Health inspection·September 13, 2021

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the care plan dated 06/01/21 revealed Resident #27 was incontinent of bowel and bladder. Interventions included pericare when incontinent, keep clean and dry and scheduled toileting every two hours. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had impaired cognition, required extensive assistance with bed mobility, transfers, toileting, and personal hygiene and was incontinent of bowel and bladder. Review of Resident #27's physician orders for August 2021 revealed an order for scheduled toileting every two hours. Observation on 09/01/21 at 9:41 A.M. of Resident #27, with Registered Nurse (RN) #525 revealed Resident #27 was wearing two incontinence liners inside an incontinence brief and a strong odor of urine was noted. RN #525 confirmed the observation and odor, and stated residents should not be wearing two liners with an incontinence brief. Interview with resident at time of observation revealed he was unable to state when he had last been provided with incontinence care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 2 of 17 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 365289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Lane Nursing and Rehabilitation 5425 High Mill Avenue NW Massillon, OH 44646 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to discard expired insulin. This affected one (Resident #3) of three residents (Resident #3, #13 and #30) reviewed for insulin medication in the 500 medication cart. The facility census was 150. Findings include: Medical record review of Resident #3 revealed an admission date of [DATE] with diagnoses including diabetes mellitus with hyperglycemia, visual loss of both eyes, and history of traumatic brain injury. Resident #3 had a physician's order dated [DATE] for Humalog 100 unit/milliliter (insulin) at breakfast, lunch and dinner per sliding scale. Review of the resident's medication administration record revealed the Humalog was administered as ordered. Observation on [DATE] at 9:44 A.M. of the medication cart on the 500 unit with Registered Nurse (RN) #517, revealed a bottle of Insulin Lispro (Humalog) was dated as opened on [DATE]. Interview with RN #517 at time of observation verified Resident #3's Insulin Lispro (Humalog) was dated as opened on [DATE]. RN #517 stated the insulin was only good for 28 days after being opened and was expired. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 3 of 17 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 365289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Lane Nursing and Rehabilitation 5425 High Mill Avenue NW Massillon, OH 44646 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 observations, interview, and review of manufacturer information for sanitizer use, the facility failed to prepare puree food under sanitary conditions. This affected 12 residents (Residents #14, #26, #36, #55, #56, #74, #88, #91, #105, #120, #127, and #142) of 12 residents who received puree diets. The facility identified 148 residents who received diets from the kitchen. Findings include: On 09/01/21 beginning at 9:30 A.M., [NAME] #411 was observed pureeing ham. From 9:34 A.M. to 9:35 A.M., [NAME] #411 was observed washing, rinsing and sanitizing the Robo Coup (food processor) canister, blades and lid. The items were shaken to remove excess water. [NAME] #411 returned to the food processor and pureed the scalloped potatoes. Between 9:38 A.M. and 9:40 A.M., [NAME] #411 washed, rinsed, and sanitized the canister, blades and lid. The items were shaken to remove excess water. [NAME] #411 returned to the food processor to puree corn. On 09/01/21 at 9:45 A.M., [NAME] #411 verified she shook the items to remove excess water and did not permit the items to air dry. On 09/01/21 at 9:46 A.M., Dining Services Director #412 verified the facility used Quat Clean sanitizer in the three compartment sink. Dining Services Director #412 verified the label on the sanitizer indicated in order to sanitize mobile items such as drinking glasses and utensils, the items were to be immersed for at least 60 seconds making sure to immerse completely, remove and let air dry. Review of the manufacturer guidelines for the Quat-Clean sanitizer indicated items were to be permitted to air dry. The facility identified Residents #14, #26, #36, #55, #56, #74, #88, #91, #105, #120, #127, and #142 as those residents who had orders for puree diets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 4 of 17 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 365289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Lane Nursing and Rehabilitation 5425 High Mill Avenue NW Massillon, OH 44646 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the administration used its resources effectively and efficiently to ensure comprehensive and effective infection control policies and practices were developed and implemented to prevent the spread of COVID-19. This affected all 150 facility residents. Residents Affected - Many Findings include: The facility failed to implement effective and recommended infection control practices and failed to use Personal Protective Equipment (PPE) appropriately to decrease the risk of the spread of Covid-19 within the facility. The facility did not effectively utilize PPE including disposable gowns, N95 respirator masks, and goggles/face shields while caring for residents, did not assure staff were completing appropriate hand hygiene while caring for residents, did not ensure a resident's guardian was notified when the resident refused to move to from a room with Covid- 19 positive resident, did not consistently and thoroughly screen visitors and staff for Covid -19, did not monitor visitation, and did not properly disinfect high touch areas including staff break rooms and common areas including handrails affecting all residents. Cross reference

