Inspection·November 30, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the facility policy titled, Safe Water Temperature, dated 02/23 revealed the facility would maintain appropriate water temperatures in resident care areas. 2. Observation of lunch service on 11/27/23 at 12:27 P.M. in the first-floor dining room revealed a cool temperature. The temperature in the dining room was 69 degrees Fahrenheit. The setting on the thermostat was set to cool and read 69 degrees Fahrenheit. Three residents, #67, #69 and #84 complained it was cold. There were 16 residents in the first-floor dining room. The temperature reading and settings on the thermostat were verified by the Director of Dining Services (DDS) #69. An interview on 11/30/23 at 08:56 A.M. with Maintenance Supervisor #18 revealed he does environmental rounds weekly and monthly. Weekly rounds check water temperatures, and air temperatures. A review of the policy titled, Safe and Homelike Environment that was undated revealed the facility will provide a safe, clean, comfortable and homelike environment. The definition of comfortable and safe temperature levels within the policy was defined as ambient temperature in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk for hypothermia/hyperthermia and is comfortable for residents. The policy also stated that the facility will maintain comfortable and safe temperature levels and strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 2 of 23 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 11/30/2023 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facilities policy review, the facility failed to follow their policy for abuse in regard to allegations of resident to resident abuse. This affected three residents (Residents #19, #48 and #103) of three reviewed for abuse. The facility census was 105. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 07/13/15. Diagnoses included cerebral infarction, schizoaffective disorder, anxiety and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. He required partial to moderate assistance for toileting and hygiene and used a wheelchair to ambulate. Review of the skin observation tool dated 10/17/23 and timed 5:30 A.M. revealed the residents' skin was intact. 2. Review the medical record for Resident #48 revealed an admission date of 07/25/23. Diagnoses included dementia, psychotic disorder and diabetes. Review of the quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired. He was independent in eating, oral hygiene, toileting showering, dressing and hygiene. 3. Review of the medical record for Resident #103 revealed an admission date of 10/16/23 and a discharge date of 11/15/23. Diagnoses included dementia, bipolar disorder, epilepsy and depression. Review of the psychiatric progress note dated 10/17/23 and timed 9:28 P.M. revealed the resident had been increasingly agitated and physically aggressive with peers, was picking fights with other residents and punched his peer who was sitting in a wheelchair three times and kicked at him once. Review of the Application for Emergency admission dated 10/17/23 revealed the resident was picking fights with other residents and punched his peer who was sitting in a wheelchair three times and kicked at him once and needed inpatient psychiatric stabilization. Interview on 11/28/23 at 1:33 P.M. with Resident #103's daughter revealed the resident used to be a boxer. She revealed the facility called her on 10/17/23 and reported the resident hit another resident and was being sent to the hospital for a psychiatric evaluation. Interview on 11/29/23 at 9:26 A.M. with the Director of Nursing (DON) revealed he was at the facility when the incident occurred and was aware Resident #19 had thrown punches, but was unsure if any contact was made. He revealed there were no injuries as a result of the incident. Interview on 11/29/23 at 1:14 P.M. with State Tested Nurse Aide (STNA) #75 revealed she was working at the time of the incident. She witnessed Resident #103 strike Resident #19 who sustained a right swollen eye as a result. She revealed he also struck Resident #48 in the stomach. Interview on 11/30/23 at 8:25 A.M. with Resident #19 revealed he was struck in the eye by a boxer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 3 of 23 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 11/30/2023 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 0607 about two months ago. He revealed one of the women who worked at the facility witnessed the incident. Level of Harm - Minimal harm or potential for actual harm Interview on 11/30/23 at 8:25 A.M. with Resident #48 revealed he could not provide any information relevant to the incident. Residents Affected - Few Review of the investigation of the incident provided by the facility revealed a statement from STNA #75 which revealed she witnessed Resident #103 strike Resident #19 and he had no injuries. The investigation revealed no evidence Resident #48 was assessed for injury. Review of the facility policy titled Abuse, neglect and exploitation, undated, revealed alleged violations observed or reported by staff and not yet investigated would be immediately investigated including identifying and interviewing all involved people including the alleged victim(s), perpetrator, witnesses and others who might have knowledge of the incident, and provide complete and thorough documentation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 4 of 23 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 11/30/2023 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facilities policy review, the facility failed to thoroughly investigate a witnessed incident of Resident to Resident abuse. This affected three Residents (Residents #19, #48 and #103) of three reviewed for abuse. The facility census was 105. