Health inspection·August 22, 2019

F 0600 resident on the left cheek with open hand. The residents were immediately separated without difficulty. Level of Harm - Minimal harm or potential for actual harm Review of a progress note dated 06/13/19 at 1:42 P.M. revealed the physician was updated regarding Resident #19's behavioral issues and he was updated on most recent encounter with another resident. The physician ordered to obtain a urine for culture and sensitivity (C&S). The son was unable to be reach because he had no voicemail set up. Residents Affected - Some Review of a progress notes dated 06/30/19 at 6:15 P.M. revealed Resident #19 was observed by staff hitting Resident #89 in the face with an open hand. The residents were separated, and their safety was maintained. There were no apparent injuries. The POA for Resident #19 was updated. Review of a progress note dated 06/30/19 at 9:54 P.M. revealed Resident #19 walked over to another unidentified resident who was sitting in a chair and smacked the resident on the hand. The residents were separated, and their safety was maintained. The family and physician were notified. Review of a progress note dated 07/15/19 at 2:36 P.M. revealed Resident #19 was pushing another unidentified resident in her wheelchair and the other resident told the resident to stop and she would not. The residents began swinging at each other and Resident #19 hit the other resident on top of the head. The residents were separated, and their safety was maintained. A message was left for the POA and the physician was notified. Review of a progress note dated 07/16/19 at 11:21 A.M. revealed Resident #19 had a new order for Depakote (mood stabilizer) 125 milligrams three times a day. Review of physician orders revealed Resident #19 had an order dated 07/16/19 for Depakote sprinkles 125 mg three times a day for dementia with behavioral disturbance. Review of the Physician's progress note dated 07/21/19 revealed during the last week Resident #19 was having episodes of aggressive behavior towards others, slapping. At this time, she is very docile. She has no evidence of a urinary tract infection. She was on Depakote 125 mg and we will check her level soon. Haldol was to be continued. Review of a Plan of Care dated 07/22/19 revealed Resident #19 had a potential to be physically aggressive towards other residents due to her dementia. The resident had altercations with other residents. Interventions included: 15 minutes checks; administer medications as ordered; analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document; assess and anticipate resident's needs; provide physical and verbal cues to alleviate anxiety; give positive feedback; assist verbalization of the source of the agitation; assist to set goals for more pleasant behavior; encourage seeking out of staff member when agitated; give the resident as many choices as possible about care and activities; monitor and document observed behavior and attempted interventions in behavior log; and when the resident becomes agitated intervene before agitation escalates, guide the resident away from the source of distress, engage calmly in conversation and if the response was aggressive the staff was to calmly walk away and re-approach later. Review of a progress note dated 07/22/19 at 1:19 P.M. revealed Resident #19 was observed by staff standing over Resident #70 in main dining room, who was in a wheelchair. Resident #19 was slapping Resident #70 repeatedly on both sides of her face and head. There were no visible signs of injury to either resident. The residents were separated, and their safety was maintained. The resident's POA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365715 If continuation sheet Page 2 of 23 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 365715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Mary's Alzheimer's Center 1899 Garfield Rd Columbiana, OH 44408 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 - Some and physician were notified. The physician ordered for Resident #19 to have 15-minute checks due to her behaviors. Review of physician orders revealed an order dated 07/23/19 for 15-minutes checks. Review of a progress note dated 07/25/19 at 10:49 A.M. revealed the physician was updated on the incident between Resident #19 and another resident. New orders were received to increase her Haldol dosage to twice daily. The son does not give consent for psychiatric services. A message was left for the son to update him on the new orders. Review of a progress note dated 07/25/19 at 1:01 P.M. revealed Resident #19 slapped another unidentified resident and there were no injuries to either resident. Review of physician orders dated 07/25/19 revealed an order for Haldol two mg twice daily. Review of a progress note dated 07/28/19 at 5:56 P.M. revealed Resident #19 was seen coming out of Resident #38 ' s room with Resident #38. Resident #19 was punching Resident #38 repeatedly in the back. The residents were separated. There were no apparent injuries to Resident #19 and Resident #19 denied pain. When the resident was asked what happened the resident replied, she pounded on me, so I pounded on her. A message was left for the resident's POA. Review of a progress note dated 07/29/19 at 4:25 P.M. revealed Resident #19 walked up Resident #66 who was sitting in a chair and slapped the resident in the face. The residents were separated, and their safety maintained. There were no injuries to either residents. Review on a behavior note dated 08/01/19 at 5:31 P.M. revealed Resident #19 slapped Resident #62 on the hand, the resident's hand was sitting on the table. The residents were separated, and safety was maintained. The interventions were effective. A message was left for the POA and the physician was notified. Review of the behavior note dated 08/07/19 at 7:05 P.M. revealed Resident #19 had physical aggression towards other residents. Interventions attempted were redirection and one on one which were slightly effective. The physician was notified, and a message was left for the resident's POA to return the call to the facility. Review of a progress note dated 08/07/19 at 10:13 P.M. revealed Resident #19 had a new order for Nuedexta 20/10 mg every day. Review of physician orders dated 08/07/19 revealed an order for Nuedexta 20/10 mg at bedtime related to dementia with behavioral disturbance. Review of the progress note dated 08/08/19 at 11:15 A.M. revealed the son of Resident #19 reported he has had some significant health problems and was in hospital for several weeks. He was updated on the incidents that had occurred over the last couple months and the resident's new orders. The facility requested consideration for psychiatric services due to her ongoing behaviors. The son indicated he wished to consult with the physician before approving any psychiatric consult. Review of progress notes dated 08/14/19 at 1:36 P.M. revealed the son of Resident #19 had not reached the physician about psychiatric services and would try again tomorrow. