Inspection visit

InspectionJuly 1, 2025

Jag Healthcare MansfieldCMS #36511834 citations on this visit

34 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 34 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, staff interview, and facility policy review, the facility failed to ensure resident code status was consistent throughout the medical record. This affected two (#26 and #110) of 20 residents reviewed for code status. The facility census was 57. Findings include 1. Review of the medical record for Resident #26 revealed an admission date of [DATE]. Diagnoses included paranoid schizophrenia, dementia, Parkinsonism, and Type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the electronic medical record (EMR) face sheet revealed the resident's code status was Do Not Resuscitate Comfort Care Arrest (DNRCC-A). Further review of the EMR revealed no physician signed DNR form. Review of a physician order dated [DATE] revealed the resident's code status was DNRCC-A. Review of the care plan dated [DATE] revealed the resident/family had chosen a DNRCC-A order. Review of the paper chart revealed a handwritten note at the front of the chart stating the resident had full code (cardiopulmonary resuscitation) status. Interview on [DATE] at 9:34 A.M., Licensed Practical Nurse (LPN) #275 revealed in an emergency she would check the resident's code status in either the paper chart or the EMR according to which record was the closest. LPN #275 verified Resident #26 had no physician signed DNR form in the EMR or the paper chart. LPN #275 further verified the EMR face sheet stated the resident was a DNRCC-A and in front of the resident's paper chart was a sheet of paper stating the resident had full code status. Interview on [DATE] at 4:01 P.M., Social Service Designee (SSD) #305 revealed the resident had a signed DNRCC-A from his previous facility not uploaded in the medical record and it should have been updated during admission. SSD #305 revealed the resident's family now wanted the resident to be a full code status. 2. Review of Resident #110's medical record revealed an admission date of [DATE]. Diagnoses include chronic pain, mild cognitive impairment, major depressive disorder, morbid (severe) obesity due to excess calories, and hypertension. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 51 Event ID: 365118 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 07/01/2025 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #110's care plan dated [DATE] verified Resident #110 wanted his code status to be a Do Not Resuscitate Comfort Care (DNRCC). Review of Resident #10's physician orders revealed an order dated [DATE] for a DNRCC code status. Observation on [DATE] at 9:34 A.M. of Resident #110's advanced directives revealed he was a Do Not Resuscitate Comfort Care (DNRCC) in the Electronic Medical Record (EMR). Upon review of the physical paper chart there was no physician signed DNR form in the record. Interview on [DATE] at 9:47 A.M. with Licensed Practical Nurse (LPN) #275 revealed if a patient were to need Cardiopulmonary Resuscitation (CPR), she would reference the advanced directive that was physically closest to her. Interview on [DATE] at 9:51 A.M. with LPN #275 verified a signed DNRCC document was not present in Resident #110's physical chart or scanned into the EMR. Review of the undated policy titled Do Not Resuscitate Order revealed a DNR order must be completed and signed by the attending physician and resident and placed in the front of the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 2 of 51 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 07/01/2025 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, interview, record review, and review of the facility policy, the facility failed to assure missing items were investigated and followed up on for one resident, (Resident #32), of three residents reviewed for missing items. The facility census was 57. Findings include: Record review for Resident #32 revealed an admission date of 01/13/23. Diagnosis included Alzheimer's disease with late onset. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #32 was severely cognitively impaired. Resident #32 was dependent for bed mobility, chair/bed chair transfers, and wheelchair mobility. Telephone interview on 06/24/25 at 10:07 A.M. with Resident #32's family member revealed Resident #32 was missing blankets, clothing items, and stuffed animals. Resident #32's family member revealed it had been a while, between a month or two but they did let the staff know. Resident #32's family member revealed they could not remember the staff names. Interview on 06/25/25 at 9:25 A.M. with Social Worker Designee (SWD) #305 revealed she had not received any resident concerns or grievances since February 2025. SWD #305 revealed if a family or resident had a concern or grievance, they would fill out a concern log located at the front desk or a staff member could fill one out for them. If it was for missing laundry or items, she would look for the item then if she could not find it she would notify the Administrator and she would take over from there. SWD #305 revealed she never had a concern log for any missing items from Resident #32 or the family. Observation with SWD #305 revealed there were no concern logs located at the front desk. Interview on 06/26/25 at 10:46 A.M. with Laundry/Housekeeping Assistant #253 revealed the laundry department gets reports of missing clothing, all the time, at least three times a week. Laundry/Housekeeping Assistant #253 revealed that sometimes families, staff or residents just come tell the laundry department what is missing but most the time they give us something in writing, usually on plain white or scrap paper or we just write it on paper. Laundry/Housekeeping Assistant #253 revealed she does not keep the notes or papers with missing items, once she looks for the item, if she cannot find it, she tells the nurse and throws the paper away and that's it. Laundry/Housekeeping observation completed with Laundry/Housekeeping Assistant #253 of the laundry room revealed two racks of clothes hanging and three full large boxes of clothing items and slippers. Laundry/Housekeeping Assistant #253 revealed these were no name items and laundry did not know who they belonged to. Interview on 06/26/25 between 11:07 A.M. and 2:01 P.M. with Certified Nursing Assistant (CNA) #227 and #231 revealed they both frequently worked with Resident #32. CNA #231 revealed, About two months ago, the family said she was missing stuffed animals but there was another resident at the facility who would wander and take stuff but I don't know what ever happened with it. CNA #227 and #231 revealed when residents or families report missing items, they go to the laundry to look for it and if they cannot find it, they tell whoever is working in laundry to keep an eye out for it. Interview on 06/26/25 at 2:06 P.M. during Resident Council meeting with nine participants, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 3 of 51 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 07/01/2025 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 Resident #3, #14, #15, #17, #22, #28, #37, #46, and #161 all confirmed verbally or with a head nod that they each had missing clothing items and this was considered by them a big problem. Resident #37 revealed they tell the laundry lady, she always says she will look into it but they never come back to follow up about the missing clothing items. Multiple residents stated out loud simultaneously they agreed with that statement and reiterated they felt it was a big problem. Resident #17 revealed twice a year they bring out all the clothes and put them in the activities room for residents to go through to see if any of their missing clothing is in there. Review of the Resident Council Meeting minutes dated 04/30/25 revealed room [ROOM NUMBER] was missing an Ohio State short sleeve shirt and woman's jean shorts. room [ROOM NUMBER] has been missing XXXL black shorts since last summer; Residents are complaining they are not getting socks back. Review of the Resident Council Minutes review dated 04/30/25 to Department Housekeeping/laundry revealed Plans of Corrections: Housekeeping was informed to look for residents missing items and follow up upon returning resident items to ensure needs were met. Administrator signed and dated 05/07/25. No follow up was documented as to finding or not finding the missing items or follow up with the residents. Review of the Resident Council Meeting minutes dated 05/28/25 revealed room [ROOM NUMBER] received clothes that did not belong to her. Review of the facility policy titled, Grievances/Complaints, Recording and Investigating undated revealed all grievances and complaints filed with the facility will be investigated and corrective action will be taken to resolve the grievances. The Grievance Officer will record and maintain all grievances and complaints on the Grievance Report. The following information will be recorded and maintained in the log: a. The date the grievance/complaint received. b. The name and room number of the resident filing the grievance/complaint. c. The name and relationship of the person filing the grievance/complaint on behalf of the resident. d. The date the alleged incident took place. e. The name of the person investigating the incident. f. The date the resident or interested party was informed of the findings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 4 of 51 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 07/01/2025 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 g. Level of Harm - Minimal harm or potential for actual harm The disposition of the grievance. h. Residents Affected - Few The grievance/complaint form will be filed with the Administrator within five working days of the incident. This deficiency represents non-compliance investigated under Complaint Number OH00166248. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 5 of 51 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 07/01/2025 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, staff interview, and facility policy review, the facility failed to ensure residents on psychotropic medications were monitored for effectiveness and adverse consequences. This affected five (#47, #51, #19, #161, and #1) of five residents reviewed for unnecessary medication. The facility identified 52 residents receiving psychotropic medications. The facility census was 57. Findings include 1. Review of the medical record for Resident #47 revealed an admission date of 09/04/24. Diagnoses included depressive disorder, dementia, anxiety, mood disorder, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of a physician order dated 03/28/25 revealed orders for Zyprexa (antipsychotic) 2.5 milligrams (mg), one tablet twice a day by mouth for bipolar depression. An order dated 05/03/25 for Sertraline (antidepressant) 50 mg, two tablets by mouth in morning for vascular dementia with psychotic disturbance. An order dated 03/20/25 for Lorazepam (antianxiety) tablet 0.5 mg, give two tablets by mouth every eight hours as needed for anxiety and restlessness for six months. Review of the medication administration record (MAR) and nurse's notes dated 05/01/25 through 06/24/25 revealed no documentation the resident was monitored for adverse effects or effectiveness of the psychotropic medications. Interview on 06/26/25 at 10:59 A.M., the Director of Nursing (DON) verified there was no documentation of monitoring for medication adverse effects or effectiveness. 2. Review of the medical record for Resident #51 revealed an admission date of 01/27/25. Diagnoses included Alzheimer's disease, bipolar disorder, mood disorder, major depressive disorder, and anxiety. Review of the quarterly MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the physician orders revealed an order dated 01/27/25 for Escitalopram (antidepressant) 20 mg daily for depression. An order dated 04/22/25 for Buspirone (antianxiety) five mg twice a day for anxiety. An order for Lorazepam (antianxiety) one mg by mouth every eight hours as needed for anxiety with no stop date. An order dated 05/03/25 for Aripiprazole (antipsychotic) 10 mg by mouth in the morning for major depressive disorder. Review of the nursing assessments dated 05/03/25 through 06/24/25 revealed no documentation the resident received an abnormal involuntary movement assessment (AIMS) for the use of the antipsychotic medication Aripiprazole. Review of the MAR and nurses notes dated 05/01/25 through 06/24/25 revealed no documentation the resident was monitored for medication effectiveness or adverse effects. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 6 of 51 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 07/01/2025 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 0605 Level of Harm - Minimal harm or potential for actual harm Interview on 06/26/25 at 10:59 A.M., the Director of Nursing (DON) verified there was no documentation of monitoring for medication adverse effects or effectiveness. The DON verified there was no stop date indicated for the as needed Lorazepam. Further interview on 06/26/25 at 2:27 P.M., the DON revealed AIMS assessments should be completed on admission, quarterly, with medication changes, and changes in condition. The DON verified an AIMS assessment had not been completed for Resident #51. Residents Affected - Some 5. Review of the medical record for Resident #1 revealed an admission date of 11/08/24, diagnoses included schizophrenia, schizoaffective disorder, major depressive disorder and anxiety disorder. Review of the MDS assessment dated [DATE] revealed Resident #1 had intact cognition and little interest or pleasure in doing things and felt down, depressed or hopeless. He required supervision or touching assistance for oral hygiene, upper and lower body dressing and personal hygiene. He was dependent on staff for toileting. Review of Resident #1's care plan dated: 11/12/24 revealed Resident #1 had medications in high-risk drug classes used in their care which can place them at risk of side effects that can adversely affect their health, safety and quality of life. The resident was prescribed medications from the following high-risk drug class: antipsychotic. Interventions included: Resident #1 will be on the lowest dose required to achieve the desired therapeutic effect and minimize side effects, monitor for appropriate clinical indication for continued use of high-risk medication and periodic review of resident's medication profile to assess the possibility of a dose reduction of the elimination of unnecessary medications. Review of the monthly physician orders for Resident #1 revealed the resident has order for Olanzapine (antipsychotic) 20 mg give one tablet by mouth in the morning related to schizophrenia form disorder active since 11/30/2024, Lurasidone HCl (antipsychotic) 20 mg give one tablet by mouth in the morning related to schizophrenia active since 11/30/2024. Interview and record review on 06/30/25 at 4:00 P.M. with DON of Resident #1's medical record confirmed Resident #1 was not monitored every shift by the nurses for potential side effects and effectiveness of the high risk medications including antipsychotics. DON confirmed monitoring Resident #1 every shift by the nurses for potential side effects and effectiveness was not initiated by the staff until 06/27/25. Review of the undated facility policy Psychotropic Medication Use, revealed psychotropic medication management included adequate monitoring for efficacy and adverse consequences. Review of the undated facility policy Antipsychotic Medication Use revealed staff would observe, document, and report to attending physician information regarding the effectiveness of antipsychotic medications and monitor and report side effects and adverse consequences on antipsychotic medications. Review of the facility policy titled, Behavioral Assessment, Intervention and monitoring, undated revealed if psychotropic medications (mind altering medications including antidepressants and antianxiety medications) are used to treat behavioral symptoms, documentation includes monitoring for efficacy and adverse consequences related to psychotropic medications. 