Health inspection·April 26, 2019

F 0550 supervision for toileting. Level of Harm - Minimal harm or potential for actual harm A care plan dated 12/20/18 revealed Resident #82 used incontinence briefs to manage her toileting needs. Residents Affected - Some Observation on 04/23/18 at 9:15 A.M. revealed Resident #82 stating she was incontinent. Resident #82 sat in the television and activity area where most of the residents on the secured unit were gathered. At 9:18 A.M., State Tested Nursing Assistant (STNA) #308 grabbed an incontinence brief and handed it to Resident #82 who was still seated with the other residents. Interview with STNA #308 immediately following the above observation revealed she should have given Resident #82 the incontinence brief in private. Review of a policy, Dignity, Respect and Privacy, revised August 2016, revealed all residents were to be treated with respect and care for in a manner than maintained their privacy, whether involved in personal hygiene or toileting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 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 365433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Omni Manor Nursing Home 3245 Vestal Road Youngstown, OH 44509 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 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not ensure a witness signature was obtained on an authorization to manage personal funds in the facility for Resident #6. This affected one of five residents reviewed for personal funds. The facility census was 115. Residents Affected - Few Findings include: Record review was conducted for Resident #6 who was admitted to the facility on [DATE] with diagnoses that included cerebral palsy and unspecified intellectual disabilities. The Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely impaired for cognitive skills for decision making, was unable to complete the resident interview for cognition and was totally dependent on staff for transfers, eating, toileting and hygiene. Resident #6's brother was listed as his Power of Attorney (POA) over his financial and clinical care. Review of the facility document titled, Trust Transaction History, dated 01/03/19 to 03/31/19 revealed Resident #6's financial liability was being paid to the facility from the income source listed as social security. Review of the facility document titled, Choice of Resident Funds Disposition, revealed an authorizing signature from Resident #6's brother dated 05/16/18 for the facility to manage the personal funds for Resident #6. The witness signature line on this form was blank. Interview was conducted on 04/23/19 at 3:10 P.M. with Bookkeeper #349 who verified they should have had a witness sign the form. Bookkeeper #349 verified they had failed to obtain a witness signature. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 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 365433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Omni Manor Nursing Home 3245 Vestal Road Youngstown, OH 44509 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of a facility self-reported incident (SRI) and associated investigation, and interviews, the facility failed to ensure adequate supervision to protect Resident #27 from sexual abuse, failed to implement their action plan to protect residents from sexual abuse, and failed to ensure staff were knowledgeable regarding interventions implemented to prevent future abuse. This affected two (Residents #79 and #27) of four residents reviewed for abuse. Findings include: Review of Resident #79's medical record revealed he was admitted to the facility 10/24/17 and diagnoses included depression. A plan of care card dated 07/13/18, and updated 10/31/18, indicated Resident #79 used a power wheelchair independently. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #79 was able to make himself understood and he understood others. Resident #79 was assessed as cognitively intact with no behavioral symptoms. Resident #79 required limited assistance with locomotion on the unit and supervision with locomotion off the unit. A Social Service note dated 02/24/19 indicated Resident #79 was found in a female resident's (not identified) room touching her breasts. The female resident was confused and did not react. Resident #79 was removed from the room and placed on 15 minute checks to ensure safety for all of the residents. A Social Service note dated 02/25/19 indicated the social worker met with Resident #79 regarding his sexually inappropriate behaviors with the female resident. Resident #79 was fully aware of touching the resident's breasts and understood he was wrong. A behavior meeting note dated 02/26/19 indicated Resident #79 was found in Resident #27's room with his hands underneath her gown touching her breasts. A care plan initiated 03/01/19 indicated Resident #79 had been sexually inappropriate with a confused female resident, having been found in her room touching her breasts. The care plan was updated (no date) with an intervention to have an orange flag placed on the electric wheelchair to monitor Resident #79's whereabouts. The order for the orange flag was not written until 03/29/19. Review of Resident #27's medical record revealed she was a female resident admitted [DATE]. Diagnoses included major depression with psychosis, stroke, dementia, and receptive aphasia (difficulty understanding written and spoken language). A quarterly MDS assessment dated [DATE] revealed Resident #27 was sometimes able to make herself understood and sometimes understood others. Resident #27 had short and long term memory problems and had severely impaired cognitive skills for daily decision making. Resident #27 required extensive assistance for locomotion on and off the unit and dressing. A psychiatrist's progress note dated 02/06/19 indicated Resident #27 was disoriented to person, place and time. The psychiatrist documented Resident #27 had poor insight, judgment and impulse control and her thought content was illogical/delusional. A nursing note dated 02/24/19 at 11:30 A.M. indicated Resident #27 was in her room and a male resident was noted to be in her room playing with her breasts as her shirt was pulled all the way up. The male resident was asked to leave the room. Review of SRI #169231 and the facility's investigation and plan of action revealed a statement by State Tested Nursing Assistant (STNA) #320 dated 02/24/16 (incorrect year) which indicated she observed Resident #79 in Resident #27's room feeling Resident #27's breast. The statement indicated Resident #79's hands were over Resident #27's shirt and that STNA #320 got the charge nurse. A copy of a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 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 365433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Omni Manor Nursing Home 3245 Vestal Road Youngstown, OH 44509 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nursing note by Licensed Practical Nurse (LPN) #321 dated 02/24/19 at 11:30 A.M. indicated Resident #27 was in her room and a male resident was playing with her breasts. The male resident had Resident #27's shirt pulled all the way up. The male resident was asked to leave the room. There was no evidence in the facility investigation that LPN #321 had been interviewed. A statement from an LPN (signature not legible) dated 02/25/19 indicated Resident #79 verified he had been in Resident #27's room over the weekend and he stated, I was fondling her boobs. The statement indicated Resident #79 was counseled and informed the behavior was inappropriate and he could not touch anyone in that manner. The LPN documented Resident #79 verbalized understanding and stated OK. I guess I won't do it again. The summary of the investigation indicated the facility's plan to protect residents from further potential sexual abuse by Resident #79 included interviewing other alert and oriented residents to determine if there had been any concerns with Resident #79. The investigation included interviews of five residents. There was no indication there were any assessments of confused residents to determine if there were signs of sexual abuse. The facility's summary also indicated Resident #79 would be referred to the psychiatrist for an evaluation. On 04/23/19 at 3:10 P.M., Social Services Director #314 verified only five alert and oriented residents had been interviewed regarding whether Resident #79 had exhibited any inappropriate sexual behaviors. Social Services Director #314 stated she interviewed residents who could provide truthful answers and who were familiar with Resident #79. Social Services Director #314 verified Resident #79 propelled throughout the facility in his motorized wheelchair, therefore placing other residents at potential risk. On 04/24/19 at 2:57 P.M., LPN #315 stated she was unaware why Resident #79 had an orange flag on his wheelchair until that morning. LPN #316, who was present, stated she thought it was so