Health inspection·June 16, 2022

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 Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #46, who required staff assistance with personal hygiene received adequate and timely nail care to maintain proper grooming/hygiene. This affected one resident (#46) of four residents reviewed for activities of daily living. Residents Affected - Few Findings include: Review of the medical record for Resident #46 revealed an admission date of 12/10/20 with diagnoses including malignant neoplasm of colon, chronic kidney disease stage four, muscle weakness and osteoarthritis. Review of the plan of care, dated 03/14/22 revealed Resident #46 had an activities of daily living/self care performance deficit related to activity intolerance, poor motivation and fatigue. Interventions included check nail length and trim on bath day and as necessary. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/07/22 revealed Resident #46 had clear speech, was understood and understands and was cognitively intact with no behaviors. The assessment revealed Resident #46 required extensive assistance from two persons for bed mobility, dressing and personal hygiene. Resident #46 required extensive assistance of one person for bathing. Review of the bath/shower sheets for Resident #46 revealed the resident was scheduled to receive a shower/bath every Tuesday and Friday. Staff documented showers/baths were completed on 06/03/22, 06/07/22 and 06/10/22. On 06/12/22 at 12:23 P.M., 06/13/22 at 3:57 P.M. and 06/14/22 at 1:23 P.M. Resident #46 was observed to have long, jagged fingernails with a brown and black substance under the nails. On 06/13/22 at 3:57 P.M. interview with Resident #46 revealed she wanted her fingernails cleaned and trimmed. The resident denied staff provided nail care when she received showers/baths. On 06/14/22 at 11:12 A.M. interview with State Tested Nursing Assistant (STNA) #35 revealed nail care was to be completed with showers/baths and as needed and documented on the shower sheets. On 06/14/22 at 1:24 P.M. interview with the Assistant Director of Nursing (ADON) confirmed Resident #46 had long, jagged fingernails with black/brown substance under the nails. The ADON said he would have a State Tested Nursing Assistant provide nail care for the resident. Review of the facility policy titled Bathing-Showering, dated 12/2006 revealed no directions related to nail care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365587 If continuation sheet Page 2 of 8 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 365587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbyshire Place Health and Rehabilitation Center L 311 Buckridge Road Bidwell, OH 45614 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, facility policy and procedure review and interview the facility failed to timely identify and comprehensively monitor non-pressure related skin impairments for Resident #220. This affected one resident (#220) of one resident reviewed for non pressure skin alterations. Residents Affected - Few Findings include: Review of the medical record for Resident #220 revealed an admission date of 05/25/22 with diagnoses including Parkinson's disease, muscle weakness, atrial fibrillation, anxiety and mood disorder. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 06/01/22 revealed Resident #220 was cognitively impaired. The assessment revealed Resident #220 required assistance with activities of daily living, received an anticoagulant and had no skin abnormalities. Review of the physician's orders for 06/2022 revealed an order for Rivaroxaban (a blood thinner medication) 10 milligrams (mg) by mouth daily for deep vein thrombosis. The resident also had an order to monitor for side effects of the blood thinner including monitor for signs/symptoms of bleeding (dark tarry stools, nosebleeds, bleeding gums, hematemesis, pinpoint areas to skin) due to anticoagulant therapy every shift. Review of the Treatment Administration Record (TAR) from 06/01/22 to 06/15/22 revealed the nurse documented two times daily of monitoring for signs/symptoms of bleeding. On 06/13/22 at 8:04 A.M. and 06/15/22 at 2:55 P.M. Resident #220 was observed to have a small skin tear that was scabbed to the right hand and a bruise to left hand. On 06/14/22 at 11:12 A.M. interview with State Tested Nursing Assistant (STNA) #35 revealed any skin issue noted during a shower would be documented on the shower sheet and reviewed by the nurse. Review of the nursing progress notes, from 06/01/22 through 06/15/22 revealed no documentation related to any type of skin tear to the right hand and/or bruising to the left hand. Review of the weekly skin assessments, dated 06/08/22 and 06/15/22 revealed Resident #220 had bruises however, there was no documentation indicating the location of the bruises, size or color and there was no mention of the skin tear to right hand. Review of the shower sheets, dated 05/28/22, 06/01/22, 06/07/22 and 06/10/22 revealed no skin conditions