Health inspection·September 7, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Dignity, dated 02/2021 revealed residents are treated with dignity and respect at all times. This deficiency substantiates Complaint Number OH00131449. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365475 If continuation sheet Page 2 of 16 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 09/07/2022 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and interview, the facility failed to ensure a medication storage room was clean and sanitary, where resident medications were stored. This affected one out of two medication storage rooms observed. The facility had a total of three medication storage rooms. The facility census was 49. Findings include: Observation on 08/30/22 at 2:45 P.M., with Registered Nurse (RN) #310 of the North Medication Storage room revealed there were multiple cabinets where over the counter stock medications were stored. The medication storage room also had three refrigerators, one for resident and stock medications, one for the storage of laboratory draws and the third was where food items were stored (a large partially used container of applesauce) used for medication administration. The hand washing sink in the medication storage room had corroded rust and a black substance covering the bottom of the sink. There were pieces of paper stuck to the edges of the sink on the inside, with soap scum, dried food, and liquid drippings splattered in the sink. The countertop between the sink and the refrigerator had dried food and liquid drippings splattered throughout. RN #310 said the dried food was applesauce. There were old medication stickers stuck to the countertop throughout the medication storage room. Multiple resident medication packets were stored on the countertop over the spills and drippings along with three boxes of unopened disposable gloves, two boxes of unopened tissues and three unopened cans of prune juice. The wall in the medication room had dried food and liquid drippings. The floor in the medication storage room had multiple dried food drippings, liquid and dried brown/black spots throughout. RN #310 verified the nurses washed their hands in the sink and she was unsure the last time the medication storage room was cleaned. RN #310 revealed the multiple packets of medications on the countertop belonged to residents who either brought in the medications from home or were discharged and the medications were pulled from the medication carts and stored on the counter in the medication room. RN #310 also verified when laboratory and urine samples were obtained, they were stored in the laboratory refrigerator. Stock over the counter medications in the cabinets and refrigerators could be used for any resident in the facility if needed. A second observation on 08/30/22 at 2:50 P.M. with the Director of Nursing (DON) and the Administrator of the north medication storage room verified the black mold like substance, rust, dried food, drink spills and the stickers in the sink in the medication room. The dried food and liquid on the countertop, the walls, and the floor, multiple medications were stored on the countertop over the spills with the gloves, tissues, and unopened prune juice cans on the countertop. The Administrator and the DON said they were unsure the last time the medication storage room was cleaned. The Administrator revealed there was no policy for cleaning the medication rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365475 If continuation sheet Page 3 of 16 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 09/07/2022 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 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and policy review, the facility failed to ensure a restorative/maintenance program was provided. This affected one resident (#50) out of one resident reviewed reviewed for restorative Care. The facility census was 49. Residents Affected - Few Findings include: Review of the medical record revealed Resident #50 was admitted to the facility on [DATE]. Diagnosis included hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, muscle wasting and atrophy. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #50 was severely cognitively impaired. Resident #50 required extensive assistance of one for bed mobility, extensive assistance of one for dressing and personal hygiene. Review of the care plan dated 06/20/22 revealed Resident #50 had an activity of daily living self performance deficit related to hemiplegia following a cerebral vascular accident, muscle wasting and atrophy. Interventions included to monitor, document, and report as needed any changes, or a decline in function. Interview on 08/30/22 at 3:36 P.M., with the Therapy Program Manager #324 revealed Resident #50 had been seen in therapy in the past. Therapy Program Manager #324 revealed the facility did not have a restorative/maintenance program and had not had one for the past one and a half to two years. Therapy Program Manager #324 revealed it would be helpful to the residents if there was a restorative program to maintain the abilities therapy worked to gain for the residents. Therapy Program Manager #324 revealed the therapy department would treat residents in therapy then after discharge the residents declined usually due to no maintenance program then the therapy department would pick the resident back up again and start over. Therapy Program Manager #324 revealed this occurred frequently. Review of the therapy notes revealed Resident #50 received Occupational Therapy (OT) on 03/21/22 for fundamentals, wheel chair positioning and strengthening and worked on passive range of motion (PROM) to increase