Health inspection·February 12, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident #58's medical record revealed he was admitted to the facility on [DATE]. He was diagnosed with Covid-19 on 11/09/23. His census tab revealed he was moved from his previous room to a new room on 11/09/23 and had remained in that room since being moved. Record review for Resident #58 revealed a review of a brief interview for mental status (BIMS) assessment dated [DATE] revealed the resident was cognitively intact. His care plans did not note he was known to make any false accusations. On 02/06/24 at 9:21 A.M., an interview with Resident #58 revealed he did report a wallet and around $600.00 dollars missing in the recent past. He was not sure what all the facility did to look into it and had not been reimbursed for the wallet or for its contents. The wallet and money went missing around the time he had Covid-19 and had been moved to a different room. On 02/08/24 at 9:00 A.M., a follow up interview with Resident #58 revealed he did not feel the facility responded adequately to his concern about his missing wallet and money. He denied he was reimbursed for the amount it would have cost him to replace that wallet with a wallet of equal value or for the amount of money he had in the wallet. He was asked about the various reports of the actual amount of money that was also missing in addition to the wallet. He stated he had $200.00 dollars in his wallet, prior to his daughter bringing money to him on 11/08/23. He stated they (him and his daughter) had planned to go out and do some Christmas shopping the day he tested positive for Covid-19 and that was why he had a large amount on him. He did not go shopping, after he tested positive for Covid-19. On 02/08/24 at 9:12 A.M., an interview with the director of nursing (DON) revealed the facility had not replaced Resident #58's wallet or the money that was known to have been in his possession by what the daughter had said was brought into the facility and given to the resident on 11/08/23. She acknowledged, if nothing else, they should have replaced the wallet with one of equal value and at least given him the minimum amount of money that he was known to have based on what was discovered during their investigation. She reported they did not substantiate the allegation of misappropriation, due to there being conflicting reports on the amount of money he had in his wallet that went missing and what other items were in his wallet when it came up missing. A review of the facility's policy on Missing Items (reviewed 05/21/20) revealed it was the facility's policy to resolve missing item issues. It was at the discretion of the Administrator to replace missing items and at what value. Permission to replace an item that exceeded $100.00 needed the approval of the Administrator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365587 If continuation sheet Page 2 of 21 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 02/12/2024 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 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, and policy review, the facility failed to ensure a resident's medication was not misappropriated and was administered to the resident it was intended for. This affected one resident (#61) of two residents reviewed for misappropriation of property. Residents Affected - Few Findings include: On 02/08/24 at 9:25 A.M., an observation of the medication administration cart for the VA/ North hall revealed there was an Insulin Lispro (fast acting insulin given as an injection subcutaneously) Kwik Pen u-100 that was found in the top drawer of the medication administration cart. It had a pharmacy label wrapped around the Kwik Pen with a resident's name that had been marked out using a black Sharpie. The last name of the resident, whom the Kwik Pen was intended for, was still visible and identified the resident by name. There was also another resident's name (first name) that had been hand written on the side of the Kwik Pen using a black Sharpie. Findings were verified by Registered Nurse (RN) #103. The facility's Director of Nursing (DON) had walked out of her office and into the nurses' station at the time RN #103 was verifying the findings. The DON was asked to identify who the resident was that had their name marked off the label on the Insulin Lispro Kwik Pen and who the resident was that had a first name added on the side of that same Insulin Lispro Kwik Pen. On 02/08/24 at 9:31 A.M., an interview with the DON revealed she was able to determine that the Insulin Lispro Kwik Pen that had the name of the resident it was intended for (as specified on the pharmacy label) marked out using a Sharpie was that of Resident #61. She also identified the name of the resident whose first name had been hand written on the side of the Insulin Lispro Kwik Pen as being that of Resident #236. She verified Resident #61 had a current order to receive Insulin Lispro 3 units subcutaneously (SQ) three times a day before meals and he also had an order to give it before meals and at bedtime as per a sliding scale. She was asked if she would consider using one resident's medications for another resident it was not intended for to be misappropriation of that resident's property. She stated she would consider that misappropriation of resident property. The facility initiated a self-reporting incident (SRI) with tracker #249939 on 02/08/24. They concluded the investigation on 02/09/24 and unsubstantiated the allegation of misappropriation of property due to their investigation determining the nurse, who had pulled Resident #61's Insulin Lispro Kwik Pen from the refrigerator it was being stored in, did not intentionally or deliberately use Resident #61's Insulin Lispro Kwik Pen for Resident #236. They claimed the nurse pulled it out of the refrigerator to be used for the other resident when that resident's blood sugar was high, without noticing it was the property of Resident #61's. They further claimed the nurse that administered the insulin to Resident #236 did not notice her mistake until after the insulin had already been given. The SRI indicated the nurse involved received education and Resident #61 was reimbursed the amount for the Insulin Lispro at the facility's cost, after it had been brought to their attention. A review of the facility's policy on Abuse (dated 04/13/22) revealed the policy indicated the residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. The policy identified misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent, use of a resident's belongings or money without the resident's consent. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365587 If continuation sheet Page 3 of 21 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 02/12/2024 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a facility self-reporting incident (SRI) report for misappropriation of property, review of the facility's related investigation, record review, resident interview, staff interview, and policy review, the facility failed to ensure a resident's allegation of misappropriation was thoroughly investigated and included interviews with all relevant employees that may have had knowledge of the alleged misappropriation. This affected one resident (#58) of two residents that were reviewed for misappropriation of property. Residents Affected - Few Findings include: A review of a SRI report with tracking #241366 dated 11/20/23 revealed the facility self-reported an allegation of misappropriation identifying Resident #58 as the resident victim and another resident (Resident #47) as the alleged perpetrator. No witnesses were identified in the report. The date and time of the occurrence was on 11/20/23 at 3:00 P.M. and the alleged incident occurred in the resident's room. Resident #58 was indicated to have been able to provide meaningful information as part of the investigation. The summary of the incident revealed Resident #58 reported his wallet was missing with $600.00 dollars and a bank card inside. He had thought the wallet was in his old room before he had been moved when testing positive for Covid-19. His daughter had informed the facility she had brought $300.00 to $400.00 dollars into the facility for the resident, but had his bank card in her possession. Both rooms (Resident #58's old room and his new room) had been searched and a report was filed with the local Sheriff's Department. Resident #58 informed the Deputy Sheriff that he thought Resident #47 may have had it. Resident #47 was interviewed by the Deputy Sheriff and the facility staff during their investigation and he denied seeing the wallet. Staff and other residents were interviewed as part of the facility's investigation. The staff interviewed confirmed the resident had a wallet, but they had not seen the wallet for several days. A review of the facility's investigation that was completed in response to Resident #58's allegation of misappropriation revealed it was determined by talking with the resident's daughter that she had brought in between $300.00 to $400.00 dollars the day before he was moved to his new room. The daughter indicated she had the resident's bank card. The resident was indicated to have a resident funds account with the facility but preferred keeping his money in his room. The facility's investigation indicated they had provided education to the resident on keeping his money in his trust account and not in his room A review of the Sheriff's Department's report dated 11/20/23 (that was included as part of the facility's investigation) revealed Resident #58 reported he only had a prepaid card and not a bank card in his wallet. He did inform the Sheriff's Deputy that he had $300.00 to $400.00 dollars in cash in his wallet and the wallet and its contents went missing on 11/18/23, after he completed his 10 day quarantine period for Covid-19. The facility staff were indicated to have been the ones to move all his property when he changed rooms after contracting a Covid-19 infection. Resident #47 was identified as having been the resident who was moved into the old room that belonged to Resident #58 before he was moved. Resident #58 talked with Resident #47, as did the Sheriff's Deputy, and they looked in Resident #47's room but did not find it The facility's investigation included statements from staff that had been obtained. In all, 35 employees of various disciplines were interviewed. One of the 35 employees (SSD #150) provided a typed statement. The other 34 completed a questionnaire in person or over the phone that asked them a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365587 If continuation sheet Page 4 of 21 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 02/12/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few series of questions. They were asked if they had seen a wallet in Resident #58's room or in his possession. If so, when and where? They also asked if they were aware of any items purchased by the resident in the last few weeks. If so, when and what? The statements did not include the titles of the employees interviewed and one failed to include the name of the staff members that had been interviewed. Residents were asked if they felt safe in the facility and if they had ever had any items missing that were not found or replaced. The investigation did not identify the staff members who assisted with moving the resident's belongings when he was moved from his old room to his new room, after contracting Covid-19. A review of Resident #58's medical record revealed he was admitted to the facility on [DATE]. He was diagnosed with Covid-19 on 11/09/23. His census tab revealed he was moved from his previous room to a new room on 11/09/23 and had remained in that room since being moved. A review of a brief interview for mental status (BIMS) assessment dated [DATE] revealed the resident was cognitively intact. His care plans did not note he was known to make any false accusations. On 02/06/24 at 9:21 A.M., an interview with Resident #58 revealed he did report a missing wallet and around $600.00 dollars missing in the recent past. He was not sure what all the facility did to look into it and had not been reimbursed for the wallet or its contents. He indicated the wallet and its contents went missing around the time he had Covid-19 and had been moved to his new room. On 02/07/24 at 2:10 P.M., an interview with the facility's Director of Nursing (DON) confirmed she completed the facility's investigation into Resident #58's allegation of missing property on 11/20/23. She was asked who the employees were that moved Resident #58 from his old room to his new room when he contracted Covid-19 on 11/09/23. She identified that resident as being State Tested Nursing Assistant (STNA) #118. She claimed STNA #118 was the only employee that assisted Resident #58 with moving his belongings to his new room. She thought her investigation included an interview with him. Further review of the facility's investigation into Resident #58's allegation of misappropriation revealed there was no statement obtained from STNA #118, nor was he one of the 34 employees who had been asked if he had seen Resident #58 with a wallet in his room or in his possession. Findings were verified by the DON on 02/07/24 at 2:20 P.M. She reviewed the staff statements that had been provided as part of their investigation and confirmed there was not a statement from STNA #118. On 02/08/24 at 9:00 A.M., a follow up interview with Resident #58 revealed he did not feel the facility responded adequately to his concern about his missing wallet/ money. He denied he had been given a new wallet of equal value or was reimbursed for the amount a similar wallet would cost to replace the one that he had lost. He also denied he was given any money to replace what he was known to have prior to the facility staff assisting him with moving his belongings on 11/09/23. He was asked about the discrepancies in the amount of what he had reported was missing and what his daughter had told the facility that was brought into him. He indicated he already had $200.00 dollars in his wallet when his daughter brought him in money on 11/08/23. He stated they (him and his daughter) had planned to go out and do some Christmas shopping the day he tested positive for Covid-19. That was why he had a large amount on him. He did not end up going shopping, after he tested positive for Covid-19. He was further asked about the bank card and indicated it was a debit card that was in his wallet along with the cash. He indicated the bank card the facility said the daughter had was his new debit card that was given to him by the bank, after the first one went missing. He denied any transactions occurred on his original bank card, after it went missing, and had been canceled. He had since purchased a Velcro wallet but it was not as nice as the one he had. He confirmed the staff had provided education to him about not keeping money in his room but it was his choice and right to do so. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365587 If continuation sheet Page 5 of 21 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 02/12/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few denied they had ever offered him a locked box for the safe storage of his valuables until after his wallet and money went missing. On 02/08/24 at 9:12 A.M., an interview with the DON revealed the facility had not replaced Resident #58's wallet or the money that was known to have been in his possession from what they gathered from the resident's daughter. She acknowledged, if nothing else, they should have replaced the wallet with one of equal value and at least given him the minimum amount of money that was known to have been in his possession when the wallet went missing. She stated the facility did not substantiate the allegation of misappropriation because there was conflicting reports of the amount of money that had been missing and what the wallet's contents were in regards to a bank card. She stated that they could not determine if the wallet and money had been misappropriated or just misplaced. She further acknowledged, if the wallet and money had not turned up by now, it was likely to remain missing. On 02/09/24 at 9:35 A.M., an interview with STNA #118 revealed he was off with Covid-19 himself on 11/09/23, when Resident #58 was moved from his old room to the new room after he contracted Covid-19. When he returned to work, Resident #58 had already been placed in his new room. On 02/09/24 at 9:40 A.M., the DON was informed STNA #118 reported he was off work with Covid-19 when Resident #58 moved on 11/09/23, when he contracted Covid-19, therefore could not have been the one that moved the resident as she had previously indicated. She questioned if that was accurate and indicated that she believed STNA #118 was working on that date and was the one that moved the resident's belongings. She was asked to review the schedule and confirmed what staff worked on 11/09/23 that could have assisted Resident #58 with his room change. She acknowledged identifying and interviewing the employee that assisted in moving the resident's belongings should have been part of their investigation in determining what happened to his wallet and money. She followed up after reviewing the 11/09/23 schedule and determined one facility employee and two agency aides had worked that day. She did not provide any evidence those employees working were interviewed as part of her investigation. A review of the facility's policy on abuse (updated on 05/24/23) revealed the residents had the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. The key to investigating abuse allegations was in an environment that facilitated the reporting of such allegations. Once reported, the facility would conduct a timely, thorough, and objective investigation of any allegation of abuse. The investigation included identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations (such as other residents, family members, staff who worked closely with the alleged perpetrator and/ or alleged victim). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365587 If continuation sheet Page 6 of 21 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 02/12/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately complete a level one Pre-admission Screening/Resident Review (PASRR) and did not list post traumatic stress disorder (PTSD) on the serious mental illness section to be reviewed for a level two. This affected one resident (#82) of two residents reviewed for PASRRs. The facility census was 90. Findings include: Record review revealed Resident #82 was admitted to the facility on [DATE] with diagnoses including dementia with behaviors, cognitive communication deficit, dysphagia, PTSD, major depression, and anxiety disorder. Review of a PASRR completed on 01/15/24 by Admissions Director (AD) #143 revealed PTSD was not indicated under the level one review for serious mental illness. Interview on 02/07/24 at 4:53 P.M. with AD #143 confirmed PTSD was not included on the level one screen for the PASRR. Review of a policy titled Pre-admission Screening dated 05/13/20 revealed it is the responsibility of the center admissions personnel or designee to ensure the correct documents are in place according to the Ohio Revised Code. The Center Admissions personnel or designee must ensure the proper steps and documents are completed prior to admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365587 If continuation sheet Page 7 of 21 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 02/12/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, the facility failed to ensure residents had a comprehensive care plan in place to address Post Traumatic Stress Disorder (PTSD) and impaired vision. This affected two residents (#25 and #82) of 20 residents reviewed for care plans. Findings include: 1. A review of Resident #25's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included adult onset diabetes mellitus, hypertension, and history of a cerebral vascular accident (stroke). A review of Resident #25's admission nursing assessment dated [DATE] revealed the resident was known to have impaired vision. There was no mention of him having the use of any glasses to address his impaired vision. A review of Resident #25's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had adequate vision with the use of corrective lenses. He was not indicated to have any communication issues and was cognitively intact. A review of Resident #25's active care plans revealed he did not have any care plan in place to address impaired vision. There was no mention on any of his care plans about the use or the need for glasses. On 02/05/24 at 2:02 P.M., an interview with Resident #25 revealed he had impaired vision and was in need of glasses. He indicated he had checked onto getting glasses in the recent past, but he was told that it would cost him around 500.00 dollars to do so. At that time, he was not in the position to be able to do so. He would like to bee seen by an optometrist so he could see what other options were out there. On 02/07/24 at 4:28 