented to person, time, and place. No changes recorded in mood and nursing was aware and monitoring due to resident having history of feeling down, tired, having poor appetite and trouble concentrating. Review of current physician order list for Resident #47 revealed orders of antipsychotic medication Risperidone tablet 0.25 milligrams (mg.) to administer three tablets by mouth at bedtime. The original medication order from date of 12/27/18 read, for sadness related to major depressive disorder, recurrent, and unspecified. Review of current medication administration record for Resident #47 revealed Risperidone medication to be scheduled for three tablets by mouth at bedtime for sadness related to major depressive disorder, recurrent, unspecified. Behavior was monitored, and nursing signed off days and hours. Interview with the Director of Nursing (DON) on 12/19/18 at 9:14 A.M. verified Resident #47 to have diagnosis of dementia and also psychosis. She reported that Resident #47 was taking antipsychotic medication of Risperidone for a documented behavior of sadness, and nursing staff tracked this behavior for her diagnosis. Interview with Licensed Practical Nurse (LPN) #209 on 12/19/18 at 2:28 P.M. revealed Resident #47 had memory issues and periods of time when she believes she was in times past, or still has young children, etc. LPN #209 reported that Resident #47 has had behavior of delusional thinking and hallucinations of talking to children that were not present. Review of the facility policy for Medication Monitoring- Antipsychotics revealed the policy was for residents to receive antipsychotic medications only when medically necessary. Every effort was made to ensure that residents who use antipsychotics receive the intended benefit of the medications and to minimize the unwanted effects of the antipsychotic medications. Additional requirements outline the target behavior must be clearly and specifically identified and monitored. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366426 If continuation sheet Page 14 of 14