Inspection·March 24, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #34's medical record revealed diagnoses including epilepsy, anxiety disorder, and history of cerebral infarction. A smoking assessment dated [DATE] indicated Resident #34 smoked. Resident #34 was oriented to person, place, and time, was able to hold cigarettes/lighter, knock off ashes, use an ashtray and extinguish the cigarettes. The smoking assessment indicated Resident #34 was not at risk related to smoking. The care plan was silent to smoking. On 03/23/22 at 9:50 A.M., the Director of Nursing (DON) was interviewed regarding the absence of a care plan addressing smoking. A care plan initiated 03/23/22 indicated Resident #34 had a potential for injury related to smoking. The goal indicated Resident #34 would safely smoke. Interventions included assisting Resident #34 to the smoking area as needed and to educate residents regarding the location of smoking areas and smoking policies. On 03/24/22 at 9:41 A.M., Licensed Practical Nurse (LPN) #656 verified the care plan regarding smoking was not individualized or comprehensive. Based on record review and interview the facility failed to ensure Resident's #28 and #34 had a comprehensive care plan for smoking. This affected two of 21 residents reviewed for care plans. The facility census was 93. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 12/01/20. Diagnoses included anemia, hypokalemia, right eye blindness, unsteadiness on feet, need for assistance with personal care, history of falling, abnormalities of gait and mobility, muscle weakness, and nicotine dependence. The annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 had moderately impaired cognition and impaired vision. Review of Resident #28's current care plan revealed it was silent to smoking. Review of the smoking assessment dated [DATE] revealed Resident #28 was identified as a smoker and was assessed as not at risk for injury related to smoking. Resident #28 has no history of burns or smoking problems. Resident #28 was able to identify locations and policy for smoking. Resident #28 was able to follow appropriate smoking techniques. Resident #28 could appropriately hold cigarette and lighter, was able to knock off ashes, use ashtray, and extinguish appropriately. Review of updated care plan dated 03/23/22 revealed Resident #28 had potential for injury related to smoking. Interventions included assist to smoking area as needed and educate on smoking policy. The updated care plan lacked individualization for Resident #28. Interview on 03/23/22 at 9:42 A.M. with License Practical Nurse (LPN) #648 confirmed Resident #28 was a smoker, and Resident #28 is compliant with facility policy for smoking. Interview on 03/24/22 at 9:41 A.M. with LPN/Restorative Nurse #656 verified lack of individualized (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 2 of 14 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 365317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691 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 0656 comprehensive care plan for Resident #28 regarding smoking. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 3 of 14 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 365317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, taste test, and recipe review the facility failed to prepare pureed foods at a consistency appropriate for safe swallowing. This had the potential to affect eight residents (Resident's #6, #12, #20, #31, #47, #72, #74 and #386) who were prescribed a pureed diet and consumed meals from the facility's kitchen. The facility census was 93. Residents Affected - Few Findings include: Observation on 03/22/22 at 3:05 P.M. of the puree preparation revealed Dietary Services Director (DSD) #628 was preparing pureed corn chowder for the dinner meal. DSD #628 was noted preparing one half gallon of corn chowder with 35 packages (two per pack) crackers. He confirmed the recipe was cut in half from 25 servings to 12. The recipe called for one gallon and three cups with 75 two-per-pack crackers. Confirmed he was looking for mashed potato-like consistency. Taste test of finished product revealed final product was smooth, however extremely thick. Regional Dietary Services Director #681 confirmed the consistency of the corn chowder upon tasting as being extremely thick. Interview at the time of the observation with Regional Dining Services Director #681 revealed it seemed too many crackers were added to the base of the recipe. Review of resident diet list revealed eight residents (Resident's #6, #12, #20, #31, #47, #72, #74 and #386) were prescribed a pureed diet. Review of the undated Soup Corn Chowder Pureed Thick recipe revealed 25 servings should include 75 two per-pack crackers and processed until smooth. There was a note stating measurements may need to be adjusted to achieve desired consistency. Review of the undated pureed guidelines stated thickening agent was to be added as needed to achieve the desired consistency. Review of personnel file for DSD #628 revealed a hire date of 11/29/22. As part of employee orientation, he had received training on menus, diets, and guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 4 of 14 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 365317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure fortified soup was of honey thick consistency for Resident #6. This affected one (Resident #6) of two residents (Resident's #6 and #30) who received honey thick liquids and fortified foods. The facility census was 93. Findings include: Review of the medical record revealed Resident #6 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis, chronic obstructive pulmonary disease (COPD), and diabetes type II. Review of the physician's order dated 12/08/21 revealed Resident #6 received a pureed texture diet with honey consistency liquids. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had significant cognitive impairment, required supervision and set-up for eating. Review of the care plan dated 12/13/21 revealed Resident #6 received a pureed diet with honey thick liquids and fortified foods and a care area for eating/nutrition that included honey thickened liquids, no straws, and no water pitcher in room. Review of the Medical Nutrition Therapy assessment dated [DATE] revealed Resident #6 received a pureed diet with honey thick liquids and had coughed/choked with his meal on 12/08/21. Observation on 03/22/22 at 11:20 A.M. of lunch tray line revealed Resident #6's meal ticket specified honey thick liquids, fortified foods, and no soup. The resident's tray included a bowl of cream of celery soup with particles of what appeared to be celery leaves the was not thickened. Interview on 03/22/22 at 11:28 A.M. with Regional Dining Services Director (RDSD) #681 verified the soup was not honey consistency. Review of the meal ticket for Resident #6 revealed the resident was ordered honey thick fluids, half a cup fortified foods with a note: *** NO SOUPS***. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 5 of 14 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 365317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure Resident #40 received assistive devices for meals. This affected one of three residents (Residents #15, #40 and #72) reviewed for nutrition. The facility census was 93. Residents Affected - Few Findings include: Review of the medical record revealed Resident #40 was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disorder (COPD), adult failure to thrive, hypertension, dementia with unspecified psychosis, and high blood pressure. Review of the physician's orders revealed an order dated 04/28/21 for a sippy cup at all meals. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 had severe cognitive impairment requiring supervision/assist of one staff for meals. Review of the care plan dated 01/12/19 revealed a care area for nutrition which included an intervention dated 07/08/21 for a sipper cup with meals. Review of the dietary progress note dated 03/09/22 written by Dietary Technician (DT) #690 revealed Resident #40 had a mechanical soft diet with pureed meats and fortified foods. Intakes were variable 25-100%. Resident #40 utilized a sippy cup during meals to promote maximum meals intake. Weights were as follows: 119.2 pounds (03/02/22), 120 pounds (02/01/22), 124.2 pounds (12/05/21), 132.8 pounds (09/14/21) for a 10.2%-significant weight loss in six months. Observations of Resident #40 on 03/21/22 at 8:35 A.M., 12:45 P.M. and on 03/22/22 at 8:30 A.M. revealed Resident #40 had a container of chocolate milk at each meal with which she struggled repeatedly to insert a straw. Staff were not observed providing any assistance during any of the observations. Resident #40 did not have a sippy cup. Interview on 03/22/22 at 8:48 A.M. with State Tested Nursing Assistant (STNA) #646 verified Resident #40 did not have a sippy cup and STNA #646 was aware of the order for a sippy cup. STNA #646 reported Resident #40 used to use one but had not used one recently. Interview on 03/23/22 at 11:14 A.M. revealed DT #690 was not aware Resident #40 was not using a sippy cup and confirmed the significant weight loss. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 6 of 14 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 365317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, record review, and policy review the facility failed to ensure the dishwasher provided sufficient sanitizer, all food was labeled, dated, and stored properly and food was prepared in a sanitary manner. This had the potential to affect all residents of the facility. The facility also failed to ensure all food in each of the three-unit resident refrigerators was covered and dated. This had the potential to affect all residents. The census was 93. Findings include: 1. Observation on 03/22/21 at 11:05 A.M. of the facility kitchen low-temperature dishwasher revealed the wash temperature of 120 Fahrenheit (F), rinse temperature of 130 F. The sanitizer revealed a level of 50 parts per million (ppm). Interview on 03/22/21 at 11:06 A.M. with Dietary Services Director (DSD) #628 verified the sanitizer was not at a sufficient level. He reported it had been low and a call was placed on 03/21/22 for service to adjust the level. Review of the dishwasher temperature logs from 01/01/22 to 03/22/22 revealed wash temperatures ranged from 125 F to 140 F. There were no rinse temperatures recorded from 01/01/22 to 02/28/22 with incomplete entries