Inspection·July 23, 2024

F 0584 headboard put the holes in the walls. Level of Harm - Minimal harm or potential for actual harm Observation made on 07/01/24 at 2:48 P.M. revealed the Main Dir. #813 and team working on Resident #79's room installing new floors, due to laminate coming up, there were no subfloors exposed, they were beginning to patch the holes in the wall where the headboard caused damage. Residents Affected - Few Interview on 07/01/24 at 2:53 P.M. with Resident #1 revealed she stated she came to the facility in April but was unsure of the date. She confirmed there were holes in her walls behind her headboard that were pretty big, and they bothered her. She stated she told the staff about them, but no one ever fixed them. Interview on 07/09/24 at 2:45 P.M. with Resident #79 revealed she confirmed she had holes in the walls in her room. She stated she has told the Administration team about them, but they have not been fixed. Review of the maintenance log from 05/01/24 to 07/01/24 revealed there was no mention of the holes in the walls in rooms for Resident #1 and Resident #79. This deficiency represents noncompliance investigated under Complaint Number OH00154346. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 2 of 27 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 07/23/2024 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 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, medical record review, shower schedule review, review of facility policy and staff and resident interview, the facility failed to ensure residents received showers per schedule or preference. This affected six Residents (#4, #10, #32, #44, #72 and #79) out of six Residents reviewed for showers. The facility census was 78. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 12/04/23. Diagnoses included major depressive disorder, generalized anxiety, chronic pain, hypertension, unspecified intellectual disabilities, and hypothyroidism. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/2024, revealed Resident #4 to have intact cognition. He was assessed to be independent for most of their activities of daily living (ADL). He was assessed to need partial assistance by staff for personal hygiene and showers. Review of Resident #4's plan of care initiated on 03/05/24, revealed the resident preferred not to take a shower and stated he only wanted bed baths. Interventions included staff to continue to encourage and assist Resident #4 to take showers or bed baths, anticipate and meet the resident's needs. Review of the requested shower sheets from 05/01/24 to 07/01/24 for Resident #4 and the Director of Nursing (DON) #804 and licensed Practical Nurse (LPN)/wound nurse (WN) #80 were only able to provide evidence of one bed bath completed on 05/14/24. Review of Resident #4's shower schedule revealed he was scheduled to have showers on the 3:00 P.M. to 11:00 P.M. shift on Mondays and Thursdays when he resided in room [ROOM NUMBER], and on Tuesdays and Fridays when he resided in room [ROOM NUMBER]. Interview on 07/02/24 at 9:45 A.M. with Resident #4 revealed he stated he does not like to take showers, he prefers bed baths, staff do not really like to help him and if he doesn't try to wash himself the staff does not to his bed baths. 2. Review of the medical record for Resident #10 revealed an admission date of 12/05/23. Diagnoses included dementia with mild agitation, hypertensive chronic kidney disease, pressure ulcer of left buttock stage III, agoraphobia, and a personal history of prostate cancer. Review of Resident #10's quarterly MDS assessment, dated 06/04/24 revealed the resident had impaired cognition, he required partial to moderate assistance from staff for toileting, and required substantial to maximal assistance with showers, personal hygiene, and dressing. Review of Resident #10's plan of care initiated 06/11/24, revealed the resident has a deficit in all ADLs including showers, personal hygiene, and dressing performance with the potential for fluctuations related to dementia and pain. Review of requested shower sheets from 05/01/24 to 07/01/24 for Resident #10, revealed DON #804 and LPN/WN #800 were not able to provide any shower sheets for the time frame requested. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 3 of 27 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 07/23/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Review of Resident #10's shower schedule revealed he was scheduled to have showers on the 7:00 A.M. to 3:00 P.M. shift on Mondays and Fridays. Interview on 07/09/24 at 11:30 A.M. with Resident #10 revealed he was alert and could answer some questions and when asked about getting showers he stated he had not had a shower in a long time. Residents Affected - Some 3. Review of the medical record for Resident #32 revealed an admission date of 04/07/16. Diagnoses included autistic disorder, anxiety disorder, hypertension, and scoliosis. Review of Resident #32's annual MDS assessment, dated 05/24/24, revealed Resident #32 had severely impaired cognition, and was dependent on staff for all ADLs including toileting, showers, personal hygiene and dressing. Review of Resident #32's plan of care initiated on 09/12/23 revealed the resident has a deficit in ADL self-performance with potential for fluctuations and/or decline related to cognitive impairment. Review of requested shower sheets from 05/01/24 to 07/01/24 for Resident #32, revealed DON #804 and LPN/WN #800 were only able to provide one shower sheet dated 05/23/24, for the time frame requested. Review of Resident #32's shower schedule revealed she was scheduled to have showers on the 3:00 P.M. to 11:00 P.M. shift on Mondays and Thursdays. 4. Review of the medical record for Resident #44 revealed an admission date of 10/19/22. Diagnoses include cerebral palsy, intellectual disabilities, pressure ulcer of sacral region stage III, history of breast cancer, hypertension, generalized anxiety, asthma and type II diabetes mellitus. Review of Resident #44's quarterly MDS assessment, dated 06/14/24, revealed Resident #44 was severely cognitively impaired and was dependent on staff for all ADLs including toileting, showers, personal hygiene, and bed mobility. Review of Resident #44's plan of care initiated 10/12/20, revealed she was at risk for alteration in skin integrity related to decreased mobility and ADL functional ability. Interventions included showers per preference or schedule, repositioned on rounds as needed, and provide skin care every A.M. and P.M. or as needed. Review of requested shower sheets from 05/01/24 to 07/01/24 for Resident #44, revealed DON #804 and LPN/WN #800 were only able to provide four shower sheets dated 05/06/24, 05/13/24, 05/16/24, and 06/05/24, for the time frame requested. Review of Resident #44's shower schedule revealed she was scheduled to have showers on the 11:00 P.M. to 7:00 A.M. shift on Sundays and Wednesdays. Observation made on 07/02/24 at 2:03 P.M. of wound care for Resident #44 by LPN/WN #800 with assistance for turning and repositioning from State Tested Nursing Assistant (STNA) #809 revealed when removing the top sheet from the resident to perform wound care there was a strong odor of urine present despite her brief being dry and indicative of the resident not being provided adequate showering/bathing. LPN/WN #800 verified the odor at the time of the observation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 4 of 27 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 07/23/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 07/09/24 at 2:30 P.M. with Resident #44 revealed she was able to answer yes and no questions and would elaborate a little bit. When asked if she received showers she said no and she could not remember the last time she had one. She stated staff had to help her with everything including washing her up and giving her showers. 5. Review of the medical record for Resident #72 revealed an admission date of 02/17/16. Diagnoses include Parkinson's disease, Stiff-Man syndrome, hypertension, torticollis, contracture to right and left hand, anxiety disorder, pressure ulcer of sacral region stage III, and muscle spasms. Review of Resident #72's quarterly MDS assessment dated [DATE] revealed the resident has severely impaired cognition and was dependent on staff for all ADLs including toileting, showers, personal hygiene, dressing and bed mobility. Review of Resident #72's plan of care initiated on 09/12/23, revealed Resident #72 has a deficit in ADL self-performance with potential for fluctuations and/or decline related to diagnosis of Parkinson, and Stiff Man Syndrome. Interventions included encouraging the resident to participate to the fullest extent possible with each interaction and praise all efforts at self-care. Review of requested shower sheets from 05/01/24 to 07/01/24 for Resident #72 revealed DON #804 and LPN/WN #800 were not able to provide any shower sheets for the time frame requested. Review of Resident #72's shower schedule revealed he was scheduled to have showers on the 11:00 P.M. to 7:00 A.M. shift on Tuesdays and Thursdays. Interview on 07/09/24 at 12:45 P.M. with Resident #72 revealed he stated he does not get showers. 