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365715 If continuation sheet Page 3 of 23 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 365715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Mary's Alzheimer's Center 1899 Garfield Rd Columbiana, OH 44408 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 - Some An interview on 08/20/19 at 2:48 P.M. with Licensed Practical Nurse (LPN) #806 indicated there were no witness statements of any of the incidents with Resident #19. An interview on 08/22/19 at 2:15 P.M. with State Tested Nursing Assistant (STNA) #800 indicated one-minute Resident #19 could be so sweet then the next minute she would be beating you. The resident would kick and hit with care. STNA #800 said Resident #19 had hit other residents. They would remove her from the situation and take her to the nurse. She indicated Resident #19 was on 15-minute checks. An interview on 08/22/19 at 2:18 P.M. with STNA #802 indicated Resident #19 was physically aggressive towards the staff and other residents. She indicated they had two behavior technicians who worked a couple times a week and they would redirect her. An interview on 08/22/19 at 2:20 P.M. with STNA #804 indicated Resident #19 had aggressive behaviors towards staff and other residents and was not easily redirected. The staff attempted one on one with her when she was being aggressive. She indicated she had witnessed Resident #19 hit other residents. Review on the facility policy, Resident Abuse Prevention Practices, dated October 2017 revealed it was the policy of the company to protect all residents from mistreatment, neglect, abuse, and misappropriation of resident property. This included protection of all residents from verbal, mental, physical, emotional, or financial abuse by staff, families, visitors or outside ancillary service employees or in any situation that would be harmful to the resident. This also included protection against corporal punishment, involuntary seclusion, or exploitation of residents. Abuse was defined as knowingly causing physical harm or recklessly causing physical harm to a resident by use of physical contact with the resident or chemical restraint, medication, or isolation as punishment, for staff convenience, excessively, as a substitute for treatment, or in amounts that preclude habilitation and treatment. Abuse was also defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, mental anguish, or deprivation by an individual, including a caretaker, of goods or services necessary to attain physical, mental, and psychosocial well-being. (Willful: the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm). The assessment and care plan process would identify and address residents with needs and behaviors which may lead to conflict or abuse. Abuse could be identified through reviewing and monitoring unusual incidents, bruising, skin tears, or behavior changes and monitoring events for patterns or trends such as shift, staff assignment, unit/location, etc. Monitoring staff for signs of stress, burnout, personal problems, or the inability to manage stress. Alleged, suspected, or observed abuse, neglect, and/or mistreatment of a resident and/or their belongings would be thoroughly investigated by the Administrator and the Director of Nursing or the designee. Alleged and suspected violations were to be reported immediately to the Department of Health using the Enhanced Information Dissemination Collection (EIDC) for on-line submission of self-reported incident and to the Corporate Quality Assurance Performance and Improvement department and/or the Corporate Attorney. In the case of any employee being suspected of allegedly abusing, neglecting, or mistreating a resident, the Administrator, Director of Nursing, Assistant Director of Nursing (where applicable), or Nursing Supervisor, in that order would suspend that individual of his/her duties until the investigation was complete. The investigation would begin immediately after receiving a complaint of abuse. The resident would be examined for injury at the time of complaint, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365715 If continuation sheet Page 4 of 23 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 365715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Mary's Alzheimer's Center 1899 Garfield Rd Columbiana, OH 44408 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 - Some appropriate medical attention given as necessary. Written statements would be taken from anyone involved or witnessing the event. A plan of support for the resident would be initiated. The residents and/or their representative would be notified of the allegation and would be updated on the investigation and the final results of the investigation. 2. Record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, Parkinson's disease, anxiety disorder and psychotic disorder with hallucinations. The Minimum Data Set assessment dated [DATE] revealed Resident #12 had severe cognitive impairment and physically aggressive behaviors towards others. He required limited assistance by staff for bed mobility, transfers and extensive assistance by staff for dressing, toileting and hygiene. Review of the Progress Notes from 01/05/19 to 07/13/19 revealed Resident #12 had acted out aggressively toward his room mate on 01/05/19 by putting a blanket over his head; on 02/24/19 he made statements he was going to kill someone; on 03/07/19 he was looking to fight someone; 03/21/19 showed aggression toward others; and on 06/27/19 he was sent to a psychiatric hospital for punching Resident #59 in the face with a closed fist ejecting her glasses from her face causing abrasions, discoloration and facial pain. Resident #12 returned to the facility on [DATE] with an order to be on every 15 minute checks. On 07/12/19 he made verbal threats to hit another resident and on 07/13/19 he made statements he was going to kill others. Record review was conducted for Resident #59 who was admitted to the facility on [DATE] with diagnoses including vascular dementia with behavioral disturbance. The Minimum Data Set assessment dated [DATE] revealed Resident #59 had severe cognitive impairment and needed extensive assistance by staff for bed mobility, transfers and toileting and total staff assistance for hygiene. An interview on 08/22/19 at 1:33 P.M. with Licensed Practical Nurse (LPN) #965 verified Resident #12 was on every 15 minute checks due to known physical aggression towards staff and other residents. LPN #965 indicated Resident #12 had a history of physically attacking other residents but had not done so for several weeks. Review of a Progress Note dated 06/25/19 authored by LPN #967 at 10:10 