Health inspection·November 6, 2025

F 0684 Level of Harm - Actual harm Residents Affected - Few assisted and a mechanical lift was used to get the resident back into bed. The nurse practitioner and family were notified. Review of the progress note dated 10/13/25 at 9:47 P.M. written by Registered Nurse (RN) #187 documented x-ray results were received for Resident #52. The on call physician was notified of the results, and an order was received to send Resident #52 to the emergency department for treatment. The family and Director of Nursing (DON) were notified. Review of the EMS run report dated 10/13/25 revealed they received a call from the facility at 9:24 P.M. requesting assistance with transporting a resident to the hospital. The report indicated upon arrival, they were met by nursing staff who stated Resident #52 had bilateral femur fractures. The staff reported Resident #52 had a fall the previous night, but they could not find a report for the fall. Due to complaints of pain, x-rays were completed and confirmed bilateral femur fractures. Interview with Resident #52 revealed she remembered falling the night before. Resident #52 reported a pain level of a nine out of ten and 50 micrograms (mcg) of fentanyl was administered for pain control. Resident #52 was transported to the Emergency Department (ED) for treatment. Review of the hospital documentation dated 10/13/25 revealed Resident #52 suffered a fracture of the left mid-femoral shaft with lipohemarthrosis (fat and bone escape from bone marrow into the joint space), and a comminuted right distal femur fracture noted above the right knee arthroplasty with the posterior fragment displaced one full width. Resident #52 underwent an open reduction and internal fixation (ORIF) of both legs on 10/14/25. Resident #52 was discharged from the hospital and returned to the facility on [DATE]. Review of the facility fall log revealed Resident #52 suffered a fall; however, the log does not specify the date or time of a fall. Interview on 11/04/25 at 8:34 A.M. with Resident #52 revealed she had one fall while at the facility. Resident #52 stated she was in a lot of pain and needed to be sent to the hospital because she broke her bones. Resident #52 could not recall why she was trying to get out of the bed, who the staff were that assisted her back into bed, or how the fall happened. Interview on 11/04/25 at 12:33 P.M. with Certified Nursing Assistant (CNA) #108 verified she worked hall 400 on 10/12/25. CNA #108 could not recall the exact time of Resident #52's fall but stated the fall had occurred sometime between 12:00 A.M. and 1:00 A.M. CNA #108 stated she heard someone talking and went to see who it was, and upon entering Resident #52's room, Resident #52 was holding onto the bedrail and was coming down out of the side of the bed. CNA #108 stated Resident #52's knees were bent and the resident landed on her knees on two blankets that were lying on the floor next to the bed. CNA #108 denied lowering the resident to the floor, stating she could not get to the resident in time as Resident #52 was already falling from the bed when she entered the room. CNA #108 stated when Resident #52 landed on the floor the residents' legs were straight out in front of her body and the resident was in a sitting position with her back against the side of the bed. CNA #108 stated she lifted the resident away from the bed to make sure the bed was not hurting her back. Once she felt the resident was safe CNA #108 said she left the resident sitting on the floor and went to get help from CNA #159. Prior to coming to Resident #52's room, CNA #159 called RN #109, who was out of the building on break. CNA #159 then went to Resident #52's room to wait for RN #109. CNA #108 stated she felt like it was taking RN #109 too long and because the resident was laying on the cold hard floor, she and CNA #159 decided to use the mechanical lift and transferred Resident #52 back into the bed. CNA #108 stated Resident #52 was not crying but had stated two or three times after the fall that her legs hurt. CNA #108 stated during her 5:00 A.M. rounds, Resident #52 had vomited. CNA #108 stated she reported this to the nurse. Interview on 11/04/25 at 2:05 P.M. with CNA #159 verified she was working hall 500 on 10/12/25. CNA #159 stated that CNA #108 had approached her as she was charting and stated that Resident #52 was trying to climb out of bed and had lowered herself to her knees while holding onto the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366426 If continuation sheet Page 2 of 5 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 11/06/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few bed railing. CNA #159 stated she called RN #109 and handed the phone to CNA #108 