6. Review of the medical record for Resident #79 revealed an admission date of 11/09/23. Diagnoses include multiple sclerosis, chronic respiratory failure with hypoxia, anxiety disorder, kidney stones, depression, and peripheral vascular disease. Review of Resident #79's quarterly MDS assessment dated [DATE] revealed she had intact cognition and required partial to moderate assistance with showers, and was dependent on staff for personal hygiene, bed mobility, and toileting. Review of Resident #79's plan of care initiated on 11/10/23 revealed she has a deficit in ADL self-performance related to decreased mobility due to a diagnosis of multiple sclerosis. Interventions included encouraging the resident to participate to the fullest extent possible with each interaction and praise all efforts at self-care. Review of requested shower sheets from 05/01/24 to 07/01/24 for Resident #79 revealed DON #804 and LPN/WN #800 were able to provide five shower sheets dated 05/12/24, 05/15/24, 05/16/24, and 06/26/24 for the time frame requested. Review of Resident #79's shower schedule revealed she was scheduled to have showers on the 7:00 A.M. to 3:00 P.M. shift on Sundays and Wednesdays. Interview on 07/01/24 at 3:22 P.M. with State Tested Nursing Assistant (STNA) #808 revealed they are unable to complete showers due to the facility getting rid of the shower aides, she stated residents might get bed baths, but they do not get showers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 5 of 27 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 07/23/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 07/02/24 at 2:45 P.M. with STNA #809 revealed she confirmed residents do not get showers like they should per the schedule or per their preference. STNA #809 stated showers are not done due to the facility getting rid of the shower aides and the floor staff are stretched pretty thin. Interview on 07/09/24 at 11:40 A.M. with DON #804 and with LPN/WCN #800 confirmed they could not produce shower sheets for Residents #10 and #72. They were able to provide only four shower sheets for Resident #44, they were only able to provide four sheets for Resident #79, and one sheet for Resident #4 and #32 for the time period requested from 05/01/24 to 07/01/24. Interview on 07/09/24 at 2:45 P.M. with Resident #79 revealed she confirmed she does not get showers per her schedule or preference. She stated most of the time she had to ask for a shower or she would not get one. Review of the facility policy titled Shower/Bath Policy, last revised December 2013, revealed the Purpose of the policy states It is the policy of Community Skilled Health Care Center to provide residents with a bath/shower according to their preference. This deficiency represents noncompliance investigated under Complaint Number OH00154092. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 6 of 27 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 07/23/2024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of hospital records, review of information from the National Pressure Injury Advisory Panel (NPIAP), review of facility policy, and interviews, the facility failed to develop and implement a comprehensive and individualized pressure ulcer program to ensure necessary care and services to prevent the development of, worsening of and promote the healing of a facility acquired pressure ulcer for Resident #44, a resident who was at risk for pressure ulcer development and dependent on staff for all activities of daily living (ADLs) including bed mobility, turning and repositioning, incontinence care for both bowel and bladder, showering, and dressing. This resulted in Immediate Jeopardy and actual harm when the facility failed to implement effective interventions to prevent the development of and timely and adequately treat a facility acquired pressure ulcer. On 06/13/24 Resident #44 was seen by a wound care team for moisture associated dermatitis (MASD) (MASD is a general term for skin inflammation or erosion caused by exposure to moisture and its contents) on the sacrum that had progressed from MASD measuring 0.3 cm in length by 0.4 cm width with 0.2 cm depth to a Stage III (full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed) pressure ulcer measuring 2.4 cm long by one cm wide with 0.3 cm depth. On 06/27/24 the ulcer deteriorated with an increase in size and measured 3.8 cm long by 1.8 cm wide with 0.7 cm depth. On 06/29/24 at 2:25 P.M. the resident was documented to have a change in condition with increased lethargy, no food intake at lunch, minimal fluid intake, abnormal vital signs including an elevated temperature of 101 degrees Fahrenheit, elevated heart rate of 90 and decreased blood pressure of 104/60. The resident had an elevated white blood cell count of 12.51 (indicative of infection) at this time. However, wound cultures ordered on this date were not obtained until 07/02/24. On 07/03/24 the resident was transferred to the hospital and admitted for treatment of sepsis secondary to decubitus/pressure ulcer. Residents Affected - Few In addition, a concern that did not rise to Immediate Jeopardy but did result in Actual Harm occurred to Resident #10, who was at risk for pressure ulcer development and/or alteration in skin integrity when the facility failed to provide the necessary care and services for the prevention and development and then worsening of a Stage III pressure ulcer. On 06/13/24 Resident #10 was assessed to have a new in-house acquired Stage III pressure ulcer measuring 1.8 cm long by 1.8 cm wide with 0.1 cm depth to the left lower buttock. The pressure ulcer deteriorated when assessed on 06/20/24 with an increase in size measuring 2.5 cm long by three cm wide with 0.1 cm depth and an increase in exudate drainage. Actual harm also occurred to Resident #72 on 06/20/24 when the facility failed to provide the necessary care and services for the prevention and development and then worsening of a Stage III pressure ulcer. Resident #72 was assessed to have an in-house acquired Stage III pressure ulcer to the sacrum measuring 3.5 cm long by 4.5 cm wide with 0.1 cm depth. The pressure ulcer deteriorated when assessed on 07/01/24 with an increase in size measuring four cm long by 4.5 cm wide with 0.3 cm depth with documentation the wound progress was exacerbated due to new damaged skin around the wound. This affected three residents (#10, #44, and #72) of six residents reviewed for pressure ulcers. The facility identified 10 residents with pressure ulcers (#7, #10, #44, #45, #46, #49, #58, #61, #65 and #72) The facility census was 78. On 07/09/24 at 12:35 P.M. the Interim Administrator and the Director of Nursing were notified Immediate Jeopardy began on 06/13/24 when Resident #44 was seen by wound care team including Wound Care Physician (WCP) #700 who identified a wound to the resident ' s sacrum had progressed from MASD to an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 7 of 27 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 07/23/2024 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few in-house acquired Stage III pressure ulcer. In addition to failing to prevent the ulcer from developing, following the identification of the pressure ulcer, the facility failed to implement adequate and necessary care and treatment resulting in a deterioration in the pressure ulcer and acute change in resident condition resulting in hospitalization (on 07/03/24) for treatment of sepsis related to the pressure/decubitus ulcer. The Immediate Jeopardy was removed on 07/10/24 when the facility implemented the following corrective actions: • On 07/03/24 Director of Nursing (DON) #804 began staff education for licensed nurses and State Tested Nursing Assistants (STNAs) on the need to ensure that all pressure relieving interventions were in place in accordance with the plans of care and that incontinence care, turning and repositioning, and showers/bed baths were implemented timely and in accordance with the plan of care for all residents, including those with wounds. All nursing staff were also in-serviced on the need to inform the nurse if wound dressings become soiled with urine or stool so they can be changed. Staff training/education was provided between 07/03/24 and 07/10/24. Any staff not In-serviced by 07/10/24 would be in-serviced prior to their next working shift. • On 07/06/24 Resident #44 was re-admitted to the facility from the hospital. Licensed Practical Nurse/Wound Nurse (LPN/WN) #800 re-assessed the resident ' s sacral wound and a new order to cleanse with normal saline, apply Santyl nickel thick and cover with bordered gauze was obtained. The resident ' s care plan was reviewed and included interventions of turn and reposition side to side, lay down after meals, and Chamosyn to buttocks after incontinence episodes was initiated. All necessary physician orders including medication orders and wound care orders were reviewed to ensure accurately reflected in the care plan. • Between 07/08/24 and 07/11/24 LPN/WN #800 initiated review of care plans for all residents who had existing wound, Resident #7, #10, #44, #45, #46, #49, #58, #61, #65 and #72. • On 07/09/24 LPN/WN #800 again reviewed all necessary physician orders for Resident #44 and the facility implemented a plan to review these orders daily to ensure they were accurately reflected in the resident ' s care plan. The resident was also scheduled to see the wound care physician on 07/11/24. • On 07/09/24 and 07/10/24 Director of Nursing (DON) #804 began in-service with all licensed nurses on the need to ensure the physician was timely notified of all wound changes, treatments were implemented in accordance with orders, and all orders for cultures and labs were obtained timely and orders for antibiotics were implemented timely. Any staff not educated by 07/10/24 would be educated would be educated prior to their next working shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 8 of 27 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 07/23/2024 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 0686 • Level of Harm - Immediate jeopardy to resident