F880. The facility failed to ensure communication with the medical director who was responsible for the implementation of care policies and coordination of the overall medical care in the facility to ensure all residents maintained their highest practicable physical and mental well-being. Interview on 08/31/21 at 4:21 P.M. with Medical Director #565 revealed he was not part of the Root Cause Analysis (RCA) regarding the current Covid-19 outbreak completed on 08/30/21 as documented by the facility. Medical Director #565 stated, I was not part of that meeting, I was not aware of it, I was never invited to attend any meeting yesterday. Medical Director #565 revealed he last spoke with the Director of Nursing (DON), A few weeks ago. Medical Director #565 revealed, At that time I told the DON, lock down, no visitors in the building, the residents are vaccinated, I believe the virus is being spread by visitors and staff. Medical Director #565 confirmed the last positive case of Covid-19 he was made aware of was 10 days ago, he was not made aware of any further cases. Record review revealed, after 08/20/20 there were 13 new residents that tested positive for Covid-19, Resident #43, #25, #88, #63, #22, #9, #105, #72, #96, #497, #119, #40, and #498. There were also 11 new staff members that tested positive for Covid-19 after 08/20/21, Occupational Therapist (OT) #564, Licensed Practical Nurse (LPN) #441, #450, #442, Registered Nurse (RN) #516, and State Tested Nursing Assistant (STNA) #471, #508, #468, #490, #503, and #477. Cross reference F880. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 5 of 17 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 365289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Lane Nursing and Rehabilitation 5425 High Mill Avenue NW Massillon, OH 44646 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on observation, record review, and interview, the facility failed to ensure identified concerns were timely and appropriately addressed through the Quality Assurance and Performance Improvement committee. This had the potential to affect all 150 residents residing at the facility. Findings include: During the annual survey, concerns related to infection control practices were identified, specifically the facility failed to implement effective and recommended use of Personal Protective Equipment (disposable gowns, N95 respirator masks, and goggles/face shields) while caring for residents to decrease the risk of the spread of Covid-19 within the facility. The facility did not assure staff were completing appropriate hand hygiene while caring for residents, did not ensure a resident's guardian was notified when the resident refused to move from a room with a resident who tested positive for Covid-19, did not consistently and thoroughly screen visitors and staff for Covid -19 and did not monitor visitation during the outbreak of Covid-19. The facility failed to properly disinfect high touch areas including staff break rooms and common areas including handrails. Cross reference F880. The facility failed to communicate with the medical director who was responsible for the implementation of care policies and coordination of the overall medical care in the facility to ensure all residents maintained their highest practicable physical and mental well-being. Interview on 08/31/21 at 4:21 P.M. with Medical Director #565 revealed he was not part of the Root Cause Analysis (RCA) (as documented by the facility) completed on 08/30/21. Medical Director #565 stated, I was not part of that meeting, I was not aware of it, I was never invited to attend any meeting yesterday. Medical Director #565 revealed he last spoke with the DON, A few weeks ago. Medical Director #565 revealed, At that time I told the DON, lock down, no visitors in the building, the residents are vaccinated, I believe the virus is being spread by visitors and staff. Medical Director #565 confirmed the last positive case of covid 19 he was made aware of was 10 days ago, he was not made aware of any further cases. Review of facility documentation of staff diagnosed with Covid-19 and date diagnosed revealed a COVID-19 outbreak started on: 07/20/21 when State Tested Nursing Assistant (STNA) #562 tested positive for COVID-19. Additional staff tested positive for Covid-19 as follows: 07/30/21 - Registered Nurse (RN) #563 and STNA #498 08/03/21 - STNAs #473 and #476 08/16/21 - Licensed Practical Nurse (LPN) #447 08/18/21 - STNA #469 08/20/21 - STNA #492 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 6 of 17 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 365289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Lane Nursing and Rehabilitation 5425 High Mill Avenue NW Massillon, OH 44646 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 0867 08/21/21 - Occupational Therapist #564 Level of Harm - Minimal harm or potential for actual harm 08/24/21 - LPN #441 and STNA #508 08/25/21 - LPN #450 and STNA #471 Residents Affected - Many 08/28/21 - STNAs #468 and #490 08/29/21 - LPN #442 08/30/21 - STNAs #502, #477 and RN #516 Review of the resident log for residents positive for Covid-19 and date diagnosed positive revealed: 08/11/21 - Resident #4, #64, #21 08/13/21 - Resident #499, 08/15/21 - Resident #46 08/18/21 - Resident #37, #42, #14, #82 08/20/21 - Resident #132, #34, #2, #35, #61, #15, #47 08/21/21 - Resident #72 08/22/21 - Resident #9, #96, #497 08/23/21 - Resident #43, #25 08/24/21 - Resident #88, #105, #119 08/27/21 - Resident #40 08/29/21 - Resident #63 08/31/21 - Resident #22, #498 Review of the facility log of positive Covid-19 residents confirmed eight residents (#40, #47, #72, #82, #96, #114, #119, and #497) resided on the 100-hall and were Covid-19 positive of the 24 residents residing on the hall. Ten