strength for 10 sessions. Resident #50 was discharged from therapy on 04/08/22. Review of the discharge summary for Resident #50 completed by OT #327 revealed improvement in sitting in the wheel chair midline (no longer leaning) for two hours, baseline was one hour. Working on range of motion (ROM) improved strengthening for positioning. Review of the therapy notes dated 08/02/22 revealed OT picked up Resident #50 for positioning and custom wheel chair due to the resident declined for wheel chair positioning. Noted in assessment was a decline due to loss in upper body strength and now required specialized tilt and space wheelchair. Resident #50 was discharged on 08/12/22 from OT. Progress notes included ROM was implemented, worked on right shoulder flexion and abduction, Resident #50 went from 20 degrees to 40 degrees. A follow-up interview on 08/30/22 at 4:45 P.M., with the Therapy Program Manager #324 revealed Resident #50's decline in function after 04/08/22 was unavoidable due to there was no restorative/maintenance program to maintain or continue strengthening Resident #50. On 08/02/22 ROM was implemented by OT and worked on the right shoulder flexion and abduction which improved from 20 degrees to 40 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365475 If continuation sheet Page 4 of 16 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 09/07/2022 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few degrees. Resident #50 was discharged on 08/12/22 with no program available to maintain the current level at discharge. Therapy Program Manager #324 revealed he expected Resident #50 to again decline due to no program available to maintain ability. Interview on 08/30/22 at 3:43 P.M., with the Director of Nursing (DON) revealed he had been at the facility as the DON for 6 and a half years and during that time had only one restorative nurse/program for a very short time. Interview on 08/31/22 at 9:16 A.M., the Administrator verified the facility had no restorative or maintenance program for any residents. Review of the facility policy titled Restorative Nursing Service, dated July 2017 revealed Residents will receive restorative nursing care as needed to help promote safety and independence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365475 If continuation sheet Page 5 of 16 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 09/07/2022 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #19 revealed admission dated 11/21/19. Diagnosis including chronic kidney disease, hypertension, endometrial cancer, impaired balance and heart disease. Residents Affected - Some Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed intact cognition. Resident needs assistance of one for bathing. Review of orders for August 2022 revealed shower given on Monday and Friday per the scheduled bath times. Review of the plan of care dated 08/02/22 revealed Resident #19 had an activity of daily living self-care performance deficit related to endometrial cancer, impaired balance and weakness. Interventions include assistance by staff with bathing/showering and to provide sponge bath when a full bath or shower cannot be tolerated. Review of the shower sheets for August 2022 revealed a shower was given on 08/19/22, no other documentation available for any other showers given. Interview on 08/29/22 at 8:51 A.M., with Resident #19 revealed she used to get showers on Monday and Friday but haven't had a shower in nine days. Observation at this time revealed her hair was greasy looking and her nails needed cleaned. 4. Review of the medical record for Resident #105 revealed an admission dated of 06/17/22. Diagnosis included fracture of right lower leg, obesity and hear failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed intact cognition. Resident needs assistance of one for bathing. Review of the August 2022 physician orders revealed showers to be given on Tuesdays and Fridays, per bathing schedule. Review of the plan of care dated 06/29/22 for activity of daily living revealed resident has self-care performance deficit related to impaired mobility, obesity, and incontinence. Interventions included provide sponge bath when a full bath or shower cannot be tolerated, and resident required assistance with bathing and showering. Review of the shower sheets for August 2022 revealed last shower was given on 07/19/22. On 08/09/22 no shower given because he was on the Covid unit and had not received a shower until 08/30/22. Interview on 08/29/22 at 9:45 A.M., with Resident #105 revealed he only received one shower and that was last week. Resident #105 said at first, he couldn't have a shower due to the cast on leg but has been able to have shower for the last month and only received one shower. Resident #105 stated he tried to wash up in the sink the best he could do. 5. Review of the medical record for Resident #154 admission dated of 08/21/22. Diagnosis include dementia, and kidney failure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365475 If continuation sheet Page 6 of 16 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 09/07/2022 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 0677 Level of Harm - Minimal harm or potential for actual harm Review of the comprehensive Data Set (MDS) assessment dated [DATE] revealed intact cognition. Resident was totally dependent on staff for bathing. Review of the physician orders dated August 2022 revealed showers every Tuesday and Friday per the bathing schedule. Residents Affected - Some Review of the plan of care dated 08/22/22 for activity of daily living revealed self-care performance deficit related to Covid-19, weakness, and impaired mobility. Intervention included provide