Health inspection·April 21, 2022

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #37's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic kidney disease with dialysis services and diabetes. Review of Resident #37's physician orders reveled an order dated 03/09/22 stating he was to have dialysis Monday through Friday via in facility dialysis. Residents Affected - Few Review of Resident #37's MDS 3.0 assessment dated [DATE] did not indicate the resident received dialysis services. Interview on 04/20/22 at 9:48 A.M. with LPN #450 confirmed Resident #37's comprehensive assessment was inaccurate and did not reflect the resident received dialysis services. Based on record review and interview, the facility failed to ensure Residents #37 and #46's comprehensive assessments were completed accurately. This affected two (Residents #37 and #46) of twenty-five residents whose records were reviewed for accurate comprehensive assessments. Findings include: 1. Review of the medical record for Resident #46 revealed an admission date of 03/17/22 with diagnoses including chronic kidney disease, essential hypertension, and acute osteomyelitis. Review of Resident #46's Admission/readmission Packet form dated 03/17/22 revealed she was admitted with a stage four pressure ulcer (deep wound that reaches the muscles, ligaments, or even bone) to the coccyx. Review of the Resident #46's Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed she had intact cognition and did not have a pressure ulcer/injury, a scar over a bony prominence, or a non-removable dressing/device. Interview on 04/20/22 at 10:46 A.M. with Licensed Practical Nurse (LPN) #450 verified Resident #46 had a stage four pressure ulcer to the coccyx and she did not accurately document the pressure ulcer on the MDS 3.0 comprehensive assessment dated [DATE]. 2. Review of the medical record for Resident #46 revealed an admission date of 03/17/22 with diagnoses including chronic kidney disease, essential hypertension, and acute osteomyelitis. Review of Resident #46's physician order dated 03/17/22 indicated to inject heparin sodium solution 5,000 units subcutaneously every eight hours as an anticoagulant. Review of Resident #46's Medication Administration Records (MARs) from 03/18/22 to 03/24/22 revealed she received heparin sodium solution 5,000 units daily. Review of the Resident #46's MDS 3.0 comprehensive assessment dated [DATE] revealed she had intact cognition and did not receive anticoagulant medications during the seven-day look back period of 03/18/22 to 03/24/22. Interview on 04/20/22 at 9:53 A.M. with LPN #450 verified Resident #46's comprehensive assessment dated [DATE] did not accurately reflect the resident's anticoagulant administration from 03/18/22 to 03/24/22 during the seven-day look back period. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365539 If continuation sheet Page 2 of 13 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 365539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Nursing & Rehab 2473 North Rd NE Warren, OH 44483 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Resident #33's care plan was revised as needed. This affected one resident (Resident #33) out of 25 residents whose comprehensive care plans were reviewed. The facility census was 67. Findings include: Review of medical record for Resident #33 revealed an admission date of 10/18/17 and diagnoses including hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, chronic respiratory failure with hypoxia, morbid obesity, schizoaffective disorder, and bipolar disorder. Review of the care plan dated 06/17/20 revealed Resident #33 had self-care deficits noted as she had a right sided hemiplegia. She required assistance with most activities of daily living except she was able to feed herself. She refused to get out of bed most of the time and refused to wear a palm guard. She wore a brace to her right lower leg. Interventions included ankle foot orthosis (AFO) to her right lower extremity, palm guard to her right hand as tolerated, and may remove for hygiene and skin checks. Review of the Occupational Therapy Discharge Summary dated 10/27/21 and completed per Occupational Therapist #901 revealed Resident #33 received occupational therapy from 09/30/21 to 10/27/21 due to hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side. There was no documentation per the discharge summary regarding Resident #33 requiring a right AFO and a right palm guard. