Inspection·May 14, 2024

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview and observation with Licensed Practical Nurse (LPN) #110 on 05/13/24 at 9:02 A.M. confirmed Resident #10 was on contact isolation for ESBL and to enter the room gown and gloves needed to be worn. LPN #110 stated those items were in the isolation cart, but when observing the isolating cart with LPN #110 she verified there were no gowns or gloves in the isolation cart outside Resident #10's room. LPN #110 stated she did not know who stocked the isolation carts at the facility. LPN #110 verified she passed medication to Resident #10 on 05/13/24 and had only worn gloves in the room as she did not have a gown to wear in the room. Observation of the supply room on 05/13/24 at 9:05 A.M. with LPN #110 revealed there were no isolation gowns in the storage room. LPN #110 confirmed there were no gowns in the supply room at the time of the observation. 2. Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included severe calorie protein calorie malnutrition, acute and chronic respiratory failure with hypoxia, local infection of the skin and subcutaneous tissue, methicillin resistant staphylococcus aureus infection, anxiety, history of transient ischemic attack, and atrial fibrillation. Review of the quarterly MDS assessment dated [DATE] revealed Resident #30 was and was coded as not requiring isolation. Review of Resident #30's medical record revealed there was no two-step Mantoux screening completed to rule out tuberculosis infection. Review of Resident #30's physician orders revealed the resident had an order dated 04/06/24 to cleanse the gastrostomy tube (a tube surgically inserted into the stomach) with normal saline, pat dry, apply triple antibiotic ointment, and cover with a split gauze daily. Additionally, Resident #30 was ordered to have a wound on the left heel cleansed with a skin protectant and covered with bordered foam daily beginning 04/16/24, and was placed on contact isolation for ESBL on 05/03/24. Interview and observation on 05/13/24 at 9:18 A.M. with LPN #100, who was the assistant director of nursing, confirmed she was the nurse on call on 05/12/24 and that she had been in the facility and no staff called or alerted her that there were no isolation gowns in the isolation carts for use. LPN #100 was observed with a case of isolation gowns in her hands and she stated she was going to stock the isolation carts. LPN #100 verified the gowns were in the facility. Observation of Resident #30's room on 05/13/24 at 9:20 A.M. revealed there was a sign on the door that indicated the resident was on contact precautions. The signage on the door instructed everyone must clean hands, put on gloves and gown prior to entering the room, and use dedicated equipment for the resident. Further observation revealed an isolation cart was outside the room. The cart had face masks, face shields, and barrier pads, but there were no gloves or gowns in the cart. Interview and observation with LPN #120 on 05/13/24 at 9:20 A.M. confirmed Resident #30 was in contact isolation and to enter the room gown and gloves needed to be worn. The isolation cart was observed with LPN #120 who confirmed there were no gowns or gloves in the isolation cart. LPN #110 verified she had passed medication to Resident #30 on 05/13/24 and had only worn gloves as she was unable to find a gown to wear. Interview with Resident #30 on 05/13/24 at 10:25 A.M. confirmed the staff do not wear gowns and (continued on next page) 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 05/14/2024 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 gloves in her room when they enter or provide care to her. Level of Harm - Minimal harm or potential for actual harm 3. Review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE] with the most recent readmission on [DATE]. Diagnoses included anemia, metabolic encephalopathy, altered mental status, urinary tract infection, ESBL resistance, diabetes, and an unstageable pressure ulcer to the heel. Residents Affected - Some Review of the quarterly MDS assessment dated [DATE] revealed Resident #50 had mild cognitive impairment and was coded as not requiring isolation. Review of Resident #50's physician orders revealed the resident was ordered right posterior thigh to be cleansed with wound cleanser, patted dry, calcium alginate with Medihoney applied, and covered with a boarder foam dressing on 05/08/24. On 05/13/24, the resident was ordered to have a wound to the top of the left heel treated with Dakins half-strength soaked gauze, apply an absorbent dressing, and secure with Kerlix on 05/13/24. Additionally, on 05/13/24, Resident #50 was ordered to have a sacrum wound cleansed with wound cleanser, patted dry, calcium alginate with Medihoney applied, and covered with a boarder foam dressing every night. Interview on 05/13/24 at 10:02 A.M. interview