P.M., an interview with Social Service Director (SSD) #150 revealed they have not had an ancillary service consent form signed by the resident yet. The resident and his daughter were back and forth on whether or not he was short term to home or if they were going to sign him up for hospice. She stated she had the form in her office to be signed if it was determined he wanted those services provided. She confirmed there had been some discussions in his last care conference about the daughter taking him somewhere local to have his eyes checked and see about getting him a pair of glasses. On 02/08/24 at 11:15 A.M., an interview with the Director of Nursing (DON) confirmed Resident #25 did not have a care plan in place to address his vision impairment or needs for an optometry appointment to get glasses. She acknowledged his admission nursing assessment identified him as having impaired vision without the use of glasses and his admission MDS assessment had him as having adequate vision with glasses. She further acknowledged the resident reported he did not have glasses, but was interested in getting some. 2. Record review revealed Resident #82 was admitted on [DATE] with diagnoses including dementia with other behaviors, cognitive communication deficit, dysphagia, post traumatic stress disorder (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365587 If continuation sheet Page 8 of 21 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 02/12/2024 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 0656 (PTSD), major depression, hypertension, and anxiety disorder. Level of Harm - Minimal harm or potential for actual harm Review of an admission minimum data set completed on 01/20/24 revealed Resident #82 had a diagnosis of PTSD, exhibited physical behaviors towards others four to six days a week, verbal behaviors towards others four to six days a week, wandered one to three days a week, and had other behaviors one to three days a week. Residents Affected - Few Review of Resident #82's comprehensive care plan revealed no care plan or interventions regarding PTSD. Observation on 02/05/24 at 5:55 P.M. revealed Resident #82 was sitting in the dining room and staff were attempting to help him get to a table for dinner when Resident #82 began screaming and threatening the staff. Interview on 02/07/24 at 3:53 P.M. with Social Worker (SW) #150 revealed Resident #82's admission assessments were completed with his representative due to Resident #82 being a poor historian. SW #150 revealed she did not ask Resident #82's representative about his history in the military. SW #150 stated she figured Resident #82 had PTSD since he is a veteran. SW #150 stated she was aware of Resident #82 exhibiting behaviors but she had not contacted his representative to discuss PTSD and triggers. SW #150 stated comprehensive care plans should be completed within five days of admission and confirmed Resident #82 did not have a care plan in place for PTSD. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365587 If continuation sheet Page 9 of 21 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 02/12/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure care plans were revised to reflect a resident's non-compliance with the use of hand splints to manage contractures and another resident's care plan was revised to reflect the use of a leg bag collection system with the use of his indwelling urinary catheter. This affected two residents (#72 and #73) of 20 residents reviewed for care plans. Findings include: 1. A review of Resident #72's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included hemiplegia and hemiparesis following a cerebral vascular accident (stroke) affecting the left non-dominant side, lack of physical exercise, contractures of the bilateral hips and the bilateral knees, muscle spasms, vascular dementia, and unspecified osteoarthritis. A review of Resident #72's physician's orders revealed the resident had the use of a palm guard to his left hand at all times to promote skin integrity. The order was in place between 05/24/23 and 02/06/24. His physician's orders included an updated order to encourage the use of a palm guard to his left hand at all times to promote skin integrity. The updated order was initiated on 02/06/24. A review of Resident #72's care plans revealed he had a care plan in place for an activities of daily living (ADL) self-care performance deficit care plan related to confusion, dementia, CVA, left hemiplegia, limited range of motion. contractures, pain, and muscle spasms. The interventions included the use of a palm guard to the left hand at all times to help maintain skin integrity. It did not indicate the resident was known to be non-compliant with it's use. On 02/06/24 at 8:53 A.M., 02/06/24 at 1:00 P.M., and 02/07/24 at 10:20 A.M., observations of Resident #72 noted him to be lying in bed without his palm guard in place to his left hand. On 02/07/24 at 10:30 A.M., an interview with State Tested Nursing Assistant (STNA) #174 revealed Resident #72 was noted to have a left hand contracture and pain related to his contractures. She reported the resident had the use of a brace on his left hand and was to wear that brace when tolerated. The majority of the time he did not want it on when offered because it hurt him to wear it. She had it on him yesterday but he only allowed it to be on for about a half hour before he became irritated and wanted it off. She offered to put it on him earlier that day around 9:45 A.M., but the resident declined. She stated he typically agreed to wear it once during the three days that she was there. On 02/07/24 at 10:55 A.M., an interview with Registered Nurse (RN) #103 confirmed Resident #72 had a contracture to his left hand. She indicated they tried to place hand rolls in his left hand or put his palm guard in place when the resident would allow. He was known to refuse the use of the palm guard at times as he could become combative with staff. On 02/07/24 at 11:20 A.M., an interview with Licensed Practical Nurse (LPN) #169 confirmed Resident #72's care plans had not been revised to reflect he was known to be non-compliant with the use of his palm guard at times. He acknowledged the resident's non-compliance with the use of the palm guard should have been reflected in his care plans, as was observed and being reported by the facility staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365587 If continuation sheet Page 10 of 21 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 02/12/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Record review of Resident #73 revealed an admission date of 12/28/23 with pertinent diagnoses of: acute and subacute infective endocarditis, cognitive communication deficit, bacteremia, obstructive reflux uropathy, dementia, hypothyroidism, hypertension, Review of Resident #73's 01/04/24 admission Minimum Data Set (MDS) assessment revealed the resident was severely cognitively impaired. The resident used a wheelchair to aid in mobility and required partial to moderate assist with toileting, and