Health inspection·August 15, 2019

F 0561 important to the resident to choose her type of bathing. Level of Harm - Minimal harm or potential for actual harm Review of the policy, Resident Care, last revised 06/2018 revealed residents would be bathed or assisted to shower per their preference. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365550 If continuation sheet Page 2 of 12 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 365550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Hills Nursing Center 3650 Beavercrest Drive Lorain, OH 44053 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and review of facility policy the facility failed to ensure housekeeping and maintenance services were provided to maintain a clean environment. This affected six Residents (#12, #16, #28, #36, #50, #260) of 22 sampled residents. The facility census was 60. Findings include: Observation on 08/14/19 at 12:05 P.M. revealed Resident #16's room (room [ROOM NUMBER]) had plastic baseboard hanging loose from the wall. The area measured approximately 12 inches. The bathroom tile around the toilet was also observed as stained with a dark substance. This encircled the entire base of the toilet base. Observation on 08/14/19 at 12:06 P.M. revealed Resident #50's room (room [ROOM NUMBER]) had a large window next to the resident's bed. The area between the outer window glass and screen was covered with spider webs and dead insects. Observation on 08/14/19 at 12:07 P.M. revealed Resident #260's room (room [ROOM NUMBER]) had a large section of damaged drywall on the right side of the room. The section measured approximately 2 feet by 6 inches. In addition, the area had five round holes approximately 1 inch in circumference above the damaged section of drywall. Observation on 08/14/19 at 12:09 P.M. revealed Resident #36's room (room [ROOM NUMBER]) had a section of baseboard in the bathroom that was peeling from the wall. In addition, the toilet base caulk was noted to be dirty and was rust colored. Observation on 08/14/19 at 12:10 P.M. revealed Resident #12's room (room [ROOM NUMBER]) toilet had dark discoloration in the toilet bowl. Observation on 08/14/19 at 12:11 P.M. of Resident #28's room (room [ROOM NUMBER]) revealed the sink was clogged and the water would not run freely down the drain. In addition, the toilet seat was loose and moved freely when the weight was applied to the toilet seat. Interview with Maintenance Director #167 on 08/14/19 at 1:08 P.M. confirmed the rooms mentioned above were in need of repair. Interview with Housekeeping Manager #146 on 08/14/19 at 3:10 P.M. revealed the window in Resident #50's room was cleaned by housekeeping on the inside, but the facility had failed to clean the outside area. Housekeeping Director #146 confirmed the window was in need of cleaning. Review of the facility policy titled Quality of Life - Homelike Environment revealed the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365550 If continuation sheet Page 3 of 12 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 365550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Hills Nursing Center 3650 Beavercrest Drive Lorain, OH 44053 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a determination summary reports from the Ohio Bureau of Pre-admission Level two Screening and Resident Review (PASRR), and staff interview, the facility failed to assess a resident with a serious mental illness accurately. This affected one resident (#46) of two reviewed for PASRR. The facility census was 60. Findings included: Medical record review revealed Resident #46 admitted to the facility on [DATE]. Diagnoses included bipolar disorder, major depressive disorder, and alcohol abuse. Review of the comprehensive Minimum Data Sets (MDS) assessment dated [DATE], section A1500, revealed the facility assessed Resident #46 as not having serious mental illness and or intellectual disabilities as determined by PASRR level two screening. Review of the PASRR Level two screening determination summary, dated 04/15/18, revealed Resident #46 was determined to have serious mental illness. Interview on 08/15/19 at 10:13 A.M., Licensed Practical Nurse (LPN) #205 revealed she was responsible for completing resident's MDS assessments. LPN #205 confirmed section A1500 of the resident's comprehensive MDS assessment, dated 07/15/19, was coded wrong and did not reflect the resident's PASRR determination of serious mental illness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365550 If continuation sheet Page 4 of 12 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 365550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Hills Nursing Center 3650 Beavercrest Drive Lorain, OH 44053 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 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm Based on medical record review, review of the quarterly Minimum Data Set (MDS) assessments and staff interviews, the facility failed to ensure a comprehensive assessment was completed after a significant change in functional ability for activities of daily living. This affected one (#2) of three residents reviewed for activities of daily living (ADLs). The facility census was 60. Residents Affected - Few Findings include Medical record review revealed Resident #2 had an admission date of 03/15/19. Diagnoses included cerebrovascular disease and dementia. Review