with LPN #100 confirmed the residents in the facility who required isolation were Resident #10 and Resident #30. LPN #100 stated Resident #50 had wounds that required dressings to be in place, however, the hospital paperwork documented no isolation was necessary. LPN #100 stated if isolation was required the admissions coordinator would have informed the facility of the need for isolation and that did not occur. LPN #100 confirmed Resident #50 was not on infection control precautions. Interview with LPN #120 on 05/13/24 at 2:25 P.M. verified she had not seen enhanced barrier precautions implemented at the facility and she did not know what those precautions were. 4. Review of Resident #60's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, palliative care, anxiety, peripheral vascular disease, and pain in her right hip. The resident had an unstageable pressure ulcer (obscured full-thickness skin and tissue loss) to the left heel diagnosed on [DATE]. Review of the quarterly MDS assessment dated [DATE] revealed Resident #60 was severely cognitively impaired, had no behaviors, required maximal assist with eating and was dependent for toileting, dressing, showering, bed mobility and transfers. Resident #60 had an unstageable pressure ulcer due to coverage of the wound bed by slough (non-viable yellow, tan, gray, green or brown tissue) and or eschar (dead or devitalized tissue that is hard or soft in texture) and did not require isolation. Review of Resident #60's medical record revealed there was no two-step Mantoux screening completed to rule out tuberculosis infection. Review of a physician order dated 05/01/24 revealed Resident #60 had an order to treat a left heel wound with iodine 10 percent (%) applied to the wound and covered with a boarder foam dressing. Interview with LPN #110 on 05/13/24 at 2:23 P.M. confirmed the facility did not have residents with wounds requiring dressings in enhanced barrier precautions. Interview with LPN #120 on 05/13/24 at 2:25 P.M. verified enhanced barrier precautions had not been (continued on next page) 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 05/14/2024 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 implemented at the facility and she did not know what those precautions were. Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing (DON) and LPN #100 on 05/13/24 at 2:40 P.M. confirmed the facility had not implemented enhanced barrier precautions for the residents in the facility who met the criteria for enhanced barrier precautions. LPN #100 verified Resident #50 and Resident #60 had wounds which required dressings and verified the residents were not in any type of isolation precautions. The DON and LPN #100 stated they were not aware enhanced barrier precautions had been implemented. Residents Affected - Some Interview with the DON and LPN #100 on 05/13/24 at 5:00 P.M. stated the standard isolation precaution policy was the policy the facility used to address the isolation needs of the residents in the facility. Interview with LPN #100 on 05/13/24 at 5:03 P.M. confirmed Resident #10, Resident #30, and Resident #60 had not been screened for tuberculosis as per the facility's policy. Review of the policy titled, Standard Isolation Precautions, dated 2002, revealed standard isolation precautions will be used in the care of all residents regardless of their diagnoses or presumed infection status. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and mucous membranes. Gloves are to be worn when touching blood, body fluids, secretions, excretions, and contaminated items. Clean gloves are to be put on just before touching mucous membranes and nonintact skin and gloves should be changes between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms. Gowns are to be worn to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions or cause soiling of clothing. Staff are to remove a soiled gown as promptly as possible and wash hands to avoid transfer of microorganisms to other residents or environments. Review of a policy titled, Tuberculosis Testing for Residents, dated 01/18/18, revealed residents will be given a two-step Mantoux test to determine exposure to tuberculosis upon admission and yearly. If the resident has had a positive Mantoux test in the past, the resident will have a chest x-radiation (x-ray) image to determine if tuberculosis is present. Thereafter, the resident will have a chest x-ray every three years. All Mantoux test results will be documented into the resident's chart and all residents will have a one-step yearly Mantoux test, thereafter, unless a chest x-ray is required. This deficiency represents non-compliance investigated under Complaint Number OH00153390. 