Resident #79 could be more easily observed if he was outdoors in his wheelchair. On 04/24/19 at 3:07 P.M., STNA #317 stated she was unsure if the use of an orange flag on Resident #79's wheelchair had a special meaning. STNA #317 stated she was unaware of any physical relationships or interactions between Resident #79 and any other residents. On 04/24/19 at 3:26 P.M., the Director of Nursing (DON) was interviewed regarding the psychiatric evaluation referred to in the SRI as no documentation was located in the medical record. The DON stated the nurse who made that notation about the incident on 02/24/19 worked for a staffing agency the facility used but she no longer worked for the agency and there was no contact information for follow-up. On 04/24/19 at 3:53 P.M., Social Services Director #314 stated the psychiatrist visited the facility twice a month. Social Services Director #314 indicated there had not been a psychiatric referral made for Resident #79 but was uncertain why it was not made. Social Services Director #314 indicated the referral would be made the week of 04/28/19 when the psychiatrist made his routine visits. On 04/24/19 at 4:28 P.M., Social Services Director #314 verified she wrote the notes from the behavior meeting conducted 02/26/19 which indicated Resident #79's hand was under Resident #27's gown touching her breasts. Social Services Director #314 stated she realized discrepancies between the accounts of what happened but that she was going by what staff told her (could not identify staff). Social Services Director #314 insisted there was only one isolated incident but was unable to explain the discrepancies in the accounts. On 04/24/19 at 4:47 P.M., LPN #306 stated the orange flag on Resident #79's wheelchair had no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 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 365433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Omni Manor Nursing Home 3245 Vestal Road Youngstown, OH 44509 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few special purpose. LPN #306 stated she was unaware of any behaviors exhibited toward other residents by Resident #79. On 04/25/19 at 8:20 A.M., Resident #79 was interviewed about his interactions with Resident #27. Resident #79 stated he knew Resident #27 from the other side but could not explain further. Resident #79 stated Resident #27's brother used to say she was crazy and he knew she acted differently, describing Resident #27 as goofy. Resident #79 stated he was not a doctor and could not say if Resident #27 was confused. Resident #79 verified he went into Resident #27's room but stated he could not recall why. While there, Resident #27 asked him to scratch her breast and he stated that was what he was doing. Resident #79 stated he would not have classified his prior relationship with Resident #27 as a friend but that she was a jolly person and an acquaintance. Resident #79 stated Resident #27 has been nothing but trouble for him. Resident #79 reacted defensively during the interview, indicating it was done and over with and would not happen again so it should be forgotten. On 04/25/19 at 9:12 A.M., the Administrator was interviewed regarding the process he used to determine if the plans of action addressed in the SRI summary were implemented. The Administrator stated staff had multiple discussions regarding the incident and he was certain the psychiatric evaluation had been completed. The Administrator also verified more resident interviews would have provided a more complete investigation. On 04/25/19 at 11:10 A.M., the Administrator verified the psychiatrist never visited/evaluated Resident #79 after the incident, stating he was surprised it was never done because staff had discussed the issue multiple times. On 04/25/19 at 2:05 P.M., Corporate Quality Assurance (QA) nurse #303 stated although the investigation did not reveal assessment of other confused residents after Resident #79 was observed exhibiting inappropriate sexual behavior toward Resident #27, all residents had skin assessments completed on a weekly basis so they would have all been assessed within one week. On 04/26/19 at 9:33 A.M., LPN #321 was interviewed via phone. LPN #321 stated she was informed by a STNA (could not recall the name as she has only worked at the facility about three times in the past six months) that Resident #79 was observed going into Resident #27's room so she went to redirect him. LPN #321 stated she observed Resident #79 with his hands on Resident #27's bare breasts fondling them. Resident #27 was just looking at Resident #79. LPN #321 stated she redirected Resident #79 to the common area at that time. LPN #321 stated she was unaware of any other behaviors exhibited by Resident #79 and there had been no report of Resident #79 exhibiting other inappropriate behaviors with staff redirecting him from the room. Review of the facility's Resident Abuse/Prevention Practices, revised November 2016, revealed sexual abuse was defined as non-consensual sexual contact of any type with a resident. The policy revealed investigations would begin immediately after receiving a complaint of abuse. Alleged, suspected, or observed abuse of a resident were to be thoroughly investigated by the Administrator and Director of Nursing or designee. The resident would be examined for injury at the time of complaint. Written statements were to be obtained from anyone involved or witnessing the event. A plan of support for the resident would be initiated. The policy indicated in the case of resident to resident abuse it was the facility's purpose to protect all residents from harm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 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 365433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Omni Manor Nursing Home 3245 Vestal Road Youngstown, OH 44509 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of a facility self-reported incident (SRI) and associated investigation, and interviews, the facility failed to conduct a thorough investigation into an allegation of sexual abuse, failed to implement their action plan to protect residents from sexual abuse, and failed to ensure staff were knowledgeable regarding interventions implemented to prevent future abuse. This affected two (Residents #79 and #27) of four residents reviewed for abuse. Residents Affected - Few Findings include: Review of Resident #79's medical record revealed he was a male resident admitted to the facility 10/24/17. Resident #79 had a diagnosis of depression. A plan of care card dated 07/13/18, and updated 10/31/18, indicated Resident #79 used a power wheelchair independently. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #79 was able to make himself understood and he understood others. Resident #79 was assessed as cognitively intact with no behavioral symptoms. Resident #79 required limited assistance with locomotion on the unit and supervision with locomotion off the unit. A Social Service note dated 02/24/19 indicated Resident #79 was found in a female resident's (not identified) room touching her breasts. The female resident was confused and did not react. Resident #79 was removed from the room and placed on 15 minute checks to ensure safety for all of the residents. A Social Service note dated 02/25/19 indicated the social worker met with Resident #79 regarding his sexually inappropriate behaviors with the female resident. Resident #79 was fully aware of touching the resident's breasts and understood he was wrong. A behavior meeting note dated 02/26/19 indicated Resident #79 was found in Resident #27's room with his hands underneath her gown touching her breasts. A care plan initiated 03/01/19 indicated Resident #79 had been sexually inappropriate with a confused female resident, having been found in her room touching her breasts. The care plan was updated (no date) with an intervention to have an orange flag placed on the electric wheelchair to monitor Resident #79's whereabouts. The order for the orange flag was not written until 03/29/19. Review of Resident #27's medical record revealed she was a female resident admitted [DATE]. Diagnoses included major depression with psychosis, stroke, dementia, and receptive aphasia (difficulty understanding written and spoken language). A quarterly MDS assessment dated [DATE] revealed Resident #27 was sometimes able to make herself understood and sometimes understood others. Resident #27 had short and long term memory problems and had severely impaired cognitive skills for daily decision making. Resident #27 required extensive assistance for locomotion on and off the unit and dressing. A psychiatrist's progress note dated 02/06/19 indicated Resident #27 was disoriented to person, place and time. The psychiatrist documented Resident #27 had poor insight, judgment and impulse control and her thought content was illogical/delusional. A nursing note dated 02/24/19 at 11:30 A.M. indicated Resident #27 was