Inspection·April 28, 2022

F 0690 Level of Harm - Actual harm Residents Affected - Few to reinsert the catheter. The results of the ultrasound needed to be called to Urologist #610. The physician instructions were sent with Resident #82 when she returned to the facility. If the catheter was replaced Resident #82 would need monthly catheter changes and as needed. Review of Resident #82's progress notes from 04/01/22 through 04/07/22 did not reveal a voiding trial was initiated and did not reveal Urologist #610 was contacted regarding urology office visit and physician orders written on 04/01/22. Review of Resident #82's progress notes on 04/07/22 revealed Resident #82's incontinence brief was wet. Resident #82 had a catheter and the catheter was clogged and unable to be irrigated. Licensed Practical Nurse (LPN) #602 contacted Urologist #610's office for instructions. LPN #602 was instructed to begin the voiding trial and if Resident #82 failed the voiding trial the catheter was to be reinserted, and the ultrasound of the kidney and bladder cancelled. The note stated Resident #82 was incontinent of urine at 6:45 P.M. Review of Resident #82's physician orders on 04/07/22 revealed begin voiding trial today (04/07/22) and if Resident #82 did not void within eight hours reinsert the catheter and update urology. Additional orders revealed bladder and renal ultrasound with post void residual (PVR) related to retention of urine. Please send results to Urologist #610. Review of Resident #82's progress notes on 04/08/22 at 9:45 A.M. revealed mobile x-ray arrived for the kidney and bladder ultrasound. Review of Resident #82's ultrasound of the kidney and bladder reported on 04/08/22 at 3:51 P.M. revealed the prevoid volume measured 806 cc and Resident #82 could not void (urinate). The medical record contained no evidence the ultrasound results were sent to Urologist #610. Review of Resident #82's progress notes on 04/10/22 at 5:34 P.M. revealed Resident #82 had increased altered mental status, restlessness and fidgeting over the past two days. The notes stated Resident #82 was incontinent of urine and it was foul smelling. Orders from the physician for a urinalysis and a urine culture and sensitivity. Review of Resident #82's physician orders on 04/10/22 revealed collect urine for urinalysis and culture and sensitivity via sterile intermittent catheterization one time only for altered mental status. Additional orders revealed Bactrim DS tablet (sulfamethoxazole-trimethoprim) 800-160 milligram, give one tablet via PEG (percutaneous endoscopic gastrostomy tube) tube two times a day for pending urinalysis, altered mental status, foul smelling urine for seven days, start after urinalysis was collected. Review of Resident #82's progress notes on 04/11/22 revealed several notes Resident #82's urine was unable to be obtained due to incontinence. A note at 2:14 P.M. revealed Resident #82 was straight cathed for a large amount dark amber cloudy urine and the urine was sent for a urinalysis and culture and sensitivity. Review of Resident #82's progress notes on 04/12/22 at 5:26 P.M. revealed Resident #82 appeared to be in discomfort and was grabbing her perineal area. Resident #82's abdomen was distended and hard, Resident #82 winced and grimaced when her abdomen was palpated and her urine was dark brown. Tylenol was given for pain, fluids were pushed throughout the shift through the PEG tube. A 16 french (size) catheter was inserted and an immediate return of 700 cubic centimeters (cc) of dark brown foul (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 If continuation sheet Page 2 of 11 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 04/28/2022 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 0690 smelling urine returned. Fifteen minutes later after the catheter was attached to a drainage bag an additional 800 cc of urine drained into the bag. Would update urology on 04/13/22. Level of Harm - Actual harm Residents Affected - Few Review of Resident #82's medical record on 04/12/22 at 8:17 P.M. revealed 500 cc of urine was obtained from the indwelling catheter drainage bag. Review of Resident #82's progress notes on 04/13/22 at 9:00 A.M. revealed Resident #82's indwelling catheter was draining dark red, bloody urine and her blood pressure was 96 (systolic) over 50 (diastolic), pulse was 110. Resident #82 was restless, alert, opened eyes, did not respond (not unusual), the physician was notified and orders were given to transport Resident #82 to the local Emergency Department. Resident #82 was transported to the Emergency Department at 9:56 A.M. Review of Resident #82's progress notes from 04/07/22 through 04/13/22 revealed documentation Resident #82 was incontinent, but there was no documentation about the amount of incontinence observed (small, moderate, large). Further review of the progress notes from 04/07/22 through 04/12/22 did not reveal documentation Resident #82's bladder was evaluated for discomfort, fullness. Review of Resident #82's progress notes from 04/08/22 through 04/13/22 (when Resident #82 was transported to the hospital) did not reveal documentation Urologist #610 was notified of the ultrasound results for her bladder and kidney. Interview on 04/27/22 at 3:28 P.M. with Licensed Practical Nurse (LPN) #602 revealed on 04/07/22 an unidentified State Tested Nursing Assistant (STNA) reported to her Resident #82's incontinence brief was wet and she had an indwelling catheter. LPN #602 stated an attempt to irrigate Resident #82's catheter was unsuccessful, the catheter was clogged and removed, and she received physician orders to start a voiding trial. LPN #602 indicated Resident #82 was incontinent of a significant amount of urine after the catheter was removed and an indwelling catheter was not re-inserted. LPN #602 stated Resident #82 was incontinent over the next few days, her urine was foul smelling, a darker color in her incontinence brief, she notified the physician and received orders on 04/10/22 for a urinalysis and culture and sensitivity. LPN #602 indicated it was the end of her shift and she passed on to the night shift nurse the need to obtain Resident #82's urine for urinalysis and culture and sensitivity. The night shift nurse did not collect the specimen and the day shift nurse on 04/11/22 collected the specimen. LPN #602 stated on 04/12/22 an unidentified STNA told her Resident #82's urine was foul smelling, and a dark color when she changed the incontinence brief, and when Resident #82 was evaluated her abdomen was distended and firm. LPN #602 stated she called the physician and received orders to insert a catheter and if there was greater than 240 cc urine, leave the catheter in. LPN #602 stated she catheterized Resident #82, had a return of 700 cc of urine, attached a drainage bag, and Resident #82 drainage bag had another 800 cc of urine in it 15 minutes later. LPN #602 indicated the results of Resident #82's urinalysis and culture and sensitivity had not been reported yet, and the Bactrim was not started until 04/11/22, after the urine was collected for the culture and sensitivity. LPN #602 stated Resident #82 was incontinent of urine since 04/07/22 when the catheter was removed. Interview on 04/27/22 at 4:02 P.M. with LPN #602 revealed the results of Resident #82's ultrasound of her bladder and kidney should have been forwarded to Urologist #610, and she did not know if that had been done. LPN #602 indicated on 04/13/22 Resident #82's urine was very dark and bloody, she notified the physician and Resident #82 was transported to the local hospital Emergency Department. Interview on 04/28/22 at 11:47 A.M. with Family Member (FM) #611 revealed Urologist #610 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 If continuation sheet Page 3 of 11 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 04/28/2022 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 0690 Resident #82's urology physician. Level of Harm - Actual harm Interview on 04/28/22 at 2:10 P.M. with the Administrator, Director of Nursing, Assistant Director of Nursing (ADON) #514, and Corporate Quality Assurance Nurse (CQAN) #612 revealed Resident #82 was incontinent of urine from 04/07/22 through 04/12/22 when the indwelling catheter was inserted. CQAN #612 stated Resident #82's urine collection for urinalysis and culture and sensitivity was unable to be obtained until 04/11/22 because she was incontinent. CQAN #612 stated Bactrim was started after the urine sample was collected. CQAN #612 stated Resident #82's ultrasound of bladder and kidney results should have been sent to Urologist #611 and that had not been done. Residents Affected - Few Interview on 04/28/22 at 3:09 P.M. with ADON #514 revealed Resident #82's orders from Urologist #610 on 04/01/22 needed clarification because of issues with incontinence. ADON #514 stated Urologist #610 was called a couple times, but he didn't know if the calls were documented in the medical record. ADON #514 indicated Resident #82's catheter was clogged on 04/07/22 and removed. Review of the facility policy titled, Indwelling Urinary Catheter Removal For Voiding Trial, dated 01/2022, revealed the facility would follow instructions from the attending physician or urinary specialist for the voiding trials, including any orders to straight catheterize to assess for urinary retention, time between voiding for additional notification (usually between six to eight hours) and any other specific instructions such as bladder scan or bladder ultrasound. If the resident was incontinent the nursing staff would document the resident