substantial to maximal assist with personal hygiene. The Resident has an indwelling urinary catheter and is frequently incontinent of bowel. Observation of Resident #73 on 02/07/24 at 10:25 A.M. revealed he was laying in bed with a urinary catheter bag attached to his leg. Interview with State Tested Nurse Aide (STNA) #115 on 02/07/24 at 10:30 A.M. verified Resident #73 had a urinary catheter bag on his leg and not the large collection bag that attaches to the bed. STNA #115 was unaware why the resident had a urinary leg catheter bag and stated he always wears a leg bag. STNA #115 stated the resident stays in bed majority of the day, but he does walk to the dining room. Interview with State Tested Nurse Aide (STNA) #188 on 02/07/24 at 10:31 A.M. revealed she was unaware why the Resident had a leg bag and stated she has never seen him with the regular large drainage bag. Review of the medical record on 02/07/24 at 10:40 A.M. revealed there was not a Physician Order for a urinary catheter leg bag to be worn at all times, and there was not a care plan addressing the leg catheter bag. Interview with the Director of Nursing (DON) on 02/12/24 at 9:55 A.M. verified the care plan did not address Resident #73 wearing the leg catheter collection bag at all times, and a care plan was developed on 02/07/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365587 If continuation sheet Page 11 of 21 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 02/12/2024 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 0699 Provide care or services that was trauma informed and/or culturally competent. 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, and interview, the facility failed to provide services to prevent Resident #82 from experiencing triggers related to post traumatic stress disorder (PTSD). This affected one resident (#82) of two residents reviewed for behaviors. The facility census was 90. Residents Affected - Few Finding included: Record review revealed Resident #82 was admitted on [DATE] with diagnoses including dementia with other behaviors, cognitive communication deficit, dysphagia, post traumatic stress disorder (PTSD), major depression, hypertension, and anxiety disorder. Review of an admission minimum data set completed on 01/20/24 revealed Resident #82 had a diagnosis of PTSD, exhibited physical behaviors towards others four to six days a week, verbal behaviors towards others four to six days a week, wandered one to three days a week, and had other behaviors one to three days a week. Review of orders revealed Resident #82 had orders in place for mirtazepine 15 milligrams (mg) at bedtime for depression, trileptal (an anticonvulsant) 300 mg twice a day for behavioral management, and vistaril 25 mg twice daily for anxiety. Review of Resident #82's comprehensive care plan revealed no care plan or interventions regarding PTSD. Observation on 02/05/24 at 5:55 P.M. revealed Resident #82 was sitting in the dining room and staff were attempting to help him get to a table for dinner when Resident #82 began screaming and threatening the staff. Interview on 02/07/24 at 3:53 P.M. with Social Worker (SW) #150 revealed Resident #82's admission assessments were completed with his representative due to Resident #82 being a poor historian. SW #150 revealed she did not ask Resident #82's representative about his history in the military. SW #150 stated she figured Resident #82 had PTSD since he is a veteran. SW #150 stated she was aware of Resident #82 exhibiting behaviors but she has not contacted his representative to discuss PTSD and triggers. SW #150 stated comprehensive care plans should be completed within five days of admission and confirmed Resident #82 did not have a care plan in place for PTSD. Interview on 02/07/24 at 4:46 P.M. with Licensed Practical Nurse (LPN) #131 revealed she was not aware Resident #82 had PTSD. LPN #131 stated when Resident #82 first arrived to the facility, he was very combative but she has learned how to approach him. LPN #131 stated when Resident #82 is agitated, she doesn't disagree with him, stays as calm as possible, and will back off if needed and reapproach at a later time. Interview on 02/08/24 at 9:36 A.M. with Activities Aides #107 revealed Resident #82 had an outburst the day prior to interview. Activities Aide #107 stated she was aware of Resident #82 having PTSD and she will just try to distract him with a new topic when he is upset. Activities Aide #107 stated she is not aware of what triggers Resident #82 and she had not received training on trauma informed care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365587 If continuation sheet Page 12 of 21 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 02/12/2024 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on record review, and staff interview the facility failed to ensure a resident had appropriate monitoring of the anticoagulant medication coumadin. This affected one resident (#8) of five residents reviewed for unnecessary medications. The facility census was 90. Residents Affected - Few Findings include: Record review of Resident #8 revealed an admission date of 08/28/23 with pertinent diagnoses of: atrial fibrillation, pressure induced deep tissue damage left heel, dysphagia, fracture of left patella, schizoaffective disorder, anxiety disorder, muscle weakness, anxiety disorder, cognitive communication deficit, repeated falls, chronic obstructive pulmonary disease, protein calorie malnutrition, obsessive compulsive disorder, hypertension, syncope and collapse, history of venous thrombosis and embolism. Review of Resident #8's 09/15/23 quarterly Minimum Data Set (MDS) revealed the resident was moderately cognitively impaired and required extensive assistance for transfer, bed mobility, dressing, toilet use and personal hygiene. The resident used a walker and wheelchair to aid in mobility and was frequently incontinent of bladder and always incontinent of bowel. The resident received seven days of anticoagulant medication during the seven day look back period. Review of a Physician Order dated 10/11/23 revealed to give Coumadin (warfarin) oral tablet two Milligram (mgs) give one tablet by mouth at bedtime for atrial fibrillation. The order was discontinued on 10/16/23. Review of a Physician Order dated 10/16/23 revealed to give Coumadin (warfarin) oral tablet two Milligrams (mgs) give one tablet by mouth at bedtime every Monday, Wednesday, Friday, Saturday, and Sunday for atrial fibrillation. Review of a Physician Order dated 10/16/23 revealed to give Coumadin (warfarin) oral tablet three Milligrams (mgs) give one tablet by mouth at bedtime every Tuesday, Thursday for anticoagulation/ atrial fibrillation. Review of a laboratory value dated 10/17/23 at 4:19 P.M. revealed INR (international normalized ratio) lab test used to check coagulation level of blood showed a lab value of 4.4 which was high. The normal range is 0.9-1.2, standard coagulation range 2.0-3.0, and aggressive anticoagulation range 2.5-3.5. There was no progress note about notifying the doctor