were noted with the resident's shower or bath. Review of the plan of care dated 06/13/22 for potential/actual skin alteration due to fragile skin revealed interventions to keep fingernails short, and weekly skin alteration checks (document size and treatment) and report abnormalities , failure to heal and signs and symptoms of infection to the physician. On 06/15/22 at 3:10 P.M. interview with the Assistant Director of Nursing (ADON) revealed a bruise or skin tear would have a physician's order to be monitored until resolved, any treatment needed and the nurse would document in the progress notes or on the weekly skin assessment the details of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365587 If continuation sheet Page 3 of 8 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 365587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbyshire Place Health and Rehabilitation Center L 311 Buckridge Road Bidwell, OH 45614 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 0684 area. Level of Harm - Minimal harm or potential for actual harm On 06/16/22 at 9:15 A.M. interview with the ADON confirmed the lack of documentation regarding the skin tear to the right hand and bruise to the left had of Resident #220. Residents Affected - Few Review of the facility undated policy titled Skin Protocol revealed a skin assessment was completed by a licensed nurse on all new admissions and weekly, and the STNA checked the residents skin twice a week with shower days. The nurse would obtain orders from the physician as needed for interventions and all interventions would be placed on the Medication Administration Record (MAR) and or Treatment Administration Record (TAR). Therapy and dietary would be notified. A care plan implemented based on the assessment, and the staff would be educated on the interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365587 If continuation sheet Page 4 of 8 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 365587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbyshire Place Health and Rehabilitation Center L 311 Buckridge Road Bidwell, OH 45614 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. Based on observation, record review, facility policy and procedure review and interview the facility failed to timely identify and provide services to address limitations to range of motion and a hand contracture for Resident #41. This affected one resident (#41) of one resident reviewed for range of motion. Findings include: Review of the medical record for Resident #41 revealed an admission date of 11/05/21 with a readmission date of 04/21/22 with diagnoses including osteoarthritis, congestive heart failure, chronic kidney disease stage three and chronic obstructive pulmonary disorder. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 11/2021 revealed Resident #41 was cognitively intact and required extensive assistance from staff for activities of daily living. The assessment revealed the resident had no impaired range of motion to the bilateral upper or lower extremities and no therapy minutes recorded. Review of the plan of care, dated 11/19/21 revealed no care plan addressing any type of range of motion needs or contracture of the right hand. Review of a significant change MDS 3.0 assessment, dated 05/30/22 revealed Resident #41 was cognitively intact and required extensive assistance from staff for activities of daily living. The assessment revealed the resident had no impaired range of motion to the bilateral upper or lower extremities and no therapy minutes recorded. Review of the physician's orders for 06/2022 revealed no orders related to care or treatment of contracture(s) or decreased range of motion for Resident #41. Review of the nursing progress notes from 03/01/22 to 06/15/22 revealed no documentation related to any type of contracture or decreased range of motion. On 06/12/22 at 2:23 P.M. 06/13/22 at 4:18 P.M. and on 06/14/22 at 10:17 A.M. Resident #41's right hand was observed in a closed with a white tissue like cloth under his fingernails to prevent them from cutting into his hand. On 06/14/22 at 10:17 A.M. interview with Resident #41 revealed his right hand was closed when he came to the facility. The resident denied using any type of brace/device for his right hand and indicated no facility staff had done any type of stretches or had worked with it. On 06/14/22 at 10:31 A.M. interview with State Tested Nursing Assistant (STNA) #35 revealed the STNA was aware Resident #41's right hand did not open. STNA #35 said the resident did not have a hand roll or carrot to put in his right hand. The STNA said she assumed the nurses were aware of the resident's right hand being closed as they provided care and administered medications to the resident every day. On 06/14/22 at 11:18 A.M. interview with Occupational Therapist #70 revealed she was not aware the resident had a contracture or decreased range of motion of his right hand until this date. A second (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365587 