was voiding and the amount of incontinence noted. If no output or minimal output was noted with eight hours of the catheter removal the attending physician would be notified to obtain orders for a straight catheter insertion to assess for retention or to re-insert the catheter. The resident would be assessed for any complaints of pain or burning with urinary output or any discomfort in the abdominal and pelvic area and these would be reported to the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 If continuation sheet Page 4 of 11 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 04/28/2022 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure Resident #97's oxygen was administered per physician orders by licensed nursing staff. This affected one resident (Resident #97) out of three residents reviewed for respiratory care. Residents Affected - Few Findings include: Review of Resident #97's medical record revealed an admission date of 01/26/22 and diagnoses included Alzheimer's disease, dementia, acute embolism and thrombosis of the left femoral vein. Review of Resident #97's Quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/01/22, revealed Resident #97 had severe cognitive impairment and required the extensive assistance of one person for bed mobility and toilet use, and required total dependence of two staff members for transfers. Review of Resident #97's care plan dated 04/01/22, revealed Resident #97 had altered respiratory status and difficulty breathing related to chronic infiltrates on chest x-ray. Resident #97 would have no complications related to shortness of breath through the review date. Interventions included oxygen settings for oxygen via nasal cannula at five liters per minute. Review of Resident #97's physician orders on 02/09/22 revealed to administer oxygen at five liters per nasal cannula continuously. Observation on 04/26/22 at 8:49 A.M. of Resident #97's oxygen concentrator revealed Resident #97 was not in her room, but observation of the oxygen concentrator revealed there was no tubing connected and the concentrator was on the setting of five liters per minute and the concentrator was blowing the oxygen into the air. State Tested Nursing Assistant (STNA) #538 confirmed the concentrator was blowing oxygen into the air at five liters per minute and Resident #97 was not in the room. Observation on 04/26/22 at 9:06 A.M. of Resident #97 revealed she was sitting in a wheelchair in the common area, wearing a nasal cannula with the tubing connected to a portable oxygen tank on the back of the wheelchair. The portable oxygen tank was set to deliver oxygen at three liters per minute. Therapy Assistant (TA) #613 arrived to transport Resident #97 to her therapy appointment and stated Resident #97's oxygen was set at three liter per minute. Interview on 04/26/22 at 9:10 A.M. of STNA #538 revealed she disconnected Resident #97 from her oxygen concentrator in the room. STNA #538 stated she connected Resident #97's oxygen to the portable tank and turned the portable tank on to three liters per minute via nasal cannula when she assisted Resident #97 into the common area. Observation on 04/27/22 at 9:27 A.M. of Resident #97 revealed she was sitting in a wheelchair in the common area with a portable oxygen tank on the back of the wheelchair. The oxygen was administered to Resident #97 at a rate of five liters per minute via nasal cannula. Observation of State Tested Nursing Assistant (STNA)'s #538 and STNA #530 revealed they transported Resident #97 from the common area to her room and used a mechanical lift to transfer her from the wheelchair to her bed. STNA #538 disconnected the oxygen tubing from the portable tank, handed the disconnected tubing to STNA #530 and STNA #530 placed the tubing in Resident #97's lap for the transfer. After the transfer was completed and Resident #97 was in her bed, STNA #530 took the oxygen tubing and connected it to the oxygen concentrator in the room, the oxygen concentrator was set at five liters per nasal cannula. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 If continuation sheet Page 5 of 11 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 04/28/2022 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 0695 Level of Harm - Minimal harm or potential for actual harm Review of facility policy titled, Oxygen Administration, dated 01/2019, revealed to check physician orders for liter flow and method of administration. Oxygen was considered a medication and oxygen administration including application, setting liter flow, switching to portable oxygen was only done by a licensed nurse. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 If continuation sheet Page 6 of 11 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 04/28/2022 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and facility policy review, the facility failed to ensure medication carts and medication storage areas did not contain expired medications and failed to ensure insulin pens were labeled with the date opened. This affected 13 residents (Resident #6, #33, #37, #46, #50, #62, #65, #83, #88, #90, #91, #106, and #113) and had the potential to affect all 109 residents residing in the facility. Findings include: 1. Observation on 04/27/22 at 8:18 A.M. of the medication cart on the South wing revealed the following findings: • Lantus Solostar 100 units per milliliter (u/ml) insulin pen for Resident #91 was not marked with the date opened. • Lispro 100 u/ml insulin pen for Resident #62 was not marked with the date opened. • Lantus 100 u/ml vial for Resident #62 was not marked with the date opened. • Haloperidol oral solution 2 milligrams per milliliter (mg/ml) for Resident #106 was not marked with the date opened. Interview with Registered Nurse (RN) #420 on 04/27/22 at 8:30 A.M. during observation of medication cart for the South wing verified the above medications were not properly labeled. 2. Observation on 04/28/22 at 8:32 A.M. of the medication cart on the North wing revealed the following findings: • Lantus Solostar 100 u/ml insulin pen for Resident #46 was not marked with the date opened. • A bottle of Artificial Tears one drop (gtt) in both eyes three times a day for Resident #46 expired 11/2021. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 If continuation sheet Page 7 of 11 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 04/28/2022 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 0761 Basaglar 100 u/ml insulin pen for Resident #83 was not marked with the date opened. Level of Harm - Minimal harm or potential for actual harm • A bottle of Milk of Magnesia for resident #50 expired 11/2021. Residents Affected - Many Observation of the medication storage room on the North wing on 04/28/22 at 8:45 A.M. revealed the following finding: • Polyethylene Glycol 3350 dissolve 17 grams (gm) in 4 to 8 ounces (oz) of water daily for Resident #88 expired 01/2022. Interview on 04/28/22 at 9:05 A.M. during the observation of medication storage on the North wing with Licensed Practical Nurse (LPN) #434 verified the above medications were either expired or not labeled properly. 3. Observation on 04/28/22 at 9:17 A.M. of the medication storage room refrigerator on the South wing revealed the following findings: • Bisacodyl 10 mg suppositories, five total in the bag, for Resident #90 expired on 03/12/22. • Bisacodyl 10 mg suppositories, three total in the bag, for Resident #33 expired on 10/20/20. • Facility stock Acetaminophen 650 mg suppositories, two total in the bag, expired on 01/29/22. Interview on 04/28/22 at 9:27 A.M. with RN #420 during the observation of the South wing medication storage refrigerator verified the above medications were expired. 4. Observation on 04/28/22 at 2:57 P.M. of the medication cart on the East wing revealed the following findings: • Lispro 100 u/ml insulin pen for Resident #37 was not marked with the date opened. • Lispro 100 u/ml insulin pen for Resident #113 was not marked with the date opened. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 If continuation sheet Page 8 of 11 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 04/28/2022 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 0761 Ondansetron HCL 4 mg tablets for Resident #6 expired on 03/23/22. Level of Harm - Minimal harm or potential for actual harm • Senna-tabs 8.6 mg for Resident #65 expired on 12/21/21. Residents Affected - Many Observation on 04/28/22 at 3:09 P.M. of the medication storage refrigerator on the East wing revealed the following finding: • A vial of Tuberculin solution 5 u/0.1 ml was not labeled with the date opened. Interview on 04/28/22 at 3:10 P.M. with LPN #700 during the observation of the medication cart and medication storage refrigerator on the East wing verified the above medications were either expired or not labeled properly. Review of the facility policy titled, Medication Administration, dated 11/2021, revealed when first opening a multi-dose vial of medications, including vaccines, the bottle would be initialed and dated. Multi-does medication pens would be initialed and dated when first opened. Manufacturer instructions would be followed for expiration dates of the medications. Review of the facility policy titled, Medication Storage Policy, dated 11/2015, revealed expired, deteriorated, or contaminated medications would be disposed of properly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 If continuation sheet Page 9 of 11 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 04/28/2022 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 0886 Perform COVID19 testing on residents and staff. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to test Resident #9 who was displaying signs and symptoms of COVID-19. This had the potential to affect all 109 residents residing in the facility. Residents Affected - Many Findings include: Review of medical record for Resident #9 revealed an admission date of 02/29/20 with diagnoses including chronic respiratory failure with hypoxia, hypertension, and gastroesophageal reflux disease. Review of quarterly Minimum Data Set assessment dated [DATE] for Resident #9, revealed he had moderate cognitive impairment. Resident #9 required extensive two-person physical assistance for bed mobility, extensive one-person physical assistance for dressing, toileting, and personal hygiene, and supervision set up help only for eating. Resident #9 had an indwelling catheter for urine and was always incontinent of bowel. Review of nursing progress note dated 04/23/22, revealed Resident #9 had an increased temperature of 99 degrees Fahrenheit, his heart rate was increased at 103 beats per minute, and his oxygen level was 77%. Resident #9 was also complaining of shivering. He was administered Tylenol and the physician was notified. Review of nursing progress note for Resident #9 dated 04/24/22, revealed he had a low-grade temperature of 99 degrees Fahrenheit. The physician was notified with orders for a urine culture and sensitivity and an antibiotic. Observation on 04/25/22 at 9:44 P.M. revealed Resident #9 lying in bed shivering with a moist cough. Interview on 04/27/22 at 8:47 A.M. with Resident #9 revealed he did have a runny nose and cough. The resident reported it had been going on for a few days, but he had stopped shivering. Interview on 04/27/22 at 11:20 A.M. with Registered Nurse (RN) #426 confirmed Resident #9 did have a low-grade fever and cough but was found to have a urinary tract infection. She confirmed he was not COVID-19 tested. Interview on 04/27/22 at 5:00 P.M. with RN #514 confirmed Resident #9 was not COVID-19 tested despite displaying symptoms. Review of facility policy titled, COVID-19 preventative measures and management protocol for Ohio, revised 03/14/22, revealed immediate droplet plus isolation for any resident with symptoms that may be COVID-19 related in an area designated for symptom related isolation or in their own room, preferably alone with the door closed. Symptoms may include decrease in pulse oxygen reading from baseline, low BP, increased temp of 100.0 or above, (two temperature increases 99 degrees), increased pulse rate from baseline, GI symptoms, cough, shortness of breath, changes in neuro status, loss of taste/smell, headache, lethargy, body aches. A COVID-19 RT-PCR or POC antigen test would be obtained when symptoms develop. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 If continuation sheet Page 10 of 11 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 04/28/2022 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident #2, Resident #32, Resident #37, Resident #39, Resident #65, Resident #68, and Resident #85 bathrooms were in good repair. This affected 7 residents (Resident #2, Resident #32, Resident #37, Resident #39, Resident #65, Resident #68, and Resident #85) of seven residents oberved for environment. Findings include: Observation on 04/26/22 at 8:47 A.M. revealed the bathroom sink faucet was observed to be leaking in the jack and [NAME] bathroom in between Residents #2, #65, and #68. Interview during the observation with Resident #2 confirmed the faucet has been leaking for a long time. Observation on 04/26/22 at 8:48 A.M. revealed the toilet seat in the jack and [NAME] bathroom for Residents #32, #37, #39, and #85 was broken off the toilet. The seat was slid to the right and half covering the opening of the toilet. Interview and observation on 04/28/22 at 8:47 A.M. with Housekeeper #462 confirmed the broken toilet seat for Residents #32, #37, #39, and #85. She revealed she notified maintenance on 04/21/22. Housekeeper #462 also confirmed the bathroom faucet for Residents #2, #65, and #68 was leaking. She reported she was unaware the faucet was leaking. Interview on 04/28/22 at 9:09 A.M. with Maintenance #408 revealed he was unaware of the maintenance issues for those two restrooms. He reported there was a maintenance log on each unit and every morning the maintenance staff checks the logs for repair requests. Observation on 04/28/22 at 9:17 A.M. revealed the maintenance repair sheet on the east wing at the nurse's station had nothing written on it. Interview at the time of the observation with State Tested Nursing Assistant (STNA) #534 confirmed there was nothing written on the repair request form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365433 If continuation sheet Page 11 of 11