3. Record review for Resident #19 revealed an admission date of 01/01/25. Diagnoses included altered mental status, dementia severe with psychotic disturbances, and major depressive disorder (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 7 of 51 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 07/01/2025 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 0605 recurrent. Level of Harm - Minimal harm or potential for actual harm Record review of the quarterly MDS dated [DATE] revealed Resident #19 was moderately cognitively impaired. Resident #19 received antianxiety medication and antidepressants. Residents Affected - Some Review of the care plan for Resident #19 dated 01/22/25 revealed Resident #19 had medications in high-risk drug classes used in their care which can place them at risk and can adversely affect their health, safety, and quality of life. The resident was prescribed medications from the following high-risk drug class: antidepressant medications. Interventions included to administer medications as ordered by the practitioner, monitor for appropriate clinical indication for continued use of high risk medication, and monitor resident for adverse effects of medications. Review of the physician orders initiated 01/02/25 for Resident #19 revealed an order for Paroxetine HCL (antidepressant) 40 milligrams (mg) give one tablet by mouth one time a day for depression. Buspirone HCL (antianxiety) five mg give one tablet by mouth two times a day related to major depressive disorder was initiated 04/22/25. Interview and record review of Resident #19's medical record for June 2025 on 06/30/25 at 3:59 P.M. with the Director of Nursing (DON) confirmed Resident #19 did not have monitoring every shift by the nurses for potential side effects and effectiveness of the high risk medications used in their care. DON confirmed monitoring Resident #19 every shift by the nurses for potential side effects and effectiveness was not initiated by the staff until 06/27/25. 4. Record review for Resident #161 revealed an admission date of 05/28/25. Diagnosis included major depressive disorder, single episode, mild. Review of the admission MDS dated [DATE] revealed Resident #161 was severely cognitively impaired. Resident #161 received antidepressant medication. Review of the care plan dated 06/22/25 revealed Resident (#161) had medications in high-risk drug classes used in their care which can place them at risk of side effects that can adversely affect their health, safety and quality of life. The resident was prescribed medications from the following high-risk drug class: antidepressant medications. Interventions included to administer medications as ordered by the practitioner, monitor for appropriate clinical indication for continued use of high risk medication, and monitor resident for adverse effects of medications. Review of the physician order dated 05/29/25 for Resident #161 revealed an order for Bupropion HCl (antidepressant) oral tablet extended release 12 hour 150 mg. Give two tablets by mouth in the morning for anxiety. Review of the physician order dated 05/28/25 for Resident #161 revealed an order Celexa (antidepressant) oral tablet 10 mg. Give one tablet by mouth in the evening related to major depressive disorder, single episode, mild. Interview and record review on 06/30/25 at 4:00 P.M. with DON of Resident #161's medical record confirmed Resident #161 was not monitored every shift by the nurses for potential side effects and effectiveness of the high risk medications including antidepressants. DON confirmed monitoring Resident #161 every shift by the nurses for potential side effects and effectiveness was not initiated by the staff until 06/27/25. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 8 of 51 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 07/01/2025 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** Based on review of the medical record, and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate. This affected four (#26, #6, #5, and #30) of 20 reviewed for accuracy of MDS assessments. The facility census was 57. Residents Affected - Some Findings include 1. Review of the medical record for Resident #26 revealed an admission date of 07/29/24. Diagnoses included paranoid schizophrenia, dementia, Parkinsonism, and Type two diabetes mellitus. Review of a Preadmission Screening and Resident Review (PASRR) Level Two assessment determination dated 12/15/22 revealed the resident met PASRR inclusion criteria for serious mental illness with a diagnosis of paranoid schizophrenia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] Section A1500 revealed the resident was documented as not having a serious mental illness by the state level two PASRR process. Interview on 08/08/24 at 11:28 A.M., MDS Licensed Practical Nurse (LPN) #208 revealed Resident #26 transferred to the facility from another facility with a transfer level of care. LPN #208 revealed the PASRR completed at the previous facility would continue upon transfer. LPN #208 verified Section A1500 of the admission MDS dated [DATE] was incorrect and should have noted the resident had a serious mental illness per the PASRR Level Two assessment. LPN #208 revealed using the Resident Assessment Instrument (RI) manual to complete MDS assessments. Review of the RI manual Section A1500 PASRR revealed to code 1, yes if PASRR Level II screening determined the resident had a serious mental illness and continue to A1510, Level II PASRR Conditions. 2. Review of the medical record for Resident #6 revealed an admission date of 11/09/23. Diagnoses included schizoaffective disorder, dementia, and depressive disorder. Review of the admission MDS dated [DATE] revealed the resident's diagnoses of schizoaffective disorder had not been included in Section I Active Diagnoses. Review of the face sheet from the resident's previous facility dated 11/03/23 revealed the resident had been diagnosed with schizoaffective disorder on 07/17/20. Interview on 06/30/25 at 1:26 P.M., MDS LPN #208 verified the resident's diagnoses of schizoaffective disorder was present on admission and was not included in the resident's active diagnoses in the MDS admission assessment dated [DATE]. 4. Record review for Resident #30 revealed an admission date of 03/11/25. Diagnoses included end stage renal disease (ESRD), unspecified protein calorie malnutrition, hypothyroidism, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was cognitively intact. Resident #30 had weight loss of 5% or more in the last month or weight loss of 10% or more in the last six months. Documentation revealed Resident #30 was on a prescribed weight loss regimen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 9 of 51 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 07/01/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the care plan for Resident #30 dated 05/07/25 revealed Resident #30 had a nutritional problem or potential nutritional problems which included low serum albumin levels, and protein-calorie malnutrition. Interview on 06/30/25 at 10:59 A.M. with Licensed Practical Nurse (LPN)/MDS Nurse #208 revealed Resident #30 was not on a prescribed weight loss regimen and stated, I don't know where I got that, I coded that in error. 3. Review of Resident #5's medical record revealed an admission date of 01/15/25. Diagnoses included chronic kidney disease, type two diabetes mellitus, pressure ulcer of sacral region, and cardiac pacemaker. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively intact. Further review of Section K of the quarterly MDS assessment revealed Resident #5 was assessed as receiving parenteral/intravenous (IV) feeding. Review of the medication administration record and treatment administration record during the seven-day look back period revealed Resident #5 had not received parenteral or IV feeding. Interview on 06/25/25 at 9:05 A.M. with MDS Licensed Practical Nurse (LPN) #208 revealed Resident #5 had not received parenteral or intravenous nutrition in the seven day look back period and should not have been marked on the MDS assessment. Further interview with LPN #208 revealed she referenced the Resident Assessment Instrument (RAI) when completing MDS assessments. Review of the Resident Assessment Instrument (RAI) version 3.0 section K0520 revealed to only check the box for Resident #5 if it occurred in the last seven days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 10 of 51 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 07/01/2025 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility policy, the facility failed to complete a baseline care plan for one, (Resident #160) of eight reviewed for baseline care plans. The facility census was 57. Findings include: Record review for Resident #160 revealed an admission date of 05/28/25. Diagnoses included heart failure, absence of right and left leg below the knee, obesity, diabetes mellitus with diabetic polyneuropathy, and low back pain. Resident #160 received hospice services. Review of the admission Minimum Data Set (MDS) dated [DATE] for Resident #160 revealed Resident #160 was moderately cognitively impaired. Resident #160 required partial/moderate assistants with eating and was dependent for toileting hygiene, bathing and bed mobility. Resident #160 had an indwelling catheter and was occasionally incontinent of bowel. Resident #160 occasionally had pain and received scheduled and as needed (PRN) pain medications. Resident #160 had shortness of breath or trouble breathing with exertion and when lying flat. Record review for Resident #160 revealed no baseline care plan was initiated until 06/18/25. Interview on 06/24/25 at 2:31 P.M. with Licensed Practical Nurse (LPN) MDS Nurse #208 confirmed Resident #160 did not have a baseline care plan initiated until 06/18/25. LPN MDS Nurse #208 revealed baseline care plans were to be initiated upon admission and completed within 72 hours of admission. Review of the facility policy titled, Care Plans-Baseline undated revealed a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 11 of 51 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 07/01/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #51 revealed an admission date of 01/27/25. Diagnoses included Alzheimer's disease, anxiety, depressive disorder, dementia, and bipolar disorder. Review of the quarterly MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the plan of care last revised 06/24/25 revealed the resident had no individualized interventions in place for bipolar disorder. Interview on 06/30/25 at 9:54 A.M., LPN MDS Nurse #208 verified Resident #51's care plan lacked interventions for bipolar disorder. 3. Review of the medical record for Resident #6 revealed an admission date of 11/09/23. Diagnoses included schizoaffective disorder, dementia, and depressive disorder. Review of the quarterly MDS dated [DATE] revealed the resident had moderate cognitive impairment. Review of the plan of care last revised 06/24/25 revealed the resident had no care plan in place with individualized interventions for schizoaffective disorder. Interview on 06/30/25 at 4:02 P.M., LPN MDS Nurse #208 verified Resident #6's care plan was lacking interventions for the schizoaffective disorder diagnoses. 4. Review of the medical record for Resident #26 revealed an admission date of 07/29/24. Diagnoses included paranoid schizophrenia, dementia, Parkinsonism, and type two diabetes mellitus. Review of the quarterly MDS dated [DATE] revealed the resident had severe cognitive impairment. Review of the plan of care last revised 05/19/25 revealed the resident had no care plan in place with individualized interventions for paranoid schizophrenia. Interview on 06/30/25 at 4:02 P.M., LPN MDS Nurse #208 verified Resident #26 should have a care plan addressing interventions for paranoid schizophrenia. Based on observation, record review, staff interview and facility policy review, the facility failed to ensure the comprehensive care plan was initiated and or individualized for the resident. This affected six residents (#6, #26, #43, #51, #56 and #160) of 27 reviewed during the annual survey. The facility census was 57. Findings include: 1. Review of the medical record for Resident #43 revealed an admission date of 05/19/25. Diagnoses included Diabetes Mellitus II, complete traumatic amputation at level between left hip and knee and right hip and knee, chronic kidney disease stage three and peripheral vascular disease. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 12 of 51 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 07/01/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 required partial/moderate assistance with personal hygiene and substantial/maximal assistance from staff for showers and bathing. Review of the functional abilities prior functioning dated 05/23/25 revealed Resident #43 required some help, and he used a manual wheelchair. Review of the plan of care dated 05/21/25 revealed there were only two care plans for Resident #43 one for the resident's risk for infection and/or trauma related to use of suprapubic catheter with appropriate interventions and the other for the risk for urinary tract infections active infection, poor toileting habits and presence of Foley catheter with appropriate interventions. There was no other care plan present in the medical record, there was no care plan which addressed the resident's need for assistance with hygiene care. Interview on 06/26/25 at 9:06 A.M. with the Director of Nursing (DON) confirmed Resident #43's care plan was not comprehensive to address all his needs. Interview on 06/30/2025 at 5:13 P.M. with Licensed Practical Nurse (LPN)/MDS Nurse #208 verified there were only two items in his care plan. The care plan for Resident #43 does not include goals upon admission and desired outcomes nor building on his strengths or reflecting current recognized standards of practice for problem areas and conditions. LPN MDS Nurse #208 stated the care plan should be based on the MDS assessment. Resident #43 should have a care plan that addressed the following areas or risk: falls, pressure ulcer, pain, need for assistance with activities of daily living (ADLs), dental health and possibly high risk medication use. Review of the facility policy, Comprehensive Person-Centered Care Plan, no date revealed the care plan should encompass all the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. 5. Record review for Resident #160 revealed an admission date of 05/28/25. Diagnoses included heart failure, absence of right and left leg below the knee, obesity, diabetes mellitus with diabetic polyneuropathy, and low back pain. Resident #160 received hospice services. Review of the admission Minimum Data Set (MDS) dated [DATE] for Resident #160 revealed Resident #160 was moderately cognitively impaired. Resident #160 required partial/moderate assistants with eating and was dependent for toileting hygiene, bathing and bed mobility. Resident #160 had an indwelling catheter and was occasionally incontinent of bowel. Resident #160 occasionally had pain and received scheduled and as needed (PRN) pain medications. Resident #160 had shortness of breath or trouble breathing with exertion and when lying flat. Record review for Resident #160 revealed a comprehensive assessment was not initiated until 06/23/25. Interview on 06/24/25 at 2:31 P.M. with LPN MDS Nurse #208 confirmed Resident #160 did not have a comprehensive care plan initiated until 06/23/25. 6. Closed record review for Resident #56 revealed an admission date of 04/07/25 and a discharge date of 06/02/25. Diagnoses included pneumonia, acute respiratory failure with hypoxia, hypertension, heart failure, physical debility, retention of urine, and wedge compression fracture of thoracic (T) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 13 of 51 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 07/01/2025 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 0656 T7-T8 vertebra sequela, multiple myeloma, and abdominal aortic aneurysm. Level of Harm - Minimal harm or potential for actual harm Review of the admission MDS dated [DATE] included Resident #56 was moderately cognitively impaired. Resident #56 had an indwelling catheter and was frequently incontinent of bowel. Resident had cancer and received antiplatelet medications. Resident #56 required assistants with activities of daily living. Residents Affected - Some Review of the comprehensive care plan for Resident #56 revealed a comprehensive care plan was never completed for Resident #56 during his stay at the facility. Interview on 06/30/25 at 5:02 P.M. with LPN MDS Nurse #208 confirmed Resident #56 did not have comprehensive care plans completed. LPN MDS Nurse stated, I don't know why they were not done. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered undated revealed the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive person-centered care plan for each resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment and no more than 21 days after admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 14 of 51 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 07/01/2025 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 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of the facility policy, the facility failed to ensure residents received proper assistance with personal hygiene and grooming tasks. This affected three residents (#43, #45 and #47) of 28 (#1, #2, #6, #7, #8, #9, #11, #15, #18, #19, #22, #28, #30, #35, #40, #42, #46, #51, #52, #53, #54, #57, #110, #161, #162 and #164) residents who required assistance from staff for activities of daily living. The census was 57. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #43 revealed an admission date of 05/19/25. Diagnoses included Diabetes Mellitus II, complete traumatic amputation at level between left hip and knee and right hip and knee, chronic kidney disease stage three and peripheral vascular disease. Review of the Minimum Data Set (MDS) admission revealed Resident #43 required partial/moderate assistance with personal hygiene and substantial/maximal assistance from staff for showers and bathing. Review of the functional abilities prior functioning dated 05/23/25 revealed Resident #34 needed some help, and he used a manual wheelchair. Review of the plan of care dated 05/21/25 revealed there were only two care plans and neither pertained to hygiene care. They were risk for infection and/or trauma related to use of suprapubic catheter with appropriate interventions and urinary tract infections active infection, poor toileting habits and presence of Foley catheter with appropriate interventions. Interview on 06/23/25 at 12:07 P.M. with Resident #43 revealed he does not get staff assistance for showers therefore does not get showers unless he is assisted by staff. He was observed to have body odor and oily hair. Interview on 06/25/25 at 8:11 A.M. Resident #43 revealed he washes up in his room because staff call off and he does not get a shower. Interviews with CNA's #227 and #231 on 06/26/25 at 1:10 P.M. and 1:29 P.M. respectively revealed sometimes there are call offs and we do the best we can. Sometimes showers are not given due to lack of sufficient staff. Review of the shower sheets for Resident #43 revealed he was showered 05/21/25, 05/28/25 and 05/31/25. There were no shower sheets for June 2025. Interview with the DON on 06/25/25 at 9:06 A.M. revealed she did not know Resident #43's scheduled shower days nor was there an order for his showers to be given on certain days. The DON also verified on 06/30/2025 at 4:00 P.M. there were no shower sheets for Resident #43 for the month of June 2025. Review of the facility policy, Activities of Daily Living (ADLs), Supporting, no date revealed appropriate care and service are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 15 of 51 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 07/01/2025 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 0677 a. Level of Harm - Minimal harm or potential for actual harm Hygiene (bathing, dressing, grooming and oral care); b. Residents Affected - Some Mobility (transfer and ambulation, including walking); c. Elimination (toileting); d. Dining (eating, including meals and snacks; and e. Communication (including speech, language and other functional communication systems). 2. Record review for Resident #45 revealed an admission date of 02/23/24. Diagnosis included chronic obstructive pulmonary disease and age-related physical debility. Review of the Annual MDS dated [DATE] revealed Resident #45 was cognitively intact. Resident #45 required supervision or touch assist with chair/bed to chair transfers and showering/bathing. Review of the care plan dated 04/07/25 revealed Resident #45 required partial/moderate assist for tub/shower transfer and supervision/touch assist for shower/bathing self. Review of the shower schedule revealed Resident #45 was to receive showers on Tuesdays/Fridays 6:00 A.M. to 6:00 P.M. Interview on 06/23/25 at 2:40 P.M. with Resident #45 revealed Resident #45 had a strong body odor. Resident #45's hair appeared oily. Resident #45 revealed she hoped to get a shower soon, she had not had one in a while. Resident #45 stated, That's my concern, I need my showers and I'm not always getting them. Interview on 06/30/25 at 2:15 P.M. with the Director of Nursing (DON) revealed if a resident received a shower, the Certified Nursing Assistant (CNA) would complete the shower form titled Comprehensive Shower Review. Each resident was scheduled a shower/bath two days a week, when the shower/bath is complete, the CNA and charge nurse signs and dates the form. Review of the Comprehensive Shower Review forms for Resident #45 from 03/01/25 through 06/30/25 with DON confirmed on 03/07/25, 03/14/25, 04/07/25, 04/15/25, 04/20/25, 05/20/25, 05/23/25, 05/27/25, and 06/06/25 Resident #45 received or was offered a shower or bath. DON confirmed there were no additional shower forms for Resident #45 to confirm she was offered or received a bath/shower. Interview on 07/01/25 at 8:19 A.M. CNA #227 confirmed every resident has a scheduled shower or bath two times a week. CNA #227 revealed the electronic medical records for each resident had a section to document the assistants needed for showers/bathing. Some residents were documented daily in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 16 of 51 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 07/01/2025 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 0677 Level of Harm - Minimal harm or potential for actual harm shower section the amount of assistants needed but that did not mean the resident received a shower or bath that day, it was only the amount of assistants normally needed. When a resident received a bath or shower, a shower form was completed by the CNA verifying the shower/bath was given. CNA #227 revealed if there were call offs or the facility was short staffed, the CNA's would be unable to do resident showers. Residents Affected - Some 3. Record review for Resident #30 revealed an admission date of 03/11/25. Diagnoses included end stage renal disease (ESRD), panic disorder, obesity, lymphedema, Chronic Obstructive Pulmonary Disease (COPD), pulmonary hypertension, and heart failure. Review of the quarterly MDS dated [DATE] revealed Resident #30 was cognitively intact. Resident #30 used a walker/wheelchair for mobility, required set up/clean up assist with the ability to come from a standing position to a sitting position, supervision or touch assist with shower/bathing, personal hygiene and upper and lower body dressing. Review of the care plan dated 06/27/25 for Resident #30 revealed Resident #30 had an activity of daily living (ADL) self-care performance related to ESRD with dialysis, oxygen use, pulmonary hypertension, and heart failure. Interventions included set up or clean up assistants with shower/bathing. Review of the shower schedule revealed showers/bathing were scheduled Tuesdays and Fridays 6:00 A.M. to 6:00 P.M. Interview on 06/23/25 at 11:56 A.M. with Resident #30 revealed she cannot shower because of her dialysis port. Resident #30 revealed she just washed up in the bathroom. Resident #30 stated, They never help, they want me to do it by myself, I think I need more help with that. Resident #30 revealed sometimes she felt weaker than other times and felt she just did not have the strength and confirmed sometimes she was not able to wash herself as well as she would like. Interview on 06/30/25 at 9:42 A.M. with Certified Nursing Assistant (CNA) #231 revealed Resident #30 preferred to wash up in the bathroom, Resident #30 put her light on when she needed help with bathing. CNA #231 revealed, Sometimes we help if needed, she will put her light on to let us know if she needs help otherwise, she does it, we do encourage her to do as much as she can. Interview on 06/30/25 at 9:48 A.M. with Resident #30 revealed, When I put the call light on for help, they come in and tell me they will be back and don't come back or say I need to do it myself. Interview on 06/30/25 at 10:43 A.M. with DON revealed if a resident was asking for assistants with bathing, based off the care plan and MDS, staff should be helping. Review of the facility policy titled, Activities of Daily Living, Supporting undated revealed Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The residents responses to interventions are monitored, evaluated and revised as appropriate. 4. Review of Resident #47's medical record revealed an admission date of 09/04/24. Diagnoses include dementia with agitation, major depressive disorder, anemia, repeated falls, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had severe cognitive impairment. Furthermore, the MDS assessment revealed Resident #47 was dependent for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 17 of 51 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 07/01/2025 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 0677 showering/bathing and personal hygiene. Level of Harm - Minimal harm or potential for actual harm Observation on 06/23/25 at 2:26 P.M. revealed Resident #47's fingernails were long and appeared to have a black/brown substance underneath the fingernails. Residents Affected - Some Interview on 06/23/25 at 3:12 P.M. with Resident #47's family member revealed she believed personal hygiene was not provided the best at the facility and she would like Resident #47 to have his fingernails trimmed and clean at all times. Interview on 06/24/25 at 2:45 P.M. with Licensed Practical Nurse (LPN) #259 verified Resident #47's fingernails were long and appeared to have a black/brown substance underneath the fingernails. Observation on 06/25/25 at 1:11 P.M. revealed Resident #47's nails remained long, and they appeared to have the same black/brown substance underneath the fingernails. Interview on 06/25/25 at 1:14 P.M. with Certified Nurse Assistant (CNA) #220 verified Resident #47's fingernails were long and appeared to have a black/brown substance underneath the fingernails. Review of the skin monitoring shower logs for Resident #47 revealed from 04/02/25 to 06/21/25 no documentation of fingernail care was provided. Review of the undated policy titled Activities of Daily Living (ADLs), Supporting revealed residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 18 of 51 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 07/01/2025 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, review of the facility policy and review of the facility assessment, the facility failed to provide an individualized activity program designed to meet the interest and care needs of one resident (#16) of two residents reviewed for activities. The facility census was 52. Residents Affected - Few Findings include: Review of Resident #16's medical record revealed an admission date of 04/02/25. Diagnoses included acquired absence of left leg below the knee, major depressive disorder, Diabetes Mellitus II with hyperglycemia and acquired absence of right foot. Review of Resident #16's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating Resident #16 was cognitively intact. Resident #16 was dependent on staff for personal hygiene, lower body dressing, shower/bathing self and toileting. Review of Resident #16's care plan dated 04/07/25 revealed it did not have a care plan for activities. Interview and observation on 06/23/25 at 9:30 A.M. with Resident #16 revealed staff do not tell her what is going on. The other day, they had a parade and didn't tell anyone. I would have loved to go. I have never seen activities posted. It's hard for me to get around. Resident's room was observed and no calendar was observed indicating what activities were occurring on the days of the month. Interview on 06/30/2025 at 8:59 A.M. with the Assistant Director of Nursing (ADON) revealed Resident #16 had a Peripherally Inserted Central Catheter (PICC) line placed and when she returned to the facility, she was too weak and tired to attend activities therefore declined to go to the Juneteenth parade. Interview on 06/30/25 at 11:58 A.M. with the Activity Director revealed activity calendars are passed out to all residents. Some residents want them taped to the wall and some prefer to keep them on their bedside table. Interview on 07/01/25 at 9:00 A.M. with Certified Nursing Assistant (CNA) #231 revealed sometime Resident #16 goes to activities and sometimes she stays in her room. Multiple observations on 06/24/25-06/25/25 and 06/30/25-07/01/25 during the day, revealed Resident #16 was not observed out of her room. Review of the facility policy, Activities and Social Services, no date revealed residents shall have the right to choose the types of activities and social events in which they wish to participate as long as such activities do not interfere with the rights of other residents in the facility. As much as possible, the facility will provide activities, social events and schedules that are compatible with the residents' interests, physical and mental assessment and over plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 19 of 51 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 07/01/2025 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** 2. Review of the medical record for Resident #110 revealed an admission date of 06/13/25. Diagnoses included chronic pain, hemiplegia and hemiparesis, cerebral infarction, hypertension, atrial fibrillation, congestive heart failure, and narcissistic personality disorder. Residents Affected - Few Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of a wound assessment report dated 06/20/25 revealed the resident had bilateral lower extremity venous ulcers. Review of a physician order dated 06/21/25 revealed to cleanse the bilateral lower extremities with wound cleanser, pat dry, apply ammonium lactate lotion to both lower legs topically, apply non-adhering dressing then a dry dressing over wounds, cover with an elastic tubular bandage and then wrap with and outer elastic bandage daily and as needed for venous ulcer wound care. Observation on 06/23/25 at 12:30 P.M. revealed Resident #110 had elastic bandages covering his bilateral lower extremities from below the knees to the top of the feet. Further observation revealed the wound dressings were not dated. Interview on 06/23/25 at 12:30 P.M., Resident #110 revealed his wound dressings had not been changed since 06/20/25 when the wound nurse assessed and changed the dressings. Resident #110 stated the staff never dated his wound dressings. Observation on 06/24/25 at 1:32 P.M., Licensed Practical Nurse (LPN) #259 verified Resident #100's wound dressings to the bilateral lower extremities were not dated. Further observation of wound care revealed LPN #259 removed the elastic cover bandage covering the wounds revealing the inner tubular elastic bandage, abdominal pad, and non-adherent were saturated with dried drainage on each lower extremity. LPN #259 applied new wound care dressings per physician orders. LPN #259 had not dated the wound dressings. Interview on 06/25/25 at 2:12 P.M., LPN #259 revealed the wound dressing appeared to not have been changed recently due to the amount of saturation of the dressings. LPN #259 verified she had not dated the residents wound care dressings to the bilateral lower extremities. Interview on 06/25/25 at 9:34 A.M., LPN #275 verified also not dating wound dressings for Resident #110. Further interview with LPN #275 revealed completing the resident's wound care dressing changes on 06/21/25. Review of the Treatment Administration Record (TAR) dated 06/21/25 through 06/24/25 revealed no documentation the resident's wound dressing to the bilateral lower extremities had been completed on 06/23/25. Interview on 06/26/25 at 11:47 A.M., the Director of Nursing (DON) verified Resident #110's wound treatment was not completed on 06/23/25. Review of the undated facility policy Wound Care revealed staff would administer wound care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 20 of 51 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 07/01/2025 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 treatments per physician orders and date, time, and initial wound care dressings when completed. Level of Harm - Minimal harm or potential for actual harm 3. Review of the medical record for Resident #27 revealed an admission date of 01/17/25. Diagnoses included chronic obstructive pulmonary disease, malignant neoplasm of colon, type two diabetes mellitus, peripheral vascular disease, acquired absence of right leg above knee, cerebral infarction, and dementia. Residents Affected - Few Review of the quarterly MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the care plan dated 04/22/25 revealed the resident had a left heel wound. Interventions included a weekly skin assessment for and provide treatment per physician order. Review of a skin/wound progress note dated 05/19/25 at 11:46 A.M. revealed a nursing assistant reported resident sock sticking to foot. Nurse assessed and found a new open area to the left heel measuring approximately three centimeters (cm) by two centimeters with light bleeding and serous drainage. The physician was notified, and a treatment was applied. Review of weekly skin/wound assessments revealed the wound was assessed on 05/27/25. Review