Health inspection·March 10, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 03/06/23 at 9:34 A.M. an interview with State Tested Nursing Assistant #479 verified the call light was not within reach of Resident #38. Review of the undated facility policy titled, Call Light, revealed the purpose was to use a call light or sound system to alert staff to the residents need. The call light should be positioned conveniently for use and within reach. 3. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE]. Diagnoses included osteoarthritis of the right and left knee, COVID-19, Vitamin B deficiency, Vitamin B deficiency, obstructive sleep apnea, carpel tunnel, hypertension, insomnia, allergic rhinitis, cognitive communication deficit, and sarcopenia. Review of the annual Minimum Data Set assessment dated [DATE] revealed Resident #47 had moderately impaired cognition. She required extensive assistance of one staff for bed mobility, dressing, toilet use and personal hygiene and two staff for transfers. Observations on 03/06/23 at 7:15 A.M. and 8:30 A.M. revealed Resident #47 was sitting up on the side of the bed reading the bible, her call light was on the floor under her bed out of her reach. On 03/06/23 at 8:30 A.M. an interview with State Tested Nursing Assistant #479 verified the call light for Resident #47 was not within her reach. Review of the undated facility policy titled, Call Light, revealed the purpose was to use a call light or sound system to alert staff to the residents need. The call light should be positioned conveniently for use and within reach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365340 If continuation sheet Page 2 of 9 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 365340 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barberton Post Acute 85 Third Street SE Barberton, OH 44203 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident #38's wheelchair referral was completed timely to obtain medical equipment to aide in proper positioning. This affected one Resident (#38) of three reviewed for positioning and mobility. Residents Affected - Few Findings include: Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, contracture of the right and left hand, COVID-19, obstructive and reflux uropathy, circadian rhythm sleep disorder, depression, hypertension, reduced mobility, abnormal weight loss, osteoporosis, sarcopenia, and dysphagia. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #38 had severely impaired cognition, required extensive assistance of two staff for bed mobility,dressing, toilet use, personal hygiene and total assistance of two staff for transfers. she had an indwelling catheter and was frequently incontinent of bowel. Review of Resident #38's physical therapy discharge record dated 10/27/22 revealed Resident #38 had a facility owned tilt in space wheelchair that was too wide and required pillows to maintain midline. Review of the home medical equipment order form dated 12/27/22 revealed a wheelchair was ordered for Resident #38. Review of the Notice of Denial of Medical Coverage dated 01/03/23 revealed Resident #38 was denied a medical item, push wheelchair with features. Observations on 03/06/23 at 7:15 A.M., 9:33 A.M., 11:30 A.M., and 1:30 PM. revealed Resident #38 was sitting in a tilt in space wheelchair with pillows on both sides of her keep her for leaning too far to the one side. On 03/09/23 at 3:00 P.M. an interview with Director of Therapy #400 revealed she had recommended a new wheelchair for Resident #38 on 10/18/22. On 03/09/23 at 3:18 P.M. an interview with Assistive Technician Professional #401 revealed she started the referral for Resident #38 back in October 2023 but verified she had no documentation to indicate she started the referral prior to 12/27/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365340 If continuation sheet Page 3 of 9 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 365340 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barberton Post Acute 85 Third Street SE Barberton, OH 44203 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 observation, review of the medical record and staff interviews, the facility failed to ensure assistive devices where in place for Resident #22 and Resident #44 to assist in maintaining range of motion. This affected two Residents (Resident #22 and #44) of three reviewed for range of motion and mobility. Findings included: 1. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE]. Diagnoses included respiratory failure, disorder of bone density, right hand contractures, COVID-19, asthma, aphasia, tracheostomy, major depressive disorder, cerebral aneurysm, encephalopathy, muscle wasting, intracerebral hemorrhage, peripheral vascular disease, epilepsy, anxiety disorder, nontraumatic subarachnoid hemorrhage, dysphagia, symbolic dysfunctions and paralytic syndrome following cerebrovascular disease. Review of the occupational therapy note dated 12/09/21 revealed Resident #22 had a history of a right hand flexor contracture with a palm protector in place from a previous occupational therapy intervention. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #22 had severely impaired cognition. She required extensive assistance of two staff members for bed mobility, transfers, dressing, toilet use, personnel hygiene, and toilet assistance of one staff for eating. She was always incontinent of bowel and bladder. Review of the undated nursing assistant Kardex revealed Resident #22 had right palm protector, may be worn at all times and removed for comfort, hygiene and skin checks. Review of the March 2023 physician's orders revealed Resident #22 did not have an order for palm protectors. Observations on 03/06/23 at 11:40 A.M. and 1:40 P.M., on 03/08/23 at 8:24 A.M., 1:49 P.M. and 3:00 P.M. and on 03/09/23 at 8:40 A.M. the hand roll for Resident #22 was laying on the dresser across the room. On 03/09/23 at 8:45 A.M. an interview with Licensed Practical Nurse #421 verified Resident #22 did not have her hand roll in her right hand and it was on the dresser across the room. She stated she does wear it but sometimes she would take it off. She stated there was not documentation she removed it in her progress notes or plan of care. Review of the undated facility policy titled, Braces/Splints, revealed the purpose to maintain functional range of motion, decrease muscle contractures and provide support and alignment for weakened limbs through use of braces and/or splints. 2. Review of the medical record for Resident #44 revealed an admission date of 10/04/22. Diagnoses included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, left hand contracture, stage III chronic kidney disease, morbid obesity, type II diabetes mellitus and epilepsy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365340 If continuation sheet Page 4 of 9 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 365340 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barberton Post Acute 85 Third Street SE Barberton, OH 44203 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 Review of the 10/17/22 occupational therapy initial evaluation for Resident #44 revealed treatment for a diagnosis of left-hand contracture with a goal of Resident #44 to wear palm protector on left hand for four plus hours daily with good comfort, fit, effectiveness and skin integrity. Review of Resident #44's care plan revealed activities of daily living self-care deficit as evidenced by requiring extensive assistance related to physical limitations. Interventions initiated on 10/31/22 included a left palm protector. Review of the 11/07/22 occupational therapy discharge summary revealed Resident #44 was tolerating the palm protector on her left hand without issues, staff were aware of wear schedule and proper application procedure. Review of Resident #44's medical record Kardex under Activities of Daily Living (ADLs) revealed a left palm protector may be worn at all times. Resident #44 may remove for comfort and hygiene. Review of the comprehensive Minimum Data Set (MDS) quarterly assessment for Resident #44 dated 01/11/23, revealed the resident had intact cognition. Resident #44 was noted to need extensive assistance of two staff for dressing, toileting and personal hygiene. Review of Resident #44's nursing progress notes from 10/01/22 through 03/08/23 did not reveal any indication of left palm protector being offered or resident refusal. Observation on 03/08/23 at 7:50 A.M. of Resident #44 revealed she did not have the left-hand palm protector on. Interview at the time of the observation with Resident #44 confirmed she was not wearing the palm protector and was unsure where it was. Interview on 03/08/23 at 10:19 A.M. with Licensed Practical Nurse (LPN) #456 confirmed Resident #44 was not wearing the left palm protector. LPN #456 stated she was unaware of an order for a left palm protector. Upon search in Resident #44's dresser, LPN #456 found the left palm protector. Observation on 03/09/23 at 11:50 A.M. of Resident #44 revealed she was wearing the left palm protector. Interview at the time of the observation revealed she used to wear the palm protector a long time ago but had not been asked about wearing the palm protector for some time. Review of 2023 facility policy called; Braces/Splints revealed facility procedure was to follow the wearing schedule as outlined by practitioner's order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365340 If continuation sheet Page 5 of 9 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 365340 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barberton Post Acute 85 Third Street SE Barberton, OH 44203 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - 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 #26's received adequate respiratory care to comprehensively address and prevent respiratory distress resulting in hospitalization. Residents Affected - Few Actual harm occurred on 02/07/23 when Resident #26 was transferred and then admitted to the intensive care unit for uncompensated respiratory acidosis requiring non-invasive ventilation. Between 02/05/23 and 02/07/23 the resident had shortness of breath, non-productive cough, audible wheezing, loss of appetite and complaints of not feeling well which were not adequately or timely addressed/treated resulting in the resident's continued deterioration