If continuation sheet Page 5 of 8 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 365587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbyshire Place Health and Rehabilitation Center L 311 Buckridge Road Bidwell, OH 45614 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 FORM CMS-2567 (02/99) Previous Versions Obsolete interview on 06/15/22 at 10:37 A.M. with Occupational Therapist #70 revealed she assessed Resident #41's hand and the hand was rigid and would not open. The therapist said Resident #41 would not be able to use a splint or brace, however she ordered a hand roll/carrot to be in place daily. Review of the facility policy titled Contractures, prevention dated 12/2006 revealed each resident must be assessed for need of contracture prevention procedures on admission and as needed. Hand rolls should be in any hand that the resident cannot move. For a resident whose hand was already severely contracted, a few pieces of gauze, rolled up, may be all that would fit into the hand. Event ID: Facility ID: 365587 If continuation sheet Page 6 of 8 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 365587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbyshire Place Health and Rehabilitation Center L 311 Buckridge Road Bidwell, OH 45614 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure oxygen tubing was changed weekly and failed to ensure humidification was being administered appropriately for Resident #25. This affected one resident (#25) of the two residents reviewed for respiratory care. Residents Affected - Few Findings include: Record review revealed Resident #25 was admitted to the facility on [DATE] and had diagnoses including acute respiratory failure with hypoxia, muscle weakness, shortness or breath and chronic obstructive pulmonary disease. Review of the care plan, dated 04/27/22 revealed the resident received oxygen therapy. Interventions included to change the humidifier bottle and tubing every week and as needed per facility policy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/28/22 revealed this resident had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 03 out of 15. The resident was assessed to require extensive assistance from one staff member for bed mobility and limited assistance from one staff member for transfers and toileting. This resident was assessed to have received oxygen in the last 14 days while residing in the facility. On 06/12/22 at 11:30 A.M. observation of the oxygen tubing for Resident #25 revealed it was connected to the concentrator and was labeled with a date of 06/01/22. The water humidification bottle was sitting on the floor not connected to the concentrator or tubing and contained a date of 06/02/22. On 06/12/22 at 2:37 P.M. observation revealed the oxygen tubing for Resident #25 was connected to the concentrator and was labeled with a date of 06/01/22. The water humidification bottle was sitting on the floor not connected to the concentrator or tubing and contained a date of 06/02/22. On 06/13/22 at 9:35 A.M. observation revealed the oxygen tubing for Resident #25 was connected to the concentrator and was labeled with a date of 06/01/22. The water humidification bottle was sitting on the floor not connected to the concentrator or tubing and contained a date of 06/02/22. On 06/13/22 at 3:45 P.M. observation revealed the oxygen tubing for Resident #25 was connected to the concentrator and was labeled with a date of 06/01/22. The water humidification bottle was sitting on the floor not connected to the concentrator or tubing and contained a date of 06/02/22. On 06/14/22 at 11:30 A.M. observation revealed the oxygen tubing for Resident #25 was connected to the concentrator and was labeled with a date of 06/01/22. The water humidification bottle was sitting on the floor not connected to the concentrator or tubing and contained a date of 06/02/22. Interview with Licensed Practical Nurse (LPN) #90 at the time of the observation verified the date of 06/01/22 on the oxygen tubing and 06/02/22 on the humidification bottle. LPN #90 also verified the humidification bottle for the oxygen was lying on the floor and was not connected to the concentrator despite the oxygen concentrator being turned on. On 06/15/22 at 3:04 P.M. interview with LPN #80 revealed oxygen tubing and humidification bottles were to be changed out weekly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365587 If continuation sheet Page 7 of 8 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 365587 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Abbyshire Place Health and Rehabilitation Center L 311 Buckridge Road Bidwell, OH 45614 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 0695 Review of the facility policy titled Departmental (Respiratory Therapy) - Prevention of Infection, revised 11/2011 revealed to change oxygen cannula and tubing every seven days, or as needed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365587 If continuation sheet Page 8 of 8