sponge bath when a full bath or shower cannot be tolerated, and resident required assistance with bathing and showering. Review of the shower sheets from 08/21/22 through 08/31/22 revealed no documentation of shower being given. Interview on 08/29/22 at 9:16 A.M., with Resident #154 revealed she had not had a shower since she was admitted to the facility. Resident #154 stated she had not refused any showers staff just does not give her one. Observation of Resident #154 at this time revealed hair oily, disheveled and fingernail dirty. Interview on 08/31/22 10:48 A.M., STNA #314 stated residents on the Covid unit was able to have showers, there was a shower on each unit. STNA #314 stated when you completed a shower you have to complete the shower sheet or if the resident refused it should be written on the shower sheet and signed by the nurse. Interview on 08/31/22 at 11:09 A.M., the Administrator revealed if a resident did not have a shower sheet, then the shower was not done. The Administrator stated there was a shower room on the Covid-19 unit and if residents wanted a shower, they could have one. The Administrator revealed the Infection Prevention Nurse was to oversee the showers to assure they were getting done throughout the facility, but she was not doing what she was supposed to be doing. The Administrator verified several residents had expressed to her they were not receiving their showers. Interview on 08/31/22 at 11:25 A.M. with STNA #323 verified the shower sheets should be filled out when giving a shower and if the shower sheet was not filled out then a shower was not given. Review of the facility policy Resident Bathing, dated 08/2015 revealed showers are provided to residents at least twice a week with staff assistance. Based on medical record review, observation, staff, resident, and family interview, review of the shower schedule, review of the shower sheets, and policy review, the facility failed to ensure routine scheduled showers were provided for residents. This affected five residents (#34, #50, #19, #105, and #154) out of five residents reviewed for showers. The facility census was 49. Findings include: 1. Review of the medical record for Resident #34 revealed an admission date of 10/07/21. Diagnosis included Parkinson's disease and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #34 was cognitively intact. Resident #34 required total dependence with bathing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365475 If continuation sheet Page 7 of 16 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 09/07/2022 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 0677 Level of Harm - Minimal harm or potential for actual harm Review of the care plan dated 08/22/22 revealed Resident #34 had an activity of daily living self-care performance deficit related to Parkinson's. Interventions included Resident #34 was totally dependent on staff to provide bath or shower per bath schedule as necessary. Review of the shower schedule revealed Resident #34 showers were due on Tuesdays and Fridays. Residents Affected - Some Interview and observation on 08/29/22 at 9:02 A.M., with Resident #34 revealed her concern she had not had a shower for two weeks. Resident #34 revealed when she asked for one she was told staff were not giving showers while other residents residing in the facility were in quarantine. Resident #34 revealed she had not even received a bed bath. Resident #34 had oily, unkept hair and a dark substance in the corners of her fingernails. Review of the shower sheets for August 2022 revealed Resident #34's only documented shower was on 08/02/22. Interview on 08/31/22 at 10:52 A.M., with Resident #34's daughter (who was also a State Tested Nursing Assistant (STNA) at the facility), STNA #314 revealed she does not work with Resident #34 but Resident #34 had told her she was not receiving her showers. STNA #314 said she told the Assistant Director of Nursing (ADON) #322 that Resident #34 was not receiving her showers. STNA #314 revealed in the past she had given her mom showers even though she wasn't assigned to that area when no one else would. Interview on 08/31/22 at 11:00 A.M., the Director of Nursing (DON) verified when showers were completed, a shower form would also be completed by the STNA and the nurse. The DON said their were no other shower sheets available for Resident #34. Interview on 09/07/22 at 12:55 P.M. with ADON #322 revealed he had never received concerns from family members, staff, or residents regarding showers. 2. Review of the medical record for Resident #50 revealed an admission date of 12/22/21. Diagnosis included hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, muscle wasting and atrophy. Review of the quarterly MDS dated [DATE] revealed the resident was severely cognitively impaired. Resident #50 was totally dependant on staff for bathing. Review of the care plan dated 06/20/22 revealed Resident #50 had an activity of daily living self-care performance deficit related to hemiplegia following a cerebral vascular accident, muscle wasting and atrophy. Interventions included the resident was dependent on staff to provide bath/showers as scheduled. Review of the shower schedule revealed Resident #50 was to have showers on Mondays and Fridays. Review of the shower sheets for the month of August 2022 revealed Resident #50 received a shower/bath on 08/06/22 and 08/13/22. Observation on 08/30/22 at 2:06 P.M. of Resident #50 with Registered Nurse (RN) #303 revealed Resident #50 was unshaven, had oily disheveled hair, and his nails were unkempt with dark matter under the nails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365475 If continuation sheet Page 8 of 16 