Inspection·July 28, 2022

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 07/27/22 at 2:26 P.M. revealed Resident #12 was sitting in a wheelchair in his room, and the call light touch pad was placed at the top of the bed out of Resident #12's reach. Interview at the time of the observation with STNA #524 confirmed the call light touch pad was not within reach of Resident #12. 3. Record review for Resident #32 revealed the resident had an admission date of 05/26/22 with diagnoses including generalized anxiety disorder, diabetes without complications, dementia without behavioral disturbance, generalized weakness, and depressive disorder. Observation on 07/26/22 at 2:55 P.M. revealed Resident #32 was in bed. The call light was observed placed in the chair at end of bed out of Resident #32's reach. Interview at the time of the observation with STNA #584 verified the call light was not within reach of Resident #32. Review of facility policy titled, Call Light, Use Of, with a review date of July 2017, revealed when providing care to residents be sure to position the call light conveniently for the resident to use. This deficiency substantiates Complaint Number OH00134006. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365555 If continuation sheet Page 2 of 17 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 365555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Brien Memorial Health Care C 563 Brookfield Ave SE Masury, OH 44438 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the facility self-reported incident (SRI), and policy review the facility failed to ensure an allegation of abuse for Resident #57 was reported timely. This affected one (Resident #57) of one resident reviewed for abuse. The facility census was 81. Findings include: Review of the medical record for Resident #57 revealed an admission date of 08/09/18 with diagnoses including delusional disorder, dementia without behavioral disturbance, unspecified mood affective disorder, and osteoarthritis. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #57 was cognitively intact. Resident #57 required total dependence for transfers and extensive assistance of two staff for bed mobility, dressing, toilet use, and personal hygiene. Review of the progress note dated 07/06/22 at 2:48 P.M. revealed a staff member noted ecchymosis (a discoloration of the skin) on Resident #57's hand. A progress note dated 07/06/22 at 4:00 P.M. revealed an x-ray had been completed on Resident #57's right hand. Review of the physician's orders for July 2022 for Resident #57 identified orders for application of ice to the right hand as needed for swelling beginning 07/06/22, elevate the right hand every shift beginning 07/06/22, and a splint to the fifth digit of right hand for five weeks beginning 07/07/22. Review of the progress note dated 07/07/22 at 8:46 A.M. revealed the x-ray results showed a fracture at the fifth proximal phalanx (pinky finger). Review of the facility's SRI tracking number 223694 dated 07/06/22 revealed Resident #57 alleged Nurse Aide #498 came into her room and bent her fingers back. Review of Nurse Aide #499's witness statement, not dated, indicated Resident #57 made the allegation to her on 07/05/22 between 3:30 A.M. and 4:00 A.M. and that the allegation was not reported to the nurse because she figured it was an old bruise. Observation on 07/25/22 at 3:22 P.M. of Resident #57's hand revealed a splint on her right pinky finger and her right middle finger was dark purple from the middle of the finger to the knuckle. Interview with Resident #57 at the time of observation revealed a male staff member had injured her hand. Interview on 07/26/22 at 3:35 P.M. with the Administrator verified Resident #57 alleged Nurse Aide #498 had caused the injury to her hand. The Administrator stated she was not informed of the incident until 07/06/22 at 1:30 P.M., approximately 34 hours after the resident initially made the allegation. She stated contracted staff who worked in the building acknowledged that they would follow the facility policy on abuse, and she confirmed it was not followed in this case. Review of the facility policy titled Resident Abuse Prevention Practices, dated 09/2019, revealed staff must report the suspicion of any incident to the Administrator, Director of Nursing, or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365555 If continuation sheet Page 3 of 17 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 365555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Brien Memorial Health Care C 563 Brookfield Ave SE Masury, OH 44438 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete supervisor immediately so an investigation can be immediately initiated. It also indicated that consultants, contractors, volunteers, and other caregivers providing services to the residents would be educated on the policy. Review of the facility policy titled Reporting Suspected Crimes Policy - Elder Justice Act, dated 10/2017, revealed all reporting must be done immediately but not later than two hours after forming the suspicion if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the event that causes the suspicion does not result in serious bodily injury. Event ID: Facility ID: 365555 If continuation sheet Page 4 of 17 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 