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 07/13/15. Diagnoses included cerebral infarction, schizoaffective disorder, anxiety and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. He required partial to moderate assistance for toileting and hygiene and used a wheelchair to ambulate. Review of the skin observation tool dated 10/17/23 and timed 5:30 A.M. revealed the residents' skin was intact. 2. Review the medical record for Resident #48 revealed an admission date of 07/25/23. Diagnoses included dementia, psychotic disorder and diabetes. Review of the quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired. He was independent in eating, oral hygiene, toileting showering, dressing and hygiene. 3. Review of the medical record for Resident #103 revealed an admission date of 10/16/23 and a discharge date of 11/15/23. Diagnoses included dementia, bipolar disorder, epilepsy and depression. Review of the psychiatric progress note dated 10/17/23 and timed 9:28 P.M. revealed the resident had been increasingly agitated and physically aggressive with peers, was picking fights with other residents and punched his peer who was sitting in a wheelchair three times and kicked at him once. Review of the Application for Emergency admission dated 10/17/23 revealed the resident was picking fights with other residents and punched his peer who was sitting in a wheelchair three times and kicked at him once and needed inpatient psychiatric stabilization. Interview on 11/28/23 at 1:33 P.M. with Resident #103's daughter revealed the resident used to be a boxer. She revealed the facility called her on 10/17/23 and reported the resident hit another resident and was being sent to the hospital for a psychiatric evaluation. Interview on 11/29/23 at 9:26 A.M. with the Director of Nursing (DON) revealed he was at the facility when the incident occurred and was aware Resident #19 had thrown punches, but was unsure if any contact was made. He revealed there were no injuries as a result of the incident. Interview on 11/29/23 at 1:14 P.M. with State Tested Nurse Aide (STNA) #75 revealed she was working at the time of the incident. She witnessed Resident #103 strike Resident #19 who sustained a right swollen eye as a result. She revealed he also struck Resident #48 in the stomach. Interview on 11/30/23 at 8:25 A.M. with Resident #19 revealed he was struck in the eye by a boxer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 5 of 23 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 11/30/2023 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 0610 about two months ago. He revealed one of the women who worked at the facility witnessed the incident. Level of Harm - Minimal harm or potential for actual harm Interview on 11/30/23 at 8:25 A.M. with Resident #48 revealed he could not provide any information relevant to the incident. Residents Affected - Few Review of the investigation of the incident provided by the facility revealed a statement from STNA #75 which revealed she witnessed Resident #103 strike Resident #19 and he had no injuries. The investigation revealed no evidence Resident #48 was assessed for injury. Review of the facility policy titled Abuse, neglect and exploitation, undated, revealed alleged violations observed or reported by staff and not yet investigated would be immediately investigated including identifying and interviewing all involved people including the alleged victim(s), perpetrator, witnesses and others who might have knowledge of the incident, and provide complete and thorough documentation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 6 of 23 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 11/30/2023 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 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 observation, record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for one resident (Resident #9) regarding dental status. This affected one resident (Resident #9) of nine reviewed for assessments. The facility census was 105. Residents Affected - Few Findings include: Review of the medical record for Resident #9 revealed an admission date of 07/10/14. Diagnoses included diabetes, dysphagia, heart failure and dementia. Review of the quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired. He required extensive assistance of two people for bed mobility, transfers, dressing, toilet use and hygiene. He required supervision and set up help for eating. He had no broken or missing teeth. Review of the care plan dated 09/29/23 revealed the resident was at risk for oral problems to due some missing teeth. Interventions included a dental consult as needed, monitoring and reporting oral pain as needed and providing the resident with the necessary items to perform adequate oral care. Interview and observation on 11/28/23 at 2:18 P.M. with Resident #9 revealed he had several broken teeth in the bottom half of his mouth. Interview on 11/28/23 at 3:11 P.M. with Licensed Practical Nurse (LPN) #77 revealed she was not sure if the resident had all his natural teeth, or any broken teeth, but she confirmed the assessment and the care plan did not match. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 7 of 23 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 11/30/2023 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 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** Based on observation, interview, and record review, the facility failed to ensure anti-embolic stockings (stockings used to prevent swelling or blood clots) were applied as ordered. This affected one resident (Resident #77) of three reviewed. The facility census was 105. Residents Affected - Few Findings include: A review of resident records for Resident #77 revealed an admission date of 02/28/22. Pertinent diagnoses included epilepsy, alcohol dependence, alcoholic cirrhosis of liver, neuromuscular dysfunction of bladder, depression, hemiplegia, impulse disorder, cerebral infarction chronic embolism (blood clot), ileostomy, hypertension (high blood pressure) and bipolar disorder. Review of the November 2023 physician's order revealed Resident #77 had orders that included anti-embolic stockings on in the morning and off in the evening. A review of the quarterly Minimum Data Set, dated [DATE] revealed Resident #77 had moderately impaired cognition. On 11/28/23 at 12:00 P.M., an interview with Resident #77 revealed anti-embolic stockings were not on because staff can't find them. On 11/29/23 at 9:45 AM, an observation of Resident #77 revealed his anti-embolic stockings were not on as ordered. At the time of the observation, Licensed Practical Nurse (LPN) #64 verified the anti-embolic stockings were not on as ordered. Resident #77 stated the anti-embolic stockings had not been applied for months. LPN #64 verified the statement by Resident #77 at the time of the observation. On 11/29/23 at 10:00 AM, a review of the treatment administration records dated 11/01/23 through 11/29/23 with Licensed Practical Nurse (LPN) #64 revealed the anti-embolic stockings were signed off for as being applied and removed on 11/28/23. The anti-embolic stockings were signed off for as being applied and removed daily for the entire month. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 8 of 23 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 11/30/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observations, review of the medical record, and interviews with staff the facility failed to ensure fall intervention were in place for Resident #26. This affected one resident (Resident #26) of six reviewed for accidents. The facility census was 105. Findings included: Review of the medical record revealed Resident #26 was admitted to the facility on [DATE]. Diagnoses alcohol dependence, seizures, chronic obstructive pulmonary disease, heart failure, anemia, psychoactive substance abuse, cerebral infarction, abnormal aortic aneurysm, schizoaffective disorder, peripheral vascular disease, anxiety disorder, depression, dementia, hypertension, COVID-19, mood disorder, and left leg amputation. Review of the annual Minimum Data Set assessment dated [DATE] revealed Resident #26 had moderately impaired cognition and he required limited assistance of one staff member for transfers. He has had no falls. Review of the physician's orders revealed Resident #26 had an order for a mat to the floor dated 10/06/23. Review of the fall risk evaluation dated 10/09/23 revealed Resident#26 was at risk for falls. Review of the plan of care dated 08/18/23 with a revision date of 11/16/23 revealed Resident #26 had an actual fall secondary to impaired physical functioning, he had unsteady gait, poor balance, and amputation. Interventions included to put his bed up against the wall to increase floor space, encourage resident to toilet prior to bed, encourage bed in the lowest position, encourage the resident to be at the nurses station when up, mat to the floor at bedside while in bed, therapy consults, and sign in the room to call for assistance. Observation on 11/27/23 at 11:12 A.M. revealed Resident #26 was in bed sleeping. The left side of his bed was against the wall. His floor mat was not on the floor on the open side of the bed. It was folded up against the wall. Observation on 11/28/23 at 8:45 A.M. revealed Resident #26 was in bed sleeping. The left side of his bed was against the wall. His floor mat was not on the floor on the open side of the bed. It was folded up against the wall. On 11/28/23 at 8:47 A.M. an interview Licensed Practical Nurse #107 verified Resident #26 did not have his floor mat on the floor on his open side of the bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 9 of 23 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 11/30/2023 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 facilities policy review, the facility failed to ensure pre and post dialysis assessments and vitals and weights were obtained as ordered for one resident (Resident #98). This affected one resident (Resident #98) of one review for dialysis services. The facility census was 105. Residents Affected - Few Findings include: Review of the medical record for Resident #98 revealed an admission date of 08/31/23. Diagnoses included respiratory failure, depression, chronic kidney disease, anemia, diabetes, dementia. and heart failure. Review of the physician's orders for November 2023 revealed an order for pre and post dialysis vitals and weights once per day on Mondays, Wednesdays and Fridays. Review of the quarterly Minimum Data Set assessment (MDS) dated [DATE] revealed the resident was severely cognitively impaired. She required extensive assistance of one person for dressing and hygiene, limited assistance of one person for toileting and supervision of one person for bed mobility and transfers. She was on dialysis. Review of the care plan dated 09/25/23 revealed the resident received renal dialysis on Mondays, Wednesdays and Fridays. Interventions included monitoring for changes in intake, labs, skin status and tolerance for dialysis sessions, weights per current orders, and a regular diet. Further review of the medical record revealed the Resident attended dialysis on 09/04/23, 09/06/23, 09/08/23, 09/11/23, 09/13/23, 09/15/23, 9/18/23, 09/20/23, 09/22/23, 09/25/23, 09/27/23, 09/29/23, 10/02/23, 10/04/23, 10/06/23, 10/09/23, 10/11/23, 10/13/23, 10/16/23, 