residents (#2, #9, #15, #34, #35, #37, #42, #61, #105 and #132) resided on the 200-hall and were Covid-19 positive of the 21 residents residing on the hall. Ten residents (#4, #21, #22, #25, #43, #46, #63 #64, #88, and #499) resided on the 300-hall and were Covid-19 positive of the 25 residents residing on the hall. One resident (#498) resided on the 600-hall and was Covid-19 positive of the nine residents residing on the hall. During the Quality Assurance (QA) review on 09/07/21 at 12:44 P.M., the Administrator indicated infection control was not a problem identified prior to state entering the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 7 of 17 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 365289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Lane Nursing and Rehabilitation 5425 High Mill Avenue NW Massillon, OH 44646 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 - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Nursing Home Guidance from the Centers for Disease Control (CDC), review of the Centers for Medicare and Medicaid Services (CMS) Quality Safety and Oversight (QSO) Memo, review of the facility COVID-19 policy, observations and interviews, the facility failed to implement effective and recommended infection control practices to prevent the spread of COVID-19. This resulted in Immediate Jeopardy on 08/30/21 when the facility did not implement appropriate personal protective equipment (PPE) including disposable gowns, gloves, N95 respirator masks and goggles/face shields while caring for residents, did not ensure a resident who tested positive for COVID 19 (Resident #47) did not reside in a room with a resident who tested negative (Resident #126) without the guardian's knowledge. The facility failed to properly disinfect high touch areas including staff break rooms and common areas including handrails and failed to ensure appropriate hand hygiene. The lack of effective infection control practices to prevent the spread of COVID-19 placed all facility residents at risk for the likelihood of harm, complications/and or death. Facility census was 150. Residents Affected - Many On 08/30/21 at 4:25 P.M., the Administrator, Director of Nursing (DON), Licensed Practical Nurse (LPN) Infection Preventionist #525, Regional Nurse #559 and Regional Nurse #560 were notified the Immediate Jeopardy began on 08/30/21 when a widespread pattern of breaks in infection control by multiple staff were observed including improper screening of visitors and staff prior to entrance to facility, incorrect use of reusable isolation gowns, staff not wearing N95 respirator masks and eye protection, breaches in appropriate handwashing, cohorting of COVID-19 positive resident with COVID-19 negative resident without knowledge of guardian, and allowing open visitation during a COVID-19 outbreak. The Immediate Jeopardy was removed on 09/01/21 when the facility implemented the following corrective actions: • On 08/30/21 at 6:00 P.M. the DON educated non-nursing department heads, Maintenance Director #438, Director of Therapy #573, Director of Housekeeping and Laundry Services #430, Dietary Manager #412, Activities/admission and Marketing Director #417 and Social Service Director #532 on proper use of PPE including return demonstration on donning and doffing and hand hygiene. • On 08/30/21 between 6:15 P.M. and 6:30 P.M. the DON and non-nursing department heads educated all staff members and Oxygen Vendor #540 (in person and via phone). Staff members included all Management team members, all Registered Nurses (RN), all LPNs, all State Tested Nursing Assistants (STNAs), all Life Enrichment staff, all Housekeeping and Laundry, all Maintenance, all Dietary, and all Therapy staff. Education included proper use of PPE including proper use/wearing of masks, eye protection, gowns and donning/doffing PPE, hand hygiene between steps if hands become contaminated, immediately after removing all PPE, handwashing during meals, routine handwashing before and after touching contaminated objects, after removing gloves, and location of additional PPE if not available on the units. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 8 of 17 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 365289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Lane Nursing and Rehabilitation 5425 High Mill Avenue NW Massillon, OH 44646 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 - Immediate jeopardy to resident health or safety Return demonstration for proper use of PPE including how to don and doff, proper mask wearing, use of eye protection, and proper handwashing techniques will be conducted upon re-entry into the facility for all employees and contracted agency staff by the assigned 500-hall nurse and DON or designee. This will be tracked using an all-staff list and the employees name will be checked off the list once the return demonstration is properly completed. A PPE competency form will be completed during this demonstration. Agency staff will always report to the 500-hall nurse. Residents Affected - Many • Contracted staff and vendors will be educated upon entry into the facility by the 500-hall nurse. This will be monitored via a separate tracking log. • Audits will be conducted by Administrator, DON, or designee to ensure proper use of PPE including masks and eye protection on four to five staff members per day for all disciplines on all shifts the first month and then four to five times per week on all shifts for all disciplines for a total of four months. The results of the audits will be reviewed by the Quality Assurance Performance Improvement (QAPI) committee including Medical Director monthly to ensure and maintain compliance. • On 08/31/21 at 9:30 A.M., Resident #106's and Resident #126's resident representative or guardian were educated on the risks of remaining in a room