Inspection·August 28, 2019

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview on 08/27/19 at 12:56 P.M. with Licensed Practical Nurse (LPN) #202 revealed the resident didn't complain to her of any tenderness, swelling or edema. She was unaware of any current swelling or edema. An observation on 08/27/19 at 1:31 P.M. with LPN #202 revealed Resident #58's right calf was noted with pitting edema, swelling to her right knee and warmth to her right leg, all observations were compared to her left leg. An interview on 08/27/19 from 1:51 P.M. through 2:23 P.M. with Physical Therapy Assistant (PTA) #233 revealed on 08/26/19, Resident #58 had bilateral distal ankle/feet swelling. She stated she notified the nurse on the resident's unit of the swelling. Review of the physician's notification board from 08/26/19 through 08/28/19 revealed on 08/26/19 there was no documented evidence of physician notification for Resident #58's swelling or edema. On 08/27/19 it was documented that the resident had right leg swelling (knee and ankle), slightly pitting, slightly warmer than the left and was sensitive to touch. An interview 08/28/19 at 9:25 A.M. with LPN #131 confirmed LPN #202 documented the 08/27/19 observation on the physician board. LPN #131 revealed the physician and nurse practitioner weren't going to be at the facility on 08/28/19. She would expect that to be passed along within 24 hours. The LPN verified the physician was not notified of the resident's swelling on 08/26/19 or 08/27/19. Review of the policy titled, Resident: Change in Condition, dated August 2018, revealed any change in condition discovered by a nurse or reported to a nurse by anyone present will be reported to the medical director or the nurse practitioner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 2 of 13 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 365118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jag Healthcare Mansfield 50 Blymyer Avenue Mansfield, OH 44903 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain a wheelchair cushion clean and in good repair for one (Resident #13) of 20 residents reviewed for maintenance and cleanliness of resident equipment and supplies. The facility census was 67. Findings include: Review of Resident #13's medical record revealed she admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, Alzheimer's disease, anxiety, major depressive disorder and muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 07/09/19, revealed Resident #13 had a severe cognitive impairment. Observations on 08/26/19 at 8:14 A.M., 08/26/19 at 11:31 A.M. and 08/26/19 at 2:17 P.M. revealed Resident #13's wheelchair cushion was dirty with apparent stains and had an eight inch rip along the seam and exposing the cushion. Interview on 08/26/19 at 2:25 P.M. with State-Tested Nursing Assistant (STNA) #98 confirmed Resident #13's wheelchair cushion was dirty with apparent stains and had an eight inch rip along the seam, exposing the cushion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 3 of 13 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 365118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jag Healthcare Mansfield 50 Blymyer Avenue Mansfield, OH 44903 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, review of facility's Self-Reported Incident, medical record review and review of facility policy, the facility failed to prevent physical abuse for one (Resident #22) of two residents reviewed for abuse. The facility census was 67. Findings include: Review of Resident #22's medical record revealed she admitted to the facility on [DATE] with diagnoses including: major depressive disorder and a history of falling. Review of the most recent Minimum Data Set (MDS) assessment, dated 07/02/19, revealed Resident #22 was moderately cognitively impaired. Resident #22 was receiving hospice services and required extensive assistance with activities of daily living. Review of the facility's Self-Reported Incident (SRI), dated 08/17/19, revealed it was an allegation of physical abuse. Resident #34 informed State-Tested Nursing Aid (STNA) #215 around 6:30 A.M. on 08/17/19 that she had smacked Resident #22's hand and had spilled her water at dinner the previous night. Licensed Practical Nurse (LPN) #121 then interviewed Resident #22 who stated she did not remember the previous night and did not remember the incident. Resident #22 reported zero pain. LPN #121 then interviewed Resident #34 who again stated she had smacked Resident #22's hand because she did not want the cookie that was being offered to her. During this process, she had also knocked over Resident #22's water. The SRI was substantiated. Review of a statement written by Licensed Nursing Home Administrator (LNHA), dated 08/19/19, revealed on Saturday 08/17/19, Resident #34 had notified staff that on 08/16/19, she had hit Resident #22 in the hand while refusing a cooking and knocked over her water. LNHA interviewed Resident #22 who stated she did not remember the incident. Resident #22 informed LNHA that she was not hurt. LNHA stated the two residents would no longer be placed with each other at meals. Review of a nursing note dated 08/17/19 revealed another resident stated she had hit a cookie out of Resident #22's hand at meal time the previous night. Resident #22 was