Health inspection·November 19, 2023

F 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure resident funds were conveyed timely upon resident discharge from the facility. This affected two residents (Resident #410 and #411) of two residents reviewed for funds conveyance. The facility census was 155. Residents Affected - Few Findings Include: 1. Resident #410 was admitted to the facility on [DATE] with diagnoses including, but not limited to, vascular dementia, generalized anxiety disorder, schizophrenia, and major depressive disorder. Resident #410 expired at the facility on [DATE]. Review of the business records for Resident #410 revealed a check in the amount of $50.13 was dispersed to the State of Ohio Treasurer on [DATE]. 2. Resident #411 was admitted to the facility on [DATE] with a readmission date of [DATE] with diagnoses including, but not limited to, Alzheimer's Disease, major depressive disorder, diabetes mellitus. Resident #411 expired at the facility on [DATE]. Review of the business records for Resident #411 revealed a check in the amount of $32.12 was dispersed to the State of Ohio Treasurer on [DATE]. Interview on [DATE] at 9:13 A.M. with Business Office Manager #372 verified that Resident #410 and #411 funds were conveyed outside of required timeframe of 30 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 2 of 32 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 11/19/2023 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 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of transfer notices, policy review, and interview, the facility failed to ensure information regarding the reason for hospital transfer was documented on the transfer notice. This affected four residents (Residents #4, #16, #125 and #151) of 31 residents reviewed for hospitalization during the initial phase of the survey. The census was 155. Findings include: 1. Review of Resident #16's medical record revealed diagnoses including Parkinson's disease, schizoaffective disorder/bipolar type, type two diabetes mellitus, anxiety disorder and chronic obstructive pulmonary disease. Review of a nursing note dated 03/07/23 at 9:30 P.M. indicated Resident #16's cheeks were flushed. Resident #16's tremors increased and her fingers were cyanotic (blue discoloration due to a lack of oxygen). Resident #16 was alert and oriented. Resident #16's oxygen saturation was originally 56-76% (normal range 90%-100%), pulse was 102 (beats per minute), blood pressure was 137/104, temperature was 98.2 and respirations were 25 (breaths per minute). The nurse called 911 who arrived and assessed Resident #16. Her oxygen saturation had risen to 97% and she refused to go to the hospital to be evaluated. The physician and guardian were updated. Review of a nursing note dated 03/08/23 at 12:30 A.M. indicated Resident #16 requested to be sent to the hospital. Resident #16 was still having tremors and was now complaining of pain in her lower legs (severity of seven on a scale of 0-10). Resident #16's temperature was 100.8 degrees orally, pulse was 117, respirations were 23, and blood pressure was 139/62. The oxygen saturation was 85%. Oxygen was applied and oxygen saturations rose to 99%. Transport was set up. A nursing note dated 03/08/23 at 6:32 A.M. indicated Resident #16 was being admitted to the hospital for sepsis due to an unspecified organism. Resident #16's sister was updated. Review of the transfer/discharge notice indicated Resident #16 was discharged to the hospital on [DATE]. The reason for the transfer was not specified. During an interview on 11/15/23 at 4:55 P.M., Licensed Social Worker (LSW) #311 verified the transfer notice was silent as to the reason Resident #16 was transferred to the hospital. 2. Review of Resident #125's medical record revealed diagnoses including cerebral infarction, heart failure, atrial fibrillation and presence of a cardiac pacemaker. Review of a nursing note dated 08/31/23 at 3:18 P.M. indicated Resident #125 was using accessory muscles to breath, moaning out and his lungs were full of rhonchi (coarse rattling respiratory sounds). Resident #125's blood pressure was 135/89, pulse was 100-105 and irregular, and oxygen saturation was 91% on room air. After oxygen was applied the oxygen saturation rose to 96% then dropped down to 91% on two liters of oxygen. The certified nurse practitioner assessed Resident #125 and gave an order to send Resident #125 to the emergency room. The Power of Attorney (POA) was aware. Review of a nursing note dated 09/01/23 at 3:42 A.M. indicated Resident #125 was admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 3 of 32 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 11/19/2023 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 0623 intensive care unit for acute hypoxic respiratory failure. Level of Harm - Potential for minimal harm On 11/15/23 at 12:00 P.M., the transfer/discharge notice was reviewed with LSW #311 who verified the transfer notice did not indicate the reason for the transfer. Residents Affected - Some 3. Review of the medical record for Resident #4 revealed an admission date of 09/01/10 with diagnoses including Parkinson's disease, congestive heart failure, chronic obstructive pulmonary disease, and chronic kidney disease. Resident #4 was transferred to the hospital on [DATE]. Review of the progress note dated 11/04/23 at 4:50 A.M. revealed Resident #4 had increased confusion and low blood pressure, which resulted in a transfer to the hospital. Review of the transfer/discharge notice, dated 11/04/23, for Resident #4 revealed she was being sent to the hospital and there was no indication as to the reason for the transfer. On 11/15/23 at 4:56 P.M., interview with Social Services Director (SSD) #311 verified the resident was not provided anything in writing regarding the reason for a transfer. 4. Review of the medical record for Resident #151 revealed a re-admission date of 08/08/23 with diagnoses including coronary artery disease, chronic respiratory failure with hypoxia, congestive heart failure, and hypertension. Resident #151 was transferred to the hospital on [DATE]. Review of the progress note dated 10/03/23 at 4:11 A.M. revealed Resident #151 had symptoms of respiratory distress, which resulted in a transfer to the hospital. Review of the transfer/discharge notice, dated 10/03/23, for Resident #151 revealed he was being sent to the hospital and there was no indication as to the reason for the transfer. On 11/15/23 at 4:56 P.M., interview with Social Services Director (SSD) #311 verified the resident was not provided anything in writing regarding the reason for a transfer. Review of the facility's Transfer Discharge Notice Policy (last dated October 2022) revealed staff would complete the notice at the time of discharge or transfer. The notice should be signed by the resident (if able) at the time of discharge or transfer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 4 of 32 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 11/19/2023 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 0625 Level of Harm - Potential for minimal harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of transfer notices, and interview, the facility failed to ensure information was provided regarding the length of time a resident's bed would be held or the cost to do so when residents were transferred to the hospital. This affected four (Residents #4, #16, #125 and #151) of 31 residents reviewed for hospitalization during the initial phase of the survey. Findings include: 1. Review of Resident #16's medical record revealed diagnoses including Parkinson's disease, schizoaffective disorder/bipolar type, type two diabetes mellitus, anxiety disorder and chronic obstructive pulmonary disease. Review of a nursing note dated 03/07/23 at 9:30 P.M. indicated Resident #16's cheeks were flushed. Resident #16's tremors increased and her fingers were cyanotic (blue discoloration). Resident #16 was alert and oriented. Resident #16's oxygen saturation was originally 56-76% (normal 90-100%), pulse was 102 beats per minute, blood pressure was 137/104, temperature was 98.2 and respirations were 25 per minute (normal 12-20 breaths per minute). The nurse called 911 who arrived and assessed Resident #16. Her oxygen saturation had risen to 97% and she refused to go to the hospital to be evaluated. The physician and guardian were updated. Review of a nursing note dated 03/08/23 at 12:30 A.M. indicated Resident #16 requested to be sent to the hospital. Resident #16 was still having tremors and was now complaining of pain in her lower legs (severity of 7 on a scale of 0-10). Resident #16's temperature was 100.8 degrees orally, pulse was 117, respirations were 23, and blood pressure was 139/62. The oxygen saturation was 85%. Oxygen was applied and oxygen saturations rose to 99%. Transport was set up. A nursing note dated 03/08/23 at 6:32 A.M. indicated Resident #16 was being admitted to the hospital for sepsis due to an unspecified organism. Resident #16's sister was updated. Review of the transfer/discharge notice indicated Resident #16 was discharged to the hospital on [DATE]. The notice indicated all residents would be charged at the routine per diem charge for holding a bed while they were absent from the facility. The notice indicated if a resident chose to have the facility hold a bed pending their stay in a hospital or any other place outside of the facility, the resident would be charged for holding a bed unless the facility was specifically instructed in writing not to hold the bed. The notice did not indicate how many days the bed hold would be covered under insurance or the daily cost for holding the bed. During an interview on 11/15/23 at 4:55 P.M., Licensed Social Worker (LSW) #311 verified the transfer notice was silent as to the duration or cost of the bed hold. 2. Review of Resident #125's medical record revealed diagnoses including cerebral infarction, heart failure, atrial fibrillation and presence of a cardiac pacemaker. Review of a nursing note dated 08/31/23 at 3:18 P.M. indicated Resident #125 was using accessory muscles to breath, moaning out and his lungs were full of rhonchi (coarse rattling respiratory sounds). Resident #125's blood pressure was 135/89, pulse was 100-105 and irregular, and oxygen saturation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 5 of 32 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 11/19/2023 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 0625 Level of Harm - Potential for minimal harm Residents Affected - Some was 91% on room air. After oxygen was applied the oxygen saturation rose to 96% then dropped down to 91% on two liters of oxygen. The certified nurse practitioner assessed Resident #125 and gave an order to send Resident #125 to the emergency room. The Power of Attorney (POA) was aware. Review of a nursing note dated 09/01/23 at 3:42 A.M. indicated Resident #125 was admitted to the intensive care unit for acute hypoxic respiratory failure. On 11/15/23 at 12:00 P.M., the transfer/discharge notice was reviewed with LSW #311 who verified the transfer notice was silent as to the duration or cost of the bed hold. 3. Review of the medical record for Resident #4 revealed an admission date of 09/01/10 with diagnoses including Parkinson's disease, congestive heart failure, chronic obstructive pulmonary disease, and chronic kidney disease. Resident #4 was transferred to the hospital on [DATE]. Review of the progress note dated 11/04/23 at 4:50 A.M. revealed Resident #4 had increased confusion and low blood pressure, which resulted in a transfer to the hospital. Review of the transfer/discharge notice, dated 11/04/23, for Resident #4 revealed a statement indicating residents would be charged per diem for holding a bed while they were absent from the facility, but there was no actual cost information provided. On 11/15/23 at 3:14 P.M., interview with Business Office Manager (BOM) #372 confirmed she did not provide residents with any information in writing regarding the actual cost of holding a bed upon transfer to the hospital. 