Inspection·May 31, 2023

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, interview, and facility policy review the facility failed to ensure meals were hot and palatable. This affected seven residents (#6, #7, #9, #13, #15, #19 and #44) of seven residents reviewed for meal palatability and had the potential to affect all residents receiving meals from the facility. The facility census was 99. Residents Affected - Some Findings include: Review of the medical record for Resident #6 revealed an admission date of 05/10/22. Diagnoses included schizophrenia, anxiety, diabetes, hyperlipidemia, and atrial fibrillation. Review of the medical record for Resident #7 revealed an admission date of 06/17/15. Diagnoses included schizophrenia, diabetes, dementia, and insomnia. Review of the medical record for Resident #9 revealed an admission date of 03/05/20. Diagnoses included schizophrenia, hypertension, and dementia. Review of the medical record for Resident #13 revealed an admission date of 06/15/22. Diagnoses included depression, dementia, and hyperlipidemia. Review of the medical record for Resident #15 revealed an admission date of 05/23/23. Diagnoses included schizophrenia, diabetes, and hyperlipidemia. Review of the medical record for Resident #19 revealed an admission date of 10/07/13. Diagnoses included depression, diabetes, and hyperlipidemia. Review of the medical record for Resident #44 revealed an admission date of 06/27/22. Diagnoses included osteoarthritis, depression, opioid dependence, tachycardia, and chronic pain syndrome. Interview on 05/30/23 at 8:25 A.M. with Resident #44 revealed the food was terrible. Observation of the tray line on 05/30/23 from 11:42 A.M. to 12:55 P.M. revealed a lunch menu of fried chicken, French fries, and mixed vegetables. As the tray line neared an end, the surveyor requested a test tray be prepared and placed on the 200-unit food cart. Observation was made as the test tray was prepared, placed on the cart at 12:47 P.M., and transported by Certified Dietary Manager (CDM) #204 to the 200-unit where it arrived at 12:51 P.M. The test tray remained on the cart in view of the surveyor, until all other trays were distributed to residents. The test tray was removed from the cart at 12:54 P.M. by CDM #204 who used a facility thermometer that confirmed the temperatures of the fried chicken and green beans were not at appropriate temperatures. The friend chicken read a temperature of 106 degrees Fahrenheit (F) and the green beans read at a temperature of 104 degrees F. The test tray did not contain French fries as the facility had no more available. CDM #204 revealed had the tray been for a resident, he would have ensured a different variety of potato was served. CDM #204 confirmed the temperatures were not considered palatable, and food temperatures should be 135 degrees or higher when it was served to the resident. Immediately following confirmation of the test tray temperatures, the surveyor taste-tested the fried chicken and green beans which were found to be lukewarm. CDM #204 also taste-tested the fried chicken and green beans and confirmed the findings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Rehabilitation and Nursing at Canal Pointe 145 Olive St Akron, OH 44310 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 0804 Level of Harm - Minimal harm or potential for actual harm Review of the policy titled Food Preparation Guidelines, dated 2023, revealed food should be palatable, attractive, and served at a safe and appetizing temperature. This deficiency represents non-compliance investigated under Complaint Number OH00142922. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Rehabilitation and Nursing at Canal Pointe 145 Olive St Akron, OH 44310 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, record review, interview, and review of the facility policy the facility failed to ensure meal and food preferences were honored. This affected five residents (#6, #7, #9, #15 and #19) of seven residents reviewed for food preferences. The facility census was 99. Findings include: Review of the medical record for Resident #6 revealed an admission date of 05/10/22. Diagnoses included schizophrenia, anxiety, diabetes, hyperlipidemia, and atrial fibrillation. Review of the physician's orders for May 2023 revealed Resident #6 was on a regular diet with double entrée. Review of the medical record for Resident #7 revealed an admission date of 06/17/15. Diagnoses included schizophrenia, diabetes, dementia, and insomnia. Review of the physician's orders for May 2023 revealed Resident #7 was on a regular diet with double entrée. Review of the medical record for Resident #9 revealed an admission date of 03/05/20. Diagnoses included schizophrenia, hypertension, and dementia. Review of the physician's orders for May 2023 revealed Resident #9 was on a regular diet with double entrée. Review of the medical record for Resident #15 revealed an admission date of 05/23/23. Diagnoses included schizophrenia, diabetes, and hyperlipidemia. Review of the physician's orders for May 2023 revealed Resident #15 was on a regular diet with double entrée. Review of the medical record for Resident #19 revealed an admission date of 10/07/13. Diagnoses included depression, diabetes, and hyperlipidemia. Review of the physician's orders for May 2023 revealed Resident #19 was on a regular diet with double entrée. Review of the lunch tray cards for Residents #6, #7, #9, #15 and #19 revealed a preference for a double entrée. The tray card for Resident #6 also revealed a dislike of potatoes, and the tray card for Resident #19 also revealed a dislike of chicken. Observation of the tray line on 05/30/23 from 11:42 A.M. to 12:55 P.M. revealed a lunch menu of fried chicken, French fries, and mixed