Health inspection·March 3, 2022

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interviews, resident interviews, and review of the facility's policy, the facility failed to ensure the residents were assisted with showers routinely and timely as scheduled. This affected two (Residents #27 and #65) of three residents reviewed for bathing. The facility identified all 92 residents required assistance or were dependent on staff for assistance with bathing. The facility census was 92. Residents Affected - Few Findings include: 1. Review of Resident #27's medical record revealed an admission date of 10/16/18. Diagnoses included tremors, congestive heart failure, asthma, and chronic kidney disease. Review of Resident #27's quarterly Minimum Data Set (MDS) assessment, dated 12/21/21, revealed the resident had a high cognitive function. Resident #27 required a one person physical assist with hygiene and was a total dependence on staff for bathing. Review of Resident #27's shower schedule revealed the resident was to have a bath every Monday and Friday. Review of Resident #27's shower documentation electronic records revealed she received a shower/bath on Wednesday 02/02/22, Friday 02/04/22, Friday 02/11/22, Saturday 02/12/22, Friday 02/18/22, Saturday 02/19/22, Monday 02/21/22, and Saturday 02/26/22. Interview with Resident #27 on 02/28/22 at 10:03 A.M. revealed the resident was not receiving timely showers. She stated she was given a shower once weekly, but had gone two weeks without a shower or bath. Interview with the Assistant Director of Nursing (ADON) #500 on 03/03/22 at 10:14 A.M. verified the facility failed to administer Resident #27's showers timely. The ADON verified Resident #27 went seven days without a shower or bath between 02/04/22 and 02/11/22 and six days between 02/12/22 and 02/18/22. 2. Review of Resident #65's medical record revealed an admission date of 11/09/20. Diagnoses included left lower extremity amputee, peripheral vascular disease, cerebral vascular accident, and dementia. Review of Resident #65's quarterly MDS assessment, dated 01/24/22, revealed the resident had a moderate impairment in cognitive function. Resident #65 required an extensive assistance two person assist for personal hygiene and bathing. Review of Resident #65's most recent care plan revealed she resident required one staff participation with bathing. Review of Resident #65's shower schedule revealed the resident was to have a bath every Wednesday and Friday. Review of Resident #65's shower documentation electronic records revealed she received a shower/bath on Tuesday 02/08/22, Monday 02/14/22, Wednesday 02/16/22, and Saturday 02/19/22. The resident was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365093 If continuation sheet Page 2 of 8 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 365093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd The 622 Center St Ashland, OH 44805 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 0677 documented as refusing a bath/shower on Tuesday 02/15/22 and Friday 02/25/22. Level of Harm - Minimal harm or potential for actual harm Interview with Resident #65 on 02/28/22 at 10:47 A.M. revealed her showers/bathes were not given timely and she may go a couple of weeks without a shower. Residents Affected - Few Interview with the Assistant Director of Nursing (ADON) #500 on 03/03/22 at 10:14 A.M. verified the facility failed to administer Resident #65's timely. The ADON verified Resident #65 went without a shower for six days between 02/08/22 and 02/14/22 and had no shower from 02/19/22 through 03/01/22. The ADON also stated the nursing staff failed to document any refusals or why the showers had not been completed. Review of the facility's policy titled Resident Shower/Bathing revealed residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. Resident bath schedules will be posted at each nurses station. The staff must document the resident bath acceptance in Point Click Care or alternative record if needed. Report any declined baths to the charge nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365093 If continuation sheet Page 3 of 8 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 365093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd The 622 Center St Ashland, OH 44805 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 review of the facility's policy, observation, record review and resident and staff interview, the facility failed to provide adequate activities for Resident #9. This affected one (Resident #9) of two residents reviewed for activities. The facility census was 92. Residents Affected - Few Findings include: Review of Resident #9's medical record revealed an initial admission date of 01/09/21. Diagnoses included anxiety, depression, and obstructive sleep apnea. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 11/24/21, revealed Resident #9 had intact cognition. Resident #9 was totally dependent on staff for bed mobility, transfers, toileting, and personal hygiene. Resident #9 considered doing things with groups of people to be somewhat important and participating in her favorite activities to be very important. Review of the plan of care, dated 10/16/21, revealed Resident #9 had the potential for alteration in scheduled/self-initiated events. Interventions included encouraging the resident to participate in activities, offering invites and encouragement, and providing assistance to and from activities as needed. Resident #9 was dependent on staff for activities, cognitive stimulation, and social interaction related to disease process, Multiple Sclerosis, immobility, and physical limitations. Interventions included assuring activities the resident was attending were compatible with the resident's physical and mental capabilities, compatible with known interests and preferences, and the resident would be provided with a program of activities that were of interest and empowered the resident. Review of the activities progress notes dated 08/02/21 at 10:07 A.M. revealed Resident #9 continued to enjoy manicures, group activities, one-on-one visits, listening to music on her phone, and going outside on walks. No activities progress notes were documented from 09/21/21 through 03/03/22 regarding the resident attending activities, declining activities, or an activities progress note update. Review of the activity logs for December 2021, January 2022, and February 2022 revealed one-on-one visits were documented as provided to the resident on 02/01/22, 02/07/22, 02/08/22, 02/09/22, 02/11/22, 02/14/22, and 02/16/22. Activities cart was documented for resident participation on 02/03/22. No other activities were documented for the resident within this time period. Interview on 03/03/22 at 10:42 A.M. with the Assistant Director of Nursing (ADON) verified there were no additional activities progress notes for Resident #9 from 09/21/21 through 03/03/22. Observations on 02/28/22 at 10:41 A.M., on 03/01/22 at 11:16 A.M., on 03/02/22 at 1:51 P.M., and on 03/03/22 at 8:47 A.M. revealed Resident #9 was sitting upright in her motorized wheelchair, with the television turned on. Interview on 02/28/22 at 10:41 A.M. with Resident #9 revealed the resident enjoyed participating in activities but the facility had not been having any activities for several months. Review of the faciliy's activities calendars for the Rehabilitation Unit dated January 2022, February 2022, and March 2022 revealed there were no scheduled group activities for January 2022 or February 2022. Activities on each calendar included self-directed activities and the March 2022 calendar included unscheduled staff visits to resident rooms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365093 If continuation sheet Page 4 of 8 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 365093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd The 622 Center St Ashland, OH 44805 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 Level of Harm - Minimal harm or potential for actual harm Interview on 03/02/22 at 2:36 P.M. with Activities Director #204 verified there were no scheduled activities or group activities for January 2022, February 2022, and March 2022. Activities Director #204 stated this was due to activities personnel being trained as State Tested Nursing Assistants (STNA) and often getting pulled to work as STNAs. Activities Director #204 reported there was a full-time activities staff member who worked the rehabilitation unit but they had not worked at the facility since August or September of 2021. Residents Affected - Few Review of the facility's policy titled Resident Activities, revised January 2002, revealed the activities department would provide activities designed to meet the specific needs and/or interests of all residents on each unit. Review of the facility's policy titled Activities Department Documentation revealed each resident's medical record would contain a quarterly activities update progress note. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365093 If continuation sheet Page 5 of 8 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 365093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd The 622 Center St Ashland, OH 44805 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and review of a nursing manual, the facility failed to ensure a midline catheter's placement per nursing standards. This affected one (Resident #65) observed for intravenous medication administration. The facility identified one resident on intravenous therapy. The facility census was 93. Residents Affected - Few Findings include: Review of Resident #65's medical records revealed an admission date of 11/09/20. Diagnoses included a bacterial infections to the right ankle and foot. Review of Resident #65's physician's order, dated 02/22/22, revealed an order to flush the midline with 10 milliliters (ml) of normal saline before and after each use every 12 hours. Observation with Licensed Practical