365555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Brien Memorial Health Care C 563 Brookfield Ave SE Masury, OH 44438 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on record review and interview, the facility failed to ensure a representative of the Office of the State Long-Term Care Ombudsman was notified of facility initiated discharges. This affected 43 residents (Resident's #17, #20, #36, #42, #43, #67, #68, #69, #80, #88, #240, #241, #242, #243, #244, #245, #246, #247, #248, #249, #250, #251, #252, #253, #254, #255, #256, #257, #258, #259, #260, #261 #262, #263, #264, #265, #266, #267, #268, #269, #270, #271 and #272). The facility census was 81. Findings include: 1. Review of the medical record for Resident #88 revealed an admission date of 04/15/22 and discharge date of 04/26/22. Diagnoses included urinary tract infection, muscle wasting, chronic kidney disease, atrial fibrillation, and congestive heart failure. Review of the Discharge Minimum Data Set (MDS) 3.0 assessment, dated 04/26/22, revealed Resident #88 was discharged with return not anticipated. Review of nursing progress notes dated 04/26/22 revealed Resident #88 was transported to the hospital for a change in condition, and then admitted with altered mental status, congestive heart failure and elevated troponin levels. Interview on 07/27/22 at 8:23 A.M. with Director of Nursing (DON) verified Resident #88 was transferred from the facility and admitted to the hospital due to a change in condition. Interview on 07/27/22 at 3:50 P.M. with DON confirmed there was no evidence a representative of the Office of the State Long-Term Care Ombudsman was notified of Resident #88's discharge. Interview on 07/28/22 at 8:20 A.M. with Administrator verified notifications of facility initiated discharges were not provided to the Office of the State Long-Term Care Ombudsman as required and stated the responsible staff member had stopped sending notifications in the recent past but was not certain of the exact date. Administrator indicated due to the error, a representative of the Office of the State Long-Term Care was emailed immediately facility initiated discharges which occurred from 01/01/22 through 07/28/22. Review of the facility discharge report, dated 07/28/22, for residents discharged from 01/01/22 to 07/28/22 revealed Resident #88 was discharged to a hospital. 2. Review of the facility discharge report, dated 07/28/22, for residents discharged from 01/01/22 to 07/28/22 revealed the following residents received a facility-initiated discharge to a hospital: • Resident #17 was discharged on 03/12/22, again on 05/08/22, and again on 07/22/22. • Resident #20 was discharged on 01/24/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365555 If continuation sheet Page 5 of 17 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 365555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Brien Memorial Health Care C 563 Brookfield Ave SE Masury, OH 44438 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 • Level of Harm - Minimal harm or potential for actual harm Resident #36 was discharged on 05/07/22, again on 05/28/22, and again on 06/01/22. • Residents Affected - Some Resident #42 was discharged on 04/08/22. • Resident #43 was discharged on 06/01/22. • Resident #67 was discharged on 07/12/22. • Resident #68 was discharged on 06/25/22. • Resident #69 was discharged on 07/15/22. • Resident #80 was discharged on 05/23/22 and again on 06/04/22. • Resident #240 was discharged on 01/11/22. • Resident #241 was discharged on 01/25/22. • Resident #242 was discharged on 02/16/22. • Resident #243 was discharged on 03/27/22. • Resident #244 was discharged on 04/23/22. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365555 If continuation sheet Page 6 of 17 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 365555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Brien Memorial Health Care C 563 Brookfield Ave SE Masury, OH 44438 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Resident #245 was discharged on 05/09/22. Level of Harm - Minimal harm or potential for actual harm • Resident #246 was discharged on 05/18/22, and again on 05/31/22. Residents Affected - Some • Resident #247 was discharged on 05/23/22. • Resident #248 was discharged on 01/05/22. • Resident #249 was discharged on 04/28/22. • Resident #250 was discharged on 06/16/22. • Resident #251 was discharged on 06/30/22. • Resident #252 was discharged on 07/03/22, and again on 07/15/22. • Resident #253 was discharged on 01/19/22. • Resident #254 was discharged on 01/20/22. • Resident #255 was discharged on 01/23/22. • Resident #256 was discharged on 01/25/22. • Resident #257 was discharged on 01/31/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365555 If continuation sheet Page 7 of 17 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 365555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Brien Memorial Health Care C 563 Brookfield Ave SE Masury, OH 44438 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 • Level of Harm - Minimal harm or potential for actual harm Resident #258 was discharged on 02/01/22. • Residents Affected - Some Resident #259 was discharged on 02/08/22. • Resident #260 was discharged on 02/23/22. • Resident #261 was discharged on 02/24/22. • Resident #262 was discharged on 04/13/22. • Resident #263 was discharged on 04/18/22, and again on 05/02/22. • Resident #264 was discharged on 04/26/22. • Resident #265 was discharged on 04/28/22. • Resident #266 was discharged on 04/29/22. • Resident #267 was discharged on 05/13/22. • Resident #268 was discharged on 06/11/22. • Resident #269 was discharged on 01/13/22. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365555 If continuation sheet Page 8 of 17 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 365555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Brien Memorial Health Care C 563 Brookfield Ave SE Masury, OH 44438 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Resident #270 was discharged on 02/06/22. Level of Harm - Minimal harm or potential for actual harm • Resident #271 was discharged on 04/26/22. Residents Affected - Some • Resident #272 was discharged on 07/07/22. Review of the facility notices of transfer/discharge forms revealed the following residents were discharged to a hospital due to need of emergent care: • Resident #17 was discharged on 03/12/22, on 05/08/22 and again on 07/22/22. • Resident #20 was discharged on 01/24/22. • Resident #36 was discharged on 05/07/22, on 05/28/22, and again on 06/01/22. • Resident #42 was discharged on 04/08/22. • Resident #43 was discharged on 06/01/22. • Resident #67 was discharged on 07/12/22. • Resident #68 was discharged on 06/25/22. • Resident #69 was discharged on 06/29/22. • Resident #80 was discharged on 05/23/22 and again on 06/04/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365555 If continuation sheet Page 9 of 17 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 365555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Brien Memorial Health Care C 563 Brookfield Ave SE Masury, OH 44438 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 • Level of Harm - Minimal harm or potential for actual harm Resident #240 was discharged on 01/11/22. • Residents Affected - Some Resident #241 was discharged on 01/25/22. • Resident #242 was discharged on 02/16/22. • Resident #243 was discharged on 03/27/22. • Resident #244 was discharged on 04/23/22. • Resident #245 was discharged on 05/09/22. • Resident #246 was discharged on 05/18/22 and again on 05/31/22. • Resident #247 was discharged on 05/23/22. • Resident #248 was discharged on 01/05/22. • Resident #249 was discharged on 04/28/22. • Resident #250 was discharged on 06/16/22. • Resident #251 was discharged on 06/30/22. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365555 If continuation sheet Page 10 of 17 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 365555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Brien Memorial Health Care C 563 Brookfield Ave SE Masury, OH 44438 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Resident #252 was discharged on 07/15/22. Level of Harm - Minimal harm or potential for actual harm • Resident #253 was discharged on 01/19/22. Residents Affected - Some • Resident #254 was discharged on 01/20/22. • Resident #255 was discharged on 01/23/22. • Resident #256 was discharged on 01/25/22. • Resident #257 was discharged on 01/31/22. • Resident #258 was discharged on 02/01/22. • Resident #259 was discharged on 02/08/22. • Resident #260 was discharged on 02/23/22. • Resident #261 was discharged on 02/24/22. • Resident #262 was discharged on 04/13/22. • Resident #263 was discharged on 04/18/22 and again on 05/02/22. • Resident #264 was discharged on 04/26/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365555 If continuation sheet Page 11 of 17 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 365555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Brien Memorial Health Care C 563 Brookfield Ave SE Masury, OH 44438 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 • Level of Harm - Minimal harm or potential for actual harm Resident #265 was discharged on 04/28/22. • Residents Affected - Some Resident #266 was discharged on 04/29/22. • Resident #267 was discharged on 05/13/22. • Resident #268 was discharged on 06/11/22. • Resident #269 was discharged on 01/13/22. • Resident #270 was discharged on 02/06/22. • Resident #271 was discharged on 04/26/22. • Resident #272 was discharged on 07/07/22. Interview on 07/28/22 at 8:20 A.M. with the Administrator verified the above listed discharge notices were emailed on 07/28/22 to the representative of the Office of the State Long-Term Care Ombudsman due to the designated staff member not sending the notices as required. Review of the facility generated email, dated 07/28/22 at 8:13 A.M., from the Administrator to the representative of the Office of the State Long-Term Care Ombudsman revealed an emailed adobe file which was attached. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365555 If continuation sheet Page 12 of 17 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 365555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Brien Memorial Health Care C 563 Brookfield Ave SE Masury, OH 44438 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** Based on interview and record review the facility failed to provide Resident #37 with showers twice a week as scheduled. This affected one (Resident #37) of three (Residents #20, #37, #47) reviewed for showers. The facility census was 81. Residents Affected - Few Findings include: Review of the medical record for Resident #37 revealed an admission date of 07/15/21. Diagnoses included end stage renal disease, herpes zoster eye disease, and dependence on renal dialysis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 had no cognitive impairment. Resident #37 required extensive two-staff physical assistance for bed mobility, dressing, toilet use, and personal hygiene; total dependence of two staff for transfers; and supervision with set-up help only for eating. Resident #37 was frequently incontinent of urine and bowel. Interview on 07/25/22 at 4:30 P.M. with Resident #37 revealed she had not received a shower for a month. She reported her shower days were scheduled for Mondays and Thursdays, but she rarely got a shower. Review of the shower schedule in the north wing nursing assistant book posted at the north wing nurse's station revealed Resident #37 was scheduled for a shower every Monday and Thursday during the day shift. Review of the shower sheets for Resident #37 from 06/01/22 to 07/27/22 revealed she only received showers on 06/03/22, 06/06/22, 06/13/22, 06/30/22, and 07/21/22. Interview on 07/27/22 at 10:57 A.M. with the Director of Nursing (DON) confirmed Resident #37 did not receive her showers as ordered and did go almost a month without a shower. This deficiency substantiates Complaint Number OH00134006. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365555 If continuation sheet Page 13 of 17 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 365555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Brien Memorial Health Care C 563 Brookfield Ave SE Masury, OH 44438 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to complete pre and post dialysis assessments for Resident #75. This affected one (Resident #75) of two residents receiving dialysis treatments. The facility census was 81. Residents Affected - Few Findings include: Review of the medical record for Resident #75 revealed an admission date of 04/03/18 with diagnoses including end stage renal disease and dependence on renal dialysis. Review of the physician orders for July 2022 identified orders for pre and post dialysis assessments every day and evening shift on Tuesday, Thursday, and Saturday beginning 06/23/22. Review of the Medication Administration Record/Treatment Administration Record (MAR/TAR) for July 2022 for Resident #238 revealed a dialysis post assessment was not completed on 07/21/22 and 07/23/22. Interview on 07/28/22 at 10:50 A.M. with the Director of Nursing (DON) verified the post dialysis assessment was not completed on 07/21/22 and 07/23/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365555 If continuation sheet Page 14 of 17 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 365555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Brien Memorial Health Care C 563 Brookfield Ave SE Masury, OH 44438 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 2. Observation on 07/27/22 at 1:20 P.M. with Licensed Practical Nurse (LPN) #569 for wound care of Resident #32 revealed LPN #569 performed handwashing and donned gloves then removed the left heel soiled dressing dated 07/26/22, discarded the dressing, and removed the soiled gloved and performed handwashing. LPN #569 donned clean gloves, cleansed Resident #32's left heel with normal saline solution, then removed the soiled gloves, using a pen dated a foam dressing with the date 07/27/22, and without performing hand hygiene applied clean gloves to soiled hands and applied Mesalt (stimulates the cleansing of heavily discharging wounds in the inflammatory phase by absorbing exudate, bacteria, and necrotic material) and the dated foam dressing to Resident #32's left heel wound bed. LPN #569 removed the soiled gloves and performed handwashing. Interview at the time of the observation with LPN #569 verified soiled gloves were removed and clean gloves were applied without performing handwashing. Residents Affected - Many Interview on 07/27/22 at 2:14 P.M. with the Director of Nursing (DON) confirmed handwashing was required when gloves were changed during wound care. Review of the facility policy titled Handwashing/Hand Hygiene, revised June 2022, revealed staff were to perform handwashing or if hands were not visibly soiled use an alcohol-based hand rub after removing gloves. 3. Review of the medical record for Resident #238 revealed an admission date of 07/21/22 with diagnoses including multiple fractures of ribs left side, personal history of transient ischemic attack, hypertension, and type two diabetes mellitus. Review of the physician orders for July 2022 identified orders for droplet-plus isolation precautions beginning 07/21/22. Observation on 07/25/22 at 12:18 P.M. revealed Nurse Aide #563 entered Resident #238's room wearing a N95 mask and eye protection. No other PPE was donned prior to entering Resident #238's room. Further observation revealed signs posted outside Resident #238's room indicating to see the nurse before entering the room, donning and doffing procedures for PPE, and a cart containing PPE was located just outside the door. Interview on 07/25/22 at 12:19 P.M. with Nurse Aide #563 verified only a N95 mask and eye protection was worn in Resident #238's room. 4. Review of the medical