in her room and a male resident was noted to be in her room playing with her breasts and her shirt was pulled all the way up. The male resident was asked to leave the room. Review of the SRI, #169231, and the facility's investigation and plan of action revealed a statement by State Tested Nursing Assistant (STNA) #320 dated 02/24/16 (incorrect year) which indicated she observed Resident #79 in Resident #27's room feeling Resident #27's breast. The statement indicated Resident #79's hands were over Resident #27's shirt and that STNA #320 got the charge nurse. A copy of a nursing note by Licensed Practical Nurse (LPN) #321 dated 02/24/19 at 11:30 A.M. indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 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 365433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Omni Manor Nursing Home 3245 Vestal Road Youngstown, OH 44509 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #27 was in her room with a male resident playing with her breasts. The male resident had Resident #27's shirt pulled all the way up. The male resident was asked to leave the room. There was no evidence of LPN #321 being interviewed. A statement from an LPN (signature not legible) dated 02/25/19 indicated Resident #79 verified he had been in Resident #27's room over the weekend and that he stated, I was fondling her boobs. The statement indicated Resident #79 was counseled and informed the behavior was inappropriate and he could not touch anyone in that manner. The LPN documented Resident #79 verbalized understanding and stated OK. I guess I won't do it again. The summary of the investigation indicated the facility's plan to protect residents from further potential sexual abuse by Resident #79 included interviewing other alert and oriented residents to determine if there had been any concerns with Resident #79. The investigation included interviews of five residents. There was no indication there were any assessments of confused residents to determine if there were signs of sexual abuse. The facility's summary also indicated Resident #79 would be referred to the psychiatrist for an evaluation. On 04/23/19 at 3:10 P.M., Social Services Director #314 verified only five alert and oriented residents had been interviewed regarding whether Resident #79 had exhibited any inappropriate sexual behaviors. Social Services Director #314 stated she interviewed residents who could provide truthful answers and who were familiar with Resident #79. Social Services Director #314 verified Resident #79 propelled throughout the facility in his motorized wheelchair, therefore placing other residents at potential risk. On 04/24/19 at 2:57 P.M., LPN #315 stated she was unaware why Resident #79 had an orange flag on his wheelchair until that morning. LPN #316, who was present, stated she thought it was so Resident #79 could be more easily observed if he was outdoors in his wheelchair. On 04/24/19 at 3:07 P.M., STNA #317 stated she was unsure if the use of an orange flag on Resident #79's wheelchair had a special meaning. STNA #317 stated she was unaware of any physical relationships or interactions between Resident #79 and other residents. On 04/24/19 at 3:26 P.M., the Director of Nursing (DON) was interviewed regarding the psychiatric evaluation referred to in the SRI as no documentation was located in the medical record. The DON stated the nurse who made the notation about the incident on 02/24/19 worked for a staffing agency the facility used but she no longer worked for the agency and there was no contact information. On 04/24/19 at 3:53 P.M., Social Services Director #314 stated the psychiatrist visited the facility twice a month. Social Services Director #314 indicated there had not been a psychiatric referral made for Resident #79 but was uncertain why it was not made. Social Services Director #314 indicated the referral would be made the week of 04/28/19 when the psychiatrist made his routine visits. On 04/24/19 at 4:28 P.M., Social Services Director #314 verified she wrote the notes from the behavior meeting conducted 02/26/19 which indicated Resident #79's hand was under Resident #27's gown touching her breasts. Social Services Director #314 stated she realized there were discrepancies between the accounts of what happened but that she was going by what staff told her (could not identify staff). Social Services Director #314 insisted there was only one isolated incident but was unable to explain the discrepancies in accounts. On 04/24/19 at 4:47 P.M., LPN #306 stated the orange flag on Resident #79's wheelchair had no special purpose. LPN #306 stated she was unaware of any behaviors exhibited toward other residents by Resident #79. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 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 365433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Omni Manor Nursing Home 3245 Vestal Road Youngstown, OH 44509 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 04/25/19 at 8:20 A.M., Resident #79 was interviewed about his interactions with Resident #27. Resident #79 stated he knew Resident #27 from the other side but could not explain further. Resident #79 stated Resident #27's brother used to say she was crazy and he knew she acted differently, describing Resident #27 as goofy. Resident #79 stated he was not a doctor and could not say if Resident #27 was confused. Resident #79 verified he went into Resident #27's room but stated he could not recall why. While there, Resident #27 asked him to scratch her breast and stated that was what he was doing. Resident #79 stated he would not have classified his prior relationship with Resident #27 as a friend but that she was a jolly person and an acquaintance. Resident #79 stated Resident #27 has been nothing but trouble for him. Resident #79 reacted defensively during the interview, indicating it was done and over with and would not happen again so it should be forgotten. On 04/25/19 at 9:12 A.M., the Administrator was interviewed regarding the process he used to determine plans of action addressed in the SRI summary were implemented. The Administrator stated staff had multiple discussions regarding the incident and he was certain the psychiatric evaluation had been completed. The Administrator also verified more resident interviews would have provided a more complete investigation. On 04/25/19 at 11:10 A.M., the Administrator verified the psychiatrist never visited/evaluated Resident #79 after the incident, stating he was surprised it was never done because staff had discussed the issue multiple times. On 04/25/19 at 2:05 P.M., Corporate Quality Assurance (QA) nurse #303 stated although the investigation did not reveal assessment of other confused residents after Resident #79 was observed exhibiting inappropriate sexual behavior toward Resident #27 all residents had skin assessments completed on a weekly basis so they would have all been assessed within one week. On 04/26/19 at 9:33 A.M., LPN #321 was interviewed via phone. LPN #321 stated she was informed by a STNA (could not recall the name as she has only worked at the facility about three times in the past six months) that Resident #79 was observed going into Resident #27's room so she went to redirect him. LPN #321 stated she observed Resident #79 with his hands on Resident #27's bare breasts fondling them. Resident #27 was just looking at Resident #79. LPN #321 stated she redirected Resident #79 to the common area at that time. LPN #321 stated she was unaware of any other behaviors exhibited by Resident #79 and there had been no report of Resident #79 exhibiting other inappropriate behaviors with staff redirecting him from the room. Review of the facility's Resident Abuse/Prevention Practices, revised November 2016, revealed sexual abuse was defined as non-consensual sexual contact of any type with a resident. The policy revealed investigations would begin immediately after receiving a complaint of abuse. Alleged, suspected, or observed abuse of a resident were to be thoroughly investigated by the Administrator and Director of Nursing or designee. The resident would be examined for injury at the time of complaint. Written statements were to be obtained from anyone involved or witnessing the event. A plan of support for the resident would be initiated. The policy indicated in the case of resident to resident abuse it was the facility's purpose to protect all residents from harm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 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 365433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Omni Manor Nursing Home 3245 Vestal Road Youngstown, OH 44509 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #22's medical record revealed an admission date of 11/08/17 and diagnoses including edema and chronic congestive heart failure. Review of the January 2019 Medication Administration Record (MAR) revealed between 01/22/19 and 01/29/19 Resident #22 