Health inspection·July 22, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Resident #87's room had one large hole in the drywall with a corner bead showing on the right bottom side of the wall by the bathroom door, and multiple chipped areas with drywall showing on bottom portion of the wall with the window. • Residents Affected - Some Resident #289's room had 20 large gouges in the wall with drywall exposed behind the headboard of the bed. • Resident #290's room had five large gouges in the drywall between the bed and the chair. • Arbor Avenue common hallway had one large white patched strip from the ceiling to the handrail located on the left wall next to the double doors. • Buckeye Boulevard common hallway had a large square shaped area free of paint with drywall showing on the area to the right of the wall with the mounted hand sanitizer container near the hallway entrance. Interview at the time of the observation with Maintenance Director #207 verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365638 If continuation sheet Page 2 of 9 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 365638 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jefferson Healthcare Center 222 E Beech St Jefferson, OH 44047 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, facility policy review, and review of Self-Reported Incident (SRI) #223561, the facility failed to ensure Resident #43 was free from verbal abuse. This affected one Resident (#43) of one resident reviewed for abuse. The facility census was 87. Findings include: Record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including panic disorder, schizophrenia, major depressive disorder, and generalized anxiety. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/04/22, revealed Resident #43 had mild cognitive impairment and required extensive assist of one staff for bed mobility, locomotion off unit, dressing, and toilet use. For transfers, Resident #43 required extensive assist of two staff. Review of the care plan, initiated on 08/06/18, revealed Resident #43 had alteration in mood or behavior by feeling bad or upset with self because of medical issues. Review of the nursing progress note dated 07/02/22 at 6:45 P.M. revealed Resident #43 yelled and used profanity toward State Tested Nursing Assistant (STNA) #294 during smoke break. Review of SRI #223561 dated 07/02/22 revealed an allegation of emotional/verbal abuse with Alleged Perpetrator (STNA #294) and victim (Resident #43) which occurred on 07/02/22. The summary indicated on 07/02/22 staff witnessed Resident #43 and STNA #294 speaking to each other with raised tone of voice during smoke pass. Staff separated STNA #43 and Resident #43. STNA #294 reported during smoke pass Resident #43 used profane language towards her and attempted to run into her with his wheelchair. The facility unsubstantiated the allegation due to lack of evidence and STNA #294 was provided with education on resident rights and customer service. STNA #294 left facility, and Resident #43 did not request police involvement. Review of SRI #223561 witness statement for Resident #43 dated 07/02/22 revealed Resident #43 and STNA #294 were discussing their personal relationship and STNA #294 stated she left him because he preferred dirty girls. Resident #43 responded stating STNA #294 was a cheater and STNA #294's family were cheaters. STNA #294 yelled out I have been waiting to get this off my chest for 12 years. Resident #43 admitted to using profanity but stated it was mutual. STNA #294 told Resident #43 to put out his cigarette, he was done with his smoke break, and would not be smoking at the next smoke break. Resident #43 refused to leave, continued to smoke, and Resident #43 and STNA #294 continued to swear at each other until Resident #43 returned into the facility and went back to his room. Review of SRI #223561 witness statement for STNA #294 dated 07/02/22 revealed STNA #294 assisted residents out for smoke break at 6:30 P.M. STNA #294 stated Resident #43 was in a foul mood and tried to hurt her feelings by calling her and her sister names. STNA # 294 stated she had many domestic disputes with Resident #43 and had told all the nurses on night shift. STNA #294 stated she still took Resident #43 on smoke breaks but was just waiting because Resident #43 was going to do this. Review of SRI #223561 witness statement for Resident #12 dated 07/02/22 revealed STNA #294 started insulting Resident #43 and he responded by swearing and calling STNA #294 names. Resident #12 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365638 If continuation sheet Page 3 of 9 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 365638 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jefferson Healthcare Center 222 E Beech St Jefferson, OH 44047 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few unable to recall the exact phrases used but indicated STNA #294 made references to Resident #43's condition by saying Well look where you are now. Resident #12 also reported STNA #294 told Resident #43 that she had been holding this in for 12 years and now was going to get it off her chest. Resident #12 stated in her own opinion, STNA #294 could have ended the discussion but kept it going. Review of SRI #223561 witness statement for STNA #258 dated 07/02/22 revealed STNA #258 was in the pantry during the time of the incident and heard the arguing outside but could not make out the words. Upon going to check it out, Resident #43 and STNA #294 had separated. Review of SRI #223561 witness statement for Licensed Practical Nurse (LPN) #234 dated 07/02/22 revealed STNA #294 came to her and indicated Resident #43 and her had argued. STNA #294 stated Resident #43 was not a person, he is a monster. STNA #294 then continued to state Resident #43 should not receive a 9:00 P.M. smoke break. LPN #234 explained to STNA #294 that staff members should treat all residents the same and cannot punish or yell at residents. Interview on 07/19/22 at 11:40 A.M. with Resident #43 verified an incident occurred with STNA #294 on 07/02/22, who was once a girlfriend several years ago. Resident #43 stated STNA #294 stated he was a loser, talked in a loud voice first, and then started to yell. Resident #43 confirmed several residents who were smoking in the area witnessed the incident. STNA #294 reported the incident and then staff came and talked with him. Resident #43 indicated not wanting to contact police since STNA #294 left and went home. Resident #43 stated STNA #294 argued with him in the past when they dated. Further interview on 07/22/22 at 10:37 A.M. with Resident #43 revealed the incident which occurred on 07/02/22 embarrassed him and made him feel bad. Resident #43 stated STNA #294 had insulted and yelled at him in front of four to five residents who were smoking at that time. Resident #43 indicated being glad STNA #294 was no longer working at the facility and stated if she was it would happen again. Review of Alleged Perpetrator (STNA #294) personnel file revealed a hire date of 03/31/22. STNA #294 was educated on abuse, neglect, exploitation and misappropriation, customer service and professionalism upon hire. A criminal background check was completed on 03/21/22, and a review of the nurse aide registry was completed on 03/22/22. Review of disciplinary action form for Alleged Perpetrator (STNA #294) dated 07/08/22 revealed a violation of resident rights which resulted in suspension from 07/02/22 through 07/08/22, a written warning, and education on customer service and resident rights with employee signing the document on 07/08/22. Interview on 07/20/22 at 12:56 P.M. with Director of Nursing (DON) and Administrator stated STNA #294 had an emotional response from the previous relationship and therefore was in violation by not listening, discussing personal issues, not using an indoor voice, and that she chose to not reveal the past relationship to the facility. They confirmed STNA #294 did not reveal the past relationship with Resident #43 and was unprofessional. They also verified STNA #294 acknowledged what she did was wrong. Interview with Administrator on 07/19/22 at 2:34 P.M. verified STNA #294 was suspended 7/02/22 through 07/08/22 pending investigation, and it was decided for STNA #294 to return with the plan for STNA #294 not to work on the hallway where Resident #43 resided. STNA #294 asked for a transfer to a sister facility but did not return and did not go to a sister facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365638 If continuation sheet Page 4 of 9 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 365638 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jefferson Healthcare Center 222 E Beech St Jefferson, OH 44047 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 0600 Level of Harm - Minimal harm or potential for actual harm Review of facility policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/21/16, revealed all alleged violations involving abuse, neglect, exploitation, and mistreatment of a resident would be thoroughly investigated; the facility would prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in process; and if an alleged violation was verified appropriate corrective action would be taken. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365638 If continuation sheet Page 5 of 9 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 365638 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jefferson Healthcare Center 222 E Beech St Jefferson, OH 44047 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide sufficient staff to meet the needs the residents. This affected Resident's #43, #69 and #78 and had the potential to affect all 87 residents residing in the facility. Findings include: Interview on 07/18/22 at 1:50 P.M. with Resident #78 stated there was not enough staff because there was only one State Tested Nursing Assistant (STNA) for every resident on the hallway and could take up to 30 minutes for staff to respond to the call light. Interview on 07/18/22 at 2:44 P.M. with Resident #43 revealed there was not enough staff since there was only one STNA all the time available on the hallway. Interview on 07/20/22 at 12:26 P.M. with family of Resident #69 revealed it was necessary to visit daily before lunch until after dinner to assist Resident #69 with meals because there was not sufficient staff, especially on the weekends, to ensure Resident #69 received adequate meal intake. Resident #69's family stated it took longer for staff to answer call lights on the weekends, staff were more hurried, and Resident #69 was pressured to finish meals quicker. Interview on 07/21/22 at 4:30 A.M. with STNA #262 verified there was one STNA to each hallway but there was occasionally a float. STNA #262 stated it was more difficult without a float because the nurse had to be relied upon for the residents who required two staff assistance, so it took longer to complete work. STNA #262 verified without a float STNA residents did not receive showers but a bed bath instead. Interview on 07/21/22 at 4:54 A.M. with Licensed Practical Nurse (LPN) #230 confirmed there was only one STNA on each hallway but usually there was a float. LPN #230 stated when there was not a float, it was harder to get residents up in the morning or lay them down for bed, and showers were completed when there was a float but if there was not, the showers were delayed or rescheduled for the next shift. Observation on 07/21/22 at 6:00 A.M. with STNA #253 of the memory care secured unit, of which resided 22 residents, revealed the STNA was alone on the unit an alarm sounded for Resident #45 who attempted to self-transfer to bed. STNA #253 entered Resident #45's room, closed the door, provided personal care, and assisted Resident #45 to bed. Interview at the time of the observation with STNA #253 verified there was no other staff on the unit to monitor the other residents while she was providing personal care to Resident #45 behind the closed door because the nurse had floated to another hallway to pass medications, and there was not a float aide. STNA #253 indicated although tasks were completed with only one aide, it took longer and would stay if necessary to get things done. Review of Facility assessment dated [DATE] through 07/28/22 