10/18/23, 10/20/23, 10/23/23, 10/25/23, 10/27/23, 10/30/23, 11/01/23, 11/03/23, 11/06/23, 11/08/23, 11/10/23, 11/13/23, 1/15/23, 11/17/23, 11/20/23, 11/22/23, 11/24/23 and 11/27/23. There was no evidence the resident was assessed before or after dialysis treatments. Review of the Residents' vitals revealed pre dialysis vitals and weights were obtained 09/06/23, 09/11/23, 09/18/23, 09/20/23, 09/22/23, 09/25/23, 09/27/23, 10/02/23, 10/04/23, 10/09/23, 10/11/23, 10/20/23, 10/23/23, 10/30/23, 11/01/23, 11/03/23, 11/06/23, 11/10/23, 11/13/23, 11/17/23, 11/24/23 and 11/27/23. Post dialysis vitals and weights were obtained on 9/04/23, 9/20/23, 09/22/23, 09/25/23, 09/27/23, 10/02/23, 10/04/23, 10/09/23, 10/20/23, 10/25/23, 10/27/23, 10/30/23, 11/03/23, 11/06/23, 11/10/23, 11 to 1523, 11/17/23, 11/22/23 and 11/27/23. Interview on 11/30/23 at 9:30 AM with the Director Of Nursing (DON) confirmed pre and post dialysis assessments were not done and vitals and weights were not obtained both before and after dialysis for Resident #98. Review of the facility policy titled Hemodialysis undated, revealed the facility would provide necessary care and treatment for the provision of dialysis to following physician's orders and monitoring for complications before and after dialysis treatments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 10 of 23 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 11/30/2023 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, review of the pharmacy recommendation, interview with staff, and review of facilities policy, the facility failed to ensure pharmacy recommendation were addressed and implemented timely. This affected one resident ( Resident #26) of five reviewed for unnecessary medications. The facility census was 105. Findings included: Review of the medical record revealed Resident #26 was admitted to the facility on [DATE]. Diagnoses alcohol dependence, seizures, chronic obstructive pulmonary disease, heart failure, anemia, psychoactive substance abuse, cerebral infarction, abnormal aortic aneurysm, schizoaffective disorder, peripheral vascular disease, anxiety disorder, depression, dementia, hypertension, COVID-19, mood disorder, and left leg amputation. Review of the annual Minimum data set assessment dated [DATE] revealed Resident #26 had moderately impaired cognition and he was administered an anti-psychotic medication seven days a week. Review of the November 2023 physician's orders revealed Resident#26 had orders for haloperidol 2.0 milligrams three times daily for restlessness and paliperidone 6.0 milligrams at bedtime related to mood disorder. Review of the Pharmacy Recommendation dated 10/22/23 revealed Resident # 26 was receiving Invega, an antipsychotics, without any Abnormal Involuntary Movement Scale (AIMS) testing done. The pharmacist suggested to have nursing complete an AIMS test at the earliest convenience. The physician agreed (no date as to when he signed the recommendation) however, the AIMS testing was never completed. It was completed during the survey on 11/29/23. On 11/29/23 at 1:51 P.M. an interview with the Director of Nursing revealed the facility did not do AIMS testing routinely, he stated they only did the testing if they believe the resident was demonstrating side effects. He stated he was going to initiate them and use them more frequently. He verified the pharmacy recommendation was not addressed timely on 10/22/23 and they just did he AIMS testing on 11/29/23 after realizing it was not addressed yet. Review of the undated facility policy titled,Use of Psychotropic Medication, revealed resident were not given psychotropic drugs unless the medication was necessary to treat a specific condition, as diagnosed and documented in the clinical record, the medication was beneficial to the resident as demonstrated by monitoring and documentation of the resident's response to the medication. Residents who receive a antipsychotic medication would have a Abnormal Involuntary Movement Scale (AIMS) test performed on admission, quarterly, with a significant change in condition, change in antipsychotic medication, as needed and as per facility policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 11 of 23 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 11/30/2023 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facilities policy review, the facility failed to ensure nonpharmacological interventions were in place prior to administering as needed (prn) pain medication and failed to ensure parameters were in place to determine which type of pain medication to administer. This affected one resident (Resident #53) of six reviewed for unnecessary medications. The facility census was 105. Residents Affected - Few Findings include: Review of the medical record for Resident #53 revealed an admission date of 01/25/23. Diagnoses included chronic obstructive pulmonary disease, heart disease, diabetes, depression, Absence of left leg below knee, hepatitis and generalized muscle weakness. Review of the physicians orders for November 2023 revealed an order for Norco (an opioid medication used to treat moderate to severe pain) 5-235 milligrams (mg) one tablet by mouth (po) every 12 hours prn for pain and Tylenol 1000 mg every eight hours as needed for pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact. He required supervision and set up help for bed mobility, transfers, hygiene, toileting and dressing. Review of the Medication Administration Record (MAR) for August 2023 revealed the resident received prn Norco on 08/16/23 one time for a pain level of 4, 08/17/23 one time for pain level of 6, twice on 08/20/23 for pain level of 5, 08/22/23 one time for pain 8, 08/23/23 time for a pain level of 