received indapamide (a diuretic/water pill medication) every day and torsemide (a diuretic medication) four days. The quarterly MDS assessment dated [DATE] indicated Resident #22 received a diuretic four days. Residents Affected - Few On 04/24/19 at 12:41 P.M., the Director of Nursing (DON) was interviewed regarding the coding of the quarterly MDS for diuretic use. On 04/24/19 at 3:40 P.M., Licensed Practical Nurse (LPN) #323 provided documentation of a MDS modification, verifying the diuretic use was inaccurately coded on the 01/29/19 MDS. 2. Record review was conducted for Resident #109 who was admitted to the facility on [DATE] with diagnoses including dementia and muscle wasting. The MDS assessment dated [DATE] indicated she was always continent of bladder and bowel, needed extensive assistance of one staff for toileting and had no cognitive impairment. The MDS assessment dated [DATE] indicated she was always continent of bladder and bowel and had no cognitive impairment. The plan of care with an initial date of 08/16/18 indicated she was at risk for skin breakdown due to incontinence. Review of the facility document titled, Bladder Elimination Task, from 03/27/19 to 04/02/19 revealed Resident #109 had six documented incontinence episodes. An interview was conducted on 04/25/19 at 10:55 A.M. with Resident #109 who revealed she preferred to wear a disposable undergarment because she could no longer tell when she had to urinate and could be incontinent of both bladder and bowel. An interview was conducted on 04/25/19 at 11:20 A.M. with Licensed Practical Nurse (LPN) #318 who verified Resident #109 was incontinent of bladder and bowel. An interview was conducted on 04/25/19 at 2:17 P.M. with CMN #313 who verified the MDS assessment dated [DATE] was inaccurate and verified he should have coded her as being occasionally incontinent based on the six documented incontinence episodes from 03/27/19 to 04/02/19. Based on record review and interview, the facility failed to ensure minimum data set (MDS) assessments were correctly coded to accurately reflect resident condition. This affected three residents (Resident #22, Resident #54 and Resident #109) of 28 residents reviewed for accurate assessments. Findings include: 1. Record review revealed Resident #54 was admitted on [DATE] with diagnoses including dementia with behavioral disturbances, Alzheimer's disease, blindness in left eye, and hypertension (high blood pressure). The medical record revealed a hospice contract was signed 05/23/18 and a physician's order dated 05/22/18 to start hospice care. A plan of care dated 05/23/18 was in place for Resident #54's hospice services, with a goal of the resident being supported to promote dignity and comfort throughout the dying process daily though 06/30/19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 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 365433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Omni Manor Nursing Home 3245 Vestal Road Youngstown, OH 44509 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident #54 was cognitively impaired but was not coded as receiving hospice services and was not coded as having a prognosis for a condition or chronic disease resulting in a life expectancy of less than six months. Interview on 04/25/19 at 1:39 P.M. with the Corporate MDS Nurse (CMN) #313 verified Resident #54's MDS dated [DATE] was coded inaccurately and did not reflect hospice services or prognosis of life expectancy of less than six months. Event ID: Facility ID: 365433 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 365433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Omni Manor Nursing Home 3245 Vestal Road Youngstown, OH 44509 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to provide restorative nursing services according to the care plan for Resident #22. This affected one of three residents reviewed for accidents. Residents Affected - Few Findings include: Review of Resident #22's medical record revealed diagnoses including emphysema, polyarthritis, chronic pain and chronic obstructive pulmonary disease. A restorative plan of care revealed Resident #22 was scheduled to receive a restorative ambulation program six to seven days a week for 15 minute sessions because she was at risk for decline with ambulation due to weakness and decreased mobility related to emphysema and decreased endurance. Review of restorative delivery records for February 2019 revealed the services were not documented as provided in accordance with the plan of care. For the week of 02/03/19 through 02/09/19 Resident #22 received five days of restorative ambulation. For the week of 02/10/19 through 02/06/19 she only received three days of restorative ambulation. For the week of 02/17/19 through 02/23/19 she only received five days of restorative ambulation. The restorative ambulation program was discontinued after Resident #22 fell and sustained a left humerus (upper arm)fracture on 03/06/19. On 04/24/19 at 12:41 P.M., the Director of Nursing (DON) was interviewed regarding the restorative delivery records not reflecting the ambulation program was delivered as planned. On 04/24/19 at 4:00 P.M., Licensed Practical Nurse (LPN) #323 verified the restorative ambulation program was not provided as planned because restorative aides were pulled from their duties to replace staff providing daily care as nursing assistants as they had reported off from work. This happened on 11 of the days the restorative services were not provided to Resident #22 in February 2019. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 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 365433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Omni Manor Nursing Home 3245 Vestal Road Youngstown, OH 44509 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure Resident #44 and Resident #97 were provided activities of interest to meet their individualized needs. This affected two of two residents reviewed for activities. The facility census was 115. Residents Affected - Few Findings included: 1. Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including stroke, legal blindness, traumatic brain injury, major depression and dementia. The Minimum Data Set (MDS) assessment dated [DATE] indicated he had severe cognitive impairment, needed extensive assistance of one to two staff for all activities of daily living. The plan of care, initiated on 11/13/17, indicated he needed assistance with all activities of daily living. An observation was conducted of Resident #44 on 04/23/19 from 11:52 A.M. to 12:33 P.M. He was initially found sitting in his wheelchair in a hallway near a common area where other residents were sitting in a group. He was approximately ten feet away from the common area and faced away from the other residents. He was wearing a soft, protective helmet on his head. At 12:00 P.M. Licensed Practical Nurse (LPN) #318 verified Resident #44 routinely sat in the hallways as he was at risk for falls and it was typical of him to sit with his head on his hands between his knees. LPN #318 indicated he was not able to participate in group activities due to his severe cognitive impairment. LPN #318 said he mostly sat in his wheelchair in common areas throughout the day except for meals and at bed time. Resident #44 was situated in the same spot during the entire observation with slight bobbing of his head noted. His eyes appeared to be closed and he did not respond to verbal stimuli. At 12:33 P.M. State Tested Nursing Assistant (STNA) #310 took him to the dining room for lunch. He was unable to participate in feeding himself and made unintelligible, soft verbal responses to STNA #307 as she spoke to him. Observation on 04/24/19 from 9:45 A.M. to 10:44 A.M. of Resident #44 revealed him sitting in his wheelchair in the hallway about five feet from the perimeter of a group activity where Activity Aide #319 was showing pictures to the group. He was leaning forward in his wheelchair half way between the back of his wheelchair and would randomly lean further forward to rest his forehead onto his knees with his eyes closed. He was not oriented to the activity. At 10:12 A.M. Activity Aide #319 pulled his wheelchair into the group and held his hand while she spoke to him directly about the picture she was holding. He rose up to a semi-slummed position, made no direct eye contact with her and proceeded to remove his helmet. Activity Aide #319 let go of his hand at 10:13 A.M. and proceeded to engage the other residents in the group. Resident #44 immediately returned to a bent over position with his head approximately three inches above his knees and and started rubbing his head. Resident #57 rolled over to him in her wheelchair and began rubbing his hair as Activity Aide #319 continued with the activity. At 11:20 A.M. STNA #308 walked up to him, put his helmet back on and walked away. At 11:27 A.M., LPN #308 went up to him, asked if he wanted to lay down in bed but he did not