Health inspection·January 9, 2024

F 0778 Level of Harm - Minimal harm or potential for actual harm #803 indicated Resident #14 was supposed to have a right kidney stent removed and the physician's office called the resident's cell phone instead of the facility. RN ADON #803 indicated the resident played the message for LPN #806 who then wrote it on an appointment paper and passed the information to the dayshift nurse (LPN #807). RN ADON #803 confirmed the form was not sent to the scheduler (Medical Records #801) and the resident subsequently missed the appointment. Residents Affected - Few Interview on 01/08/24 at 8:06 A.M. with Resident #14 revealed she was ready for her appointment on 12/22/23 and they came and told her that it was canceled. She stated she was not sure why it was canceled. Interview on 01/08/24 at 10:54 A.M. with the DON indicated Resident #14 was originally scheduled for surgery to implement a nephrostomy tube and possible removal/replacement of a kidney/ureter stent on 11/28/23 and they failed to provide orders for Benadryl and prednisone since the resident was allergic to iodine. She stated the radiology department returned the resident to the facility without completing the surgery and set up a new date of 12/22/23 for the nephrostomy tube placement and possible stent removal. The resident's right nephrostomy catheter was placed on 12/22/23 and the resident was scheduled for surgery on 12/26/23 to remove a right kidney stone and/or replace the kidney/ureter stent. The DON indicated the radiology office called the resident on her cell phone and left a message with the exact date/time of the surgery. The DON confirmed the resident had LPN #806 listen to the message and she wrote it on a note in the resident's chart and left the note on the computer for the dayshift nurse to put in the orders. The DON confirmed the note was accidentally placed in the resident's record and the appointment was not placed in the computer or provided to the scheduler. The DON confirmed transportation was not set up for the resident and the resident missed the appointment. The DON confirmed the new surgery was scheduled for 01/24/24 and the radiology office would call with an exact time prior to the procedure. Interview on 01/08/24 at 12:57 P.M. with Physician's Office #804 indicated the physician had to reschedule the resident's surgery dated 12/26/23 to remove a right kidney stone and possible replacement of a right kidney/ureter stent. 2. Review of Resident #24's medical record revealed the resident was readmitted on [DATE] with diagnoses including cataract extraction left eye, hemiplegia and diabetes. Review of Resident #24's MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #24's Appointment form dated 03/09/23 revealed the resident had an eye follow-up on 12/06/23 at 9:50 A.M. Interview on 01/08/24 at 7:08 A.M. with Resident #24 revealed his eye appointment was missed and it had to be rescheduled. Interview on 01/08/24 at 7:32 A.M. with Medical Records #801 indicated she missed Resident #24's eye appointment on 12/06/23 and failed to set up transportation for the appointment. The appointment was rescheduled for 01/10/24. Review of the Resident Outpatient Appointments policy revised 11/30/23 revealed the policy was to provide the resident with assistance to outpatient visits with facility arranged transportation or with family. To ensure appropriate documents go with the resident to appointments to ensure continued (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365634 If continuation sheet Page 2 of 3 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 365634 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE McCrea Manor Nsng and Rehab Ctr LLC 2040 McCrea Street Alliance, OH 44601 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 0778 quality of care. Level of Harm - Minimal harm or potential for actual harm This deficiency represents non-compliance investigated under Master Complaint Number OH00149796 and Complaint Numbers OH00149689, OH00149596. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365634 If continuation sheet Page 3 of 3