with a COVID-19 positive resident including the possibility of hospitalization and death by Regional Director of Operations #560 and LPN Infection Preventionist #525. The two residents refused to move from their rooms after being educated on the risks of exposure and transmission and the possible outcomes that could occur. The physicians were notified, and the local Health Department was notified and stated continued co-habitation was appropriate. Moving forward the facility will ensure that any COVID-19 negative resident who refuses to move from a COVID-19 positive room and/or resident representative/guardian/family members will be thoroughly educated on the risks of exposure, transmission, and illness up to and including hospitalization and possible death by the administrator. Documentation of this education will be entered in the resident's clinical record. • On 08/31/21 at 11:00 A.M., the DON was educated by Director of Quality Assurance on how to communicate to Central Supply/ Housekeeping and Laundry Services Director #430 if demand for PPE increased for any reason IE. increase in isolation, increase in census, etc. • On 08/31/21 at 12:00 P.M., reusable gowns were taken out of use and replaced with disposable gowns. • On 08/31/21 at 2:00 P.M., Screener/STNA #566, was removed from screening and sent home due to failure to properly screen staff and visitors upon entry to the facility. Screener/STNA #566 was brought back into facility on 09/01/21 at 2:00 P.M. and given disciplinary action for failure to follow (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 9 of 17 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 365289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Lane Nursing and Rehabilitation 5425 High Mill Avenue NW Massillon, OH 44646 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 proper screening procedures by the Administrator. Level of Harm - Immediate jeopardy to resident health or safety • Residents Affected - Many On 08/31/21 at 2:00 P.M., all employees assigned to conduct screening were educated on proper screening procedures by Regional Administrator #575. The 500-hall nurse was assigned to be the designated screener on off hours. Any employee that will be assigned to conduct off hours screening will be educated by the Administrator, DON, or designee on proper screening procedures on their next assigned shift upon entry to the facility. • Audits were assigned to be conducted by Administrator or designee four to five times per day for the first month and then four to five times per week on all shift for a total of four months, to ensure proper screening procedures. The results of the audits will be reviewed by the QAPI committee including Medical Director monthly to ensure and maintain compliance. • On 08/31/21 at 6:00 P.M., Housekeeping and Laundry Services Director #430 were educated by the Administrator on how to conduct a daily PPE inventory, how to calculate the facility burn rate for all PPE supplies, and ordering additional supplies when needed. The PPE burn rate and daily inventory will be reported to Administrator and DON daily in morning meeting to ensure PPE levels remain compliant with need. The Administrator and DON will report compliance with PPE levels to QAPI committee monthly to ensure and maintain appropriate par levels. • On 08/31/21 at 6:00 P.M. all high touch surface areas were cleaned throughout the facility by housekeeping staff. • On 08/31/21 at 6:20 P.M. the Administrator notified all residents via letter and their families via email of the visitation policy and examples of what would qualify as a compassionate care visit. • On 09/01/21 at 11:00 A.M., the Director of Housekeeping #430 educated all housekeeping staff on appropriate cleaning procedures, definition of high touch areas, and frequency of cleaning high touch areas which is at least once per day or more often if necessary. • On 09/01/21 at 12:00 P.M., managers were educated by the DON that all compassionate care visits need to be approved by the DON to ensure they met all requirements of compassionate care visitation. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 10 of 17 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 365289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Lane Nursing and Rehabilitation 5425 High Mill Avenue NW Massillon, OH 44646 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 - Immediate jeopardy to resident health or safety Residents Affected - Many Audits will be conducted by Housekeeping Director #430 or designee four to five times per day for the first month and then four to five times per week on all shifts for a total of four months. The results of the audits will be reviewed by the QAPI committee including Medical Director monthly to ensure and maintain compliance. Although the Immediate Jeopardy was removed on 09/01/21, the facility remained out of compliance at Severity Level 2 (no actual harm with harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of facility documentation revealed a COVID-19 outbreak began on 07/20/21 when STNA #562 tested positive for COVID-19. On 08/30/21 there were 21 residents, who were positive for Covid 19. Eight of 24 residents residing on the 100-hall (Residents #40, #47, #72, #82, #96, #114, #119, and #497). Ten of 21 residents residing on the 200-hall (Residents #2, #9, #15, #34, #35, #37, #42, #61, #105 and #132). Three of 25 residents residing on the 300-hall (Residents #25, #63, and #88). Four residents expired with diagnoses including COVID-19 since the outbreak began (Residents #499, #46, #43, and #40). 