respond. At 11:35 A.M., LPN # 305 took Resident #44 to his room and with assistance from STNA #308, transferred him into bed for a nap. Interview was conducted on 04/25/19 at 9:11 A.M. with Activity Director #312 who revealed Resident #44 was very low functioning cognitively and was to received one-to-one (individual) activity visits from activity staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 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 365433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Omni Manor Nursing Home 3245 Vestal Road Youngstown, OH 44509 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility document titled, MDS: Section F, dated 10/04/18 indicated Resident #44's preferences for everyday living which were important to him were to go outside, listen to gospel music and have family visits. The document indicated he was to be offered one-to-one activities. Review of Resident #44's activity participation log for April 2019 revealed he was provided seven one-to-one activity sessions with Activity Aide #319 or Activity Aide #325 on 04/02/19, 04/05/19, 04/09/19, 04/12/19, 04/17/19, 04/22/19 and 04/24/19 for the month. The activities included reality orientation, walk through halls and tactile sensory. There was no evidence Resident #44 was provided activities with gospel music or going outside which were listed as his preferences. There was no record of any family visits. Interview on 04/25/19 at 3:38 P.M. with Activity Director #312 revealed one-to-one visits should be a minimum of 15 to 20 minutes. She said Resident #44 loved music but her staff mostly sit with him in his room looking at military photos or a favorite book his family brought in for him. Activity Director #312 verified Resident #44 had not participated in gospel music or going outside for his one-to-one activities for April 2019. Activity Director #312 said they had music on Resident #44's unit on Saturday for all the residents and said it could not be individualized for each resident's preferences since they only had one activity aide for the whole facility on Saturdays. 2. Review of Resident #97's medical record revealed an admission date of 03/17/16 with diagnoses including Alzheimer's disease, dysphagia (difficulty swallowing), heart failure, depression and dementia without behavioral disturbance. Review of an annual MDS assessment dated [DATE] revealed the resident was cognitively impaired. This assessment revealed music was very important, being around animals was very important, being with groups with people was somewhat important, going outside when the weather was good was very important, and it was not important to participate in religious services or practices. Review of activity documentation for Resident #97 from February 2019 through April 2019 revealed eight activities recorded for February 2019, nine activities recorded for March 2019, and three activities recorded for April 2019. Wandering through halls was marked as an activity on 02/08/19, 02/12/19, 02/19/19, 02/21/19, 02/27/19, 03/05/19, 03/11/19, 03/13/19, 03/19/19 and 03/29/19. A notation for 04/22/19 indicated partial participation with eye contact was documented regarding staff conversation with Resident #97 about pictures and the resident's shirt. A notation for 04/23/19 indicated partial participation and eye contact was documented for a balloon toss activity. Review of an undated plan of care contained a notation directing staff, when wandering, provide distractions such as snacks, conversation to decrease risk of irritating others. Review of a care plan revised 12/11/18 for impaired cognitive function related to dementia, impaired decision making and Alzheimer's disease revealed a goal of maintaining cognitive function through the review date of 07/01/19. Listed interventions included engage the resident in simple, structured activities that avoid overly demanding tasks. The care plan indicated Resident #97 preferred events with animals and music and staff were to keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Review of an activities care plan dated 01/21/18 revealed activities were to be provided as documented in the preferences for customary routine interview which indicated Resident #97 loved sweets, participated in religious services, napped on and off throughout the day, enjoyed [NAME] and oldies (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 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 365433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Omni Manor Nursing Home 3245 Vestal Road Youngstown, OH 44509 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few music, watched television and enjoyed special snacks like cookies and ice cream. No revisions or updates were made to this document. Observation on 04/22/19 at 10:32 A.M. revealed Resident #97 was alone in the dining room while activities were provided in a different area of the secured unit. Resident #97 did not respond to her name or any of the surveyor's questions. She continued to self-propel her wheelchair in the dining room and at one point, was flipping up the lid of the dirty linen hamper. Observation on 04/23/19 at 10:14 A.M. revealed Resident #97 in her wheelchair by one of the exit doors of the secured unit, away from the dining and television areas of the unit. A sing-a-long activity was going on at that time. Interview on 04/24/19 at 4:14 P.M. with State Tested Nursing Assistant (STNA) #304 revealed the secured unit only provided a morning and an afternoon activity for residents. STNA #304 stated the only evening activities provided consisted of a church service on Sundays. Interview on 04/25/19 at 9:41 A.M. with STNA #308 revealed Resident #97 did not participate in activities and the secured unit only had two activities during day shift if Bingo was scheduled. Interview on 04/25/19 at 11:02 A.M. with Activity Director #312 revealed the facility required activity staff to also be STNA-trained. She said only four activity aides worked in the department in addition to herself. Activity Director #312 verified Resident #97's care plan for activities was not person centered and did not address the resident's programming needs, which included one-to-one meetings with facility staff. Activity Director #312 stated the facility was providing one-to-one activities twice a week. She said if Resident #97 started to wander, staff would not go get her or try to offer her additional activity choices. An additional interview on 04/25/19 at 3:38 P.M. with Activity Director #312 revealed only one activity staff person was present on the weekends to provide activity programming for all residents in the facility. This programming consisted of music and movies and one-to-one visits if able. Activity Director #312 said the activity staff person was also involved with serving lunch and dinner and answering call lights. She confirmed activity staff were pulled away from activities to work on the floor as a nursing assistant on a weekly basis. Review of a policy for resident activities, revised March 2013, revealed the facility provided an ongoing program of activities designed to meet the interest and physical, mental and psychosocial well-being of each resident. The resident's individual activity plan of care was to be reviewed by the activity coordinator at least quarterly and with any significant change. Individual or group activities should be planned and reviewed according to this schedule. Activities included bingo, cards, singing, exercises, crafts, discussion groups, reading groups, talking books, shopping and short excursions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 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 365433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Omni Manor Nursing Home 3245 Vestal Road Youngstown, OH 44509 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interviews the facility failed to provide a nutritional supplement according to physician orders for Resident #44. This affected one of six residents reviewed for nutrition. Residents Affected - Few Findings included: Record review for Resident #44 revealed he was admitted to the facility on [DATE] with diagnoses including stroke, legal blindness, traumatic brain injury, major depression and dementia. The Minimum Data Set (MDS) assessment dated [DATE] indicated he had severe cognitive impairment, needed extensive assistance of one to two staff for bed mobility, transfers, toileting, eating, dressing and hygiene. The plan of care with an initial date of 11/02/17 indicated he had the potential for skin, nutrition and hydration problems related to his cognitive impairment, was at risk for weight loss and should be provided nutritional supplements as ordered. Review of the Medical Nutrition Therapy Evaluation dated 04/09/19, authored by Registered Dietitian (RD) #301, on indicated that Resident #44 was 84 percent of his ideal body weight, was trending a weight loss over the last six months and needed