health or safety On 07/10/24 Licensed Practical Nurse/Wound Nurse (LPN/WN) #800, LPN #801, LPN #802, and LPN #803 completed skin sweeps and new Braden Scales on all facility residents. No new pressure ulcers or infections were identified. All resident care plans would be reviewed by 07/12/24 to ensure appropriate preventative interventions were in place and appropriate treatments were in place if appropriate. Residents Affected - Few • On 07/10/24 DON #804 posted the STAT phone number for the lab at all nurse ' s stations to ensure staff had access and were calling the correct number when STAT labs need to be drawn, and in-serviced all nurses on the number as well as the need to contact the DON or Administrator if the lab cannot be reached. • On 7/10/24 LPN/WN #800 checked all culture containers (urine and swabs) and discarded all expired items and contacted the lab to request non-expired culture containers be provided. LPN/WN #800 would then check culture containers monthly and discard expired containers. • On 07/10/24 DON #804 in-serviced all licensed nurses on the process for monthly checking of culture containers for expired containers and on the need to check all containers, including swabs for expiration prior to use. • On 7/10/24 an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, DON #804, LPN/WN #800, and Medical Director (MD) #900 to review the plan. MD #900 was notified of the Immediate Jeopardy on 07/10/2024 at the QAPI meeting. The meeting included a discussion of skin issues identified with the skin/wound CQI report. • The facility implemented a plan for LPN/WN or designee to complete observations of at least five random residents per day for four weeks to ensure pressure relieving interventions were being implemented in accordance with the plan of care, including offloading, incontinence care provided timely, and showers completed in accordance with the plan of care and shower schedule. The observation/audits would include residents with and without wounds. All audits would be reviewed by the QAPI committee. • The facility implemented a plan for LPN/WN or designee to complete observations/audits of at least three residents with wounds per day to ensure wound treatments were being implemented as ordered, dressings were changed if soiled, and new orders for labs or cultures are implemented timely. The audits/observations would be completed for four weeks, and all audits would be reviewed by the QAPI committee. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 9 of 27 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 07/23/2024 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Although the Immediate Jeopardy was removed on 07/10/24, the facility remained out of compliance at a Severity Level 3 (Actual Harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1.Review of Resident #44 ' s medical record revealed the resident had diagnoses including cerebral palsy, type two diabetes mellitus, overactive bladder, urinary incontinence, unspecified intellectual disabilities, hypertension and pressure ulcer of sacral region. Review of Resident #44 ' s care plan revised 11/06/23 revealed Resident #44 was at risk for alteration in skin integrity related to decreased mobility. Interventions included to be laid down after breakfast to promote skin integrity, bariatric bed for positioning, body check nightly, bath days and as needed, cushion to chair with non-skid above and below, keep linen dry and wrinkle free every shift, maintain pressure relief mattress, provide skin care every morning and night and as needed, reposition on rounds and as needed, resident preferences on baths/showers and side to side turns while in bed. Review of Resident #44 ' s medical record revealed there was no documentation of timely incontinence care, turning and repositioning of the resident from side to side, or showers being completed timely per the resident ' s care plan and preference Review of Resident #44 ' s quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition and required substantial to maximal assistance by staff for eating and dressing. The assessment revealed Resident #44 was dependent on staff for all other activities of daily living (ADLs) including oral hygiene, toileting, showers, personal hygiene, and bed mobility. Resident #44 was always incontinent of bowel and bladder. Review of the physician orders for Resident #44 ' s revealed the following orders: initiated 05/07/24 Chymosin Ointment 0.45%-20% apply to coccyx and right buttock topically every shift for incontinence and apply heavily with episodes of incontinence. Initiated on 10/19/2022 side to side turns while in bed, reposition on rounds and as needed, Low Air Loss (LAL) mattress to bed at all times initiated on 11/01/23, resident in bed after all meals. Weekly Skin Assessments every night shifts every Wednesday for health maintenance initiated 05/01/24, cleanse sacral wound with normal saline (NS), apply collagen sheet and bordered gauze three times a week and as needed on Tuesday, Thursday, and Saturday, initiated on 06/22/24. Review of the shower schedule for Resident #44 revealed the resident was to receive showers twice a week. Review of shower sheets for Resident #44 from the date range of 05/01/24 to 07/01/24 revealed Resident #44 had only received a shower on 05/06/24, 05/13/24, 05/16/24 and 06/05/24 during this time period. Review of a Wound Evaluation and Management Summary dated 06/06/24 by WCP #700 revealed Resident #44 had Moisture Associated Dermatitis (Site #3) noted as healing, measuring 0.3 cm length by 0.4 cm width with 0.2 cm depth. The treatment plan consisted of Chymosin twice daily for nine days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 10 of 27 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 07/23/2024 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Review of a Wound Evaluation and Management Summary dated 06/13/24 by WCP #700 revealed Resident #44 ' s MASD to the sacrum exacerbated due to multifactorial events which was noted to have deteriorated to a Stage III pressure ulcer and was measuring larger in size at 2.4 cm long by one cm wide with 0.3 cm depth, with drainage of light serous (a clear to pale yellow watery fluid). On 06/13/24 WCP #700 changed the treatment plan to Collagen gel/paste three times per week for 30 days and cover with gauze island with border apply this as well three times per week for 30 days. Residents Affected - Few Record review revealed the resident was assessed by WCP #700 on 06/20/24 at which time the Stage III pressure ulcer to Resident #44 ' s coccyx/sacrum measured 2.1 cm long by one cm wide with 0.7 cm depth, with light serosanguinous (a thin watery fluid, pink in color due to small amounts of red blood cells) drainage. The wound bed consisted of 20% thick adherent devitalized necrotic (dead) tissue, 20% slough (dead tissue separating from living tissue), and 60% granulation (new) tissue. There were no changes made to the wound treatment orders at this time. Review of Resident #44 ' s care plan updated 06/24/24 revealed Resident #44 was at risk for alteration in skin integrity related to decreased mobility. Interventions included Resident #44 was to be laid down after breakfast to promote skin integrity on buttocks, bariatric bed for positioning, bilateral heel protectors, body check nightly, bath days, and as needed, Chymosin ointment to buttocks every shift, cushion to chair with non-skid above and below, keep linen dry and wrinkle free every shift, maintain pressure relief mattress, and notify the physician with any changes. The plan indicated staff were to provide skin care every A.M. and P.M. and as needed. Resident #44 was unaware of bowel and bladder urges, unable to transfer to toilet due to total dependence on staff for transfers. The goals listed in the care plan were that the resident would remain as dry as possible without skin breakdown. Interventions included staff to administer overactive bladder medication per physician orders, change the resident as needed, assist the resident to ensure peri care after each incontinent episode to prevent skin breakdown, and check the resident every round for incontinence. The care plan indicated the resident was to receive showers twice a week. Review of Resident #44 ' s medical record revealed there was no documentation of timely incontinence care, turning and repositioning of the resident from side to side, or showers being completed timely per the resident ' s care plan and preference Further review of the Wound Evaluation and Management Summary dated 06/27/24 by WCP #700 revealed the Stage III pressure wound to Resident #44 ' s coccyx/sacrum had deteriorated again with exacerbation due to multifactorial issues including poor incontinence care, poor turning and reposition, and not off-loading pressure by turning the resident every two hours and as needed to ensure direct pressure was not on the resident ' s coccyx/sacrum. On 06/27/24 WCP #700 measured the wound to be 3.8 cm long by 1.8 cm wide with 0.7 cm depth, with light serous drainage, 20% thick adherent devitalized necrotic tissue, 20% slough, and 60% granulation tissue. There were no changes to treatment orders at this time by WP #700. Review of Resident #44 ' s progress notes revealed a change in condition was noted on 06/29/24 with the resident having increased lethargy, no food intake at lunch, minimal fluid intake record throughout the day and (abnormal) vital signs with a temperature of 101.0 Fahrenheit (F)(elevated), pulse 90 (elevated), blood pressure (BP) 104/60 (hypotensive). Notification was made to Resident #44 ' s Nurse Practitioner (NP) who gave orders for a STAT Complete Blood Count (CBC), Complete Metabolic Panel (CMP), urinalysis with culture and sensitivity (UA C&S), wound cultures, and a chest x-ray. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 11 of 27 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 07/23/2024 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few There was a delay in obtaining the laboratory work, and wound cultures due to expired wound culture collection swabs and no one contacting the appropriate number for STAT lab draws. The NP was updated on the delay and gave further orders to start Resident #44 on the antibiotic, Rocephin 1 gram (gm) intramuscularly (IM) for five days on 07/03/24 at 10:52 A.M. The antibiotics were not scheduled to be given until 07/04/24 but should have been started immediately per facility policy for antibiotic administration. Review of Resident #44 ' s wound culture results, ordered on 06/29/24, which was not collected until 07/02/24 due to all the wound culture swabs at the facility being expired, resulted on 07/06/24 revealed the cultures were positive for Escherichia coli. (E. Coli). On 07/03/24 at 11:45 A.M. Resident #44 ' s Primary Care Physician (PCP), Medical Director (MD) #900 was informed of the change in condition and the recommendations of the NP. MD #900 gave orders to send the resident to the emergency room for evaluation and treatment. Consequently, review of hospital records revealed Resident #44 was admitted to the hospital for treatment of the Stage III pressure injury of the sacral region. Resident #44 was hospitalized from [DATE] to 07/06/24 with treatment provided for sepsis including fluid resuscitation per hospital protocol for severe sepsis, along with two intravenous (IV) antibiotics of Cefepime and Flagyl. Resident #44 returned to the facility on [DATE] with continuation of antibiotics including Cephalexin and Flagyl by mouth. During an interview on 07/01/24 at 3:22 P.M. with State Tested Nursing Assistant (STNA) #808, the STNA indicated she believed the facility was short staffed most of the time, showers were not completed due to the facility getting rid of the shower aide position, and residents (including Resident #44), were not provided with timely incontinence care, or turned and repositioned when they should be. Observations made on 07/02/24 at 9:45 A.M. and 11:00 A.M. with STNA #809 and on 07/02/24 at 4:45 P.M. with LPN/WCN #800 of Resident #44 ' s positioning while in bed revealed Resident #44 was in the same position on her right side with positioning wedges used that were flat. The resident did not appear to be positioned properly on the positioning wedge pillows and pressure was not reduced from sacral wound at the time of these observations. Interview on 07/02/24 at 10:00 A.M. with LPN/WN #800 revealed Resident #44 ' s sacral wound had worsened from MASD to a Stage III pressure ulcer due to staff not providing her with timely incontinence care, staff not turning the resident per her plan of care, staff not repositioning the resident timely when she was in her wheelchair, and staff not providing showers or giving the resident a bed bath per her plan of care. LPN WN #800 also revealed staff were unable to collect the wound cultures ordered on 06/29/24 due to all the wound culture swabs being expired, and they would not receive new ones until Monday 07/01/24 when the lab brought them to the facility. Observation made on 07/02/24 at 2:03 P.M. of wound care for Resident #44 by LPN/WN #800 with assistance for turning and repositioning from STNA #809 revealed when removing the top sheet from the resident to perform wound care there was a strong odor of urine present, the resident ' s brief was dry, however when they rolled the resident over the dressing to sacral wound dated 07/01/24 had feces on the outside of the dressing and underneath the dressing in the wound. They provided incontinence care to the resident, removed the old dressing, washed hands and changed gloves and cleansed the wound with normal saline. Upon assessment of the wound, LPN/WN #800 found new necrotic tissue. While providing wound care LPN/WN #800 stated when she did the treatment last on 06/28/24 the center of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 12 of 27 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 07/23/2024 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 0686 Level of Harm - Immediate jeopardy to resident health or safety wound had white granulation tissue in the center of the wound and now there was necrotic tissue the approximate size of a quarter, with redness around the peri wound edges, indicating possible infection. The wound had a foul odor present. The wound was dressed per physician ' s orders with no concerns identified with wound care technique. The resident was turned onto her right side and positioning wedges used. Resident #44 was on a low air loss mattress. She had orders for a tilt and space wheelchair with a pressure reducing cushion in the chair which was present in the hallway. Residents Affected - Few Interview via phone on 07/08/24 at 10:53 A.M. with WCP #700 revealed he stated MASD should never progress to a pressure ulcer. He stated the facility staff do not turn and reposition or provide timely incontinence care. WCP #700 stated Resident #44 ' s wound deterioration was a direct result of staff not caring for the resident appropriately and per her care plan. Interview on 07/09/24 at 11:40 A.M. with DON #804 and with LPN/WN #800 confirmed they were able to provide only four shower sheets for Resident #44 for the time frame requested of 05/01/24 to 07/01/24. Interview on 07/09/24 at 12:30 P.M. with DON #804 confirmed Resident #44 developed an in-house Stage III pressure ulcer due to a lack of proper care, including staff not turning and repositioning the resident every two hours or as needed, staff not providing timely incontinence care, showers/bed baths, or providing proper care for the resident. Interview on 07/09/24 at 1:45 P.M. with DON #804 revealed when asked what the expectation was for antibiotic administration, DON #804 stated antibiotics should be scheduled to be given as soon as possible as they have a starter box in the medication room with antibiotics in them. She stated the nurse should have started Resident #44 ' s ordered Rocephin immediately on 07/03/24 and not scheduled it for 07/04/24. 2. Review of Resident #10 ' s medical record revealed an admission date of 12/05/23 with diagnoses including unspecified dementia with mild agitation, hypertension, chronic kidney disease stage II, and Stage III pressure ulcer of left buttock (06/13/24). Review of Resident #10 ' s quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment, required set up help or clean up help only for eating, he was independent for bed mobility, supervision, or touching assistance for oral hygiene, partial to moderate assistance for toileting, and substantial to maximal assistance for showers, dressing, and personal hygiene. Review of Resident #10 ' s care plan dated 06/11/24 revealed the resident had the potential for pressure ulcer development and or alteration in skin integrity related to decreased mobility and side effects related to medications. The goal was Resident #10 would have intact skin free of redness, blisters, or discoloration by or through the review date. Interventions included administering medications as ordered, monitor and document for side effects, administering treatments as ordered and monitor for effectiveness and staff will encourage the resident to turn and reposition on care rounds and as needed. Review of the shower schedule for Resident #10 revealed he was to receive showers twice a week. Review of progress notes for Resident #10 from 05/01/24 to 07/01/24 revealed there were no notes stating the resident refused care such as incontinence care, repositioning and or showers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 13 of 27 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 07/23/2024 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of Resident #10 ' s physician orders revealed pressure reduction mattress to bed at all times initiated on 12/05/23, cushion to chair with non-skid above and below cushion initiated on 12/05/23, reposition on rounds and as needed initiated on 12/05/23, weekly skin assessments every day shift every Monday initiated on 05/06/24, pad and protect left buttock with foam dressing every day shift every Monday, Wednesday, and Friday initiated on 06/12/24. Review of Resident #10 ' s Initial Wound Evaluation and Management Summary dated 06/13/24 revealed the resident had an inhouse acquired Stage III pressure ulcer to the left lower buttock measuring 1.8 cm long by 1.8 cm wide with 0.1 cm depth with light serous drainage, 80 % granulation tissue. Treatment recommendations at this time were for Leptospermum honey, apply three times per week for 30 days and cover with dry dressing three times per week for 30 days, other recommendations were to off-load the wound, and reposition per facility protocol. Review of Resident #10 Wound Evaluation and Management Summary dated 06/20/24 revealed the wound deteriorated as the wound was larger in size measuring 2.5 cm long by three cm wide with 0.1 cm depth with moderate serous drainage, 20% thick adherent devitalized necrotic tissue, 10% slough, 50% granulation tissue and 20% other viable tissue including the dermis and subcutaneous tissue. Wound progress was noted to be not at goal. There were no changes made to the treatment plan at this time, and recommendations were to off-load the wound, and reposition per facility policy which was every two hours and as needed. Interview on 07/02/24 