1. Review of Resident #126's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, Alzheimer's disease and schizoaffective disorder, bipolar type. The resident was vaccinated for COVID-19 on 06/07/21 and 07/07/21. Review of Resident #126's MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition with a Brief Interview Mental Status (BIMS) score of 13. Resident #126 was COVID-19 negative. An Amended Letter of Guardianship form dated 06/23/14 indicated the resident had a guardian of person. Review of Resident #72's medical record revealed the resident was admitted on [DATE] with diagnoses including adult failure to thrive, unspecified dementia without behavioral disturbance and muscle weakness. The resident was vaccinated for COVID-19 on 04/15/21 and 05/13/21. Review of Resident #72's MDS 3.0 assessment dated [DATE] indicated the resident exhibited intact cognition with a BIMS score of 14. The resident was able to make his own decisions. A friend was listed as emergency contact number one. Review of Resident #72's physician orders revealed an order dated 08/21/21 indicating the resident was placed in droplet isolation precautions due to COVID-19 positive diagnosis. Review of a statement dated 08/21/21 revealed Resident #126 signed the statement indicating he was fully aware of the risks of continuing in the current room with a COVID-19 positive roommate (Resident #72). He accepted the risks and indicated he would like to continue to stay where he was. The statement indicated the risks and education had been given to him. The risks were not included on the statement and the resident's signature was not dated. Review of a progress note dated 08/30/21 at 12:34 P.M. revealed Resident #126 was questioned regarding changing rooms due to roommate (Resident #72) testing positive for COVID-19 on 08/19/21. The resident refused the room move. The resident was re-questioned on this date (08/30/21) and the resident continued to refuse. Further review of the medical record revealed no documentation of Resident #126's guardian being informed of the roommate's positive COVID-19 test or risks associated with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 11 of 17 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 365289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Lane Nursing and Rehabilitation 5425 High Mill Avenue NW Massillon, OH 44646 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 Resident #126 sharing a room with Resident #72. Level of Harm - Immediate jeopardy to resident health or safety Interview on 08/31/21 at 6:46 A.M. with the DON indicated the infection preventionist talked to Resident #126 about the risks and benefits of staying in a room with a COVID-19 positive roommate. The DON said the resident signed an agreement on 08/30/21 verifying the risks and benefits were explained to the resident. Residents Affected - Many Interview on 08/31/21 at 7:05 A.M. with LPN Infection Preventionist #525 indicated Resident #126's guardian was not notified because the resident's BIMS score was high enough that he was able to make his own decisions. LPN Infection Preventionist #525 also indicated she discussed the possible risks and benefits with Resident #126 including pneumonia, fevers, and respiratory sickness. Upon further questioning LPN Infection Preventionist #525 confirmed she told the resident of the possibility of hospitalization and death. Interview on 09/01/21 at 10:00 A.M. with Epidemiologist #567 revealed she had spoken with LPN Infection Preventionist #525 in the past regarding two residents, one COVID-19 positive (Resident #47) and one COVID-19 negative (Resident #106) residing in the same room. At that time, it was her understanding there was no other room available on the same hall for the exposed resident, so she suggested to quarantine the exposed resident in place to prevent the infection from spreading to additional halls. Epidemiologist #567 said it was her understanding from the DON that there would be consistent staffing on the unit where the COVID-19 residents were residing to assist in preventing the spread of COVID-19. Epidemiologist #567 confirmed she was not made aware of Resident #72 who was diagnosed positive for COVID-19 on 08/21/21 and was rooming with (Resident #126) who was negative for COVID-19. 2. Observation on 08/30/21 at 9:08 A.M. revealed STNA #487 (who was working on the 400 unit) coming out of a resident room with prescription glasses and no face shield or goggles. Interview with STNA #487 at the time of the observation indicated she started her shift at 7:00 A.M. and the goggles that were provided did not fit over her glasses so she could not wear them. STNA #487 indicated the facility did have a face shield available; however, the administrative staff did not bring her a face shield or bigger goggles. Observation and interview on 08/30/21 at 9:31 A.M. with Housekeeping/Laundry Supervisor #430 revealed she and the Corporate Central Supply person ordered facility supplies. The facility used disposable and re-washable gowns. There were two storage rooms for PPE, one on 100 hall in the supervisor office and one downstairs in the storage room. Observation of the storage unit downstairs revealed multiple stacked boxes of reusable gowns, two large boxes of disposable gowns, multiple boxes of masks, gloves, goggles, and face shields. Housekeeping/Laundry Supervisor #430 stated, We have never run out of PPE. Observation on 08/30/21 at 10:19 A.M. revealed LPN #454 on the 300-hall dementia unit in the hallway standing at the medication administration cart. LPN #454 was not wearing eye protection. Interview with LPN #454 at the time of the observation indicated there were five residents residing on the unit who were diagnosed as COVID-19 positive and on isolation precautions. She indicated the facility was supposed to bring her a pair of goggles to wear while she was on the unit. LPN #454 revealed she wore goggles while in COVID-19 positive rooms and stated she requested eye protection from the wound nurse. Interview on 08/30/21 at 10:23 A.M. with RN #517 indicated the facility did not have