for 01/26/22, 01/28/22, 01/30/22, 02/23/22, 02/25/22, 02/26/22 and 02/27/22. The sanitizer level for 01/01/22 to 02/28/22 were marked with a checkmark with no indication of the actual level. The sanitizer was recorded from 03/01/22 to 03/22/22 at 50 ppm. Review of the sanitizer test strips used by the facility revealed the sanitizer should be at 65 to 75 ppm. 2. Observation on 03/21/22 at 7:15 A.M. of the kitchen revealed four opened undated bags of cereal, four opened undated bags of pasta, two open uncovered boxes of cream of wheat, and one plastic container of cereal labeled RB undated. The refrigerator contained one clear pitcher of brown liquid labeled Honey Chex dated use by 02/15/22, 20 cartons of milk with an expiration date of 03/16/22, one opened gallon of orange juice dated sell by 02/10/22, a large metal pan of 12-15 foil wrapped items undated, one container of an unidentifiable item dated 03/13/22 - 03/17/22, and one pan with lunchmeat opened and undated. The freezer contained two bags of opened undated chicken breasts. Interview on 03/21/22 at 7:53 A.M. with [NAME] #636 identified the clear pitcher of brown liquid labeled Honey Chex as chocolate milk, the large metal pan of 12-15 foil wrapped items as chicken sandwiches, and one container dated 03/13/22 - 03/17/22 as egg salad. [NAME] #636 confirmed these items as well as the cereal, pasta, cream of wheat, milk, orange juice, and chicken breasts should have been used or discarded. Review of the facility's policy for Food Storage dated October 2014 stated lunch meats should be discarded seven days after opening. Review of the facility's undated policy for Food Stock Rotation stated dairy items would be used by the expiration date or thrown out and opened items would be dated with the opening date and sealed airtight. Staff were expected to clean the refrigerator daily and discard expired food. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 7 of 14 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 365317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm 3. Observation on 03/22/22 at 10:40 A.M. revealed [NAME] #635 touching her ears, hair, and face, taking beverages from the cooler by the top of the cup and placing them on trays to be served to the residents. Observation on 03/22/22 at 11:00 A.M. revealed Dining Services Aide #631 placing a grey bin of individually wrapped rolls of cutlery on top of a stack of napkins. Residents Affected - Many Interview with Regional Dining Services Director (RDSD) #681 at the time of the observations confirmed [NAME] #635 should have washed her hands prior to placing the drinks on the resident's trays, and the tray of cutlery should not have been placed on the napkins. Review of the facility's Sanitation and Food Handling policy, dated October 2014, stated all employees would wash their hands after touching their hair, nose, face, or other body parts. 4. Observation on 03/23/22 at 8:40 A.M. on the dementia unit revealed approximately two thirds of a an approximately 14-inch fresh fruit pizza, uncovered and unlabeled on the bottom shelf of the refrigerator. Interview on 03/25/22 at 08:45 A.M. with Registered Nurse (RN) #626 verified the fruit pizza should not be uncovered and undated in the refrigerator. Night shift was responsible for taking the refrigerator temperatures and checking the refrigerator. The RN removed the item and disposed of it. Observation on 03/23/22 at 9:10 A.M. of the unit refrigerator for the residents of the 300 and 500 halls revealed a wrapped deli sandwich with a sell by date of 03/20/22 with no labeling indicating ownership and an unlabeled small round plastic food container with a thick off-white liquid. Interview on 03/23/22 at 9:20 A.M. with Licensed Practical Nurse (LPN) #656 verified the sandwich and round plastic container should not have been in the refrigerator unlabeled and had been removed. Observation on 03/23/22 at 9:25 A.M. with LPN #602 of the unit refrigerator for the residents of the 100 and 200 halls revealed two undated plastic containers of food. One had the name of a resident no longer at the facility. Interview on 03/23/22 at 9:25 A.M. with LPN #602 verified the undated food should not have been in the refrigerator. The resident whose name was on the container was discharged on 03/19/22 Review of the undated Food Storage of Outside Food Brought into Facilities Policy revealed residents and families were given a food education sheet upon admission that addresses transport, storage, and reheating (if needed) of perishable food. all perishable food brought in from outside the facility and stored in the facility will be dated and labeled with the resident name. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 8 of 14 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 365317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, policy review, and interview, the facility failed to ensure a resident exhibiting symptoms of new onset shortness of breath, cough, and decreased oxygen saturation levels was tested to rule out COVID-19. This affected one (Resident #69) of 24 residents reviewed for infections. The facility census was 93. Residents Affected - Few Findings include: Review of Resident #69's medical record revealed diagnoses including acute or chronic congestive heart failure (CHF), atrial fibrillation, and malignant neoplasm of the prostate, acute cholecystitis, chronic myeloproliferative disease, diverticulitis of intestine, acute respiratory failure with hypoxia, acute kidney failure, and obesity. Upon admission, an order was written for oxygen at two to five liters per minute via nasal cannula to maintain an oxygen saturation level above 92% if Resident #69 had shortness of breath as needed. A physician's progress note dated 02/11/22 indicated Resident #69 had new onset of atrial fibrillation. Breath sounds were diminished. Edema was noted to the extremities, but pedal pulses were palpable. A physician's progress note dated 02/18/22 indicated breath sounds were clear/diminished and respirations were non-labored. Resident #69 was assessed for shortness of breath with none noted. A physician's progress note dated 03/04/22 indicated assessment for shortness of breath was negative, but Resident #69 did have edema. Breath sounds were clear but diminished. Respirations were non-labored. Resident #69 had chest pain with orders to do an electrocardiogram (EKG) and troponin levels. An order was written for omeprazole (gastric acid secretion reducing agent) 20 milligrams every day. A physician's progress note dated 03/11/22 indicated Resident #69 had no chest pain or dyspnea. Breath sounds were clear but diminished. Respirations were non-labored. A COVID 19 respiratory screen dated 03/17/22 at 11:20 P.M. indicated Resident #69's temperature was 97.2, respirations were 18, and oxygen saturation was 96% on room air. Lung sounds were clear. There was no cough or fatigue, runny nose, sore throat, headache, or shortness of breath. A physician's progress note dated 03/18/22 indicated Resident #69 had no cough, no dyspnea or chest pain. Breath sounds were clear but diminished. Respirations were non-labored. The physician documented acute rhinitis and gave an order to start Claritin (allergy medication). A Medicare Skilled assessment dated [DATE] at 7:20 P.M. indicated Resident #69 was alert and oriented. His temperature was 97.8, pulse was 88, respiratory rate was 18, blood pressure was 108/72, and oxygen saturation was 95% on room air. Lungs were clear to auscultation. Review of oxygen saturation levels between 02/08/22 and 12:00 A.M. on 03/19/22 were documented at or above 90% on room air. A nursing note dated 03/19/22 at 9:11 A.M. indicated Resident #69 had an emesis and loose stool (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 9 of 14 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 365317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 after medication administration. Level of Harm - Minimal harm or potential for actual harm A Medicare Skilled assessment dated [DATE] at 10:10 P.M. indicated Resident #69's temperature was 97.3, pulse was 98, respiratory rate 20, blood pressure 122/70, and oxygen saturation was 83% on room air. Breath sounds were clear to auscultation but diminished at the bases. Resident #69 was started on Doxycycline (antibiotic) for possible lung infection and a chest x-ray was ordered. Resident #69 was experiencing shortness of breath when sitting at rest. Residents Affected - Few A COVID-19 respiratory screen dated 03/19/22 at 10:10 P.M. indicated Resident #69 also had a moist/productive cough and shortness of breath. Oxygen was applied at three liters per nasal cannula. A medication administration record note dated 03/20/22 at 12:11 A.M. indicated oxygen saturation raised to 90% with oxygen at three liters per nasal cannula. A nursing note dated 03/20/22 at 1:43 A.M. indicated Resident #69 continued to exhibit some shortness of breath. An x-ray was to be done at 8:00 A.M. Respiratory rate was 20 and oxygen saturation was 93% on three liters per nasal cannula. Resident #69 denied the need to be transferred to the hospital for evaluation. A nursing note dated 03/20/22 at 3:02 P.M. indicated the physician was notified of STAT x-ray results and an order was placed for Lasix (diuretic) 20 milligrams every day. A Medicare Skilled assessment dated [DATE] at 8:00 P.M. indicated a temperature of 97.5, pulse of 62, respiratory rate of 16, blood pressure of 126/97, and oxygen saturation level of 91% with oxygen on. Lung sounds were diminished at the bases and rales (abnormal lung sounds) in the left lower lobe. Resident #69 had shortness of breath at rest, when lying flat, and with exertion. A nursing note dated 03/20/22 at 8:00 P.M. indicated Resident #69 continued to show use of accessory muscles and oxygen was increased to five liters per nasal cannula. Oxygen saturation levels ranged between 90-93%. The x-ray revealed mild congestive heart failure. The first dose of Lasix was administered. Resident #69 did not wish to be transferred to the hospital for evaluation. A COVID respiratory screen dated 03/20/22 at 8:00 P.M. indicated a temperature of 97.5, respiratory rate of 16, and oxygen saturation of 91% on oxygen. Lung sounds were diminished at the bases with rales auscultated in the left lower lobe. Resident #69 had a moist/productive cough and shortness of breath. Resident #69 reported a less productive cough of yellow sputum. A nursing note dated 03/21/22 at 12:05 P.M. indicated Resident #69 