assessed, no injury was noted, no complaint of pain and Resident #22 stated she did not recall the incident. During an interview on 08/27/19 at 11:02 A.M. with LNHA, LNHA verified he did substantiate the physical abuse SRI involving Resident #34 hitting Resident #22, that occurred on 08/16/19. Review of the facility's undated policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property revealed it is the policy of the facility to support the residents' right to be free from physical, verbal, mental and emotional abuse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 4 of 13 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 365118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jag Healthcare Mansfield 50 Blymyer Avenue Mansfield, OH 44903 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, review of facility's Self-Reported Incident, review of medical records and review of facility policy, the facility failed to thoroughly investigate an allegation of physical abuse for one (Resident #22) of two residents reviewed for abuse. The facility census was 67. Residents Affected - Few Findings include: Review of Resident #22's medical record revealed she admitted to the facility on [DATE] with diagnoses including: major depressive disorder and a history of falling. Review of the most recent Minimum Data Set (MDS) assessment, dated 07/02/19, revealed Resident #22 was moderately cognitively impaired. Resident #22 was receiving hospice services and required extensive assistance with activities of daily living. Review of the facility's Self-Reported Incident (SRI), dated 08/17/19, revealed it was an allegation of physical abuse. Resident #34 informed State-Tested Nursing Aid (STNA) #215 around 6:30 A.M. on 08/17/19 that she had smacked Resident #22's hand and had spilled her water at dinner the previous night. Licensed Practical Nurse (LPN) #121 then interviewed Resident #22 who stated she did not remember the previous night and did not remember the incident. Resident #22 reported zero pain. LPN #121 then interviewed Resident #34 who again stated she had smacked Resident #22's hand because she did not want the cookie that was being offered to her. During this process, she had also knocked over Resident #22's water. The SRI was substantiated. Review of a statement written by Licensed Nursing Home Administrator (LNHA), dated 08/19/19, revealed on Saturday 08/17/19, Resident #34 had notified staff that on 08/16/19, she had hit Resident #22 in the hand while refusing a cooking and knocked over her water. LNHA interviewed Resident #22 who stated she did not remember the incident. Resident #22 informed LNHA that she was not hurt. LNHA stated the two residents would no longer be placed with each other at meals. Review of a nursing note dated 08/17/19 revealed another resident stated she had hit a cookie out of Resident #22's hand at meal time the previous night. Resident #22 was assessed, no injury was noted, no complaint of pain and Resident #22 stated she did not recall the incident. During an interview on 08/27/19 at 11:02 A.M. with LNHA, LNHA verified he did not complete a thorough investigation by confirming he did not interview any other residents or any staff members who were present in the dining room on 08/16/19. LNHA stated he did not interview any additional staff or residents because no one witnessed the incident. When asked how he knew no one had witnessed it if he did not interview others, he stated Resident #34 had told him no one was around to see it and that he believed what she said had occurred. Review of the facility's undated policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property revealed it is the policy of the facility to support the residents' right to be free from physical, verbal, mental and emotional abuse. The policy further revealed it was the policy of the facility that reports of abuse are promptly and thoroughly investigated. The policy revealed the investigation would include the following: who was involved, resident statements, and involved staff and witness statements of events. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 5 of 13 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 365118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jag Healthcare Mansfield 50 Blymyer Avenue Mansfield, OH 44903 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on observation, resident and staff interview, review of the Resident Assessment Instrument (RAI) and review of the medical record, the facility failed to complete accurate Minimum Data Set (MDS) assessments for two (Resident #11 and #20) of 20 residents reviewed for accurate MDS assessments. The census was 67. Findings include: 1. Record review for Resident #11 revealed the resident was admitted to the facility on [DATE] with diagnoses including dysphagia and dementia. Review of Resident #11's care plan, dated 07/10/18, revealed he had broken teeth related to poor oral hygiene. Review of the MDS assessment, dated 07/06/19, revealed he was cognitively intact. The MDS also stated that Resident #11 had no broken natural teeth. Interview and observation on 08/25/19 at 9:46 A.M. revealed Resident #11 stated he has had a broken tooth for a couple years. Observation of the resident's mouth revealed Resident #11's top left tooth was broken. Interview on 08/26/19 at 3:15 P.M. with MDS Coordinator #196 confirmed Resident #11 has had a care plan for broken teeth since 07/10/18 and that Resident #11's broken natural teeth were not captured on his most recent MDS, dated [DATE]. 