Health inspection·December 5, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few him, but his head was stuck under the bed and his head hit the bed. The SRI revealed STNA #612 retrieved assistance from other staff and Resident #6 communicated that he did not want STNA #612 working with him anymore and that he wanted to file a police report. The SRI revealed the police were notified and came to the facility. The SRI revealed STNA #612 was suspended immediately, and an investigation was initiated. The SRI revealed after the investigation, STNA #612 was terminated, and the facility substantiated the incident as abuse as it was verified by evidence. Review of Police Report #23-23497 dated 11/02/23 at 2:50 P.M. revealed Police Officer #900 was dispatched to the facility for a report of assault. He arrived at the facility and Resident #6 had requested to file a report. The report revealed on 11/02/23 at approximately 5:30 A.M. STNA #612 went to check his brief. The brief was dry as Resident #6 was able to tell when he was wet. The report revealed STNA #612 changed him anyways even though Resident #6 told her not to change him. The report revealed she rolled him in the bed, and he hit his lip on the bed railing. The report revealed he pressed his call button, but STNA #612 took it away from him. The report revealed he fell out of bed trying to get his call button after she left his room. The report stated the aide came back in and tried to get him back in bed but was unable and then went to get help. The report revealed when he was on the floor the staff tried to lift him into bed, but his head was stuck under the bed, and STNA #612 yanked him. The report revealed staff members helped Resident #6 get back into bed and STNA #612 stood in the doorway and laughed at him. The report revealed he was advised to speak with a prosecutor to file criminal charges, and STNA #612 was suspended pending investigation. Review of the witness statement dated 11/02/23 completed by Interim Director of Nursing (DON) #613 revealed she was completing walking rounds and heard a third shift aide (STNA #607) say, just look at his lip. The statement revealed STNA #607 stated there was an incident between Resident #6 and STNA #612. She went into Resident #6's room and noticed his upper lip was swollen. The statement revealed he had hit it on the grab bar. The statement revealed it happened when STNA #612 rolled him when she changed him and that it was not an accident. She revealed she left the room to obtain statements before the third shift left. Interim DON #613 no longer worked at the facility, unable to interview. Review of witness statement dated 11/02/23 and completed by STNA #612 revealed at 4:00 A.M. she checked Resident #6, and he was wet, so she changed him. The statement revealed he was upset that she had to change him. She revealed while turning him, he lunged towards the wall, and she completed changing him. The statement revealed Resident #6 was still upset with her. The statement revealed 40 minutes later she heard Resident #6 calling for help and she found him on his knees on the ground and his arms on the bed, she lowered him to the floor and retrieved assistance. Review of the witness statement dated 11/02/23 and completed by RN #610 revealed STNA #612 went into Resident #6's room to check him and insisted on cleaning him up as he was soaking wet. The statement revealed Resident #6 was very angry as she was cleaning him up and after she left the room he got out of bed. The statement revealed STNA #612 went back into his room, and he was on his knees, and she assisted him to the floor. The statement revealed STNA #612 came and got her but that he had wiggled his head underneath the bed a little. The statement revealed when they were sliding him out from underneath the bed, he lifted his head and hit his head on the bottom of the bed. The statement revealed three staff then transferred him to his bed. She revealed he was very angry and stated he wanted the police called and he kept saying to keep STNA #612 out of his room. Review of the witness statement dated 11/02/23 and completed by RN/ Restorative #609 and RN/ MDS #608 revealed they entered Resident #6's room at approximately 8:00 A.M. to interview him regarding (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 2 of 4 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 365412 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Skilled Healthcare 1320 Mahoning Ave NW Warren, OH 44483 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the incident. They used a communication board as well as verbalizing during the interview as he had a communication barrier due to his ALS. The statement revealed Resident #6 stated STNA #612 came into his room to change him and was rough when rolling him to his right side. The statement revealed when she rolled him, he hit his lip on the positioning bar. The statement revealed she left, and she did not give him his call light. He attempted to reach for it and his legs slid off the bed, but the upper half of his body stayed on the bed. He revealed he yelled for help and STNA #612 came back in and attempted to assist him back into the bed but was unable. She then proceeded to lower him to the floor. He revealed three staff then came to assist. Review of the witness statement completed by the Director of Nursing (DON) dated 11/02/23 revealed she had a phone interview with STNA #612 who revealed on 11/02/23 at 2:00 A.M. she offered Resident #6 the urinal and he was dry. She revealed at 4:00 A.M. he was upset with her that she woke him up, but he was soaked in urine. The statement revealed she changed his brief and he lunged towards the wall while she was rolling him over. She revealed he did not hit the wall or bed. She then revealed he was trying to hit her while she was buckling his brief and she quickly buckled it, put a pillow under his arms and placed his call light in his right hand. She revealed she had ensured he was in the middle of the bed, lowered his bed and placed his table back on the side of his bed. She revealed 40 minutes later she heard him crying and when she went into his room, he was on his knees leaning over his bed. She revealed she tried to lift him, but he was too heavy, and she lowered him to the ground and placed a pillow under his head. She then revealed she notified RN #610 of the incident. The statement revealed they went to his room and RN #610 was on his right side and she was on his left as they attempted to