enough personal protective equipment (PPE), and the facility did not enforce mask use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 12 of 17 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 365289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Lane Nursing and Rehabilitation 5425 High Mill Avenue NW Massillon, OH 44646 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 - Immediate jeopardy to resident health or safety Residents Affected - Many Interview on 08/30/21 at 10:33 A.M. with LPN #543 revealed the facility did not have eye protection that fit her properly because she wore prescription glasses, and the eye protection available did not fit over her prescription glasses. LPN #543's eye protection was observed on the medication administration cart. Interview on 08/30/21 at 10:42 A.M. with LPN #454 revealed everyone on the 300-hall was supposed to be under quarantine and the residents with isolation carts outside of their rooms were positive for COVID-19 and on isolation. LPN #454 stated they did not wear face shields, gowns, or gloves with the other residents; full PPE was only used with COVID-19 positive residents. LPN #454 was wearing an N95 respirator mask and prescription glasses at the time of the interview. An observation of STNA #487 on 08/30/21 at 10:47 A.M. revealed STNA #487 was not wearing eye protection and was wearing an N95 respirator mask with the bottom strap of the mask hanging below her chin. Interview with STNA #487 at time of observation revealed the eye protection was so scratched that she could not see when wearing it and she could not secure the bottom strap of the N95 respirator mask correctly because of her hair braids. Observation and interview with LPN #447 on 08/30/21 at 11:01 A.M. revealed residents on isolation for COVID-19 had two gowns, hanging side by side, on the door, one for the nurse and one for the STNAs. LPN #447 did not know which gown was to be used by which staff member. The facility had no system to designate which gown belonged to which staff. At the end of the day two clean gowns were placed on the doors for the next shift. LPN #447 confirmed Residents #9, #34, #61 and #105's room doors only had one hook to hang the two gowns. The one hook had one gown on top of the other gown. LPN #447 stated, I know we are contaminating our clothes by putting those on every time we go in the room, they are hanging on top of each other, but what are we supposed to do? This is what they told us we have to do, I am worried about taking this home to my family, we are not doing it right and they know it. LPN #447 said when she cared for the other residents on the hall who were not COVID-19 positive, she did not wear a gown. Observation of LPN #447 on 08/30/21 at 11:43 A.M. revealed she took the top gown on the outside of Resident #34's door and entered the room which was a COVID-19 positive room. Observation on 08/30/21 between 11:20 A.M. and 12:00 P.M. revealed LPN #447 and STNA #494 distributing lunch trays. Goggles were not disinfected when LPN #447 and STNA #494 exited rooms of COVID-19 positive residents and prior to entering rooms of residents who had tested negative for COVID-19. Interview with LPN #447 and STNA #494 immediately after the observation verified, they had not disinfected their goggles after exiting rooms of COVID-19 positive residents. LPN #447 and STNA #494 indicated they did not clean their goggles until the end of their shift, both stated they were never told they were supposed to clean their eye protection at other times. Observation of Maintenance #436 on 08/30/21 at 12:14 P.M. revealed he was at the nursing station on the 100 hall making copies. Maintenance Director #436 was not wearing eye protection. Interview with Maintenance Director #436 at the time of the observation confirmed he was not wearing goggles or a face shield; he also indicated he usually implemented the eye protection. The 100 unit had both COVID-19 positive residents who were in isolation precautions and negative residents who were not in quarantine or isolation precautions. Interview on 08/30/21 at 12:15 P.M. with LPN #67 revealed there were no disposable gowns immediately available. LPN #67 reported staff reused washable gowns on each shift. LPN #67 indicated the PPE (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 13 of 17 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 365289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Lane Nursing and Rehabilitation 5425 High Mill Avenue NW Massillon, OH 44646 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 bins should be stocked with disposable gowns. Level of Harm - Immediate jeopardy to resident health or safety Observation on 08/30/21 at 12:47 P.M. revealed STNA #561 delivering a lunch tray to Resident #129 who was on quarantine for COVID-19. STNA #561 did not perform hand hygiene before delivering the meal tray or upon exiting the room. STNA #561 hung the reusable/washable gown she doffed with the inside of the gown touching the outside of another gown hung on the same hook. STNA #561 did not sanitize her face shield after exiting the room and proceeded to deliver a meal tray to Resident #598's room, who was also in quarantine for COVID-19. Prior to entering Resident #598's room, STNA #561 donned a used gown from the hook on the door. Prior to donning, the inside of the gown was in contact with the outside of another used gown hanging on the door. While in Resident #598's room STNA #561 was observed touching the bed control and over bed table. STNA #561 did not perform hand hygiene or disinfect her face shield on exiting the room. Residents Affected - Many Observation of meal pass on the 100-hall on 08/30/21 at 1:02 P.M. with LPN Unit Manager #526 revealed STNA #524 donning a reusable cloth gown taken from the hall side of Resident #40's and #96's closed