Health inspection·September 12, 2019

F 0578 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on medical record review and staff interview, the facility failed to ensure advanced directives were correct in the medical record for one (Resident #59) of 24 sampled residents. The facility census was 78. Residents Affected - Few Findings include: Review of Resident #59's paper medical record identified admission to the facility occurred on 04/13/18. The paper medical chart included an admission and discharge form, which identified Resident #59 wished to be a Full Code (requested resuscitative measures being completed in the event of cardiac arrest) resuscitative status. Further review of the paper medical record revealed a Do Not Resuscitate (DNR) form, dated 01/21/19, identified Resident #59 changed the code status to DNR. The chart identified the paper forms had conflicting information. Interview on 09/10/19 at 11:12 A.M., Licensed Practical Nurse (LPN) #55 stated the admission and discharge form was copied and sent with a resident when they needed to go to the hospital. LPN #55 stated she was not aware of whom should be updating the form following changes to a resident code status. LPN#55 confirmed Resident #59's advanced directives wishes are conflicting in the paper chart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365475 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 365475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Nursing Center of Mansfield 535 Lexington Avenue Mansfield, OH 44907 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews and staff interview, the facility failed to ensure written notification regarding the reason for a hospital transfer was provided to residents and families for six (#24, #49, #64, #80, #179, and #181) out of seven residents reviewed for hospital transfer. The facility census was 78. Findings include: 1. Review of Resident #24's medical record identified admission to the facility occurred on 04/04/10. Resident #24 required hospitalization from 06/10/19 through 06/18/19 for changes laboratory values. There was no evidence in the record a written notification was provided to Resident #24's family regarding the reason for hospital transfer. 2. Review of Resident #49's medical record identified admission to the facility occurred on 06/14/18. Resident #49 required hospitalization from 08/11/19 through 08/16/19 for issues with constipation. There was no evidence in the record a written notification was provided to Resident #49 and her family regarding the reason for hospital transfer. 3. Review of Resident #64's medical record identified admission to the facility occurred on 01/06/18. Resident #64 required hospitalization on 08/01/19 through 08/05/19 for surgery following a fractured hip. There was no evidence in the record a written notification was provided to Resident #64 and her family regarding the reason for the hospital transfer. 4. Review of Resident #181's medical record identified admission to the facility occurred on 01/26/18. Resident #181 required hospitalization from 08/16/19 through 08/23/19 for end stage renal disease. There was no evidence in the record a written notification was provided to Resident #181 and his family regarding the reason for hospital transfer. 5. Review of the closed medical record for Resident #80 revealed an admission date of 05/21/19. The record revealed on 07/11/19 Resident #80 was transferred to the hospital. There was no documentation the facility provided the resident and the resident's representative written notification of the reason for the transfer. 6. Medical record review revealed Resident #179 admitted to the facility on [DATE]. Diagnoses included hip fracture and dementia. Review of a nurse progress note, dated 08/24/19, revealed the resident was transferred to the hospital at 7:08 P.M. Review of a hospital Discharge summary, dated [DATE], revealed the resident was admitted to the hospital, on 08/24/19. There was no documentation the facility provided the resident and the resident's representative written notification of the reason for the transfer. Interview on 09/11/19 at 10:50 A.M., the Administrator confirmed the facility does not have a current system in place to send written notification to residents and family regarding the reason for discharge. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365475 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 365475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Nursing Center of Mansfield 535 Lexington Avenue Mansfield, OH 44907 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of a facility policy, the facility failed to provide private pay residents notification of the facility bed hold policy upon discharge to an acute care hospital for two (#179 and #80) of two private pay residents reviewed for hospitalization. The facility census was 78. Findings included: 1. Medical record review revealed Resident #179 admitted to the facility on [DATE]. Diagnoses included hip fracture and dementia. Review of a nurse progress note, dated 08/24/19, revealed the resident was transferred to the hospital at 7:08 P.M. Review of a hospital Discharge summary, dated [DATE], revealed the resident was admitted to the hospital, on 08/24/19. There was no documentation the facility provided the resident and/or the resident's representative written notification of the facility bed hold policy. 2. Review of the closed medical record for Resident #80 revealed an admission date of 05/21/19. The record revealed on 07/11/19 Resident #80 was transferred to the hospital. There was no documentation the resident was provided a notice of the bed hold policy at the time of discharge to the hospital. Interview on 09/11/19 at 03:00 P.M., Licensed Social Worker (LSW) #100 stated the facility provides the bed hold policy Medicaid residents, but not private pay residents when they are transferred to the hospital. Review of the undated facility policy titled Bed Hold & Leave of Absence Policy revealed the facility provides information to the resident at admission regarding it's bed hold and leave of absent policy. At the time of transfer to a hospital or therapeutic leave, the facility will informed the resident and /or representative of the number of bed hold days remaining if the resident participates in the Medicaid program. All other residents will indicate at the time of admission whether they will pay for a bed hold in the event of a hospital transfer or therapeutic leave. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365475 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 365475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Nursing Center of Mansfield 535 Lexington Avenue Mansfield, OH 44907 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm Based on medical record review, review of facility policy, resident interview, and staff interviews, the facility failed to monitor daily bowel movements, failed to hold antidiarrheal medication in the absence of any bowel movements, and failed to have a care plan in place to address a resident's bowel needs. This resulted in actual harm when Resident #49 was not having her bowel movements monitored, did not have a bowel movement documented for five consecutive days, and continued to receive an antidiarrheal medication three times a day which resulted in the resident being hospitalized for a fecal impaction. This affected one (#49) of five residents sampled for medication reviews. The facility census was 78. Residents Affected - Few Findings include: Review of Resident #49's medical record identified admission to the facility occurred on 06/14/18. Diagnoses included chronic kidney disease, stroke, irritable bowel syndrome (IBS) and high blood pressure. Review of the quarterly Minimum Data Set assessment, dated 06/30/19, revealed Resident #49 had intact cognition. Resident #49 was incontinent of bowel and was dependant on staff for toileting needs. The medical record identified a lack of plan of care for Resident #49 for constipation/diarrhea. Review of the physician orders revealed on 04/26/19 an order was received for Lomotil (anti-diarrheal) three times a day. An order dated 06/22/19 revealed hold all anti-diarrhea medications in the absence of stools. Review of the Certified Nurse Practitioner (CNP) progress notes dated 07/01/19 identified Resident #49 was experiencing both constipation and diarrhea secondary to her medical diagnosis of IBS. The CNP documented there was inconsistent charting by the staff of the residents's bowel movements. The notes documented nursing staff were instructed on how to administer her current medications and when to hold. Review of the progress notes dated 08/11/19 at 2:23 A.M. revealed Resident #49 was having large coffee ground emesis, was complaining of weakness, and requested to be sent to the emergency room. Review of the emergency room admission notes, dated 08/11/19, identified Resident #49 was noted to have a fecal impaction (severe bowel condition in which a mass of stool becomes stuck in the colon). Resident #49 underwent a colonoscopy in the hospital which identified a stercoral ulcer (results from prolonged constipation), which was identified by the physician as likely from the impaction of stool. Reviewed of Resident #49's bowel records for 08/01/19 through 08/11/19 revealed Resident #49 was not documented to have any bowel movements from 08/01/19 through 08/05/19 and from 08/07/19 through 08/11/19. Review of the August 2019 Medication Administration Record (MAR) revealed the Lomotil was administered three times a day from 08/01/19 through 08/11/19, with the exception of 