continued using axillary muscles. Respirations were labored and diminished at the bases. Oxygen saturation levels were 90-93% on oxygen at five liters. The physician was notified of lab results. On 03/21/22 at 2:48 P.M., Licensed Practical Nurse (LPN) #602 exited Resident #69's room and informed the surveyor Resident #69 was willing to see the surveyor. LPN #602 stated Resident #69 was short of breath and requested attempts at conversation be restricted to yes or no questions. Observations of Resident #69 revealed he was in bed with the head of the bed elevated and oxygen was running at four liters per minute. Resident #69 was short of breath and gulping for air before being able to speak. Resident #69 indicated the shortness of breath was of quick onset. On 03/21/22 at 3:10 P.M., LPN #602 indicated she had not worked over the weekend but nodded (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 10 of 14 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 365317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few affirmatively when informed Resident #69 indicated the onset of his symptoms was new. LPN #602 was uncertain as to whether a COVID test had been completed to rule out COVID. A chest x-ray had indicated CHF and he was given Lasix. A Medicare Skilled assessment dated [DATE] at 4:00 P.M. indicated a temperature of 97.1, pulse of 94, respiratory rate of 18, blood pressure of 107/66, and oxygen saturation of 93% with oxygen on at five liters. Breath sounds were diminished at the bases, and Resident #69 had shortness of breath at rest and when lying flat. On 03/22/22 at 7:25 A.M., the Director of Nursing (DON) was interviewed regarding the facility's policies, CDC recommendations for symptomatic residents, observations made of Resident #69 and lack of COVID testing with symptoms that could be indicative of COVID 19. The DON stated she knew the physician was aware of Resident #69's symptoms and a chest x-ray had been done. The DON stated she wanted to investigate the matter. On 03/22/22 at 7:40 A.M., an unidentified staff member with full personal protective equipment entered Resident #69's room with COVID testing supplies. At 7:53 A.M., the DON reported the COVID 19 test was negative but Resident #69 agreed to go to the hospital for evaluation. Review of a COVID testing order indicated an order to test all residents and staff on an ongoing basis according to regulatory guidelines. A nursing note dated 03/22/22 at 8:31 A.M. indicated a temperature of 98.2, pulse of 109, respiratory rate of 34, blood pressure of 107/66, and oxygen saturation level of 98% on oxygen. The note indicated shortness of breath, labored or rapid breathing, inability to eat or sleep due to shortness of breath, cough, and abnormal lung sounds. The note indicated the physician had been trying to manage Resident #69 in house due to the resident not wanting to go to the emergency room. The prior evening Lasix was discontinued, and orders were received to get a urinalysis, culture and sensitivity and blood cultures, and to start fluids after a stat chest x-ray. Fluids were delayed by complications. It appeared to be renal failure complicated by CHF causing respiratory failure. Resident #69's continued decline was discussed with the physician and Resident #69 was willing to go to the hospital. An order was received to send Resident #69 to the emergency room for evaluation. A nursing note dated 03/22/22 at 9:10 A.M. indicated at the beginning of the nurse's shift, the day nurse was trying to contact the physician about lab results. New orders were received to discontinue Lasix and to get a urinalysis with culture and blood cultures and to start 0.9% normal saline at 70 milliliters per hour for 48 hours. Resident #69 was assessed, and his respiratory rate was 40 using accessory muscles to breathe. There were no audible lung sounds below the nipple line bilaterally. Stridor was noted on the left side. The physician was notified, and she ordered a stat chest x-ray before the initiation of fluids. The order was completed at 10:30 P.M. Results about an hour and a half later showed improvements. Resident #69 continued to be very short of breath. A COVID test was performed and was negative. Resident #69 was transported to the hospital at 8:00 A.M. A nursing note dated 03/22/22 at 2:50 P.M. indicated Resident #69 was admitted to the hospital with respiratory failure. Review of the facility's COVID-19 Employee, Resident, and Contracted Personnel Testing policy (revised March 2022) revealed the facility would test any residents who had signs or symptoms of COVID 19 no matter of their vaccination status. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 11 of 14 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 365317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Review of facility handout sheets for symptoms of COVID 19 from the Centers for Disease Control (CDC), updated 02/22/21) indicated symptoms included cough, shortness of breath, nausea or vomiting and diarrhea. Older adults and people who had severe underlying medical conditions like heart or lung disease seemed to be at higher risk for developing more serious complications from COVID -19 illness. Emergency warning signs included trouble breathing. Residents Affected - Few Review of CDC Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes (updated 09/10/21) indicated anyone with even mild symptoms of COVID-19, regardless of vaccine status, should receive a viral test as soon as possible. Residents should be actively monitored for symptoms consistent with COVID 19 daily. Ideally, include an assessment of oxygen saturation via pulse oximetry. Older adults with SARS-CoV-2 infection may not show common symptoms such as fever or respiratory symptoms. Because some of the symptoms were similar, it might be difficult to tell the difference between influenza, COVID 19 and other acute respiratory infections, based on symptoms alone. Consider testing for pathogens other than CoV-2 and initiating appropriate infection prevention precautions for symptomatic older adults. On 03/24/22 at 12:10 P.M., Resident #69's attending physician was interviewed. The attending physician indicated Resident #69 had shortness of breath upon admission but had been weaned from oxygen after about one week. The physician indicated Resident #69 had developed symptoms of shortness of breath and cough which was consistent with congestive heart failure and his x-ray. She did not have a COVID test done because he was afebrile. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 12 of 14 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 365317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691 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 - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews the facility failed to provide a safe and homelike environment. This affected three (Resident's #35, #66, and #77) of 24 residents reviewed for environment. The facility census was 93. Findings include: Review of medical record revealed Resident #77 was admitted on [DATE] with diagnoses including syncope and collapse, encephalopathy, and dementia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #77 had mildly impaired cognition. The resident required extensive assistance of two staff for transfers and toileting. Review of medical record revealed Resident #66 was admitted [DATE] with diagnoses including end stage renal disease, respiratory failure, dependence on renal dialysis, and history of transient ischemic attack. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #66 had mildly impaired cognition. The resident required limited assistance of one staff for transfers and toilet use. Review of medical record revealed Resident #35 was admitted on [DATE] with diagnoses including diabetes mellitus, osteoarthritis, and history of falls. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #35 had mildly impaired cognition. The resident required supervision for transfers and toileting. Observation and interview with Resident #35 on 03/21/22 at 11:13 A.M. revealed a clear liquid on the left side of the toilet that was shared by Resident's #35, #66, and #77. Resident #35 stated the floor was wet around the toilet and would run into his room if a bath blanket was not put on the floor. Resident #35 stated the maintenance person only put silicone around the base of the toilet and did not change the wax ring when he was informed the toilet was leaking. Observation on 03/22/22 at 2:24 P.M. revealed the toilet for Resident's #35, #66, and #77 had a large bath blanket on the floor around the toilet. A clear liquid was noted to the left side of the toilet. Interview on 03/22/22 at 3:43 P.M. State Tested Nursing Assistant (STNA) #644 verified the toilet for Resident's #35, #66, and #77's toilet was leaking. Interview on 03/22/22 at 3:51 P.M. Resident #75 stated they were the spouse of Resident #77 and the toilet shared by Resident's #35, #66, and #77 had been leaking for two weeks. Interview on 03/22/22 at 4:00 P.M. with Maintenance Director #669 verified the floor and bath blanket was wet in the bathroom Resident's #35, #66, and #77 shared. Maintenance Director #669 stated he believed the wetness was from a resident urinating on the floor. Maintenance Director #669 stated he had replaced the wax ring to the toilet recently and had put silicone around the base of the toilet. Observation on 03/23/22 at 10:47 A.M. and 1:40 P.M. revealed a wet bath blanket around the toilet shared by Resident's #35, #66, and #77. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 13 of 14 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 365317 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smithville Western Care Center 4110 East Smithville Western Road Wooster, OH 44691 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 Interview on 03/23/22 at 1:42 P.M. Head of Housekeeping #616 verified there had been liquid around the toilet Resident's #35, #66, and #77 used. Head of Housekeeping #616 stated a bath blanket was used because of the liquid on the floor. Head of Housekeeping #616 verified the liquid and a bath blanket were both a potential fall hazard. The housekeepers tried to mop the bathroom and changed the bath blanket several times during the day. Residents Affected - Few Interview on 03/23/22 at 3:24 P.M. Maintenance Director #669 verified the wax ring had not been replaced on the toilet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365317 If continuation sheet Page 14 of 14