Nurse (LPN) #134 on 03/03/22 at 9:22 A.M. revealed LPN #134 completed the physician ordered flush on Resident #65's midline intravenous access. LPN #134 was observed cleaning the access and placing a 10 ml syringe of normal saline to the access site. LPN #134 pushed the solution directly into the midline catheter without checking for any blood return prior to administering the normal saline. Interview with LPN #134 on 03/03/22 at 9:35 A.M. verified she failed to check for catheter placement prior to administering normal saline to Resident #65. Interview with the Director of Nursing on 03/03/22 at 11:22 A.M. verified the facility did not have a policy regarding this issue. Review of the nursing manual found at https://www.bd.com/assets/documents/PDH/CVC/BDPI_Hickman-[NAME]-Broviac_BD-30813_Nursing-Procedure-Manual_ revealed prior to administering normal saline the catheter placement must be confirmed by aspirating slowly until a blood return is visualized. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365093 If continuation sheet Page 6 of 8 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 365093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd The 622 Center St Ashland, OH 44805 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, policy review, and staff interview, the facility failed to ensure posted nursing staff information was updated timely and accurate. This had the potential to affect all 92 residents residing in the facility. Residents Affected - Many Findings include: Observation of the posted nursing staff information on 02/28/22 at 8:12 A.M. and at 10:50 A.M. revealed the posted nursing staff information was from 02/25/22 and contained the staff numbers for the 7:00 A.M. to 3:00 P.M. shift. Observation of the posted nursing staff information on 03/02/22 at 7:41 A.M. and at 9:13 A.M. revealed the posted nursing staff information was from 03/01/22 and contained the staffing numbers for the 7:00 A.M. to 3:00 P.M. shift. Interview on 03/02/22 at 10:20 A.M. with the Licensed Practical Nurse (LPN) #265 revealed the nurse supervisors were to update and post nursing staff information each shift. Interview on 03/02/22 at 11:16 A.M. with the Assisted Director of Nursing (ADON) #156 verified nurse supervisors were to update and post nurse staff information each shift. The ADON #156 further verified the posted nursing staff information was not up to date and information was missing. Review of the facility's policy titled BIPA (Benefits Improvement and Protection Act of 2000) Report, dated 02/28/06 with a revision date of 06/23/15, stated the Nursing Supervisor is responsible for initiating, updating, and posting the daily nurse staff information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365093 If continuation sheet Page 7 of 8 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 365093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd The 622 Center St Ashland, OH 44805 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and policy review, the facility failed to remove expired medications from the medications carts and medication storage rooms. This affected three of six medication carts and two of three medication storage rooms. This had the potential to affect all 92 residents residing in the facility. Findings include: Observation of Windsor medication cart on 03/01/22 at 7:55 A.M. revealed a bottle of CoQ 10 was found with an expiration date of 01/2022 and a bottle of aspirin 325 milligrams (mg) was located in the cart with an expiration date of 11/2021. Observation of the Windsor [NAME] Hall medication room on 03/01/22 at 8:22 A.M. revealed the following medications expired: Melatonin (sleep aid) 3.0 mg expired 10/2021, Loperamide (anti-diarrhea) 2.0 mg expired 11/2021, B6 vitamins 100 mg expired 11/2021, Geri Dry diphenhydramine (antihistamine) expired 11/2021, and cetirizine hydrochloride (antihistamine) 10 mg which had expired on 07/2021. Observation of the [NAME] hall cart on 03/01/22 at 8:35 A.M. revealed two bottles of Vitamin B12 500 mg had expired in 03/2021 and two bottles of simethocone (gas relief) 125 mg had expired on 06/2021. Observation of the medication room on the [NAME] hall on 03/01/22 at 8:43 A.M. revealed a bottle of Vitamin B12 500 mg was found to be expired in 03/2021 and a bottle of Geri Dry Allergy Relief had expired in 11/2021. Interview with Licensed Practical Nurses #134 and #192 and Registered Nurse #110 on 03/01/22 between 7:58 A.M. and 8:46 A.M. verified the medications had expired and should have been removed from the medication carts and medication storage rooms. These medications were stock and used by all residents who were prescribed them. Review of the facility's policy titled Medication Storage, dated May 2017, revealed it was the policy of the facility to ensure all medications house on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendation and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365093 If continuation sheet Page 8 of 8