08/08/19, when a nurse held the morning dose. The MAR also identified licensed nursing staff were to record bowel movements each shift (three times a day). The MAR for August 2019 identified no entries were completed by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365475 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 365475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Nursing Center of Mansfield 535 Lexington Avenue Mansfield, OH 44907 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 0684 nursing staff indicating if Resident #49 had any bowel movements. Level of Harm - Actual harm Interview on 09/12/19 at 10:44 A.M., Resident #49 identified she had issues with constipation and diarrhea from her diagnosis of IBS. Resident #49 stated she will sometimes go four to five days without a bowel movement and it is difficult to get staff to give her something. Residents Affected - Few Interview on 09/12/19 at 9:53 A.M., State Tested Nursing Assistant (STNA) #77 identified when a resident has a bowel movement the aides document this in the facility's computerized charting system. Interview on 09/12/19 at 9:59 A.M., Licensed Practical Nurse (LPN) #210 revealed the nursing staff print off the STNA bowel record documentation daily. The nurses are supposed to review these bowel records daily to identify residents who have not had a bowel movement in the past three days. If a residents does not have a bowel movement in three days the bowel protocol should be initiated. LPN#210 confirmed the bowel movement monitoring for Resident #49 was not being completed consistently. She also verified the nursing staff should have held the medications when Resident #49 was not having bowel movements and/or diarrhea. LPN#210 confirmed the MAR for August additionally listed the physician order to hold all diarrhea medications in the absence of stools. LPN #210 also verified there was no evidence on the MAR that any licensed nursing staff started the bowel protocol for Resident #49 when she went longer than 3 days without a bowel movement on 08/03/19 and 08/10/19. Interview on 09/12/19 at 2:11 P.M., the Director of Nursing (DON) verified the facility staff were not documenting bowel movements for Resident #49 consistently and was receiving the Lomotil when the order read to hold if no bowel movement. The DON confirmed Resident #49 did not have a plan of care for the constipation and diarrhea issues prior to today. Review of the facility policy titled Bowel Protocol, dated 01/17, revealed STNAs will monitor resident bowel movements. The nurse will monitor the documented results. If the resident has not had a bowel movement in three days, the resident will receive 30 milliliters of milk of magnesia and if no results a bisacodyl suppository will be administered on the fourth day. If there are no results from the suppository, the next shift provides a Fleets enema. The physician will be notified of a resident complaint of severe abdominal pain, has rectal bleeding or vomiting during this regimen, or if no results after these measures have been taken. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365475 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 365475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Nursing Center of Mansfield 535 Lexington Avenue Mansfield, OH 44907 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm Based on medical record review, staff interview, responsible party interview, observation, review of skin sweeps, and policy review, the facility failed to provide appropriate pressure ulcer prevention and treatment for a resident identified at risk. This resulted in actual harm when Resident #279 was admitted without a pressure ulcer, was assessed to be at risk for the development of a pressure ulcer, and was not provided pressure reduction prior to or immediately after the development of reddened areas on the buttocks. The reddened areas worsened into a stage 3 pressure ulcer on the right buttock and a stage 2 pressure ulcer on the left buttocks. This affected one (#279) out of four residents reviewed for pressure ulcers. The facility identified six residents with pressure ulcers. The facility census was 78. Residents Affected - Few Findings included: Review of Resident #279's medical record revealed an admission date of 08/29/19. Diagnoses included dementia without behavioral disturbances, Alzheimer's disease, anxiety disorder, macular degeneration, hypertension, and chronic obstructive pulmonary disease. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 09/05/19, revealed Resident #279 had impaired cognition. The skin assessment identified the resident at risk for developing pressure ulcers. Review of the plan of care card, dated 08/29/19, revealed two assist for transfer, bed mobility, and not ambulatory. Interventions for pressure relieving mattress and pressure relieving device to chair. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 09/05/19, revealed the resident had impaired cognition. Furthermore, the skin assessment identified the resident at risk for developing pressure ulcers. Review of the admission nursing assessment identified the Resident #279 was admitted without any pressure ulcers. Review of weekly skin sweeps revealed the skin inspection dated 09/03/19 documented Resident #279 had redness to the skin on the buttocks. Review of physician orders dated 09/03/19 revealed a treatment to apply barrier cream to the buttocks for excoriation twice daily and as needed with incontinence. Review of the skin sweep dated 09/06/19 revealed the assessment was absent of documentation of any redness to buttocks. Review of the physician orders dated 09/09/19 revealed orders were received for a pressure relief mattress to the bed, a pressure reducing cushion to the wheelchair, and skin sweeps two times a week on Tuesday and Friday. Interview on 09/09/19 at 9:29 A.M., with Resident #279's responsible party revealed while visiting the resident she/he complained of pain to his/her bottom. Upon looking at the area of pain, the responsible party noticed open areas. The facility had not reported anything about the resident's skin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365475 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 365475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Nursing Center of Mansfield 535 Lexington Avenue Mansfield, OH 44907 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 having open areas or that they were providing treatment to the areas other than the barrier cream. Level of Harm - Actual harm Observation on 09/10/19 at 9:57 A.M., of the excoriation to the buttocks of Resident #279 with License Practical Nurse (LPN) #38 and State Tested Nursing Assistant (STNA) #86 revealed two open areas with excoriation present on the bilateral buttocks. Residents Affected - Few Interview on 09/10/19 at 9:57 A.M., LPN #38 verified she/he was not aware of the Resident #279's open areas and the areas have not been addressed. LPN #38 indicated the only physician order was for the barrier cream to the excoriated areas. LPN #38 reported she/he would complete an assessment and notify the Certified Nurse Practitioner (CNP) and the responsible party. Review of the progress note dated 09/10/19 at 12:28 P.M., revealed Resident #279's left buttock had a stage 2 pressure ulcer, with partial thickness loss. The wound bed had visible granulation tissue noted, was pink in color, and no slough was noted. The left buttock ulcer measured revealed 1.0 centimeters (cm) by 4.1 cm by 0.2 cm. The peri area was pink in color without odor or drainage noted. The wound tissue was dry with a well defined edge. Review of the progress note dated 09/10/19 at 12:28 P.M., revealed Resident #279's right buttock had a stage 3 pressure ulcer, with partial thickness loss. The ulcer measured 0.3 cm by 1.6 cm by 0.2 cm, the wound bed was yellow in color, no drainage was noted, no odor present. The wound tissue was dry with well defined edges. The resident had peeling skin noted to the areas on the buttock, as well as pink blanchable skin noted to her buttock. Review of orders written by the CNP on 09/10/19 at 10:15 A.M., revealed to discontinue the barrier cream to the buttock. Start Z Guard paste protectant cream topically to affected area twice a day and as needed until healed. The responsible party was notified. Review of facility policy titled Guidelines for Prevention of Pressure Injury/skin Issues, dated 10/2017, revealed a skin prevention program recognizing the need for wound and skin preventative care is a responsibility of every nurse, including STNAs. It is important to determine a resident's risk for developing pressure injuries and other skin issues on their admission or anytime they have a change in their overall health status. A risk assessment tool, the Braden Scale, will assist the nurse in determining appropriate prevention interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365475 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 365475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Nursing Center of Mansfield 535 Lexington Avenue Mansfield, OH 44907 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, medical record review, resident interview, and staff interview, the facility failed to provide interventions to secure a urinary catheter to prevent pulling of the catheter tubing for one (#49) of four residents reviewed for catheters. The facility identified a total of 13 residents who utilize urinary catheters. The facility census was 78. Findings include: Review of Resident #49's medical record revealed an admission date of 06/14/18. Diagnoses included chronic