at 10:00 A.M. with LPN/WN #800 revealed Resident #10 developed a Stage III in-house acquired pressure ulcer that subsequently deteriorated due to the resident not being repositioned timely and per facility policy by facility staff. Additional review of Resident #10 ' s medical record revealed there was no documentation of timely incontinence care, turning and repositioning of the resident from side to side, or showers being completed timely per the resident ' s care plan and preference. For the date range of 05/01/24 to 07/01/24 there were no shower sheets to evidence the resident had been given any showers in that time period. Interview on 07/01/24 at 3:22 P.M. with STNA #808 indicated she believed the facility was short staffed most of the time, showers were not completed due to the facility getting rid of the shower aide position, and residents (including Resident #10), were not provided with timely incontinence care, or turned and repositioned when they should be. Observations made on 07/02/24 at 10:00 A.M. and 2:03 P.M. with STNA #808, and on 07/09/24 at 12:45 P.M., and 2:00 P.M., with STNA #809 of positioning for Resident #10 revealed Resident #10 was laying on his back with no pillows supporting his weight to offload the pressure to his left buttocks. Interview via phone on 07/08/24 at 10:53 A.M. with WCP #700 confirmed Resident #10 ' s wound deteriorated due to the resident not being repositioned timely and per facility policy to off load the pressure from the wound. Wound care observations were attempted on 07/08/24 at 10:00 A.M. and 1:00 P.M., however the resident refused to allow the State surveyor to watch his wound care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 14 of 27 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 07/23/2024 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview on 07/09/24 at 11:30 A.M. with Resident #10 revealed he was alert and could answer questions. When asked about his showers, repositioning, and incontinence care he stated staff help but stated he had not had a shower in long time. The resident also stated he did not receive timely incontinence care or timely repositioning. Interview on 07/09/24 at 11:40 A.M. with DON #804 and with LPN/WN #800 confirmed they could not produce shower sheets for Residents #10. 3. Review of Resident #72 ' s medical record revealed an admission dated of 02/17/16 with diagnoses including Parkinson ' s disease, disease of spinal cord, Stiff-Man syndrome, hypertension, and an in-house acquired Stage III pressure ulcer to the sacrum as of 06/20/24. Review of Resident #72 ' s care plan dated 05/24/24 revealed the resident was at risk for alteration in skin integrity related to Parkinson ' s disease. The goal was Resident #72 would have skin remain dry and intact through target date, interventions included air mattress to bed for skin preventions, body check nightly on bath days and as needed, chair cushion when in wheelchair or bedside chair, Chymosin ointment to buttocks as ordered by the physician, Resident #72 was to be laid down after breakfast to promote skin integrity on buttocks, keep linen dry and wrinkle free every shift, moisturizer daily to dry skin, barrier cream to buttocks, apply after each episode of incontinence. Review of Resident #72 ' s quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment, required supervision or touching assistance for eating, and was dependent on staff for all other ADLs including oral hygiene, showers, toileting, dressing, personal hygiene, and bed mobility. Review of the shower schedule for Resident #72 revealed he was to receive showers twice a week. Review of progress notes for Resident #72 from 05/01/24 to 07/01/24 revealed there were no notes stating the resident refused care such as incontinence care, repositioning and or showers. Review of Resident #72 ' s physician ' s orders revealed orders for Chymosin Ointment to buttocks/peri-area topically every shift for incontinence episodes initiated 07/01/24, Pommel Cushion to wheel chair with Dycem above and below, for positioning initiated 10/15/18, Bariatric bed for positioning initiated 11/27/18, check and change on rounds and as needed for incontinence care initiated 01/19/22, body pillow while in bed for positioning every shift initiated 04/29/24, Resident to be laid down in bed after all meals every shift for prevention initiated 04/29/24, weekly skin assessments evening shift on Wednesdays initiated 05/08/24, Cleanse stage III pressure ulcer to sacrum with normal saline apply Medi honey topically and cover with border gauze change three times a week and as needed every day shift on Tuesday, Thursday, and Saturday initiated on 06/21/24. Review of Resident #72 ' s Initial Wound Evaluation and Management Summary dated 06/20/24 revealed Resident #72 was being seen due to a new in-house acquired Stage III pressure ulcer to his sacrum measuring 3.5 cm length by 4.5 cm width with 0.1 cm depth, with light serous exudate, 50% granulation tissue, 20 % other viable tissue including dermis and subcutaneous (Sub Q) tissue, and 30% skin. Treatment orders at this time were for leptospermum honey applied three times per week for 30 days and cover with dry dressing three times per week for 30 days. Further recommendations were to offload the wound, and to reposition per facility protocol. Review of Resident #72 ' s Wound Evaluation and Management Summary dated 06/27/24 revealed Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 15 of 27 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 07/23/2024 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete #72's Stage III pressure ulcer measured two cm length by 2.5 cm width by 0.1 cm depth with light serous drainage, 70 % granulation tissue, 10 % slough, and 20% other viable tissues including the dermis and Sub Q. There was no change to the treatment orders, or recommendations. Review of Resident #72 ' s Wound Evaluation and Management Summary dated 07/05/24 revealed Resident #72 ' s Stage III pressure ulcer to his sacrum deteriorated as evidenced by an increase in size with the ulcer measuring four cm length by 4.5 cm width by 0.3 cm depth, moderate serous drainage, 70 % granulation tissue, 10 % slough, 20 % other viable tissues such as dermis and sub-q. Wound progress Event ID: Facility ID: 365412 If continuation sheet Page 16 of 27 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 07/23/2024 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to maintain sufficient nursing services staff to meet the total care needs of residents according to their plan of care. This affected six residents (#4, #10, #32, #44, #72 and #79) and had the potential to affect all 78 residents residing in the facility. Findings include: Review of the Facility Assessment (dated 05/16/24) revealed the average daily census at the facility was 85. On page three and four of the assessment, the staffing plan was outlined and indicated to meet the acuity needs of the residents, the licensed nurses and State Tested Nursing Assistants (STNA) would provide a range of 3.28 to 4.78 hours of direct resident care per resident per day. Interview on 07/01/24 at 3:22 P.M. with State Tested Nursing Assistant (STNA) #808 revealed staff were unable to complete showers due to the facility getting rid of the shower aides. She stated residents might get bed baths, but they do not get showers. STNA #808 stated the facility was short staffed most of the time and staff were not able to turn/reposition residents timely nor provide timely incontinence care. Interview on 07/02/24 at 10:00 A.M. with Licensed Practical Nurse (LPN)/Wound Nurse (WN) #800 revealed she was the wound nurse for the facility, and she had concerns about the residents not getting showered, not getting timely incontinence care and not being turned and repositioned as they should be to prevent skin breakdown (related to a lack of staff). Interview on 07/02/24 at 2:45 P.M. with STNA #809 revealed residents do not get showers like they should per the schedule or per their preference. STNA #809 stated showers were not done due to the facility getting rid of the shower aides and the floor staff were stretched pretty thin. Interview was conducted with the DON on 07/09/24 at approximately 1:30 P.M. and revealed she was the Minimum Data Set (MDS) nurse for the facility who took over the role of the DON on 06/21/24 since the prior DON stopped working at the facility on 06/21/24. She said the current Administrator was interim and came out of retirement to oversee the facility with his first day worked of 06/28/24. The DON revealed she had identified staffing concerns related to meeting the acuity needs of the residents and had done some education with the staff but still needed to do more training since she had only been in the DON position a few weeks prior to the start of this survey. On 07/09/24 at 3: 33 P.M. to 3:56 P.M. an evaluation of the facility staffing was completed with Human Resources (HR) #805 and Staffing Coordinator (SC) #806 who provided the schedules and payroll punch details for 06/07/24 to 06/13/24 and 06/21/24 to 06/27/24. For the date range of 06/07/24 to 06/13/24 licensed nurses and STNAs provided a range of 3.20 to 3.65 hours of direct care per resident per day and for the date range of 06/21/24 to 06/27/24 the licensed nurses and STNAs provided a range of 2.95 to 3.56 hours of direct resident care per resident per day which did not meet the minimum range of hours of 3.28 to 4.78 identified in the Facility Assessment staffing plan for licensed nurses and STNAs to meet resident acuity needs. These findings were verified with HR #805 and SC #806 at the time of the completion of the staffing tool. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 17 of 27 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 07/23/2024 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 07/09/24 at 4:00 P.M. interview with HR #805 and SC #806 revealed in order to meet resident acuity needs including but not limited to providing showers/bathing, incontinence care and regular turning/repositioning there needed to be eight State Tested Nursing Assistants (STNA) on the day shift, seven STNA on afternoon shift and seven STNA on midnight shift. At the time of the interview, both confirmed on 06/08/24 there were only five STNA on day shift, on 06/09/24 there were only six STNA on day shift, on 06/10/24 there were only six STNA on afternoon shift, on 06/21/24 there were only six STNA on day shift and six STNA on afternoon shift and on 06/27/24 there were only six STNA on day shift as per the staffing tool referenced prior. Both also confirmed the facility no longer had a shower aide position so the STNA's on each unit were responsible for giving showers to the residents. The following resident specific findings were identified related to insufficient staffing: 1. Review of the medical record for Resident #44 revealed the resident had diagnoses including cerebral palsy, intellectual disabilities, pressure ulcer of sacral region stage III, history of breast cancer, hypertension, generalized anxiety, asthma and type II diabetes mellitus. Review of Resident #44's plan of care initiated 10/12/20, revealed she was at risk for alteration in skin integrity related to decreased mobility and activity of daily living (ADL) functional ability. Interventions included showers per preference or schedule, repositioned on rounds as needed, and provide skin care every A.M. and P.M. or as needed. Review of Resident #44's shower schedule revealed she was scheduled to have showers on the 11:00 P.M. to 7:00 A.M. shift on Sundays and Wednesdays. Review of Resident #44's quarterly Minimum Data Set (MDS) assessment, dated 06/14/24, revealed Resident #44 was severely cognitively impaired and was dependent on staff for all ADLs including toileting, showers, personal hygiene, and bed mobility. Further review of Resident #44's medical record revealed there was no documentation of timely incontinence care, turning and repositioning of the resident from side to side, or showers being completed timely per the resident's care plan and preference Review of requested shower sheets from 05/01/24 to 07/01/24 for Resident #44, revealed DON #804 and LPN/WN #800 were only able to provide four shower sheets dated 05/06/24, 05/13/24, 05/16/24, and 06/05/24, for the time frame requested. Observation made on 07/02/24 at 2:03 P.M. of wound care for Resident #44 by LPN/WN #800 with assistance for turning and repositioning from State Tested Nursing Assistant (STNA) #809 revealed when removing the top sheet from the resident to perform wound care there was a strong odor of urine present despite her brief being dry and indicative of the resident not being provided adequate showering/bathing. LPN/WN #800 verified the odor at the time of the observation. At the time of the survey, Resident #44 was being treated for an in-house acquired pressure ulcer (See findings at F686). Interview via telephone on 07/08/24 at 10:53 A.M. with Wound Care Physician (WCP) #700 revealed he had seen Resident #44 due to moisture associated dermatitis (MASD) that turned into a pressure ulcer. WCP #700 revealed MASD should never progress to a pressure ulcer. The physician stated the facility staff do not turn and reposition as they should, nor do they provide timely incontinence care for Resident #44 which was why Resident #44 developed a pressure ulcer from MASD. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 18 of 27 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 07/23/2024 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 07/09/24 at 11:40 A.M. with DON #804 and LPN/WN #800 confirmed they were able to provide only four shower sheets for Resident #44. Interview on 07/09/24 at 2:30 P.M. with Resident #44 revealed she was able to answer yes and no questions and would elaborate a little bit. When asked if she received showers she said no and she could not remember the last time she had one. She stated staff had to help her with everything including washing her up and giving her showers. 2. Review of the medical record for Resident #4 revealed an admission date of 12/04/23. Diagnoses included major depressive disorder, generalized anxiety, chronic pain, hypertension, unspecified intellectual disabilities, and hypothyroidism. Review of Resident #4's plan of care initiated on 03/05/24, revealed the resident preferred not to take a shower and stated he only wanted bed baths. Interventions included staff to continue to encourage and assist Resident #4 to take showers or bed baths, anticipate and meet the resident's needs. Review of Resident #4's shower schedule revealed he was scheduled to have showers on the 3:00 P.M. to 11:00 P.M. shift on Mondays and Thursdays when he resided in room [ROOM NUMBER], and on Tuesdays and Fridays when he resided in room [ROOM NUMBER]. Review of the requested shower sheets from 05/01/24 to 07/01/24 for Resident #4 revealed Director of Nursing (DON) #804 and LPN/WN #800 were only able to provide evidence of one bed bath completed on 05/14/24. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/2024, revealed Resident #4 to have intact cognition. He was assessed to be independent for most of their activities of daily living (ADL). He was assessed to need partial assistance by staff for personal hygiene and showers. Interview on 07/02/24 at 9:45 A.M. with Resident #4 revealed he stated he does not like to take showers, he prefers bed baths, staff do not really like to help him and if he doesn't try to wash himself the staff did not provide his bed baths. Interview on 07/09/24 at 11:40 A.M. with DON #804 and LPN/WN #800 confirmed one sheet for Resident #4 for the time period requested from 05/01/24 to 07/01/24. 3. Review of the medical record for Resident #10 revealed an admission date of 12/05/23. Diagnoses included dementia with mild agitation, hypertensive chronic kidney disease, pressure ulcer of left buttock stage III, agoraphobia, and a personal history of prostate cancer. Review of Resident #10's quarterly MDS assessment, dated 06/04/24 revealed the resident had impaired cognition, he required partial to moderate assistance from staff for toileting, and required substantial to maximal assistance with showers, personal hygiene, and dressing. Review of Resident #10's plan of care initiated 06/11/24, revealed the resident has a deficit in all ADLs including showers, personal hygiene, and dressing performance with the potential for fluctuations related to dementia and pain. The care plan also stated the staff will encourage the resident to turn and reposition during care rounds. Review of Resident #10's shower schedule revealed he was scheduled to have showers on the 7:00 A.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 19 of 27 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 07/23/2024 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 0725 to 3:00 P.M. shift on Mondays and Fridays. Level of Harm - Minimal harm or potential for actual harm Review of requested shower sheets from 05/01/24 to 07/01/24 for Resident #10, revealed DON #804 and LPN/WN #800 were not able to provide any shower sheets for the time frame requested. Residents Affected - Many Interview on 07/09/24 at 11:30 A.M. with Resident #10 revealed he was alert and could answer some questions and when asked about getting showers he stated he had not had a shower in a long time. The resident also said the staff do not encourage him to turn and reposition. 4. Review of the medical record for Resident #32 revealed an admission date of 04/07/16. Diagnoses included autistic disorder, anxiety disorder, hypertension, and scoliosis. Review of Resident #32's plan of care initiated on 09/12/23 revealed the resident had a deficit in ADL self-performance with potential for fluctuations and/or decline related to cognitive impairment. Review of Resident #32's annual MDS assessment, dated 05/24/24, revealed Resident #32 had severely impaired cognition, and was dependent on staff for all ADLs including toileting, showers, personal hygiene and dressing. Review of Resident #32's shower schedule revealed she was scheduled to have showers on the 3:00 P.M. to 11:00 P.M. shift on Mondays and Thursdays. Review of requested shower sheets from 05/01/24 to 07/01/24 for Resident #32, revealed DON #804 and LPN/WN #800 were only able to provide one shower sheet dated 05/23/24, for the time frame requested. 5. Review of the medical record for Resident #72 revealed an admission date of 02/17/16. Diagnoses include Parkinson's disease, Stiff-Man syndrome, hypertension, torticollis, contracture to right and left hand, anxiety disorder, pressure ulcer of sacral region stage III, and muscle spasms. Review of Resident #72's plan of care initiated on 09/12/23, revealed Resident #72 had a deficit in ADL self-performance with potential for fluctuations and/or decline related to diagnosis of Parkinson, and Stiff Man Syndrome. Interventions included encouraging the resident to fully participate as possible with each interaction and praise all efforts at self-care. In addition, the resident was to be provided incontinence care. Review of the physician order dated 01/19/22 revealed Resident #72 was to be checked and changed on rounds and as needed for incontinence care. Review of Resident #72's quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognition and was dependent on staff for all ADLs including toileting, showers, personal hygiene, dressing and bed mobility. He was incontinent of bladder and bowel. Review of Resident #72's shower schedule revealed he was scheduled to have showers on the 11:00 P.M. to 7:00 A.M. shift on Tuesdays and Thursdays. Review of requested shower sheets from 05/01/24 to 07/01/24 for Resident #72 revealed DON #804 and LPN/WN #800 were not able to provide any shower sheets for the time frame requested. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 20 of 27 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 07/23/2024 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 07/09/24 at 11:40 A.M. with DON #804 and LPN/WN #800 confirmed they could not produce shower sheets for Resident #72. Interview on 07/09/24 at 12:45 P.M. with Resident #72 revealed he was alert and able to answer questions. He stated he does not get showers and staff do not check on him regularly for repositioning or incontinence care. 6. Review of the medical record for Resident #79 revealed an admission date of 11/09/23. Diagnoses include multiple sclerosis, chronic respiratory failure with hypoxia, anxiety disorder, kidney stones, depression, and peripheral vascular disease. Review of Resident #79's quarterly MDS assessment dated [DATE] revealed she had intact cognition and required partial to moderate assistance with showers, and was dependent on staff for personal hygiene, bed mobility, and toileting. Review of Resident #79's plan of care initiated on 11/10/23 revealed she had a deficit in ADL self-performance related to decreased mobility due to a diagnosis of multiple sclerosis. Interventions included encouraging the resident to fully participate as possible with each interaction and praise all efforts at self-care. Review of requested shower sheets from 05/01/24 to 07/01/24 for Resident #79 revealed DON #804 and LPN/WN #800 were able to provide five shower sheets dated 05/12/24, 05/15/24, 05/16/24, and 06/26/24 for the time frame requested. Review of Resident #79's shower schedule revealed she was scheduled to have showers on the 7:00 A.M. to 3:00 P.M. shift on Sundays and Wednesdays. Interview on 07/09/24 at 11:40 A.M. with DON #804 and LPN/WN #800 confirmed they were only able to provide four sheets for Resident #79. Interview on 07/09/24 at 2:45 P.M. with Resident #79 revealed she confirmed she does not get showers per her schedule or preference. She stated most of the time she had to ask for a shower or she would not get one. Review of the facility policy titled Shower/Bath Policy, last revised December 2013, revealed the purpose of the policy was to provide residents with a bath/shower according to their preference. A request was made to review any additional policy and procedures related to turning and repositioning and frequency of incontinence care; however, no additional information was provided. This deficiency represents non-compliance investigated under Complaint Numbers OH00155024, OH00154346 and OH00154092. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 21 of 27 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 07/23/2024 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility administration did not ensure proper management of all resources for the highest practicable wellbeing of all residents which included failure to eradicate bed bugs, failure to ensure sufficient nursing staff to meet the resident's acuity needs, and failure to ensure resident rooms were maintained in a manner to protect the resident right to a safe, clean, comfortable environment. This had the potential to affect all 78 residents living in the facility. The facility census was 78. Residents Affected - Many Findings include: Review of the undated job description for the Administrator revealed it was the essential function of the Administrator to enforce implementation of policies and procedures, supervise all department supervisors and administrative staff, assume responsibility with department supervisors to ensure adequate staffing, and establish systems to ensure compliance with all state, federal and local regulations. Review of the undated job description for the Director of Nursing revealed responsibilities included managing the nursing department to maintain quality standards, directs the nursing staff in its entirety, making clinical rounds to determine quality of care, maintain staffing at an acceptable level and assuming responsibility for nursing services compliance with state, federal and local regulations. Interview was conducted with the Administrator on 07/09/24 at approximately 12:00 P.M. who revealed he was the Interim Administrator who had only been on the job at the facility for a few days, so he was still getting acclimated to the needs of the facility. This Administrator stated he started in the position on 06/28/24 because the prior administrator left on 06/27/24. Interview was conducted with the DON on 07/09/24 at approximately 1:30 P.M. and revealed she was the Minimum Data Set (MDS) nurse for the facility who took over the role of the DON on 06/21/24 since the prior DON stopped working at the facility on 06/21/24. She said the current Administrator was interim and came out of retirement to oversee the facility with his first day worked of 06/28/24. The DON revealed she had identified staffing concerns related to meeting the acuity needs of the residents and had done some education with the staff but still needed to do more training since she had only been in the DON position a few weeks prior to the start of this survey. During the onsite investigation, the following concerns were identified related to a lack of comprehensive and effective administrative oversight: 1. Review of the Facility Assessment (dated 05/16/24) revealed the average daily census at the facility was 85. On page three and four of the assessment, the staffing plan was outlined and indicated to meet the acuity needs of the residents, the licensed nurses and STNA would provide a range of 3.28 to 4.78 hours of direct resident care per resident per day. Interview on 07/01/24 at 3:22 P.M. with State Tested Nursing Assistant (STNA) #808 revealed staff were unable to complete showers due to the facility getting rid of the shower aides. She stated residents might get bed baths, but they do not get showers. STNA #808 stated the facility was short (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 22 of 27 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 07/23/2024 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many staffed most of the time and staff were not able to turn/reposition residents timely nor provide timely incontinence care. Interview on 07/02/24 at 10:00 A.M. with Licensed Practical Nurse (LPN)/Wound Nurse (WN) #800 revealed she was the wound nurse for the facility, and she had concerns about the residents not getting showered, not getting timely incontinence care and not being turned and repositioned as they should be to prevent skin breakdown (related to a lack of staff). Interview on 07/02/24 at 2:45 P.M. with STNA #809 revealed residents do not get showers like they should per the schedule or per their preference. STNA #809 stated showers were not done due to the facility getting rid of the shower aides and the floor staff were stretched pretty thin. On 07/09/24 at 3: 33 P.M. to 3:56 P.M. an evaluation of the facility staffing was completed with Human Resources (HR) #805 and Staffing Coordinator (SC) #806 who provided the schedules and payroll punch details for 06/07/24 to 06/13/24 and 06/21/24 to 06/27/24. For the date range of 06/07/24 to 06/13/24 licensed nurses and STNAs provided a range of 3.20 to 3.65 hours of direct care per resident per day and for the date range of 06/21/24 to 06/27/24 the licensed nurses and STNAs provided a range of 2.95 to 3.56 hours of direct resident care per resident per day which did not meet the minimum range of hours of 3.28 to 4.78 identified in the Facility Assessment staffing plan for licensed nurses and STNAs to meet resident acuity needs. These findings were verified with HR #805 and SC #806 at the time of the completion of the staffing tool. On 07/09/24 at 4:00 P.M. interview with HR #805 and SC #806 revealed in order to meet resident acuity needs including but not limited to providing showers/bathing, incontinence care and regular turning/repositioning there needed to be eight State Tested Nursing Assistants (STNA) on the day shift, seven STNA on afternoon shift and seven STNA on midnight shift. At the time of the interview, both confirmed on 06/08/24 there were only five STNA on day shift, on 06/09/24 there were only six STNA on day shift, on 06/10/24 there were only six STNA on afternoon shift, on 06/21/24 there were only six STNA on day shift and six STNA on afternoon shift and on 06/27/24 there were only six STNA on day shift as per the staffing tool referenced prior. Both also confirmed the facility no longer had a shower aide position so the STNA's on each unit were responsible for giving showers to the residents. 