Health inspection·September 26, 2019

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to conduct quarterly Minimum Data Set (MDS) 3.0 assessments in a timely manner. This affected four residents (#9, #10, #13 and #15) of 14 residents whose medical records were reviewed for completion of assessments. Residents Affected - Some Findings include: On 09/24/19 beginning at 4:30 P.M., Minimum Data Set (MDS) 3.0 assessment completion and submission information was reviewed with Registered Nurse (RN) Minimum Data Set (MDS) Coordinator #350. The following findings were noted regarding quarterly MDS 3.0 assessments: 1. Review of Resident #9's Assessment Lookup Information revealed a quarterly MDS 3.0 assessment was scheduled with an Assessment Reference Date (ARD) of 07/23/19. The log indicated the MDS was not completed. MDS Coordinator #350 verified Resident #9 had a quarterly MDS assessment with an ARD of 07/23/19 which had not been completed. 2. Review of Resident #10's Assessment Lookup information revealed a quarterly MDS 3.0 assessment was scheduled with an ARD of 07/29/19. The log indicated data entry had not been completed. MDS Coordinator #350 verified Resident #10 had a MDS with a ARD of 07/29/19 which was not completed. 3. Review of Resident #13's Assessment Lookup Information revealed a quarterly MDS 3.0 assessment was scheduled with an ARD of 07/31/19. The log indicated data entry had not been completed. MDS Coordinator #350 verified Resident #13's quarterly MDS with an ARD of 07/31/19 had not been completed. 4. Review of Resident #15's Assessment Lookup Information revealed a quarterly MDS 3.0 assessment with an ARD of 08/18/19 had not been completed. MDS Coordinator #350 verified Resident #15's quarterly MDS with an ARD of 08/18/19 was not completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365574 If continuation sheet Page 2 of 5 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 365574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crandall Nursing Home 800 S 15th St Sebring, OH 44672 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure resident Minimum Data Set (MDS) 3.0 assessments were transmitted in the required time frames. This affected seven residents (#1, #2, #4, #5, #6, #7, and #8) of 14 residents reviewed for submission of assessments. Residents Affected - Some Findings include: On 09/24/19 beginning at 4:30 P.M., submission of Minimum Data Set (MDS) 3.0 assessments were reviewed with Registered Nurse (RN) Minimum Data Set (MDS) Coordinator #350 with the following concerns identified regarding submission of assessment data: 1. Review of Assessment Lookup logs for Resident #1 indicated there was a quarterly MDS 3.0 assessment dated [DATE]. The log indicated data entry was completed 07/26/19 but the assessment had not been submitted. MDS Coordinator #350 verified Resident #1 had a MDS with an ARD of 07/05/19 which was completed 07/26/19 but had not been submitted. 2. Review of Assessment Lookup logs for Resident #2 indicated there was an annual MDS 3.0 assessment with an ARD of 07/06/19. The log indicated data entry was completed 08/02/19. The assessment had not been submitted. MDS Coordinator #350 verified Resident #2 had a MDS with an ARD of 07/06/19 which was not completed until 08/02/19 and which had not been submitted yet. 3. Review of Assessment Lookup logs for Resident #4 indicated there was a significant change MDS 3.0 assessment with an ARD of 07/03/19. The log indicated a data entry complete date of 08/02/19. The assessment had not been submitted. MDS Coordinator #350 verified Resident #4 had a MDS with an ARD of 07/03/19 which was marked as complete 08/02/19 but not submitted yet. 4. Review of Assessment Lookup logs for Resident #5 revealed there was a quarterly MDS 3.0 assessment with an ARD of 07/04/19. The log indicated a data entry date of 09/15/19. The assessment was not submitted until 09/20/19. MDS Coordinator #350 verified Resident #5 had a MDS with an ARD of 07/04/19 which was completed late (09/15/19) and submitted late (09/20/19). 5. Review of Assessment Lookup Information for Resident #6 revealed there was a comprehensive annual MDS 3.0 assessment with an ARD of 08/10/19. Data entry was completed 09/23/19 but had not been submitted. MDS Coordinator #350 verified Resident #6 had a MDS with an ARD of 08/10/19 which was marked as completed 09/23/19 but which had not been submitted yet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365574 If continuation sheet Page 3 of 5 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 365574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crandall Nursing Home 800 S 15th St Sebring, OH 44672 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 0640 Level of Harm - Minimal harm or potential for actual harm 6. Review of Assessment Lookup information for Resident #7 revealed there was a quarterly MDS 3.0 assessment dated [DATE]. The assessment was not submitted until 09/20/19. MDS Coordinator #350 verified Resident #7 had a MDS with an Assessment Reference Date of 07/05/19. The MDS was not completed until 09/13/19 and was not submitted until 9/20/19. Residents Affected - Some 7. Review of Assessment Lookup information for Resident #8 revealed there was a quarterly MDS 3.0 assessment with an ARD of 07/10/19. The log indicated data entry was not completed until 09/22/19 and not been submitted. MDS Coordinator #350 verified Resident #8 had a MDS with a ARD of 07/10/19 which was not completed until 09/22/19 so it was done late and not yet submitted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365574 If continuation sheet Page 4 of 5 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 365574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crandall Nursing Home 800 S 15th St Sebring, OH 44672 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Potential for minimal harm Based on record review and interview the facility failed to ensure quarterly quality assurance (QA) meetings were attended by a physician and the administrator, owner or board member. This had the potential to affect all 165 residents residing in the facility. Residents Affected - Many Findings include: Review of quarterly sign in sheets for the QA meetings held in 10/11/18 and 01/10/19 revealed no evidence of physician attendance. The January 2019 sign in sheet did not contain the signature of the administrator, owner or board member. On 09/26/19 at 6:05 P.M., QA nurse #360 verified the Administrator was a member of the QA committee but did not attend the quarterly meeting on 01/10/19. There was no physician attendance during quarterly QA meetings held 10/11/18 and 01/10/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365574 If continuation sheet Page 5 of 5