door. Residents #40 and #96 were in droplet transmission-based precautions as of 08/23/21 due to a diagnosis of COVID-19. STNA #524 was observed touching her clothing with the gown while donning. Interview at this time with STNA #524 confirmed she accidentally touched her clothing with the gown. Interview on 08/31/21 at 7:05 A.M. with the DON indicated the facility ordered disposable gowns on 08/31/21 because they ran out of disposable gowns on 08/28/21 and had to use washable cloth gowns. The DON confirmed there was no shortage from the supply company that provided the disposable isolation gowns. Interview on 08/31/21 at 7:05 A.M. with LPN Infection Preventionist #525 indicated on the 100-hall, the cloth isolation gowns should have been hanging inside the resident rooms. LPN Infection Preventionist #525 did not know why the gowns were hanging on the hall side of the doors. Interview on 08/31/21 at 7:09 A.M. with Laundry #432 indicated the facility had been using cloth isolation gowns for about five months and each floor was responsible to take the contaminated cloth isolation gowns to laundry. Interview on 08/30/21 at 9:24 A.M. with Housekeeping/Laundry Supervisor #430 revealed resident rooms/bathrooms were cleaned once per shift. Railings and high touch areas in the halls were disinfected three times per week. Housekeeping/Laundry Supervisor #430 stated staff did not have time to do it more than three times per week. Housekeeping/Laundry Supervisor #430 indicated she cleaned the staff breakrooms once per day. Interview on 08/31/21 at 9:29 A.M. with LPN Infection Preventionist #525 revealed staff stored their masks at the front of the facility, on a table with their name in a brown bag. All staff were to get a new mask every three days. Masks were to be rotated, the staff wore one mask for three days then rotated to the next mask for three days, then the third. Each staff member was responsible for monitoring the order their masks were supposed to be worn and rotated. LPN Infection Control Nurse #525 confirmed the staff were using reusable isolation gowns indicating the staff had been using the reusable gowns since the beginning of the COVID-19 pandemic. The staff were to place the gowns in the soiled container to be washed at the end of their shift and the new shift coming on was to get clean gowns, one for the nurse and one for the STNA. The gowns were to hang on the door of the resident who was in isolation and it was up to the nurse and STNA to know which gown to wear. LPN Infection Control Nurse #525 confirmed the isolation gowns that were hanging on top of each other, used by nurses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 14 of 17 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 365289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Lane Nursing and Rehabilitation 5425 High Mill Avenue NW Massillon, OH 44646 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 - Immediate jeopardy to resident health or safety Residents Affected - Many and STNAs would contaminate each other and the personal clothing of the staff member donning the gown. Observation on 08/31/21 at 11:42 A.M. revealed a long table located in the front lobby of the facility with 83 small brown paper bags on the table. Fifty-eight of the brown bags were open at the top, exposing a variety of masks, from one to four, located in each opened bag. Some masks were folded in half and some were open with the head bands appearing stretched. Each bag had a name on the outside of the bag. Observation on 08/30/21 at 11:44 A.M. revealed Oxygen Vendor #540 in Resident #23's room, replacing the oxygen tubing on the resident's oxygen concentrator machine. Oxygen Vendor #540 thanked the resident and left the room without sanitizing or washing his hands prior to leaving the room. Interview with Oxygen Vendor #540 at the time of the observation confirmed he did not wash or sanitize his hands after handling the resident's oxygen tubing or prior to leaving the resident's room. Resident #23 was not in quarantine and was COVID-19 negative. Observation on the 600-unit on 08/30/21 at 12:00 P.M. revealed the PPE bins located outside of Residents #129, #596 and #597's rooms did not contain hand sanitizer. Interview on 08/30/21 at 12:20 P.M. with LPN #447 and STNA #494 revealed they worked with residents who were positive for COVID-19 and they took their breaks in the only break room available which was shared by all staff. Observation on 08/30/21 at 1:11 P.M. revealed STNA #496 delivering a lunch tray to Resident #133. STNA #496 commented she observed a spill and left the room to obtain towels from another room, touching the door handle before returning to the room of Resident #133 to place the towels on the floor. STNA #496 did not perform hand hygiene upon leaving Resident #133's room to obtain salt and pepper from the cart and returning to the room. STNA #496 proceeded to apply salt and pepper to the resident's food and open the milk carton. STNA #496 left Resident #133's room for the second time without washing her hands. STNA #496 proceeded to the common area where she served Resident #18's tray, touching the over bed table and the blanket that was on Resident #18. STNA #496 moved Resident #18's cup that was sitting on the overbed table, removed the plastic wrap over the food, and opened crackers and milk carton. Without washing her hands or using hand sanitizer STNA #496 proceeded to the meal cart and served Resident #111. Interview on 08/30/21 at 1:17 P.M. with STNA #496 verified she had not performed hand hygiene between residents and stated she was supposed to perform hand hygiene before exiting each room. STNA #496 then obtained a tray and served Residents #194 and #38 without performing hand hygiene. Observation on 08/31/21 at 6:50 A.M. revealed STNA #566 sitting at a desk monitoring visitors and staff