Inspection·February 29, 2024

F 0600 Level of Harm - Immediate jeopardy to resident health or safety On 02/16/24, LPN #206 completed a body assessment on Resident #55. No signs of injuries were noted on Resident #55. • On 02/16/24, Director of Nursing (DON) notified Resident #55's guardian of the incident. Residents Affected - Few • On 02/16/24, Medical Director was notified of the incident and ordered Resident #84 be sent to the hospital. • On 02/16/24, Resident #84 was sent to the hospital for evaluation. • On 02/16/24, Resident #84 was transported from the hospital to another nursing facility and will not be returning to O'Brien Memorial Health Care Center. • On 02/16/24 at 10:15 A.M., LPN #206 performed skin checks on all residents residing on the dementia unit with no noted injuries. • On 02/16/24 at 12:39 P.M., Resident #55 was kept under direct supervision of staff at all times, until he was transferred to Generations Behavioral Health. • On 02/16/24 at 12:45 P.M., Regional Quality Assurance (QA) Nurse #205 interviewed all residents on the dementia unit concerning any inappropriate behavior or touching directed to them. No concerns were identified. • On 02/16/24 at 2:30 P.M., the Inter-Disciplinary Team (IDT) discussed all residents on the unit following a chart review. IDT noted no additional residents with sexualized behaviors. • On 02/26/24 at 2:40 P.M., Regional QA Nurse #205 educated DON and Registered Nurse (RN) #210. DON and RN #210 began educating all staff on abuse policies, including reporting of escalating resident behaviors (physical, verbal or sexual). Behaviors will be documented in point click care (PCC) progress notes by floor nurses. Behaviors will be communicated to oncoming shift by nurse-to-nurse report, then reviewed by IDT daily (Monday thru Friday) and implement interventions as necessary and update (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365555 If continuation sheet Page 2 of 7 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 02/29/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety the care plan accordingly. Interventions may include 15-minute checks, 1 on 1 supervision, and/or behavioral health hospitalization. Escalating behaviors that occur on the weekends will be reported to the DON and physician by the floor nurse and immediately addressed. In-service emphasized the facility abuse policies apply to all residents regardless of level of cognition. All staff will be in serviced by 02/27/2024 at 2:30 P.M. Those that are not in-serviced will not be permitted to work until in-servicing is completed. Residents Affected - Few • On 02/27/24, a Quality Assurance and Performance Improvement (QAPI) meeting was held with the Medical Director, Administrator, DON to discuss the review of the incident and the action plan. No additional measures were added. • Starting 02/27/24, the DON or designee will randomly interview three staff three times a week for four weeks to ensure staff understand the abuse policy and know signs and symptoms of escalating behaviors that may make residents at risk for abuse from other residents. The DON or designee will also randomly observe residents throughout the facility three times a week for four weeks for evidence of escalating behaviors and to determine if the behaviors are appropriately addressed. • As of 02/27/24 Resident #55 remains at Generations Behavioral Health Care with no current plans of being discharged . Although the Immediate Jeopardy was removed on 02/27/24 the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of the medical record for Resident #55 revealed an admission date of 10/31/23 with diagnoses including personal history of transient ischemic attack and cerebral infarction without residual deficits, aphasia following cerebral infarction, and dysphagia following cerebral infarction. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 02/06/24, revealed Resident #55 had severely impaired cognition, had no signs of psychosis or behaviors toward self or others in the previous seven days during the lookback period, and required supervision for wheelchair use. Review of the progress note dated 02/15/24 at 7:18 A.M. revealed Resident #55 was attempting to grab or touch staff members inappropriately and Resident #55 was observed touching himself inappropriately in the hallway, while attempting to grab at a staff member's genital area. Resident #55 was redirected to his room with good results. Review of the progress note dated 02/15/24 at 1:18 P.M. revealed Resident #55 had continuing sexual behaviors. Resident #55 saw staff enter the shower room, Resident #55 entered the shower room, pulled out his penis, and began touching himself. Staff redirected Resident #55 to a private area, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365555 If continuation sheet Page 3 of 7 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 02/29/2024 