Inspection·October 17, 2019

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on interview, record review and policy review, the facility failed to have consistent documentation related to Resident's #47 and #54's wishes related to life-sustaining treatments. This affected two of 24 records during the screening process. Findings include: 1. Review of the medical record revealed Resident #47 was on Hospice services. The medical record had a clear sleeve under the advanced directives tab that had a white sheet of paper indicating DNRCC (do not resuscitate comfort care) and the other side of the clear sleeve was a green sheet indicating DNRCCA (do not resuscitate comfort care arrest). The electronic medical record had DNRCCA in the current physician orders. Review of the Hospice binder contained a DNRCCA form. 2. Review of Resident #54's medical record contained a form under the advanced directives sleeve indicated DNRCCA; however, the electronic medical record current physician orders indicated the resident desired to be Full Code status. Interview with the corporate nurse on 10/17/19 at 9:22 A.M. indicated the nurse should look in the hard chart under advanced directives for the code status. He reviewed Resident #47's progress notes and reported the most recent documentation about code status was in September 2019 after a hospitalization where he had requested to have Full Code status. He verified the advance directive tab in the chart should have been updated to Full Code. Review of the resident's rights policy regarding treatment and advanced directives, dated 01/01/19, upon admission advanced directives would be placed in the chart as well as communicated to staff. The facility would periodically assess for decision making ability and advanced directives would be reviewed during the care planning process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365320 If continuation sheet Page 2 of 16 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 365320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regency Care of Copley 2631 Copley Road Akron, OH 44321 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on recorded review and interview, the facility failed to provide the correct Quality Improvement Organization Appeal information (QIO) on their Notice of Medicare Non-Coverage letter for Residents #32 and #53. This affected two of three residents reviewed for notice of Medicare Non-Coverage. The facility census was 58. Residents Affected - Few Findings include: Review of the Notice of Medicare Non-Coverage letter (NOM-NC), revealed Residents #32 and #53 letters were sent by certified mail within the required time frame. Further review revealed both letters were not updated with the new QIO information for appeals. Interview with Social Worker (SW) #103 on 10/17/19 at 10:00 A.M. confirmed the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365320 If continuation sheet Page 3 of 16 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 365320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regency Care of Copley 2631 Copley Road Akron, OH 44321 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, record review and interview, the facility failed to provide a home like environment. This affected Residents #11, #12, #15, and #48 of 58 residents who reside in the facility. Residents Affected - Some Findings: Environmental tour was conducted with Maintenance Director (MD) #104 on 10/17/19 from 8:25 A.M. to 8:50 A.M. Resident #11's base board padding under the sink had peeled away from the wall exposing the wall and tile flooring. Resident #12's room contained wall damage by the bed, Resident #15's tube feed pole was dirty, and Resident #48's door to the room had significant damage by the door handle where the catch lock meets when closing the door. Review of the maintenance request log did not reveal any work orders for the rooms that were inspected. Interview with the MD #104 on 10/17/19 at 8:50 A.M. confirmed the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365320 If continuation sheet Page 4 of 16 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 365320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regency Care of Copley 2631 Copley Road Akron, OH 44321 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on staff interview, review of personnel files and the abuse policy and procedure, the facility failed to implement policies and procedures including screening of all employees against the State of Ohio Nurse Aide Registry to identify if an employee had a finding concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property and failed to obtain reference checks. This affected four (Housekeeping Staff #60, #62 and #63 and Dietary Aide #61) of personnel files reviewed. This had the potential to affect all 58 residents in the facility resulting in substandard quality care. Residents Affected - Many Findings include: Review of 12 personnel files revealed four staff were not checked against the State of Ohio Nurse Aide Registry. Review of three Housekeeping Staff (#60, #62 and #63) and Dietary Aide #61 lacked evidence they were screened against the State of Ohio Nurse Aide Registry for negative findings. State Tested Nurse Aides (STNA) #64, #65 and #66, Registered Nurses (RN) #67 and #71 and Licensed