A.M. revealed Resident #59 was punched in the face by a closed fist of Resident #12 resulting in swelling and dark discoloration area measuring four centimeters (cm) by two cm and a one cm by one cm abrasion to the bridge of her nose where glasses were ejected from her face. Review of a Progress Note dated 06/25/19 at 5:31 P.M. authored by LPN #967 revealed Resident #59 was experiencing pain during manipulation of her head for an x-ray and was medicated with Tylenol. Review of a Progress Noted dated 06/25/19 at 10:32 P.M. authored by LPN #967 revealed Resident #39's x-rays of nasal and facial bones were negative for fractures. Review of the facility document titled Summary Report, dated 06/26/19, authored by LPN #806 revealed at 10:10 A.M. it was noted Resident #12 was involved in a resident to resident altercation with a female resident (Resident #59) where he drew his arm back and struck Resident #59 in the face with a closed fist. Review of the document titled Resident Abuse Prevention Practices, dated October 2017 revealed it was the policy of the company to protect all residents from mistreatment, neglect, abuse, and misappropriation of property. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365715 If continuation sheet Page 5 of 23 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 365715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Mary's Alzheimer's Center 1899 Garfield Rd Columbiana, OH 44408 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** 4. Record review revealed Resident #80 was admitted to the facility on 11/05/. The primary diagnosis for admission was vascular dementia with behavioral disturbances. The comprehensive assessment dated [DATE] had a brief interview for mental status score of 02 of a possible 15 and indicating severe cognitive impairment. Residents Affected - Some Review of the medical record for Resident #80 revealed a nursing note dated 06/25/19 stating Resident #80 had grabbed another resident by the back of the shirt and pulled the resident to the ground. The staff separated the residents for safety reasons. No injuries were sustained by either resident and psychology consults were placed with medication adjustments made and urine samples obtained to rule out a urinary tract infection. Review of a nursing note dated 07/26/19 revealed Resident #80 was involved in an altercation with another resident while seated at the dining room table, both residents were slapping at each other. No injuries were sustained by either resident and the physician was notified. Review of the document titled Resident Abuse Prevention Practices, last revised 10/2017 revealed it was the policy of the company to protect all residents from mistreatment, neglect, abuse, and misappropriation of property. This document stated, under section V-Investigation, alleged, suspected, or observed, and/or mistreatment of a resident and or their belongings are thoroughly investigated by the Administrator and the Director of Nursing or the designee. Alleged and suspected violations are reported immediately to the Department of Health using EIDC (Enhanced Information and Dissemination and Collection) for on-line submission of self-reported incidents (SRI). Review of the Department of Health website for on-line submission was silent to evidence the facility had completed the SRI on-line submission for the two identified incidents of physical altercations involving Resident #80 and evidenced non-compliance with the policy of reporting all allegations of alleged, suspected or observed mistreatment of a resident. Interview on 08/22/19 at 1:20 P.M. with Registered Nurse #120, the director of nursing and the administrator revealed the corporate policy was not to report resident to resident altercations between dementia residents. The facility staff did an internal incident report on altercations but was under the impression they did not need to be reported as a self-reported incident since the dementia residents were not capable of willful actions due to their cognitive status. Based on medical record review, staff interviews and facility policy review the facility failed to follow their abuse policy and procedure in relation to reporting incidents of resident to resident abuse to the State agency. This affected four (Residents #3 #12, #19, and #80) of six residents reviewed for resident to resident abuse. Findings include: 1. Review of the medial record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of dementia with behavioral disturbance, Alzheimer's disease, pseudobulbar, hypertension, muscle weakness, urinary tract infections and bipolar schizophrenic disorder. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #19 had severely impaired cognition and wandering behaviors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365715 If continuation sheet Page 6 of 23 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 365715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Mary's Alzheimer's Center 1899 Garfield Rd Columbiana, OH 44408 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 - Some Review of discontinued orders revealed Resident #19 had a discontinued order dated 06/12/19 for 15 minutes checks for one week, an order dated 06/13/19 for a urinalysis and culture and sensitivity (C&S), and an order discontinued on 11/09/18 for Haldol (antipsychotic) five milligram (mg) at 4:00 P.M. and start 2 mg daily. Review of a physician's telephone order dated 01/13/19 revealed to hold Resident #19's Nuedexta (mood stabilizer) until available, an ordered dated 02/17/19 to hold the Nuedexta until it was available from the pharmacy. The Neudexta was discontinued on 02/21/19. Review of progress notes dated 04/10/19 at 10:36 P.M. revealed Resident #19 and another resident were seen in south hallway slapping each other with open hands in the arms and shoulders. The residents were separated, and their safety maintained. Resident #19 stated she was slapped on the right cheek. She had no apparent injuries and denied pain. The Power of Attorney (POA) was unable to be reached because he did not have an answering machine set up. A message was left at an alternate contact. Review of a progress note dated 04/26/19 at 11:30 A.M. revealed Resident #19 was observed by a staff member pushing another resident in their wheelchair, when the other resident asked Resident #19 to stop pushing her Resident #19 slapped the other resident on the right side of the face. The residents were separated, and their safety was maintained. Resident #19 was brought to the south nurse's station. Review of a progress note dated 04/26/19 at 5:05 P.M. revealed Resident #19 and another resident grabbed onto each other's hands squeezing aggressively facing each other. The residents were separated to maintained safety. Review of the progress note dated 06/13/19 at 11:50 A.M. revealed Resident #19 walked up to