8, 08/24/23 one time for pain level of 8, 08/26/23 one time for a pain level of 6, 08/27/23 one time for a pain level of 8 and 08/28/23 one time for pain level 6. Review of the MAR for September 2023 revealed the resident received prn Norco on 09/01/23 one time for pain level of 8, 09/02/23 one time for pain level of 8, 09/05/23 one time for a pain level of 8, 09/09/23 one time for a pain level of 8, 09/10/23 one time for pain level of 8, 09/12/23 one time for pain level of 6 and one time for pain level of 9, 09/15/23 one time for pain level of 8, 09/19/23 one time four pain level of 7, 09/22/23 one time for pain level of 6, 09/23/23 one time for a pain level of 8 and 09/24/23 one time for a pain level of 4. Review of the MAR for October 2023 revealed the resident received prn Norco 10/22/23 one time for a pain level of 7. Further review of the medical record revealed no evidence the facility had attempted non pharmacological interventions prior to administering prn Norco. Interview and observation on 11/28/23 at 2:24 PM revealed Resident #53 was sitting on his bed using his cell phone. He reported no pain or discomfort at the time. Interview and observation on 11/29/23 at 8:18 AM revealed Resident #53 was lying in bed watching TV and had no complaints of pain. Interview on 11/29/23 at 9:21 AM with the Director Of Nursing (DON) revealed it depended on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 12 of 23 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 11/30/2023 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pain level reported by the resident as to whether or not the facility would attempt non pharmacological interventions or just administer pain medication. He could not explain what level of pain word substantiate the need for pain medicine to be administered. He confirmed non pharmacological interventions were not always documented. Interview on 11/29/23 at 2:51 PM with the DON revealed the facility did not do non pharmacological interventions and the residents typically asked for and received whatever pain medication they wanted. Review of the facility policy titled Pain Management undated, revealed non pharmacological interventions including but not limited to environmental comfort measures, physical repositioning and cognitive or behavioral interventions would be attempted as part of pain management and lower doses of medication would initially be administered before titrating upward. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 13 of 23 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 11/30/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facilities policy review, the facility failed to ensure one resident (Resident #97) had a diagnosis for a prescribed antipsychotic. This affected one resident (Resident #97) of six reviewed for unnecessary medications. The facility census was 105. Findings include: Review of the medical record for Resident #97 revealed an admission date of 10/18/23. Diagnoses included depression, anxiety, substance abuse and cardiac arrest. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. He needed partial to moderate assistance with showering, set up assistance for hygiene and was independent and eating. Review of the physicians orders for November 2023 revealed an order for Zyprexa (an antipsychotic medication) 5 milligrams (mg) once per day for depression. Interview on 11/29/23 at 2:44 PM with the Director of Nursing confirmed the resident did not have an appropriate diagnosis for Zyprexa. Review of the facility policy titled Psychotropic drug use undated, revealed the facility would ensure psychotropic drugs were used for the correct reason, and with the appropriate diagnosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 14 of 23 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 11/30/2023 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 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 observation, record review, interview, and facilities policy review, the facility failed to ensure Resident #63's, Resident #74's and Resident #95's medications were administered as ordered by the physician causing a medication error rate of 45 percent. This affected three ( Resident #63,#74, and #95) out of five residents observed during medications administration. The facility census was 105. Residents Affected - Few Findings include: 1. Resident #63 was admitted on [DATE] with diagnoses including urinary tract infection, acute kidney failure, uropathy, depression, emphysema, gastroesophageal reflux disease, shortness of breath, quadriplegia, high blood pressure, osteoarthritis, pulmonary nodule, anemia, lumbago with sciatica nerve pain, chronic fatigue, alcohol abuse, psychoactive substance use. Resident #63's plan of care initiated on 09/20/23 indicated interventions to administer medications as ordered by the physician to manage his diagnosis of high blood pressure, gastroesophageal reflux disease, symptoms of dehydration and shortness of breath. Resident #63's physician orders dated 11/01/23 to 11/30/23 indicated to administer the following medications, daily at 9:00 A.M.: -amlodipine besylate 5 milligrams (mg) one time of day orally for high blood pressure. -ferrous fumerate 324 mg one time of day orally for supplement. -folic acid 1 mg one time of day orally for supplement. -lisinopril 20 mg one time of day orally for high blood pressure. -magnesium oxide 400 mg one time of day orally for supplement. -potassium chloride extended release 10 milliequivalents (mEq) one time of day orally for high blood pressure. -vitamin B1 one tablet orally one time of day. -vitamin B12 500 mg one time of day orally for supplement. -vitamin D3 25 mg one time of day orally for supplement. An