2. Review of the medical record for Resident #20 revealed an admission date of 04/06/19 with diagnoses including anxiety and depression. Review of Resident #20's weight record revealed Resident #20 weighed 118.8 pounds (lbs) on 07/01/19 and weighed 125.4 lbs on 06/06/19 indicating a significant 5.3 percent (% weight loss from 06/06/19 to 07/01/19. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/03/19, revealed Resident #20 did not have significant weight loss in the past one month or six months. Interview with MDS Coordinator #196 on 08/27/19 at 3:25 P.M. verified Resident #20's quarterly MDS assessment dated [DATE] was inaccurate and should have indicated the resident had significant weight loss in the past one month or six months. Review of the RAI Manual dated October 2018 revealed significant weight loss is defined at 5% weight loss in 30 days or 10% weight loss in 180 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 6 of 13 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 365118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jag Healthcare Mansfield 50 Blymyer Avenue Mansfield, OH 44903 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, family interview, staff interview and review of facility policy and procedure, the facility failed to assess and monitor Resident's #40's ongoing scab to his nose. This affected one (#40) of one resident reviewed for skin conditions. The facility census was 67. Residents Affected - Few Findings include: Record review for Resident #40 revealed the resident was admitted to the facility on [DATE]. Diagnoses included anemia, dementia with behavioral disturbance, major depressive disorder, anxiety, and chronic kidney disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 06/06/19, revealed he was severely cognitively impaired. Review of Resident #40's skin assessments from 04/18/19 through 08/25/19 revealed no evidence of Resident #40's scab or picking at his scab. Observations on 08/25/19 at 1:28 P.M., 08/26/19 at 8:12 A.M., 08/26/19 at 10:09 A.M., 08/26/19 at 11:37 A.M., 08/26/19 at 2:30 P.M., and 08/27/19 at 11:09 A.M. revealed a pea-sized brown scab on the tip of Resident #40's nose. A phone interview on 08/25/19 at 1:28 P.M. with Resident #40's granddaughter revealed Resident #40 had the scab on the tip of his nose that has been there a while. The granddaughter stated Resident #40 often picked and scratched at his nose and would not let it heal. She stated she had jokingly told staff she was going to knit him mittens to keep him from picking at his nose scab. Review of a nursing note, dated 08/26/19, revealed Resident #40 was noted to have a small scabbed area on the tip of his nose. The nursing note further revealed Resident #40 was noted to be rubbing his nose throughout the day. The physician was notified and Resident #40 will be seen by the physician on his next rounds. An interview on 08/27/19 at 11:09 A.M. with Licensed Practical Nurse (LPN) #93 stated she was not sure what had caused the scab on Resident #40's nose. An interview with the Assistant Director of Nursing (ADON) #200 on 08/27/19 at 11:43 A.M. revealed she had asked staff about the scab and they had informed her that he had been picking at it prior, and that staff was under the impression that the scab, comes and goes. ADON confirmed there had not been any documentation on Resident #40's scab or picking at his nose prior to a nursing note that had been written on 08/26/19. An interview with State-Tested Nursing Assistant (STNA) #90 on 08/27/19 at 1:06 P.M. revealed Resident #40 had had the scab on his nose for at least three months. Review of the facility policy titled, Skin Assessment and Monitoring, dated 02/2018 revealed residents would be assessed for any skin impairments or pressure areas upon admission, re-admission and weekly from head to toe. The policy further revealed any skin impairments were to be documented in the weekly skin assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 7 of 13 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 365118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jag Healthcare Mansfield 50 Blymyer Avenue Mansfield, OH 44903 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, resident interview, staff interview, and review of facility policy and procedure, the facility failed to re-assess Resident #36's pain after the discontinuation of a pain relieving medicated patch. This affected one resident (#36) of one resident reviewed for pain management. The facility identified 30 residents on a pain management program. The facility census was 67. Residents Affected - Few Findings include: Review of Resident #36's medical record revealed a admission date of 09/18/18. Diagnoses included osteoporosis, difficulty walking, altered mental status, testicular pain and kidney stones. Review of the care plan, dated 06/05/19, revealed the resident had chronic neck pain with interventions to monitor, record and report complaints of pain and notify the physician if interventions were unsuccessful or if there was a significant change from the