to have the six ounce NJD supplement increased from twice a day to three times a day. A physician order dated 04/09/19 indicated Resident #44 was to be provided a nutritious juice drink (NJD) three times a day at meals in addition to his usual diet and staff were to record the amount of NJD consumed. Resident #44's weights from 10/05/18 to 04/05/19 as were as follows: 10/05/18 - 131# (pounds), 11/06/18 128#, 12/05/18 - 129#, 01/07/19 - 124#, 02/11/19 - 128#, 03/05/19 - 125# and 04/05/19 - 119#. The weight records revealed a 4.8 percent weight loss from 03/05/19 to 04/05/19. Meal observation conducted of the lunch meal on 04/23/19 from 12:33 P.M. to 12:48 P.M. revealed Resident #44's lunch tray contained ground chicken club, spinach, cornbread, margarine, homebaked cookie, two-percent milk and decaffeinated coffee. State Tested Nursing Assistant (STNA) #307 began to feed Resident #44 at 12:38 P.M. There was no NJD on his tray and it was not included on his tray or meal ticket. Interview was conducted on 04/23/19 at 12:44 P.M. with STNA #307 who verified there was no NJD supplement on Resident #44's and said it was not sent from the kitchen for the meal. STNA #307 explained that he was supposed to get the NJD supplement with breakfast but she was not aware if he was supposed to have it for lunch, She said that was why she never questioned it. Meal observation was conducted of the lunch meal on 04/24/19 from 12:29 P.M. to 12:49 P.M. There was no NJD supplement provided for Resident #44 at the lunch meal. Interview was conducted on 04/24/19 at 12:35 P.M. with STNA #308 who was feeding Resident #44. STNA #308 verified there was no NJD supplement provided on the lunch meal tray for Resident #44. Review of a copy of Resident #44's tray tickets followed by the kitchen staff to prepare Resident #44's meal trays revealed a six ounce NJD supplement was on the tray tickets for breakfast and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 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 365433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Omni Manor Nursing Home 3245 Vestal Road Youngstown, OH 44509 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dinner. There was none indicated on the tray ticket for lunches, so dietary staff were not serving the NJD supplement on the lunch meal tray. Review of the Treatment Administration Record (TAR) for Resident #44 dated 04/01/19 to 04/30/19 revealed no NJD supplements were offered at any meal on 04/08/19, 04/09/19 and 04/10/19. This supplement was also not administered as ordered from 04/14/19 to 04/17/19 and 04/19/19 to 04/24/19. Interview was conducted on 04/24/19 at 2:55 P.M. with Registered Dietitian (RD) #301 and Corporate RD #302. The TAR and meal tray tickets from April 2019 were reviewed with them. RD#301 and RD #302 verified Resident #44 should have been receiving the NJD supplement at all three meals. They also verified the TAR reflected he was not receiving it as ordered and the lunch tray tickets were printed without the NJD supplement on it. Meal observation was conducted on 04/25/19 from 5:33 P.M. to 5:37 P.M. At 5:37 P.M., STNA #350 began feeding Resident #44 and verified he did not have the NJD supplement on his dinner tray. STNA #350 stated she did not believe he needed the supplement at the meal anyway because he accepted his meal. STNA #350 verified the NJD supplement was not sent from the kitchen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 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 365433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Omni Manor Nursing Home 3245 Vestal Road Youngstown, OH 44509 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 - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on record review and interview, the facility failed to ensure sufficient staff were available to provide restorative nursing services. This affected one resident (Resident #22) of three residents reviewed for accidents and had the potential to affect all 36 other residents identified by the facility who were currently on restorative nursing programs (Residents #1, #4, #5, #6, #10, #17, #19, #20, #21, #23, #25, #26, #28, #29, #32, #35, #38, #40, #47, #53, #57, #58, #61, #69, #71, #76, #77, #78, #85, #86, #101, #102, #105, #107, #109, and #113). Findings include: Review of Resident #22's medical record revealed diagnoses including emphysema, polyarthritis, chronic pain and chronic obstructive pulmonary disease. A restorative plan of care revealed Resident #22 was scheduled to receive a restorative ambulation program six to seven days a week for 15 minute sessions because she was at risk for decline with ambulation due to weakness and decreased mobility related to emphysema and decreased endurance. Review of restorative delivery records for February 2019 and March 2019 revealed the services were not documented as provided in accordance with the plan of care. The restorative ambulation program was discontinued after Resident #22 fell and sustained a left humerus fracture on 03/06/19. On 04/24/19 at 12:41 P.M., the Director of Nursing (DON) was interviewed regarding the restorative delivery records not reflecting the ambulation program was delivered as planned. On 04/24/19 at 4:00 P.M., Licensed Practical Nurse (LPN) #323 verified the restorative ambulation program was not provided as planned because restorative aides were pulled from their duties to replace staff who had reported off 11 of the days the services were not received in February 2019. On 04/26/19 at 8:27 A.M., Restorative State Tested Nursing Assistant (STNA) #326 verified restorative staff were pulled from the restorative nursing program to work an assigned unit at times. Although some restorative services could be provided, not all of the programs were able to be implemented. The facility identified 36 other residents currently on restorative nursing programs, Residents #1, #4, #5, #6, #10, #17, #19, #20, #21, #23, #25, #26, #28, #29, #32, #35, #38, #40, #47, #53, #57, #58, #61, #69, #71, #76, #77, #78, #85, #86, #101, #102, #105, #107, #109, and #113. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 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 365433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Omni Manor Nursing Home 3245 Vestal Road Youngstown, OH 44509 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview, the facility failed to ensure medications were administered in accordance with physician orders resulting in three medication errors out of 25 opportunities with a medication error rate of 12%. This affected three (Residents #17, #48, and #72) of eight residents observed for medication administration. Residents Affected - Few Findings include: 1. On 04/24/19 at 8:07 A.M., Licensed Practical Nurse (LPN) #306 was observed administering medication to Resident #48. As LPN #306 prepared to apply a Lidocaine 5% patch (applied topically to the skin for pain) to Resident #48's arm she discovered there was already a patch on the right arm. LPN #306 removed the Lidocaine patch from the right arm and applied the new patch to the left arm. Immediately following the application of the patch, LPN #306 verified the order for the Lidocaine patch indicated it was to be applied for 12 hours then removed for 12 hours. LPN #306 verified the Medication Administration Record (MAR) revealed the lidocaine patch had been applied on the right arm the morning of 04/23/19. Although, it was documented as removed the evening of 04/23/19, it remained on the arm until she removed it at 8:07 A.M. on 04/24/19. 2. On 04/24/19 at 8:26 A.M., LPN #305 was observed administering 17 grams of Miralax (laxative) mixed in four ounces of water to Resident #82. Review of Resident #82's physician order sheet revealed instructions for nurses to mix the Miralax with 6-8 ounces of fluid. On 04/24/19 at 5:00 P.M., LPN #305 verified she had not mixed the Miralax with the prescribed amount of fluid. LPN measured the amount of fluid the cup could hold and verified the cup did not hold six ounces of fluid. 3. On 04/24/19 at 11:20 A.M., Registered Nurse (RN) #351 was observed administering two units of Novolin R insulin into Resident #17's left arm. After injecting the insulin, RN #35 was observed rubbing the injection site. Review of the Novolin R drug insert information revealed instructions not to rub the injection site after administration of the insulin. On 04/24/19 at 11:21 A.M., RN #351 was interviewed regarding the rationale for rubbing the insulin injection site and stated it was habit. Review of the facility's Medication Administration policy, revised January 2019, revealed nurses were instructed to review the MAR for medication administration orders and instructions and to follow the instructions. These three medication errors out of 25 opportunities resulted in a medication error rate of 12%. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 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 365433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Omni Manor Nursing Home 3245 Vestal Road Youngstown, OH 44509 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and policy review, the facility failed to ensure safe storage of resident foods. This had the potential to affect 113 of 115 residents receiving meals/food from the facility (the facility identified two residents, Resident #9 and Resident #48, as not receiving meals/food from the facility). The facility census was 115 residents. Findings include: Observational tour of the resident snack areas with Kitchen Manager (KM) #300 on 04/22/19 starting at 9:38 A.M. revealed the following concerns: the North unit refrigerator had a container of resident food dated 03/24/19; the East unit refrigerator had three unlabeled and undated plates of resident food and the [NAME] unit had a container of some type of dip that was unlabeled and undated. Interview with KM #300 at the time of the above observations revealed dietary staff only monitored the expiration dates of facility-provided nourishments. KM #300 stated foods were to be labeled, dated and discarded within three days if not consumed. Review of a facility policy, Refrigerator and Freezer Outside of Nutrition Services, revised February 2018, revealed these areas were checked every two to three days for proper temperatures and any food items nearing the expiration date were to be removed. Review of a facility policy,Outside Source Food, revised November 2016, revealed foods brought in to the facility were to be labeled with the resident's name, food contents and the date. Food brought in could be stored in a facility refrigerator in limited quantities at the facility's discretion and was to be stored for five days from the date brought into the facility. These facility policies did not provide any information as to which facility staff were responsible for monitoring resident food stored in the nourishment refrigerators. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 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 365433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Omni Manor Nursing Home 3245 Vestal Road Youngstown, OH 44509 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to accurately represent the acuity needs of the residents, update the assessment when contracted services from staffing agencies were added to the facility and annually educate all staff on abuse training. This had the potential to affect all residents in the facility. The facility census was 115. Findings included: 1. An interview was conducted on 04/25/19 at 9:31 A.M. with the Director of Nursing (DON) who said the facility began utilizing two staffing agencies on 11/26/18 to provide additional State Tested Nursing Assistants and Licensed Nurses to the facility due to staffing challenges. Record review was conducted of the active nurse staffing list provided by the DON revealed approximately 66 agency nursing services staff had been set-up to use the electronic documentation system for the facility. Record review was conducted of the Facility Annual assessment dated [DATE]. The addition of the two contracted staffing agencies was not included on the assessment. An interview was conducted on 04/26/19 at 2:35 P.M. with the DON who verified the use of staffing agencies had not been added to the facility assessment. 2. The Facility Assessment indicated that all staff were to be evaluated annually for competencies and provided abuse training at orientation and annually. The personnel file for Licensed Practical Nurse (LPN) #343 revealed she had not had annual abuse training, a competency evaluation or dementia with behaviors training. LPN #343 was listed on the active staffing list for the facility. An interview was conducted on 04/26/19 at 10:59 A.M. with Corporate Registered Nurse (CRN) #344 who verified LPN #343 had not completed the annual training and competency evaluation because she only worked per diem (as needed) and had last worked on 09/17/18. CRN #344 verified LPN #343's date of hire was 11/08/16 and she was eligible, as an active staff member, to work in the facility at any time. The personnel files were reviewed for State Tested Nursing Assistants (STNA) #345, #347 and #348. STNA #345 and STNA #348 had no evidence they received annual dementia with difficult behaviors training. STNA #347 had no evidence of annual abuse training or annual dementia with difficult behaviors training. An interview was conducted on 04/26/19 at 2:43 P.M. with CRN #344 who verified STNAs #345, #347 and #348 had not had the annual abuse and/or dementia with difficult behaviors trainings. 3. Review of the Facility Annual Assessment, specifically the section to address the acuity needs of the residents revealed the average facility census was 115. Incorrect numbers of residents who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 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 365433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Omni Manor Nursing Home 3245 Vestal Road Youngstown, OH 44509 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete needed one to two staff for assistance with bathing, dressing, toileting, eating and transferring were identified and were listed between 261 to 333 residents. Interview on 04/26/19 at 3:59 P.M. with the Administrator verified the numbers to reflect the acuity needs of the residents on the Facility Annual Assessment were inaccurate and he would need to update those numbers. Event ID: Facility ID: 365433 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 365433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Omni Manor Nursing Home 3245 Vestal Road Youngstown, OH 44509 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review the facility failed to ensure meal and supplement intake records were consistently recorded. This affected two residents (Resident #42 and Resident #49) of six residents reviewed for nutrition. The facility census was 115 residents. Findings include: 1. Review of Resident #42's medical record revealed an admission date of 02/04/19 with diagnoses including repeated falls, hypertension (high blood pressure), depression and hypothyroidism. Review of physician orders for April 2019 revealed an order dated 02/27/19 for a no added salt diet with vanilla ice cream at dinner. Review of the April 2019 treatment administration record (TAR) revealed oral intakes at meals were not recorded for dinner on 04/02/19; all three meals on 04/03/19; breakfast and lunch on 04/04/19, 04/05/19 and 04/06/19; dinner on 04/07/19; all three meals on 04/08/19, 04/09/19 and 04/10/19; breakfast and lunch on 04/11/19, 04/12/19 and 04/13/19; all three meals on 04/14/19; dinner on 04/15/19; all three meals on 04/16/19 and 04/17/19; dinner on 04/18/19; breakfast and lunch on 04/19/19; dinner on 04/21/19, 04/22/19 and 04/23/19. Review of the April 2019 TAR revealed intakes for before-bed (HS) snack were not recorded on 04/02/19, 04/07/19, 04/08/19, 04/09/19, 04/10/19, 04/14/19, 04/15/19, 04/16/19, 04/18/19, 04/19/19, 04/21/19, 04/22/19 and 04/23/19. Review of the April 2019 TAR revealed intakes for fluid at meals was not recorded for dinner on 04/02/19; breakfast, lunch and dinner on 04/03/19; breakfast and lunch on 04/04/19, 04/05/19 and 04/06/19; dinner on 04/07/19; all three meals on 04/08/19, 04/09/19 and 04/10/19; breakfast and lunch on 04/11/19, 04/12/19 and 04/13/19; all three meals on 04/14/19; dinner on 04/15/19; all three meals on 04/16/19 and 04/17/19; dinner on 04/18/19; breakfast and lunch on 04/19/19 and dinner on 04/21/19, 04/22/19 and 04/23/19. Review of the April 2019 TAR revealed intakes for vanilla ice cream at dinner (as a supplement) were only recorded five out of 23 opportunities on 04/01/19, 04/04/19, 04/05/19, 04/15/19 and 04/23/19. Review of the electronic medical record (EMR) for meal intakes from 03/27/19 through 04/24/19 revealed missing meal intakes on 03/27/19, 03/29/19, 04/05/19, 04/08/19, 04/17/19, 04/19/19 and 04/20/19. Interview on 04/24/19 at 2:48 P.M. with Registered Dietitian (RD) #301 and Corporate Registered Dietitian (CRD) #302 revealed nursing staff documented meal and supplement intakes in three areas: on the TAR, on paper intake records and on the computer in the EMR. Interview on 04/25/19 at 8:35 A.M. with Corporate Quality Assurance Nurse (CQAN) #303 revealed until the electronic medical record was fully implemented in July 2019, staff were still required to document all meal and supplement intakes on the TARs, paper intake records and in the EMR. Review of a policy on clinical documentation, updated May 2018, revealed treatments were to be charted at the time the treatment was performed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 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 365433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Omni Manor Nursing Home 3245 Vestal Road Youngstown, OH 44509 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of Resident #49's medical