observation of Registered Nurse (RN) #79 administer medications to Resident #63 on 11/28/23 at 8:01 A.M. revealed the magnesium oxide, Vitamin B12 and Vitamin D3 medications listed above were not administered. A review of Resident #63 Medication Administration Record (MAR) dated 11/01/23 to 11/30/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 15 of 23 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 11/30/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm indicated RN #79 had documented she had administered the magnesium oxide, vitamin B12 and vitamin D3 medications during the medication administration scheduled for 9:00 A.M. on 11/28/23. An interview with RN #79 on 11/28/23 at 10:10 A.M. verified the above findings and stated she thought she had administered all the medications to Resident #63 that were scheduled at 9:00 A.M. on 11/28/23. Residents Affected - Few 2. Resident #74 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, cerebrovascular disease with encysted hydrocele (fluid collection along the spermatic cord), dementia, atherosclerotic heart disease, chest pain, malnutrition, kidney stones, anxiety, depression, dementia with mood disturbance, autonomic neuropathy, hyperlipidemia, osteoarthritis, eye disease, amnesia, prostate cancer, affective mood disorder, and ulnar nerve lesion. Resident #74's plan of care initiated on 02/10/23 indicated the administer medications as ordered by the physician to manage his alteration in fluid balance, allergic reactions, behavioral symptoms, impaired cognitive function, impaired dentition, anticoagulation, pain level, mood disorder, chronic obstructive pulmonary disease. A review of Resident #74's physician orders dated 11/01/23 to 11/30/23 indicated to administer the following medications every day, scheduled to administer at 8:00 A.M. or 9:00 A.M.: - aspirin 81 mg orally once a day to prevent deep vein thrombosis. - duloxetine hydrochloride delayed release 30 mg orally once a day for depression. - finasteride 5 mg orally once a day for benign prostatic hypertrophy. - flonase suspension 50 micrograms/actuation (mcg/act) one spray in each nostril one time of day for allergies. - lasix 40 mg one time of day orally for edema. - provera 5 mg orally one time of day for sexual behavior. - tagamet HB (heart burn) 200 mg administer two tablets orally once a day for sexual behaviors. - thera M (multiple vitamin with minerals) administer one tablet once a day for vitamin deficiency. - fenobibrate 145 mg orally one a day for hypertriglyceride. - ativan 0.5 mg orally two times a day for anxiety. - colace 100 mg administer two tablets twice a day for constipation. - carvedilol 3.125 mg orally two times a day for high blood pressure. - eliquis 5 mg orally two times a day for deep vein thrombosis. - lamictal 50 mg orally two times a day for mood disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 16 of 23 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 11/30/2023 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 0759 - lyrica 150 mg orally every 12 hours for neuropathy. Level of Harm - Minimal harm or potential for actual harm - Tylenol 325 mg administer 2 tablets three times a day for pain. Residents Affected - Few An observation on 11/28/23 at 8:15 A.M. of RN #79 administer Resident #74's medications listed above revealed she did not administer the provera, Thera M, Tagamet, Colace, and Tylenol medications listed above. A review of Resident #74's Medication Administration Record (MAR) dated 11/01/23 to 11/30/23 indicated RN #79 had documented she had administered the provera, Thera M, Tagamet, Colace, and Tylenol medications during the medication administration scheduled for 8:00 A.M. or 9:00 A.M. on 11/28/23. An interview with RN #79 on 11/28/23 at 10:10 A.M. verified the above findings and stated she thought she had administered all the medications to Resident #74 that were scheduled at 8:00 A.M. or 9:00 A.M. on 11/28/23. 3. Resident #95 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, fractured right radial styloid process, anxiety, alcohol induced disorder, chronic hepatitis C, chronic pain, and cancerous neuroendocrine tumors. Resident #95's plan of care initiated on 08/07/23 indicated intervention to administer medications to manage aggressive behaviors, and on 09/08/23 administer medications to manage anxiety, depression, pain level, and chronic obstructive pulmonary disease. Resident #95's physician orders dated 11/01/23 to 11/30/23 indicated to administer the following medications at 8:00 A.M. or 9:00 A.M.: - folic acid 1 mg orally once a day for supplement. - magnesium oxide 400 mg once a day orally for supplement. - thiamine hydrochloride 100 mg orally once a day for alcohol-induced disorder. - sertraline hydrochloride 50 mg orally once a day for anxiety. - buspirone hydrochloride 5 mg orally once a day for anxiety. - ibuprofen 600 mg orally twice a day for pain. - risperdal 0.5 mg orally twice a day for psychosis. - Anoro Ellipta 62.5-25 mcg/act aerosol powder, breath activated one puff orally one time of day for shortness of breath. A review of Resident #95's Medication Administration Record (MAR) dated 11/01/23 to 11/30/23 indicated RN #79 had documented she had administered the magnesium oxide, thiamine, Anoro Ellipta medications as listed above during the medication administration scheduled for 8:00 A.M. or 9:00 A.M. on 11/28/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 17 of 23 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 11/30/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An observation on 11/28/23 at 8:17 A.M. of RN #79 administer medications to Resident #95 revealed she did not administer the magnesium oxide, thiamine, Anoro Ellipta