of the quarterly MDS functional assessment completed 04/17/19 revealed Resident #2 required the extensive assistance of two staff members for bed mobility, transfers, dressing and toilet use. The resident also required the extensive assistance of one staff member for personal hygiene. Review of the quarterly MDS functional assessment completed 07/18/19 revealed Resident #2 was independent (no help or staff oversight at any time) with bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and locomotion on and off the unit. Interview on 08/14/19 at 12:47 P.M. with the MDS Coordinator #205 revealed she had not completed the comprehensive significant change assessment within two weeks of the residents noted improvement in functional abilities. Further interview with the MDS Coordinator #205 reveled she followed the guidelines in the Resident Assessment Instrument (RAI) manual to complete resident assessments. Interview on 08/15/19 at 1:57 P.M. with the Director of Nursing (DON) revealed the facility misunderstood the RAI manual regarding late loss ADL changes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365550 If continuation sheet Page 5 of 12 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 365550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Hills Nursing Center 3650 Beavercrest Drive Lorain, OH 44053 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 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** Based on medical record review and staff interview, the facility failed to ensure quarterly Minimum Data Sets (MDS) assessments were accurate. This affected one resident (#57) of nineteen residents reviewed during the annual survey. The facility census was 60. Residents Affected - Few Findings include: Medical record review revealed Resident #57 admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease, muscle wasting and atrophy, and hypertension. Review of the resident's quarterly MDS assessments, dated 07/13/19 and 07/17/19, section M1030, revealed the resident did not have any vascular wounds coded on either MDS assessment. Review of a Skin Grid, dated 07/12/19, revealed the resident had a new vascular wound on his left toe that measured 3 centimeters (cm) long by 3 cm wide by 0.1 cm deep. Interview on 08/14/19 11:54 A.M., Licensed Practical Nurse (LPN) #205 revealed she was responsible for completing resident's MDS assessments. LPN #205 confirmed on 07/12/19, Resident #57 was diagnosed with a vascular ulcer on his left toe. LPN #205 further confirmed the resident's quarterly MDS assessments, dated 07/13/19 and 07/17/19, section M1030, was inaccurate and did not reflect the resident's current condition to include the vascular ulcer on his left toe. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365550 If continuation sheet Page 6 of 12 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 365550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Hills Nursing Center 3650 Beavercrest Drive Lorain, OH 44053 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff and resident interviews, and facility policy review, the facility failed to ensure physical therapy recommendations for restorative ambulation were completed. This directly affected one (#2) of one resident reviewed for activities of daily living (ADL). The facility identified five residents (#2, #4, #10, #18, #58) as receiving restorative services. The facility census was 60. Findings include Medical record review revealed Resident #2 had an admission date of 03/15/19. Diagnoses included cerebrovascular disease and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had mild cognitive impairment. Further review of the MDS functional assessment revealed the resident was walked in her room and corridor one to two times. Continued review of the MDS mobility assessment revealed the resident used a wheelchair and no walker in the look back period. Review of a physical therapy Discharge summary dated [DATE] revealed discharge recommendations for ambulation and active range of motion in the restorative nursing program to maintain current level of performance and in order to prevent decline. Review of the plan of care last revised on 07/10/19 revealed staff were to ambulate the resident with a walker to and from the dining room for meals 15 to 30 minutes per day, six to seven days per week. Review of the restorative look back report from 07/30/19 through 08/12/19 revealed no documentation the resident was ambulated 15 to 30 minutes daily for six to seven days per week. Further review of the nurse's notes dated 07/30/19 through 08/10/19 revealed no documentation the resident had refused restorative services. Interview on 08/13/19 at 3:33 P.M. with State Tested Nursing Assistant (STNA) #117 revealed Resident #2 could walk short distances with a stand by assist. STNA #117 was not aware of Resident #2 using a walker. Interview on 08/14/19 at 9:01 A.M. with STNA #106 revealed Resident #2 used to have a walker. Interview on 08/14/19 at 9:07 A.M. with Licensed Practical Nurse (LPN) #200 revealed she had not seen Resident #2 use a walker. LPN #200 revealed the resident used her wheel chair to get around the facility. Interview on 08/14/19 at 8:55 A.M. with Physical Therapy Assistant (PTA) #160 revealed Resident #2 could ambulate with a walker with staff. PTA #160 revealed Resident #2 was not safe to use walker independently. Interview on 08/14/19 at 2:56 P.M., the Director of Nursing (DON) verified there was no documentation Resident #2 was ambulated with her walker six to seven days week. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365550 If continuation sheet Page 7 of 12 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 365550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Hills Nursing Center 3650 Beavercrest Drive Lorain, OH 44053 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Interview on 08/14/19 at 4:05 P.M. with Resident #2 revealed staff had not walked her with her walker. Resident #2 was not aware where staff were keeping her walker. Interview on 08/15/19 at 9:07 A.M. with the Director of Nursing (DON) revealed there were five residents (#2, #4, #10, #18, #58) who received restorative care. Residents Affected - Few Review of the policy Restorative Nursing Services, last revised 08/2018 revealed a restorative nursing program assists residents to achieve and maintain their optimal functional level consistent with their capabilities, goals and preferences. Restorative goals are individualized and outlined the resident's plan of care. Restorative goals support and assist residents to develop, maintain and strengthen their physiological and psychological resources. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365550 If continuation sheet Page 8 of 12 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 365550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Hills Nursing Center 3650 Beavercrest Drive Lorain, OH 44053 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview and review of a facility policy, the facility failed to remove expired food items from the kitchen. This had the potential to affect all residents who resided in the facility except three (#1, #37, #311) residents identified by the facility who did not receive meals from the kitchen. The facility census was 60. Findings include: Observation of the kitchen on 08/12/19 at 9:35 A.M. revealed two loafs of Nickels white bread with a use by date of 07/23/19 and a third loaf dated 08/10/19. The bread in one of the two packages dated 07/23/19 was observed to be approximately 80% covered with a green substance. A package of 12 hotdog buns dated 08/10/19, one with with three hotdog buns dated 08/10/19, one with eight hotdog buns dated 08/06/19, and a package of 12 hamburger buns dated 08/10/19 were also observed. Interview on 08/12/19 at 9:50 A.M., Dietary Manger (DM) #401 revealed it was the facility policy to not use bread after the printed date on the package regardless to whether is was an expiration date or a use by date. The date printed on the package was considered the expiration date. DM #401 confirmed there were two loafs of Nickels white bread with a use by date of 07/23/19 and a third loaf dated 08/10/19, a package of 12 hotdog buns dated 08/10/19, one with with three hotdog buns dated 08/10/19, one with eight hotdog buns dated 08/06/19, and a package of 12 hamburger buns dated 08/10/19. DM #401 confirmed the white bread in one of the two packages dated 07/23/19 was covered approximately 80% with a green substances. DM #401 stated the substance was mold and she was concerned the expired bread was on shelves mixed with fresh bread. Review of a facility policy titled, Food Storage (Dry, Refrigerated, and Frozen), dated 2016, revealed the facility was to store food using appropriate methods to ensure the highest level of food safety. Staff were to rotate products so the oldest were used first and staff were supposed to be instructed to use products with the earliest expiration date before those with a later date. Further review revealed staff were to discard food that was passed the expiration date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365550 If continuation sheet Page 9 of 12 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 365550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Hills Nursing Center 3650 Beavercrest Drive Lorain, OH 44053 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure resident's medications and treatments were documented in the medical record. This affected two resident (#51 and #261) of six residents reviewed for medications and treatments. The facility census was 60. Findings include: 1. Medical record review revealed Resident #51 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, vascular dementia with behavioral disturbances, impulse disorder and major depressive disorder. Review of the comprehensive Minimum Data Sets (MDS) dated [DATE] revealed the resident's cognition was moderately impaired. Review of the most recent plan of care revealed Resident #51 had been observed displaying sexual behavior in inappropriate locations. Interventions included to limit at risk situation, provide alternative activities, redirect from entering resident rooms without permission, and allow the resident to express need for companionship. Review of the resident's psychiatric hospital discharge orders, dated 06/27/19, revealed the resident was to continue to take Tagamet 200 milligrams (mg) twice a day for inappropriate sexual behaviors when he admitted to the facility. Review of the resident's admission orders, dated 07/12/19, revealed the resident was ordered Tagamet 200 mg twice a day. Review of the resident's Medication Administration Record (MAR) for 08/2019 revealed the resident was ordered to receive Tagamet 200 mg at 9:00 A.M. and 9:00 P.M. Further review revealed no documented evidence the resident received and/or refused the medication at 9:00 A.M. on 08/01/19, 08/07/19, 08/08/19, 08/10/19, 08/11/19, 08/12/19, and 08/13/19 or at 9:00 P.M. on 08/11/19, 08/12/19, and 08/13/19. Interview on 08/14/19 at 3:08 P.M., the Director of Nursing (DON) confirmed the resident was ordered to continue to take Tagamet 200 mg twice a day while a resident at the facility. The DON further confirmed there was no documented evidence the resident was administered and/or refused this medication at 9:00 A.M. on 08/01/19, 08/07/19, 08/08/19, 08/10/19, 08/11/19, 08/12/19, and 08/13/19 or at 9:00 P.M. on 08/11/19, 08/12/19, and 08/13/19. 