of a progress note dated 05/30/25 at 12:47 P.M. revealed the wound nurse practitioner noted the resident had a diabetic foot ulcer to the left lateral foot measuring 2.4 cm in length by three cm in width by 0.1 cm in depth with moderate serous drainage. New wound care orders included to cleanse with wound cleanser, apply calcium alginate with silver to base of wound and secure with bordered foam daily and as needed. Also to float heels while in bed with the use of heel boots. Review of a weekly skin/wound assessment dated [DATE] revealed no assessment of the resident's left heel was completed. Further review of the weekly skin/wound assessments revealed no further weekly wound assessments had been completed since 05/30/25. The resident had appointments at an outside wound care provider on 06/05/25 and 06/19/25 with no wound measurements provided. Observation on 06/24/25 at 2:21 P.M., of wound care for Resident #27 with Licensed Practical Nurse (LPN) #259 revealed a wound on the left posterior heel with discoloration approximately 2.5 centimeters in length and 1.5 cm in width with no depth as the skin was intact. There was no drainage or signs of infection. Interview on 06/30/25 at 1:51 P.M., the Director of Nursing (DON) confirmed there was no documentation of weekly wound assessments completed for Resident #27 since 05/30/25. The DON revealed nursing staff should be completing weekly wound evaluations to monitor, measure, and assess the wound. Review of the undated facility policy Wound Care, revealed no guidelines for the frequency of wound assessments. Further review of the policy revealed to document wound assessment data (wound bed color, size, drainage) obtained when inspecting the wound. Based on observation, interview, record review, and review of the facility policy, the facility/ Hospice Registered Nurse (RN) failed to assure Resident #160 received pain medications when she expressed she was having pain throughout the procedure of an indwelling catheter reinsertion and peri care and the facility failed to address a change in condition timely for Resident #160 when her peri area, buttocks, and under her bilateral breast were observed by facility staff and Hospice RN to be deep red. Additionally the facility failed to ensure wound care was provided and timely complete wound (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 21 of 51 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 07/01/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assessments were completed for two (#110, #27) of three residents reviewed for wound care. The facility identified seven residents with non-pressure wounds. The facility census was 57. Findings include: 1. Record review for Resident #160 revealed an admission date of 05/28/25. Diagnoses included heart failure, obesity, Diabetes Mellitus with diabetic polyneuropathy, and low back pain. Resident #160 received hospice services. Review of the admission Minimum Data Set (MDS) dated [DATE] for Resident #160 revealed Resident #160 was moderately cognitively impaired. Resident #160 required partial/moderate assistants with eating and was dependent for toileting hygiene, bathing and bed mobility. Resident #160 had an indwelling catheter and was occasionally incontinent of bowel. Resident #160 occasionally had pain and received scheduled and as needed (PRN) pain medications. Review of the care plan dated 06/23/25 revealed Resident #160 was at risk for infection and/or trauma related to use of foley catheter, neurogenic bladder. Interventions included to check for patency and urinary output every shift; Monitor for signs and symptoms of urinary tract infection (UTI): burning on urination, flank pain, hematuria, decreased urinary output, change in mental status, change in behavior, fever, change in color, clarity and/or odor of urine. Review of the physician orders for Resident #160 revealed an order dated 05/29/25 to keep foley diagnosis is oliguria. An additional order revised 05/30/25 revealed keep foley catheter 16 french 10 milliliter (ml) balloon diagnosis is oliguria. A revised order dated 06/19/25 revealed keep foley catheter 16 french 10 milliliter (ml) balloon diagnosis is neurogenic bladder. Review of the physician orders revealed orders dated 05/30/25 for Morphine Sulfate (opioid) oral solution 20 mg/ml give 10 mg by mouth every six hours for pain and 10 mg by mouth every one hour as needed for pain or shortness of breath. Review of the physician orders for Resident #160 revealed an order dated 05/30/25 revealed an order for Enhanced Barrier Precautions (EBP) due to foley catheter every day and night shift. Observation on 06/23/25 at 10:08 A.M. revealed Resident #160 was lying in bed. Resident #160's husband was present and revealed he just arrived to visit with Resident #160. Resident #160 had no top or pants on and was completely uncovered. Resident #160 was scratching at her peri area aggressively. The brief Resident #160 was wearing had been saturated with a red substance. Resident #160 was not responding to questions and continued scratching. Resident #160's husband placed Resident #160's call light on. Observation on 06/23/25 at 10:10 A.M. revealed Certified Nursing Assistant (CNA) #280 entered Resident #160's room. CNA #280 confirmed Resident #160 had blood inside her brief saturating the center peri area of the brief. CNA #280 turned Resident #160 to her side. A moderate amount of blood was observed on the pad under Resident #160. The indwelling catheter was lying on the mattress next to Resident #160 with a fully inflated balloon. The catheter had blood on the tubing and balloon. At 10:11 A.M. CNA #226 entered the room and assisted CNA #280 with peri care. Multiple old and new scratches were observed on Resident #160's thighs. CNA #226 revealed some of the scratches were older and some were new. There was blood with blood clots inside Resident #160's brief that CNA #226 and #280 removed. At 10:26 A.M. Registered Nurse (RN) #299 entered the doorway of the room. RN #299 did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 22 of 51 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 07/01/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few observe or assess Resident #160, RN #299 stood in the doorway and revealed she will come in and replace the indwelling catheter when her medication pass was completed. RN #299 then exited the room. Observation after peri care was completed revealed Resident #160's vaginal area was deep red, under bilateral breasts were deep red and the buttocks/peri area was deep red. Interview on 06/23/25 at 10:45 A.M. with RN #299 revealed when asked if she was going to replace Resident #160's indwelling catheter, She is hospice so, I am going on break right now. Interview on 06/23/25 at 1:09 P.M. with Hospice #320's Hospice RN #321 revealed Resident #160 had an indwelling catheter due to urinary retention. Hospice RN #321 revealed Resident #160 never removed her indwelling catheter prior to today. Observation revealed Hospice RN #321 placed a pair of clean disposable gloves on. Hospice RN #321 did not wash her hands prior to placing the clean gloves on. Hospice RN then place a pair of sterile gloves over the clean gloves. Hospice RN #321 then attempted to insert the indwelling catheter into Resident #160's urethra with no assistants. Resident #160 was morbidly obese and was not following direction. Hospice RN #321 then attempted several times inserting the catheter into the urethra which was not visible due to positioning. Resident #160 repeatedly yelled out., ow, ow ,ow during the entire procedure of attempting to place the indwelling catheter into the urethra. Hospice RN #321 then inserted the catheter in the area, pushed 30 milliliters (ml) of fluid in the catheter balloon while Resident #160 continued yelling out, ow, ow, ow. Hospice RN #321 confirmed Resident #160's was very red inside her vaginal area and under her breast. Hospice RN #321 also confirmed Resident #160 was having pain during the procedure and confirmed she never offered any as needed pain medication before or during the procedure. Per Hospice RN #321, Resident #160 had as need pain medication available for use if needed. Hospice RN #321 revealed Resident #160 was incontinent of urine on her brief. Hospice RN #321 turned Resident #160 to her right side. Resident #160's buttocks was deep red, Hospice RN #321 pulled Resident #160's brief from under her ripping the brief into several pieces as she kept pulling on it grabbing different areas of the brief. Surveyor suggested waiting for assistants to continue with the care. At 1:28 P.M. Licensed Practical Nurse (LPN) #261 entered the room to assist. Observation revealed the indwelling catheter came out. Hospice RN #321 revealed it fell out because it was not in the right area. Observation revealed during peri care provided by Hospice RN and LPN #261, Resident #160 continued to yell out, ow, ow, ow every time her vaginal area was touched. Hospice RN #321 never offered pain medication. Hospice RN #321 confirmed she never offered Resident #160 any pain medication although Resident #160 repeatedly yelled out in pain throughout the procedure, and confirmed Resident #160 had as needed pain medication available. Interview on 06/24/25 at 1:35 P.M. with RN #299 revealed the Hospice nurse never told her about the red areas in the vaginal area, buttocks or under the breast and confirmed Resident #160 never received orders to treat the areas. RN #299 revealed she will call hospice for new orders. RN #299 confirmed she never attempted to replace Resident #160's indwelling catheter on this day either, she was waiting for Hospice. Review of the physician order for Resident #160 revealed an order dated 06/24/25 for Diflucon 200 mg by mouth for yeast for five days until finished. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 23 of 51 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 07/01/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of the water temperature logs, and policy review, the facility failed to maintain safe water temperatures between 105 degrees Fahrenheit (F) and 120 degrees F. This had the potential to affect all residents except eleven residents (#5, #7, #10, #16, #20, #32, #33, #36, #39, #162, and #163) who the facility identified as dependent for mobility. The facility census was 57. Findings include: Review of the water temperature reading logs revealed on 02/11/25 the water temperature in resident room [ROOM NUMBER] was 121.8 degrees F. On 04/14/25 the water temperature in resident room [ROOM NUMBER] was 123.1 degrees F, the water temperature in the dining hall was 134.6 degrees F, and the water temperature in resident room [ROOM NUMBER] was 123.8 degrees F. On 04/28/25 the water temperature in the activities room was 123.3 degrees F. On 05/14/25 the water temperature in the dining hall sink was 130.9 degrees F and in resident room [ROOM NUMBER] the water temperature was 122 degrees F. On 05/27/25 the activities sink water temperature was 127 degrees F. On 06/03/25 the water temperature in the activities room was 122.4 degrees F and the water temperature in the dining hall was 131.4 degrees F. On 06/11/25 the water temperature in resident room [ROOM NUMBER] was 120.8 degrees F. Observation on 06/25/25 at 8:12 A.M. with Maintenance Supervisor (MS) #278 of the water temperature in Resident #2's room verified the water temperature to be 122 degrees F. Observation on 06/25/25 at 8:15 A.M. with MS #278 of the water temperature in the shower room by nurses' station #2 verified the water temperature to be 121 degrees F. Observation on 06/25/25 at 8:18 A.M. with MS #278 of the water temperature in Resident #51's room verified the water temperature to be 121 degrees F. Observation on 06/25/25 at 8:20 A.M. with MS #278 of the water temperature in the shower room by nurses' station #1 verified the water temperature to be 120.4 degrees F. Observation on 06/25/25 at 8:24 A.M. with MS #278 of the water temperature in Resident #39's room verified the water temperature to be 123 degrees F. Observation on 06/25/25 at 8:27 A.M. with MS #278 of the water temperature in Resident #42's room verified the water temperature to be 121.8 degrees F. Observation on 06/25/25 at 8:57 A.M. with MS #278 of the water temperature in the dining room sink verified the water temperature to be 141.4 degrees F. Interview on 06/25/25 at 8:57 A.M. with MS #278 revealed he was new to his position as Maintenance Supervisor, and he was not trained. MS #278 revealed he was not aware of what the water temperatures were supposed to be. Interview on 06/25/25 at 10:54 A.M., the Director of Nursing (DON) revealed there had been no resident burn incidents related to the hot water temperatures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 24 of 51 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 07/01/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Review of the undated facility policy titled Water Temperatures, Safety of revealed water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees Fahrenheit or the maximum allowable temperature per state regulation. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 25 of 51 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 07/01/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review revealed the facility failed to ensure an indwelling catheter for one resident, Resident #160 was addressed timely to include a physical assessment and reinsertion when Resident #160 removed the catheter. The facility also failed to notify the primary care physician of the catheter and failed to notify the primary care physician and Hospice provider of the results of a urinalysis timely that resulted in bacterial growth requiring treatment of an antibiotic. This affected one resident, Resident #160 and had the potential to affect an additional seven residents, Resident #5, #26, #35, #36, #40, #43, and #50 identified by the facility as having indwelling catheters. The facility census was 57. Findings include: Record review for Resident #160 revealed an admission date of 05/28/25. Diagnoses included heart failure, Absence of right and left leg below the knee, obesity, diabetes mellitus with diabetic polyneuropathy, and low back pain. Resident #160 received hospice services. Review of the admission Minimum Data Set (MDS) dated [DATE] for Resident #160 revealed Resident #160 was moderately cognitively impaired. Resident #160 was dependent for toileting hygiene, bathing and bed mobility. Resident #160 had an indwelling catheter and was occasionally incontinent of bowel. Review of the care plan dated 06/23/25 revealed Resident #160 was at risk for infection and/or trauma related to use of foley catheter, neurogenic bladder. Interventions included to check for patency and urinary output every shift; Monitor for signs and symptoms of urinary tract infection (UTI): burning on urination, flank pain, hematuria, decreased urinary output, change in mental status, change in behavior, fever, change in color, clarity and/or odor of urine. Review of the physician orders for Resident #160 revealed an order dated 05/29/25 to keep foley diagnosis is oliguria. An additional order revised 05/30/25 revealed keep foley catheter 16 french 10 milliliter (ml) balloon diagnosis is oliguria. A revised order dated 06/19/25 revealed keep foley catheter 16 french 10 milliliter (ml) balloon diagnosis is neurogenic bladder. Review of the Nursing Progress Note for Resident #160 dated 06/15/25 at 2:08 A.M. included Resident #160 complained of urgency stating she felt like she had to pee. Increased agitation and confusion. Urine in catheter bag was cloudy and had a strong odor. The note included would speak with hospice for a urine analysis culture and sensitivity (UA C&S) laboratory test Review of the Nursing Progress Note for Resident #160 dated 06/16/25 at 11:59 A.M. revealed Certified Nursing Assistant (CNA) reported urine had a foul odor. Resident educated to consume more water due to strong urine. Review of the Nursing Progress Note for Resident #160 dated 06/18/25 at 9:24 A.M. revealed a call was placed to hospice to obtain a urine sample to send to lab for a UA C&S due to cloudy urine and a strong urine smell and increased confusion. Review of the physician orders for Resident #160 revealed an order dated 06/18/25 revealed an order to collect urine for a urinalysis, culture and sensitivity to be sent to laboratory and notify (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 26 of 51 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 07/01/2025 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 0690 hospice of results. Level of Harm - Minimal harm or potential for actual harm Review of the Nursing Progress Note for Resident #160 dated 06/19/25 at 6:09 A.M. revealed urine collected from resident this A.M. and sent to lab for a UA C&S. Residents