record for Resident #21 revealed an admission date of 11/02/21 with diagnoses including schizophrenia, schizoaffective disorder, chronic pain syndrome, type two diabetes mellitus, and COVID-19 (dated 09/17/21). Review of the physician orders for July 2022 identified orders for COVID-19 precautions during outbreak and cared for by staff using full PPE beginning 07/25/22. Observation on 07/26/22 at 9:03 A.M. revealed Nurse Aide #557 entered Resident #21's room wearing a N95 mask and eye protection to assist Resident #21. No other PPE was donned prior to entering Resident #21's room. Further observation revealed signs posted outside Resident #21's room indicating to see the nurse before entering the room, donning and doffing procedures for PPE, and a cart containing PPE was located just outside the door. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365555 If continuation sheet Page 15 of 17 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 365555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Brien Memorial Health Care C 563 Brookfield Ave SE Masury, OH 44438 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 - Many Interview on 07/26/22 at 9:04 A.M. with Nurse Aide #557 verified only a N95 mask and eye protection was worn. Nurse Aide #557 stated she did not pay attention to the precaution signs posted outside Resident #21's room. Based on observation, interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidance the facility did not ensure staff followed proper isolation precautions while entering and exiting rooms for five (Resident's #21, #49, #79, #83 and #238) and the facility failed to ensure staff used proper handwashing guidelines during wound care for Resident #32. This affected six (Resident's #21, #32, #49, #79, #83 and #238) and had the potential to affect all 81 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #79 revealed an admission date of 07/02/20. Diagnoses included COVID-19, dementia, and congestive heart failure. A physician order, dated 07/19/22, indicated droplet plus isolation for ten days. Interview on 07/25/22 at 9:51 A.M. with Clinical Director #502 confirmed Resident #79 was on transmission-based precautions, droplet precautions, due to being positive with COVID-19. Observation on 07/25/22 at 10:21 A.M. revealed Laundry #560 entered Resident #79's room, which was designated as a droplet precaution room, with clean personal clothing wearing a N95 respirator mask, eyewear, and gloves. Laundry #560 delivered the personal laundry into Resident #79's closet, closed the closet, and exited the room without replacing the N95 respirator mask, cleaning the eyewear, removing the gloves, or performing handwashing. Laundry #560 then retrieved clean personal laundry from the clean laundry cart while wearing the same soiled gloves and entered Resident #83's room and delivered the clean personal laundry into Resident #83's closet, closed the closet, and exited the room without removing the soiled gloves or performing hand hygiene. Laundry #560 then retrieved clean personal laundry from the clean laundry cart while wearing the same soiled gloves and entered Resident #49's room and delivered the clean personal laundry into Resident #49's closet, closed the closet, and exited the room without removing the soiled gloves or performing hand hygiene. Interview at the time of the observation with Laundry #560 verified not wearing a gown prior to entering Resident #79's room, and not replacing the N95 respirator mask, cleaning the eyewear, removing the gloves, and performing handwashing upon exiting Resident #79's room. Laundry #560 further confirmed not performing appropriate hand hygiene after leaving Resident #79's room and between Resident #83 and #49's room. Laundry #560 stated she was not sure what the droplet precautions included. Review of the facility of droplet precautions titled Droplet Plus Precautions, dated 03/31/20, revealed the facility will use droplet precautions for residents with or suspected of having COVID-19. Personal protective equipment (PPE) would include masks, face shields/eye protection, isolation gowns, and gloves. Review of the Infection Control Guidance, updated 02/02/22, from the Centers for Disease Control located at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, revealed to adhere to standard precautions and to wear a N95 respirator, gown, gloves, and eye protection for health care workers who enter a room of a resident with SARS-CoV-2 (COVID-19) infections. Review of the Sequence for Removing Personal Protective Equipment https://www.cdc.gov/niosh/emres/2019_ncov_ppe.html from the Centers for Disease Control, revealed to put on gown, mask, eyewear, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365555 If continuation sheet Page 16 of 17 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 365555 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE O'Brien Memorial Health Care C 563 Brookfield Ave SE Masury, OH 44438 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 gloves upon entering isolation room and upon exiting room, gloves should be removed, goggles should be disinfected, gown should be removed, N95 should be discarded, and hand hygiene should be performed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365555 If continuation sheet Page 17 of 17