another female resident, who was sitting in a wheelchair. The resident screamed and Resident #19 struck the seated resident on the left cheek with open hand. The residents were immediately separated without difficulty. Review of a progress note dated 06/13/19 at 1:42 P.M. revealed the physician was updated regarding Resident #19's behavioral issues and he was updated on most recent encounter with another resident. The physician ordered to obtain a urine for culture and sensitivity (C&S). The son was unable to be reach because he had no voicemail set up. Review of a progress notes dated 06/30/19 at 6:15 P.M. revealed Resident #19 was observed by staff hitting another resident in the face with an open hand. The residents were separated, and their safety was maintained. There were no apparent injuries. The POA for Resident #19 was updated. Review on a progress note dated 06/30/19 at 9:54 P.M. revealed Resident #19 walked over to another resident who was sitting in a chair and smacked the resident on the hand. The residents were separated, and their safety was maintained. The family and physician were notified. Review of a progress note dated 07/15/19 at 2:36 P.M. revealed Resident #19 was pushing another resident in her wheelchair and the other resident told the resident to stop and she would not. The residents began swinging at each other and Resident #19 hit the other resident on top of the head. The residents were separated, and their safety was maintained. A message was left for the POA and the physician was notified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365715 If continuation sheet Page 7 of 23 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 365715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Mary's Alzheimer's Center 1899 Garfield Rd Columbiana, OH 44408 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 Review of a progress note dated 07/16/19 at 11:21 A.M. revealed Resident #19 had a new order for Depakote (mood stabilizer) 125 milligrams three times a day. Review of physician orders revealed Resident #19 had an order dated 07/16/19 for Depakote sprinkles 125 mg three times a day for dementia with behavioral disturbance. Residents Affected - Some Review of the Physician's progress note dated 07/21/19 revealed during the last week Resident #19 was having episodes of aggressive behavior towards others, slapping. At this time, she is very docile. She has no evidence of a urinary tract infection. She was on Depakote 125 mg and we will check her level soon. Haldol was to be continue. Review on a Plan of Care dated 07/22/19 revealed Resident #19 had a potential to be physically aggressive towards other residents due to her dementia. The resident had altercations with other residents. Interventions included: 15 minutes checks; administer medications as ordered; analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document; assess and anticipate resident's needs; provide physical and verbal cues to alleviate anxiety; give positive feedback; assist verbalization of the source of the agitation; assist to set goals for more pleasant behavior; encourage seeking out of staff member when agitated; give the resident as many choices as possible about care and activities; monitor and document observed behavior and attempted interventions in behavior log; and when the resident becomes agitated intervene before agitation escalates, guide the resident away from the source of distress, engage calmly in conversation and if the response was aggressive the staff was to calmly walk away and re-approach later. Review of a progress note dated 07/22/19 at 1:19 P.M. revealed Resident #19 was observed by staff standing over another female resident in main dining room, who was in a wheelchair. Resident #19 was slapping the other female resident repeatedly on both sides of her face and head. There were no visible signs of injury to either resident. The residents were separated, and their safety was maintained. The resident's POA and physician were notified. The physician ordered for Resident #19 to have 15-minute checks due to her behaviors. Review of physician orders revealed an order dated 07/23/19 for 15-minutes checks. Review of a progress note dated 07/25/19 at 10:49 A.M. revealed the physician was updated on the incident between Resident #19 and another resident. New orders were received to increase her Haldol dosage to twice daily. The son does not give consent for psychiatric services. A message was left for the son to update him on the new orders. Review of a progress note dated 07/25/19 at 1:01 P.M. revealed Resident #19 slapped another resident and there were no injuries to either resident. Review of physician orders dated 07/25/19 revealed an order for Haldol two mg twice daily. Review of a progress note dated 07/28/19 at 5:56 P.M. revealed Resident #19 was seen coming out of another resident's room with another resident. Resident #19 was punching the other resident repeatedly in the back. The residents were separated. There were no apparent injuries to Resident #19 and Resident #19 denied pain. When the resident was asked what happened the resident replied, she pounded on me, so I pounded on her. A message was left for the resident's POA. Review of a progress note dated 07/29/19 at 4:25 P.M. revealed Resident #19 walked up to another (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365715 If continuation sheet Page 8 of 23 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 365715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Mary's Alzheimer's Center 1899 Garfield Rd Columbiana, OH 44408 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 - Some female resident who was sitting in a chair and slapped the resident in the face. The residents were separated, and their safety maintained. There were no injuries to either residents. Review on a behavior note dated 08/01/19 at 5:31 P.M. revealed Resident #19 slapped another resident on the hand, the resident's hand was sitting on the table. The residents were separated, and safety was maintained. The interventions were effective. A message was left for the POA and the physician was notified. Review of the behavior note dated 08/07/19 at 7:05 P.M. revealed Resident #19 had physical aggression towards other residents. Interventions attempted were redirection and one on one which were slightly effective. The physician was notified, and a message was left for the resident's POA to return the call to the facility. Review of a progress note dated 08/07/19 at 10:13 P.M. revealed Resident #19 had a new order for Nuedexta 20/10 mg every day. Review of physician orders dated 08/07/19 revealed an order for Nuedexta 20/10 mg at bedtime related to dementia with behavioral disturbance. Review of the progress note dated 08/08/19 at 11:15 A.M. revealed the son of Resident #19 reported he has had some significant health