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #33 had intact cognition. She required extensive assist of two people with bed mobility and was totally dependent of two staff with transfers. She required extensive assist of one person with personal hygiene. She had no splints and no range of motion restorative programs ordered. Review of physician orders for April 2022 revealed Resident #33 did not have an order for a right AFO to her right lower extremity or an order for a right palm guard. Interview and observation on 04/18/22 at 7:20 P.M. revealed Resident #33 did not have a palm guard to her right hand or a right AFO to her right lower leg. She revealed the staff had not put a palm guard to her right hand or a right AFO in quite a while. She revealed did not know where these items were located, she had not seen them in her room. Observation on 04/19/22 at 4:25 P.M., 04/21/22 at 7:44 A.M., and 04/21/22 at 10:56 A.M. revealed Resident #33 was not wearing a right palm guard or a right AFO. Interview on 04/21/22 at 7:47 A.M. with State Tested Nursing Assistant (STNA) #809 revealed he routinely worked on Resident #33's unit and revealed he was not aware of Resident #33 having a right palm guard or a Right AFO as he had never applied them or had never seen them. STNA #809 revealed Resident #33 usually refused all care to her right side but on occasion would allow him to place a folded-up washcloth in her right hand. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365539 If continuation sheet Page 3 of 13 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 365539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Nursing & Rehab 2473 North Rd NE Warren, OH 44483 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/21/22 at 9:33 A.M. with Licensed Practical Nurse (LPN) #810 revealed she was Resident #33's nurse and Resident #33 did not have an order for a right palm guard or a right AFO. LPN #810 revealed she had never seen Resident #33 wear these items. Interview on 04/21/22 at 8:52 A.M. with LPN/MDS #450 revealed she was responsible for developing and revising the care plans for the residents. She verified she must have overlooked and had not revised Resident #33's plan of care as she verified Resident #33 did not utilize a right palm guard or a right AFO as these were old interventions. Interview on 04/21/22 at 9:58 A.M. with Rehabilitation Director #813 revealed Resident #33 was discharged from occupational therapy on 10/27/22 and therapy did not recommend Resident #33 utilize a right palm guard or a right AFO. Interview on 04/21/22 at 11:23 A.M. with the Director of Nursing verified Resident #33's care plan was not revised as she was not supposed to have interventions in her care plan that included a right palm guard or right AFO. Review of facility policy labeled, Goals and Objectives, Care Plans dated April 2009 revealed care plan goals and objectives were to be reviewed and revised when there was a significant change, desired outcome not achieved, and at least quarterly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365539 If continuation sheet Page 4 of 13 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 365539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Nursing & Rehab 2473 North Rd NE Warren, OH 44483 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 interview and record review the facility failed to ensure Resident #16 received restorative nursing range of motion and restorative ambulation program per his plan of care. This affected one resident (Resident #16) out of one resident reviewed for restorative nursing programs. The facility identified eight residents (Resident #2, #14, #16, #21, #30, #42, #49, #56) who had a restorative nursing program. Residents Affected - Few Findings include: Review of the medical record for Resident #16 revealed an admission date of 03/09/17 and diagnoses including hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, chronic obstructive pulmonary disease, hypertension, and nicotine dependence. Review of Physical Therapy Discharge Summary dated 11/02/21 and completed by Physical Therapist #900 revealed Resident #16 received physical therapy from 08/10/21 to 11/01/21 due to hemiplegia and hemiparesis following cerebrovascular disease affecting his left non-dominant side. Discharge recommendations included a restorative ambulation program for Resident #16 that included to ambulate with one person assist with the railing on his right side and he was to be followed by a wheelchair with one person assist. Review of the care plan dated 11/01/21 revealed Resident #16 had an inability to transfer and ambulate independently due to hemiparesis. Interventions included a restorative ambulation program six to seven days a week at least 15 minutes per day, encourage Resident #16 to walk 100 feet with a gait belt with one assist and a wheelchair was to follow, and refer to therapy as needed. Further review of the care plan dated 11/01/21 revealed Resident #16 had a risk for decline of range of motion to his bilateral lower extremities related to hemiplegia, cerebral infarction, and deconditioning. Interventions included restorative nursing range of motion six to seven days per week at least 15 minutes per day, encourage to perform active range of motion to bilateral lower extremities, assist as needed with two sets of 15 repetitions, and refer to therapy as needed. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had impaired cognition, required extensive assist of two people with bed mobility and transfers, required limited assist of one person with ambulation and extensive assist of one person with personal hygiene. During the assessment period he received three days of restorative range of motion and one day of restorative ambulation. Review of POC Response History restorative ambulation program documentation for Resident #16 revealed in the last 30 days from 03/23/22 to 04/20/22 Resident #16 received his restorative ambulation program one time, 04/07/22. Review of POC Response History restorative range of motion program documentation for Resident #16 revealed in the last 30 days from 03/23/22 to 04/20/22 Resident #16 received his program on 03/24/22, 03/30/22, 04/07/22, and 04/12/22. Interview on 04/18/22 at 8:35 P.M. with Resident #16 revealed he was to have restorative nursing range of motion and ambulation but that he was not receiving as scheduled. He revealed there was one (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365539 If continuation sheet Page 5 of 13 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 365539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Nursing & Rehab 2473 North Rd NE Warren, OH 44483 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 staff that completed the restorative program but that was about once a week or once every two weeks. Level of Harm - Minimal harm or potential for actual harm Interview on 04/21/22 at 8:52 A.M. with Licensed Practical Nurse (LPN)/MDS #450 revealed she oversaw the restorative nursing program at the facility, but Registered Nurse/ Infection Control #808 was supposed to take over the program and he had not. LPN/MDS #450 revealed State Tested Nursing Assistant (STNA) #812 was the restorative aide but was no longer completing restorative therapy as he was working the floor as an STNA instead. LPN/MDS #450 revealed they were in the process of hiring a new restorative aide and the nursing staff on the floor was to complete the nursing programs if they had the time to complete. LPN/MDS #450 revealed she did not track or monitor if the programs were being completed and she did not know what frequency the restorative programs were being completed. LPN/MDS #450 revealed she thought the program was on hold since they did not have a restorative aide any longer. LPN/MDS #450 had not completed any documentation regarding the residents' progress in the restorative nursing program since the programs were not being completed. Residents Affected - Few Interview on 04/21/22 at 9:28 A.M. with the Director of Nursing (DON) revealed there were several management changes and at this time there was no restorative programs being completed unless the nursing staff had the time to complete the program as the programs were still part of the tasks on their electronic point click documentation. The DON revealed there was no restorative documentation that she could locate as to when the restorative programs had stopped being completed. The DON verified Resident #16 had not received his restorative nursing ambulation and range of motion program per his plan of care. Interview on 04/21/22 at 9:58 A.M. with Director of Rehabilitation #813 verified after discharge from therapy, per the discharge summary, Resident #16 was to receive restorative nursing range of motion and ambulation. Director of Rehabilitation #813 was not aware restorative nursing programs were not being completed as recommended. Review of undated facility policy labeled, Restorative Nursing Programming' revealed the purpose of the policy was to strive towards achieving the resident's highest functional level and maintain communication between nursing, restorative nursing and therapy. The policy revealed a functional baseline assessment would be completed by the licensed therapist or by the registered nurse/ licensed nurse as basis for formulating plan of care and treatment. Documentation of the restorative care would be performed daily and as needed. A progress note would be documented at minimum quarterly by the registered nurse and the licensed nurse would evaluate the continued need of service quarterly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365539 If continuation sheet Page 6 of 13 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 365539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Nursing & Rehab 2473 North Rd NE Warren, OH 44483 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure physician orders were obtained timely for Resident #165's wound care to the laproscopic wound on her right upper quadrant. This affected one (Resident #165) of two residents reviewed for general skin conditions. Residents Affected - Few Findings include: Review of Resident #165's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including asthma and incisional hernia with obstruction without gangrene. Review of Resident #165's Admission/readmission Packet form dated 04/07/22 indicated the resident had a abdominal midline incision hernia repair. Review of Resident #165's progress note dated 04/14/22 at 2:36 A.M. authored by Licensed Practical Nurse (LPN) #805 indicated drainage was observed at the incision site in the right upper quadrant. Pus without odor was cleaned with normal saline and a dressing applied. Further review of the medical record revealed Resident #165 did not have a physician order for wound care to her right upper quadrant until 04/16/22. Interview on 04/21/22 at 10:30 A.M. with LPN Wound Nurse #801 confirmed Resident #165's medical record did not have evidence the physician was notified until 04/16/22 and orders obtained for wound care to the laproscopic wound in the right upper quadrant which was draining tan pus. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365539 If continuation sheet Page 7 of 13 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 365539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Nursing & Rehab 2473 North Rd NE Warren, OH 44483 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Resident #16 donned a safety apron during smoking per his intervention on his care plan and that the designated smoking area was maintained in a clean, safe, and sanitary manner. This affected one resident (Resident #16) out of two residents (Resident #16 and #33) reviewed for smoking and had the potential to affect six residents (Resident #8, #12, #16, #50, #316 and #367) who smoke in the designated smoking area off the 600 unit. Findings include: Review of the medical record for Resident #16 revealed an admission date of 03/09/17 and diagnoses included hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, chronic obstructive pulmonary disease, hypertension, and nicotine dependence. Review of quarterly smoking safety assessment dated [DATE] and completed by Licensed Practical Nurse (LPN) #811 revealed Resident #16 was a smoker and required supervision when he smoked. There was no documentation on the smoking assessment regarding Resident #16 requiring a smoking apron when he smoked. Review of the care plan dated 11/03/21 revealed Resident #16 was a cigarette smoker by personal choice. Interventions included instruct Resident #16 about smoking risks and hazards, he was to be supervised while smoking and he was to wear a smoking apron for safety while smoking. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had impaired cognition. He required extensive assist of two people with bed mobility and transfers. He required limited assist of one person with ambulation and extensive assist of one person with personal hygiene. Observation on 04/19/22 at 9:40 A.M. revealed Resident #16 outside in the designated smoking area off the 600- unit. Resident #16 was not wearing a smoking apron while he smoked. Six residents (Residents #8, #12, #16, #50, #316 and #367) were observed smoking while State Tested Nursing Assistant (STNA) #809 monitored the smoking session. Further observation revealed a trash can on the patio that was full of paper and debris and mixed throughout the papers and debris were multiple cigarette butts. The trash can was located next to the fireproof receptacles. In addition, there were multiple cigarette butts laying on the ground in the designated smoking area. Interview on 04/19/22 at 9:58 A.M. with STNA #809 verified there were multiple cigarette butts mixed in throughout the trash can that contained paper and other debris located on the patio in the designated smoking area outside off the 600-unit. STNA #809 also verified there was multiple cigarette butts laying on the ground. STNA #809 verified Resident #16 was not wearing a smoking apron. STNA #809 revealed he monitored the smoking sessions routinely and was not aware Resident #16 needed to wear a smoking apron. Interview on 04/19/22 at 4:30 P.M. with Resident #16 revealed he had never worn a smoking apron while he smoked. Interview on 04/21/22 at 8:52 A.M. with Licensed Practical Nurse (LPN)/MDS #450 revealed completed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365539 If continuation sheet Page 8 of 13 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 365539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Nursing & Rehab 2473 North Rd NE Warren, OH 44483 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 0689 Level of Harm - Minimal harm or potential for actual harm the care plans for the residents at the facility. She verified Resident #16 had an intervention in his care plan to don a smoking apron when he smoked for safety that she had added 11/03/21. LPN/MDS #450 said there had been several changes in management, and she thought someone told her to add the smoking apron as an intervention for Resident #16 but she could not remember who had told her and why he needed to wear a smoking apron. Residents Affected - Some Observation on 04/21/22 at 9:41 A.M. revealed Resident #16 was outside smoking in the designated area off the 600-unit and he was not wearing a smoking apron. Resident #16 was monitored by STNA #809. Interview on 04/21/22 at 9:42 A.M. with LPN #810 revealed