medications to Resident #95 as listed above. An interview with RN #79 on 11/28/23 at 10:10 A.M. verified the above findings and stated she thought she had administered all the medications to Resident #95 that were scheduled at 8:00 A.M. and 9:00 A.M. on 11/28/23. A review of the facility policy and procedure titled Medication Administration (undated) indicated medications were administered by licensed staff who were legally authorized to do so in the state of Ohio, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The explanation and compliance guidelines included the licensed staff to compare the medication source with MAR to verify resident name, medication name, form, dose, route, and time. Administer medications within 60 minutes of the scheduled time unless otherwise ordered by the physician. Observe resident consume the medication(s), wash hands and sign/document the administration on the resident's MAR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 18 of 23 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 11/30/2023 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview the facility failed to store flour in a manner to prevent contamination. This had the potential to affect all 105 residents in the facility. The facility census was 105. All residents receive meals from the kitchen. Findings Included: On 11/27/23 at 9:00 A.M. a tour of the kitchen with the Director of Dining Services (DDS) #69 revealed two styrofoam cups in the flour bin. This was verified by DDS #69 at the time of the kitchen tour. A review of the policy titled, Food Safety Requirements that was undated revealed the definition of contamination is the unintended presence of potentially harmful substances including, but not limited to microorganisms, chemicals, or physical objects. It also revealed that food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of food to the resident. Elements of the process include storage of food in a manner that helps prevent the deterioration or contamination of the food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 19 of 23 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 11/30/2023 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 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on record review and interview, the facility failed to submit complete and accurate staffing information for the Payroll-Based Journal (PBJ) report to Centers for Medicare and Medicaid Services (CMS) for the third fiscal quarter of 2023. This had the potential to affect all 105 residents in the facility. Findings include: Review of [NAME] PBJ Staffing data report revealed facility triggered for low weekend staffing and one star staffing for Quarter Three of the fiscal year 2023. Interview on 11/30/23 at 10:05 A.M. with Administrator revealed he did research with the corporate/home office and determined this was a reporting error. The hours were not added for some agency nursing staff for that period as well as some nursing managers who worked the weekends, which was not included in the corporate PBJ report sent into CMS. On 11/30/23 at 10:11 A.M. the Administrator sent a follow up email to this surveyor confirming that after additional research the Administrator had found the submitter of the PBJ staffing information submitted to CMS did not include the agency staffing and the weekend managers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 20 of 23 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 11/30/2023 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 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** 2. Review the personnel records for State Tested Nurses Aide (STNA) #70 revealed a hire date of 08/05/22. There was no evidence a tuberculosis test was administered before her hire date for 2023. Residents Affected - Some Review the personnel records for STNA #75 revealed a hire date of 06/09/22. There was no evidence a tuberculosis test was administered before her hire date for 2023. Interview on 11/30/23 at 11:15 A.M. with the Director of Nursing (DON) confirmed the TB tests were not administered timely. Review of the facility policy titled Tuberculosis Risk Assessment Worksheet dated 03/02/23, revealed screening of employees for TB infection on would occur annually. Based on observation, record review, interview and review of facility policy the facility failed to ensure staff washed their hands to prevent possible cross contamination of germs during medication administration for four (Resident #63, Resident #74, Resident #85, and Resident #95) out of six residents observed during medication administration and failed to ensure all employees were administered a baseline Tuberculosis (TB) test . This had the potential to affect all 105 residents in the facility. Findings include: 1. Resident #63 was admitted on [DATE] with diagnoses including urinary tract infection, acute kidney failure, uropathy, depression, emphysema, gastroesophageal reflux disease, shortness of breath, quadriplegia, high blood pressure, osteoarthritis, pulmonary nodule, anemia, lumbago with sciatica nerve pain, chronic fatigue, alcohol abuse, psychoactive substance use. Resident #63's plan of care initiated on 09/20/23 indicated interventions to administer medications as ordered by the physician to manage his diagnosis of high blood pressure, gastroesophageal reflux disease, symptoms of dehydration and shortness of breath. 