vegetables. Certified Dietary Manager (CDM) #204 plated the meals and gave them to dietary aide #211. Interview at the time of the observation with CDM #204 confirmed he looked at the tray cards to ensure preferences are honored. He confirmed preferences were not honored for Residents #6, #7, #9, #15, and #19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Rehabilitation and Nursing at Canal Pointe 145 Olive St Akron, OH 44310 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 0806 Level of Harm - Minimal harm or potential for actual harm Interview on 05/30/23 at 4:00 P.M. with Registered Dietitian #20 confirmed residents who had a physician's order for double entree was a preference and not an order from the physician. Review of the policy titled Food Preparation Guidelines, dated 2023, revealed staff would accommodate preferences. Residents Affected - Some This deficiency is an incidental finding to Complaint Number OH00142922. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Rehabilitation and Nursing at Canal Pointe 145 Olive St Akron, OH 44310 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of the facility policy the facility failed to ensure the environment was maintained in a clean and sanitary manner. This affected four residents (#44, #73, #74, and #93) and had the potential to affect all 99 residents residing in the facility. Findings include: Review of the medical record for the Resident #44 revealed an admission date of 06/27/22. Diagnoses included osteoarthritis, depression, opioid dependence, tachycardia, and chronic pain syndrome. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had moderately impaired cognition. He required extensive assistance of two people for transfers, extensive assistance of one person for toilet use, limited assistance of one person for bed mobility, ambulation in and out of his room, dressing, and hygiene. He had no delusions, hallucinations, or behavioral concerns. Review of the medical record for Resident #73 revealed an admission date of 07/10/14. Diagnoses included diabetes, heart failure, hypertension, insomnia, and dementia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #73 was severely cognitively impaired. He required extensive assistance of two people for bed mobility and transfers, extensive assistance of one person for toilet use and hygiene, and limited assistance of one person for dressing and eating. Review of the medical record for Resident #74 revealed an admission date of 08/10/18. Diagnoses included diabetes, schizophrenia, and sleep apnea. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #74 was cognitively intact. He required limited assistance of one person for transfers and toilet use and supervision for bed mobility, dressing, eating, and hygiene. Review of the medical record for Resident #93 revealed an admission date of 06/24/22. Diagnoses included diabetes, heart failure, gout, and anxiety. Review of the quarterly MDS assessment dated [DATE] revealed Resident #93 was cognitively intact. He required limited assistance of one person for transfers, dressing, toilet use, and hygiene. He had no delusions or hallucinations. Observation and interview on 05/30/23 at 8:04 A.M. with Resident #93 revealed a large insect on the floor which the resident identified as a centipede. Registered Nurse (RN) #201 confirmed the observation and stepped on the centipede. Interview on 05/30/23 at 8:25 A.M. with Resident #44 revealed he felt the facility was filthy, and housekeeping did not clean enough. Observation of the environment on the 400-hall near the nurse's station on 05/30/23 at 1:50 P.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365259 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Divine Rehabilitation and Nursing at Canal Pointe 145 Olive St Akron, OH 44310 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 revealed multiple large pieces of debris. Interview at the time of the observation with RN #201 revealed the remnants were from lunch and removed the debris with a paper towel. Observation on 05/30/23 at 1:56 P.M. of Resident #73 and #74's bedroom revealed multiple large pieces of brown debris on the floor between the two beds. Resident #73 identified the debris as crumbs of chicken from lunch. Observation on 05/31/23 at 7:36 A.M. of Resident #73 and #74's bedroom revealed the same debris remained on the floor as what was observed on 05/30/23 at 1:50 P.M. The floor was also sticky with two or three footprints and many dark black spots ranging in size from approximately two to five inches. Interview at the time of the observation with Licensed Practical Nurse (LPN) #209 confirmed the debris and confirmed the floors were not clean. Interview on 05/31/23 at 7:36 A.M. with LPN #209 revealed the facility had a hard time keeping housekeepers, and there were times when routine cleaning was delayed on incomplete. Observation of the environment on the 400-hall near the nurse's station on 05/31/23 at 7:41 A.M. revealed multiple large pieces of debris and a white liquid on the floor. Interview on 05/31/23 at 10:29 A.M. with Director of Housekeeping #210 revealed housekeepers work 8:00 A.M. to 4:00 P.M. There was no one working outside of those hours, and the State Tested Nurse Aides (STNAs) were not helpful if cleaning needed done. He was aware housekeepers did not go back to rooms once they were cleaned and there were times common areas and resident rooms got dirty after housekeeping staff were gone for the day. Review of the facility policy titled, Routine Cleaning and Disinfection, dated 2023, revealed the facility would ensure routine cleaning to ensure a safe and sanitary environment. This deficiency represents non-compliance investigated under Complaint Number OH142922. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 7 of 7