problems and was in hospital for several weeks. He was updated on the incidents that had occurred over the last couple months and the resident's new orders. The facility requested consideration for psychiatric services due to her ongoing behaviors. The son indicated he wished to consult with the physician before approving any psychiatric consult. Review of progress notes dated 08/14/19 at 1:36 P.M. revealed the son of Resident #19 had not reached the physician about psychiatric services and would try again tomorrow. An interview on 08/20/19 at 1:23 P.M. with the Administrator indicated she did not file any Self-Reported (SRI) incidents related Resident #19's physical abuse of other residents. An interview on 08/20/19 at 2:06 P.M. with Registered Nurse #810 indicated there were not any SRIs completed because the residents all had dementia and there were no injuries. An interview on 08/20/19 at 2:48 P.M. with Licensed Practical Nurse (LPN) #806 indicated there were no witness statements of any of the incidents and she did not believe any SRIs were completed on any of the incidents with Resident #19. An interview on 08/22/19 at 2:15 P.M. with State Tested Nursing Assistant (STNA) #800 indicated one-minute Resident #19 could be so sweet then the next minute she would be beating you. The resident would kick and hit with care. STNA #800 said Resident #19 had hit other residents. They would remove her from the situation and take her to the nurse. She indicated Resident #19 was on 15-minute checks. An interview on 08/22/19 at 2:18 P.M. with STNA #802 indicated Resident #19 was physically aggressive towards the staff and other residents. She indicated they had two behavior technicians who worked a couple times a week and they would redirect her. An interview on 08/22/19 at 2:20 P.M. with STNA #804 indicated Resident #19 had aggressive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365715 If continuation sheet Page 9 of 23 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 365715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Mary's Alzheimer's Center 1899 Garfield Rd Columbiana, OH 44408 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 - Some behaviors towards staff and other residents and was not easily redirected. The staff attempted one on one with her when she was being aggressive. She indicated she had witnessed Resident #19 hit other residents. Interview on 08/22/19 at 1:20 P.M. with Registered Nurse #120, the director of nursing and the administrator revealed the corporate policy was not to report resident to resident altercations between dementia residents. The facility staff did an internal incident report on altercations but was under the impression they did not need to be reported as a self-reported incident since the dementia residents were not capable of willful actions due to their cognitive status. Review on the facility policy, Resident Abuse Prevention Practices, dated October 2017 revealed it was the policy of the company to protect all residents from mistreatment, neglect, abuse, and misappropriation of resident property. This included protection of all residents from verbal, mental, physical, emotional, or financial abuse by staff, families, visitors or outside ancillary service employees or in any situation that would be harmful to the resident. This also included protection against corporal punishment, involuntary seclusion, or exploitation of residents. Abuse was defined as knowingly causing physical harm or recklessly causing physical harm to a resident by use of physical contact with the resident or chemical restraint, medication, or isolation as punishment, for staff convenience, excessively, as a substitute for treatment, or in amounts that preclude habilitation and treatment. Abuse was also defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, mental anguish, or deprivation by an individual, including a caretaker, of goods or services necessary to attain physical, mental, and psychosocial well-being. (Willful: the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm). The assessment and care plan process would identify and address residents with needs and behaviors which may lead to conflict or abuse. Abuse could be identified through reviewing and monitoring unusual incidents, bruising, skin tears, or behavior changes and monitoring events for patterns or trends such as shift, staff assignment, unit/location, etc. Monitoring staff for signs of stress, burnout, personal problems, or the inability to manage stress. Alleged, suspected, or observed abuse, neglect, and/or mistreatment of a resident and/or their belongings would be thoroughly investigated by the Administrator and the Director of Nursing or the designee. Alleged and suspected violations were to be reported immediately to the Department of Health using the Enhanced Information Dissemination Collection (EIDC) for on-line submission of self-reported incident and to the Corporate Quality Assurance Performance and Improvement department and/or the Corporate Attorney. In the case of any employee being suspected of allegedly abusing, neglecting, or mistreating a resident, the Administrator, Director of Nursing, Assistant Director of Nursing (where applicable), or Nursing Supervisor, in that order would suspend that individual of his/her duties until the investigation was complete. The investigation would begin immediately after receiving a complaint of abuse. The resident would be examined for injury at the time of complaint, and appropriate medical attention given as necessary. Written statements would be taken from anyone involved or witnessing the event. A plan of support for the resident would be initiated. The residents and/or their representative would be notified of the allegation and would be updated on the investigation and the final results of the investigation. 