4. Review of the medical record for Resident #151 revealed a re-admission date of 08/08/23 with diagnoses including coronary artery disease, chronic respiratory failure with hypoxia, congestive heart failure, and hypertension. Resident #151 was transferred to the hospital on [DATE]. Review of the progress note dated 10/03/23 at 4:11 A.M. revealed Resident #151 had symptoms of respiratory distress, which resulted in a transfer to the hospital. Review of the transfer/discharge notice, dated 10/03/23, for Resident #151 revealed a statement indicating residents would be charged per diem for holding a bed while they were absent from the facility, but there was no actual cost information provided. On 11/15/23 at 3:14 P.M., interview with Business Office Manager (BOM) #372 confirmed she did not provide residents with any information in writing regarding the actual cost of holding a bed upon transfer to the hospital FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 6 of 32 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 11/19/2023 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, and interview, the facility failed to ensure restorative programs for ambulation and/or transfers were consistently implemented and evaluated for two (Residents #58 and #127) of six residents reviewed for activities of daily living. The facility identified nine residents on restorative ambulation or transfer programs. The census was 155. Residents Affected - Few Findings include: 1. Review of Resident #58's medical record revealed diagnoses including right sided weakness and paralysis following a stroke, chronic obstructive pulmonary disease, polyneuropathy, atrial fibrillation, anemia, and osteoarthritis. Review of a physical therapy (PT) Discharge summary dated [DATE] indicated interventions provided during PT included activities to promote safe ambulation. Resident #58 had demonstrated improved tolerance to transfers and mobility with a hemi-walker (designed for individuals with the use of only one hand or arm. Lighter than a walker and more stable than a cane) with minimal episodes of loss of balance. The discharge summary indicated to facilitate Resident #58 maintaining her current level of performance and in order to prevent decline, development of and instruction in a restorative nursing program (RNP) for ambulation was completed. Review of a therapy referral for Restorative Nursing Services (RNS) form dated 08/14/23 indicated at the time of discharge from PT Resident #58 was able to ambulate 70-200 feet with a hemi-walker with close stand by assist to contact guard assist for safety and stability with the wheelchair following. Resident #58 required verbal cues for occasional safety awareness. The form indicated precautions for intermittent toe catching. RNS recommendations were made to ambulate with the hemi-walker up to 200 feet with contact guard assistance with the wheelchair following. Use a gait belt and watch for toe catch. RNS staff teaching was completed. The referral was silent as to how often the program was to be offered/provided. Review of restorative delivery records revealed between 08/14/23 and 10/13/23 the ambulation program was offered 22 times. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated walking in the room and in the corridor only occurred once or twice. All balance tests revealed Resident #58 was unsteady and only able to stabilize with staff assistance during transfers and ambulation. There were no evaluations of the restorative ambulation program located in the medical record. Review of a PT evaluation dated 10/13/23 indicated Resident #58 was referred due to a documented decline in function and a recent fall. Resident #58 presented with significant functional limitations that prevented her from returning to her prior level of function in the facility. Resident #58 was demonstrating bilateral lower extremity weakness, impaired balance, impaired functional activity tolerance, and impaired gait pattern with increased episodes of toe catching and decreased step length. Resident #58 was not likely to return to her prior level of function in the facility without skilled PT intervention. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 7 of 32 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 11/19/2023 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/14/23 at 1:31 P.M., Restorative nursing assistant #395 stated she was the only restorative aide for the facility. Restorative nursing assistant #395 stated not every resident received restorative programs every day. Restorative nursing assistant #395 verified the restorative program was not specific to the frequency with which it was to be offered. On 11/14/23 at 3:00 P.M., Licensed Practical Nurse (LPN) #352, the restorative nurse, stated restorative programs were set up to be delivered as tolerated. There was no direction as to the frequency the programs were to be offered. LPN #352 stated some residents might need restorative services more often than other residents. LPN #352 verified there were no guidelines/orders for frequency and it would be up to the determination of the restorative aide. When interviewed regarding the gaps in delivery records LPN #352 stated sometimes the restorative aide was pulled to work an assignment on the floor. During August and September she believed Restorative nursing assistant #395 was being pulled to work on the floor three to four times a week. On 11/14/23 at 4:05 P.M., Therapy Director #427 stated therapy did not provide information regarding frequency with which restorative programs were to be offered because if the residents did not receive the services the stated number of days the facility would be cited. Therapy Director #427 stated she did rounds every week for residents on restorative programs and spoke to residents and staff to determine if there had been any declines. Therapy Director #427 stated although therapy had to place some residents back on therapy she could not state with certainty if it was related to failure to provide routine restorative programs. On 11/15/23 at 9:11 A.M., Restorative nursing assistant #395 stated she had been in her current position since February 2023. Restorative nursing assistant #395 stated this date she offered restorative programs every day unless she worked the unit and was only able to offer restorative programs to those residents on the unit to which she was assigned. Restorative aide #395 stated she was not documenting refusals or if a resident was not available. Restorative aide #395 provided no explanation as to why she had previously stated not every resident received restorative programs every day. Restorative nursing assistant #395 stated if the length of the programs ordered exceeded the time she had available to offer the programs she would just alternate days, providing some programs on Monday, Wednesday and Friday and other programs on Tuesday and Thursday then doing the opposite the following week unless the order designated a program was to be provided every day. Therefore, each restorative program would be offered at least five times in a 14 day period. On the morning of 11/15/23, LPN #352 provided restorative progress notes dated 04/05/23, 07/05/23 and 10/10/23 indicating an evaluation was made of the restorative program. On 11/15/23 at 8:40 A.M., LPN #352 stated she understood the concern about the facility not designating frequency of the programs and the concern the aide was left to determine the frequency the programs were offered and if the aide was qualified to do so. On 11/15/23 at 12:37 P.M., LPN #352 verified all the restorative progress notes indicating an evaluation had been completed were documented on 11/14/23. LPN #352 stated the assessments were time consuming to document but she discussed the residents and made observations with the restorative aide and therapy and would identify if somebody was deteriorating and needed re-evaluated. 2. Review of Resident #127's medical record revealed diagnoses including left sided weakness and paralysis following a stroke, hypertension, and type two diabetes mellitus. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 8 of 32 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 11/19/2023 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 0676 Level of Harm - Minimal harm or potential for actual harm Review of a care plan initiated 05/01/23 indicated Resident #127 was at risk for decline and needed a transfer program. Interventions included providing a restorative nursing program as tolerated. Review of a PT Discharge summary dated [DATE] indicated Resident #127 would continue a restorative nursing program (RNP) consisting of standing in the standing frame in the therapy gym up to 30 minutes. Residents Affected - Few Review of restorative delivery records between 08/26/23 and 11/13/23 revealed the restorative transfer program was offered/provided eight times. Restorative records were not provided from 10/14/23 - 10/28/23. Resident #127 was hospitalized from [DATE] - 10/28/23. During an interview on 11/14/23 at 1:31 P.M., restorative nursing assistant #395 stated not every resident on caseload received restorative services every day. Restorative nursing assistant #395 stated Resident #127 returned from the hospital with a port coming out of his back and he had not been permitting transfers. Restorative nursing assistant #395 reported Resident #127 was transferring three times a week before being hospitalized . Before going to the hospital Resident #127 was standing for 30 minutes. On 11/14/23 at 3:00 P.M., Licensed Practical Nurse (LPN) #352, the restorative nurse, stated restorative programs were set up to be delivered as tolerated. There was no direction as to the frequency the programs were to be offered. LPN #352 stated some residents might need restorative services more often than other residents. LPN #352 verified there were no guidelines/orders for frequency and it would be up to the determination of the restorative aide. When interviewed regarding the gaps in delivery records LPN #352 stated sometimes the restorative aide was pulled to work an assignment on the floor. On 11/14/23 at 4:05 P.M., Therapy Director #427 stated therapy did not provide information regarding frequency with which restorative programs were to be offered because if the residents did not receive the services the stated number of days the facility would be cited. Therapy Director #427 stated she did rounds every week for residents on restorative programs and spoke to residents and staff to determine if there had been any declines. Therapy Director #427 stated although therapy had to place some residents back on therapy she could not state with certainty if it was related to failure to provide routine restorative programs. On 11/15/23 at 9:11 A.M., Restorative nursing assistant #395 stated she had been in her current position since February 2023. Restorative nursing assistant #395 gave conflicting information than what was offered on 11/14/23, stating she offered restorative programs every day unless she worked the unit and was only able to offer restorative programs to those residents on the unit to which she was assigned. Restorative aide #395 stated she was not documenting refusals or if a resident was not available. Restorative aide #395 provided no explanation as to why she had previously stated not every resident received restorative programs every day. Restorative nursing assistant #395 stated if the length of the programs ordered exceeded the time she had available to offer the programs she would just alternate days, providing some programs on Monday, Wednesday and Friday and other programs on Tuesday and Thursday then doing the opposite the following week unless the order designated a program was to be provided every day. Therefore, each restorative program would be offered at least five times in a 14 day period. On the morning of 11/15/23, LPN #352 provided restorative progress notes dated 03/08/23, 06/06/23 and 08/30/23 indicating an evaluation was made of the restorative program. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 9 of 32 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 11/19/2023 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/15/23 at 8:40 A.M., LPN #352 stated she understood the concern about the facility not designating frequency of the programs and the concern the aide was left to determine the frequency the programs were offered and if the aide was qualified to do so. On 11/15/23 at 12:37 P.M., LPN #352 verified all the restorative progress notes indicating an evaluation had been completed were documented on 11/14/23. LPN #352 stated the assessments were time consuming to document but she discussed the residents and made observations with the restorative aide and therapy and would identify if somebody was deteriorating and needed re-evaluated. Review of the facility's Restorative Nursing policy (revised October 2014) revealed residents and/or family would be encouraged to be as actively involved as possible in their own restorative program. Restorative nursing programs that had been initiated would be maintained until either the goals had been met or, in some cases, until the likelihood that success was not imminent had been determined. Restorative nursing programs would, therefore, be provided for any resident who had been identified as having a need for such service. The services would include consistent and structured programs designed by the Restorative Nurse and carried out by floor aides and specially trained restorative aides on a day to day basis. The restorative nurse or licensed nurse would complete his/her assessment and made recommendations to the physician. A physician's order for the appropriate restorative program would be obtained based on the assessment. The physician order would specify, the content and extent (for example, the type of program, frequency and duration) of the restorative program. The restorative nurse or licensed nurse would develop a comprehensive care plan. The care plan would define functional problem, measurable goal(s) and time frames, interventions include specific approaches, frequency of services, duration and service provider. The restorative nurse or licensed nurse, along with the floor aides or restorative aides, would implement the programs and document on a daily basis. The restorative nurse or licensed nurse would re-evaluate resident restorative programs quarterly, with a significant change and as needed. Progress notes needed to describe the resident's progress/lack of progress toward goal achievement and the effectiveness/lack of effectiveness of the interventions that were utilized. Also identify any obstacles that might be slowing the progress of the restorative program(s). The restorative nurse or licensed nurse, in conjunction with the Interdisciplinary Team (IDT) would review restorative care plans and update, as appropriate, at least quarterly, with a significant change and as needed. Restorative nursing programs would be terminated and/or considered for functional maintenance programs when all goals were successfully met or the likelihood that success was not imminent had been determined. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 10 of 32 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 11/19/2023 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 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, review of the medical record, and interview the facility failed to ensure Resident #134 was transported to a non-emergent emergency room visit for evaluation after a fall and wound dressings were applied as ordered for Resident #46. This affected one resident (Resident #134) of eight residents reviewed for accidents and one resident (Resident #46) of three residents reviewed for pressure ulcers. The census was 155. Residents Affected - Few Findings included: Review of the medical record revealed Resident #134 was admitted to the facility on [DATE]. Diagnoses included lumbar fracture, diabetes, major depressive disorder, osteoarthritis bilateral knees, respiratory failure, and kidney disease. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #134 had intact cognition. Review of the progress note dated 08/25/23 at 2:30 A.M. revealed the nurse was informed by the nursing assistant after answering his call light Resident #134 stated he had fallen out of bed. Upon entering his room he was observed in bed lying on his left side. There were no open injuries seen. Resident #134 stated he had fallen out of bed, went to the bathroom, walked back to bed and his hip had hurt the whole time he was up and moving. His vitals were obtained, all proper parties were notified. The physician ordered a stat x-ray. Review of the radiology report dated 08/25/23 revealed Resident #134 had a unilateral right hip x-ray without the pelvis done at the facility by the mobile service . The report indicated he did not have any acute osseous findings and recommendation was to repeat a multi-view imaging in one week or sooner if clinically warranted especially if symptoms continue to persist or progress. Review of the Change in Function assessment dated [DATE] at 8:49 A.M. revealed the nursing assistants report the resident's right hip pain decreased ability of the resident to complete functional mobility. Review of the Therapy Screen note dated 08/25/23 at 11:00 A.M. revealed Resident #134 had increased right hip pain and a decline in mobility since recent fall. The X-ray of the right hip was negative. Review of the Change in Function assessment dated [DATE] at 7:15 A.M. revealed Resident #134 continued to complain of right hip pain with ambulation and therapy was notified to evaluate. Resident #134 was offered an as needed pain medication and declined and stated his pain was not severe. Review of the Change in Function assessment dated [DATE] at 8:49 A.M. revealed the nursing assistants reported the resident's right hip pain decreased his ability to complete functional mobility. Review of the Therapy Screen noted dated 08/29/23 at 7:47 A.M. revealed Resident #134 was demonstrating increased right hip pain decreasing his ability to complete functional mobility and transfers. Review of the Change in Function assessment dated [DATE] at 8:50 A.M. revealed the nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 11 of 32 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 11/19/2023 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 0684 assistants reported the resident's right hip pain decreased his ability to complete functional mobility. Level of Harm - Minimal harm or potential for actual harm Review of the Health Status note dated 08/29/23 at 3:18 P.M. revealed the estimated time of arrival for the transport was three to five hours. The residents responsible party and physician were updated. Resident was going to the emergency room (ER) for a magnetic resonance imaging of the head and spine along with an x-ray of the lower body. Residents Affected - Few Review of the Health Status note dated 08/30/23 at 5:30 A.M. revealed the facility received a call from the transport company stating the transport would be out to transport the resident to the ER between 7:00 and 8:00 A.M. The resident and physician were aware. Review of the nurse's note dated 08/30/23 at 6:55 P.M. revealed the transport was called and Resident #134 was on the list to be transported to the hospital but were unable to give an estimated time. Review of the Nurse's note dated 08/31/23 at 11:30 A.M. the transport showed up to transport Resident #134 to the hospital. Review of the radiology cat scan report from the emergency room dated 08/31/23 revealed Resident #134 had an acute comminuted mildly displaced fracture of the right superior pubic ramus with an extension into the pubic body, acute nondisplaced transverse fracture of the right inferior pubic