Health inspection·February 20, 2020

F 0550 Level of Harm - Minimal harm or potential for actual harm 2. Record review was conducted for Resident #6 who was admitted to the facility on [DATE] with diagnoses including vascular dementia, swallowing problems, schizoaffective disorder and bipolar disorder. The MDS assessment dated [DATE] revealed she needed the assistance of two staff for bed mobility, transfers, dressing and toileting and one staff assistance for eating. The current plan of care indicated the resident required the assistance of one staff for eating. Residents Affected - Few Observation was conducted on 02/20/20 at 8:58 A.M. and Resident #6 was observed being fed breakfast in her room by LPN #810, who was standing while feeding the resident. Interview was conducted on 02/20/20 at 12:41 P.M. with LPN #810 who verified she stood while feeding the breakfast to Resident #6. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365460 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Health Care Center 1735 Belmont Avenue Youngstown, OH 44504 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 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview, the facility failed to ensure ongoing concerns from resident council meetings concerning fresh ice water daily were addressed/resolved timely. This affected Residents #3, #7, #17, #45 and #150 and had the potential to affect all other residents except 13 residents: six residents who do not take fluids orally (Residents #12, #19, #27, #29, #41 and #44); five residents on thickened liquids (Residents #6, #14, #28, #30 and #100); and eight residents with percutaneous endoscopic gastrostomy feeding tubes (Residents #12, #14, #19, #21, #27, #29, #37 and #44). The facility census was 48. Residents Affected - Some Findings included: Review of the facility's Resident Council Meeting Minutes and Need for Improvement/Resident Family Concerns, dated 01/08/19 through 01/14/20 revealed repeat concerns. On 07/16/19, a concern from residents was documented that ice water distribution was inconsistent. On 09/10/19, a concern was documented about residents not being given fresh drinking water. On 01/14/20, a concern was documented of water not being passed to residents on a regular basis. There was no documented follow-up from the facility staff/administration to attempt to resolve issues related to water pass to residents. Observation and interview was conducted on 02/18/20 at 3:10 P.M. of Resident #150's room and at 3:54 P.M. of Resident #7's room. Both residents had water pitchers on their bed side tray tables that were one third to half full of water without ice. The pitchers were room temperature to touch. Resident #150 and Resident #7 both reported they had not been passed fresh water that day. They both said they did not get fresh water on most days unless they asked for it. Interview was conducted on 02/20/20 from 9:25 A.M. to 9:56 A.M. with a group of residents. Those in attendance were Residents #3, #7, #33 and #45. The residents asked Activity Coordinator (AC) #814 to stay and AC #814 remained present throughout the meeting. When asked if the council felt administration addressed the concerns expressed by the resident council, they were in agreement that some concerns were addressed, but not all. When asked to elaborate Resident #3, #7 and #45 revealed they did not receive fresh drinking water daily. Resident #3 said on 02/19/20 around 9:00 P.M. to 10:00 P.M. she had asked State Tested Nursing Assistant (STNA) #818 to bring her some fresh water. She said STNA #818 took her water pitcher and never brought any water back for her to drink. Resident #3 shared sometimes she went for days without fresh water being passed to her and the only way she gets any is if she asks for it several times. Resident #7 said warm water will sit in his water pitcher for days and the only people who get fresh water are those who can go get it themselves or if he repeatedly asks for it. Resident #45 nodded in agreement to Resident #7's concern. Resident #45 said the staff does not pass him fresh water. Resident #3 said she had tried to go get her own ice and water but the staff told her she was not allowed to do it. All three of the residents expressed they felt the situation would not change because they had brought it to the attention of the prior administrator and the new administrator and they still were not receiving fresh ice water or fresh water every day as they should be receiving it. AC #814 verified the residents had brought this concern up several times before and it remained a concern of residents. Observation and interview was conducted on 02/20/20 at 10:03 A.M. with Resident #17. The resident was oriented to the conversation and was sitting in a wheelchair in her room. The resident had no water to drink in her room and said she often goes without water and is not able to get it for herself. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365460 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Health Care Center 1735 Belmont Avenue Youngstown, OH 44504 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 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some General observations were conducted on 02/20/20 from 10:03 A.M. to 10:11 A.M. of the resident rooms on the South unit and there was no evidence fresh water had been passed. Interview was conducted on 02/20/20 at 10:11 A.M. with STNA #817 who identified herself as working on the South unit from 6:00 A.M. to 3:00 P.M. STNA #817 revealed she was supposed to pass fresh water when she started her day on the unit. She said she was usually not able to do it due to the number of residents who need up assistance to get up for breakfast or showered. STNA #817 verified she had not passed fresh water to any of the residents. Interview was conducted on 02/20/20 at 10:22 A.M. with Licensed Practical Nurse (LPN) #809 who revealed it was the expectation the STNA's pass fresh ice water to all resident's unless they are ordered not to have water or other fluids by mouth. They said STNA's are to pass fresh water to residents, preferably within the first two hours of each shift. LPN #809 said she was not aware the residents were not receiving fresh water pass each shift. Interview was conducted on 02/20/20 at 11:34 A.M. with the Administrator who said any concerns expressed by resident council and any related follow-up was documented within the resident council documents, which he had provided. He said there were no water related concerns on their grievance log. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365460 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Health Care Center 1735 Belmont Avenue Youngstown, OH 44504 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications were documented at the time of administration per best nursing practice guidelines. This finding affected eight (Residents #5, #16, #25, #30, #37, #44, #48 and #100) of sixteen residents residing on the memory care unit. Residents Affected - Some Findings include: Observation on 02/18/20 at 8:53 A.M. confirmed Registered Nurse (RN) #806 was standing at the medication cart by the nursing station documenting on the computer. The nurse indicated she had completed her entire medication pass to her assigned residents and was now documenting the medications she had previously administered to Residents #25 and #48. Interview on 02/18/20 at 9:00 A.M. with RN #806 confirmed she had completed medication administration for all residents including Residents #25 and #48 and was documenting the administration of the medications after completion of her medication pass and not after each individual resident received his or her medications. RN #806 also indicated she was completing documentation at the same time for medications she had already administered to Residents #5, #16, #30, #37, #44 and #100. She verified she did not document the medications given at the time she actually administered each resident's medications per best practice guidelines. Review of the Medication Administration policy dated 05/19 indicated nursing staff were to chart the medication as given on the medication administration record. The eight rights of residents for medication administration, found on NursingCenter.com, by [NAME] nursing publications, indicate nurses are to document administration of medications after they are given with the time and any other specific information that is necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365460 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Health Care Center 1735 Belmont Avenue Youngstown, OH 44504 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews the facility did not ensure Resident #28 was provided a restorative nursing program as recommended by physical and occupational therapies. This affected one of 16 residents screened and one of one resident reviewed for positioning. The facility census was 48. Findings included: Record review for Resident #28 revealed he was admitted to the facility on [DATE] with diagnoses including profound intellectual disabilities, blindness in right eye, legal blindness, abnormal posture, swallowing problem, generalized anxiety and unspecified bipolar disorder. The Plan of Care, initiated on 11/21/19, revealed Resident #28 was dependent on staff for personal care and performance due to him being nonverbal with profound mental retardation. All of his care needs would need to be anticipated by staff. The Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was unable to complete the brief interview for mental status due to his impaired cognition and was dependent on two staff for bed mobility, transfers, dressing and toilet use and needed the assistance of one staff for eating. Review of the facility document titled, Physical Therapy Evaluation and Plan of Treatment, dated 11/22/19, authored by Physical Therapist (PT) #812, revealed Resident #28's right lower extremity had a 20 degree impairment of knee flexion and the left lower extremity had a 40 degree knee flexion impairment. The document titled, Physical Therapy Discharge Summary, dated 01/08/20, authored by PT #812, revealed Resident #28 was to be discharged from physical therapy on 01/08/20 with a recommendation for a restorative nursing program for continued range of motion to be provided. Review of the facility document titled, Occupational Therapy Evaluation and Plan of Treatment, dated 11/22/19, authored by Occupational Therapist (OT) #815, revealed Resident #28 was being seen for treatment to the upper extremities for strengthening for positioning and contracture management. The document titled, Occupational Therapy Discharge Summary, dated 01/14/20, authored by OT #816 recommended a restorative nursing program for self-feeding. Review of the, 5 Day Cut Notice, dated 01/09/20, authored by Certified Occupational Therapy Assistant (COTA) #813 revealed physical therapy ended on 01/08/20, occupational therapy ended on 01/14/20 and the discharge plan was for the resident to be long term care without a restorative program. Review of a nursing progress note dated 01/16/20, authored by Registered Nurse (RN) #805, revealed Resident #28 was not receiving any type of restorative program and indicated he had no contractures (limited movement of a joint due to changes in muscles, tendons and ligaments around the joint). Review of the facility evaluation titled, Restorative MDS version 5, dated 01/17/20, authored by RN #805, timed 2:08 P.M. and locked at 2:22 P.M. revealed Resident #28 had impaired range of motion to his upper and lower extremities (arms/hands and legs/feet) on both sides, contractures on both sides of his body and indicated a restorative program was in place. Observation was conducted on 02/18/20 at 12:49 P.M. and 5:05 P.M. of Resident #28 