2. Record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, Parkinson's disease, anxiety disorder and psychotic disorder with hallucinations. The Minimum Data Set assessment dated [DATE] revealed Resident #12 had severe cognitive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365715 If continuation sheet Page 10 of 23 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 365715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Mary's Alzheimer's Center 1899 Garfield Rd Columbiana, OH 44408 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 - Some impairment and physically aggressive behaviors towards others. He required limited assistance by staff for bed mobility, transfers and extensive assistance by staff for dressing, toileting and hygiene. Review of the Progress Notes from 01/05/19 to 07/13/19 revealed Resident #12 had acted out aggressively toward his room mate on 01/05/19 by putting a blanket over his head; on 02/24/19 he made statements he was going to kill someone; on 03/07/19 he was looking to fight someone; 03/21/19 showed aggression toward others; and on 06/27/19 he was sent to a psychiatric hospital for punching Resident #59 in the face with a closed fist ejecting her glasses from her face causing abrasions, discoloration and facial pain. Resident #12 returned to the facility on [DATE] with an order to be on every 15 minute checks. On 07/12/19 he made verbal threats to hit another resident and on 07/13/19 he made statements he was going to kill others. Record review was conducted for Resident #59 who was admitted to the facility on [DATE] with diagnoses including vascular dementia with behavioral disturbance. The Minimum Data Set assessment dated [DATE] revealed Resident #59 had severe cognitive impairment and needed extensive assistance by staff for bed mobility, transfers and toileting and total staff assistance for hygiene. An interview on 08/22/19 at 1:33 P.M. with Licensed Practical Nurse (LPN) #965 verified Resident #12 was on every 15 minute checks due to known physical aggression towards staff and other residents. LPN #965 indicated Resident #12 had a history of physically attacking other residents but had not done so for several weeks. Review of a Progress Note dated 06/25/19 authored by LPN #967 at 10:10 A.M. revealed Resident #59 was punched in the face by a closed fist of Resident #12 resulting in swelling and dark discoloration area measuring four centimeters (cm) by two cm and a one cm by one cm abrasion to the bridge of her nose where glasses were ejected from her face. Review of a Progress Note dated 06/25/19 at 5:31 P.M. authored by LPN #967 revealed Resident #59 was experiencing pain during manipulation of her head for an x-ray and was medicated with Tylenol. Review of a Progress Noted dated 06/25/19 at 10:32 P.M. authored by LPN #967 revealed Resident #39's x-rays of nasal and facial bones were negative for fractures. Interview on 08/22/19 at 1:20 P.M. with Registered Nurse #120, the director of nursing and the administrator revealed the corporate policy was not to report resident to resident altercations between dementia residents. The facility staff did an internal incident report on altercations but was under the impression they did not need to be reported as a self-reported incident since the dementia residents were not capable of willful actions due to their cognitive status. Review of the facility document titled Summary Report, dated 06/26/19, authored by LPN #806 revealed at 10:10 A.M. it was noted Resident #12 was involved in a resident to resident altercation with a female resident (Resident #59) where he drew his arm back and struck Resident #59 in the face with a closed fist. Review of the document titled Resident Abuse Prevention Practices, dated October 2017 revealed it was the policy of the company to protect all residents from mistreatment, neglect, abuse, and misappropriation of property. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365715 If continuation sheet Page 11 of 23 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 365715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Mary's Alzheimer's Center 1899 Garfield Rd Columbiana, OH 44408 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 3. Record review revealed Resident #3 was admitted on [DATE] with diagnoses including but not limited to dysphasia, delusional disorder, generalized anxiety disorder, Alzheimer's disease and major depressive disorder. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was severely cognitively impaired with no behaviors, required extensive assist of two for activities of daily living and supervision only for ambulation. Residents Affected - Some Review of the progress note of 03/19/19 revealed Resident #3 was found by staff on the hallway by the south unit shower room hitting another female resident (Resident #54) repeatedly in the head. When staff tried to intervene, the other resident hit Resident #3 in the face. Staff separated the residents. Neither resident sustained any injury. Review of the progress note dated 04/26/19 revealed Resident #3 was in the south hallway with her arms around another resident squeezing the other resident's hand aggressively and yelling. There was no injury to the other resident. Review of the progress note dated 04/30/19 revealed Resident #3 was found yelling in the south hallway and being verbally and physically aggressive with staff and another resident (Resident #78). Resident #3 scratched the other resident. Review of the care plan dated 08/12/19 revealed care areas for behaviors, wandering, and communication problem due to cognitive loss. Interview on 08/22/19 at 1:20 P.M. with Registered Nurse #120, the director of nursing and the administrator revealed the corporate policy was not to report resident to resident altercations between dementia residents. The facility staff did an internal incident report on altercations but was under the impression they did not need to be reported as a self-reported incident since the dementia residents were not capable of willful actions due to their cognitive status. Review of the document titled Resident Abuse Prevention Practices, dated October 2017 revealed it was the policy of the company to protect all residents from mistreatment, neglect, abuse, and misappropriation of property. This document stated, under section V-Investigation, alleged, suspected, or observed, and/or mistreatment of a resident and or their belongings are thoroughly investigated by the Administrator and the Director of Nursing or the designee. Alleged and suspected violations are reported immediately to the Department of Health using EIDC (Enhanced Information and Dissemination and Collection) for on-line submission of self-reported incidents (SRI). Review of the Department of Health website for on-line submission of a SRI was silent to any evidence of the alleged abuse related to Resident #3 and the three identified events of physical altercations and resident to resident abuse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365715 If continuation sheet Page 12 of 23 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 365715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Mary's Alzheimer's Center 1899 Garfield Rd Columbiana, OH 44408 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review revealed Resident #80 was admitted to the facility on 11/05/. The primary diagnosis for admission was vascular dementia with behavioral disturbances. The comprehensive assessment dated [DATE] had a brief interview for mental status score of 02 of a possible 15 and indicating severe cognitive impairment. Review of the medical record for Resident #80 revealed a nursing note dated 06/25/19 stating Resident #80 had grabbed another resident by the back of the shirt and pulled the resident to the ground. The staff separated the residents for safety reasons. No injuries were