Affected - Few Review of the Nursing Progress Notes for Resident #160 from 06/19/25 through 06/24/25 at 2:00 P.M. revealed no further documentation, results or orders from UA or C&S obtained 06/19/25. Observation on 06/23/25 at 10:08 A.M. revealed Resident #160 was lying in bed. Resident #160's husband was present and revealed he just arrived to visit with Resident #160. Resident #160 had no top or pants on and was completely uncovered. Resident #160 was scratching at her peri area aggressively. The brief Resident #160 was wearing had been saturated with a red substance. Resident #160 was not responding to questions and continued scratching. Resident #160's husband placed Resident #160's call light on. Observation on 06/23/25 at 10:10 A.M. revealed Certified Nursing Assistant (CNA) #280 entered Resident #160's room. CNA #280 confirmed Resident #160 had blood inside her brief saturating the center peri area of the brief. CNA #280 turned Resident #160 to her side. A moderate amount of blood was observed on the pad under Resident #160. The indwelling catheter was lying on the mattress next to Resident #160 with a fully inflated balloon. The catheter had blood on the tubing and balloon. At 10:11 A.M. CNA #226 entered the room and assisted CNA #280 with peri care. CNA #226 revealed Resident #160 was last changed at 6:00 A.M.; There was blood with blood clots inside Resident #160's brief that CNA #226 and #280 removed. At 10:26 A.M. Registered Nurse (RN) #299 entered the doorway of the room. RN #299 did not observe or assess Resident #160, RN #299 stood in the doorway and revealed she will come in and replace the indwelling catheter when her medication pass was completed. RN #299 then exited the room. Interview on 06/23/25 at 10:45 A.M. with RN #299 revealed when asked if she was going to replace Resident #160's indwelling catheter, She is hospice so, I am going on break right now. Interview on 06/23/25 at 12:14 P.M. with RN #299 revealed the hospice nurse never came yet and she would let the surveyor know when the hospice nurse comes to replace Resident #160's indwelling catheter. Interview on 06/23/25 at 1:09 P.M. with Hospice #320's, Hospice RN #321 revealed Resident #160 had an indwelling catheter due to urinary retention. Hospice RN #321 revealed Resident #160 never removed her indwelling catheter prior to today. Observation revealed Hospice RN #321 placed a pair of clean disposable gloves on. Hospice RN #321 did not wash her hands prior to placing the clean gloves on. Hospice RN then place a pair of sterile gloves over the clean gloves. Hospice RN #321 never placed an isolation gown on. Hospice RN #321 then attempted to insert the indwelling catheter into Resident #160's urethra with no assistance. Resident #160 was morbidly obese and was not following direction. Observation revealed Hospice RN was attempting to hold the catheter in one hand, spread Resident #160's legs with her arms while trying to separate the labia with the second hand to visualize the urethra. Hospice RN #321 then attempted several times inserting the catheter into the urethra which was not visible due to positioning. Hospice RN #321 then inserted the catheter in the area with no urine return observed, pushed 30 milliliters (ml) of fluid in the catheter . Hospice RN #321 confirmed there was no urine return. At 1:28 PM Licensed Practical Nurse (LPN) #261 entered the room to assist. LPN #261 never placed an isolation gown on. Observation revealed the indwelling catheter came out. Hospice RN #321 revealed it fell out because it was not in the right area. LPN #261 revealed she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 27 of 51 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 07/01/2025 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 0690 would look to see if the facility had another indwelling catheter for Resident #160. Level of Harm - Minimal harm or potential for actual harm Interview on 06/23/25 at 2:04 P.M. with RN #299 confirmed she did not place Resident #160's indwelling catheter in stating, I did not change the catheter myself because I was busy, there are only two nurses., use to be three, now two nurses for all residents, there's not enough time. Residents Affected - Few Observation on 06/24/25 at 1:35 P.M. revealed Resident #160 was lying in bed. Resident #160 did not have an indwelling catheter. Interview with RN #299 revealed Resident #160 had the catheter replaced on 06/23/24 by the hospice nurse then Resident #160 pulled it out again last night. RN #299 revealed Hospice was called this A.M., they said they will notify Resident #160's case worker and will call back. RN #299 revealed Hospice never called back yet and confirmed Resident #160's primary physician was never notified of the catheter coming out. RN #299 revealed, Most hospice companies take care of everything so we just notify hospice. RN #299 revealed she will call hospice for new orders. RN #299 confirmed she never attempted to replace Resident #160's indwelling catheter on this day either, she was waiting for Hospice. Interview 06/24/25 1:47 P.M. with Director of Nursing (DON) revealed an acceptable amount of time to wait to assess a resident when a resident has a change in condition such as an indwelling catheter coming out would be immediate. The nurse should stop what they are doing and assess the resident including any trauma to the area from the catheter being pulled out. The facility nurse should address the concern, replace the catheter then update hospice and the primary physician. Record review for Resident #160 revealed the UA C&S results for the urine obtained 06/19/25 were not available in the medical records and there was no further documentation after the urine was obtained regarding the urinalysis results. Interview with DON on 06/24/25 at 3:30 P.M. confirmed Resident #160 did not have the UA obtained on 06/19/25 or C&S results in the medical record and no follow up on the results were documented. Interview on 06/24/25 at 4:45 P.M. with DON revealed she called the lab and obtained the results of the UA C&S for Resident #160. Review of the lab results revealed the results were faxed to the facility on [DATE] at 4:20 P.M.; Resident #160 had greater than 100,000 growths of both Escherichia coli and pseudomonas aeruginosa. DON revealed the lab said they just got the results and never sent a preliminary. Interview on 06/24/25 at 4:57 P.M. with Resident #160's husband revealed he noticed a huge change in his wife about two weeks ago and revealed she was sluggish, more confused, not herself. Review of the physician order for Resident #160 revealed an order was written on 06/24/25 for Cipro (antibiotic) 250 mg give one tablet orally two times a day for urinary tract infection (UTI) for seven days. Telephone interview on 06/25/25 at 10:04 A.M. with Laboratory Director #324 revealed Resident #160's urinalysis was obtained from the facility on 06/19/25 at 2:00 A.M.; The urinalysis result were reported faxed to the facility on [DATE] at 7:33 A.M. The C&S was completed on 06/21/25 at 8:55 A.M. but not faxed until 06/24/25. Lab Director #324 revealed when a urinalysis is completed that required a C&S, the urinalysis is sent to a different location for the C&S. The staff that completed the urinalysis at the first lab for Resident #160 did not put the fax request in so that the second lab who completed the C&S was aware to fax the results to the facility. Some facilities have electronic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 28 of 51 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 07/01/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few access to obtain results immediately and some prefer to be faxed. The lab does not know unless it is written on the request that they need to fax it. Lab Director #324 confirmed the C&S result would not have been sent to the facility if they did not call to request it on 06/24/25. Review of the lab confirmation sent via e-mail from Laboratory Director #324 confirmed the abnormal urinalysis report for Resident #160 was successfully sent via fax to the facility on [DATE] at 11:20 A.M.; The C&S was sent via fax to the facility on [DATE] successfully at 4:33 P.M. Interview on 06/25/25 at 3:20 P.M. with DON confirmed the facility should have followed up on the lab results for the urinalysis and the C&S for Resident #160 and the nurses should have notified the hospice and physician when they received the results. This deficiency represents non-compliance investigated under Complaint Number OH00166248. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 29 of 51 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 07/01/2025 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility policy, the facility failed to ensure a resident with significant weight loss received timely follow up and the physician was notified. This affected one, (#30) of two residents reviewed for weight loss. The facility census was 57. Residents Affected - Few Findings include: Record review for Resident #30 revealed an admission date of 03/11/25. Diagnoses included end stage renal disease (ESRD), unspecified protein calorie malnutrition, hypothyroidism, and Type Two Diabetes Mellitus. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was cognitively intact. Resident #30 had a weight loss of five percent (%) or more in the last month or loss of 10 % or more in the last six months. Review of the care plan for Resident #30 dated 05/07/25 revealed Resident #30 had a nutritional problem or potential nutritional problems related to ESRD, dialysis, low serum albumin levels, overweight, diabetes, chronic obstructive pulmonary disease (COPD) and diagnosis protein-calorie malnutrition. Interventions included Registered Dietitian (RD) to evaluate and make diet change recommendations as needed (PRN). Review of the physician orders for Resident #30 revealed an order for renal diet regular texture thin consistency, low cholesterol, low saturated fats, low sodium, low potassium, for diet initiated 03/11/25 and medpass (nutritional supplement) 2.0 four ounces with each administration two times a day initiated 04/30/25. Review of the Medication Administration Record (MAR) for Resident #30 for June 2025 revealed Resident #30 drank 0% of the medpass 2.0 (38 of the 54 times) the med pass was offered. Review of the weight record for Resident #30 revealed on 05/05/25 Resident #30 weighed 200.2 pounds (lb). On 06/25/25 Resident #30 weighed 169.2 (15.48%) weight loss. Review of the progress note for Resident #30 dated 05/21/25 at 12:55 P.M. completed by Dietitian #325 revealed current weight 174.2 pounds (LB) was discussed at risk management meeting, down 26 lbs since 05/06, request reweigh. No change in (Resident #30's) medical status noted. Record review of the weight record for Resident #30 revealed the next weight was completed 05/28/25 and the weight was 171.6 lbs. Record review of Resident #30's medical record revealed no further documentation was completed by the Dietitian after 05/21/25 until 06/11/25. Review of the progress note for Resident #30 dated 06/11/25 at 2:46 P.M. completed by Dietitian #325 revealed the June monthly weight was reviewed. Noted 31# weight loss on 30 days. Meal intakes remain 75-100%. Current weight 173#. Requesting a reweigh. Record review of the weight record for Resident #30 revealed the next weight was completed 06/12/25 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 30 of 51 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 07/01/2025 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 0692 and the weight was 169.5 lbs. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #30's medical record revealed no further documentation was completed by the Dietitian after 06/11/25. Residents Affected - Few Interview on 06/30/25 10:23 A.M. with Dietitian #325 revealed she tried to review residents' weights monthly and as needed. Dietitian #325 confirmed she did not follow up on Resident #30's significant weight loss after the reweigh in May 2025 or June 2025. Dietitian #325 revealed she forgot to follow up and review the reweighs and confirmed there was no follow up on Resident #30's weight loss. Dietitian #325 revealed the supplement from 05/13/25 was not working for Resident #30. Dietitian #325 stated, I am so sorry, I forgot to follow up on her. Interview on 06/30/25 at 10:31 A.M. with the Director of Nursing (DON) revealed the Dietitian should have been notified of the reweighs and the she should have reevaluated Resident #30 for the significant weight loss and the physician should have also been notified. Interview on 06/30/25 at 10:47 A.M. with Resident #30 revealed she was not sure why she was having weight loss, it was just happening. Resident #30 revealed she did not like the medpass and stated, I am trying to get the dietitian in to get me some boost, I would like that. Review of the facility policy titled, Dietitian undated revealed our facility's dietitian is responsible for, but not necessarily limited to assessing nutritional needs of residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 31 of 51 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 07/01/2025 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 0695 Provide safe and appropriate respiratory care 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** 2. Record review for Resident #160 revealed an admission date of 05/28/25. Diagnosis included heart failure, obesity, and diabetes mellitus with diabetic polyneuropathy. Residents Affected - Few Review of the admission Minimum Data Set (MDS) dated [DATE] for Resident #160 revealed Resident #160 was moderately cognitively impaired. Resident #160 required partial/moderate assistants with eating and was dependent for toileting hygiene, bathing and bed mobility. Resident #160 had shortness of breath or trouble breathing with exertion and when lying flat. Review of the care plan for Resident #160 dated 06/23/25 revealed Resident #160 utilized oxygen therapy related to congestive heart failure, shortness of breath and asthma. Interventions included oxygen settings two to five liters as needed or SP02 less than 90%. Review of the physician orders for Resident #160 revealed an order dated 05/29/25 for oxygen two to five liters as needed for shortness of breath or SPO2 less than 90 %. Observation on 06/23/25 at 10:08 A.M. revealed Resident #160 was lying in bed. Resident #160's husband was present and revealed he just arrived to visit with Resident #160. Resident #160 had no top or pants on and was completely uncovered. Resident #160 was not responding to questions. The nasal cannula and tubing connected to the oxygen concentrator was lying on the floor next to the concentrator. The concentrator was not running. Resident #160's husband placed Resident #160's call light on. Observation on 06/23/25 at 10:10 A.M. revealed Certified Nursing Assistant (CNA) #280 entered Resident #160's room. At 10:11 A.M. CNA #226 entered the room and assisted CNA #280 with peri care. At 10:26 A.M. Registered Nurse (RN) #299 entered the doorway of the room. RN #299 did not observe or assess Resident #160, RN #299 stood in the doorway and revealed she will come in and replace Resident #160's indwelling catheter when her medication pass was completed. RN #299 then exited the room. CNA #280 picked Resident #160's nasal cannula off the floor, placed it back in Resident #160's nares and turned on the oxygen concentrator. The concentrator was set at 1.5 liters per minute. No assessment was completed to determine Resident #160's oxygen saturation level and no shortness of breath was observed. Upon exit of the room, CNA #280 confirmed she picked up the oxygen tubing off the floor and placed it in Resident #160's nares then turned the concentrator on. Interview on 06/30/25 at 8:22 A.M. with Registered Nurse (RN) #300 revealed CNA's were not permitted to turn on or off oxygen concentrators. Interview on 06/30/25 at 8:40 A.M. with the Director of Nursing (DON) revealed CNA's were not permitted to apply oxygen or turn on or off oxygen use. Review of the facility policy titled, Oxygen Administration undated revealed the purpose of this procedure is to provide guidelines for safe oxygen administration. The nasal cannula is a tube that is placed approximately one/half inch into the resident's nose. It is held in place by an elastic band placed around the resident's head. Before administering oxygen, and while the resident is receiving oxygen therapy, assess for signs and symptoms of cyanosis, hypoxia, oxygen toxicity, vital signs, lung sounds, and oxygen saturation. Based on medical record review, observation, resident interview, staff interview, and policy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 32 of 51 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 07/01/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm review, the facility failed to ensure physician orders for oxygen contained Liters Per Minute (LPM). This affected two residents (#42 and #160) of two residents reviewed for respiratory care. The facility identified 14 residents receiving oxygen therapy. The facility census was 57. Findings include: Residents Affected - Few Review of Resident #42's medical record revealed an admission date of 02/02/24. Diagnoses include chronic obstructive pulmonary disease, anxiety, atrial fibrillation, and atherosclerotic heart disease. Review of Resident #42's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had intact cognition. Review of Resident #42's physician orders revealed an order to apply oxygen via nasal cannula to keep oxygen saturation (SpO2) level at 93 percent (%) and above. Observation on 06/23/25 at 10:22 A.M. revealed Resident #42 was wearing oxygen via nasal cannula set at five liters per minute (LPM). Concurrent interview with Resident #42 revealed she always wore oxygen. Interview on 06/25/24 at 9:40 A.M. with Licensed Practical Nurse (LPN) #275 verified Resident #42's oxygen was set to five LPM. Interview on 06/25/24 at 9:43 A.M. with LPN #275 verified the physician order for Resident # 42's oxygen had not stated the oxygen LPM. Interview on 06/26/25 at 11:01 A.M., the Director of Nursing (DON) verified a physician order should specify liters per minute for oxygen administration. Review of the undated policy titled Oxygen Administration revealed oxygen should be administered per the physicians orders. Further review of the policy revealed unless otherwise ordered, start the flow of oxygen at the rate of two to three liters per minute. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 33 of 51 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 07/01/2025 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on resident interviews, staff interviews, review of the Facility Assessment (FA) and review of staffing reports, the facility failed to have sufficient staff to meet resident needs as identified in the FA. This had the potential to affect all 57 residents in the facility. The facility census was 57. Findings include: Interview with Resident #43 on 06/23/25 at 12:07 P.M. revealed the facility had several call offs over the weekend resulting in him not getting a shower. Observation on 06/23/25 at 12:07 P.M. revealed Resident #43 had body odor and oily hair. Review of the medical record for Resident #43 revealed an admission date of 05/19/25. Diagnoses included Diabetes Mellitus II, complete traumatic amputation at level between left hip and knee and right hip and knee, chronic kidney disease stage three and peripheral vascular disease. Review of the admission Minimum Data Set (MDS) assessment revealed Resident #43 required partial/moderate assistance with personal hygiene and substantial/maximal assistance from staff for showers and bathing. Review of the functional abilities prior functioning dated 05/23/25 revealed Resident #43 needed some help, and he used a manual wheelchair. Review of the plan of care dated 05/21/25 revealed there were only two care plans for Resident #43 and neither pertained to hygiene care, bathing or showering. Review of the staffing tool with the Administrator on 06/26/25 at 11:26 A.M., dated 06/16/25 through 06/22/25 revealed on Saturday 06/21/25 and Sunday 06/22/25 the facility staffing fell below the 2.50 minimum staffing requirement and had 2.37 hours of care per resident per day on both 06/21/25 and 06/22/25. A second interview with Resident #43 on 06/25/25 at 8:11 A.M. revealed he washed up in his room. He wanted to shower over the weekend but due to Certified Nursing Assistant (CNA) call-offs, he did not get a shower. Interviews with CNA's #227 and #231 on 06/26/25 at 1:10 P.M. and 1:29 P.M. respectively revealed sometimes there are call offs and we do the best we can. Sometimes showers are not given due to lack of sufficient staff. Interview on 06/26/25 at 11:26 A.M. with the Administrator confirmed the facility failed to meet the 2.50 minimum required staffing on 06/21/25 and 06/22/25 resulting in the Administrator coming in and working as a CNA, still leaving the facility short staffed. The facility sent out a mass text for volunteers to work. A bonus was offered to get staff to work when there are call-offs. The facility does not use agency workers to fill vacant shifts in the schedule. Review of the Resident council dated 03/26/25 revealed call lights were not being answered in a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 34 of 51 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 07/01/2025 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete timely manner. Resident council dated 02/26/25 revealed call lights were not being answered timely. Resident council dated 01/29/25 revealed the nursing/CNA care is not satisfactory and residents are waiting long periods of time to get care. Review of the 12/26/24 Resident Council revealed residents as a whole are complaining about staff not being available and those who are working seem to be exhausted. Review of the FA dated 06/18/25 revealed there are 31 residents who are dependent on staff for bathing. These Residents are: #3, #4, #5, #10, #12, #13, #14, #16, #17, #20, #21, #23, #24, #25, #26, #27, #29, #31, #32, #33, #34, #36, #37, #38, #39, #47. #48, #50, #55, #160 and #163. There are 28 residents who require assistance of one to two staff for bathing and they are Residents #1, #2, #6, #7, #8, #9, #11, #15, #18, #19, #22, #28, #30, #35, #40, #42, #43, #45, #46, #51, #52, #53, #54, #57, #110, #161, #162 and #164. The staffing plan revealed the facility will remain staffed without the use of third party supports (I.E. agency staff or state supported temporary staffing) in direct care. The facility has increased cross-training and leadership/frontline staff duty integration to ensure the delivery of care and services. Direct care staff members, specifically Certified Nursing Assistants (CNAs) plan is for three to five full-time employees on days 6:00 A.M. to 6:00 P.M. shift and one to two full-time employees on night shift from 6:00 P.M. to 6:00 A.M. Note that in the event of CNA unavailability, licensed staff will be substituted as necessary. Direct care staffing per patient day (PPD's) remain consist with an average PPD of 2.5; current staff are stable and most are tenured. Event ID: Facility ID: 365118 If continuation sheet Page 35 of 51 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 07/01/2025 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 0759 Ensure medication error rates are not 5 percent or greater. 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, staff interview, and policy review, the facility failed to ensure the medication error rate did not exceed five percent (%). Two errors occurred for 31 observed opportunities for an error rate of 6.45%. This affected two residents (#12 and #161) of five residents reviewed for medication administration. This had the potential to affect an additional 10 residents (#3, #8, #11, #14, #16, #27, #28, #30, #43, and #57) who received insulin via insulin pen. The facility census was 57. Residents Affected - Few Findings include: 1. Review of Resident #12's medical record revealed an admission date of 10/02/24. Diagnoses include Alzheimer's disease, altered mental status, atrial fibrillation, hypertension, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of Resident #12's physician orders revealed an order for Cosopt Ophthalmic Solution 2-0.5%. Instill one drop in both eyes two times a day for Glaucoma, primary open angle. Observation on 06/25/25 at 7:16 A.M. of medication administration with Registered Nurse (RN) #300 revealed the Cosopt Ophthalmic Solution for Resident #12 was unavailable. Concurrent interview with RN #300 revealed that RN #300 would notify the doctor of the unavailable medication and that he re-ordered the medication. 2. Review of Resident #161's medical record revealed an admission date of 05/28/25. Diagnoses include type two diabetes mellitus, major depressive disorder, and iron deficiency anemia. Review of the admission MDS assessment dated [DATE] revealed the resident had moderate cognitive impairment. Review of Resident #161's physician orders revealed an order for Humalog 100 unit/milliliter (ml). Inject 16 units subcutaneously before meals for diabetes related to type two diabetes mellitus. Also included in the physician's orders was a sliding scale insulin order for blood sugar regulation. Observation on 06/25/25 at 10:59 A.M. revealed RN #300 checked Resident #161's blood glucose level with a result of 293. Per the physician's orders and sliding scale, RN #300 stated he would administer 22 units of insulin. Observation on 06/25/25 at 11:00 A.M. of RN #300 administering insulin revealed RN #300 had not primed the insulin pen prior to administering the 22 units of insulin. Concurrent interview with RN #300 verified he should have primed the insulin pen prior to administration. Review of the manufacturer instructions for a Humalog insulin pen revealed to prime the pen, turn the dose knob to select two units. Holding the pen with the needle pointing up, tap the cartridge holder gently to collect air bubbles at the top. Eject the two units of insulin and hold the dose knob until you see insulin at the tip of the needle. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 36 of 51 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 07/01/2025 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the undated policy titled Insulin Administration Purpose revealed nursing staff have access to manufacturer instructions. Review of the undated facility policy Administering Medications revealed medications would be administered in a safe and timely manner, and as prescribed. There were no guidelines for priming an insulin pen prior to administration. This deficiency represents noncompliance investigated during Complaint Number OH00166248. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 37 of 51 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 07/01/2025 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #56 revealed an admission date of 04/07/25 and a discharge date of 06/02/25. Diagnoses included pneumonia, acute respiratory failure with hypoxia, heart failure, hypertension, chronic obstructive pulmonary disease, and Alzheimer's disease. Residents Affected - Few Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate cognitive impairment. Review of the physician orders dated 04/08/25 revealed an order for Lasix 20 milligrams, one tablet by mouth every 24 hours as needed for edema or greater than three-pound weight gain in 24 hours, weigh daily in the morning, if greater than three-pound weight gain, give the as needed Lasix. Review of the Medication Administration Record (MAR) dated 05/01/25 through 06/02/25 revealed Resident #56 was not weighed per physician orders on 05/01/25, 05/12/25, 05/13/25, 05/16/25, 05/17/25, 05/18/25, 05/20/25, 05/21/25, 05/22/25, 05/26/25, 05/27/25, and 05/30/25. Further review of the MAR revealed on 05/03/25 the resident weighed 98.5 pounds and on 05/04/25 the resident weighed 103.6 pounds. On 05/25/25 the resident weighed 102.6 pounds, and no weights were completed on 05/26/25 and 05/27/25. On 05/28/25 the resident weighed 109 pounds. Continued review of the MAR revealed the resident was not administered the as needed Lasix for the greater than three-pound weight gains on 05/04/25 and 05/28/25. Interview on 06/26/25 at 12:05 P.M., the Director of Nursing (DON) verified Resident #56's weights were not obtained per physician orders, and the resident was not administered Lasix per physician orders for greater than three-pound weight gains. Review of the undated facility policy Administering Medications revealed medications would be administered in a safe and timely manner, and as prescribed, including any required time frame. This deficiency represents noncompliance investigated during Complaint Number OH00166248. Based on medical record review, staff interview, and facility policy review, the facility failed to ensure residents remained free from significant medications errors. This affected two (#161, #56) of six residents reviewed for medication administration. This had the potential to affect an additional 11 residents (#3, #8, #11, #12, #14, #16, #27, #28, #30, #43, and #57) who received insulin via insulin pen. The facility census was 57. Findings include: 1. Review of Resident #161's medical record revealed an admission date of 05/28/25. Diagnoses include type two diabetes mellitus, major depressive disorder, and iron deficiency anemia. Review of the admission MDS assessment dated [DATE] revealed the resident had moderate cognitive impairment. Review of Resident #161's physician orders revealed an order for Humalog 100 unit/milliliter (ml). Inject 16 units subcutaneously before meals for diabetes related to type two diabetes mellitus. Also included in the physician's orders was a sliding scale insulin order for blood sugar regulation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 38 of 51 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 07/01/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 06/25/25 at 10:59 A.M. revealed Registered Nurse (RN) #300 obtained the blood glucose level of 293 for Resident #161. Per the physician's orders and sliding scale, RN #300 stated he would administer 22 units of insulin. Observation on 06/25/25 at 11:00 A.M. of RN #300 administering insulin revealed RN #300 had not primed the insulin pen prior to administering the 22 units of insulin. Concurrent interview with RN #300 verified he should have primed the insulin pen prior to administration. Review of the manufacturers instructions for a Humalog insulin pen revealed to prime the pen, turn the dose knob to select 2 units. Holding the pen with the needle pointing up, tap the cartridge holder gently to collect air bubbles at the top. Eject the two units of insulin and hold the dose knob until you see insulin at the tip of the needle. Review of the undated policy titled Insulin Administration Purpose revealed nursing staff have access to manufacturer instructions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 39 of 51 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 07/01/2025 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 0800 Level of Harm - Minimal harm or potential for actual harm Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation and interviews, the facility failed to serve an appropriate amount of meat (protein) with the lunch meal. This had the potential to affect all residents at the facility. The facility census was 57. Residents Affected - Many Findings include: Observation on 06/25/25 at 11:33 A.M. of the food service tray line revealed [NAME] #245 was serving residents meals. Observation revealed there were noodles in one pan and gravy with small chunks of beef in another pan. Observation revealed [NAME] #245 was placing the noodles with a four ounce scoop on each residents plate. The beef and gravy was served with a six ounce scoop. Observation revealed when [NAME] #245 placed the meat with gravy on each plate, some plates received one piece of stew meat, some had two and some had three pieces of meat. The pieces of meat varied in size from approximately one inch by one inch size pieces to 1/2 inch by 1/2 inch size pieces. [NAME] #245 confirmed the sizes of the pieces of meat and revealed, We are given two little bags of beef stew meat for all the residents. [NAME] #245 revealed the pieces of meat were added to the gravy before serving. Dietary Manager (DM) #236 entered the area and revealed each piece of meat was one ounce serving and each resident should receive three pieces of meat. DM #236 confirmed there was no scale to weigh the meat to confirm they were each one ounce and [NAME] revealed they were not each one ounce and confirmed residents randomly received one to three small pieces of meat per serving. Observations and or interviews on 06/25/25 between 11:46 A.M. and 1:12 P.M. with Residents #2, #3, #4, #6, #9, #23, #26, #27, #28, #46, #51, #53, and #25 revealed they received a small amount of meat, one to two pieces each resident. Telephone interview on 06/26/25 at 9:49 A.M. with Dietitian #325 revealed with beef and noodles, the recipe called for six ounces of beef and gravy and revealed the recipe should include how much meat each resident should receive. Dietitian #325 revealed each resident should receive at least three or four pieces of the meat with each serving. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 40 of 51 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 07/01/2025 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation and interview, the facility failed to puree food items to a smooth texture with no chunks of food remaining. This had the potential to affect four residents, Resident #8, #20, #34, and #160, identified by the facility as receiving a pureed only diet. The facility census was 57. Findings include: Observation on 06/25/25 at 10:41 A.M. of processing pureed foods with [NAME] #247 revealed [NAME] #247 placed mixed vegetables in the food processor to puree the vegetables. When completed, [NAME] #247 placed the pureed vegetables in a metal pan and confirmed the vegetables were completed and ready to place on the steam table to serve. Observation revealed several visible small chunks throughout the pureed vegetables. Taste of the pureed vegetables revealed the chunks were the texture of several pieces of skin from the mixed vegetables that did not puree. [NAME] #247 confirmed the chunks of food in the pureed vegetables and confirmed that she was going to serve the residents the prepared pureed vegetables. Phone interview on 06/26/25 at 9:39 A.M. with Speech Therapist (ST) #326 revealed pureed foods should be smooth, no chunks or lumps of food should be present. ST #326 revealed chunks of food in a pureed item would not be acceptable. Telephone interview on 06/26/25 at 9:49 A.M. with Dietitian #325 confirmed the pureed foods should be completely smooth and confirmed there should be no chunks present in the pureed food items. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 41 of 51 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 07/01/2025 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, interview, and review of the facility policy, the facility failed to ensure expired food items were disposed of and not stored with other food items used for resident meals. This had the potential to affect all 57 residents residing at the facility. Findings include: Observation on 06/23/25 at 8:10 A.M. with Dietary Manager (DM) #236 revealed in walk in cooler labeled #1 there were two metal containers, one with a bulk amount of sliced ham with an expiration date of 06/11/25 that was opened and partially used. A second bag that was in the container had a bulk amount of sliced salami, partially used with an expiration date of 06/14/25. A third bag had a bulk amount of sliced roast beef, partially used with an expiration date of 06/14/25. The second metal container had a second bag of sliced ham unopened with an expiration date of 06/19/25. Observation of the dry food storage area revealed a large container of barbeque sauce with approximately 1/4 container left with an expiration date of 05/19/25. DM #236 verified all expired foods. Review of the facility policy titled, Food Receiving and Storage undated revealed all foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date). Refrigerated foods are labeled, dated and monitored so they are used by their used by date, frozen or discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 42 of 51 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 07/01/2025 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on review of Quality Assessment and Assurance (QAA) meeting sign-in documentation, staff interview, and facility policy review, the facility failed to have required Quality Assessment and Assurance quarterly meetings with required members. This had the potential to affect all residents. The facility census was 57. Residents Affected - Many Findings include: Review of the QAA sign in sheets revealed the facility had no documentation of QAA meetings for the first, second, and third quarters of 2024. The facility allowed viewing of fourth quarter QAA meeting documentation for 12/17/24 but there was no sign-in sheet for required members. Further review of the QAA sign-in sheets revealed the facility had a QAA meeting on 01/31/25 not attended by the Medical Director and another meeting on 02/28/25 not attended by the Director of Nursing or Infection Preventionist. Interview on 07/01/25 at 8:53 A.M. with the Administrator verified the facility had no documentation of quarterly QAA meetings prior the fourth quarter of 2024. The Administrator revealed the building was under new ownership beginning 11/01/24. The Administrator verified there was no documentation all required members were present during the 12/2024 fourth quarter meeting. Further interview with the Administrator revealed required members were not all present together for a QAA meeting for the first quarter of 2025. Review of the undated policy titled Quality Assurance and Performance Improvement (QAPI) Program Governance and Leadership revealed the following individuals serve on the committee: administrator, or a designee who is in a leadership role, director of nursing services, medical director, infection preventionist, and representatives of the following departments as requested by the administrator: pharmacy, social services, activity services, environmental services, human resources, and medical records. The committee would meet at least quarterly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 43 of 51 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 07/01/2025 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** 5. Review of the medical record for Resident #110 revealed an admission date of 06/13/25. Diagnoses included chronic pain, hemiplegia and hemiparesis, cerebral infarction, hypertension, atrial fibrillation, congestive heart failure, and narcissistic personality disorder. Residents Affected - Many Review of the admission MDS assessment dated [DATE] revealed the resident had intact cognition. Review of a physician order dated 06/20/25 revealed the resident had orders for contact precautions due to bilateral lower extremities wound infection. Review of a wound assessment report dated 06/20/25 revealed the resident had bilateral lower extremity venous ulcers. Review of a physician order dated 06/21/25 revealed to cleanse the bilateral lower extremities with wound cleanser, pat dry, apply ammonium lactate lotion to both lower leg topically, apply non-adherent dressing then a dry dressing over wounds, cover with tubular elastic dressing and wrap with elastic bandage daily and as needed for venous ulcer wound care. Observation on 06/24/25 beginning at 1:32 P.M. of wound care for Resident #110 with Licensed Practical Nurse (LPN) #259 revealed LPN #259 applied a gown and gloves when entering the resident's room. There was a sign on the resident's door indicating contact precautions required. LPN #259 removed the wound dressing from the resident's left lower extremity (LLE). LPN #259 then removed her gloves and applied new gloves without performing hand hygiene after removing the contaminated gloves. LPN #259 then removed the wound care dressing from the resident's right lower extremity (RLE). LPN #259 then removed the gloves, washed hands, and applied new gloves. LPN #259 cleansed the wound on the LLE then using the same contaminated gloves, cleansed the wound of the RLE. LPN #259 then removed the gloves without performing hand hygiene and applied a new pair of gloves. LPN #259 applied ammonium lactate topically to the LLE then using the same contaminated gloves applied ammonium lactate topically to the RLE. LPN #259 then removed gloves and washed hands. LPN #259 then dressed the wound to the LLE, removed gloves, used hand sanitizer, then went into the hallway outside the resident's room wearing a contaminated gown. LPN #259 returned and completed the wound dressing to the RLE. Interview on 06/24/25 at 2:12 P.M., LPN #259 verified using the same gloves for the RLE and LLE and not performing hand hygiene between glove changes. LPN #259 also verified not removing the contaminated gown before exiting the resident's room to obtain additional wound care supplies. Review of the undated facility policy Wound Care revealed to remove gloves and wash hands after removing a wound dressing then apply new gloves to apply wound treatment. Further review of the policy revealed no guidelines for staff when treating multiple wounds. Review of the undated facility policy Handwashing/Hand Hygiene revealed hand hygiene was required immediately after glove removal. Review of the undated facility policy Isolation-Categories of Transmission-Based Precautions revealed for resident's on contact precautions for staff to wear a disposable gown upon entering the room and remove before leaving the room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 44 of 51 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 07/01/2025 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 3. Record review of the Legionella reduction plan revealed the facility did not have a text description of the building water systems and flow diagrams. Additionally the facility had no measures in place to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water systems based on nationally accepted standards. Residents Affected - Many Interview with the Administrator on 06/30/25 at 11:30 A.M. revealed the facility was negative for Legionella. Interview with the Maintenance Director on 06/30/25 at 5:00 P.M. confirmed he did not have a description of the building water systems text and flow diagrams where Legionella and other opportunistic waterborne pathogens could grow and spread. He did not have measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water systems based on nationally accepted standards. He did not have testing protocols with acceptable ranges to intervene when control limits were not met. He stated when he took over the job December 2024, all the Legionella tools and records were gone. Interview with the Administrator on 07/01/25 at 9:10: A.M. confirmed the facility did not have a facility specific risk assessment or a description of the building's water systems using text and flow diagrams including where Legionella and other opportunistic waterborne pathogens could grow and spread. The facility did not have measures in place to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water system based on nationally accepted standards or a way to intervene when control limits were not met. Review of the undated facility policy, Legionella Water Management Program, revealed the facility was committed to the prevention, detection and control of water-borne contaminants including Legionella. The purpose of the water management program was to identify areas in the water system where Legionella bacteria could grow and spread and to reduce the risk of Legionnaire's disease. 4. Record review of Resident #15 revealed an admission date of 04/18/22. Diagnoses included end stage renal disease, dependence on renal dialysis, cerebral infarction and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. Record review for Resident #15 revealed physician orders dated 06/03/24 for Enhanced Barrier Precautions (EBP)due to a right chest hemodialysis palindrome. Review of the Minimum Data Set (MDS) 3.0 dated 06/05/25 revealed Resident #15 required substantial/maximum assistance for toileting. Review of the care plan dated 04/18/22 revealed Resident #15 required hemodialysis (HD) related to end stage renal disease and a new fistula, right arm hemodialysis, and had a palindrome in his right chest. Interventions included EBP precautions dated 06/24/25, monitor signs and symptoms of infection to the access site such as redness, swelling, warmth or drainage, and no blood pressures, needle sticks or laboratory draws from the arm with the fistula. Observation on 06/26/25 at 1:10 P.M. of the STOP See Nurse sign on Resident #15's the door indicated staff assisting this resident should wear gown and gloves when assisting with care. Observation on 06/26/25 at 1:10 P.M. revealed Certified Nursing Assistant (CNA) #227 walked past personal protective equipment (PPE) and the stop sign on Resident #15's door. She was observed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 45 of 51 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 07/01/2025 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 assisting Resident #15 off the commode and into his wheelchair. Level of Harm - Minimal harm or potential for actual harm Interview on 06/26/25 at 1:18 P.M. with CNA #227 confirmed she did not don PPE per the stop sign on Resident #15's door, and she assisted Resident #15 off the commode and into his wheelchair. Residents Affected - Many Review of the undated facility policy, Enhanced Barrier Precautions revealed a gown and gloves were to be applied prior to performing a high contact resident care activity such as dressing, bathing/showering, transferring, providing hygiene, changing linen, changing briefs or assisting with toileting, device care or use and wound care. Based on observation, resident and staff interview, record review, and review of the facility policy, the facility failed to maintain infection control practices during care including perineal care, foley catheter care, toileting, and meal service. The facility also failed to ensure a program was in place to prevent and stop the growth of water borne illness. The facility failed to maintain Enhanced Barrier Precautions (EBP)/Contact Precautions, and did not maintain proper infection control practices during wound care, medication administration, and glucometer cleaning. This had the potential to affect all residents residing at the facility. The facility census was 57. Findings include: 1. Record review for Resident #160 revealed an admission date of 05/28/25 with a diagnosis including neurogenic bladder. Resident #160 received hospice services. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #160 revealed Resident #160 was moderately cognitively impaired and dependent on staff for toileting hygiene and bed mobility. Resident #160 had an indwelling catheter and was occasionally incontinent of bowel. Review of the care plan dated 06/23/25 revealed Resident #160 was at risk for infection and/or trauma related to the use of a foley catheter and neurogenic bladder. Interventions included EBP due to the use of a Foley catheter dated 06/23/25 and for a Foley catheter 16 French due to a neurogenic bladder. Review of the physician orders for Resident #160 revealed an order dated 05/29/25 for a Foley catheter for oliguria, the order was not specific related to the size of the catheter or balloon. A revised order dated 06/19/25 revealed an order for a Foley catheter 16 french 10 milliliter (ml) balloon for a diagnosis of neurogenic bladder. Review of the physician orders for Resident #160 revealed an order dated 05/30/25 for Enhanced Barrier Precautions (EBP) due to Foley catheter use every day and night shift. Review of the Nursing Progress Note for Resident #160 dated 06/15/25 at 2:08 A.M. included Resident #160 complained of urgency, stating she felt like she had to urinate and she had increased agitation and confusion. The urine in catheter bag was cloudy and had a strong odor. The note included staff would speak with hospice for a urinalysis culture and sensitivity (UA C&S). Review of the Nursing Progress Note for Resident #160 dated 06/16/25 at 11:59 A.M. revealed the Certified Nursing Assistant (CNA) reported Resident #160's urine had a foul odor. Review of the Nursing Progress Note for Resident #160 dated 06/18/25 at 9:24 A.M. revealed a call (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 46 of 51 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 07/01/2025 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 - Many was placed to hospice to obtain a urine sample to send to the laboratory for a UA C&S due to cloudy urine, a strong urine smell and increased confusion. Observation on 06/23/25 at 10:08 A.M. revealed Resident #160 was lying in bed. Resident #160's husband was present and revealed he just arrived to visit with Resident #160. Resident #160 had no top or pants on and was completely uncovered. Resident #160 was scratching at her perineal area aggressively. The brief Resident #160 was wearing had been saturated with a red substance. Resident #160 was not responding to questions and continued scratching. Resident #160's husband placed Resident #160's call light on. Observation and interview on 06/23/25 at 10:10 A.M. revealed Certified Nursing Assistant (CNA) #280 entered Resident #160's room. CNA #280 confirmed Resident #160 had blood inside her brief saturating the center perineal area of the brief. CNA #280 turned Resident #160 to her side. A moderate amount of blood was observed on the pad under Resident #160. The indwelling catheter was lying on the mattress next to Resident #160 with a fully inflated balloon. The catheter had blood on the tubing and balloon. At 10:11 A.M. CNA #226 entered the room and assisted CNA #280 with peri care. There was blood with blood clots inside Resident #160's brief that CNA #226 and #280 removed. Observation during perineal care revealed neither CNA #280 nor #226 wore an isolation gown. CNA #280 then picked Resident #160's nasal cannula off the floor with her bare hands, placed it back in Resident #160's nares and turned on