2. Reivew of the exterminator invoice dated 05/23/24 revealed the facility had a chemical treatment completed for bed bugs along with their routine pest control measures. On 06/05/24 they had a chemical treatment for bed bugs completed to room [ROOM NUMBER], and then again on 06/27/24 they had a chemical treatment for bed bugs in the facility along with their monthly pest control measures. Observation made on 07/01/24 at 2:44 P.M. of the physical environment revealed in resident room [ROOM NUMBER] and room [ROOM NUMBER], both rooms unoccupied at the time of the observation, there were multiple bed bugs present. Interview on 07/01/24 at 2:58 P.M. with Resident #21 revealed she confirmed there are bed bugs in the rooms across the hall from her in rooms 118 and room [ROOM NUMBER]. She stated the exterminators have been out multiple times with no luck of getting rid of them. She stated she had seen them in the hallway as well. Interview on 07/01/24 at 3:22 P.M. with STNA #808 revealed she confirmed there were bed bugs in the facility in the room of Resident #4, and also in room [ROOM NUMBER] and 101. She stated the facility was only using chemicals to try to get rid of them however you have to heat treat everything in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 23 of 27 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 07/23/2024 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 0835 order to eradicate them. Level of Harm - Minimal harm or potential for actual harm Interview on 07/02/24 at 9:45 A.M. with Resident #4 revealed he confirmed he was being treated for bed bug bites, he had them in his room when he occupied room [ROOM NUMBER]. He stated they moved him to room [ROOM NUMBER] and he had bed bugs in there as well, and now he is in his current room [ROOM NUMBER]. Residents Affected - Many Interview on 07/02/24 at 2:45 P.M. with State Tested Nursing Assistant (STNA) #809 revealed she confirmed there were bed bugs in the facility and they have been there since May 2024. She stated residents complain about them to her. Interview on 07/02/24 at 3:21 P.M. with Exterminator #600 revealed all belongings need laundered with high heat, minimize contact, monitor visitation, normally yes they treat the adjacent rooms but this facility only wanted the chemical treatment to the one room where hundreds of bed bugs were found, she stated this would not kill all the bed bugs and they need to do a heat treatment on the infested room and the room next to it due to being the only way to get rid of bed bugs. She confirmed they were scheduled to come out on Friday 07/05/24 to do a heat treatment to room [ROOM NUMBER] and room [ROOM NUMBER]. Interview on 07/09/24 at 11:45 A.M. with the Director of Nursing (DON) #804 confirmed there was one resident (Resident #4) who was treated for bed bug bites. His room was moved from #120 to #105 due to the bed bugs. Interview on 07/09/24 at 11:52 A.M. with the Environmental Director (ED) #807 confirmed Grace exterminating was here on 07/05/24 and heat-treated Resident rooms #120 and #118 for bed bugs, cut holes in walls and applied a powder chemical as well for treatment of bed bugs. The facility was tearing out all the drywall in room [ROOM NUMBER] and cabinets and replacing all of them. He stated once they are done with room [ROOM NUMBER], they will move on to #118. 3. Observation made on 07/01/24 at 12:15 P.M. and at 2:40 P.M. revealed there were holes in the walls of rooms for Resident #1 and #79. The holes were in the wall behind the headboards. Interview on 07/01/24 at 1:02 P.M. with the Environmental Director (ED) #807 revealed he confirmed there were holes in the walls of rooms for Resident #1 and #79. He stated they have the equipment to fix the holes but have not done it yet. Interview on 07/01/24 at 2:45 P.M. with the Maintenance Director (Main Dir.) #813 revealed he confirmed there were holes in the walls of rooms for Resident #1 and #79. He stated they knew about them but have not fixed them yet. He stated it was from the beds being pushed up against the wall and the headboard put the holes in the walls. Observation made on 07/01/24 at 2:48 P.M. revealed the Main Dir. #813 and team working on Resident #79's room installing new floors, due to laminate coming up, there were no subfloors exposed, they were beginning to patch the holes in the wall where the headboard caused damage. Interview on 07/01/24 at 2:53 P.M. with Resident #1 revealed she stated she came to the facility in April but was unsure of the date. She confirmed there were holes in her walls behind her headboard that were pretty big, and they bothered her. She stated she told the staff about them, but no one ever fixed them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 24 of 27 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 07/23/2024 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 0835 Level of Harm - Minimal harm or potential for actual harm Interview on 07/09/24 at 2:45 P.M. with Resident #79 revealed she confirmed she had holes in the walls in her room. She stated she has told the Administration team about them, but they have not been fixed. Review of the maintenance log from 04/01/24 to 07/01/24 revealed there was no mention of the holes in the walls in rooms for Resident #1 and Resident #79. Residents Affected - Many This deficiency identified noncompliance during the investigation of Master Complaint Number OH00155219 and Complaint Numbers OH00155024, Oh00154346 and OH00154092. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 25 of 27 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 07/23/2024 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 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, record review and review of exterminator invoices the facility failed to maintain an effective pest control program for bed bugs. This affected one resident (Resident #4) of eleven residents reviewed for physical environment and had the potential to affect the additional 77 residents residing in the facility. The facility census was 78. Residents Affected - Few Findings include: Review of the medical record for Resident #4 revealed an admission date of 12/04/23. Diagnoses included rash and other nonspecific skin eruption, major depressive disorder, generalized anxiety, hypertension, atrial fibrillation, and hypothyroidism. Review of Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. He was independent with eating, oral hygiene, toileting hygiene, dressing, and bed mobility. Resident #4 required partial assistance for showers and personal hygiene. Review of Resident #4's physician orders dated 06/03/24 revealed the resident was prescribed hydrocortisone cream 1%, applied to arms, lower back, and abdomen topically two times a day for itching from rash caused by bed bugs. Reivew of the exterminator invoice dated 05/23/24 revealed the facility had a chemical treatment completed for bed bugs along with their routine pest control measures. On 06/05/24 they had a chemical treatment for bed bugs completed to room [ROOM NUMBER], and then again on 06/27/24 they had a chemical treatment for bed bugs in the facility along with their monthly pest control measures. Observation made on 07/01/24 at 2:44 P.M. of the physical environment revealed in resident room [ROOM NUMBER] and room [ROOM NUMBER], both rooms unoccupied at the time of the observation, there were multiple bed bugs present. Interview on 07/01/24 at 2:58 P.M. with Resident #21 revealed she confirmed there are bed bugs in the rooms across the hall from her in rooms 118 and room [ROOM NUMBER]. She stated the exterminators have been out multiple times with no luck of getting rid of them. She stated she had seen them in the hallway as well. Interview on 07/01/24 at 3:22 P.M. with STNA #808 revealed she confirmed there were bed bugs in the facility in the room of Resident #4, and also in room [ROOM NUMBER] and 101. She stated the facility was only using chemicals to try to get rid of them however you have to heat treat everything in order to eradicate them. Interview on 07/02/24 at 9:45 A.M. with Resident #4 revealed he confirmed he was being treated for bed bug bites, he had them in his room when he occupied room [ROOM NUMBER]. He stated they moved him to room [ROOM NUMBER] and he had bed bugs in there as well, and now he is in his current room [ROOM NUMBER]. Interview on 07/02/24 at 2:45 P.M. with State Tested Nursing Assistant (STNA) #809 revealed she confirmed there were bed bugs in the facility and they have been there since May 2024. She stated residents complain about them to her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 26 of 27 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 07/23/2024 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 07/02/24 at 3:21 P.M. with Exterminator #600 revealed all belongings need laundered with high heat, minimize contact, monitor visitation, normally yes they treat the adjacent rooms but this facility only wanted the chemical treatment to the one room where hundreds of bed bugs were found, she stated this would not kill all the bed bugs and they need to do a heat treatment on the infested room and the room next to it due to being the only way to get rid of bed bugs. She confirmed they were scheduled to come out on Friday 07/05/24 to do a heat treatment to room [ROOM NUMBER] and room [ROOM NUMBER]. Interview on 07/09/24 at 11:45 A.M. with the Director of Nursing (DON) #804 confirmed there was one resident (Resident #4) who was treated for bed bug bites. His room was moved from #120 to #105 due to the bed bugs. Interview on 07/09/24 at 11:52 A.M. with the Environmental Director (ED) #807 confirmed Grace exterminating was here on 07/05/24 and heat-treated Resident rooms #120 and #118 for bed bugs, cut holes in walls and applied a powder chemical as well for treatment of bed bugs. The facility was tearing out all the drywall in room [ROOM NUMBER] and cabinets and replacing all of them. He stated once they are done with room [ROOM NUMBER], they will move on to #118. This deficiency represents noncompliance investigated under Complaint Number OH00155219, OH00154346 and OH00154092. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365412 If continuation sheet Page 27 of 27