Health inspection·August 15, 2019

F 0602 Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record revealed Resident #52 had diagnoses that included chronic pain syndrome and spastic hemiplegia. Review of physician's orders for November 2018 revealed Resident #52 was ordered Oxycodone (narcotic pain medication) 15 mg every six hours. Residents Affected - Few Review of the self-reported incident dated 11/11/18 A.M. at 6:30 A.M. revealed Resident #52 stated she had not received her 6:00 A.M. pain medication. The physician was notified and gave an order for a one time dose of Oxycodone 15 mg to be administered at that time. Review of the controlled drug record form dated 11/07/18 through 11/11/18 revealed RN #600 signed out a Oxycodone for Resident #52 at 6:00 A.M. A written statement dated 11/11/18 at 1:07 P.M. by LPN #410 revealed RN #600 had not signed out any of the night shift narcotics until narcotic count was being completed at shift change. Interview on 08/13/19 at 2:58 P.M. with the Director of Nursing (DON) revealed she met RN #600 at the time clock when he returned for work the evening of 11/11/18. She informed RN #600 a drug test was required due to the allegations. RN #600 refused and became belligerent. DON explained it was the company policy that a drug test be performed or he would be terminated. RN #600 made threats towards the DON and left the facility. DON stated she felt due to RN #600's reaction, it was possible he had taken narcotics from the residents. The DON revealed RN #600's nursing license was currently suspended. Review of the undated storage of controlled medications policy and procedure revealed the narcotic record form must be signed when the medication was removed from the narcotic box. If a count discrepancy occurs in the change of shift verification, an investigation was made immediately to determine the cause. 3. Review of Resident #52's medical record revealed the resident had diagnoses including cerebral infarction, chronic obstructive pulmonary disease, post consussional syndrome, major depressive disorder, atherosclerotic heart disease, chronic pain syndrome, hypertension, neuromuscular dysfunction, psoriasis, transient cerebral ischemic attacks, osteoporosis, spastic hemiplegia affecting left non-dominant side, anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/10/19 revealed Resident #52 had intact cognition. Review of a facility Self Report Incident, dated 07/21/19 revealed during the meal service, Resident #52 told the dietary server, she had loaned $50.00 to another dietary employee, Dietary Aide #605, who had only repaid $25.00. Resident #52 expressed concern as she had not received the balance. As the investigation ensued, Dietary Aide #605 acknowledged she had borrowed the money, and stated a co-worker did the same. Resident #52 was interviewed twice and verified that she did give the money to Dietary aide #605 of her own volition and did not feel that she would have been subject to retaliation had she not done so. Resident #52 stated she was trying to be nice to Dietary Aide #605. Resident #52 also confirmed she loaned $40.00 to Dietary #603 who paid the money back right away. Dietary Aide #603 was interviewed by the Human Resource Director and Dietary Manager and affirmed the version of events. Resident #52 was alert and oriented with a Brief Interview for Mental Status score of 13 and diagnoses including cerebral infarction, atherosclerotic heart disease, and major depressive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365591 If continuation sheet Page 2 of 13 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 365591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Lawn Nursing Home 15028 Old Lincolnway East Dalton, OH 44618 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few disorder. The facility repaid the balance to Resident #52. Dietary Aide #605 repaid the facility the $25.00 on 07/24/19. As a result of the investigation, the facility Social Worker recommended to Resident #52, she not loan personal funds, which she stated that she understood. Review of a nurse's note, dated 7/22/2019 at 8:11 P.M. revealed the resident's sister was called to notify her that the resident had lent money to staff members. She was informed the outstanding balance was reimbursed to resident. Review of Disciplinary Action Form, dated 07/22/19 revealed Dietary Aide #603 was terminated for misappropriation of resident funds as the employee borrowed money for a resident. Review of Disciplinary Action Form, dated 07/22/19 revealed Dietary Aide #605 was terminated for misappropriation of resident funds as the employee borrowed money for a resident. An interview on 08/12/19 at 4:33 P.M. with Resident #52 revealed she had overheard Dietary Aide #603 talking to someone on the phone. She was telling the person she did not have any money to put gas in her car. She stated she offered her $20.00 and Dietary Aide #603 paid her back on pay day. Resident #52 indicated Dietary Aide #605 came down to her room and said she was in trouble and started to cry. Dietary Aide #605 stated she didn't have any money to buy food to feed her kids. Resident #52 stated it had really pulled at