Practical Nurses (LPN) #68, #69 and #70 had evidence they were screened on the State of Ohio Nurse Aide Registry and were in good standing. The identification of findings would be necessary to determine if any employee had actions identified that would validate allegations of abuse, neglect, exploitation, mistreatment of residents, or misappropriation of their property. The facility provided a document that they hired 52 staff since the last annual survey dated 09/20/19. Twelve of the new hires were not nurses, aides, therapy or activity staff and had no evidence they were screened against the State of Ohio Nurse Aide Registry. Interview with the Business Office Manager (BOM) #420 on 10/16/19 at 8:50 A.M. indicated only the nurses and aides had been checked. Interview with the Administrator on 10/16/19 at 9:10 A.M. said the Ohio Department of Health Abuse Investigator came out and told him he had to check all staff against the State of Ohio Nurse Aide Registry. Interview with the Corporate Nurse on 10/16/19 at 10:26 A.M. provided evidence the facility screened all activity, housekeeping, laundry and dietary staff today against the State of Ohio Nurse Aide Registry. Interview with BOM #420 on 10/16/19 at 10:41 A.M. verified activity, housekeeping, dietary and laundry staff had not been screened against the State of Ohio Nurse Aide Registry until this morning. Review of the Ohio Resident Abuse Policy dated 03/03/17 identified screening to include not employing individuals who had a finding of abuse, neglect, mistreatment, exploitation, involuntary seclusion and/or misappropriation of property reported into a state nurse aide registry. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365320 If continuation sheet Page 5 of 16 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 365320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regency Care of Copley 2631 Copley Road Akron, OH 44321 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 provide personal hygiene and bathing services for Resident's #30 and #35 who were dependent on staff for activities of daily living. This affected two Residents (#30 and #35) of five Residents (#5, #15, #30, #35 and #52) reviewed for activities of daily living. The facility census was 58. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including open wound right lower leg, Methicillin resistant staphylococcus aureus infection, morbid obesity, Parkinson's disease, heart failure, diabetes, chronic pain, dementia without behaviors, major depressive disorder, schizophrenia, peripheral vascular disease and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated she was severely cognitively impaired and was totally dependent on one person for bathing. Review of the activity of daily living plan of care indicated she required the extensive assistance of one staff with bathing/showing as necessary and to provide a sponge bath when a full bath or shower could not be tolerated. Review of the nurse aide documentation indicated she was to be bathed on Monday's and Thursdays. Review of the electronic bath records and the shower sheets revealed she received six of eight showers in August 2019, five of nine showers in September 2019 and two of four in October 2019. Resident #35 was observed on 10/15/19 at 1:26 P.M. and daily through 10/17/19 at 10:05 A.M. to have greasy separated hair. Interview with the family on 10/17/19 at 9:35 A.M. said Resident #35's hair was oily, and he wished she could have more baths. He said prior to her admission she bathed daily. He said he requested she receive more baths in the past but said due to the lack of staff they bathe residents once a week. Interview with the Director of Nursing on 10/17/19 at 2:57 P.M. indicated the resident just got a shower today after surveyor inquiry. 2. A medical record review revealed Resident #30 was admitted to the facility on [DATE] with the diagnoses of chronic ischemic heart disease, dementia, cerebral infarction, major depressive disorder, noncompliance, psychosis, mild cognitive impairment, anemia and schizophrenia. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #30 had severely impaired cognition and required extensive assistance of one staff member for all activities of daily living. The resident was always incontinent of bowel and bladder. Observations on 10/16/19 at 9:00 A.M. and 10/17/19 at 8:33 A.M. revealed Resident #30 had not been shaved. An interview on 10/17/19 at 10:00 A.M. the Director of Nursing indicated the residents should be shaved as needed. An interview on 10/17/19 at 10:26 A.M. Licensed Practical Nurse (LPN) #401 indicated she was not aware of Resident #30 refusing to be shaved. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365320 If continuation sheet Page 6 of 16 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 365320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regency Care of Copley 2631 Copley Road Akron, OH 44321 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview on 10/17/19 at 3:52 P.M. State Tested Nursing Assistant (STNA) #402 indicated the men were shaved usually every other day. She indicated she shaved Resident #30 on Sunday when she was here. She verified he needed to be shaved. An interview on 10/17/19 at 3:54 P.M. Resident # 30 indicated he liked to be clean shaved and wanted shaved. Review of the facility policy dated 01/01/19, Grooming a Resident's Facial Hair, revealed it was the practice of the facility to assist residents with grooming facial hair to help maintain proper hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365320 If continuation sheet Page 7 of 16 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 365320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regency Care of Copley 2631 Copley Road Akron, OH 44321 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 - Few 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 observations, medical record review and staff interview, the facility failed to provide restorative nursing programs as recommended by the physical therapist. This affected one resident (Resident #15) of two reviewed for mobility and a decline in activities of daily living. The facility census was 58. Findings include: Review of a medical record revealed Resident #15 was admitted to the facility on [DATE] withe the diagnoses of anoxic brain damage, quadriplegia, dysphagia, contractures of muscle at multiple sites, spinal stenosis, gastrostomy, chronic respiratory failure and poisoning by heroin. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 had severely impaired cognition, required total dependence of two staff members for bed mobility, transfers, dressing, toilet use, required one staff member for personal hygiene and was not on restorative programs. She was always incontinent of bowel and bladder. Observation on 10/16/19 at 9:14 A.M. revealed Resident #15 had extensive contractures to both elbows, both wrists, both knees and all of her fingers. Review of the Occupational Therapy Discharge summary dated [DATE] revealed the staff was to be providing Resident #15 with a maintenance program for passive range of motion (PROM) to her bilateral upper extremities (BUE) to decrease any further contractures of BUE. An interview on 10/17/19 05:22 PM the Director of Nursing verified there was no documentation Resident #15 had received restorative nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365320 If continuation sheet Page 8 of 16 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 365320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regency Care of Copley 2631 Copley Road Akron, OH 44321 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide Resident #32 with intervention to prevent constipation. This affected one resident (Resident #32) of five reviewed for unnecessary medications. The facility census was 58. Findings include: Review of a medical record revealed Resident #32 was admitted to the facility on [DATE] with the diagnoses of dementia, anxiety disorder, osteoporosis, and muscle weakness. Review of the 60-day Minimum Data Set (MDS) 3.0 assessment revealed Resident #32 had severely impaired cognition, required extensive assistance of two staff members for transfers and one staff member for toilet use. The resident was frequently incontinent of bowel and bladder. Observation on 10/15/19 at 9:30 A.M. Resident #32 was moaning and complaining of her belly hurting. She indicated she had to go to the bathroom, and she had not had a bowel movement for four days. Review of the October 2019 physician's orders revealed an order dated 09/30/19 for 100 milligrams (mg) of Colace, a stool softener, twice a day for constipation and a order dated 10/14/19 for 30 milliliters (ml) of Milk of Magnesia Suspension (MOM), a laxative, every 24 hours as needed for constipation, however the MOM was never administered. Review of the Bowel Elimination Record from 10/01/19 to 10/13/19 revealed Resident #32 had not had a bowel movement (BM) documented. The resident had had a small BM on 10/14/19, a medium BM an 10/15//19 and 10/17/19. An interview on 10/17/19 at 3:22 P.M. the Director of Nursing indicated the facility does not have a bowel protocol. She verified Resident #32 had not had a BM documented from 10/02/19 to 10/13/19. She indicated the computer would trigger a warning if the resident had not had a BM in three days, and the nurse's were to administer something to the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365320 If continuation sheet Page 9 of 16 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 365320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regency Care of Copley 2631 Copley Road Akron, OH 44321 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to timely address Resident #15's weight loss. This affected one resident (Resident #15) of two residents reviewed for nutrition. The facility census was 58. Findings included: Review of a medical record revealed Resident #15 was admitted to the facility on [DATE] with the diagnoses of anoxic brain damage, quadriplegia, dysphasia, contractures of muscle at multiple sites, spinal stenosis, gastrostomy, chronic respiratory failure and poisoning by heroin. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 had severely impaired cognition, required total dependence of two staff members for bed mobility, transfers, dressing, toilet use, required one staff member for personal hygiene and was not on restorative programs. She was always incontinent of bowel and bladder. The resident had not had a weight loss or gain and received enteral tube feeding. Review of the October 2019 physician's order revealed an order dated 09/12/19 for an enteral feed tube of Isosource 1.5 at 55 milliliters an hour continuously. Review of weights revealed Resident #15 had weighed 120.4 pounds on 08/02/19 and dropped to 114.2 on 09/01/19 for a loss of 6.56 percent in six months and a loss of five percent for one month. The resident's current weight was 118.4 for a 4.2 pound weight gain since the resident enteral tube feed was increased. An interview on 10/17/19 at 10:15 A.M., Registered Dietitian #400 indicated she had just started last week and did not know why Resident #15's weight loss was not address until 09/12/19. She verified at this time Resident #15 had a significant weight loss from 08/02/19 to 09/01/19 with no interventions put into place until 09/12/19. Review of the facility policy, Weight Monitoring, dated 01/01/19, revealed based on the resident's comprehensive assessment, the facility would ensure all residents maintain acceptable parameter of nutritional status, such as usual body weight or desirable body weight range and electrotype balance, unless the residents's clinical condition demonstrates this was not possible or resident preferences indicate otherwise. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365320 If continuation sheet Page 10 of 16 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 365320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regency Care of Copley 2631 Copley Road Akron, OH 44321 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** Based on observation, staff interview, review of manufacture guidelines and review of the facility policy, the facility failed to discard expired culture tubes in the Emerald unit medication room and Lantus insulin for Resident #5. This had the potential to affect 29 residents (Resident #28, #33, #42, #9, #54, #49, #16, #52, #36, #19, #45, #57, #47, #35, #59, #23, #13, #44, #259, #26, #7, #29, #5, #25, #50, #38, #6, #56 and #10) on the Emerald unit and Resident #5 on the Sapphire unit. Findings include: 1. Observation on [DATE] at 8:35 A.M. of the Emerald unit Medication storage room with Registered Nurse (RN) #405 revealed 23 Remel Micro Test M6 culture tubes with the expiration date of [DATE]. An interview at this time, RN #405 verified the culture tubes were expired. 2. Observation on [DATE] at 10:05 A.M. of the Sapphire unit medication cart with Licensed Practical Nurse (LPN) #401 revealed a 10 milliliters (ml) multiple dose vial of Lantus insulin for Resident #5 had an opened dated on [DATE] (36 days). An interview at this time LPN #401 indicated insulin should only be opened in the medication cart for 30 days. She verified the Lantus insulin for Resident #5 was passed the date safe to be used. Review of the facility policy dated [DATE], Medication Disposal and Returns, revealed the nursing staff would date multi-dose vials and discard opened vials as outlined to decrease the risk of contamination and bacterial or fungal growth from multi-dose vials. When initially entering a multiple dose, nursing staff shall date the vial when first entered. If a multi-dose has been opened or accessed, the vial should be dated and discarded within 28 days unless the manufacturer recommendations or available literature specifies a different date for that opened vial Review of the Sanofi-Aventis Lantus manufacturer guidelines section 16.2 revealed a 10 ml multiple- dose vial was good for 28 days opened at room premature, 28 days not in use unopened at room temperature, and not in use unopened in the refrigerator until expiration date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365320 If continuation sheet Page 11 of 16 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 365320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regency Care of Copley 2631 Copley Road Akron, OH 44321 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. 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 and staff interviews, the facility failed to obtain physician's order laboratory tests for Resident #30. This affected one (Resident #30) of 23 residents records reviewed. The facility census was 58. Residents Affected - Few Findings include: A medical record review revealed Resident #30 was admitted to the facility on [DATE] with the diagnoses of chronic ischemic heart disease, dementia, cerebral infarction, major depressive disorder, noncompliance, psychosis, mild cognitive impairment, anemia and schizophrenia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 had severely impaired cognition and required extensive assistance of one staff member for all activities of daily living. The resident was always incontinent of bowel and bladder. Review of the October 2019 physician's orders revealed Resident # 30 had an order dated 09/12/19 to obtain three stool samples for occult blood. Review of laboratory tests dated 09/12/19 revealed Resident #30 had a low hemoglobin level of 8.8 grams per deciliter (g/dL) with normal levels being 14.0-18.0 g/dL. Review of laboratory tests dated 06/03/19 revealed Resident #30's previous hemoglobin level was 10.1 g/dL. Review of the physician's progress notes date 09/12/19 revealed Resident #30 hemoglobin was low at 8.8 g/dL, and a stool for occult blood was ordered. Review of the September 2019 Medication Administration Records (MARS) revealed