for her to explain what had happened. After the phone call had ended, CNA #108 and CNA #159 went into Resident #52's room. CNA #159 stated Resident #52 was sitting on the floor with both legs out in front of her. CNA #159 stated Resident #52 stated she was trying to get out of bed to get her medicine. CNA #159 stated Resident #52 was not crying but did complain of knee pain when being transferred back to bed using the mechanical lift. CNA #159 stated when they got Resident #52 back into bed, RN #109 was in the room to assess the resident. CNA #159 stated for falls, they are not to move the resident until the nurse has assessed the resident, but she did not think this incident was a fall since Resident #52 lowered herself to the floor. An additional interview on 11/06/25 at 8:12 A.M. with CNA #108 revealed after Resident #52 had been assisted back into bed after falling, she and CNA #159 cleaned Resident #52 up as she had been incontinent. CNA #108 verified Resident #52 stated her legs hurt during incontinence care. CNA #108 denied letting the nurse know at the time; however, CNA #108 stated she did let the nurse know around 5:00 A.M. that Resident #52 complained of bilateral leg pain and that the resident had vomited. Interview on 11/06/25 at 8:30 A.M. with CNA #300 revealed she worked hall 400 on the dayshift on 10/13/25. CNA #300 stated CNA #108 gave her report but did not report a fall for Resident #52 during the night. CNA #300 stated, at the beginning of her shift she walks around the unit to visualize all of her residents and the morning of 10/13/25, Resident #52 was asleep during her first round at 7:00 A.M., and CNA #300 stated this was not uncommon as Resident #52 usually gets out of bed around 9:15 A.M. CNA #300 stated at approximately 9:15 A.M. on 10/13/25 she went to provide Resident #52 care and when attempting to provide care Resident #52 screamed out in pain and the resident's legs looked swollen. CNA #300 stated she got the nurse immediately. CNA #300 stated LPN #165 was on the phone with a physician regarding another resident at the facility but that LPN #165 stated she would go and see Resident #52 as soon as she was off of the phone. CNA #300 stated after the nurse assessed Resident #52, LPN #165 told her to make the resident a two person assist until further notice, and that LPN #165 had reached out to the physician to obtain orders for x-rays. CNA #300 stated she checked on Resident #52 more frequently and did not move her unless absolutely necessary. Interview on 11/06/25 at 9:01 A.M. with LPN #165 revealed she worked day shift on 10/13/25. LPN #165 stated she usually worked halls 400 and 500 and is very familiar with the residents on those hallways. LPN #165 stated she received report from RN #109 the morning of 10/13/25 and was not told that Resident #52 had suffered a fall. LPN #165 stated Resident #52 was bedbound and never attempted to get out of bed. LPN #165 stated CNA #300 went into Resident #52's room to provide care and when she attempted to provide care, Resident #52 was screaming in pain. LPN #165 said she checked the medical record and progress notes and did not find anything unusual. LPN #165 stated when she assessed Resident #52, the resident would scream in pain any time LPN #165 touched her legs. LPN #165 stated she called the Nurse Practitioner (NP) and obtained an order for stat x-rays, and x-rays were completed around 4:00 P.M. In a follow up interview with CNA #108 on 11/06/25 at 10:19 A.M., CNA #108 revealed she only reported the fall to CNA #159 and RN #109. CNA #108 stated she did not give the aides on the day shift report, therefore the aides on days were not told of the incident. Interview on 11/06/25 at 1:24 P.M. with RN #109 revealed she had worked the night shift on 10/12/25 and worked halls 400 and 500. RN #109 stated she saw Resident #52 at 8:00 P.M. during her medication pass and had not noted any abnormalities with Resident #52. RN #109 stated she went on break around midnight and had been outside for two minutes when she received a call from CNA #159 informing her that Resident #52 had put her legs over the side of the bed. RN #109 stated this was abnormal for Resident #52, so she immediately came into the building and went to Resident #52's room. RN #109 said upon entering the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366426 If continuation sheet Page 3 of 5 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 11/06/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few room she saw Resident #52 lying in bed with the mechanical lift pad underneath her, a mechanical lift was in the corner of Resident #52's room, with both CNA #108 and CNA #159 at Resident #52's bedside. RN #109 stated CNA #108 said that Resident #52 had her