2. Review of Resident #261's medical record revealed an admission date of 07/13/19. Diagnoses included congestive heart failure, morbid obesity, diabetes type 2, left lower leg fracture, cellulitis, and obstructive sleep apnea. Review of Resident #261's admission MDS dated [DATE] revealed the resident had a high cognitive function. All activities of daily living required total dependence except eating. The resident was noted to be at risk for skin break down but had no pressure ulcers but did require surgical wound care. Review of Resident #261's most recent Care Plan revealed the resident had potential for alteration in skin integrity and required protective/preventative skin care maintenance related to decreased mobility, morbid obesity, poor hygiene, diabetes mellitus and Foley catheter use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365550 If continuation sheet Page 10 of 12 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 365550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Hills Nursing Center 3650 Beavercrest Drive Lorain, OH 44053 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #261's medical record revealed a physician's order dated 08/01/19 revealed to apply ET mix cream (antifungal) to excoriated areas every shift and as needed. Review of Resident #261's MAR dated August 2019 revealed no evidence the ET mix cream was applied on 08/11/19, 08/12/19 and 08/13/19 on the day shift and on 08/06/19, 08/09/19, 08/10/19, 08/11/19, 08/12/19 and 08/13/19 on the afternoon shift. Review of Resident #261's medical record revealed a physician's order dated 08/01/19 to apply Baza cream (antifungal) to buttocks twice daily. Review of Resident #261's MAR revealed no evidence the Baza Cream was applied on 08/01/19, 08/02/19, 08/06/19, 08/09/10, 08/10/19/ 08/11/19, 08/12/19, 08/13/19 on the afternoon shift and on 08/10/19 during the day shift. Interview with the DON on 08/13/19 at 3:22 P.M. revealed Resident #261's ointments were completed but the nursing staff failed to sign the task as completed on the MAR. Interview with Licensed Practical Nurse (LPN) #200 on 08/13/19 at 4:01 P.M. revealed the LPN cared for Resident #261 and stated the State Tested Nursing Aides (STNAs) applied the Baza cream to the buttocks twice daily and the ET mix to excoriated areas. LPN #200 verified the nursing staff failed to sign the MAR that it was completed. Interview with STNA's #114 and #149 on 08/13/19 at 4:04 P.M. revealed the aides did not apply the Baza cream nor the ET mix to the resident because they were physician prescribed. The STNA's revealed the nursing staff were to complete the care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365550 If continuation sheet Page 11 of 12 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 365550 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Hills Nursing Center 3650 Beavercrest Drive Lorain, OH 44053 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 medical record review, observation, staff interview and review of facility policy, the facility failed to implement infection prevention and control practices during the administration of insulin. This directly affected one (#40) of four residents observed for medication administration. The facility identified 14 residents (#4, #19, #21, #22, #28, #40, #41, #44, #48, #49, #53, #56, #261, #262) who received insulin. The facility census was 60. Residents Affected - Few Findings include Medical record review revealed Resident #40 had an admission date of 08/14/19. Diagnoses included, diabetes mellitus, hypertension, and cerebral infarction. Review of the 08/2019 monthly physician orders revealed the resident was ordered Admelog (100 units/milliliter) four units subcutaneously three times a day with meals. Observation on 08/13/19 at 8:10 A.M. during medication administration revealed Licensed Practical Nurse (LPN) #200 administered a subcutaneous injection of insulin to Resident #40 without wearing gloves. Interview on 08/13/19 at 8:13 A.M. with LPN #200 revealed she forgot to wear gloves during the administration of insulin to Resident #40. Interview on 08/14/19 at 9:01 with the Director of Nursing (DON) revealed nurses were required to wear gloves during insulin administration. The DON identified 14 residents (#4, #19, #21, #22, #28, #40, #41, #44, #48, #49, #53, #56, #261, #262) who required insulin administration. Review of the policy for Medication Administration, effective 06/21/17 revealed licensed nurses were required to wear gloves during the administration of injectable medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365550 If continuation sheet Page 12 of 12