Health inspection·June 6, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm On 06/05/19 at 8:07 A.M. and 12:09 P.M., observations revealed Resident #278's urine collection bag was hanging on the side bed rail, uncovered and visible from the hallway. On 06/05/19 at 11:12 A.M., interview with Director of Nursing (DON) verified the urine collection bag was hanging on the side bed rail, was uncovered and visible from the hallway. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365665 If continuation sheet Page 2 of 6 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 365665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Wind Health Care Center 300 23rd Street NE Massillon, OH 44646 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 assess Resident #30's pressure ulcer. This affected one resident (Resident #30) of two residents reviewed for pressure ulcers. The facility identified six residents with pressure ulcers. Residents Affected - Few Findings Include: Record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including muscle weakness, paraplegia, and dementia. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 03/08/19 revealed the resident had no pressure ulcer. Review of the Weekly Skin Condition Data Tracking Sheet, dated 05/28/19, revealed an unstageable pressure ulcer, located on the left, lateral malleolus, measuring 2.5 centimeters (cm) length (l) by 2.0 cm width (w) with 0 cm depth (d). The wound bed was described as purple and non-blanching. Review of the Weekly Skin Condition Data Tracking Sheet, dated 06/04/19, revealed a Deep Tissue Injury (DTI), located on the left, lateral malleolus, measuring 1.0 centimeters (cm) length (l) by 0.9 cm width (w) with 0 cm depth (d). The wound bed was described as red/brown and non-blanching. Review of the care plan, dated 06/03/19, revealed an alteration in skin integrity as evidenced by an unstageable pressure ulcer, located on the left malleolus, with interventions including to monitor/document location, size and treatment of skin injury. Observation on 06/04/19 at 1:10 P.M., of Resident #30's dressing change, revealed a DTI, located on the left, lateral malleolus. During interview at the time of the dressing change, on 06/04/19 at 1:15 P.M., Licensed Practical Nurse (LPN) #107 revealed she had made a mistake on the previous skin assessment, the wound was not an unstageable pressure ulcer, but a DTI. LPN #107 further revealed that both skin assessments revealed intact skin, and no slough or eschar. LPN #107 verified the wound had improved, as indicated by the new measurements/assessment on 06/04/19. During interview on 06/04/19 at 1:20 P.M., the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) #104 verified the Weekly Skin Condition Data Tracking Sheet, dated 05/28/19, revealed the wound was identified as an unstageable pressure ulcer; however, the wound description indicated a DTI. The ADON revealed the facility utilizes The National Pressure Ulcer Advisory Panel Pressure Injury Stages clinical resource for guidance and definitions. The ADON further revealed that based on these definitions, Resident #30 had a DTI and not an unstageable pressure ulcer. Review of the facility policy titled Skin Observations, dated July 2011 revealed nursing management shall monitor impaired skin breakdown skin trackers for healing, appropriate treatment, nursing documentation, and need for referral to wound specialist. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365665 If continuation sheet Page 3 of 6 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 365665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Wind Health Care Center 300 23rd Street NE Massillon, OH 44646 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. Based on record review and staff interview the facility failed to ensure Resident #53's behaviors were monitored related to the use of psychoactive medications. This affected one resident (Resident #53) of five residents reviewed for unnecessary medication use. Findings Include: Review of Resident #53's medical record revealed an admission date of 07/26/18 with admission diagnoses that included schizoaffective disorder and depression. Physician orders identified Prozac 50 milligram (mg) every day for depression initiated on 10/24/18 and Zyprexa (antipsychotic) 5 mg every day due to schizoaffective disorder initiated on 07/27/18. Review of Resident #53's care plan indicated a plan for mood and/or behavior symptoms related to depression and schizoaffective disorder had been developed. Interventions included monitoring/recording and reporting of any identified signs and symptoms of behaviors, depression and mood disturbance. Further review of the medical record found no evidence of any monitoring and documentation of monitoring of any behaviors for Resident #53. Interview with the Director of Nursing on 06/05/19 at 2:45 P.M. verified no behavior monitoring had been completed for Resident #53. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365665 If continuation sheet Page 4 of 6 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 365665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Wind Health Care Center 300 23rd Street NE Massillon, OH 44646 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to follow contact based precautions for Resident #40 to prevent the spread of infection. This affected one resident (Resident #40) and had the potential to affect all 19 residents (Resident #20, #27, #28, #8, #7, #65, #67, #78, #5, #12, #77, #68, #25, #43, #29, #4, #75, #11 and #40) of 19 residents residing on the unit. Residents Affected - Some Findings Include: Record review revealed Resident #40 was admitted to the facility on [DATE] and was diagnosed with a urinary tract infection on 05/28/19. Resident #40's most recent quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident was always incontinent or urine and bowel. Resident #40's laboratory results dated [DATE] revealed she had escherichia coli (E-coli) extended-spectrum beta-lactamases (ESBL) bacteria in her urine. Resident #40's physician orders revealed she was ordered contact isolation precautions on 06/01/19. Observation on 06/03/19 at 10:10 A.M. with Licensed Practical Nurse (LPN) #100 revealed Resident #40 had a cart full of personal protection equipment outside of her room, with no sign to advise staff or visitors to see the nurse before entering. Two staff, State Tested Nursing Assistant (STNA) #101 and STNA #102 were in Resident #40's room without PPE on. Interview with LPN #100 at this time confirmed there was not a sign to inform staff and visitors to see the nurse before entering. LPN #100 revealed to enter Resident #40's room, one should wear a gown, gloves, and a mask for transmission based precautions. LPN #100 revealed he was unsure why the staff were in Resident #40's room without PPE on. Interview on 06/03/19 at 10:12 A.M. with STNA #101 and STNA #102 after exiting Resident #40's room revealed they were checking on Resident #40 as she just returned from the shower. STNA #100 and STNA #101 confirmed they were not wearing PPE, and explained a gown and gloves (not a mask) should be worn in Resident #40's room. Interview on 06/05/19 at 10:23 A.M. with Assistant Director of Nursing (ADON) #104 revealed when a resident was on transmission based precautions there should be a sign on the wall to notify staff and visitors to see the nurse before entering. ADON #104 confirmed Resident #40 was on contact isolation precautions for a urinary tract infection. ADON #104 revealed the facility staff were encouraged to always were PPE when going into a resident's room, and in Resident #40's room a gown, gloves, and mask should be worn. ADON #104 revealed a sign was placed in the PPE cart indicating the type of precautions the resident was on, and what to wear. ADON #104 provided this sign that was in Resident #40's PPE cart that confirmed she was on contact isolation and a gown, mask, and gloves should be worn. The facility identified 19 residents, Resident #20, #27, #28, #8, #7, #65, #67, #78, #5, #12, #77, #68, #25, #43, #29, #4, #75, #11 and #40 who resided on the unit. Review of the facility undated policy titled, Isolation Precautions revealed it was the facility policy to take appropriate precautions, including isolation, to prevent transmission of infectious agents. Facility staff would apply transmission based precautions, in addition to standard precautions, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365665 If continuation sheet Page 5 of 6 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 365665 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Wind Health Care Center 300 23rd Street NE Massillon, OH 44646 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 to residents who were known or suspected to be infected or colonized with infectious agents, which require, as determined by the Centers for Disease Control, additional controls to effectively prevent transmission. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365665 If continuation sheet Page 6 of 6