the order for occult blood stools were on the MARS but were never obtained and sent to the laboratory. Review of the October 2019 MARS revealed the order for occult blood stools were on the MARS but were never obtained and sent to the laboratory. Review of the bowel movement record from September 2019 revealed Resident #30 had bowel movements on 09/12/19, 09/16/19, 09/17/19, 09/19/19, two times on 09/20/19, two times on 09/21/19, 09/22/19, 09/23/19, 09/25/19, 09/26/19, 09/27/19, 09/28/19, and 09/29/19 An interview on 10/17/19 at 11:20 A.M. Licensed Practical Nurse (LPN) #410 indicated he had wrote the order for the laboratory tests and put the order into the computer. LPN #410 indicated the facility sent the occult blood stools out to the laboratory to be tested, and the laboratory would send the results to the facility. Interview on 10/17/19 at 3:15 P.M. the Director of Nursing verified Resident #30's stools were never sent to the laboratory to be tested for occult blood. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365320 If continuation sheet Page 12 of 16 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 365320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regency Care of Copley 2631 Copley Road Akron, OH 44321 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and policy review, the facility failed to maintain a clean and sanitary kitchen. This affected all residents who take food by mouth. The facility census was 58. Residents Affected - Many Findings include: The initial tour of the kitchen was conducted with the Dietary Manager (DM) #404 on 10/15/19 at 8:45 A.M. The DM #404 verified the following: the walk in cooler had a container the DM #404 identified as containing coleslaw and another with vegetables that was not labeled or dated. A milk carton and dried spilled milk was on the floor in the walk in cooler. A cup was stored in a container the DM #404 identified as thickener. The large stand mixer was heavily splattered with a dried beige substance on the splash guard, turning mechanism and outside of the bowl. The whish attachment stored in the bowl also had areas of dried food debris. Two Vulcan ovens were heavily rusted on the outside. There was a moderate amount of food debris on the floor of the oven. The back covers were stained and had oily drips over the flat top. The space between the flat top and the burners had black charred food debris. The wall behind the ovens had a moderate amount of grease. Three tiered carts were observed to transport food from one area to the other and were soiled with food debris. The floor and wall in the dish washing area was heavily soiled with thick scum. Interview with DM #404 on 10/15/19 at 9:00 A.M. verified the above observations. She said the dietary aides were responsible for cleaning and labeling items. Tray line temperatures were observed on 10/16/19 at 7:25 A.M. by Dietary Aide (DA) #421. She took a probe thermometer out of the sheath and put it into oatmeal. She began looking around for a wipe. There were alcohol wipes on the shelf next to her. She looked over the alcohol wipes and said she does not want to use them. She got a white towel and wiped the probe of the thermometer. She tested cream of wheat, egg patty, sausage patties, puree eggs and pureed muffins and wiped off the probe with the dish towel after each food item. After the food temperatures were taken the tray line began. There was a tray of coffee in mugs with lids. There was an excess amount of spilled coffee on the tray and some on the plastic lids. Each cup that was put on a food tray splashed coffee on the meal tray and onto the clean napkins. On 10/16/19 at 11:00 A.M., DA #421 was observed to puree foods. The DM #404 had to direct her to change her gloves and wash her hands prior to hand tearing food to place in the food processor. At the end of the process, after DA #421 tore food, poured milk out of a gallon jug, operated the food processor and stirred the mixture, she used her soiled gloved finger to scrape food from the rubber spatula into the steam table pan. During a test tray on 10/16/19 at 12:04 P.M., DM #404 was observed to use an alcohol swab to cleanse the probe of the thermometer. Interview with DM #404 on 10/16/19 at 12:04 P.M. verified the probe thermometer should be cleansed with an alcohol swab after each food item. Review of the undated thermometer policy and procedure indicated to clean and sanitize the thermometer before and between each product tested. The use of individually wrapped alcohol pads were acceptable; however, allow time for the alcohol to evaporate before using. 2. Observation on 10/15/19 at 11:50 AM revealed the closed metal meal cart came of out to the Emerald unit with lunch trays. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365320 If continuation sheet Page 13 of 16 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 365320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regency Care of Copley 2631 Copley Road Akron, OH 44321 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 outside of the meal cart had a large amount of a white substance and a tan substance splashed all over the outside of the cart. There was a thick, black, sticky substance on the bottom ledge of the meal cart along with a large amount of food debris. The inside of the meal cart had a white substance splashed inside of it and had a large amount of food debris littering the bottom shelve. There were old, dried, noodles in the bottom corners in the inside of the meal cart. An interview at this time, State Tested Nursing Assistant (STNA) #406 verified the meal cart was very dirty. She indicated the meal carts were always dirty, you always are putting your hand in something sticky, and it was gross. Observation on 10/15/19 at 12:00 P.M. the metal meal cart came out to the Sapphire unit with lunch trays. The outside of the meal cart had a white substance splashed al over the outside of it. There was a thick, black, sticky substance on the bottom ledge of the meal cart along with food debris. The inside of the meal cart had a large amount of dried food debris in the corners. An interview at this time, STNA #407 verified the meal cart was very dirty. Review of the cleaning task worksheet revealed it was the morning and evening dishwashers responsibility to clean the meal carts twice a day. An interview on 10/16/19 at 3:45 P.M. Dietary Manager #404 indicated the meal carts were to be cleaned in the morning after breakfast and in the evening after supper. She indicated the staff indicated to her the meal carts had been cleaned. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365320 If continuation sheet Page 14 of 16 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 365320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regency Care of Copley 2631 Copley Road Akron, OH 44321 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Potential for minimal harm Based on interview and review of the Quality Assessment and Assurance (QAA) Committee attendance records, the facility failed to ensure the QAA committee ensured the Medical Director or his/her designee attended the quarterly QAA meetings. This had the potential to affect all 58 residents. Residents Affected - Many Findings include: Review of the two QAA attendance records dated 04/30/19 and 07/30/19 verified the Medical Director nor his designee attended the meetings to provide valuable perspective in identifying, analyzing and correcting problems in resident care areas and other areas affecting the facility. Interview with the Administrator on 10/15/19 at 10:30 A.M. during the entrance conference and further interview with the Administrator during the QAA interview on 10/17/19 at 4:49 P.M. verified the Medical Director nor his designee attended the quarterly QAA meetings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365320 If continuation sheet Page 15 of 16 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 365320 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regency Care of Copley 2631 Copley Road Akron, OH 44321 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and review of pest control documentation, the facility failed to maintain a pest free environment. This affected all 58 residents in the facility. Residents Affected - Many Findings include: The kitchen was observed on 10/15/19 at 8:45 A.M. There were small winged flying insects near the dish washing area and around the steam table. Interview with Dietary Manager (DM) #420 on 10/15/19 at 9:00 A.M. said they had a problem with gnats. She said after each meal she puts bleach down the drains and was not able to eliminate the gnats. A subsequent visit to the kitchen on 10/16/19 at 11:00 A.M. revealed gnats were still flying around the kitchen. Interview with Director of Maintenance #104 on 10/16/19 at 2:50 P.M. said they have monthly pest control who treat the kitchen for gnats, and the Dietary Manager also does a bleach treatment after every meal. Review of the pest control service reports indicated the facility was treated for flying insects monthly. The service report dated 04/29/19 indicated the kitchen had an accumulation of food product in grout lines from damaged goods noted. It noted to please remove food product to prevent attraction by pests. Standing water was identified in the kitchen. This could provide a breeding site for flies. Standing water should be eliminated. On 05/22/19, the kitchen had the same recommendations as 04/29/19. The severity was medium. The drains were treated for fruit flies. On 06/12/19, debris or other material in the drain causing a blockage in the kitchen. Please remove the debris to unblock the drain and prevent attraction by pests. Mop sink. An accumulation of food product in grout lines from damaged goods noted. Please remove food product to prevent attraction by pests. Standing water in the kitchen could provide a breeding site for flies. Eliminate standing water. On 08/29/19, they treated all floor drains, conducted a thorough inspection and made recommendations to staff. On 09/18/19, a high severity of an accumulation of food product from damaged goods was noted. Please remove food product to prevent attraction by pests. A water leak/standing water was inside the kitchen. The recommendation was to please remove water and repair the leak to prevent unsanitary conditions and attraction by pests, debris or other material in the drain was causing a blockage. Please remove debris to unblock the drain and prevent attraction by pests. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365320 If continuation sheet Page 16 of 16