Inspection·August 18, 2022

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** Based on medical record reviews and staff interviews, the facility failed to ensure the residents Minimum Data Set (MDS) assessments were completed to accurately reflect the resident's status. This affected one (#19) of 12 residents sampled during the survey. The facility census was 43. Residents Affected - Few Findings include: Review of Resident #19's medical record identified admission to the facility on [DATE] with medical diagnosis including anxiety, chronic pain, morbid obesity and bilateral lower leg lymphedema. Resident #19 is cognitively intact and able to answer all questions and make needs known. Review of Resident #19's quarterly minimum data set (MDS) dated [DATE] identified sections C and D were not completed with the residents input. Section C of the MDS assesses for cognition and Section D assesses for resident mood and behavior. Interview with Registered Nurse (RN) #96 on 08/16/22 at 7:39 A.M. confirmed that she completes the MDS assessments for the residents. RN #96 confirmed sections C and D on Resident #19's MDS dated [DATE] were not completed with input from the resident and she is not sure what occurred. The interview with RN #96 confirmed the previous MDS dated [DATE] did identify issues with Resident #19's mood so that section should of been completed. The interview with RN #96 identified this may have been a case where the facility was in outbreak for Coronavirus Disease 2019 (COVID-19). The interview with RN #96 confirmed Resident #19 does have a cell phone that she could have used to complete the interview. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 2 of 7 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 08/18/2022 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on medical record review and resident and staff interviews, the facility failed to ensure residents were invited to attend care conferences and/or meetings regarding their care. This affected one (#19) of 12 sampled residents. The facility census was 43. Findings include: Review of Resident #19's medical record identified admission to the facility occurred on 12/25/21. Resident #19 had medical diagnosis including anxiety, chronic pain, morbid obesity, lymphedema and chronic foot infections. Resident #19 was identified as being cognitively intact. Review of Resident #19's medical record identified a care conference was held on 02/02/22 at which time Resident #19 and her husband attended. The record identified no additional meetings were held until 07/14/22. The care plan meeting notes identified the facility staff participated (dietary, social services and nursing manager) in the meeting; however, Resident #19 and her husband did not. The notes identified no evidence Resident #19 and her husband were invited to participate in the meeting. Interview with Resident #19 on 08/15/22 at 10:18 A.M. revealed she has not had a care conference with the facility for a very long time. Resident #19 identified she and her husband would attend the meetings regarding her care if she was notified. Interview with Registered Nurse (RN) #96 on 08/16/22 at 7:39 A.M. revealed the care plan meetings should be conducted quarterly in line with the Minimum Data Sets (MDS) dates. RN #96 revealed she provides the dates to the social services director (SSD) whom sets up care planning meetings for residents/families. Interview with Social Services Director (SSD) #109 on 08/16/22 at 10:41 A.M. confirmed the facility missed care meetings for Resident #19 from 02/02/22 through 07/14/22 and she is not sure what happened. SSD #109 confirmed the meeting on 07/14/22 did occur without Resident #19 and she was not sure what occurred. SSD #109 confirmed Resident #19's meetings have not been completed quarterly and there was no evidence the facility attempted to invite Resident #19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 3 of 7 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 08/18/2022 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 Based on medical record review, observations and staff and resident interviews, the facility failed to ensure a residents wound care was completed as physician ordered. This affected one (#19) out of 12 sampled residents. The facility census was 43. Residents Affected - Few Findings include: Review of Resident #19's medical record identified admission to the facility occurred on 12/25/21. Resident #19 had medical diagnosis including anxiety, chronic pain, morbid obesity, lymphedema and chronic foot infections. Resident #19 was identified as cognitively intact. Review of Resident #19's medical record identified on 06/30/22 the physician ordered clean open, seeping areas to the right lower leg, apply non-stick protective dressing and wrap with kerlix, change daily and as needed. Interview with Resident #19 on 08/15/22 at 10:25 A.M. revealed she has open, draining lymphedema to her right calf area. Resident #19 identified nursing staff are not putting a dressing on the area as the physician ordered. Resident #19 identified some nurses will do the dressing and others say it should be open to air and they do not do the dressing. Observation of Resident #19's right leg on 08/15/22 at 10:25 A.M. revealed the resident's leg was observed propped up on a pillow. The pillow was saturated with a large amount of yellow-thick drainage around the entire open area. Resident #19's leg was observed without a dressing. Resident #19 identified the nurse last night does not complete the dressing and just leaves it open. Observation of Resident #19 on 08/15/22 at 4:44 P.M. without a dressing to the right leg, however the pillow was clean. Observation of Resident #19's right lower leg on 08/16/22 at 7:17 A.M. and 8:10 A.M. with no bandage on the right lower leg. Observation and interview with Licensed Practical Nurse (LPN) #116 on 08/16/22 at 9:07 A.M. confirmed there was no dressing to Resident #19's leg at this time. LPN #116 confirmed the dressing is scheduled for night shift staff and as needed. LPN #116 confirmed Resident #19 wound to the calf has large amounts of drainage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 4 of 7 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 08/18/2022 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 