as they entered. Unidentified Staff Members #569, #570 and #571 and Surveyor #572 entered the facility, and each had their temperature taken by STNA #566. STNA #566 documented the name, date, and temperature on a form. No screening questions were asked, and no screening forms were completed for Unidentified Staff Members #569, #570 and #571 or Surveyor #572. STNA #566 said there were no questions to ask. Interview on 08/31/21 at 9:29 A.M. with LPN Infection Preventionist #525 confirmed there was one breakroom for staff and there were no restrictions for any staff to use the breakroom. LPN Infection Preventionist #525 revealed only compassionate care visits were allowed on the floors with COVID-19 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 15 of 17 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 365289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Lane Nursing and Rehabilitation 5425 High Mill Avenue NW Massillon, OH 44646 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 - Immediate jeopardy to resident health or safety Residents Affected - Many positive residents. Other visitors were permitted to visit indoors on all other halls. LPN Infection Preventionist #525 confirmed there were COVID-19 positive residents and COVID-19 negative residents residing on the 100, 200, 300 and 600 halls. On 08/31/21 there were three new positive cases, one on 100 hall, one on 300 hall and one on 600 hall. Interviews on 08/31/21 at 10:00 A.M. and 10:18 A.M. with the DON confirmed family members were visiting residents inside the facility. The DON stated, If the resident does not have COVID-19, all the family has to do is call and say I want to visit and they can visit, they don't need a reason. Every resident visit is considered compassionate care. If the resident has COVID then the visit would be limited for end of life only. The DON indicated high touch areas, including handrails, were cleaned every hour by housekeeping and by nursing staff when housekeeping was not working. Interview on 08/31/21 at 11:17 A.M. with STNA #566 (the screener who was assessing visitors and staff who entered the facility) confirmed there were three visitors recently who came to visit Resident #3. STNA #566 indicated she assessed the temperatures of all three visitors but did not document two of the temperatures (both children) and completed the screening questionnaire for the adult only. STNA #566 indicated visitors could go to residents' rooms unassisted or monitored. STNA #566 revealed she started her shift at 5:00 A.M. on 08/31/21. Her duties were to monitor staff and visitor temperatures. STNA #566 said, When visitors come in, I fill out the name, date and temperature. Observation of STNA #566's desktop revealed to the left there was a staff questionnaire and to the right was a visitor questionnaire. STNA #566 revealed she had been instructed to ask visitors and staff questions and stated, I was told to ask questions but no, I do not always ask everyone, sometimes there's a lot of people, some I did and some I didn't, it just depends. Observation and interview on 08/31/21 at 11:39 A.M. with Visitor #568 revealed she and her two children were sitting outside with Resident #3. Visitor #568 and her two children were wearing cloth masks, Resident #3 had no mask and was not social distancing with the visitors. Visitor #568 confirmed she was aware of positive COVID-19 residents located on one hall only and was not aware of any other residents in the building having COVID-19. Visitor #568 said she and her children visited frequently. Interview on 08/31/21 at 11:34 A.M. with RN #517 confirmed residents did get visitors, and the three visitors who arrived to visit Resident #3 went to his room then assisted him to an outdoor area to visit. RN #517 confirmed visitors were not escorted or monitored when visiting the facility. Observation on 08/31/21 at 1:15 P.M. revealed four unidentified staff members in the break room. Interview on 08/31/21 at 3:05 P.M. with LPN #454 revealed We get one mask for three shifts. I don't keep the clean masks with the dirty ones. We then put them in the brown bag, at the end of the three days we throw the brown bag away. Interview on 08/31/21 at 3:07 P.M. with LPN #518 revealed We get three masks, we keep the three in brown bags, we write one two and three on the bags, we put the line through one, two, and three as we use them. After three shifts we change to mask two, we keep the first mask in the same bag, we date the mask, we wear each mask for three shifts. Review of a Team Facilitator Root Cause Analysis (RCA) document dated 08/30/21 revealed the team members involved in the RCA meeting included the Administrator, DON, LPN Infection Preventionist #525, and Medical Director #565. The RCA was regarding the current COVID-19 outbreak. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 16 of 17 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 365289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rose Lane Nursing and Rehabilitation 5425 High Mill Avenue NW Massillon, OH 44646 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 - Immediate jeopardy to resident health or safety Interview on 08/31/21 at 4:21 P.M. with Medical Director #565 revealed he was not part of the RCA completed on 08/30/21. Medical Director #565 stated, I was not part of that meeting, I was not aware of it, I was never invited to attend any meeting yesterday. Medical Director #565 revealed he last spoke with the DON, A few weeks ago. Medical Director #565 revealed, At that time I told the DON, lock down, no visitors in the building, the residents are vaccinated, I believe the virus is being spread by visitors and staff. Medical Director #565 confirmed the last positive case of COVID-19 he was made aware of w[TRUNCATED] Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 17 of 17