lift him with a two-person transfer. The statement revealed RN #610 lifted him quickly and they were not in sync causing him to hit the right side of his head causing a red mark to his head. She revealed Resident #6 was pushing her away and she walked away but stood by the door. Interview on 12/04/23 at 12:49 P.M. with STNA #607 revealed on 11/02/23 she was working night shift with STNA #612. She revealed she was standing at the nursing station and STNA #612 came up and stated Resident #6 was yelling and throwing himself out of the bed. She revealed she immediately responded as this was very odd as she felt Resident #6 was always cooperative. She revealed when RN #610, STNA #607, and STNA #612 entered the room he was lying on the floor with his head positioned underneath the bed. She revealed RN #610 and STNA #607 immediately went up to him and just ripped him straight up without checking him, explaining what they were doing or trying to figure out why he was yelling. She revealed when they had attempted to transfer him back in bed, he hit his head on the bed frame. She revealed she stated, wait, wait as we need to transfer him safely into bed. She revealed they then assisted him back into bed in a safe manner. She revealed after they got him into bed, Resident #6 was crying, as he wanted STNA #612 out of his room and stated he wanted the police to be called. She revealed she had STNA #612 leave his room and immediately notified Interim DON #613 of the incident. She revealed she felt something happened as she had taken care of Resident #6 several times and never seen him upset especially to the point of trying to get out of bed. She felt this was out of character, he was cognitively intact and able to verbalize what happened. Interview on 12/04/23 at 2:01 P.M. with Resident #6 with assistance of communication devices/ verbalization revealed on 11/02/23 at approximately 5:30 A.M. STNA #612 came into his room to change him. He revealed he told her No five or six times as he revealed he knew when he was wet, and he was not. He revealed she continued to change him despite telling her No and she rolled him towards the window. He revealed she rolled him hard causing him to hit his lip on the position enabler bar. He revealed it hurt as his lip swelled. He revealed his call light was in his hand and he pushed the call light to get other staff's attention regarding the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 3 of 4 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 365412 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Skilled Healthcare 1320 Mahoning Ave NW Warren, OH 44483 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few incident. He revealed STNA #612 turned around and shut the call light off. He revealed he pushed his call light again two more times and each time she turned it off. He revealed she then took his call light out of his hand so he could not ring for assistance. He revealed she then proceeded to leave the room. He revealed he was looking for his call light to get staff assistance for help and report the incident. He revealed when he was looking for his call light, his legs came over the side of the bed resulting in him falling to the floor. He revealed he was lying on the floor with his head partially underneath the bed yelling for help. He revealed STNA #612 came back into the room and proceeded to lift him back into bed. He revealed she was unable, and he continued to yell for help. He revealed STNA #612 went to get other staff: RN #610 and STNA #607. He revealed RN #610 and STNA #612 attempted to lift him back into bed but because his head was stuck underneath the bed his side of his head hit the bed frame. He revealed STNA #607 had tried to stop them and then they were able to get my head out from underneath the bed and lifted him into the bed. He revealed he reported the incident to STNA #607 and revealed STNA #612 was standing in the doorway laughing. He revealed STNA #607 made STNA #612 leave the room. He revealed he requested the police be notified and they came out, and he filed a report. He verified he felt the incident was abuse. He revealed he felt safe now as he did not file anything further with the prosecutor as STNA #612 no longer worked at the facility. He revealed that was the first time STNA #612 had provided care for him. Interview on 12/04/23 at 2:30 P.M. with the Administrator verified Resident #6 was cognitively intact and his account of the incident remained consistent. She verified she substantiated the SRI for abuse. Interview on 12/04/23 at 2:36 P.M. with RN/ MDS #608 and RN/ Restorative #609 revealed they both went into Resident #6's room on 11/02/23 to interview him regarding the incident. They revealed Resident #6 was cognitively intact and able to communicate with communication devices and verbalization. They revealed Resident #6 reported STNA #612 went into his room to change him and was rough. They revealed she rolled him into the right position enabler bumping his lip. RN/ Restorative #609 revealed there was a small red spot on his upper lip. They revealed Resident #6 wanted the police notified which they did. Interview on 12/05/23 at 8:45 A.M. with RN #610 revealed STNA #612 had stated when she checked Resident #6, he was wet but that he had stated he did not want to be changed. RN #610 stated STNA #612 stated she felt she had to change him because he was wet. She revealed then a while later he was found out of bed on his knees and STNA #612 lowered him to the floor and retrieved her for assistance. She revealed his head was slightly under the bed so when she went to pull him out by the pillow, he lifted his head at the same time hitting his head on the bed frame. She then revealed three staff assisted him back to bed. She revealed he requested the police to be contacted as he was upset STNA #612 had changed him, but RN #610 stated, she did because he was wet. Review of the facility policy labeled, Abuse, Mistreatment, Neglect, Misappropriation of Resident Property and Exploitation, dated 2016, revealed the facility would not tolerate abuse, neglect, misappropriation. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. The policy revealed abuse also included the deprivation by an individual of goods or services that were necessary to attain or maintain physical, mental, and psychosocial well-being. This deficiency represents non-compliance investigated under Complaint Number OH0000148188. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 4 of 4