in health and subsequent hospitalization. This affected one resident (#26) of two residents reviewed for hospitalizations. Findings include: Review of open electronic medical record for Resident #26 revealed admission date of 10/16/20 and diagnoses included acute and chronic respiratory failure with hypoxia, morbid obesity due to excess calories, need for assistance with personal care, and diabetes mellitus. Resident #26 had a hospitalization from 02/07/23 to 02/16/23 for acute respiratory failure. Review of progress note dated 02/05/23 at 7:43 A.M. revealed Resident #26 was given Albuterol Sulfate Nebulizer treatment for productive cough with audible wheezing. Review of progress note dated 02/05/23 at 11:04 A.M. revealed Resident #26 was given another Albuterol Sulfate Nebulizer treatment for shortness of breath and wheezing. Review of progress note dated 02/05/23 at 5:33 P.M. revealed Resident #26 indicated she was not feeling well. Resident #26 did not have a fever and was refusing to eat dinner. Review of progress note dated 02/05/23 at 9:59 P.M. revealed Resident #26 had shortness of breath, a productive cough, and oxygen (O2) saturation of 87 percent (%). Resident #26 was placed on two liters (L) of O2 and O2 saturation came up to 93%. Resident #26 was given scheduled inhaler. Progress note indicated will continue to monitor. There was no evidence of contact with physician or nurse practitioner. Review of physician's orders from 02/05/23 revealed no order for O2 treatments or monitoring of respiratory status. Review of progress notes dated 02/06/23 revealed no follow up or monitoring of Resident #26's respiratory status. There was no evidence of contact with physician or nurse practitioner. Review of physician's orders from 02/06/23 revealed no order for O2 treatments or monitoring of respiratory status. Review of Minimum Data Set (MDS) Discharge assessment dated [DATE] revealed Resident #26 was sent to acute care hospital and was having shortness of breath with exertion, sitting at rest, and lying flat. Review of the plan of care revealed Resident #26 had no care plan initiated to address her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365340 If continuation sheet Page 6 of 9 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 365340 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barberton Post Acute 85 Third Street SE Barberton, OH 44203 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 0695 respiratory needs. Level of Harm - Actual harm Review of O2 saturation summary from January 2023 to February 2023 revealed Resident #26's O2 saturation on 01/25/23 was 97% on room air, on 02/07/23 was 75% on room air, and on 02/17/23 was 90% on room air. There were no additional instances of monitoring documented from 02/05/23 to 02/07/23. Residents Affected - Few Review of the medication administration record (MAR), and treatment administration record (TAR) from February 2023 revealed Resident #26 received Spiriva inhaler (two puffs) once daily for chronic obstructive pulmonary disease (COPD), Symbicort inhaler (one puff) twice daily for acute/chronic respiratory failure with hypoxia, and Albuterol sulfate nebulizer (one application) every four hours as needed. There was no evidence of O2 treatments ordered or provided. Review of paper medical record for Resident #26 revealed no physician's orders for O2 treatments, no monitoring of respiratory status, and no evidence of notification/evaluation by physician/nurse practitioner from 02/05/23 to 02/06/23 for Resident #26's change in condition. Review of progress note dated 02/07/23 at 9:40 P.M. revealed Resident #26 was having respiratory distress and physician was notified. Physician gave order to send to hospital. Review of Acute Care Transfer assessment dated [DATE] revealed Resident #26 had and unplanned transfer related to respiratory distress. Review of vital signs revealed Resident #26's O2 saturation was 75%, pulse was 135 beats per minute (bpm), and 20 respirations per minute. Review of progress note dated 02/08/23 at 1:24 A.M. revealed Resident #26 was admitted to intensive care unit with diagnosis of respiratory infection. Review of hospital documentation dated 02/08/23 revealed Resident #26's chief complaint was shortness of breath. Resident #26 arrived at emergency room on three liters of O2 with O2 saturation of 93%. Resident #26 was given DuoNeb (bronchodilator treatment that relaxes and opens airway to lungs to make breathing easier) treatment by emergency medical services enroute. Infectious work up was started and intensive care unit (ICU) was consulted for admission due to carbon dioxide retention and need for non-invasive ventilation (NIV) (mechanism to deliver positive pressure ventilation via face mask rather than intubation). Upon evaluation Resident #26 had confusion and had productive cough with brown sputum. Arterial blood gas (ABG) test revealed uncompensated respiratory acidosis. Resident #26 was placed on NIV and admitted to ICU. Resident #26 lung sounds were diminished with wheezing and was tachycardic. Resident #26 was started on 60 milligrams (mg) Solumedrol every six hours for COPD, Levalbuterol three times daily for