kidney disease, stroke, irritable bowel syndrome (IBS) and high blood pressure. Review of the quarterly Minimum Data Set assessment, dated 06/30/19, revealed Resident #49 had cognition intact. The assessment identified Resident #49 had a urinary catheter due to neurogenic bladder. Observation on 09/10/19 at 2:01 P.M. of State Tested Nursing Assistant (STNA) #26 providing catheter care for Resident #49 revealed there was no type of anchoring device to secure the catheter and tubing and prevent any pulling of the tubing. Interview with Resident #49 during the observation on 09/10/19 at 2:01 P.M. revealed it had been a long time since she had a strap applied to secure the catheter. Resident #49 stated at times the catheter tubing does get pulled on during care and movement. Interview during the observation on 09/10/19 at 2:01 P.M., STNA #26 confirmed Resident #49 did not have an anchoring device. STNA #26 stated she would have to ask the nursing staff to provide her with one. Interview on 09/10/19 at 2:20 P.M., the Director of Nursing revealed the current catheter policy does not address the use of any interventions to secure a urinary catheter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365475 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 365475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Nursing Center of Mansfield 535 Lexington Avenue Mansfield, OH 44907 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of medical records, review of meal tickets, and staff interviews, the facility failed to provide specialized eating equipment per physician order for one (#24) out of one resident reviewed for adaptive eating equipment. The facility identified four residents who have orders for adaptive eating equipment. The facility census was 78. Residents Affected - Few Findings include: Review of Resident #24's medical record identified admission to the facility occurred on 04/04/10. Diagnosis included a stroke. Review of a physician order dated 04/11/19 revealed Resident #24 was to have sippy cups with meals. Review of the nutrition plan of care revealed an intervention dated 04/15/19 for a sippy cup with meals. Observation of the main dining room meal service on 09/10/19 at 5:40 P.M. revealed Resident #24 had coffee in a regular cup, juice in a regular glass, and milk in a blue sippy cup. Review of Resident #24's meal ticket identified the use of sippy cups with meals. Observation of the meal service on 09/11/19 at 8:36 A.M. revealed Resident #24 had coffee in a regular cup, juice in a regular glass, and milk in a blue sippy cup. Interview on 09/11/19 at 11:56 A.M. with Therapy Director #300 stated Resident #24's should have all her liquids in the specialized sippy cups. Observation of the kitchen on 09/11/19 at 3:37 P.M. revealed only one sippy cup was available. The staff in the kitchen were also unable to locate any other specialized sippy cups. Interview on 09/11/19 at 3:47 P.M., Dietary Manager (DM) #300 confirmed the kitchen has only one sippy cup available for use and Resident #24 has not been receiving all her fluids in a sippy cup at meals. Observation of the meal service on 09/12/19 at 7:55 A.M. revealed Resident #24 received juice in a regular glass and milk in a blue sippy cup. Interview on 09/12/19 at 8:00 A.M., State Tested Nurse Aide (STNA) #27 confirmed Resident #24's meal ticket indicates the use of sippy cups. STNA #27 stated sippy cups are not available. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365475 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 365475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Nursing Center of Mansfield 535 Lexington Avenue Mansfield, OH 44907 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. Based on observation and staff interviews, the facility to ensure a clean environment was maintained in the main dinning room. This affected 24 residents (#3, #6, #11, #12, #14, #15, #17, #18, #22, #23, #24, #29, #31, #37, #38, #50, #59, #60, #64, #68, #70, #71, #76 and #182) whom were identified to eat in the main dinning room. The facility census was 78. Findings include: Observation on 09/09/19 11:56 A.M. of the main dining room identified there were 11 light fixtures with plastic covers. The light fixtures were located above the dinning room tables and were observed with multiple dead bugs located inside. Observations and interview on 09/10/19 at 4:10 P.M. with the Administrator confirmed the lighting fixtures contained multiple dead bugs and were located above the dinning room tables where residents eat. The facility identified 24 residents (#3, #6, #11, #12, #14, #15, #17, #18, #22, #23, #24, #29, #31, #37, #38, #50, #59, #60, #64, #68, #70, #71, #76 and #182) to eat in the main dinning room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365475 If continuation sheet Page 11 of 11