being assisted at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365460 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Health Care Center 1735 Belmont Avenue Youngstown, OH 44504 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few meals by staff. He required total assistance by State Tested Nursing Assistant (STNA) #807 and STNA #808 to consume his food and beverages. He appeared frail, underweight for his frame and was not capable of responding to verbal stimuli by the staff member except to make unintelligible noises in response to his name. His arms and hands were curled up onto his chest and his entire body was leaning toward the right side of his specialized wheelchair past midline position the entire time the staff member fed him. He was drooling at the mouth and he repeatedly pulled his legs into a curled position as if he was trying to go into a fetal position. He readily consumed a pureed diet with honey thickened liquids fed to him by STNA #807 and STNA #808 and could not feed himself at all during the observations. Interview was conducted on 02/19/20 at 1:13 P.M. with RN #805 who revealed Resident #28 liked to curl up like a pretzel in bed, had problems with positioning, was at risk for contractures but was not currently on a restorative nursing program because he was not contracted. RN #805 verified she had documented on the 01/17/20 Restorative MDS form that the resident was contracted on both sides of his body and needed a restorative nursing program but she said she made a mistake on the form. Interview and record review was conducted on 02/19/20 at 2:18 P.M. with Director of Therapy (DOT) #811 who verified the occupational therapist and physical therapist who treated Resident #28 did recommended a restorative nursing program for both his upper and lower extremities but COTA #813 inaccurately marked the 5 Day Cut Notice to say he did not need a restorative nursing program. Interview was conducted via phone on 02/19/209 at 2:44 P.M. with COTA #813, with DOT #811, present during the interview. COTA #813 verified she had inaccurately marked the 5 Day Cut Notice and Resident #28 did need to be on a restorative nursing program for upper extremity strengthening. Interview was conducted via phone on 02/19/20 at 2:45 P.M. with Physical Therapist (PT) #812, with DOT #811 present during the interview. PT #812 revealed she had personally treated Resident #28 and he had been discharged from physical therapy on 01/08/20 needing a restorative nursing program for range of motion to both of his lower extremities. Interview was conducted on 02/19/20 at 3:41 P.M. with DOT #811 who said she screened Resident #28 and he had no upper or lower extremity contractures and she was recommending the restorative nursing program as per the prior discharge recommendations written on 01/08/20 and 01/14/20 by the other therapists. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365460 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Health Care Center 1735 Belmont Avenue Youngstown, OH 44504 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #21's pressure ulcer wound care was documented accurately. This finding affected one (Resident #21) of one resident reviewed for pressure ulcer wounds. Findings include: Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including paraplegia (paralysis of the legs/lower body), spastic hemiplegia (neuromuscular conditions of muscles of one side of the body being in a constant state of contraction) and pressure ulcer. Review of Resident #21's physician orders revealed an order dated 01/23/20 for nursing staff to cleanse the coccyx pressure ulcer with normal saline, pack with iodoform roping and cover with a foam dressing daily. Review of Resident #21's progress notes, medication administration records (MARS) and treatment administration records (TARS) from 01/23/20 to 02/19/20 revealed the pressure ulcer treatment was not documented as completed as ordered on 01/24/20, 01/29/20, 01/31/20, 02/01/20, 02/02/20, 02/05/20, 02/06/20, 02/07/20, 02/09/20, 02/15/20 and 02/16/20. Interview on 02/19/20 at 1:11 P.M. with Registered Nurse (RN) #805 indicated the facility was having a hard time with agency nursing staff not documenting resident care. RN #805 confirmed she checked residents every day for wound care completion and she had not identified any concerns with Resident #21's pressure ulcer wound care being completed as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365460 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365460 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Health Care Center 1735 Belmont Avenue Youngstown, OH 44504 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility did not ensure residents received the influenza vaccine timely. This affected seven (Residents #13, #17, #19, #26, #29, #30 and #46) of thirty-two residents reviewed for influenza vaccine. Residents Affected - Some Findings include: Review of facility Influenza Vaccine consent forms for 2019 revealed Resident #13's guardian signed the consent on 10/02/19, Resident #17's family gave verbal consent on 10/23/19, Resident #19's family signed the consent on 09/27/19, Resident #26 signed the consent on 11/06/19, Resident #29's guardian signed the consent on 10/02/19, Resident #30's guardian signed the consent on 10/01/19 and Resident #46's family signed the consent on 09/23/19. Review of the influenza tracking form authored by the facility confirmed Residents #13, #17, #19, #26, #29, #30 and #46 were administered the influenza vaccine on 02/18/20. Interview on 02/19/20 at 9:05 A.M. with Licensed Practical Nurse (LPN) #804, with Regional Registered Nurse (RN) #803 in attendance, confirmed she did not administer the influenza vaccine to seven residents in a timely manner and indicated it was her error. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365460 If continuation sheet Page 9 of 9