Inspection·April 5, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview and observation on 04/03/23 at 12:27 P.M. with Resident #50 revealed she did not get her showers per her preference and as scheduled. She revealed she was to receive a shower twice a week but that she had not had a shower for at least 13 days. She revealed she felt her hair was greasy since it had not been washed in 13 days. Observation revealed her hair appeared greasy. Interview on 04/03/23 at 4:24 P.M. and on 04/04/23 at 10:44 A.M. with the Director of Nursing verified Resident #50 had a preference and was scheduled to receive a shower every Tuesday and Friday. She verified she did not have documentation Resident #50 had a shower and/or was offered a shower on the following scheduled shower days: 02/03/23, 02/10/23, 03/03/23, 03/14/23, 03/21/23, 03/24/23, 03/28/23, 03/31/23, and 04/04/23. She verified she had no documentation Resident #50 received a shower and/or was offered a shower from 02/15/23 to 02/21/23 (seven days), and from 03/17/23 to 04/03/23 (18 days). She revealed she was not aware Resident #50 had voiced a previous concern to the Ombudsman regarding not getting her showers per her preference and/or as scheduled. 2. Review of the closed medical record for Resident #73 revealed an admission date of 12/14/22 and a discharge date of 12/29/22. Diagnoses included chronic obstructive pulmonary disease, muscle weakness, morbid obesity, lymphedema, and lack of coordination. Review of the care plan dated 12/14/22 revealed Resident #73 had a person-centered care plan. Intervention included one staff assist with bathing and grooming. Review of the facility form labeled Shower Sheet revealed Resident #73 had a shower on 12/18/22. On 12/27/22 she refused a shower but did have a bed bath completed on this day. Review of the admission MDS assessment dated [DATE] revealed Resident #73 had intact cognition. She required extensive assistance of two people with bed mobility, transfers, dressing, personal hygiene, and toileting. She required physical help from two people in part of the bathing activity. Review of the facility form labeled ITM Meeting-V1 dated 12/28/22 and completed by MDS/ Licensed Practical Nurse (LPN) #608 revealed an interdisciplinary team meeting was held on 12/28/22 with Resident #73. The form revealed her bathing preference was to have a shower twice a week. Interview on 04/03/23 at 9:59 A.M. with Resident #73 revealed she preferred to have a shower at least twice a week while at the facility, but she had gone over ten days without a shower. She revealed she was unhappy with the care and services she received while at the facility, especially her personal hygiene including showers. Interview on 04/03/23 at 4:24 P.M. and on 04/04/23 at 10:44 A.M. with the Director of Nursing verified staff were to document per the shower sheet when a resident had a shower. She verified Resident #73's preference and schedule were to receive a shower twice a week. She verified Resident #73 went from 12/19/22 to 12/26/23 (eight days) without any documentation that Resident #73 received a shower and/or had documentation she had refused a shower. Review of the facility form labeled Shower Sheet revealed the facility staff were to document on the form when a shower was provided. The form revealed staff would complete the form and turn the form into the floor nurse. The form revealed the floor nurse would check and sign the completed sheet. The form revealed if a resident refused the shower and/or bath, the nurse would talk with the resident. The form revealed if the resident continued to refuse the nurse would document on the form the refusal and have the resident sign the form. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365555 If continuation sheet Page 2 of 6 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 04/05/2023 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 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy labeled Bath (Shower), dated August 2018, revealed the frequency of baths and showers were based on resident preference. This deficiency represents non-compliance investigated under Master Complaint Number OH00141387, Complaint Number OH00139832, and Complaint Number OH00139091. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365555 If continuation sheet Page 3 of 6 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 04/05/2023 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview, record review, and review of the facility policy on Dialysis revealed the facility failed to ensure nursing staff completed pre and post dialysis assessments for residents receiving dialysis. This affected three residents (#19, #61, and #71) of three residents reviewed for dialysis. This had the potential to affect three residents (#19, #58 and #61) currently receiving dialysis. Residents Affected - Few Findings included: 1. Review of the closed medical record for Resident #71 revealed an admission date of 12/27/22 and discharge to the hospital on [DATE]. Diagnoses included nondisplaced fracture of the left ilium, end stage renal disease, dependence on renal dialysis, moderate protein-calorie malnutrition, congestive heart failure, and seizures. Review of the physician orders for December 2022 and January 2023 revealed Resident #71 had an order to receive dialysis from an outside center every Tuesday, Thursday, and Saturday. Review of the admission Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #71 had impaired cognition. He required extensive assistance of one person with locomotion on and off the unit. He received dialysis. Review of the care plan dated 01/10/23 revealed Resident #71 required hemodialysis due to renal failure. Interventions included check and change dressing at access site daily, document communication between dialysis center team and facility team, dialysis every Tuesday, Thursday, and Saturday, and monitor, document, and report any signs of infection to access site, changes in level of consciousness, changes in skin turgor, changes in heart and/or lung sounds. There was no intervention listed in the care plan to complete pre and post dialysis assessments with each dialysis scheduled day which included assessment of vital signs. Review of the Pre and Post Dialysis Status Sheets from 12/27/22 to 01/26/23 revealed Resident #71 had one pre and post dialysis assessment dated [DATE] and completed by Licensed Practical Nurse (LPN) #615. There were no other pre and post dialysis forms in Resident #71's medical record. Interview on 04/03/23 at 1:31 P.M. with Dialysis Center Registered Nurse (RN) #679 revealed Resident #71 had come to the dialysis center on 12/29/22, 12/31/22, 