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 09/07/2022 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 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 observation, staff interview, and medical record review, the facility failed to ensure activities in the secured memory care unit, were provided throughout the day. This affected one resident (#36) out of one resident reviewed for activities in the secure memory care unit. There were seven residents residing in the secure memory care unit. The facility census was 49. Residents Affected - Few Findings Include: Review of the medical record for Resident #36 revealed an admission date of 06/27/22. Diagnosis including anxiety, dementia, and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Review of the physician orders for August 2022 revealed admit Resident #36 to the secured memory care unit related to dementia. Review of the activities notes for August 2022 revealed activities were only provided four times through out the month. Review of the plan of care dated 07/07/22 revealed Resident #36 was dependent on staff for emotional, intellectual, physical, and social need related to cognitive deficits. Interventions include provide with activities calendar, review resident's activity needs with family, assist to activity functions, provide one on one if unable to attend out of room events and resident prefers activities are crafts, listening to music, watching television and reading newspaper/magazines. Observation on 08/30/22 at 8:43 A.M. of Resident #36 revealed resident sitting at table with nothing in front of her, no television on or music playing. Observation on 08/30/22 at 2:58 P.M. of Resident #36 sitting at a table in the common area with nothing in front of her. Three other residents (Resident #26, #37 and #46) sitting at table with nothing to do. Observation on 08/31/22 at 10:15 A.M. of residents in the memory care unit revealed no activities being provided at this time. Resident #36 sitting at a table with nothing to do. Interview on 08/31/22 at 12:03 P.M., with Activity staff #08 said there was not an activity calendar for the memory care unit at this time. She stated she was the only one doing activities and does not know what they do in the memory care unit. Activity Staff #08 verified the television was not on and no activities were being offered to Resident #36 at this time. Interview on 08/31/22 at 12:26 P.M., the Activity Director #307 revealed she just started about three weeks ago and did not know she needed to have an activity calendar for the memory care unit. Activity Director #307 verified she has not offered any activities to the residents in the memory care unit since she started. Review of the facility policy titled Activity Program, dated 11/2017 revealed the facility provides, based on the comprehensive assessment, care plan and preferences of each resident , an on-going program to support residents in their choice of activities, both facility sponsored groups and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365475 If continuation sheet Page 9 of 16 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 09/07/2022 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 0679 individual activities. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365475 If continuation sheet Page 10 of 16 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 09/07/2022 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and medical record review, the facility failed to follow the audiologist recommendations to remove excessive wax build up. This affected one resident (#08) out of two residents reviewed for axillary services. The census was 49. Residents Affected - Few Findings Include: Review of the medical record for resident #08 revealed an admission date of 08/12/20. Diagnosis included heart failure, edema and weakness. The resident had highly impaired hearing and no hearing aids. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed impaired cognition. Review of the plan of care dated 08/13/20 revealed resident has a communication problem related to intermittent confusion, difficulty finding works at times, and hard of hearing. Interventions included arrange audiology consult as per physician orders, does not have hearing aids but utilizes personal amplifier with headphones intermittently. Review of the audiologist note dated 05/24/22 revealed wax removal needed to the right ear, the wax was too deep for curette (tool used to remove wax from ears) removal. Recommendations for wax removal with a specialist. Review of the audiologist notes dated 07/27/22 revealed wax needed removal to the right ear, wax was too deep for curette removal. Recommendations for wax removal with a specialist. Interview and observation on 08/29/22 at 10:44 A.M., with Resident #08 revealed the resident had difficulty hearing when interviewing her. She stated she had build up in her right ear and did not have her hearing aide in. Interview on 08/31/22 at 11:37 A.M., with Social Work Designee (SSD) #309 stated he was told by the audiologist the facility physician would need to write an order to have her ears cleaned. The SSD #309 verified she did not realize it had not been done. Interview on 08/31/22 at 12:33 P.M. with the Director of Nursing (DON) verified he did not know that Resident #08 had wax build up and was referred to a specialist. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365475 If continuation sheet Page 11 of 16 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 09/07/2022 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interview, and review of the National Pressure Injury Advisory Panel (NPIAP) staging, the facility failed to ensure early identification and ensure treatments of skin injuries were completed. This resulted in Actual Harm when Resident #50 acquired a pressure ulcer to the coccyx and the wound was not assessed or treated until the wound progressed into a stage three pressure ulcer (full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia). This affected one resident (#50) out of three residents reviewed for pressure ulcers. The facility census was 49. Residents Affected - Few Findings include: Review of the medical record for Resident #50 revealed an admission date of 12/22/21. Diagnoses included hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, muscle wasting and atrophy. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #50 was severely cognitively impaired. Resident #50 was at risk for pressure ulcer injuries and had an unhealed unstageable pressure ulcer. Resident #50 was always incontinent of bowel and bladder. Review of the care plan dated 12/24/21 revealed Resident #50 had an activity of daily living self-performance deficit related to hemiplegia following a cerebral vascular accident, muscle wasting and atrophy. Resident #50 also had potential for wounds or pressure ulcer development. Interventions included to monitor, document, and report as needed any changes in skin status. Administer treatments as ordered and monitor for effectiveness. Review of the Braden scale for predicting pressure sores dated 03/23/22 revealed Resident #50 was at high risk for developing pressure sores. Review of the physician orders revealed on 02/03/22 an order was received for weekly skin assessments with a bath or a shower per the bathing schedule. Review of the Treatment Administration Record (TAR) for April 2022 revealed biweekly showers were scheduled every Monday and Thursday with skin checks. The TAR was initialed on 04/04/22 and 04/07/22. Review of the shower sheets/skin assessments for Resident #50 for April 2022 revealed shower sheets/skin assessments were completed 04/14/22 and 04/18/22. No other shower sheets were provided and no open areas were documented. Review of the Certified Nurse Practitioner (CNP) #306 consultation note dated 04/11/22 revealed a new wound on 04/11/22 to the coccyx. The wound to the coccyx was an in house pressure, stage three measuring 3.0 centimeters (cm) in length by 2.0 cm in width by 0.1 cm in depth. The wound bed had 90% slough/eschar (dead tissue). Record review of the physician orders dated 04/11/22 revealed Resident #50 received an order for normal saline, honey gel, alginate foam, three times a week and as needed to the coccyx. Observation of the wound care to Resident #50's coccyx on 08/30/22 at 2:06 P.M. with Registered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365475 If continuation sheet Page 12 of 16 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 09/07/2022 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 Level of Harm - Actual harm Residents Affected - Few Nurse (RN) #303 revealed the old dressing removed by RN #303 on Resident #50's coccyx was dated 08/28/22. RN #303 verified the dressing change was now completed daily and this was the dressing she applied two days prior. Resident #50 had a pressure ulcer to his coccyx. Interview on 08/31/22 at 10:00 A.M., with the Director of Nursing (DON) revealed skin assessments for residents were completed weekly on shower days and documented on the shower sheet or skin observation form in the residents medical record once completed. Interview on 08/31/22 at 11:09 A.M. with the Administrator, revealed she had multiple complaints from residents of showers not completed. The Administrator revealed if the shower sheet (same as the skin assessment sheet) was not completed then it was not done. The Administrator revealed the Infection Control Nurse was supposed to oversee these were completed, but she was just not doing what she was supposed to do. Review of the TAR dated 08/29/22 revealed the treatment to Resident #50's coccyx dated 08/29/22 was signed as completed by Licensed Practical Nurse (LPN) #304. Interview on 08/31/22 at 4:53 P.M., with LPN #304 confirmed she did not complete Resident #50's dressing change to his coccyx on 08/29/22 and did sign the TAR the treatment was completed. Interview on 09/01/22 at 10:50 A.M., with the Wound Care Nurse Licensed Practical Nurse (LPN) #301 verified Resident #50's wound to his coccyx developed in house and first found as a stage three pressure ulcer on 04/11/22. Wound Care Nurse LPN #301 verified assigned weekly skin assessments should be completed by the nursing staff to assess for new areas of skin breakdown. The assessments should be documented when completed in the residents medical record on the skin assessment tool. The Wound Care Nurse LPN #301 verified there were no weekly skin observation tools completed for Resident #50 in the medical record for the month of April prior to finding Resident #50's coccyx wound at a stage three on 04/11/22. A follow-up interview on 09/07/22 at 9:00 A.M. with the DON, revealed the facility had no policy available for resident routine skin assessments or the process for nurses providing wound care. Review of the National Pressure Injury Advisory Panel: Pressure Injury Stages: revealed a pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. A Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365475 If continuation sheet Page 13 of 16 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 09/07/2022 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, review of the temperature logs, and policy review, the facility failed to monitor the temperatures daily to maintain a temperature of 36 to 41 degrees Fahrenheit in the resident medication storage refrigerators. This affected two medication storage room refrigerators out of two reviewed. The facility identified three medication storage room refrigerators. The facility census was 49. Findings include: 1. Observation and interview on 08/30/22 at 12:57 P.M. of the East Medication Storage room refrigerator temperature logs for August 2022 with Registered Nurse (RN) #303 revealed the medication storage refrigeration had one temperature completed on 08/08/22, 08/25/22 and 08/27/22. RN #303 verified no refrigerator temperature monitoring was completed on any other days during the month of August 2022. 