her heart strings so she gave Dietary Aide #605 $50.00 and she was supposed to pay her back on payday. When payday came she only gave her $25.00. Resident #52 indicated the facility paid her back the other $25.00 and both girls were fired. She stated she was close with both the girls. Review of the undated facility policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, revealed the facility would not tolerate Abuse, Neglect, Exploitation of its residents or the Misappropriation of Resident Property. Misappropriation of Resident Property was 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: 365591 If continuation sheet Page 3 of 13 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 365591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Lawn Nursing Home 15028 Old Lincolnway East Dalton, OH 44618 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 0606 Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Level of Harm - Minimal harm or potential for actual harm 2. Review of the the employee file for Registered Nurse (RN) #600 revealed a hire date of 09/10/18. Further review of the employee file revealed RN #600 had not been checked on the Nurse Aide Registry (NAR) or Bureau of Criminal Identification and Investigation (BCII), and had not had references checked prior to being hired. Residents Affected - Many Interview on 08/13/19 at 3:48 P.M. with Administrator #140 verified RN #600 was not checked against the NAR, did not have a BCII check completed and did not have reference checks completed at the time of hire. Based on review of personnel files, review of the facility new hire list, review of the facility abuse policy and staff interview the facility failed to ensure all potential new staff hires were checked against the Nurse Aide Registry (NAR) prior to employment to ensure the employee did not have a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property and failed to complete a background check and fingerprinting with the Bureau of Criminal Identification and Investigation for Registered Nurse (RN) #600. This affected one RN, five supervisor employees, 15 housekeeping staff, four laundry staff, 11 dietary staff, three maintenance staff and one administrative staff member and had the potential to affect all 81 residents residing in the facility. Findings include: 1. Review of the new hire list dated 06/28/19 to 08/13/19 and review of employee personnel files revealed the following employees had been hired within this time period: Laundry staff #801, #804, #805, #806, Housekeeping staff #807, #230, #808, #809, #200, #174, #100, #810, #811, #812, #813, #814, #815, #816 and #151, Dietary Staff #817, #818, #182, #176, #819, #360, #820, #605, #630, #821 and #190, Administrative staff #822, Housekeeping/Laundry Supervisor staff #823, #824, #825, #826 and #827, Maintenance staff #828, #829 and #830. Record review revealed no evidence any of these employees had been checked against the Nurse Aide Registry to ensure none of the employees had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property prior to or at the time of hire. An interview on 08/14/19 at 2:30 P.M. with Administration #140 revealed she did not have the Nurse Aide Registry Information on all new hires since the last survey but she did have the dates they were checked on a log she kept. However, the Administrator verified she did not have physical evidence including a Nurse Aide registry printout for the new hires at the time of their hire including for Laundry staff #801, #804, #805 and #806, Housekeeping staff #807, #230, #808, #809, #200, #174, #100, #810, #811, #812, #813, #814, #815, #816 and #151, Dietary Staff #817, #818, #182, #176, #819, #360, #820, #605, #630, #821 and #190, Administrative staff #822, Housekeeping/Laundry Supervisor staff #823, #824, #825, #826 and #827, Maintenance staff #828, #829 and #830. She stated she just printed the physical copy out today. Review of the undated facility policy, titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, revealed it was the facility policy to undertake background checks of all employees and to retain on file prior to hiring a new employee of the Ohio Nurse Assistant Registry and any other nurse assistant registries the facility had reason to believe contain information on an individual prior to using the individual as a nurse assistant. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365591 If continuation sheet Page 4 of 13 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 365591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Lawn Nursing Home 15028 Old Lincolnway East Dalton, OH 44618 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to effectively implement their abuse policy and procedure to ensure narcotic medications and funds were not misappropriated for Resident #50 and Resident #52 and to ensure all proper and required screening procedures were completed at the time of hire to ensure no employee had a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation or had a disqualifying offense based on a criminal background check. This affected one RN, five supervisor employees, 15 housekeeping staff, four laundry staff, 11 dietary staff, three maintenance staff and one administrative staff member. In addition, this affected two residents (#50 and #52) and had the potential to affect all 81 residents residing in the facility. Residents Affected - Many Findings include: 1. Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease and calculus of kidney with ureter. Review of physician's orders for November 2018 revealed Resident #50 was ordered Percocet (narcotic pain medication) 5/325 milligram (mg) every six hours. Review of a facility self-reported incident, dated 11/11/18 A.M. at 6:30 A.M. revealed Resident #50 stated he had not received his 6:00 A.M. pain medication. Review of the controlled drug record form dated 11/04/18 through 11/11/18, revealed Registered Nurse (RN) #600 signed out a Percocet for Resident #50 at 6:00 A.M. A written statement, dated 11/11/18 at 1:07 P.M. by Licensed Practical Nurse (LPN) #410 revealed RN #600 had not signed out any of the night shift narcotics until narcotic count was being completed at shift change. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/30/19 revealed the resident was cognitively intact and received opioid medication. Interview on 08/13/19 at 2:58 P.M. with the Director of Nursing (DON) revealed she met RN #600 at the time clock when he returned for work the evening of 11/11/18. She informed RN #600 a drug test was required due to the allegations. RN #600 refused and became belligerent. DON explained it was the company policy that a drug test be performed or he would be terminated. RN #600 made threats towards the DON and left the facility. DON stated she felt due to RN #600's reaction, it was possible he had taken narcotics from the residents. The DON revealed RN #600's nursing license was currently suspended. Review of the undated storage of controlled medications policy and procedure revealed the narcotic record form must be signed when the medication was removed from the narcotic box. If a count discrepancy occurs in the change of shift verification, an investigation was made immediately to determine the cause. 2. Review of the medical record revealed Resident #52 had diagnoses that included chronic pain syndrome and spastic hemiplegia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365591 If continuation sheet Page 5 of 13 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 365591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Lawn Nursing Home 15028 Old Lincolnway East Dalton, OH 44618 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of physician's orders for November 2018 revealed Resident #52 was ordered Oxycodone (narcotic pain medication) 15 mg every six hours. Review of the self-reported incident dated 11/11/18 A.M. at 6:30 A.M. revealed Resident #52 stated she had not received her 6:00 A.M. pain medication. The physician was notified and gave an order for a one time dose of Oxycodone 15 mg to be administered at that time. Review of the controlled drug record form dated 11/07/18 through 11/11/18 revealed RN #600 signed out a Oxycodone for Resident #52 at 6:00 A.M. A written statement dated 11/11/18 at 1:07 P.M. by LPN #410 revealed RN #600 had not signed out any of the night shift narcotics until narcotic count was being completed at shift change. Interview on 08/13/19 at 2:58 P.M. with the Director of Nursing (DON) revealed she met RN #600 at the time clock when he returned for work the evening of 11/11/18. She informed RN #600 a drug test was required due to the allegations. RN #600 refused and became belligerent. DON explained it was the company policy that a drug test be performed or he would be terminated. RN #600 made threats towards the DON and left the facility. DON stated she felt due to RN #600's reaction, it was possible he had taken narcotics from the residents. The DON revealed RN #600's nursing license was currently suspended. Review of the undated storage of controlled medications policy and procedure revealed the narcotic record form must be signed when the medication was removed from the narcotic box. If a count discrepancy occurs in the change of shift verification, an investigation was made immediately to determine the cause. 3. Review of Resident #52's medical record revealed the resident had diagnoses including cerebral infarction, chronic obstructive pulmonary disease, post consussional syndrome, major depressive disorder, atherosclerotic heart disease, chronic pain syndrome, hypertension, neuromuscular dysfunction, psoriasis, transient cerebral ischemic attacks, osteoporosis, spastic hemiplegia affecting left non-dominant side, anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/10/19 revealed Resident #52 had intact cognition. Review of a facility Self Report Incident, dated 07/21/19 revealed during the meal service, Resident #52 told the dietary server, she had loaned $50.00 to another dietary employee, Dietary Aide #605, who had only repaid $25.00. Resident #52 expressed concern as she had not received the balance. As the investigation ensued, Dietary Aide #605 acknowledged she had borrowed the money, and stated a co-worker did the same. Resident #52 was interviewed twice and verified that she did give the money to Dietary aide #605 of her own