Inspection·June 29, 2022

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure the Ombudsman's office was notified of resident transfers to the hospital as required. This affected one (Resident #263) of one resident reviewed for hospitalization. This had the potential to affect all residents. The facility census was 70. Findings include: Review of the medical record revealed Resident #263 was admitted to the facility on [DATE] with diagnoses including dysphagia, lack of coordination, and muscle weakness. Review of the medical record for Resident #263 was sent to the hospital on [DATE] and was subsequently admitted to the hospital. Review of both the electronic and hard charts revealed no documented evidence the office of the Ombudsman was notified of the residents transfer to the hospital. Interview with the Administrator on 06/28/22 at 1:45 P.M. verified the Ombudsman had not been notified of any facility transfers to the hospital including Resident #263. 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 06/29/2022 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure bed hold notices were provided to residents upon transfer to the hospital as required. This affected one (Resident #263) of one resident reviewed for hospitalization. This had the potential to affect all residents. The facility census was 70. Findings include: Review of the medical record revealed Resident #263 was admitted to the facility on [DATE] with diagnoses including dysphagia, lack of coordination, and muscle weakness. Review of the medical record revealed Resident #263 was sent to the hospital on [DATE] and was subsequently admitted to the hospital. Review of both the electronic and hard charts revealed no documented evidence Resident #263 was provided a bed hold notice upon transfer to the hospital. Interview with the Administrator on 06/28/22 at 1:45 P.M. verified no bed hold notice had been given to Resident #263 or any other resident upon transfer to the hospital. 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 06/29/2022 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 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 and interview, the facility failed to ensure care conferences were completed as required. This finding affected two (Resident's #10 and #37) of three residents reviewed for care planning. The facility census was 70. Findings include: 1. Review of Resident #10's medical record revealed he was admitted on [DATE] with diagnoses including muscle weakness, mixed hyperlipidemia, and major depressive disorder. Review of Resident #10's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited intact cognition and his sister was emergency contact number one and the care conference person. Review of Resident #10's progress notes from 02/17/22 to 06/27/22 did not reveal documented evidence a quarterly care conference was completed. Interview on 06/27/22 at 12:03 P.M. with Social Services Designee (SSD) #668 indicated the last care conference completed for Resident #10 was on 12/17/21 and she denied another care conference was completed quarterly as required. 2. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, bipolar disorder, and Methicillin-resistant Staphylococcus aureus (MRSA). Review of the electronic and hard chart revealed a care conference was held on 09/21/21. No other care conferences were documented in the medical record. Interview on 06/27/22 at 2:39 P.M. with SSD #668 verified the lack of care conferences after 09/21/21. Review of the undated Interdisciplinary Team Care Planning policy indicated a comprehensive care plan for each resident should be developed within seven days of completion of the resident MDS. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate shall be informed of the right to participate and encouraged to participate. Every effort would be made to schedule care plan meetings at the best time of the day for the resident and family. 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 06/29/2022 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to ensure the posted nurse staffing information was available daily as required. This finding had the potential to affect all 70 residents residing in the facility. Residents Affected - Many Findings include: Observation on 06/26/22 at 2:10 P.M. with the Administrator of the posted nurse staffing information revealed the form was dated 06/09/22. Interview on 06/26/22 at 2:12 P.M. with the Administrator confirmed the posted nurse staffing form did not reflect the daily staffing information as required. 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 06/29/2022 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and interview the facility failed to maintain the outside courtyard area (designated smoking area) in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 70. Findings include: On 06/27/22 at 12:51 P.M., observation of the courtyard/designated smoking area revealed more than 20 cigarette butts on the ground, in the combustible trash can, and combustible trash in the cigarette butts only metal can. Interview with the Maintenance Director #664 verified this finding at the time of observation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365665 If continuation sheet Page 6 of 6