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 interviews and policy review, the facility failed to ensure residents were free from unnecessary medications when the facility administered medications outside of the physician ordered parameters. This affected two (#1 and #42) out of five residents reviewed for unnecessary medications. The facility census was 43. Residents Affected - Few Findings include: 1. Review of Resident #1's medical record identified admission to the facility occurred on 04/20/22 with medical diagnosis including; cirrhosis of the liver with ascites, low blood pressure (BP) and malnutrition. Resident #1 was receiving hospice care for end of life since 05/13/22. Review of Resident #1's medication regimen for the month of August 2022 revealed the resident was ordered Midodrine HCL five mg three times a day. Further review of orders revealed the Midodrine HCL five mg was to be held if the systolic blood pressure (BP) was above 100 and the diastolic BP was above 70 (systolic BP is identified as the top number and diastolic BP is identified as the bottom number). Review of Resident #1's medication administration record (MAR) for the month of August 2022 identified several occasions where Resident #1 received his Midodrine HCL five mg tablet and was not held in accordance with the physician set BP parameters. The instructions identified hold for systolic BP above 100 and diastolic BP above 70. The review of the MAR revealed the following: on 08/04/22 BP was 128/78 and Midodrine was given; on 08/07/22 BP was 128/74 and Midodrine was given; on 08/09/22 BP was 120/84 and Midodrine was given; on 08/13/22 BP was 109/71 and Midodrine was given; on 08/14/22 BP was 128/74, 121/70 and Midodrine was given two times; and on 08/15/22 BP was 130/74 and Midodrine was given. Interview with Registered Nurse (RN #102) on 08/16/22 at 2:45 P.M. confirmed Resident #1 received several doses of Midodrine HCL five mg in the month of August 2022 that should have been held in accordance with the parameters. 2. Review of medical record for Resident #42 revealed an admission date of 06/05/20. Diagnosis including dementia, heart failure and hypertension. Review of the physician orders for August 2022 revealed Furosemide (for edema) 40 milligrams (mg) one tablet daily, with parameters to hold for systolic blood pressure below 100 or a Heart Rate (HR) below 60. Review of the Medication Administration Record for August 2022 revealed on 08/03/22 Furosemide 40 mg was given with a HR of 58. Interview on 08/18/22 at 9:30 A.M. with RN #102 verified that Furosemide 40 mg should not of been given on 08/03/22 due to the HR was outside of the parameters to be given. Review of facility policy titled General Guidelines for Medication Administration, dated 03/01/07, revealed medications are to be administered in accordance with written orders of the attending physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 5 of 7 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 08/18/2022 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, staff interview and review of maintenance report, the facility failed to provide a safe homelike environment for all residents. This affected three (#11, #31 and #42) out of 43 resident rooms observed during the survey. The facility census is 43. Finding Include: Observation on 08/15/22 at 10:34 A.M. of Resident #11's room revealed the wall behind resident's bed had two large areas of paint pealed off the wall and multiply gouged marks, revealing drywall. Observation on 08/15/22 at 10:58 A.M. of Resident #31's room revealed the air condition vents broken and missing. Observation on 08/15/22 at 11:00 A.M. of Resident #42's room revealed the air condition vents were broke and missing. Interview and observation on 08/16/22 at 2:26 P.M. with Maintenance Director #100 revealed housekeeping and nursing staff are to fill out maintenance forms, when they see areas in the facility that needs repaired. Maintenance Director #100 verified the air condition vents were broken in Resident #31 and #42's room and the wall in Resident #11's room had gouged walls and peeling paint. Review of the Maintenance report for the last 30 days revealed Resident #11, #31 and #43 room maintenance was not on the maintenance report to be completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 6 of 7 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 08/18/2022 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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, observations, staff interview, review of a maintenance task list and policy review, the facility failed to ensure an effective pest control program was in place to ensure a resident's room did not have an infestation of flies. This affected one (#36) out of 12 sampled residents for pest control. The facility census was 43. Residents Affected - Few Finding include: Review of Resident #36's medical record identified admission to the facility on [DATE] with medical diagnosis including; dementia, liver cancer with metastasis, major depression and Alzheimer's disease. Resident #36 started hospice services starting on 08/11/22 for end of life care. Observations of Resident #36 on 08/15/22 at 10:56 A.M. The observation revealed approximately five flies crawling on Resident #36's blankets and bed. Observations of Resident #36 on 08/16/22 at 6:47 A.M., 8:12 A.M. and 8:23 A.M. Resident #36 room was observed with multiple flies on or near the bed. Observation of Resident #36 on 08/16/22 at 10:21 A.M. with Licensed Practical Nurse (LPN) #90 confirmed there were several flies on Resident #36's bed. LPN #90 confirmed she went into the room with a fly swatter and killed 15 flies. The interview with LPN #90 confirmed the facility put some type of bug light in the room last week for issues with flies. Review of the maintenance task listing (used to notify maintenance of issues) was completed for the month of July and August 2022. The listing did not evidence a concern for excessive flies in the building. Review of the facility policy titled Pest Control dated January 2018 identified the facility will maintain the facility to be free of pest or rodents while utilizing the contracted providers should the need arise. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 7 of 7