record revealed an admission date of 04/12/18 and diagnoses including dementia with behavioral disturbance, constipation, chronic kidney disease stage three; major depressive disorder and unspecified psychosis. Review of physician's orders for April 2019 revealed an order dated 11/16/18 for a regular diet with finger foods; Four ounces, four times a day of TwoCal (a liquid supplement) with medication pass and six ounces nutritious juice drink (a supplement) three times a day with meals. Review of the April 2019 TAR revealed oral intakes for HS snacks were not recorded on 04/01/19, 04/02/19, 04/07/19, 04/08/19, 04/09/19, 04/14/19, 04/15/19, 04/16/19, 04/18/19, 04/19/19, 04/21/19, 04/22/19 and 04/23/19. Review of the April 2019 TAR revealed oral intakes for meals were not recorded for all three meals on 04/01/19; dinner on 04/02/19; all three meals on 04/03/19; breakfast and lunch on 04/04/19, 04/05/19 and 04/06/19; dinner on 04/07/19; all three meals on 04/08/19, 04/09/19 and 04/10/19; breakfast and lunch on 04/11/19, 04/12/19 and 04/13/19; all three meals on 04/14/19; dinner on 04/15/19; all three meals on 04/16/19 and 04/17/19; dinner on 04/18/19; all three meals on 04/19/19; and dinner on 04/21/19, 04/22/19 and 04/23/19. Review of the April 2019 TAR revealed fluid intakes at meals were not recorded for all three meals on 04/01/19; dinner on 04/02/19; all three meals on 04/03/19; breakfast and lunch on 04/04/19, 04/05/19 and 04/06/19; dinner on 04/07/19; all three meals on 04/08/19, 04/09/19 and 04/10/19; breakfast and lunch on 04/11/19, 04/12/19 and 04/13/19; all three meals on 04/14/19; dinner on 04/15/19; all three meals on 04/16/19 and 04/17/19; dinner on 04/18/19; all three meals on 04/19/19; and dinner on 04/21/19, 04/22/19 and 04/23/19. Review of the April 2019 TAR revealed nutritious juice was to be given three times a day with meals and was not administered for all three meals on 04/01/19; dinner on 04/02/19; all three meals on 04/03/19 and 04/04/19; dinner on 04/07/19; all three meals on 04/08/19, 04/09/19 and 04/10/19; breakfast and lunch on 04/11/19 and 04/12/19; all three meals on 04/14/19, 04/16/19 and 04/17/19. The supplement was changed to a once daily administration on 04/19/19 and was not marked as administered on 04/21/19. Review of meal intake records in the electronic medical record from 03/27/19 to 04/24/19 revealed missing meal intakes on 03/29/19, 04/15/19 and 04/17/19. Interview on 04/24/19 at 2:48 P.M. with Registered Dietitian (RD) #301 and Corporate Registered Dietitian (CRD) #302 revealed nursing staff documented meal and supplement intakes in three areas: on the TARs, on paper intake records and on the computer in the EMR. Interview on 04/25/19 at 8:35 A.M. with Corporate Quality Assurance Nurse (CQAN) #303 revealed until the electronic medical record was fully implemented in July 2019, staff were still required to document all meal and supplement intakes on the TARs, paper intake records and in the EMR. Review of a policy on clinical documentation, updated May 2018, revealed treatments were to be charted at the time the treatment was performed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 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 365433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Omni Manor Nursing Home 3245 Vestal Road Youngstown, OH 44509 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure appropriate infection control practices were maintained for Resident #216, who was on contact isolation. This had the potential to affect the other residents on the South wing, one of four resident units. The facility identified 34 residents (Residents #4, #5, #8, #21, #22, #23, #26, #27, #32, #38, #39, #46, #53, #54, #55, #59, #62, #64, #71, #75, #76, #77, #79, #85, #92, #95, #102, #103, #104, #107, #109, #110, #215, #216) who resided on South wing. Residents Affected - Some Findings include: Resident #216 was admitted to the facility on [DATE] and diagnoses included cellulitis. Review of Resident #216's medical record revealed a physician order dated 04/19/19 for contact isolation to be in place due to pseudomonas, an infection, in his leg wounds. On 04/24/19 at 9:50 A.M., State Tested Nursing Assistant (STNA) #352 was observed pushing an over bed table with a water mug out of Resident #216's room and leaving the table sitting in the hall outside the door, took the water mug and walked down the hall. At 9:54 A.M., STNA #352 returned to Resident #216's room providing him with a mug of ice water in a mug that had the same appearance as the one removed from the room. On 04/24/19 at 10:46 A.M., STNA #352 verified the water mug had been removed from Resident #216's isolation room and taken to the ice chest sitting on the south hall near the nursing station to be filled. STNA #352 indicated no special precautions were required although Resident #216 was on isolation precautions. Review of the facility Contact Precautions policy, revised September 2015, revealed contact precautions should be used in addition to standard precautions for residents with specific infections that could be transmitted by direct and indirect contact. Gloves should be removed before leaving the resident's room and hand hygiene should be performed immediately. After glove removal and hand hygiene, hands should not touch potentially contaminated environmental surfaces or items. Review of the Policy On Miscellaneous Aspects of Isolation: Dishes, Water Pitchers, Etc, policy dated March 2011, indicated in general, no special precautions or procedures were indicated unless the item was visibly contaminated or likely to be contaminated with infective material. Water pitchers were to be treated the same as dishes and eating utensils. If items were visibly contaminated with infective material, reusable dishes, utensils and trays would be bagged and labeled before being returned to the food service department. Personnel who handled the dishes should wear gloves and wash their hands before handling clean dishes or food. Review of the facility's Procedure For Passing Ice, dated March 2011, indicated the ice chest should be kept in the hall and moved to the door of each resident's room. When staff were through passing ice, empty the ice chest and leave it open to air dry. Ice and the scoop were to be stored in the Clean Utility Room or other clean area. The policy was silent regarding any special procedure for distributing ice to residents who were in isolation. This had the potential to affect the other 34 residents residing on the South wing, Residents #4, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 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 365433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Omni Manor Nursing Home 3245 Vestal Road Youngstown, OH 44509 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 #5, #8, #21, #22, #23, #26, #27, #32, #38, #39, #46, #53, #54, #55, #59, #62, #64, #71, #75, #76, #77, #79, #85, #92, #95, #102, #103, #104, #107, #109, #110, #215, and #216. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 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 365433 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Omni Manor Nursing Home 3245 Vestal Road Youngstown, OH 44509 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 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on record review and interview the facility failed to provide annual abuse prevention training to all staff. This affected four of 11 staff personnel files reviewed and had the potential to affect all residents in the facility. The facility census was 115. Findings included: 1. Review of the personnel file for Licensed Practical Nurse (LPN) #343 no annual abuse training, competency evaluation or dementia with behaviors training. LPN #343 was listed on the active staffing list for the facility. An interview was conducted on 04/26/19 at 10:59 A.M. with Corporate Registered Nurse (CRN) #344 who verified LPN #343 was not included in the annual training and competency evaluation because she only worked per diem (as needed) and had last worked on 09/17/18. CRN #344 verified LPN #343's date of hire was 11/08/16 and she was eligible as an active staff member to work in the facility at any time. 2. The personnel files for State Tested Nursing Assistants (STNAs) #345, #347 and #348 were reviewed. There was no documentation to indicate STNA #345 and STNA #348 had received annual dementia with difficult behaviors training. Three was no documentation STNA #347 had received annual abuse training or annual dementia with difficult behaviors training. Interview was conducted on 04/26/19 at 3:21 P.M. with CRN #344 who confirmed that all staff are to be trained on the abuse policy and how to care for dementia residents with difficult behaviors at least annually. CRN #344 verified STNA #345, STNA #347 and STNA #348 were all active staff for the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 If continuation sheet Page 27 of 27