she was Resident #16's nurse and verified Residents #16 was not wearing smoking apron while smoking and revealed she had never seen Residents #16 wear a smoking apron when he smoked. Interview on 04/21/22 at 11:23 A.M. with the Director of Nursing (DON) verified Resident #16's care plan indicated he was to have a smoking apron on while smoking but revealed she felt his care plan was possibly inaccurate as he had not been utilizing a smoking apron while he smoked. The DON said they would have Resident #16 re-assessed to see if he needed a smoking apron while he smoked. Review of facility policy labeled, Smoking Policy- Residents dated July 2017 revealed the facility would establish and maintain safe resident smoking practices. The policy revealed any smoking-related privileges, restrictions, and concerns would be noted on the care plan and all personnel caring for the resident would be alerted to these issues. The policy revealed metal containers with self-closing cover devises were in smoking areas and ashtrays would be emptied only into designated receptacles. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365539 If continuation sheet Page 9 of 13 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 365539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Nursing & Rehab 2473 North Rd NE Warren, OH 44483 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 and record review, the facility failed to properly store, label, and dispose of resident medications. This affected one resident (Resident #14) of three residents on the 700 unit who received latanoprost ophthalmic solution (eye drops), one resident (Resident #2) of two residents on the 700 unit who received Lantus (long acting insulin), one resident (Resident #10) of one resident on the 700 unit who received Novolog (short acting insulin), one resident (Resident #57) of one resident on the 700 unit who received trifluridine ophthalmic solution (eye drops), and one resident (Resident #30) of four residents on the 600 unit who received Novolin (short acting insulin). Findings include: 1. Observation on 04/19/22 at 1:56 P.M. on the 700 unit with Licensed Practical Nurse (LPN) #456 during medication storage review revealed Resident #14 had latanoprost ophthalmic solution with an opened date of 03/03/22 with manufacturer's directions to discard after six weeks of opening. Resident #14's latanoprost should have been discarded on 04/14/22. Interview on 04/19/22 at 2:07 P.M. with LPN #456 confirmed Resident #14's latanoprost ophthalmic solution should have been discarded 04/14/22. 2. Observation on 04/19/22 at 1:56 P.M. on the 700 unit with LPN #456 during medication storage review revealed Resident #2 had Lantus with an opened date of 03/12/22 with manufacturer's directions to discard after twenty-eight days of being opened. Resident #2's Lantus should have been discarded 04/09/22. Interview on 04/19/22 at 2:07 P.M. with LPN #456 confirmed Resident #2's Lantus should have been discarded 04/09/22. 3. Observation on 04/91/22 at 1:56 P.M. on the 700 unit with LPN #456 during medication storage review revealed Resident #10's Novolog did not have an open date recorded. Interview on 04/19/22 at 2:07 P.M. with LPN #456 confirmed Resident #10's Novolog did not have an open date recorded. 4. Observation on 04/19/22 at 2:14 P.M. on the 700 unit with LPN #461 during medication storage review revealed Resident #57 had a container of trifluridine ophthalmic solution stored in the medication cart. The trifluridine manufacturer's directions stated to refrigerate. Interview on 04/19/22 at 2:14 P.M. with LPN #461 stated Resident #57 received trifluridine at 10:30 A.M. and LPN #461 put the container in the medication cart after administration. LPN #461 confirmed Resident #57's trifluridine should have been placed in the medication refrigerator. 5. Observation on 04/19/22 at 2:24 P.M. on the 600 unit with LPN #463 during medication storage review revealed Resident #30 had opened Novolin that did not have an opened date recorded. Interview on 04/19/22 at 2:24 P.M. with LPN #463 confirmed Resident #30's Novolin did not have an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365539 If continuation sheet Page 10 of 13 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 365539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Nursing & Rehab 2473 North Rd NE Warren, OH 44483 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 opened date recorded. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy, Administering Medications, revealed instructions to record the date opened on the container when opening a multi-dose container. The expiration dates/beyond use dates on the medication label was to be checked prior to administering. Residents Affected - Some Review of the facility's policy, Storage of Medications, revealed directions for medications requiring refrigeration indicated the medications were to be stored in a refrigerator located in the drug room at the nurses' station or other secured location. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365539 If continuation sheet Page 11 of 13 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 365539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Nursing & Rehab 2473 North Rd NE Warren, OH 44483 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a multi-use glucometer was appropriately disinfected and sanitized between resident use to prevent cross contamination. This affected one resident (Resident #13) of nine residents (Resident #11, #13, #14, #18, #25, #37, #40, #46, #167) who received blood glucose testing (BGT) on the 500 unit. Residents Affected - Few Findings include: Review of Resident #13's medical record revealed an admission date of 12/15/21 with diagnoses including type two diabetes without complications, acute kidney failure and essential hypertension. Review of Resident #13's Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed Resident #13 was cognitively impaired. Review of Resident #13's physician order dated 03/01/22 indicated to complete a BGT twice daily for glucose monitoring. Observation on 04/18/22 at 9:10 P.M. with Registered Nurse (RN) #452 revealed she obtained Resident #43's BGT by using a multi-use glucometer. RN #452 returned to the medication cart after obtaining the blood sugar reading and did not disinfect and sanitize the glucometer which she placed on top of the medication administration cart. RN #452 picked up the glucometer at 9:20 P.M. and walked to Resident #13's room to obtain a BGT with the same glucometer used for Resident #43. Interview on 04/18/22 at 9:25 P.M. with RN #452 confirmed she was supposed to disinfect the glucometer between residents to prevent possible cross contamination. Review of the facility's policy, Blood Sampling - Capillary (Finger Sticks), revealed reusable devices were to be clean and disinfected after each use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365539 If continuation sheet Page 12 of 13 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 365539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Nursing & Rehab 2473 North Rd NE Warren, OH 44483 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure Resident #30 and Resident #64 had or that facility had documented evidence that they were offered the pneumococcal vaccine. This affected two residents (Resident #30 and #64) out of five residents (Resident #8, #20, #28, #30, #64) reviewed for immunizations. The facility census was 67. Residents Affected - Few Findings include: 1. Review of medical record for Resident #30 revealed an admission date of 07/31/19 and diagnoses including diabetes, morbid obesity, congestive heart failure, dementia, and history of COVID-19. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had impaired cognition. The MDS assessment also revealed Resident #30 was not up to date regarding his pneumococcal vaccination as the MDS revealed he was not offered the vaccine. Review of undated facility form labeled, Immunization Audit Report for Resident #30 revealed no documentation Resident #30 received or that he was offered the pneumococcal vaccine. Interview on 04/19/22 at 6:02 P.M. with Infection Control/ Registered Nurse #608 and the Director of Nursing verified Resident #30 was over the age of 65 and the facility had no record that he had received or that he had been offered the pneumococcal vaccine. 2. Review of medical record for Resident #64 revealed an date of 05/12/17 and diagnoses including visual loss, hypertension, chronic kidney disease, and personal history of COVID-19. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64's cognitive status was not assessed. The MDS assessment also revealed Resident #64 was not up to date regarding his pneumococcal vaccination as the MDS revealed he was not offered the vaccine. Review of undated facility form labeled, Immunization Audit Report for Resident #64 revealed no documentation Resident #64 received or that he was offered the pneumococcal vaccine. Interview on 04/19/22 at 6:02 P.M. with Infection Control/ Registered Nurse #608 and the Director of Nursing verified Resident #64 was over the age of 65 and the facility had no record that he had received or that he had been offered the pneumococcal vaccine. Review of the undated facility policy labeled; Pneumococcal Vaccine revealed the facility would offer all residents pneumococcal vaccines to aid in preventing pneumococcal infection. The policy revealed prior to or upon admission residents would be assessed for eligibility to receive the pneumococcal vaccine series and would be offered the vaccine series within 30 days of admission to the facility unless medically contraindicated. The policy revealed if the residents refused appropriate entries would be documented in the resident's medical record and for those residents who received the vaccine it also would be documented per the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365539 If continuation sheet Page 13 of 13