01/03/23, 01/05/23, 01/07/23, 01/10/23, 01/13/23, and 01/17/23 for dialysis. She revealed the dialysis center did not receive any pre- dialysis assessments and/or communication from the facility which she felt was a concern especially that Resident #71 had multiple medical co-morbidities as she felt he was medically unstable and displayed altered mental status symptoms at times requiring the center to send Resident #71 to the hospital during dialysis on a couple of occasions. Interview on 04/04/23 at 10:44 A.M. with the Director of Nursing verified pre and post dialysis assessments were to be completed before and after any resident received dialysis and that the pre dialysis assessment should be sent to dialysis as a form of communication with dialysis regarding the resident's status. She verified Resident #71 had only one pre and post dialysis assessment in his medical record on 01/17/23. She verified pre and post dialysis assessments were not completed on: 02/29/22, 12/31/22, 01/03/23, 01/05/23, 01/07/23, 01/10/23, and 01/13/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365555 If continuation sheet Page 4 of 6 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 04/05/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of the medical record for Resident #61 revealed an admission date of 07/15/21 and diagnoses including end stage renal disease, dependence on renal dialysis, chronic kidney disease with heart failure, and morbid obesity. Review of the care plan dated 08/05/22 revealed Resident #61 required hemodialysis due to renal failure. Interventions included check and change dressing at access site daily, dialysis three times a week, monitor vital signs and notify physician of abnormalities, monitor, document, and report any signs of infection to access site, changes in level of consciousness, changes in skin turgor, changes in heart and/or lung sounds. There was no intervention listed in the care plan to complete pre and post dialysis assessments with each dialysis scheduled day which included assessment of vital signs. Review of the February 2023 and March 2023 physician orders revealed Resident #61 received dialysis every Tuesday, Thursday, and Saturday from an outside center. Review of the quarterly MDS assessment dated [DATE] revealed Resident #61 had impaired cognition. She received dialysis. Review of the Pre and Post Dialysis Status Sheets from 02/01/22 to 04/03/23 revealed Resident #61 had pre and post dialysis forms completed on: 02/04/23, 02/15/23, 02/28/23, 03/04/23, 03/07/23, and 03/14/23. There were no other pre and post dialysis forms in Resident #61's medical record. Interview on 04/03/23 at 9:26 A.M. with Resident #61 revealed she had impaired cognition and could not remember if the facility nursing staff assessed her before and/or after dialysis. Interview on 04/03/23 at 1:31 P.M. with Dialysis Center RN #679 revealed Resident #61 had dialysis three times a week: Tuesday, Thursday, and Saturday. She revealed the dialysis center did not receive any pre dialysis assessments and/ or communication from the facility from any of the residents that received dialysis from the facility. Interview on 04/04/23 at 10:44 A.M. with the Director of Nursing verified pre and post dialysis assessments were to be completed before and after any resident received dialysis and that the pre dialysis assessment should be sent to dialysis as a form of communication with dialysis regarding the resident's status. She verified Resident #61 had dialysis every Tuesday, Thursday, and Saturday. She verified pre and post dialysis assessments were not completed on: 02/02/23, 02/07/23, 02/09/23, 02/11/23, 02/14/23, 02/18/23, 02/21/22, 02/23/23, 02/25/23, 03/02/23, 03/09/23, 03/11/23, 03/16/23, 03/18/23, 03/21/23, 03/23/23, 03/25/23, 03/28/23, 03/30/23, and 04/01/23. 3. Review of medical record for Resident #19 revealed an admission date of 03/24/23 with diagnoses including end stage renal disease, congestive heart failure, diabetes, and dependence on renal dialysis. Review of the physician orders for March 2023 revealed Resident #19 had an order to receive dialysis every Monday, Wednesday, and Friday. Review of the care plan dated 03/24/23 revealed Resident #19 had a person-centered plan of care. The care plan did not reveal anything regarding Resident #19 receiving dialysis three times a week and/or Resident #19 receiving pre and post dialysis assessments on dialysis days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365555 If continuation sheet Page 5 of 6 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 04/05/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Pre and Post Dialysis Status Sheets from 03/24/23 to 04/03/23 revealed Resident #19 had one Pre and Post dialysis assessment completed on 04/03/23. There were no other pre and post dialysis forms in Resident #19's medical record. Interview on 04/04/23 at 9:21 A.M. with Dialysis Center/ RN Manager #682 verified Resident #19 came to dialysis every Monday, Wednesday, and Friday. She revealed Resident #19 only comes with a bag and jacket with no binder in the bag that included a pre-dialysis assessment and/or communication form on her dialysis days. Interview on 04/04/23 at 10:44 A.M. with the Director of Nursing verified pre and post dialysis assessments were to be completed before and after any resident who received dialysis and that the pre dialysis assessment should be sent to dialysis as a form of communication with dialysis regarding the resident's status. She verified Resident #19 had only one pre and post dialysis assessment in her medical record which was dated 04/03/23. She verified pre and post dialysis assessments for Resident #19 were not completed on: 03/27/23, 03/29/23, and 03/31/23. Review of the facility policy labeled Dialysis Services, dated June 2022, revealed the facility clinical director would exchange important resident information with the dialysis center including change in condition and pertinent labs. The policy revealed the facility nursing staff would complete a pre and post dialysis assessment for residents that received dialysis with each dialysis schedule which included assessment of vital signs. The policy revealed upon return from dialysis an assessment was to be completed of the dialysis site to monitor for any complication including bleeding, signs and symptoms of infection, and for bruit (the presence of a bruit and a thrill means blood was moving through the Arteriovenous Fistula that was used for hemodialysis). This deficiency represents non-compliance investigated under Complaint Number OH00141197. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365555 If continuation sheet Page 6 of 6