volition and did not feel that she would have been subject to retaliation had she not done so. Resident #52 stated she was trying to be nice to Dietary Aide #605. Resident #52 also confirmed she loaned $40.00 to Dietary #603 who paid the money back right away. Dietary Aide #603 was interviewed by the Human Resource Director and Dietary Manager and affirmed the version of events. Resident #52 was alert and oriented with a Brief Interview for Mental Status score of 13 and diagnoses including cerebral infarction, atherosclerotic heart disease, and major depressive disorder. The facility repaid the balance to Resident #52. Dietary Aide #605 repaid the facility the $25.00 on 07/24/19. As a result of the investigation, the facility Social Worker recommended to Resident #52, she not loan personal funds, which she stated that she understood. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365591 If continuation sheet Page 6 of 13 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 365591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Lawn Nursing Home 15028 Old Lincolnway East Dalton, OH 44618 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of a nurse's note, dated 7/22/2019 at 8:11 P.M. revealed the resident's sister was called to notify her that the resident had lent money to staff members. She was informed the outstanding balance was reimbursed to resident. Review of Disciplinary Action Form, dated 07/22/19 revealed Dietary Aide #603 was terminated for misappropriation of resident funds as the employee borrowed money for a resident. Review of Disciplinary Action Form, dated 07/22/19 revealed Dietary Aide #605 was terminated for misappropriation of resident funds as the employee borrowed money for a resident. An interview on 08/12/19 at 4:33 P.M. with Resident #52 revealed she had overheard Dietary Aide #603 talking to someone on the phone. She was telling the person she did not have any money to put gas in her car. She stated she offered her $20.00 and Dietary Aide #603 paid her back on pay day. Resident #52 indicated Dietary Aide #605 came down to her room and said she was in trouble and started to cry. Dietary Aide #605 stated she didn't have any money to buy food to feed her kids. Resident #52 stated it had really pulled at her heart strings so she gave Dietary Aide #605 $50.00 and she was supposed to pay her back on payday. When payday came she only gave her $25.00. Resident #52 indicated the facility paid her back the other $25.00 and both girls were fired. She stated she was close with both the girls. Review of the undated facility policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, revealed the facility would not tolerate Abuse, Neglect, Exploitation of its residents or the Misappropriation of Resident Property. Misappropriation of Resident Property was the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. 4. Review of the new hire list dated 06/28/19 to 08/13/19 and review of employee personnel files revealed the following employees had been hired within this time period: Laundry staff #801, #804, #805, #806, Housekeeping staff #807, #230, #808, #809, #200, #174, #100, #810, #811, #812, #813, #814, #815, #816 and #151, Dietary Staff #817, #818, #182, #176, #819, #360, #820, #605, #630, #821 and #190, Administrative staff #822, Housekeeping/Laundry Supervisor staff #823, #824, #825, #826 and #827, Maintenance staff #828, #829 and #830. Record review revealed no evidence any of these employees had been checked against the Nurse Aide Registry to ensure none of the employees had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property prior to or at the time of hire. An interview on 08/14/19 at 2:30 P.M. with Administration #140 revealed she did not have the Nurse Aide Registry Information on all new hires since the last survey but she did have the dates they were checked on a log she kept. However, the Administrator verified she did not have physical evidence including a Nurse Aide registry printout for the new hires at the time of their hire including for Laundry staff #801, #804, #805 and #806, Housekeeping staff #807, #230, #808, #809, #200, #174, #100, #810, #811, #812, #813, #814, #815, #816 and #151, Dietary Staff #817, #818, #182, #176, #819, #360, #820, #605, #630, #821 and #190, Administrative staff #822, Housekeeping/Laundry Supervisor staff #823, #824, #825, #826 and #827, Maintenance staff #828, #829 and #830. She stated she just printed the physical copy out today. Review of the undated facility policy, titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, revealed it was the facility policy to undertake background checks of all employees and to retain on file prior to hiring a new employee of the Ohio Nurse Assistant Registry and any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365591 If continuation sheet Page 7 of 13 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 365591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Lawn Nursing Home 15028 Old Lincolnway East Dalton, OH 44618 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many other nurse assistant registries the facility had reason to believe contain information on an individual prior to using the individual as a nurse assistant. 