of INR values. Review of a laboratory value dated 10/24/23 at 4:16 P.M. revealed a high INR value of 4.9. Review of a progress note dated 10/25/23 at 10:47 A.M. revealed the nurse notified Physician #200 of INR 4.9 from lab draw on 10/24/23 and new orders were received to hold coumadin and recheck in morning. All responsible parties aware. Review of a progress note dated 10/26/23 at 4:04 P.M. revealed contacted Physician #200 to notify him that INR redraw from today is still pending at this time. New orders received to hold coumadin again tonight. All responsible parties aware. Review of a laboratory value dated 10/26/23 at 6:19 P.M. revealed a real critical high INR value of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365587 If continuation sheet Page 13 of 21 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 02/12/2024 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 0757 6.0. Level of Harm - Minimal harm or potential for actual harm Review of a progress note dated 10/26/23 at 11:20 P.M. revealed received INR results and sent to Physician #200 via facility phone, no new orders received. Residents Affected - Few Review of the medication administration record from 10/27/23 to 11/01/23 revealed it was documented Resident #8 received coumadin as ordered every day. Review of a laboratory value dated 10/31/23 and 11/01/23 revealed there was not enough blood for INR labs to be completed so the company will redraw. Review of a laboratory value dated 11/02/23 at 6:40 P.M. revealed a real critical high INR value of 8.1. Review of a progress note dated 11/02/23 at 7:09 P.M. revealed Lab results sent to Physician #200. He stated to hold coumadin and recheck in morning. Review of the medical record medication administration record from 11/02/23 to 11/09/23 revealed the coumadin was held for elevated lab levels and due to starting paxlovid (a medication to treat Covid-19). A new anticoagulant (eliquis) was started on 12/05/23 due to fluctuating INR levels Review of a laboratory value dated 11/03/23 revealed a real critical high INR value of 8.6. Review of a laboratory value dated 11/06/23 revealed a high INR value of 4.1 Review of a laboratory value dated 11/07/23 revealed a high INR value of 3.3 Review of a laboratory value dated 11/09/23 revealed a high INR value of 2.1 Interview with Physician #200 on 02/07/24 at 11:34 A.M. revealed he wanted Resident #8 INR levels to be in the upper range of 2.5 to 3.5 due to multiple comorbidities including deep vein thrombosis, pulmonary embolism, smoking, atrial fibrillation, and being non mobile. Physician #200 revealed he was never notified of the 4.4 INR value on 10/17/23 or the 6.0 INR on 10/26/23. He stated he would have held the coumadin on 10/17/23 and 10/26/23 and would have drawn an INR the next day to check the levels. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365587 If continuation sheet Page 14 of 21 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 02/12/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, staff interview, and policy review, the facility failed to ensure medications were properly stored to include labeling that identified who the medication belonged to, date multi-use vials/ insulin pens were first accessed/ used, and medications did not exceed the expiration date on stock medication supplies. This affected one resident (#70) of two residents reviewed for medication administration and two residents (#12 and #236) with review of two of three medication administration carts. Findings include: 1. On 02/08/24 at 9:20 A.M., the medication administration cart for the short hall/ rehabilitation unit was checked for medication storage. There were multi-use vials of Lidocaine 5 milliliters and sterile water that was in the top drawer of the medication cart. The multi-use vials were loose inside the cart and not stored in a bag/ box with any labels that would identify who the medications were used for. The multi-use vials also did not include a date on either bottle that identified when they had first been accessed. Findings were verified by Registered Nurse (RN) #103. On 02/08/24 at 9:21 A.M., an interview with RN #103 revealed the multi-use vials of Lidocaine and sterile water were being used for Resident #12. She stated the resident was on an intravenous antibiotic, but they lost peripheral access. They were using the Lidocaine and sterile water to mix with the antibiotic so it could be given intramuscularly until the resident was able to have a PICC line (a peripherally inserted central catheter) inserted. The multi-use vials were not currently being used, but she acknowledged they were not labeled to show who they belonged to or when they had first been accessed. 2a.) On 02/08/24 at 9:25 A.M., an observation of the medication administration cart for the VA/ North hall revealed there was a stock bottle of Vitamin B-12 100 mcg in the top drawer of the medication cart that had an expiration date of October 2023. A Vitamin B-12 tablet had been noted to be pulled from that stock bottle during a medication administration observation for Resident #70 on 02/07/24 at 8:13 A.M. Findings were verified by RN #103. On 02/08/24 at 9:26 A.M., an interview with RN #103 revealed she acknowledged Resident #70 had a dose of Vitamin B-12 pulled from that stock bottle during a medication administration observation of her giving medications to Resident #70 the day before. She removed the stock bottle of Vitamin B-12 from the medication cart and disposed of it. 2b.) On 02/08/24 at 9:27 A.M., further observation of the medication administration cart for the VA/ North hall revealed there was a Lantus Flex-pen (a multi-use insulin administration pen that required the needle to be changed between uses) 100 units/ milliliters (ml) that was loose in the cart and was not stored in any type of packaging that included a label. There was no identification to identify what resident it was to be used for and did not have a date written on it to identify when it was first accessed/ used. Findings were verified by RN #103. 