the oxygen concentrator. Upon exit of the room, CNA #280 confirmed Resident #160 did not have an Enhanced Barrier Precaution (EBP) and there were no Personal Protective Equipment (PPE) in or near the room. CNA #280 revealed Resident #160 was not on EBP and there was no need to wear an isolation gown or there would be a sign on the door. CNA #280 confirmed she picked up the oxygen tubing off the floor with her bare hands and placed it in Resident #160's nares then turned the concentrator on. Interview on 06/23/25 at 1:09 P.M. with Hospice Registered Nurse (RN) #321 revealed Resident #160 had an indwelling catheter due to urinary retention. Observation revealed Hospice RN #321 placed a pair of clean disposable gloves on and she did not don an isolation gown. Hospice RN #321 did not wash her hands prior to placing the clean gloves on. Hospice RN then place a pair of sterile gloves over the clean gloves. Hospice RN #321 then attempted to insert the indwelling catheter into Resident #160's urethra with no assistance. Resident #160 was morbidly obese and was not following direction. Observation revealed Hospice RN #321 was attempting to hold the catheter in one hand, spread Resident #160's legs with her arms while trying to separate the labia with the second hand to visualize the urethra. Hospice RN #321 then attempted several times inserting the catheter which was not visible due to positioning. Hospice RN #321 revealed Resident #160 was incontinent of urine on her brief. Hospice RN #321 turned Resident #160 to her right side. Hospice RN #321 pulled Resident #160's brief from under her ripping the brief into several pieces as she kept pulling on it, grabbing different areas of the brief. Surveyor suggested waiting for assistance to continue with the care. At 1:28 P.M., Licensed Practical Nurse (LPN) #261 entered the room to assist. LPN #261 never placed an isolation gown on. Observation revealed the indwelling catheter came out, the catheter the Hospice RN had just placed. Observation revealed perineal care was provided by Hospice RN #321 and LPN #261. Hospice RN #321 turned Resident #160 to her left side. While LPN #261 held Resident #160 on her left side, Hospice RN #321 bent her body down, while closely visualizing and pulling pieces of torn brief from under Resident #160, Hospice RN #321's hair was touching Resident #160's thigh and then the bed. Hospice RN #321 confirmed she bent her head down to the bed so low to see under Resident #160's side that her hair was touching Resident #321's body and bed. Hospice RN #321 stated, I usually put it up, I don't have anything to put it up with today. Hospice RN #321 confirmed she never washed her hands prior to putting on clean gloves then placing sterile gloves over the clean gloves. Both Hospice RN #160 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 47 of 51 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 07/01/2025 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 and LPN #261 verified neither wore an isolation gown during the care. Level of Harm - Minimal harm or potential for actual harm Interview on 06/24/25 at 4:45 P.M. with Director of Nursing (DON) revealed she called the lab and obtained the results of the UA C&S for Resident #160. Review of the lab results revealed Resident #160 had greater than 100,000 growths of both Escherichia coli and pseudomonas aeruginosa, indicating an infection. The DON further confirmed Resident #160 had an order for EBP and appropriate PPE was to be utilized for care. Residents Affected - Many Review of the physician order for Resident #160 revealed an order dated 06/24/25 for Diflucan 200 mg by mouth for yeast for five days until finished. An additional order was written on 06/24/25 for Cipro 250 mg give one tablet orally two times a day for a urinary tract infection (UTI) for seven days. Review of the undated facility policy, Enhanced Barrier Precautions revealed a gown and gloves were to be applied prior to performing a high contact resident care activity such as dressing, bathing/showering, transferring, providing hygiene, changing linen, changing briefs or assisting with toileting, device care or use and wound care. 2. Observation and interview on 06/25/25 at 12:06 P.M. revealed the meal hall cart was delivered to the floor identified as Ford Hall with resident's meal trays. Observation revealed Certified Nursing Assistant (CNA) #227, CNA #231, and Dietary Manager (DM) #236 began passing the residents meal trays to their rooms along with drinks they prepared for the trays as they passed each tray. Observation revealed CNA #227 delivered the meal tray to Resident #14. A sign was on the entrance way to Resident #14's room revealing Resident #14 was on Enhanced Barrier Precautions (EBP). CNA #227 never donned any personal protective equipment (PPE). Observation revealed CNA #227 repositioned Resident #14 in bed then set up the meal tray. CNA #227 then left the room and returned to the meal cart and continued passing trays. CNA #227 never washed her hands or used hand sanitizer. DM #236 revealed there were 23 or 24 trays on the cart to be passed to residents. Residents on the hall included Resident #14, #15, #16, #30, #36, and #43 who were identified by the Director of Nursing (DON) as being on EBP. Residents #13, #29, #40 and #162 were identified by the DON as being on Contact precautions. Observation of the complete tray pass to Ford Hall residents revealed CNA #231 and DM #236 never washed their hands or used hand sanitizer before or after passing any of the meal trays. CNA #227 was observed using hand sanitizer on one occasion during the tray pass. CNA #227, and CNA #231 confirmed they passed trays to the residents including residents on EBP and Contact Precautions, repositioned residents and never wore PPE, washed their hands or used hand sanitizer with the exception of CNA #227 using hand sanitizer on one occasion. DM #236 also confirmed she passed several resident trays and never washed her hands or used hand sanitizer. Interview on 06/26/25 at 10:11 A.M. with DON revealed staff should be cleaning their hands between each meal tray passed. Review of the undated facility policy, Enhanced Barrier Precautions revealed a gown and gloves were to be applied prior to performing a high contact resident care activity such as dressing, bathing/showering, transferring, providing hygiene, changing linen, changing briefs or assisting with toileting, device care or use and wound care. 6. Review of Resident #14's medical record revealed an admission date of 07/15/24. Diagnoses include type two diabetes mellitus with neuropathic arthropathy, anemia in chronic kidney disease, dyspnea, and muscle wasting and atrophy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 48 of 51 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 07/01/2025 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 Review of Resident #14's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had intact cognition. Review of Resident #14's physician orders revealed an order for Sevelamer HCL oral tablet 800 milligrams (mg), three tablets by mouth before meals related to end stage renal disease. Residents Affected - Many Observation on 06/25/25 at 7:30 A.M. revealed Registered Nurse (RN) #300 was preparing to administer medication to Resident #14. While preparing Resident #14's medication, RN #300 poured four pills into the medication container lid that he would transfer to Resident #14's medication cup. RN #300 placed his bare finger over a pill in the medication container lid and poured the other three pills into Resident #14's medication cup. Concurrent interview with RN #300 verified he should not have touched the pills when preparing the medications. Interview on 06/30/25 at 3:59 P.M. with the Director of Nursing (DON) verified it was not proper infection control to touch medications with your bare hand during medication administration. Review of the undated policy titled Administering Medications revealed staff were to follow established facility infection control procedures to administer medications in a safe manner. 7. Review of Resident #3's medical record revealed an admission date of 03/07/24. Diagnoses include type two diabetes mellitus, morbid obesity, osteoarthritis, hypertension, anemia, and chronic atrial fibrillation. Review of Resident #3's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had moderately impaired cognition. Review of Resident #3's physician orders revealed an order for a Humalog per sliding scale. Give insulin subcutaneously before meals and at bedtime related to diabetes mellitus. Observation on 06/25/25 at 7:50 A.M. revealed Licensed Practical Nurse (LPN) #259 obtained a blood glucose reading from Resident #3 prior to administering insulin. After obtaining the blood glucose level, LPN #259 cleansed the glucometer with an alcohol swab. Interview on 06/25/25 at 7:59 A.M. with LPN #259 verified she used an alcohol swab to clean the glucometer. LPN #259 verified three residents use the same glucometer, Resident #3, #28, and #1. Interview on 06/30/25 at 11:20 A.M. with the Director of Nursing (DON) revealed staff should clean the glucometers per the manufacturers instructions. The DON stated staff usually cleaned the glucometers with a Sani-wipe, but staff were not supposed to use alcohol wipes to clean the glucometers. Review of the undated policy titled Glucometer Cleaning revealed all glucometers will be cleaned and disinfected using Clorox Germicidal wipes, EPA Reg. No. 67619-12, or equivalent. A 1:10 bleach solution is also acceptable (1 part bleach to 9 parts water). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 49 of 51 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 07/01/2025 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 - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and review of service provider quotes, the facility failed to maintain the function of the wheelchair automatic push pad door openers for the facility front entrance double doors. This affected 14 residents (#1, #6, #8, #15, #17, #19, #27, #28, #30, #37, #40, #43, #45, and #53) identified by the facility as independent with wheelchair mobility. The facility census was 57. Findings include Observations on 06/24/25 at 7:40 A.M., on 06/25/25 at 7:50 A.M., on 06/26/25 at 7:41 A.M., and on 06/30/25 at 7:45 A.M. revealed the wheelchair accessible push pads used to open the facility front entrance set of double doors were not in working order. Further observation revealed there was a doorbell outside of the facility by the outer set of exterior doors. Interview on 06/30/25 at 7:45 A.M., the Administrator verified the push pad buttons to open each set of the double doors were not working. Interview on 06/30/25 at 8:35 A.M., the Director of Maintenance (DOM) #278 revealed the openers for front door push pads were at the end of its life. DOM #278 revealed the push pads to the exterior set of doors may work one out of ten times. DOM #278 revealed the push pads had not been working on and off since December 2024 and residents had gotten stuck in the entrance space between the two sets of doors. DOM #278 revealed he had notified the owner in April and in May of 2025 of the push pads needing replaced. DOM #278 revealed he obtained quotes in May of 2025, then got the quotes updated in June of 2025, and continued to wait on approval to get the push pads replaced. Interview on 06/30/25 at 11:54 A.M. with Resident #1 stated the push pads to open the front doors had not been working for a few weeks. Resident #1 stated as soon as they get fixed, they break again. Resident #1 revealed it was hard to open the doors on his own when the push pads were not working. Interview on 06/30/25 at 11:58 A.M. with Resident #15 revealed the push pads on the front entrance doors had not been working regularly for the last two years. Resident #15 revealed the doors were hard to open without the push pads. Interview on 06/30/25 at 12:02 P.M. with Registered Nurse (RN) #300 revealed the push pads for the front doors had been working on and off for the past month. Interview on 06/30/25 at 12:05 P.M. with Resident #43 revealed he had to push the push pads multiple times and the door would only start to open. Resident #43 revealed he could get out each set of doors, but it was easier when the button worked. Interview on 06/30/25 at 12:07 P.M. with Resident #30 revealed the push pad buttons had not been working for a few weeks. Resident #30 revealed she had to use the wheelchair to push open the doors. Observation on 07/01/25 at 7:42 A.M. revealed the push pads continued to fail to open both the outer and inner exterior doors to the facility when pushed multiple times to activate. Review of the service provider quotes dated 05/01/25 and 06/04/25 revealed quotes to remove and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 50 of 51 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 07/01/2025 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 install new handicap operator on the interior and exterior vestibule doors. The service provider noted current ADA operators (automatic door operator designed to meet the requirements of the Americans with Disabilities Act) were not designed for use on larger steel doors which had affected their longevity. Service ability was becoming difficult as the operators were at end-of-life and should be replaced for safety and reliability concerns. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365118 If continuation sheet Page 51 of 51

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Citations

34 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0578GeneralS&S Dpotential for harm
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
0605GeneralS&S Epotential for harm
F605 - Respect and Dignity
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
0641GeneralS&S Epotential for harm
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
0655GeneralS&S Dpotential for harm
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
0656GeneralS&S Epotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0677GeneralS&S Epotential for harm
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
0679GeneralS&S Dpotential for harm
F679 - Activities
Provide activities to meet all resident's needs.
0689GeneralS&S Epotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0692GeneralS&S Dpotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0725GeneralS&S Fpotential for harm
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
0759GeneralS&S Dpotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
0800GeneralS&S Fpotential for harm
F800 - Food and nutrition services
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
0805GeneralS&S Epotential for harm
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0880GeneralS&S Fpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0921GeneralS&S Epotential for harm
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
0584GeneralS&S Dpotential for harm
F584 - Safe Environment
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.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0690GeneralS&S Dpotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0760GeneralS&S Dpotential for harm
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
0868GeneralS&S Fpotential for harm
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
0015GeneralS&S Fpotential for harm
Address subsistence needs for staff and patients.
0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
0363GeneralS&S Fpotential for harm
Install corridor and hallway doors that block smoke.
0372GeneralS&S Fpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
0521GeneralS&S Fpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
0712GeneralS&S Fpotential for harm
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
0741GeneralS&S Fpotential for harm
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
0753GeneralS&S Fpotential for harm
Have restrictions on the use of highly flammable decorations.
0914GeneralS&S Fpotential for harm
F914 - Be designed or equipped to assure full visual privacy for each
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
0918GeneralS&S Fpotential for harm
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
0923GeneralS&S Fpotential for harm
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.

FAQ · About this visit

Common questions about this visit

What happened during the July 1, 2025 survey of Jag Healthcare Mansfield?

This was a inspection survey of Jag Healthcare Mansfield on July 1, 2025. The surveyor cited 34 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Jag Healthcare Mansfield on July 1, 2025?

Yes, 34 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate ..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 1, 2026. If you believe any information is inaccurate, report it here.

Inspection·July 1, 2025