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 0600 returning to his room. Level of Harm - Immediate jeopardy to resident health or safety Review of the Psychiatric Nurse Practitioner note dated 02/15/24 revealed Resident #55 was assessed due to sexually inappropriate behaviors. Resident #55 began displaying sexually inappropriate behaviors on that day by exposing himself and grabbing at a nurse aide's vaginal area, which the note indicated was uncharacteristic for Resident #55. The note also indicated Resident #55 began to fondle himself while the Psychiatric Nurse Practitioner was evaluating him. There were no signs of mania, hypomania, psychosis, delusions, hallucinations, or paranoia. New diagnoses included cognitive decline likely vascular dementia and excess sexual drive. New orders were added for a urinalysis with culture and sensitivity to rule out a urinary tract infection as an organic cause of the behaviors, Exelon patch daily, Namenda daily, and continue to monitor and support with a follow-up scheduled for two to four weeks from the date of service. Residents Affected - Few Review of the behavior care plan, initiated on 02/15/24, revealed Resident #55 attempted to grab at staff members inappropriately. Interventions included administer medications as ordered and monitor/document for side effects and effectiveness, anticipate and meet the resident's needs, assist the resident to develop more appropriate methods of coping and interacting, encourage the resident to express feelings appropriately, caregivers to provide the opportunity for positive interaction and attention, stop and talk with resident as passing by, educate the resident on successful coping and interaction strategies, explain all procedures to the resident before starting and allow the resident time to adjust to changes, discuss the resident's behavior and explain why the behavior is inappropriate or unacceptable to the resident, intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, divert attention, remove from situation and take to alternate locations as needed, minimize potential for the resident's disruptive behaviors by offering tasks which divert attention, monitor behavior episodes and attempt to determine the underlying cause, consider the location/time of day/persons involved/situation and document the behavior with potential causes, praise any indication of the resident's progress or improvement in behavior, and provide a program of activities that is of interest and accommodates resident. There were no interventions identified to provide increased supervision for Resident #55 related to the change in behavior. Review of Resident #55's urinalysis results, dated 02/15/24, revealed there was no indication of a urinary tract infection. Review of the progress note dated 02/16/24 at 8:35 A.M. revealed Resident #55 had touched a female resident inappropriately. Resident #55 was assisted back to his room and placed on close observation. Both residents were examined, and no apparent injuries were noted. The physician was notified, and new orders were given for Paxil daily and a psychiatric consult. Review of the progress note dated 02/16/24 at 10:29 A.M. revealed the nurse was in another room administering medications when she heard a STNA saying stop, no! get away and the nurse stepped into the hallway. Upon entering Resident #84's room, the nurse observed Resident #84 standing against the wall between the beds with her pants and brief down around her knees. The STNA was moving Resident #55 away from Resident #84 and Resident #55 had his arms outstretched toward Resident #84's genital area. Resident #55 was immediately removed from Resident #84's room and Resident #84 was assessed for injury with no injuries identified. Review of the progress note dated 02/16/24 at 12:07 P.M. revealed the physician ordered for Resident #55 to be sent to a psychiatric hospital for evaluation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365555 If continuation sheet Page 4 of 7 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 02/29/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Review of the progress note dated 02/16/24 at 12:39 P.M. revealed Resident #55 was transferred to the psychiatric hospital at that time. 2. Review of the medical record for Resident #84 revealed an admission date of 12/19/23 with diagnoses including dementia, Alzheimer's disease with early onset, unspecified mental disorder, and major depressive disorder. Residents Affected - Few Review of the quarterly Minimum Data Set (MDS) Assessment, dated 02/02/24, revealed Resident #84 had severe cognitive impairment, had no signs of psychosis or behaviors toward self or others in the previous seven days during the lookback period, and required supervision for activities of daily living (ADLs). Review of the progress note dated 02/16/24 at 8:35 A.M. revealed a State Tested Nurse