sustained by either resident and psychology consults were placed with medication adjustments made and urine samples obtained to rule out a urinary tract infection. Review of a nursing note dated 07/26/19 revealed Resident #80 was involved in an altercation with another resident while seated at the dining room table, both residents were slapping at each other. No injuries were sustained by either resident and the physician was notified. Review of the document titled Resident Abuse Prevention Practices, last revised 10/2017 revealed it was the policy of the company to protect all residents from mistreatment, neglect, abuse, and misappropriation of property. This document stated, under section V-Investigation, alleged, suspected, or observed, and/or mistreatment of a resident and or their belongings are thoroughly investigated by the Administrator and the Director of Nursing or the designee. Alleged and suspected violations are reported immediately to the Department of Health using EIDC (Enhanced Information and Dissemination and Collection) for on-line submission of self-reported incidents (SRI). Review of the Department of Health website for on-line submission was silent to evidence the facility had completed the SRI on-line submission for the two identified incidents of physical altercations involving Resident #80 and evidenced non-compliance with the policy of reporting all allegations of alleged, suspected or observed mistreatment of a resident. Interview on 08/22/19 at 1:20 P.M. with Registered Nurse #120, the director of nursing and the administrator revealed the corporate policy was not to report resident to resident altercations between dementia residents. The facility staff did an internal incident report on altercations but was under the impression they did not need to be reported as a self-reported incident since the dementia residents were not capable of willful actions due to their cognitive status. Based on medical record review, staff interviews and review of the facility's abuse policy the facility failed to report incidents of resident to resident abuse to the State agency. This affected four (Residents #3, #12, #19, and #80) of six residents reviewed for resident to resident abuse. Findings include: 1. Review of the medial record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of dementia with behavioral disturbance, Alzheimer's disease, pseudobulbar, hypertension, muscle weakness, urinary tract infections and bipolar schizophrenic disorder. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #19 had severely impaired cognition and wandering behaviors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365715 If continuation sheet Page 13 of 23 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 365715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Mary's Alzheimer's Center 1899 Garfield Rd Columbiana, OH 44408 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of discontinued orders revealed Resident #19 had a discontinued order dated 06/12/19 for 15 minutes checks for one week, an order dated 06/13/19 for a urinalysis and culture and sensitivity (C&S), and an order discontinued on 11/09/18 for Haldol (antipsychotic) five milligram (mg) at 4:00 P.M. and start 2 mg daily. Review of a physician's telephone order dated 01/13/19 revealed to hold Resident #19's Nuedexta (mood stabilizer) until available, an ordered dated 02/17/19 to hold the Nuedexta until it was available from the pharmacy. The Neudexta was discontinued on 02/21/19. Review of progress notes dated 04/10/19 at 10:36 P.M. revealed Resident #19 and another resident were seen in south hallway slapping each other with open hands in the arms and shoulders. The residents were separated, and their safety maintained. Resident #19 stated she was slapped on the right cheek. She had no apparent injuries and denied pain. The Power of Attorney (POA) was unable to be reached because he did not have an answering machine set up. A message was left at an alternate contact. Review of a progress note dated 04/26/19 at 11:30 A.M. revealed Resident #19 was observed by a staff member pushing another resident in their wheelchair, when the other resident asked Resident #19 to stop pushing her Resident #19 slapped the other resident on the right side of the face. The residents were separated, and their safety was maintained. Resident #19 was brought to the south nurse's station. Review of a progress note dated 04/26/19 at 5:05 P.M. revealed Resident #19 and another resident grabbed onto each other's hands squeezing aggressively facing each other. The residents were separated to maintained safety. Review of the progress note dated 06/13/19 at 11:50 A.M. revealed Resident #19 walked up to another female resident, who was sitting in a wheelchair. The resident screamed and Resident #19 struck the seated resident on the left cheek with open hand. The residents were immediately separated without difficulty. Review of a progress note dated 06/13/19 at 1:42 P.M. revealed the physician was updated regarding Resident #19's behavioral issues and he was updated on most recent encounter with another resident. The physician ordered to obtain a urine for culture and sensitivity (C&S). The son was unable to be reach because he had no voicemail set up. Review of a progress notes dated 06/30/19 at 6:15 P.M. revealed Resident #19 was observed by staff hitting another resident in the face with an open hand. The residents were separated, and their safety was maintained. There were no apparent injuries. The POA for Resident #19 was updated. Review on a progress note dated 06/30/19 at 9:54 P.M. revealed Resident #19 walked over to another resident who was sitting in a chair and smacked the resident on the hand. The residents were separated, and their safety was maintained. The family and physician were notified. Review of a progress note dated 07/15/19 at 2:36 P.M. revealed Resident #19 was pushing another resident in her wheelchair and the other resident told the resident to stop and she would not. The residents began swinging at each other and Resident #19 hit the other resident on top of the head. The residents were separated, and their safety was maintained. A message was left for the POA and the physician was notified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365715 If continuation sheet Page 14 of 23 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 365715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Mary's Alzheimer's Center 1899 Garfield Rd Columbiana, OH 44408 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 0609 Level of Harm - Minimal harm or potential for actual harm Review of a progress note dated 07/16/19 at 11:21 A.M. revealed Resident #19 had a new order for Depakote (mood stabilizer) 125 milligrams three times a day. Review of physician orders revealed Resident #19 had an order dated 07/16/19 