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 05/14/2024 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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, staff interview, and policy review, the facility failed to ensure residents were offered influenza vaccinations annually as required. This affected one (#40) of five residents reviewed for influenza vaccinations. The facility census was 41. Residents Affected - Few Findings Include: Review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizophrenia, chronic obstructive pulmonary disease, type two diabetes, dementia, anemia, delusional disorder, auditory hallucinations, and complete traumatic amputation of the left lower leg at the knee level. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #40 was cognitively intact. The resident was coded to not receive the influenza vaccination as it was not offered and the pneumococcal vaccination was coded as up to date. Review of Resident #40's vaccination documentated revealed the resident's the last documented influenza vaccination was dated 10/14/22. Interview with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #100 on 03/15/24 at 3:35 P.M. confirmed Resident #40 did not receive an influenza vaccination nor had the resident declined an influenza vaccination during the past influenza season. Review of the influenza vaccine policy dated 2002 revealed all residents and employees who have contact with residents will be offered the influenza vaccine annually to encourage and promote the benefits associated with immunizations against influenza. Between October 1st and November 30th each year, annual influenza vaccinations shall be administered to residents and employees who have contact with residents, unless the vaccination is medically contraindicated or the resident or employee refuses the vaccine due to personal or religious reasons. Appropriate entries must be documented in the residents' medical records indicating the date of the receipt or refusal of the annual influenza vaccination. 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 05/14/2024 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and facility staff interview, the facility failed to offer the vaccination or obtain documentation of residents' SARS-CoV2 (COVID-19) vaccination status for three (#10, #30, and #50) of five residents reviewed for vaccinations. The facility census was 41. Findings Include: 1. Review of Resident #10's medical record revealed the resident was admitted on [DATE] with the most recent readmission on [DATE]. Diagnoses include osteomyelitis of the shoulder, bacteremia, extended spectrum beta lactamase resistance (ESBL), klebsiella pneumoniae, methicillin susceptible staphylococcus aureus infection, pseudomonas, pneumonia, chronic obstructive pulmonary disease, depression, atrial fibrillation, and fusion of the spine. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact. Review of Resident #10's vaccination documentation revealed there was no documented COVID-19 vaccinations, history of vaccinations, or declination of vaccinations in the resident's medical record or in facility records. 2. Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included severe calorie protein calorie malnutrition, acute and chronic respiratory failure with hypoxia, local infection of the skin and subcutaneous tissue, methicillin resistant staphylococcus aureus infection, anxiety, history of transient ischemic attack, and atrial fibrillation. Review of the quarterly MDS assessment dated [DATE] revealed Resident #30 was cognitively intact. Review of Resident #30's vaccination documentation revealed there were no documented COVID-19 vaccinations, history of vaccinations, or declination of vaccinations in the resident's medical record or in facility records. 3. Review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE] with the most recent readmission on [DATE]. Diagnoses included anemia, metabolic encephalopathy, altered mental status, urinary tract infection, extended spectrum beta lactamase resistance, diabetes, and an unstageable pressure ulcer to the heel. Review of the quarterly MDS assessment dated [DATE] revealed Resident #50 had mild cognitive impairment. Review of Resident #50's vaccination documentation revealed there were no documented COVID-19 vaccinations, history of vaccinations, or declination of vaccinations in the resident's medical record or in facility records. Interview with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #100 on 05/13/24 at (continued on next page) 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 05/14/2024 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 0887 Level of Harm - Minimal harm or potential for actual harm 5:00 P.M. verified Resident #10, Resident #30, and Resident #50 had no documentation of COVID-19 vaccination status or declination of the vaccination in their medical record. This deficiency represents non-compliance investigated under Complaint Number OH00153390. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 7 of 7