residents past experience of pain. Review of the Minimum Data Set (MDS) assessment, dated 06/25/19, revealed the resident had intact cognition and he had frequent pain. The MDS assessment, dated 08/19/19, revealed the resident had constant pain and rated his pain a level eight (zero being no pain at all and ten being the most severe pain ever). He was not on a scheduled pain medication regimen and he did not receive as needed pain medications. Review of Resident #36's physician orders revealed an order for Aspercreme Lidocaine four percent (%) patch to each side of neck topically once daily for pain. This order was discontinued on 07/02/19 after a pharmacy recommendation stated there should be no more than one patch used in a 24 hour period. A new order was created for 07/03/19 stating Aspercreme Lidocaine four % patch to neck once daily for 12 hours on and 12 hours off, with instructions to alternate sides and remove per the schedule. The resident also had orders, dated 06/18/19, for Cyclobenzaprine five milligrams (mg) every eight hours as needed for muscle pain and cramping. Review of the most recent pain scale assessment, dated 07/01/19, revealed the resident's pain ranged from zero to six out of ten. There was no other pain assessments completed after 07/01/19. An interview on 08/25/19 at 9:05 A.M. with Resident #36 revealed his neck and shoulder pain was not controlled even though he was on the Cyclobenzaprine as needed. Subsequent interview on 08/28/19 at 8:05 A.M. with Resident #36 revealed staff have maybe only assessed his pain once since the Aspercreme order modification on 07/02/19, but reported he was still in constant pain. An interview on 08/27/19 at 1:33 P.M. with Licensed Practical Nurse (LPN) #202 revealed Resident #36 used to have an Aspercreme Lidocaine four % patch for both sides of his upper back/neck, but one was discontinued. She stated the resident was still verbalizing he was still in pain with the one patch and she wasn't sure if the physician was notified of the continued pain after the discontinuation of the one patch. LPN #202 confirmed there was no re-assessment of the resident's pain assessments since 07/01/19 and verified the physician was not notified of any continued pain since the medicated patch modification on 07/02/19. Review of the policy titled, Management of the Patient in Pain, dated March 2010, revealed (regarding general pain interventions) staff should evaluate the effectiveness of the pain medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 8 of 13 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 365118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jag Healthcare Mansfield 50 Blymyer Avenue Mansfield, OH 44903 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 0697 administered by using the pain scale and to notify the physician of inadequate pain relief. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 9 of 13 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 365118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jag Healthcare Mansfield 50 Blymyer Avenue Mansfield, OH 44903 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 observations and staff interviews, the facility failed to ensure daily staff postings were updated each day. This had the potential to affect all 67 residents residing in the facility. Residents Affected - Many Findings include: Observation on 08/25/19 at 2:37 P.M. revealed the daily staff posting was dated 08/23/19. Interview with Director of Nursing on 08/25/19 at 2:37 P.M. verified the daily staff posting was dated 08/23/19. During the interview, the DON stated that the daily staff postings for Saturday and Sunday were completed on Monday due to the individual responsible for updating them not working on the weekends Observation on 08/27/19 at 9:47 A.M. revealed the daily staff posting was dated 08/26/19. Interview with Assistant Director of Nursing #200 on 08/27/19 at 9:47 A.M. verified the daily staff posting was dated 08/26/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 10 of 13 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 365118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jag Healthcare Mansfield 50 Blymyer Avenue Mansfield, OH 44903 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview and record review, the facility failed to ensure food service equipment was maintained in a sanitary manner and resident food items were dated and labeled. This affected 66 of 67 residents who receive food from the kitchen (Resident #17 received nothing by mouth). The facility census was 67. Findings include: 1. Observation on 08/25/19 at 8:40 A.M. revealed a white substance on Cereal #1, Cereal #2, Cereal #3 and Cereal #4's cereal dispensers as well as a brownish substance with a hardened clear drip on the tip of the thickened juice dispenser. Observation on 08/25/19 at 8:46 A.M. revealed a white substance around the outside of the hot water dispenser as well as a brownish substance around the outside of the coffee dispenser. Interview with Dietary Manager #149 on 08/25/19 at 9:02 A.M. verified the above findings. 