revealed there was no information on the number of staff needed to meet the needs for each resident. Review of Resident Council minutes from 01/31/22 through 06/30/22 revealed on 01/31/22 snacks were not always passed; on 02/25/22 a complaint of more staff was needed on 300 hallway; on 05/31/22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365638 If continuation sheet Page 6 of 9 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 365638 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jefferson Healthcare Center 222 E Beech St Jefferson, OH 44047 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many there was a staff delay returning a resident from dialysis; and on 06/30/22 a resident complained of a bed not being made. Review of staffing tool from 06/24/22 through 06/26/22, 07/03/22 through 07/09/22, and 07/15/22 through 07/17/22 revealed the facility was below the daily direct care requirement of 2.50 hours per resident on 06/25/22, 06/26/22, 07/03/22, 07/09/22, 07/15/22, 07/16/22, and on 07/17/22. Interview at the completion of the staffing tool on 07/20/22 at 10:27 A.M. with Human Resources #215 verified the staffing tool was accurate and the facility was under the staff requirements due to call offs, which the facility was unable to cover. Human Resources #215 stated the facility had a contract with an agency for temporary staff but did not used them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365638 If continuation sheet Page 7 of 9 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 365638 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jefferson Healthcare Center 222 E Beech St Jefferson, OH 44047 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on record review and interview, the facility failed to ensure staff needs were identified on the facility assessment as required. This had the potential to affect all 87 residents. Findings include: Review of the facility assessment, dated 07/07/22 to 07/28/22, revealed it did not contain an evaluation of the overall number of facility staff needed to ensure a sufficient number of qualified staff were available to meet the needs of each resident. Interview on 07/22/22 at 9:39 A.M. with Director of Nursing, Administrator, and Corporate Nurse #296 verified the facility assessment did not contain facility staffing needs as required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365638 If continuation sheet Page 8 of 9 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 365638 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jefferson Healthcare Center 222 E Beech St Jefferson, OH 44047 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 3. Observation on 07/21/22 at 4:30 A.M. of STNA #262 on B wing hallway was not wearing a facemask or eyewear. Interview at the time of the observation with STNA #262 verified a facemask or eyewear was not donned while in a resident care area. STNA #262 walked to the nurse's station where a facemask and goggles were setting on the countertop and donned the items. STNA #262 stated the facemask was removed because it was easier to breathe. Residents Affected - Some Review of Personal Protective Equipment (PPE), reviewed 10/21/21, from the Centers for Disease Control and Prevention Healthcare-Associated Infections (HAIs), located at https://www.cdc.gov/hai/prevent/ppe.html, revealed to put on a mask or respirator, secure ties or elastic bands at the middle of the head and neck; fit the flexible band to the nose bridge; fit it snug to the face and below the chin; and place goggles or a face shield over the face and eyes and adjust to fit. Based on observation, interview, and the review of guidelines from the Centers for Disease Control and Prevention (CDC), the facility failed to maintain infection control practices for the spread of infectious diseases by not ensuring staff properly donned and maintained the wearing of facemasks while in resident care areas and hand hygiene was not performed after removing gloves. This affected two (Residents #295 and #413) and had the potential to affect all 87 residents residing in the facility. Findings include: 1. Observation on 07/18/22 at 10:04 A.M. of D wing hallway revealed State Tested Nursing Assistant (STNA) #252 was observed exiting Resident #413's room, which required droplet precautions, while wearing the upper strap of the N95 respirator on back of head and the lower strap dangling under chin. STNA #252 also did not perform hand hygiene after removing her soiled gloves as she exited Resident #413's room. STNA #252 stated she normally wears both straps to the N95 but this time she did not and confirmed she did not wash her hands with soap or water or sanitize her hands with an alcohol-based sanitizer after removing gloves. At the time of confirmation, STNA #252 sanitized hands with an alcohol-based sanitizer. 2. Observation on 07/18/22 at 2:56 P.M. of D wing revealed Medical Records #205 entering Resident #295's room, which required droplet precautions, with a surgical mask underneath the N95 respirator. The upper strap of the N95 was secured on the back of the head and the lower strap was dangling under her chin. Medical Records #205 confirmed upon exit of Resident #295's room the N95 respirator was not worn properly. Review of facility policy titled Infection Control-Standard Precautions, dated 05/05/17, revealed after removing gloves, hand hygiene needs to be performed to avoid transfer of microorganisms to other residents or environments. Review of Personal Protective Equipment (PPE), reviewed 10/21/21, from the Centers for Disease Control and Prevention Healthcare-Associated Infections (HAIs), located at https://www.cdc.gov/hai/prevent/ppe.html, revealed to put on a mask or respirator, secure ties or elastic bands at the middle of the head and neck; fit the flexible band to the nose bridge; fit it snug to the face and below the chin; and place goggles or a face shield over the face and eyes and adjust to fit and to wash hands or use an alcohol based sanitizer immediately after removing PPE. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365638 If continuation sheet Page 9 of 9