ramus, acute non displaced fracture of the right L5 transverse process and the right S1 articular facet with inferior extension in the right sacral ala. Review of the emergency room report dated 08/31/23 revealed Resident #134 was admitted to the ER for evaluation of right hip pain. The resident stated he fell out of bed on 08/24/23 after having a nightmare. He stated his pain has been localized to the right hip. He stated they did do x-ray at the nursing home but they were negative however his pain was getting progressively worse, He stated prior to the fall he was able to ambulate with a cane but since the fall he has been using a wheelchair the majority of the time. Review of the Nurse's note dated 09/01/23 at 1:18 A.M. revealed Resident #134 returned from the ER with a diagnosis of a multiple pubic rami fracture and fracture of traverse process of lumbar vertebra. He had new orders for Percocet 5-325 milligrams every six hours as needed for five days. Resident was to follow up with the orthopedic surgeon. He was resting in bed with the call light within in reach. The physician was notified. On 11/15/23 at 3:30 P.M. an interview with Resident #134 revealed after his fall, he was in a lot of pain. He stated they did an x-ray the next day and it was negative. He stated he was not able to walk so he was using a wheelchair. He stated he started working with therapy and the pain got worse. He stated therapy told him they thought his pelvis and they decided to send him to the hospital to get an x ray but it took three days to get him transport to the hospital and he does not know why. He stated his pelvis was broken. He stated he used the wheelchair for a while then went to a rollator walker and now he was using a cane. He stated they only had Tylenol to give him but he did not really want to take anything because he does not like to take pain medications. He stated it only really hurt when he tried to walk. On 11/16/23 at 9:25 A.M. an interview with the Director of Nursing revealed they had discussed his condition and the fact the non-emergency transport was taking too long and the resident stated he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 12 of 32 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 11/19/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was okay to wait. She verified there was no documentation he stated he was okay with waiting or the physician stated it was okay for him to wait. On 11/16/23 at 10:10 A.M. an interview with Licensed Practical Nurse #352 revealed Resident #134 had two x-rays done at the facility, one in 08/25/23 and another one done on 08/31/23, with both stating he did not have any fractures. She stated he did not complain of any pain until 08/28/23. She stated he was offered pain medication and declined. She stated he was okay with waiting on the transport but verified there was no documentation the physician was notified or documentation he was okay with waiting for the transport. 2. Record review for Resident #46 revealed an admission date of 07/26/23. Diagnoses included congestive heart failure, Alzheimer's Disease, protein-calorie malnutrition, anxiety, dysphasia, and peripheral vascular disease. Review of the Braden assessment, dated 09/30/23, revealed a score of 13 (moderate risk for skin breakdown). A review of the quarterly Minimum Data Set (MDS) Assessment, dated 10/02/23, revealed Resident #46 was at risk of developing pressure ulcers and did not have an open area to the skin at that time. A review of the care plan, dated 10/11/23, revealed Resident #46 was to have moisture barrier cream after each incontinent episode, a pressure reducing cushion to wheelchair and bed. Resident #46 was also to have a Braden assessment (a scoring system for the measurement for skin break down potential) quarterly. A review of wound assessments revealed moisture associated skin damage (MASD) acquired 10/12/23. The initial measurements were 1.0 centimeter (cm) long by 1.0 cm wide by 0.1 cm deep. An order for barrier cream and a foam dressing were ordered on this date. Physician orders included a pressure reducing mattress to bed and to cleanse coccyx area with normal saline, pat dry apply topical treatment and cover with bordered foam. The dressing was to be changed three times per week on Tuesday, Thursday, and Saturday and as needed. A review of the weekly skin assessment, dated 11/09/23, revealed the MASD was improving with measurements of 0.3 cm long by 0.3 cm wide by 0.1 cm deep. On 11/13/23 at 9:15 AM, interview with Resident #46 stated she had a sore on her bottom. On 11/13/23 at 1:30 PM, observation revealed Resident #46 did not have a dressing applied to the coccyx. This was verified by Licensed Practical Nurse (LPN) #410 at the time of observation. On 11/16/23 at 8:45 AM, interview with Registered Nurse (RN) #387 and RN #404 revealed direct care staff were notified by nursing of dressing needs during shift report and staff was to notify nursing if a wound dressing was off or soiled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 13 of 32 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 11/19/2023 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, policy review, observations, and interview, the facility failed to ensure services were provided to maintain or improve a resident's range of motion. This affected four (Residents #58, #91, #125 and #127) of five residents reviewed for limited range of motion. Findings include: 1. Review of Resident #58's medical record revealed a diagnoses of right side weakness and paralysis following a stroke and right hand contracture. Review of a care plan initiated 08/28/20 revealed Resident #58 had a self care deficit due to post stroke and right sided weakness and chronic obstructive pulmonary disease. An intervention dated 10/13/20 indicated a right resting hand splint was to be donned six to eight hours as tolerated. Check skin integrity before applying and after removing. A care plan initiated 12/02/20 revealed Resident #58 was at risk for decline in active and passive range of motion. An intervention dated 10/28/22 indicated an intervention for Restorative Nursing Services (RNS) for range of motion (ROM) as tolerated. Review of a therapy referral for Restorative Nursing Services (RNS) dated 10/27/22 revealed at the time of discharge from therapy Resident #58 was tolerating a splint to the right hand six to eight hours with skin checks every shift. Recommendations were made to encourage Resident #58 to stretch the right upper extremity with a therapy tech in all planes. Range with ten second holds working from the shoulder to the hand. Review of therapy restorative records from 08/11/23 to 11/13/23 revealed a RNS passive range of motion program (PROM) was offered/provided 43 times. On 11/13/23 at 10:26 A.M., Resident #58 was observed sitting in a chair with the fingers of her right hand flexed and appeared to have a contracture. Resident #58 stated she did not know if she wore splints or if staff did any exercises/range of motion. There were no splints on. Subsequent observations on 11/13/23 at 12:03 P.M. and 2:06 P.M. and on 11/14/23 at 11:41 A.M., 1:55 P.M., 2:06 P.M. and 2:27 P.M. revealed no splint use. Review of the November 2023 Treatment Administration Record (TAR) revealed the splint was not applied on night shift on 11/13/23. On 11/14/23 at 1:31 P.M., restorative nursing assistant #395 verified Resident #58 was on a restorative program for ROM but the program instruction were not specific to the frequency the program was to be offered. On 11/14/23 at 2:45 P.M., State Tested Nursing Assistant (STNA) #391 verified Resident #58 was supposed to wear a hand splint but she had forgotten to offer the hand splint. STNA #391 did not recall applying the hand splint on 11/13/23. At 2:53 P.M., STNA #391 offered to apply the hand splint and Resident #58 agreed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 14 of 32 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 (X3) DATE SURVEY COMPLETED A. Building 11/19/2023 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 11/14/23 at 3:00 P.M., Licensed Practical Nurse (LPN) #352 revealed when restorative programs were set up the programs did not designate the frequency they were to offered. It was left up to the restorative aide. When interviewed about gaps/extended periods between the programs being offered LPN #352 stated there were times when the restorative aide was pulled to work the floor or was on vacation. On the morning of 11/15/23, LPN #352 provided restorative assessments dated 04/05/23, 07/05/23 and 10/10/23. On 11/15/23 at 12:37 P.M., LPN #352 verified the restorative assessments provided were all documented on 11/14/23. 2. Review of Resident #125's medical record revealed diagnoses including stroke, heart failure and atrial fibrillation. On 09/08/23 an order was written for a resting left hand splint with wear time as tolerated. A quarterly Minimum Data Set (MDS) assessment revealed Resident #125 had functional limitation in range of motion of both lower extremities and one upper extremity. Resident #125 denied pain over the prior five days. Observations on 11/13/13 at 11:32 A.M., 2:09 P.M. and 2:20 P.M. revealed Resident #125 was observed lying in bed with no splint applied. On 11/13/25 at 2:25 P.M., State Tested Nursing Assistant (STNA) #428 stated she had never seen Resident #125 wear a splint and she had not attempted to apply it. STNA #428 indicated she was unsure about Resident #125's ability to tolerate the splint. Subsequent observations on 11/14/23 at 11:48 A.M. and 2:24 P.M. revealed Resident #125 did not have a left hand splint applied. On 11/14/23 at 2:45 P.M., STNA #391 stated Resident #125 was dependent for activities of daily living. STNA #391 indicated Resident #125 would cry out in pain with splint use so it was not being applied. Observations on 11/15/23 at 9:20 A.M. and 9:35 A.M. revealed no splint use. On 11/15/23 at 9:45 A.M., Registered Nurse (RN) #394 verified Resident #125 would not wear the left hand splint because of pain. When RN #394 moved Resident #125's fingers of the left hand to check his fingernails and skin integrity he made a short groaning sound then stopped when RN #394 stopped moving his fingers. Further record review revealed a nursing note dated 11/15/23 at 10:12 A.M. which indicated nursing staff notified the restorative nurse that the splint to Resident #125's left hand was no longer fitting properly. Therapy was notified to evaluate for new orthotics. On 11/15/23 12:37 P.M., LPN #352 stated prior to that morning nobody had reported Resident #125 was not tolerating the use of the hand splint. When the nurse reported it to her LPN #352 asked if staff had been documenting any concerns regarding the splint use. The nurse confirmed for her staff were documenting the splint was being applied. LPN #352 indicated she encouraged the nurse to ensure the use of splints was being documented accurately so issues could be identified and appropriate action taken if they were unable to be utilized. 