Aide (STNA) reported a male resident on the memory care unit was noted touching Resident #84 inappropriately and she yelled for him to stop. Facility staff separated the residents, performed skin checks, and obtained vital signs with no abnormal findings. Review of the progress note dated 02/16/24 at 9:57 A.M. revealed the nurse was in another room administering medications when she heard a STNA saying stop, no! get away and the nurse stepped into the hallway. Upon entering Resident #84's room, the nurse observed Resident #84 standing against the wall between the beds with her pants and brief down around her knees. The STNA was moving Resident #55 away from Resident #84 and Resident #55 had his arms outstretched toward Resident #84's genital area. Resident #55 was immediately removed from Resident #84's room and Resident #84 was assessed for injury with no injuries identified. Review of the progress note dated 02/16/24 at 11:18 A.M. revealed emergency services arrived to transport Resident #84 to the hospital for evaluation. Review of the progress note dated 02/16/24 at 5:40 P.M. revealed Resident #84's husband arrived to the facility to collect Resident #84's belongings and he indicated he was happy Resident #84 was being transferred to another facility. Review of the emergency department provider note, dated 02/16/24, revealed Resident #84 arrived to the emergency department on 02/16/24 at 10:24 A.M. for evaluation after a suspected sexual assault. Emergency Medical Services (EMS) staff reported to the hospital staff that Resident #84 was in her room when another resident with dementia had her pressed against the wall, Resident #84's pants were down, and she was screaming. EMS staff reported they administered Versed en route for agitation. The physical exam revealed a small, linear abrasion on the anterior wall of the vaginal canal and no other lesions, erythema, ecchymosis, or bleeding was noted. The emergency department physician reviewed and discussed the case, including pertinent history and exam findings, with the medical resident assigned to Resident #84 and agreed with a diagnosis of sexual assault of adult. Resident #84's hospital discharge plan was to discharge to a new nursing facility. Review of the facility's Self-Reported Incident (SRI) #244255 for sexual abuse, dated 02/16/24, indicated Resident #55 was observed in Resident #84's room with his hands in Resident #84's vaginal area while Resident #84 was telling him to stop. Facility staff observed Resident #84 against the wall in her room between two beds and with Resident #55 in his wheelchair in front of her. Resident #84's pants and brief were observed around her ankles and Resident #55 was observed with his hand on Resident #84's vaginal area. State Tested Nurse Aide (STNA) #207 responded to hearing Resident #84 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365555 If continuation sheet Page 5 of 7 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 02/29/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few saying no, stop and witnessed the incident. STNA #207 told Resident #55 to stop touching Resident #84, after which Resident #55 did stop momentarily and then resumed touching Resident #84's vaginal area. Resident #55 stopped and re-started twice while staff were in the process of separating the two residents. Local law enforcement was notified of the incident and a criminal investigation was underway. After investigating the incident, the facility concluded that abuse did not occur because both Residents #55 and #84 were cognitively impaired. The facility came to this conclusion despite the fact that Resident #55 was observed with his hand on Resident #84's vaginal area and that Resident #84 kept saying no, stop while Resident #55 was touching her vaginal area, indicating it was unwanted sexual contact. On 02/21/24 at 12:50 P.M., interview with Corporate Quality Assurance (QA) Nurse #205 stated the incident between Resident #55 and Resident #84 was reported to local law enforcement and the facility's investigation was still in progress. On 02/21/24 at 1:48 P.M., interview with Licensed Practical Nurse (LPN) #206 stated, in regard to the incident that occurred on 02/16/24, she was across the hall and heard STNA #207 say no, stop. LPN #206 said upon entering Resident #84's room, she observed Resident #84 to be against the wall with her pants around her knees and her arms crossed over her chest in a guarded position. LPN #206 said STNA #207 removed Resident #55 from Resident #84's room. LPN #206 stated Resident #84 was guarded, and it was difficult to assess her for injury following the incident. LPN #206 said both Resident #55 and Resident #84 were cognitively impaired and unable to state what happened. LPN #206 stated Resident #55 had newly evident sexually inappropriate behaviors toward himself and facility staff within a couple days prior to the