2c.) On 02/08/24 at 9:28 A.M., further review of the medication administration cart for the VA/ North hall revealed there was a Levemir flex-pen in the top drawer of the medication cart that was identified to be that of Resident #236. It was not dated to show when the flex-pen had first been used (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365587 If continuation sheet Page 15 of 21 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 02/12/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few so the staff knew what date it should be discarded. Findings were verified by RN #103. The Director of Nursing (DON) walked out of her office into the nurses' station and was informed of the concerns with the insulin flexpens being found in the medication cart that did not identify a name of a resident it was being used for or dates when first accessed. On 02/08/24 at 9:31 A.M., an interview with the DON revealed all items in the medication administration cart should have proper labeling to identify who they belonged to and multi-use vials/ flex-pens should be dated when first accessed. A review of the facility's policy on Medication- Insulin Administration dated 08/21/23 revealed insulin vials and pens should be disposed of after 28 days or according to manufacturer's recommendations after opening. A review of the facility's policy on Medication and Treatment Storage issued 08/07/23 revealed it was the policy of the facility to ensure accurate labeling and dating of medications and treatments for safe administration and safe and secure storage of all medications and treatments. Labeling of all medications and biologicals dispensed by the pharmacy would be consistent with applicable federal and state requirements and currently accepted pharmaceutical principles and practices including expiration dates and with appropriate accessory and precautionary instructions. Medications designed for multiple administrations, the label would identify the specific resident for whom it was prescribed. Multi-use vials would be dated when the vial was first accessed. If a multi-dose vial had been opened or accessed, the vial should be dated and discarded within 28 days unless the manufacturer specified a different date for that opened vial. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365587 If continuation sheet Page 16 of 21 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 02/12/2024 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Based on record review, and staff interview the facility failed to promptly notify the physician of a high and critical high INR (international normalized ratio) lab value for the anticoagulant medication coumadin. This affected one resident (#8) of five residents reviewed for unnecessary medications. The facility census was 90. Findings include: Record review of Resident #8 revealed an admission date of 08/28/23 with pertinent diagnoses of: atrial fibrillation, pressure induced deep tissue damage left heel, dysphagia, fracture of left patella, schizoaffective disorder, anxiety disorder, muscle weakness, anxiety disorder, cognitive communication deficit, repeated falls, chronic obstructive pulmonary disease, protein calorie malnutrition, obsessive compulsive disorder, hypertension, syncope and collapse, history of venous thrombosis and embolism. Review of Resident #8's 09/15/23 quarterly Minimum Data Set (MDS) revealed the resident was moderately cognitively impaired and required extensive assistance for transfer, bed mobility, dressing, toilet use and personal hygiene. The resident used a walker and wheelchair to aid in mobility and was frequently incontinent of bladder and always incontinent of bowel. The resident received seven days of anticoagulant medication during the seven day look back period. Review of a Physician Order dated 10/11/23 revealed to give Coumadin (warfarin) oral tablet two Milligram (mgs) give one tablet by mouth at bedtime for atrial fibrillation. The order was discontinued on 10/16/23. Review of a Physician Order dated 10/16/23 revealed to give Coumadin (warfarin) oral tablet two Milligrams (mgs) give one tablet by mouth at bedtime every Monday, Wednesday, Friday, Saturday, and Sunday for atrial fibrillation. Review of a Physician Order dated 10/16/23 revealed to give Coumadin (warfarin) oral tablet three Milligrams (mgs) give one tablet by mouth at bedtime every Tuesday, Thursday for anticoagulation/ atrial fibrillation. Review of a laboratory value dated 10/17/23 at 4:19 P.M. revealed INR (international normalized ratio) lab test used to check coagulation level of blood showed a lab value of 4.4 which was high. The normal range is 0.9-1.2, standard coagulation range 2.0-3.0, and aggressive anticoagulation range 2.5-3.5. There was no progress note about notifying the doctor of INR values. Review of a laboratory value dated 10/24/23 at 4:16 P.M. revealed a high INR value of 4.9. Review of a progress note dated 10/25/23 at 10:47 A.M. revealed the nurse notified Physician #200 of INR 4.9 from lab draw on 10/24/23 new orders received to hold coumadin and recheck in morning. All responsible parties aware. Review of a progress note dated 10/26/23 at 4:04 P.M. revealed contacted Physician #200 to notify him that INR redraw from today is still pending at this time. new orders received to hold coumadin again tonight. All responsible parties aware. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365587 If continuation sheet Page 17 of 21 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 02/12/2024 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 0773 Review of a laboratory value dated 10/26/23 at 6:19 P.M. revealed a real critical high INR value of 6.0. Level of Harm - Minimal harm or potential for actual harm Review of a progress note dated 10/26/23 11:20 P.M. revealed received INR results and sent to Physician #200 via facility phone, no new orders received. Residents Affected - Few Review of the medication administration record from 10/27/23 to 11/01/23 revealed it was documented Resident #8 received coumadin as ordered every day. Review of a laboratory value dated 10/31/23 and 11/01/23 revealed there was not enough blood for INR labs to be completed so the company will redraw. Review of a laboratory value dated 11/02/23 at 6:40 P.M. revealed a real critical high INR value of 8.1. Review of a progress note dated 11/02/23 at 7:09 P.M. revealed lab results sent to Physician #200. He stated to hold coumadin and recheck in morning. Review of the medical record medication administration record from 11/02/23 to 11/09/23 revealed the coumadin was held for elevated lab levels and due to starting paxlovid (a medication to treat Covid-19). A new anticoagulant (eliquis) was started on 12/05/23 due to fluctuating INR levels Review of a laboratory value dated 11/03/23 revealed a real critical high INR value of 8.6. Review of a laboratory value dated 11/06/23 revealed a high INR value of 4.1 Review of a laboratory value dated 11/07/23 revealed a high INR value of 3.3 Review of a laboratory value dated 11/09/23 revealed a high INR value of 2.1 Interview with Physician #200 on 02/07/24 at 11:34 A.M. revealed he wanted Resident #8's INR levels to be in the upper range of 2.5 to 3.5 due to multiple comorbidities including deep vein thrombosis, pulmonary embolism, smoking, atrial fibrillation, and being non mobile. Physician #200 revealed he was never notified of the 4.4 INR value on 10/17/23 or the 6.0 INR on 10/26/23. He stated he would have held the coumadin on 10/17/23 and 10/26/23 and would have drawn an INR the next day to check the levels. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365587 If continuation sheet Page 18 of 21 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 02/12/2024 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to follow a dietary order for a resident and did not ensure texture of pureed foods was without grainy texture. This affected one resident (#54) and had the potential to affect six residents receiving pureed diets. The facility census was 90. Findings include: 1. Record review revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including dementia with behaviors, dysphagia following unspecified cerebrovascular disease, and avoidance/restrictive food intake disorder. Review of a dietary order dated 01/25/24 revealed Resident #54 should receive a regular diet with mechanical soft texture with fortified foods and no bread. Observation on 02/07/24 at 11:24 A.M. revealed Dietary Manager (DM) #132 preparing Resident #54's tray for lunch. DM #132 was preparing a Philly cheese steak sandwich for Resident #54 and placed the meat, cheese and vegetables on bread. The plate was then placed on a tray and put in the meal cart for delivery. At 11:25 A.M. after two more trays were prepared and placed on the cart, the surveyor intervened and made staff aware Resident #54 had a dietary order for no bread. Interview on 02/07/24 at 2:26 P.M. with Speech Therapist (ST) #192 revealed Resident #54 could have items such as cake or biscuits, but was not able to comprehend what a sandwich was so when she sees one, she does not eat as much. Review of a policy titled Accuracy of Tray Line dated 03/01/11 revealed it is the center's policy to provide meals that are accurate, follow physician orders and patient/resident requests. It is the responsibility of the Dietary Manager to ensure each meal served is accurate. 2. Observation on 02/07/24 at 9:36 A.M. revealed DM #132 preparing meals for residents requiring a pureed diet. DM #132 reported there are five residents who receive a pureed texture diet. DM #132 began by combining 30 ounces of beef, 20 ounces of vegetables, 10 slices of cheese, three buns, and a large, unmeasured pour of au jus in the food processor. After pureeing for about fifteen seconds, DM #132 then added seven more buns to the mixture and continued pureeing the food. Once DM #132 stated she was finished with processing the pureed food, she poured the mixture into a pan. There were visible chunks of green peppers. DM #132 and surveyor tested the pureed food and DM #132 acknowledged it was grainy, then poured the pan of pureed Philly cheese steaks back in the food processor and added in an unmeasured pour of au jus. Once pureed, DM #132 and surveyor tested mixture and it was smooth. DM #132 then poured the food back into the pan she previously used to put the mixture in without cleaning it or ensuring there were no chunks left in the pan. DM #132 then used a clean food processor to puree the vegetables, using 10 four ounce scoops of mixed vegetables and five spoon fulls of thickener. Food was processed for approximately two minutes then tested. Skin from peas was still present in the mixture, and DM #132 pureed the mixture for an additional two minutes. Once completed, the pureed mixture was smooth. DM #132 confirmed findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365587 If continuation sheet Page 19 of 21 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 02/12/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to maintain proper hand hygiene during tray line. This had the potential to affect all 90 residents in the building. Residents Affected - Many Findings included: Observation of lunch tray line on 02/07/24 which began at 10:55 A.M. revealed the following: At 11:03 A.M., Dietary Aide (DA) #104 touched her face three times and did not wash her hands. DA #104 then began touching trays and drinks. At 11:15 A.M., DA #104 touched her ear, then placed her hands on her hips. DA #104 did not wash her hands prior to touching trays. At 11:23 A.M., DA #104 touched her upper lip and did not wash her hands prior to touching trays. At 11:27 A.M., DA #104 touched her face twice and did not wash her hands prior to touching trays. At 11:34 A.M., Dietician #128 coughed into her arm, did not wash her hands or change gloves, then continued to help serving lunch. Interview on 02/07/24 at 11:45 A.M. with DM #132 confirmed all findings. Review of a policy titled IC- Hand Hygiene/Hand Washing (dated 03/18/13) revealed it is the policy of the center to provide guidelines to staff for proper and appropriate hand washing and hygiene techniques that will aid in the prevention of the transmission of infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365587 If continuation sheet Page 20 of 21 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 02/12/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review the facility failed to maintain a clean, homelike environment related to walls in disrepair and a dirty bathroom. This affected five residents (#5, #11, #52, #57, and #72) who resided in rooms [ROOM NUMBER]. The facility census was 90. Findings include: 1. Record review of Resident #72 revealed an admission date of 04/12/23 with pertinent diagnoses of hemiplegia and hemiparesis, contracture right and left hip, protein calorie malnutrition, polyneuropathy, epilepsy, hypertension, depression, hyperlipidemia, gastrostomy status, cerebral infarction, pain, and vascular dementia, Record review of Resident #57 revealed an admission date of 06/27/23 with pertinent diagnoses of: obstructive and reflux uropathy, chronic kidney disease stage three, chronic pain syndrome, benign prostatic hyperplasia, atrial fibrillation, hypertension, and retention of urine. Observation of room [ROOM NUMBER] on 02/12/24 at 10:10 A.M. revealed there was multiple large deep scratches on the walls. Interview with Maintenance Manager (MM) #116 on 02/12/24 at 10:10 A.M. verified there was multiple large deep scratch marks on the wall of resident room [ROOM NUMBER]. 2. Record review of Resident #11 revealed an admission date of 11/16/21 with pertinent diagnoses of: degenerative disease of basal ganglia, Covid-19, cognitive communication deficit, chronic kidney disease stage three, neuromuscular dysfunction of the bladder, hypertension, mild intellectual disability, and peripheral vascular disease. Record review of Resident #5 revealed an admission date of 06/29/23 with pertinent diagnoses of: acute respiratory failure with hypoxia, anorexia, anxiety disorder, atherosclerosis of coronary artery bypass without angina pectoris, benign prostatic hyperplasia, chronic cholecystitis, chronic kidney disease, chronic obstructive pulmonary disease, and hypertension. Record review of Resident #52 revealed an admission date of 12/28/21 with pertinent diagnoses of: congestive heart failure, atrial fibrillation, Covid-19, anemia, mixed hyperlipidemia, anorexia, hypokalemia, generalized anxiety disorder, heart failure, congenital hiatus hernia, and hypothyroidism. Observation of the adjoining bathroom of room [ROOM NUMBER] and 323 on 02/12/24 at 10:06 A.M. revealed there was a black substance on the tiles around the toilet, and a brown substance on the bathroom call light and cord. Interview with Maintenance Manager (MM) #116 on 02/12/24 at 10:06 A.M. verified there was a black substance on the tiles around the toilet, and a brown substance on the bathroom call light and cord of resident rooms [ROOM NUMBERS]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365587 If continuation sheet Page 21 of 21