3. On 11/13/23 at 11:18 A.M., Resident #127 stated he had lost use of his entire left side after a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 15 of 32 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 11/19/2023 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 0688 stroke. Resident #127 indicated staff did not routinely provide exercises or don splints to his left arm. Level of Harm - Minimal harm or potential for actual harm Review of Resident #127's medical record revealed diagnoses including left side weakness and paralysis following a stroke, anxiety disorder and depression. Residents Affected - Some Review of a therapy referral for RNS dated 03/28/23 indicated recommendations for a program to encourage a resting hand splint to the left hand for six to eight hours and to do left arm stretching with shoulder flexion/abduction, elbow extension, wrist extension, digit extension and encourage any active range of motion of holds at end range. Review of restorative delivery records from 08/26/23 through 11/13/23 revealed active range of motion services was offered/provided eight times. Restorative records were not provided from 10/14/23 - 10/28/23. Resident #127 was hospitalized from [DATE] - 10/28/23. During an interview on 11/14/23 at 1:31 P.M., restorative nursing assistant #395 stated not every resident on caseload received restorative services every day. Restorative nursing assistant #395 verified the program instructions were not specific as to the frequency of the program to be delivered. On 11/14/23 at 3:00 P.M., Licensed Practical Nurse (LPN) #352, the restorative nurse, stated restorative programs were set up to be delivered as tolerated. There was no direction as to the frequency the programs were to be offered. LPN #352 stated some residents might need restorative services more often than other residents. LPN #352 verified there were no guidelines/orders for frequency and it would be up to the determination of the restorative aide. When interviewed regarding the gaps in delivery records LPN #352 verified the records did not reflect the restorative program was provided consistently. On the morning of 11/15/23, LPN #352 provided restorative progress notes dated 03/08/23, 06/06/23 and 08/30/23 indicating an evaluation was made of the restorative program. On 11/15/23 at 8:40 A.M., LPN #352 stated she understood the concern about the facility not designating frequency of the programs and the concern the aide was left to determine the frequency the programs were offered and if the aide was qualified to do so. On 11/15/23 at 12:37 P.M., LPN #352 verified all the restorative progress notes indicating an evaluation had been completed were documented on 11/14/23. LPN #352 stated the assessments were time consuming to document but she discussed the residents and made observations with the restorative aide and therapy and would identify if somebody was deteriorating and needed re-evaluated. 4. Record review revealed Resident #91 was admitted on [DATE] to the facility with diagnoses that included but not limited to heart failure, chronic obstructive pulmonary disease, and diabetes mellitus. Review of Resident #91's care plan dated 03/23/21 with a revision date of 08/16/21 revealed Resident #91 was art risk for decline in active range of motion (AROM) and passive range of motion (PROM) related to intolerance, decreases mobility, disease process, lack of motivation and weakness. Interventions included but not limited to assess for progress and need for program quarterly and as needed, explain procedures and equipment, offer physical and verbal cues as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 16 of 32 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 11/19/2023 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #91 was cognitively intact and required extensive assistance with two staff for mobility and total dependent with two for transfer. Resident #91 had three days of passive range of motion during the seven-day look back period. Review of Resident #91's physician orders for November 2023 revealed functional maintenance program (FMP) for range of motion (ROM) as tolerated. Review of Resident #91's Kardex revealed that Resident #91 stated FMP for ROM as tolerated. Review of Resident #91's Kardex instructions dated 11/12/23 revealed staff to assist Resident #91 to provide Active Range of Motion/Passive Range of Motion to bilateral lower extremities in all planes as tolerated in supine. Perform hip flexion/extension, hip abduction/adduction, knee flexion/extension and ankle plantar flexion/dorsiflexion. Perform ten times reps to each motion or up to resident's tolerance. The number of minutes spent providing ROM was recorded as not applicable. Review of FMP tracking for Resident #91 revealed that not applicable was noted for the following dates: 10/04/23, 10/10/23, 10/11/23, 10/18/23, 11/01/23 and 11/11/23 on both shifts, 10/02/23, 10/03/23, 10/07/23, 10/21/23, 10/22/23, 10/25/23, 11/05/2, 11/06/23, 11/08/23, 11/09/23, 11/12/23 and 11/13/23 on the afternoon shift. There were no refusals on the tracking documentation. Interview on 11/13/23 at 4:04 P.M. with Resident #91 revealed that he had limited range of motion (ROM) to both legs and left arm. Resident #91 stated that at times staff assist him in moving his lower extremities and left arm. Resident #91 stated staff come in when they have time, but it is not consistent. Interview on 11/14/23 at 11:00 A.M. with Resident # 91 revealed that he must do restorative himself. Interview on 11/14/23 at 2:59 P.M. with Restorative Licensed Practical Nurse (LPN) #352 revealed that Resident # 91 is on a FMP. The State Tested Nursing Assistants (STNAs) know what is expected of them because it comes up in the Kardex. LPN #352 verified that the documentation of Resident #91's FMP. Interview on 11/19/23 at 7:21 A.M. with Registered Nurse (RN) #348 revealed RN #348 does restorative when it's ordered on the treatment administration record (TAR) and was not aware of any nightshift nurse aides doing any range of motion or movement with residents. Review of the facility's Restorative Nursing policy (revised October 2014) revealed residents and/or family would be encouraged to be as actively involved as possible in their own restorative program. Restorative nursing programs that had been initiated would be maintained until either the goals had been met or, in some cases, until the likelihood that success is not imminent had been determined. Restorative nursing programs would, therefore, be provided for any resident who had been identified as having a need for such service. The services would include consistent and structured programs designed by the Restorative Nurse and carried out by floor aides and specially trained restorative aides on a day to day basis. The restorative nurse or licensed nurse would complete his/her assessment and made recommendations to the physician. A physician's order for the appropriate restorative program would be obtained based on the assessment. The physician order would specify, the content and extent (for example, the type of program, frequency and duration) of the restorative program. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 17 of 32 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 11/19/2023 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete restorative nurse or licensed nurse would develop a comprehensive care plan. The care plan would define functional problem, measurable goal(s) and time frames, interventions include specific approaches, frequency of services, duration and service provider. The restorative nurse or licensed nurse, along with the floor aides or restorative aides, would implement the programs and document on a daily basis. The restorative nurse or licensed nurse would re-evaluate resident restorative programs quarterly, with a significant change and as needed. Progress notes needed to describe the resident's progress/lack of progress toward goal achievement and the effectiveness/lack of effectiveness of the interventions that were utilized. Also identify any obstacles that might be slowing the progress of the restorative program(s). The restorative nurse or licensed nurse, in conjunction with the IDT would review restorative care plans and update, as appropriate, at least quarterly, with a significant change and as needed. Restorative nursing programs would be terminated and/or considered for functional maintenance programs when all goals were successfully met or the likelihood that success was not imminent had been determined. Event ID: Facility ID: 365289 If continuation sheet Page 18 of 32 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 11/19/2023 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 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 interview the facility failed to ensure fall interventions were in place for Resident #36, and failed to ensure medications were not left at the bedside for Residents #147 and #355. This affected three residents (Resident #36, #147 and #335) of eight residents reviewed for accidents. Findings included: 1. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE]. Diagnoses included heart failure, borderline personality disorder, chronic obstructive pulmonary disease, suicidal ideation, major depressive disorder, schizophrenia, asthma, post-traumatic stress disorder, and auditory hallucinations. Review of the physician's orders revealed Resident #36 had an order to have a floor mat to the open side of the bed dated 01/03/23. Review of the plan of care dated 01/16/23 revealed Resident #36 had a potential for falls related to psychotropic medication use, decreased cognition, weakness, decreased mobility, obesity, and arthritis. Interventions included floor mat to open side of the bed. Review of the nurse aide [NAME] revealed Resident #36 was to have a floor mat to the open side of the bed. Review of the fall risk assessment dated [DATE] revealed Resident #36 was at a higher risk for falls. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #36 had moderately impaired cognition. Observations on 11/13/23 at 9:44 AM and 10:36 A.M. revealed Resident #36 was sleeping in bed; the left side of her bed was against the wall and the floor mat was not on the floor on the open side of the bed. It was folded up against the wall. On 11/13/23 at 10:40 A.M. an interview with Registered Nurse #324 verified her mat was not on the floor beside her bed. Observation on 11/15/23 at 9:30 A.M. revealed Resident #36 was in bed sleeping, the left side of her bed was against the wall and her fall mat was not on the floor on the open side of the bed. It was folded up at the end of the bed on the floor. On 11/15/23 at 9:31 A.M. an interview with Licensed Practical Nurse #319 verified the fall mat was not on the floor per physician orders. 2. Review of the medical record revealed Resident #147 was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, chronic obstructive pulmonary disease, human immunodeficiency virus, atherosclerotic heart disease, chronic kidney disease, and COVID-19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 19 of 32 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 11/19/2023 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 0689 Review of the admission MDS dated [DATE] revealed Resident #147 had intact cognition. Level of Harm - Minimal harm or potential for actual harm Review of the November 2023 physician's orders revealed Resident #147 did not have an order to have any medications, inhalers, or creams at bedside. Residents Affected - Few Observation on 11/13/23 at 9:10 A.M. and 10:22 A.M. revealed there was a bottle of Ketorolac Tromethamine Ophthalmic Solution 0.5 %, a bottle of saline nasal spray, a Combivent inhale, and an albuterol inhaler on the bedside stand of Resident #147. On 11/13/23 at 10:23 A.M. an interview with Registered Nurse #404 revealed Resident #147 did not have orders for the inhalers, she verified he did not have orders to self-administer any medications or for medication to be left at bedside. On 11/13/23 at 10:24 A.M., an interview with Resident #147 revealed he had been using the inhalers, nasal spray, and eye drops. He stated they all came from the Veterans Administration. 3. Review of the medical record revealed Resident #355 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, severe protein-calorie malnutrition, atherosclerotic heart disease, respiratory failure, COVID-19, depression, anxiety disorder, hypertension, and pulmonary nodule. Review of the admission MDS assessment dated [DATE] revealed Resident #355 had intact cognition. Reviewed of the November 2023 physician's orders revealed Resident #355 did not have an order to have any medications, inhalers, or creams at bedside. Observation on 11/13/23 at 9:25 A.M. and 10:33 A.M. revealed Resident #355 had a Incruse Ellipta inhaler, a Breo Ellipta inhaler, Combivent Respimat inhaler, ventolin inhaler and mometasone furoate 0.1% cream on his bedside stand. On 11/13/23 at 10:35 A.M. an interview with Registered Nurse #404 revealed Resident #355 only had an order for the Ventolin to be at the bedside, not the other medications. Review of the facility policy titled, Medication Administration Policy, dated 03/22 revealed the policy was to ensure medications were administered in a safe and sanitary manner. The nurse would remain with the resident until are consumed. No medication would be left at bedside with a resident that was not ordered and care planned to self-administer medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 20 of 32 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 11/19/2023 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of schedules and time punches, and interview, the facility failed to ensure there was sufficient staff to consistently provide restorative programs and to respond to call lights in a timely manner. This affected two (Residents #58, #127) of six residents reviewed for activities of daily living and two (Residents #58 and #127) of five residents reviewed for range of motion and one additional resident (Resident #140) who was identified as not having the call light responded to timely. This had the potential to affect all residents. Findings include: 1. During a resident council meeting with Residents #4, #10, #19, #28, #31, #33, #57, #64, #117 and #126 the residents had a majority consensus that the facility did not have sufficient staff with multiple residents reporting it could take up to an hour to get assistance with some residents reporting they were incontinent as a result. Residents reported there had been restorative programs that were not provided because the restorative aide got pulled to the floor and were unable to provide restorative services. On 11/14/23 at 1:31 P.M., Restorative nursing assistant #395 stated she was the only restorative aide for the facility. Restorative nursing assistant #395 stated not every resident received restorative programs every day. On 11/14/23 at 3:00 P.M., Licensed Practical Nurse (LPN) #352, the restorative nurse, stated restorative programs were set up to be delivered as tolerated. When interviewed regarding the gaps in delivery records for Resident #58's ambulation and range of motion restorative programs and Resident #127's transfer and range of motion restorative programs, LPN #352 stated sometimes the restorative aide was pulled to work an assignment on the floor. During August and September she believed Restorative nursing assistant #395 was being pulled to work on the floor three to four times a week. LPN #352 verified at times the therapy aide might provide restorative services for a few residents when the restorative aide was not working. Comparison of restorative nursing assistant #395's schedule and time punches which differentiated when restorative nursing assistant #395 worked as a restorative aide and when she worked on the floor revealed since 08/01/23 restorative aide #395 was on vacation from 08/01/23 to 08/05/23. Her scheduled revealed restorative nursing assistant #395 was scheduled the following days but worked the floor as a state tested nursing assistant: 08/07/23 for 8.84 hours 08/08/23 for 6.5 hours 08/10/23 for 9.95 hours 08/21/23 for 10.24 hours 08/22/23 for 8.22 hours (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 21 of 32 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 11/19/2023 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 0725 08/25/23 for 1.5 hours Level of Harm - Minimal harm or potential for actual harm 09/09/23 for 9.25 hours 09/18/23 for 8.25 hours Residents Affected - Some 09/26/23 had paid time off 09/29/23 for 8.13 hours 09/30/23 had paid time off 10/03/23 for 8.07 hours 10/17/23 for 8.53 hours 10/24/23 for 2.12 hours The facility identified 14 residents receiving restorative programs, Residents #19, #39, #53, #56, #58, #73, #88, #118, #111, #114, #122, #127, #130, and #137. 2. Review of the medical record revealed Resident #140 was admitted to the facility on [DATE]. Diagnoses are trimalleolar fracture of the left lower leg, kidney disease, diabetes, nonalcoholic steatohepatitis, depression, gout, cystitis, and constipation. Review of the Five-Day Medicare Minimum Data Set assessment dated [DATE] revealed Resident #140 had intact cognition, required two assist with toilet use and was occasionally incontinent of bladder and bowel. Observation of the call light monitor device at the 500 hall nurses' station on 11/15/23 at 8:36 A.M. revealed the call light for Resident #140 was on for 36 minutes. An interview at this time with Registered Nurse #338 verified the call light had been on for 36 minutes. He called over to the 600-hall unit and asked the staff to answer the call light in Resident #140's room. Observation of the call light monitor device at the 500 hall nurse's station on 11/15/23 at 8:50 A.M. revealed the call light of Resident #140 was still on after 50 minutes. On 11/15/23 at 11/15/23 at 8:53 P.M. an interview with Resident #140 stated his call light was still on because he needed the urinal. He stated the Nursing Assistant left it on because she was passing out the breakfast trays so she was not allowed to give him the urinal while she was passing out the trays. He stated he was told it was an Ohio Department of Health regulation. His call light had now been on 53 minutes. On 11/15/23 at 8:57 A.M. an interview with Agency State Tested Nursing Assistant #428 revealed she was the only aide on the 600 unit and she was feeding two other residents so she could not get to his call light. She stated the nurse could have answered the call light and given him the urinal. On 11/15/23 at 9:23 A.M. an interview with the Director of Nursing revealed the facility did not have a policy stating the staff cannot take someone to the bathroom while they are passing meal trays. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 22 of 32 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 11/19/2023 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete She stated they just need to be aware of infection control. She stated she would like to have all call light answered within five minutes but they do not really have a specific time. She stated she does not really want them going over 15-20 minutes. On 11/16/23 at 11:21 A.M. an interview with the Administrator revealed the call light system was ridiculous and he wanted to go back to the old system. He stated he was confident the call light times will get better once they completely eliminate agency staff. Event ID: Facility ID: 365289 If continuation sheet Page 23 of 32 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 11/19/2023 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 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 observation, medical record review, review of the narcotic count sheet and interview the facility failed to ensure residents were free from unnecessary psychotropic medications and failed to ensure medications were administered per physician orders. This affected one resident (Resident #66) of five residents reviewed for unnecessary medications. The census was 155. Findings included: Review of the medical record revealed Resident #66 was admitted to the facility on [DATE]. Diagnoses included dementia with behavioral disturbance, depression, psychosis, insomnia, post traumatic stress disorder, and chronic pain. Review of the comprehensive Minimum Data Set assessment dated [DATE] revealed Resident #66 had severely impaired cognition. Review of the November 2023 physician's orders revealed Resident #66 had an order for oxycodone hydrochloride (HCL) (pain medication) five milligrams (mg) one or two tablets every four hours as needed for pain dated 02/19/23. He had an as needed order for Ativan (anti-anxiety medication) 0.5 mg every four hours as needed for agitation for 14 days dated 11/03/23. However, the medical record did not contain documentation of agitation or behaviors