legs over the side of the bed and was holding onto the railing. RN #109 stated at no point did CNA #108 report that Resident #52 had touched the floor. RN #109 stated she compared Resident #52's knees and looked over her legs and did not see any abnormalities. RN #109 stated she was not aware Resident #52 went to the ground and was not aware that CNA #108 and CNA #159 had picked her up from the floor. RN #109 denied being told by CNA #108 that Resident #52 was complaining of pain or had vomited. Review of the facility policy dated 10/17/16 titled Fall Management revealed when a resident falls they will receive prompt medical attention and immediate needs will be quickly assessed and responded to. When it is necessary for EMS to be contacted, the resident is provided comfort until EMS arrives. In follow up to a fall, appropriate intervention directed by the physician will be implemented and family will be notified, further evaluation of the resident's health condition, the environment, equipment, medication, staff, resident practices, and other factors will be determined by the interdisciplinary care team (IDT) and the care plan updated as appropriate. The IDT will also determine if additional facility wide, resident specific, staff, resident or family education, or any other measures need to be implemented. The deficiency was corrected on 10/14/25 when the facility implemented the following corrective actions: - On 10/13/25, the Medical Director was notified of Resident #52's fall and of the x-ray results of bilateral femur fractures. - On 10/13/25, an ad hoc Quality Assurance meeting was held to discuss incident and action plan, including review of the facilities fall policy. - On 10/13/25, CNA #108 and CNA #159 were immediately reeducated by the Administrator and Director of Nursing (DON) via phone on what is a fall and that a resident is not to be transferred after being found on the floor until the nurse has assessed the resident. - On 10/14/25, RN #109 was immediately reeducated by the Administrator and DON via phone on what is a fall including that being lowered to the floor is considered a fall and requires an incident report and provider notification. - On 10/14/25, skin sweeps were completed on residents who were unable to be interviewed by the DON, and the facility wound nurse for possible injuries related to any change in planes. No injuries were found. - On 10/14/25, all interviewable residents were interviewed by the DON for any falls that were not reported. No unreported falls were discovered. - On 10/14/25, nursing staff were re-educated on fall response protocol including education that residents lowered to the floor is considered a fall as there is a change in plane, the need to complete a head to toe assessment, notification of family and physician, incident report in Point Click Care (PCC), fall risk evaluation, pain assessment, in the progress note - document the fall, complete set of vitals, any injury, physician and family notification, and new implemented intervention. - On 10/14/25, CNAs were educated on falls. Education included staying with the resident, call for the nurse, provide support, comfort, and reassurance to the resident, do not move the resident as the nurse has to assess the resident, and fill out the CNA witness statement. - On 10/14/25, the DON, Assistant Director of Nursing (ADON), and Unit Manager conducted leadership rounds focusing on staff awareness of post-fall procedures. - On 10/14/25, the DON reviewed all previous falls from the 10/01/25 forward were reviewed to ensure timely reporting, notification, documentation, and nurse assessment. - Upon Resident #52's return to the facility on [DATE], the IDT completed a fall risk assessment for Resident #52 and updated the care plan to reflect one fall in the last 30 days. Resident #52 remained a high fall risk with no additional interventions identified. Ongoing monitoring will include:- Weekly leadership rounds focusing on staff awareness of post-fall procedures will occur weekly until compliance is identified. - Starting 10/15/25, the DON or designee will review falls (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366426 If continuation sheet Page 4 of 5 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 11/06/2025 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 0684 Level of Harm - Actual harm daily for two weeks and then weekly for 30 days to ensure timely reporting, notification, documentation, and nurse assessment. - All audits will be reviewed at Quality Assurance and Performance Improvement (QAPI). This deficiency represents non-compliance investigated under Master Complaint Number 2651423. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366426 If continuation sheet Page 5 of 5