tachycardia, and Cefepime and Vancomycin for pending infectious disease work-up. Resident #26 was diagnosed with acute kidney injury, human metapneumovirus, and right lower lobe pneumonia secondary to strep pneumonia. Interview on 03/09/23 at 10:31 A.M. with Director of Nursing (DON) confirmed Resident #26 received O2 treatments without an order, there was no evidence of physician notification, no evidence of continued monitoring of Resident #26's respiratory status, and there was no evidence of a care plan to address Resident #26's respiratory status. DON confirmed Resident #26 went out to hospital for respiratory distress on 02/07/23. Interview on 03/09/23 at 11:09 A.M. with Licensed Practical Nurse (LPN) #422 via phone revealed Resident #26's roommate had been sick shortly before Resident #26 had started showing signs of shortness of breath. LPN #422 recalled Resident #26's O2 saturation was low on 02/05/23 and the resident was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365340 If continuation sheet Page 7 of 9 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 365340 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barberton Post Acute 85 Third Street SE Barberton, OH 44203 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 0695 Level of Harm - Actual harm Residents Affected - Few provided with nebulizer treatment. LPN #422 indicated the resident's O2 saturation was lower than she had ever seen for the resident, so she contacted the physician who gave order for O2 treatment. LPN #422 indicated she applied O2 treatment and checked back half and hour later with improvements in O2 saturation. LPN #422 indicated monitoring documentation and contact to the physician would be located in progress notes and oxygen treatments would be found in orders. LPN #422 indicated she had forgotten to put in progress note and orders for Resident #26 as it was nearing the end of her shift. Review of facility policy Change in Status, Identifying and Communicating, Long-Term Care, dated 08/19/22, revealed when a nurse recognizes a potentially life-threatening condition or significant change in a resident's status, the nurse must communicate with other health care providers to meet the resident's needs. The nurse must keep up to date on resident's status and monitor for changes. An identified notable change included shortness of breath. The policy indicated the care plan should address resident risk factors, allow for rapid identification of change in status, and define baseline assessment findings. Nursing staff are expected to document communication with other health care providers and vague/subjective communication can lead to delayed treatment. Review of facility policy Oxygen Administration, Long-Term Care, dated 11/28/22, revealed prior to implementation of oxygen treatment nursing staff should verify order for oxygen therapy. Nursing staff were to monitor the resident's response to treatment and frequently check for signs of hypoxia. Documentation should be completed on the procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365340 If continuation sheet Page 8 of 9 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 365340 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barberton Post Acute 85 Third Street SE Barberton, OH 44203 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 staff interviews, the facility failed to repair a large hole in the drywall in the room of Resident #22. This affected one resident ( Resident #22) out of 28 residents observed for physical environment. Findings included: Review of the medical record revealed Resident #22 was admitted to the facility on [DATE]. Diagnoses included respiratory failure, disorder of bone density, right hand contractures, COVID-19, asthma, aphasia, tracheostomy, major depressive disorder, cerebral aneurysm, encephalopathy, muscle wasting, intracerebral hemorrhage, peripheral vascular disease, epilepsy, anxiety disorder, nontraumatic subarachnoid hemorrhage, dysphagia, symbolic dysfunctions and paralytic syndrome following cerebrovascular disease. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #22 had severely impaired cognition. She required extensive assistance of two staff members for bed mobility, transfers, dressing, toilet use, personnel hygiene, and and toilet assistance of one staff for eating. She was always incontinent of bowel and bladder. Observation on 03/06/23 at 7:22 A.M. revealed Resident #22 had a large six inch wide by nine inch long hole in her wall on the left side of the air conditioning unit by the bathroom. On 03/06/23 at 8:10 A.M. an interview with State Tested Nursing Assistant #479 stated the hole had been there for a while. On 03/08/23 at 10:06 A.M. an interview with Director of Maintenance #477 verified there was a large hole in the wall and wall paper torn off the wall in the room of Resident #22. He indicated he was not aware there was a hole in the wall because the staff never told him. He stated he does not do environmental rounds as often as he should because he was also covering the housekeeping supervisor position. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365340 If continuation sheet Page 9 of 9