2. Resident #74 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, cerebrovascular disease with encysted hydrocele (fluid collection along the spermatic cord), dementia, atherosclerotic heart disease, chest pain, malnutrition, kidney stones, anxiety, depression, dementia with mood disturbance, autonomic neuropathy, hyperlipidemia, osteoarthritis, eye disease, amnesia, prostate cancer, affective mood disorder, and ulnar nerve lesion. Resident #74's plan of care initiated on 02/10/23 indicated the administer medications as ordered by the physician to manage his alteration in fluid balance, allergic reactions, behavioral symptoms, impaired cognitive function, impaired dentition, anticoagulation, pain level, mood disorder, chronic obstructive pulmonary disease. 3. Resident #95 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, fractured right radial styloid process, anxiety, alcohol induced disorder, chronic hepatitis C, chronic pain, and cancerous neuroendocrine tumors. Resident #95's plan of care initiated on 08/07/23 indicated intervention to administer medications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 21 of 23 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 11/30/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to manage aggressive behaviors, and on 09/08/23 administer medications to manage anxiety, depression, pain level, and chronic obstructive pulmonary disease. 4. Resident #85 was admitted on [DATE] with diagnoses including schizoeffective disorder, chronic obstructive pulmonary disease, obesity, hyperlipidemia, alcohol abuse, obstructive sleep apnea, asthma, mood disorder, insomnia, depression, diabetes mellitus, intellectual disabilities, anxiety and low back pain. Resident #85's plan of care initiated on 12/08/22 indicated to administer medications as ordered by the physician to manage diagnoses including depression, schizoeffective disorder, anxiety, mood disorder, pain, chronic obstructive pulmonary disease. On 04/04/23 the plan of care indicated to administer medications according to the physician order to manage behaviors. On 06/16/23 the plan of care indicated to administer medications as ordered by the physician to manage allergic reactions. An observation on 11/28/23 between 8:00 A.M. and 8:30 A.M. of Registered Nurse (RN) #79 administer medications to Resident #63, Resident #74, Resident #95, and Resident #85 revealed a failure to wash/sanitize her hands to prevent cross contamination of germs. RN #79 approached the medication cart to administer medications to Resident #63 on 11/28/23 at 8:01 A.M. RN #79 started dispensing the medications but did not wash/sanitize her hands prior to starting the task. After dispensing the medications in to a medication cup, RN #79 then poured a cup of water and placed her right index finger inside the cup holding the lip of the cup and carried the cup of water in to Resident #63's room. RN #79 proceeded to administer the medications and water to Resident #63. RN #79 exited the room and did not wash/sanitize her hands and approached the medication cart, tucked her hair behind her ears, and started to dispense medications to Resident #74 in a medication cup. RN #79 dispensed nine medications in a medication cup, and entered Resident #74's room. RN #79 administered Resident #74 the medications and exited the room without washing/sanitizing her hands. RN #79 then approached the medication cart and proceeded to dispense five medications in a medication cup to administer to Resident #95. RN #79 entered Resident #95's room and administered the medications to Resident #95. RN #79 exited Resident #95's room and did not wash/sanitize her hands. LPN #79 proceeded to gather Resident #85's medications from the medication cart and was asked to wash/sanitize her hands. RN #79 stated she had already dispensed a narcotic medication and could not wash her hands until after she had administered Resident #85 his medications. RN #79 proceeded to dispense the rest of Resident #85's medications in a medication cup and entered Resident #85's room without washing/sanitizing her hands and administered the medications to Resident #85. Immediately following the observation on 11/28/23 at 8:30 A.M. RN #79 verified she the above findings. A review of the facility policy and procedure titled Hand Hygiene (undated) indicated all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations in the facility. The policy explanation and compliance guidelines included the use of gloves does not replace hand hygiene. Perform hand hygiene prior to donning gloves, and immediately after removing the gloves, when hands are visibly dirty, hands are soiled with blood and/or body fluids, before and after eating, after using the restroom, exposure to infectious diseases, after caring for someone with infectious diarrhea, when coming on duty, between resident contact, after handling contaminated objects, before performing invasive procedures, before and after donning personal protective equipment, before preparing and handling medications, before and after handling clean or soiled dressings, linens etc., before performing resident care procedures, before and after care of residents in isolation precautions, after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365259 If continuation sheet Page 22 of 23 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 11/30/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete handling items potentially contaminated with blood, body fluids, secretions, or excretions, when moving from a contaminated body site to a clean body site, after assistance with personal bodily functions, after sneezing, coughing, and/or blowing or wiping nose, before going off duty and when in doubt. A review of the facility policy and procedure titled Medication Administration (undated) indicated medications were administered by licensed staff who were legally authorized to do so in the state of Ohio, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Event ID: Facility ID: 365259 If continuation sheet Page 23 of 23