incident with Resident #84, but that those behaviors were not directed toward other residents. On 02/21/24 at 1:56 P.M., interview with STNA #207 stated, in regard to the incident that occurred on 02/16/24, she was walking down the hall carrying a meal tray and pushing an empty wheelchair when she heard Resident #84 saying no, stop and saw Resident #55 in Resident #84's room. STNA #207 said she observed Resident #84 was against the wall between the two beds and Resident #55 was in his wheelchair in front of Resident #84. STNA #207 stated Resident #84's pants and brief were around her ankles and Resident #84 was saying no, no, stop while Resident #55 had his whole hand on her private area and was moving his fingers around. STNA #207 said she loudly told Resident #55 to stop, which he did momentarily and looked at STNA #207 before grabbing Resident #84's vaginal area and resuming moving his fingers around. STNA #207 said in the few seconds it took her to set the meal tray down and separate Resident #55 and Resident #84, she continued loudly telling Resident #55 to stop and he did stop momentarily twice before grabbing Resident #84's vaginal area again. STNA #207 said Resident #84 kept saying no, stop the entire time Resident #55 was touching her. STNA #207 said Resident #84 appeared terrified during the interaction. STNA #207 said Resident #55 had been displaying sexually inappropriate behaviors such as masturbating in the hallway and attempting to grab at staff, but she stated his behaviors were never directed toward another resident prior to this incident. On 02/21/24 at 2:03 P.M., interview with STNA #208 stated, in regard to the incident that occurred on 02/16/24, she was in the dining room on the memory care unit when she heard STNA #207 yelling in the hallway. STNA #208 said she arrived to Resident #84's room at the same time as LPN #206. Upon entering Resident #84's room, Resident #84 was against the wall between the beds trying to back away from Resident #55 and STNA #207 was removing Resident #55 from the room. STNA #208 stated Resident #84's pants and brief were around her ankles. STNA #208 stated she assisted Resident #84 to the bathroom. STNA #208 stated Resident #84 was very agitated and resistive to allow staff to assess her. She stated staff assessed Resident #84 the best that they could and there were no apparent injuries (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365555 If continuation sheet Page 6 of 7 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 02/29/2024 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 0600 noted. Level of Harm - Immediate jeopardy to resident health or safety On 02/21/24 at 3:49 P.M., interview with the Administrator and Corporate QA Nurse #205 stated the facility's investigation concluded no abuse had occurred because both residents were cognitively impaired. The Administrator stated Resident #84 had a history of being combative with staff and Resident #84 would have been fighting back if she wanted Resident #55 to stop what he was doing. Corporate QA Nurse #205 stated the fact that Resident #55 continued to touch Resident #84 after staff told him to stop was an indication of his impaired cognition because anyone who was caught doing something they knew was wrong would have stopped what they were doing and left the immediate area. Both the Administrator and Corporate QA Nurse #205 stated Resident #55's actions were not willful or deliberate because he did not have the cognition to recognize what he was doing was wrong, so they believed abuse did not occur. Residents Affected - Few On 02/27/24 at 4:04 P.M., interview with Corporate QA Nurse #205 verified that the emergency department provider note indicated Resident #84 had a small, linear abrasion on the anterior wall of the vaginal canal. In addition, Corporate QA Nurse #205 insisted there was nothing in the provider note that specifically indicated the injury occurred as a result of the incident between Resident #84 and Resident #55. Review of facility policy titled Resident Abuse Prevention Practices, dated 10/2022, revealed all residents would be protected from verbal, mental, emotional, or financial abuse by staff, families, residents, visitors or outside ancillary service employees or in any situation that would be harmful to the resident. The facility's policy defines sexual abuse as Non-consensual sexual contact of any type with a resident. Includes but is not limited to sexual harassment, sexual coercion, or physical sexual assault. Sexual contact is non-consensual if either the resident appears to want the contact to occur but lacks the cognitive ability to consent or does not want the contact to occur. This deficiency represents non-compliance investigated under Complaint Numbers OH00151199, OH00151206, and OH00151277. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365555 If continuation sheet Page 7 of 7