5. Review of the the employee file for Registered Nurse (RN) #600 revealed a hire date of 09/10/18. Further review of the employee file revealed RN #600 had not been checked on the Nurse Aide Registry (NAR) or Bureau of Criminal Identification and Investigation (BCII), and had not had references checked prior to being hired. Interview on 08/13/19 at 3:48 P.M. with Administrator #140 verified RN #600 was not checked against the NAR, did not have a BCII check completed and did not have reference checks completed at the time of hire. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365591 If continuation sheet Page 8 of 13 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 365591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Lawn Nursing Home 15028 Old Lincolnway East Dalton, OH 44618 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, Alzheimer's disease, syndrome of inappropriate secretions of antidiuretic hormone, hypertension, rheumatoid arthritis, macular degeneration, major depressive disorder, presence of intraocular lens, viteous degeneration, xerosis cutis, peripheral vascular disease, dementia, hallucination, and anxiety disorder. Residents Affected - Few Review of the Significant Change MDS 3.0 assessment, dated 07/22/19 revealed Resident #33 had severely impaired cognition and required extensive assistance with all activities of daily living. Observations on 08/12/19 at 10:43 A.M., 08/13/19 at 2:45 P.M., and 08/14/19 at 8:45 A.M. revealed Resident #33 had long, dirty fingernails. Review of shower sheets dated 07/22/19, 07/24/19, 07/29/19, 07/31/19, 08/05/19, 08/07/19, 08/12/19 revealed staff documented Resident #33 had her nails cleaned and trimmed. Review of shower sheets dated 07/15/19 and 07/17/19 revealed Resident #33 refused to have her nails trimmed. During an interview on 08/14/19 at 9:30 A.M. Licensed Practical Nurse #177 verified Resident #33 had long, dirty fingernails. Review of the facility policy titled Care of Fingernails and Toenails, dated 02/2018 revealed the purpose of the procedure was to clean the nail bed, to keep nails trimmed, and to prevent infections. Nail care included daily cleaning and regular trimming. Based on observation, record review and interview the facility failed to ensure Resident #9 and Resident #33, who required staff assistance for activities of daily living including personal hygiene and nail care received timely and adequate care. The affected two residents (#9 and #33) of three residents reviewed for activities of daily living (ADL) care. Findings include: 1. Review of the medical record for Resident #9 revealed the resident was admitted to the facility on [DATE] with a diagnosis including dementia. Review of the plan of care, dated 02/10/16 revealed the resident needed assistance for activities of daily living. Interventions included staff would assist as needed with daily hygiene. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/13/19 revealed the resident had impaired cognition. The resident required supervision of one staff for personal hygiene. Observation on 08/12/19 at 2:50 P.M., 08/13/19 at 8:54 A.M. and 2:49 P.M. and 08/14/19 at 8:08 A.M. of Resident #9 revealed the resident had long facial hair and had not been shaved. Interview on 08/14/19 at 8:08 A.M. with Resident #9 revealed she did not like that she had long facial hair and did not know what to do to get rid of it. Resident #9 stated she would like to have her facial hair removed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365591 If continuation sheet Page 9 of 13 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 365591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Lawn Nursing Home 15028 Old Lincolnway East Dalton, OH 44618 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 08/14/19 at 8:34 A.M. with Registered Nurse (RN) #152 revealed residents were to be shaved on shower days or when needed with morning care. RN #152 stated the nurse was to document refusals and the State tested nursing assistant staff should be documenting on shower sheets. Observation on 08/14/19 at 9:00 A.M. of Resident #9 with RN #152 verified Resident #9 needed to be shaved and had long chin hairs. Review of facility policy titled Resident Care, dated 06/2018 revealed staff would provide general care as necessary for each resident, which included personal hygiene and shaving. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365591 If continuation sheet Page 10 of 13 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 365591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Lawn Nursing Home 15028 Old Lincolnway East Dalton, OH 44618 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed ensure geriatric (geri) sleeves were provided as ordered for Resident #33 as ordered by the physician. This affected one resident (#33) of one reviewed for skin conditions. Residents Affected - Few Findings include: Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE] with the diagnoses of chronic obstructive pulmonary disease, Alzheimer's disease, syndrome of inappropriate secretions of antidiuretic hormone, hypertension, rheumatoid arthritis, macular degeneration, major