supporting the need for Ativan to be added to the resident's treatment regimen Review of the November 2023 medication administration record (MAR) revealed Resident #66 was administered two tablet of Oxycodone HCL 5 mg on 11/07/23 at 8:50 P.M. for a pain level 10 out of 10, on 11/08/23 at 7:17 A.M. for a pain level five out of 10, at 11:19 A.M. for pain level three out of ten, and at 4:00 P.M. for a pain level five out 10. However he was given Ativan 0.5 mg instead of oxycodone HCL Review of the progress notes from 11/06/23 to 11/12/23 revealed no documentation of a medication error occurring for Resident #66. Review of the nurse's note dated 11/03/23 at 11:41 A.M. revealed the physician was notified in regards to the power of attorney for Resident #66 reported the resident was having increased congestion and agitation during the night. New orders were received including, but not limited to, Ativan 0.5 mg orally every four hours as needed, Review of the Medication Incident Report dated 11/10/23 revealed on 11/09/23 it was discovered Agency Licensed Practical Nurse (LPN) #426 had administered two Ativan 0.5 mg tablets to Resident #66 instead of two oxycodone HCL 5 mg tablets on 11/07/23 at 9:00 P.M. The medication was signed out on the MAR under the oxycodone HCL order not the Ativan order. Review of the Medication Incident Report dated 11/10/23 revealed on 11/09/23 it was discovered Registered Nurse (RN) #344 administered two Ativan 0.5 mg tablets to Resident #66 instead of two oxycodone HCL tablet on 11/08/23 at 7:19 A.M., 11:30 A.M., and 4:00 P.M. The medication was signed out on the MAR under the oxycodone HCL order not the Ativan order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 24 of 32 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 11/19/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Ativan (lorazepam) narcotic count sheet revealed Resident #66 was given two Ativan on 11/07/23 at 9:00 P.M. by Agency LPN #426 and on 11/08/23 at 7:19 A.M., 11:30 A.M., and 4:00 P.M. by RN # 344. On 11/19/23 at 11:08 A.M. an interview with Registered Nurse (RN) #344 revealed n 11/07/23 Resident #66 was becoming agitated and wandering up and down the halls so she knew from his behavior he was having increased pain because that was usually what he did when he was in pain. She stated he was out of his oxycodone and she did not realize it and administered two Ativan 0.5 mg tablets to him for three doses. She verified she had not looked at the cards and the tablets looked so much alike. She stated he did not seem any more sedated than normal because he usually slept off and on throughout the day and he had to be cued to wake up and eat most days. She stated she did not know why he was out of his oxycodone and she did not know why he was on the Ativan. On 11/19/23 at 11:50 A.M. an interview with the Director of Nursing revealed Resident #66 was ordered Ativan 0.5 mg as needed every four hours because his son was visiting the resident on 11/02/23 on midnight shift and told the dayshift nurse the next day the resident was agitated. She verified there was no documentation of his behaviors and no nurses had witnessed any behaviors to support the need for Ativan for agitation. She stated they did not realize he was out of his oxycodone until 11/10/23 and he was mistakenly given Ativan 0.5 mg in place of the oxycodone HCL 5 mg. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 25 of 32 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 11/19/2023 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 - Some 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** 2. On 11/14/23 at 12:10 P.M., observation of the medication room in the 400 hall revealed one box of Multistix urinalysis dip sticks to test for urinary tract infections with an expiration date of 08/31/23. Licensed Practical Nurse (LPN) #410 verified the urinalysis test strips were expired. Observation of the medication cart in the 400 hall revealed a bottle of Biotene mouth wash, labeled for Resident #46, had an expiration date of 08/03/22. At the time of observation, LPN #410 verified the Biotene was expired. 3. On 11/14/23 at 2:55 P.M., observation of the medication room in the 100 hall revealed an open one milliliter vial of Tubersol (a multi-dose solution used for tuberculosis testing) in the refrigerator. The vial of tubersol was not labeled as to when it was opened. At the time of observation, Registered Nurse (RN) #404 verified the vial was open and was not labeled as to when it was opened. 4. On 11/15/23 at 9:55 A.M., observation of the medication storage room in the 200 hall revealed a bottle of Ketoconazole four ounces without a resident name, with an expiration date August 2023, a 60 gram bottle of nystatin without a resident name that was one quarter full with an expiration date of September 2022, Afrin nasal spray that was labeled with Resident #75's name with an expiration date of August 2023, and a bottle of Flonase nasal spray labeled with Resident #75's name with an expiration date of March 2023. The aforementioned was verified by LPN #330 at the time of observation. 5. On 11/15/23 at 10:25 A.M., observation of the medication storage room for the wing containing the 500, 600, 700, and 800 halls revealed liquid docusate sodium (a stool softener) 473 milliliters, three full bottles unopened with an expiration date of October 2023. The aforementioned was verified by RN #338 at the time of observation. Fifty five residents residing on the 500, 600, 700 and 800 halls received stock medications from the [NAME] Terrace medication storage room . On 11/15/23 at 3:00 P.M., interview with the Director of Nursing (DON) revealed that medication carts and medication storage rooms were to be checked weekly by unit managers for expired medications and non-labeled items. Based on observation and interview the facility failed to ensure medications were properly secured and stored and failed to ensure expired medications and supplies were timely disposed. This had the potential to effect 11 cognitively impaired and independently mobile residents (Resident #5, #50, #52, #66, #69, #81, #83, #121, #135, #154, and #404) on the the secured dementia unit and all 25 residents on the 100 unit who had the potential to receive the tubersol solution, two residents (#46 and #75) whose medications were expired on the 200 unit, and all 55 residents who reside on the 500, 600, 700, and 800 units who received stock medications from the [NAME] Terrace (500, 600, 700 and 800 units) medication storage room. The facility census was 155. Findings included: 1. Observation of the secure dementia unit on 11/19/23 at 11:08 A.M. revealed the medication cart was left in the hallway outside of room [ROOM NUMBER], unattended while Registered Nurse (RN) #344 was in the medication room down the other hallway with the door closed. There were several residents in the hallway wandering around on the unit. An interview at this time with RN #344 verified she had left the medication cart unattended and unlocked while she went to the medication room to get a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 26 of 32 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 11/19/2023 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 medication for a resident. Level of Harm - Minimal harm or potential for actual harm The facility identified 11 cognitively impaired and independently mobile residents (Resident #5, #50, #52, #66, #69, #81, #83, #121, #135, #154, and #404) on the the secured dementia unit. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 27 of 32 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 (X3) DATE SURVEY COMPLETED A. Building 11/19/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, record review and interview, the facility failed to maintain accurate medical records. This affected three (Residents #96, #125 and #138) of 34 resident records reviewed for accurate medical records The census was 155. Findings include: 1. Review of Resident #125's medical record revealed diagnoses including stroke, heart failure and atrial fibrillation. On 09/08/23 an order was written for a resting left hand splint with wear time as tolerated. A quarterly Minimum Data Set (MDS) assessment revealed Resident #125 had functional limitation in range of motion of both lower extremities and one upper extremity. Resident #125 denied pain over the prior five days. Observations on 11/13/13 at 11:32 A.M., 2:09 P.M. and 2:20 P.M. revealed Resident #125 was observed lying in bed with no splint applied. On 11/13/25 at 2:25 P.M., State Tested Nursing Assistant (STNA) #428 stated she had never seen Resident #125 wear a splint and she had not attempted to apply it. STNA #428 indicated she was unsure about Resident #125's ability to tolerate the splint. Subsequent observations on 11/14/23 at 11:48 A.M. and 2:24 P.M. revealed Resident #125 did not have a left hand splint applied. On 11/14/23 at 2:45 P.M., STNA #391 stated Resident #125 was dependent for activities of daily living. STNA #391 indicated Resident #125 would cry out in pain with splint use so it was not being applied. Review of the November 2023 Treatment Administration Record (TAR) indicated Resident #125 had the left hand splint on 20 shifts through 11/14/23. Observations on 11/15/23 at 9:20 A.M. and 9:35 A.M. revealed no splint use. On 11/15/23 at 9:45 A.M., Registered Nurse (RN) #394 verified Resident #125 would not wear the left hand splint because of pain. When RN #394 moved Resident #125's fingers of the left hand to check his fingernails and skin integrity he made a short groaning sound then stopped when RN #394 stopped moving his fingers. RN #394 indicated she had to modify the information she had already entered into the TAR for 11/15/23 due to the original entry regarding splint use was inaccurate. Further record review revealed a nursing note dated 11/15/23 at 10:12 A.M. which indicated nursing staff notified the restorative nurse that the splint to Resident #125's left hand was no longer fitting properly. Therapy was notified to evaluate for new orthotics. On 11/15/23 12:37 P.M., LPN #352 stated prior to that morning nobody had reported Resident #125 was not tolerating the use of the hand splint. When the nurse reported it to her, LPN #352 asked if staff had been documenting any concerns regarding the splint use. The nurse confirmed for her staff were documenting the splint was being applied. LPN #352 indicated she encouraged the nurse to ensure the use of splints was being documented accurately so issues could be identified and appropriate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 28 of 32 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 11/19/2023 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 0842 action taken if they were unable to be utilized. Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record for Resident #96 revealed an admission date of 02/01/23 with diagnoses including dementia, type two diabetes, and muscle weakness. Residents Affected - Few Review of the quarterly Minimum Data Set (MDS) Assessment, dated 10/03/23, revealed Resident #96 had moderately impaired cognition. The assessment indicated he had no functional limitation in range of motion, utilized a wheelchair for mobility, and had one fall with minor injury since the last assessment. Review of the safety progress note, dated 10/21/23 at 10:30 A.M., indicated Resident #96 experienced a fall and complained of pain to the right hip. The note indicated no injuries were identified. Review of Licensed Practical Nurse (LPN) #410's incident witness statement, dated 10/21/23 at 10:30 A.M., revealed Resident #96 had a skin tear to the left lower extremity and complained of pain to the right hip. Review of the weekly skin assessments dated 10/25/23, 11/01/23, and 11/08/23 indicated Resident #96's skin was intact. There was no documentation of a skin tear to the left lower extremity. Review of the admission assessment, dated 11/17/23, revealed Resident #96 had a scab to the lower left shin with orders to apply pad and protect. On 11/16/23 at 11:21 A.M., interview with the Administrator verified the incident witness statement indicated Resident #96 had a skin tear and the incident progress note indicated there was no injury. On 11/16/23 at 11:39 A.M., interview with LPN #410 confirmed Resident #96 had a skin tear on his lower left extremity that was identified during the skin check after a fall. He said he could not determine if the skin tear was caused by the fall and that was the reason it was not documented in the medical record. Review of the facility policy titled Fall Management and Incident Intervention Protocol, dated 07/2022, revealed if a resident experienced a fall, a nurse would conduct an assessment and document all assessment findings in the clinical record. 3. Review of the medical record for Resident #138 revealed an admission date of 06/28/23 with diagnoses including history of traumatic hemorrhage of cerebrum, acute and chronic respiratory failure with hypoxia, gastrostomy status, dysphagia, unspecified psychosis, altered mental status, personal history of alcohol abuse, and post traumatic stress disorder. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 10/14/23, revealed Resident #138 had severely impaired cognitive skills for daily decision making. The assessment also indicated Resident #138 received a majority of calories and fluid from a tube feeding, and received tracheostomy (trach) care during the review period. Review of the progress note dated 10/24/23 at 8:30 A.M. revealed Resident #138 had pulled his trach out and facility staff were unable to replace the trach. Resident #138 was sent out to the hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 29 of 32 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 11/19/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the progress note dated 10/24/23 at 12:00 P.M. revealed Resident #138 returned from the hospital with no trach in place and he was maintaining his oxygen level without it. Review of the physician's orders for November 2023 identified orders for nothing by mouth (NPO) (ordered 07/22/23), Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) milligrams (mg)/3 milliliters (mL) via trach every 4 hours as needed (ordered 07/22/23), Seroquel oral tablet 25 mg by mouth once daily in the morning (ordered 09/07/23), Seroquel oral tablet 50 mg by mouth once daily at bedtime (ordered 09/07/23), and Zinc oral tablet 50 mg by mouth once daily in the morning (ordered 08/25/23). Review of the behavior assessments dated 11/06/23, 11/07/23, 11/08/23, 11/09/23, 11/11/23, 11/12/23, 11/13/23, and 11/14/23 indicated Resident #138 did not receive any psychoactive medications. Review of the electronic medication administration record (eMAR) for November 2023 revealed Resident #138 received Seroquel (an antipsychotic) and Ativan (an anti-anxiety medication) on 11/06/23, 11/07/23, 11/08/23, 11/09/23, 11/11/23, 11/12/23, 11/13/23, and 11/14/23. On 11/14/23 at 2:32 P.M., interview with the Director of Nursing (DON) verified Resident #138 had orders for an Albuterol inhaler to be administered via trach and he no longer had a trach in place. The DON verified the orders for Seroquel and Zinc to be given by mouth and confirmed Resident #138 had orders for NPO, meaning nothing was provided by mouth. She confirmed the route of administration for the specified medications were inaccurate. She also verified the behavior assessments did not indicate Resident #138 received psychoactive medications and that he did receive Seroquel and Ativan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 30 of 32 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 11/19/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations and interviews the facility failed to maintain a clean, sanitary environment This had the potential to affect eight residents (Resident #7, #29, #36, #84, #87, #100, #103, #125) for environment and all 18 residents (Resident #1, #2, #13, #20, #25, #42, #70, #74, #75 #78, #89, #99, #112, #122, #123, #126, #134, #143) on the 200 unit who used the shower room. The facility census was 155. Findings Included: 1. Observations on 11/13/23 at 9:05 A.M., 1:46 P.M., and 3:00 P.M. revealed there was fecal matter on the toilet seat and the floor in front of the toilet in the shared bathroom of Resident #29 and #103. On 11/13/23 at 3:00 P.M. an interview with State Tested Nursing Assistant (STNA) #406 verified the fecal matter on the toilet seat and the floor in front of the toilet in the shared bathroom of Resident #29 and #103. She stated the 100 and 200 units did not have a housekeeper today so it was the aides' responsibility to clean up any messes. On 11/15/23 at 10:45 A.M. an interview with Housekeeping Director #317 revealed all the units should have at least one housekeeper scheduled daily. She stated every room and bathroom was to be cleaned daily. She stated there should have been a housekeeper on the 100 and 200 Units Further interview on 11/15/23 at 11:00 A.M. with Housekeeping Director #317 revealed on 11/13/23 the housekeeper on the 200 Unit was a no call no show but there should have been a housekeeper working on the 100 Unit. 2. Observations on 11/13/23 at 8:58 A.M., 1:45 P.M., and 3:00 P.M. revealed there was fecal matter on the toilet and toilet seat in the shared bathroom of Resident #7, #87, and #100. On 11/13/23 at 3:00 P.M. an interview with STNA #406 verified the fecal matter on the toilet and toilet seat in the shared bathroom of Resident #7, #87, and #100. She stated the 100/200 Units did not have a housekeep today so it was the aides' responsibility to clean up any messes. On 11/15/23 at 10:45 A.M. an interview with Housekeeping Director #317 revealed all the units should have at least one housekeeper scheduled daily. She stated every room and bathroom was to be cleaned daily. She stated there should have been a housekeeper on the 100 and 200 Units Further interview on 11/15/23 at 11:00 A.M. with Housekeeping Director #317 revealed on 11/13/23 the housekeeper on the 200 Unit was a no call no show but there should have been a housekeeper working on the 100 Unit. 3. Observation of the 200 unit shower/tub room on 11/13/23 at 2:31 P.M. revealed there was fecal matter smeared on the wall right beside the tub in three places. There was a hand print and finger mark smears down the wall. An interview at this time with STNA #345 verified there was fecal matter smeared on the wall of the 200 Unit shower/tub room. She stated she would clean it immediately. On 11/15/23 at 10:45 A.M. an interview with Housekeeping Director #317 revealed all the units (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 31 of 32 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 11/19/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some should have at least one housekeeper scheduled daily. She stated every room and bathroom was to be cleaned daily. She stated there should have been a housekeeper on the 100 and 200 Units Further interview on 11/15/23 at 11:00 A.M. with Housekeeping Director #317 revealed on 11/13/23 the housekeeper on the 200 Unit was a no call no show but there should have been a housekeeper working on the 100 Unit. Resident #1, #2, #13, #20, #25, #42, #70, #74, #75 #78, #89, #99, #112, #122, #123, #126, #134, #143 were identified to use the 200 Hall shower/tub room. 4. Observation of the room of Resident #84's on 11/15/23 at 10:35 A.M. revealed several large orange/brown colored stains on the carpet upon entrance in to the room and on the left side of his bed. Further observations at that time revealed the carpet was sticky when you walked across it and the carpet had large wrinkles in it causing it to roll. The resident's family member was at the bedside and she stated it has been like that for awhile. On 11/15/23 at 10:40 A.M. an interview with Maintenance Director #318 revealed he did not take care of the carpet. He stated if it was up to him he would have all the carpet replaced but it was not up to him, it was up to Corporate to make that decison. On 11/15/23 at 10:45 A.M. an interview with Housekeeping Director #317 revealed she had told Corporate about the carpet in Resident #84's before but it had been a while so she didn't know the exact date. Further interview on 11/15/23 at 11:00 A.M. with Housekeeping Director #317 revealed she went to look at the carpet in Resident #84's room and verified it was sticky and had stains on it. She stated she asked the resident's family member if she wanted the carpet scrubbed today and the wife stated to do it the next day. She verified the carpet was wrinkled and was rolled in spots. She stated she did speak to Corporate and they stated Resident #84's room was next on the list to have the carpet replaced. 5. Observation on 11/15/23 at 1:15 P.M. revealed the positioning wedge cushion used to prop Resident #125 was soiled with a brown substance covering the wedge An interview at this time with Registered Nurse #394 revealed the wedge had tube feeding solution on it. She verified the wedge was dirty and they were using it to position the resident on his side. She stated they do not put it against his body but between the sheet and bed pad. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365289 If continuation sheet Page 32 of 32