2. Observation of the station one refrigerator on 08/27/19 at 12:58 P.M. revealed resident food items which included mashed potatoes, meatloaf, vegetable stew and ranch dressing. All of these items were neither labeled nor dated. Interview with Licensed Practical Nurse #189 on 08/27/19 at 12:58 P.M. verified the above food items were for residents and were neither labeled nor dated. Review of the facility's undated policy titled Food and Nutrition Services-Infectious Control revealed all food and nutrition services areas and equipment were to be cleaned and/or sanitized as scheduled. Leftovers shall be promptly and properly covered, labeled, dated and stored under refrigeration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 11 of 13 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 365118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jag Healthcare Mansfield 50 Blymyer Avenue Mansfield, OH 44903 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review for Resident #120 revealed the resident was admitted to the facility on [DATE]. Diagnoses included included muscle weakness and chronic kidney disease. Residents Affected - Few Review of the physicians orders for Resident #120 revealed an order, dated 08/25/19, for an indwelling catheter. Observation of Resident #120 on 08/25/19 at 11:35 A.M. revealed Resident #120 was up sitting in his wheelchair in his room. Resident #120's indwelling catheter tubing was observed to be on the floor. Interview with STNA #900 on 08/25/19 at 11:35 A.M. verified Resident #120's indwelling catheter tubing was improperly touching the floor. Based on medical record review, observation, staff interview and review of facility policy and procedure, the facility failed to maintain infection control after personal care for three residents. This affected three (#40, #52 and #120) of three residents reviewed for urinary tract infections. The facility identified three residents with indwelling urinary catheters. The census was 67. Findings include: 1. Review of Resident #40's medical record revealed an admission date of 10/08/09 and the diagnoses of obstructive and reflux uropathy. Review of the physician orders revealed an order for indwelling urinary catheter care every shift. Review of the Minimum Data Set (MDS) assessment, dated 06/06/19, revealed the resident had an indwelling catheter. The resident's care revealed the indwelling catheter was in place due to diagnoses of obstructive uropathy with interventions for catheter care every shift per orders. An observation on 08/26/19 from 1:15 P.M. through 1:30 P.M. of perineal care and catheter care for Resident #40 with State Tested Nursing Aide (STNA) #122 revealed the STNA provided perineal care to Resident #40 with the use of gloves. After finishing the perineal care, the STNA did not remove her gloves or wash her hands and proceeded to pull up the resident's sheets, gave the resident his call light, touched the dirty rags/towels (used for personal care) and placed them next to the residents head on the bed, touched an entire roll of trash bags, placed the dirty rags in the trash bags, elevated the head of the residents bed with the bed remote. She then removed her gloves and left the room without washing her hands. An interview on 08/26/19 at 1:45 P.M. with STNA #122 confirmed she did not remove gloves after perineal care and continued to touch items in the resident's room. Review of the policy titled Handwashing, dated 02/20/18, revealed staff are to wash their hands before and after entering and leaving a patients room. 2. Review of Resident #52's medical record revealed an admission date of 07/30/19. Diagnoses included urine retention, urinary tract infection, and infection and inflammatory reaction due to indwelling urethral catheter. Review of the Minimum Data Set (MDS) assessment, dated 08/12/19, revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 12 of 13 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 365118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jag Healthcare Mansfield 50 Blymyer Avenue Mansfield, OH 44903 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident had an indwelling catheter. The care plan, dated 08/12/19, revealed the resident had an indwelling catheter with interventions for catheter care every shift. An observation on 08/26/19 from 1:35 P.M. through 1:45 P.M. of perineal care and catheter care for Resident #52 with STNA #98 revealed the STNA provided perineal care with gloves on. After the personal care was provided with gloves on, the STNA did not removed her gloves or wash her hands and proceeded to place the wash rag, rinse rag and dry towel (used to provide the personal care) onto the resident's bedside table without a barrier. The STNA then (with the same gloves) touched the remote to elevate the head of the bed, moved the bedside table, obtained a new bag from trash can and touched the bathroom door handle. Then, the STNA removed the gloves, then washed her hands. An interview on 08/26/19 at 1:45 P.M. with STNA #98 confirmed she did not remove her gloves or wash her hands after she provided perineal care to Resident #52 and proceeded to touch items in the resident's room. Review of the policy titled Catheter Care: Foley Catheter, dated May 2017, revealed after cleaning up and drying off the resident, staff were to remove dirty gloves, be sure the resident is dry and comfortable, be sure their bed is in order, and place their call light in reach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 13 of 13