depressive disorder, presence of intraocular lens, viteous degeneration, xerosis cutis, peripheral vascular disease, dementia, hallucination, and anxiety disorder. Review of nurse's notes, dated 06/26/19 at 2:24 P.M. revealed the resident had a skin tear to her left elbow area. The injury occurred while transferring from wheelchair to the bed. The measurements were 1.5 centimeters in diameter. The edges were not approximated. An order was obtained to cleanse the wound with normal saline, pat dry, apply triple antibiotic ointment and cover with a border gauze. The order was to change the dressing every third day and as needed until healed. An order was also received for geri-sleeves to be worn at all times except for hygiene. Review of the significant change Minimum Data Set (MDS) 3.0 assessment, dated 07/22/19 revealed Resident #33 had severely impaired cognition and required extensive assistance from staff with all activities of daily living. Review of the August 2019 physician's orders revealed Resident #33 had an order for geri-sleeves at all times except for hygiene. Observations on 08/13/19 at 2:45 P.M. and 5:17 P.M. and on 08/14/19 at 8:45 A.M. revealed Resident #33 only had the left geri-sleeve on. An interview on 08/14/19 at 9:30 A.M. with Licensed Practical Nurse #177 verified Resident #33 only had a geri-sleeve to her left arm and they were to be on both arms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365591 If continuation sheet Page 11 of 13 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 365591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Lawn Nursing Home 15028 Old Lincolnway East Dalton, OH 44618 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 and interview the facility failed to properly fill the humidifier bottle on the oxygen concentrator for Resident #33 with distilled water. This affected one resident (#33) of 19 residents who received oxygen therapy. Residents Affected - Few Findings include Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE] with the diagnoses of chronic obstructive pulmonary disease, Alzheimer's disease, syndrome of inappropriate secretions of antidiuretic hormone, hypertension, rheumatoid arthritis, macular degeneration, major depressive disorder, presence of intraocular lens, viteous degeneration, xerosis cutis, peripheral vascular disease, dementia, hallucination, and anxiety disorder. Review of the significant change Minimum Data Set (MDS) 3.0 assessment, dated 07/22/19 revealed Resident #33 had severely impaired cognition and required extensive assistance from staff with all activities of daily living. Review of the August 2019 physician's orders revealed Resident #33 had an order, dated 08/29/17 for her oxygen humidifier bottle to be changed weekly Observation on 08/13/19 at 8:56 A.M. and 2:45 P.M. and on 08/14/19 at 8:45 A.M. and 10:20 A.M. revealed Resident #33's humidifier bottle on her oxygen concentrator was empty. An interview on 08/14/19 at 10:20 A.M. with Licensed Practical Nurse #250 verified Resident #33's humidifier bottle should have been filled with distilled water. An interview on 08/14/19 at 11:23 A.M. with the Director of Nursing indicated the nurses were to fill the humidifier bottles when they were empty. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365591 If continuation sheet Page 12 of 13 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 365591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Lawn Nursing Home 15028 Old Lincolnway East Dalton, OH 44618 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to have a current physician's order before administering the antipsychotic medication, Haldol to Resident #65 and failed to ensure the resident had an appropriate diagnosis for the use of the antipsychotic medication Seroquel. This affected one resident (#65) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #65's medical record revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Parkinson's disease, dementia, major depressive disorder, psychosis, hallucinations, and anxiety. The quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/29/19 revealed Resident #65 had severe cognitive impairment. The MDS also revealed the resident had not exhibited any behaviors during the assessment period. Review of the physician's orders revealed an order, dated 07/24/19 for the antipsychotic medication, Haldol 2.5 milligram (mg) intramuscular injection (IM) as needed daily for 14 days. Review of the medication administration record (MAR) revealed Resident #65 was administered Haldol 2.5 mg IM on 08/09/19, two days after the ordered had ended. Interview on 08/15/19 at 11:50 A.M. Director of Nursing verified Resident #65 did not have an active order for Haldol when it was administered on 08/09/19. In addition, review of a physician's order dated 06/29/19 revealed Resident #65 was ordered the antipsychotic medication, Seroquel 25 mg daily for depression. Interview on 08/15/19 at 10:21 A.M. with the Director of Nursing revealed the Seroquel should have been ordered for psychosis with hallucinations instead of depression. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365591 If continuation sheet Page 13 of 13