Inspection·August 17, 2023

F 0580 07/25/23 to place the mattress for Resident #101 on the floor for safety. Level of Harm - Minimal harm or potential for actual harm This deficiency resulted from incidental findings during the investigation of Complaint Number OH00145424. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 2 of 5 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 08/17/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. Based on the observations and interviews with staff, the facility failed to ensure rooms for Resident #7 and #101 and the shower rooms on the third and fourth floors were maintained in a clean, sanitary manner. This affected two residents ( Resident #7 and #101) of three residents reviewed for physical environment in their rooms, and had the potential to affect all 47 residents (Resident #1, #2, #3, #8, #10, #11,#14, #17, #18, #19, #20, #21, #23, #24, #27, #29, #30, #37, #38, #40, #41, #45, #49, #50, #53. #55, #61, #63, #64, #68, #69, #71, #72, #74, #75, #76, #77, #78, #81, #86, #87, #89, #92, #94, #97, #99 and #100) on the third floor and all 27 residents ( Resident #4, #5, #13, #22, #25, #26, #28, #31, #33, #34, #39, #42, #48, #51, #52, #57, #58, #59, #73, #79, #88, #90, #91, #93, #96, #98, and #101) on the fourth floor where the shower rooms were located for use by those residents. The facility census was 101. Findings included: 1. Observation of the room of Resident #7 on 08/17/23 at 10:10 AM revealed the floor was dirty with dirt buildup around the perimeter of the room. There was an unidentifiable brown substance splashed up all over his dresser, the wall and floor behind his recliner and on his bed frame. Interview with State Tested Nursing Assistant #203 at this time revealed the facility was short housekeepers and her and the other aides do the best they can to clean. On 08/17/23 at 10:13 AM an interview with Licensed Practical Nurse (LPN)#201 verified the above concerns in the room of Resident #7. She stated they have had an ongoing issue with housekeepers and they were doing the best they could but the building was really big. 2. Observation in the room of Resident #101 on 08/16/23 at 10:25 A.M. revealed there was a large area on the floor in the middle of the room with something gray and sticky spilled on it, there was something brown spilled on the floor by the top right corner of the mattress he was currently lying on, which was directly on the floor, he had no bed in the room. There was dirt debris build-up along the wall around the top of his mattress. There was a sign on the door that stated to please deep clean this room. He was sleeping on a mattress on the floor with the right side against the wall and the left side had a mat on the floor. On 08/16/23 at 10:30 A.M. an interview with Housekeeper #205 revealed she was able to clean every room on her floor daily. She stated they were short housekeepers and only had one housekeeper per floor. Further Observation in the room of Resident #101 with LPN # 201 on 08/17/23 at 9:10 A.M. revealed his room still had the large area on the floor in the middle of the room with something gray and sticky spilled on it, there also was still something brown spilled on the floor by the top right corner of the mattress and there was still dirt debris build-up along the wall around the top of his mattress. LPN #210 verified these concerns at this time. 3. Observation on 08/16/23 at 10:05 A.M. revealed the third-floor shower room was dirty, there was mold on the shower tile and mold in the grout lines on the wall and around the base of the shower floor. There were clumps of hair on the shower wall, trash debris on the floor, the floor had a buildup of dirt, there was feces on the toilet lid and smeared in the toilet, and there was a yellow substance dried around the base of the toilet. The small shower had mold (easily wiped off) on the walls (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 3 of 5 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 08/17/2023 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 0584 and was dirty. Level of Harm - Minimal harm or potential for actual harm An interview at this time with LPN #200 verified the above concerns in the third-floor shower room. She stated the staff does not use the small shower. Residents Affected - Some 4. Observation on 08/16/23 at 10:20 A.M. revealed the fourth-floor shower room was dirty with trash debris on the floor. The small shower had trash debris laying all over the shower floor and the drain. An interview at this time with LPN # 201 verified the above concerns and stated it looked like someone dumped something down the drain and did not clean it up. This deficiency represents non-compliance investigated under Complaint Number OH00145424 and OH00145359. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 4 of 5 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 08/17/2023 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 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 and staff interview, the facility failed to store, prepare and serve food under sanitary conditions. This affected all residents in the facility, as there were no residents identified by the facility as receiving nothing by mouth (NPO). The facility census was 101. Findings included: Observations during the kitchen tour with Dietary Manger #600 on 08/16/23 at 10:35 A.M. revealed the following concerns: there were two black, three-tiered carts dirty with food debris and food splashed down the sides of them, the top of the plate warmer was dirty with food debris and dust, two metal carts for the oven pans were dirty with food splashed on them, two drink carts were dirty with dirt and food debris, and three trash cans in the food preparation area with no lids on them. An observation of the walk-in cooler revealed a bag of pepperoni, a quarter of a whole ham wrapped in plastic wrap, a plastic container of shredded cheddar cheese, a plastic container o shredded mozzarella cheese, a plastic container of shredded parmesan cheese, a plastic container of bacon bits and a half a tomato wrapped in plastic wrap were all not dated as to when they were opened. An interview at this time with the Dietary Manager #600 verified the above concerns. This deficiency resulted from incidental findings during the investigation of Complaint Number OH00145424. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 5 of 5