2. Observation and interview on 08/30/22 at 2:40 P.M. with RN #310 of the North Medication Storage room refrigerator temperature logs for August 2022 revealed the medication storage refrigeration had one temperature completed on 08/08/22, 08/25/22 and 08/27/22. RN #310 verified no refrigerator temperature monitoring was completed on any other days during the month of August 2022. Record review of the facility policy titled Storage of Medications, dated November 2020 revealed the facility stored all drugs an biological's in a safe, secure and orderly manner. The facility will have a temperature log on each refrigerator. Nursing staff is to record the temperature of the fridge each shift on the log with the date, time and initials of person checking the temperature. Refrigerators should be tempting between 36 and 41 degrees. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365475 If continuation sheet Page 14 of 16 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 09/07/2022 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, policy review, review of online resources for the Centers for Disease Control and Prevention (CDC), and the Center for Medicare and Medicaid Services (CMS), the facility failed to ensure staff wore Personal Protective Equipment (PPE) as required to the prevent the potential spread of COVID-19. This had the potential to affect all 49 residents residing in the facility. Residents Affected - Some Findings include: 1. Observation and interview on 08/29/22 at 7:30 A.M. revealed Licensed Practical Nurse (LPN) #311 walked down the hallway with resident rooms and through the front lobby without a face mask or eye protection. LPN #311 went into the front lobby area and grabbed an N95 respirator mask from the check in desk. This was verified by LPN #311. LPN #311 indicated the need for an N95 respirator mask and eye protection due to the facility outbreak status, however had not donned PPE on yet since start of the shift at 7:00 A.M. 2. Observation and interview on 08/29/22 at 7:40 A.M., revealed LPN #312 standing at the medication cart outside of East Wing Nursing Station. There were several residents sitting in dining room adjacent to the medication cart waiting for breakfast. LPN #312 was not wearing face mask or eye protection. LPN #312 verified the finding and indicated I have had one on all day and I can't breathe. LPN #312 indicated the need for an N95 respirator mask and eye protection due to the facility outbreak status. 3. Observation and interview on 08/29/22 at 7:43 A.M., revealed Housekeeper #313 walking down the hallway with resident rooms. Housekeeper #313 had an N95 respirator mask in hand and put mask on when approached. Housekeeper #313 had no eye protection on at this time. This was verified with Housekeeper #313. Housekeeper #313 indicated they were unsure if eye protection was required. 4. Observation and interview on 08/29/22 at 7:46 A.M., revealed State Tested Nursing Assistant (STNA) #314 exiting a resident room and STNA #314 had no eye protection on. STNA #314 verified findings and indicated they wore glasses for vision needs and no goggles or face shield were required. Interview on 08/30/22 at 2:17 P.M., with the Infection Preventionist (IP) #301 revealed the facility was in outbreak status since 07/21/22. IP #301 confirmed staff should be wearing an N95 respirator mask and eye protection including face shields and goggles. IP #301 indicated if no additional positive staff and residents the facility would be out of outbreak status on 09/05/22. Review of an online resource from CDC titled COVID Data Tracker at https://covid.cdc.gov/covid-data-tracker/ revealed the county in which the facility was situated was experiencing a high (red) community transmission rate of COVID-19. Review of an online resource per the CDC titled Infection Control Guidance for Healthcare Professionals about Coronavirus (COVID-19) at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html, revealed the use of eye protection in healthcare facilities is recommended in areas with moderate to substantial community transmission and staff should don eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365475 If continuation sheet Page 15 of 16 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 09/07/2022 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of an online resource per the CDC titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, last updated 02/02/22, revealed the recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic are to implement source control measures. Source control refers to the use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Source control options for healthcare professionals include: A NIOSH-approved N95 or equivalent or higher-level respirator or a respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators or a well-fitting facemask. Review of facility policy titled COVID-19 Outbreak Policy, dated 05/24/22, revealed in a facility COVID-19 outbreak staff will wear N95 respirator mask and eye protection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365475 If continuation sheet Page 16 of 16