for Depakote sprinkles 125 mg three times a day for dementia with behavioral disturbance. Residents Affected - Some Review of the Physician's progress note dated 07/21/19 revealed during the last week Resident #19 was having episodes of aggressive behavior towards others, slapping. At this time, she is very docile. She has no evidence of a urinary tract infection. She was on Depakote 125 mg and we will check her level soon. Haldol was to be continue. Review on a Plan of Care dated 07/22/19 revealed Resident #19 had a potential to be physically aggressive towards other residents due to her dementia. The resident had altercations with other residents. Interventions included: 15 minutes checks; administer medications as ordered; analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document; assess and anticipate resident's needs; provide physical and verbal cues to alleviate anxiety; give positive feedback; assist verbalization of the source of the agitation; assist to set goals for more pleasant behavior; encourage seeking out of staff member when agitated; give the resident as many choices as possible about care and activities; monitor and document observed behavior and attempted interventions in behavior log; and when the resident becomes agitated intervene before agitation escalates, guide the resident away from the source of distress, engage calmly in conversation and if the response was aggressive the staff was to calmly walk away and re-approach later. Review of a progress note dated 07/22/19 at 1:19 P.M. revealed Resident #19 was observed by staff standing over another female resident in main dining room, who was in a wheelchair. Resident #19 was slapping the other female resident repeatedly on both sides of her face and head. There were no visible signs of injury to either resident. The residents were separated, and their safety was maintained. The resident's POA and physician were notified. The physician ordered for Resident #19 to have 15-minute checks due to her behaviors. Review of physician orders revealed an order dated 07/23/19 for 15-minutes checks. Review of a progress note dated 07/25/19 at 10:49 A.M. revealed the physician was updated on the incident between Resident #19 and another resident. New orders were received to increase her Haldol dosage to twice daily. The son does not give consent for psychiatric services. A message was left for the son to update him on the new orders. Review of a progress note dated 07/25/19 at 1:01 P.M. revealed Resident #19 slapped another resident and there were no injuries to either resident. Review of physician orders dated 07/25/19 revealed an order for Haldol two mg twice daily. Review of a progress note dated 07/28/19 at 5:56 P.M. revealed Resident #19 was seen coming out of another resident's room with another resident. Resident #19 was punching the other resident repeatedly in the back. The residents were separated. There were no apparent injuries to Resident #19 and Resident #19 denied pain. When the resident was asked what happened the resident replied, she pounded on me, so I pounded on her. A message was left for the resident's POA. Review of a progress note dated 07/29/19 at 4:25 P.M. revealed Resident #19 walked up to another (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365715 If continuation sheet Page 15 of 23 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 365715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Mary's Alzheimer's Center 1899 Garfield Rd Columbiana, OH 44408 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some female resident who was sitting in a chair and slapped the resident in the face. The residents were separated, and their safety maintained. There were no injuries to either residents. Review on a behavior note dated 08/01/19 at 5:31 P.M. revealed Resident #19 slapped another resident on the hand, the resident's hand was sitting on the table. The residents were separated, and safety was maintained. The interventions were effective. A message was left for the POA and the physician was notified. Review of the behavior note dated 08/07/19 at 7:05 P.M. revealed Resident #19 had physical aggression towards other residents. Interventions attempted were redirection and one on one which were slightly effective. The physician was notified, and a message was left for the resident's POA to return the call to the facility. Review of a progress note dated 08/07/19 at 10:13 P.M. revealed Resident #19 had a new order for Nuedexta 20/10 mg every day. Review of physician orders dated 08/07/19 revealed an order for Nuedexta 20/10 mg at bedtime related to dementia with behavioral disturbance. Review of the progress note dated 08/08/19 at 11:15 A.M. revealed the son of Resident #19 reported he has had some significant health problems and was in hospital for several weeks. He was updated on the incidents that had occurred over the last couple months and the resident's new orders. The facility requested consideration for psychiatric services due to her ongoing behaviors. The son indicated he wished to consult with the physician before approving any psychiatric consult. Review of progress notes dated 08/14/19 at 1:36 P.M. revealed the son of Resident #19 had not reached the physician about psychiatric services and would try again tomorrow. An interview on 08/20/19 at 1:23 P.M. with the Administrator indicated she did not file any Self-Reported (SRI) incidents related Resident #19's physical abuse of other residents. An interview on 08/20/19 at 2:06 P.M. with Registered Nurse #810 indicated there were not any SRIs completed because the residents all had dementia and there were no injuries. An interview on 08/20/19 at 2:48 P.M. with Licensed Practical Nurse (LPN) #806 indicated there were no witness statements for any of the incidents and she did not believe any SRIs were completed on any of the incidents with Resident #19. An interview on 08/22/19 at 2:15 P.M. with State Tested Nursing Assistant (STNA) #800 indicated one-minute Resident #19 could be so sweet then the next minute she would be beating you. The resident would kick and hit with care. STNA #800 said Resident #19 had hit other residents. They would remove her from the situation and take her to the nurse. She indicated Resident #19 was on 15-minute checks. An interview on 08/22/19 at 2:18 P.M. with STNA #802 indicated Resident #19 was physically aggressive towards the staff and other residents. She indicated they had two behavior technicians who worked a couple times a week and they would redirect her. An interview on 08/22/19 at 2:20 P.M. with STNA #804 indicated Resident #19 had aggressive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365715 If continuation sheet Page 16 of 23 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 365715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Mary's Alzheimer's Center 1899 Garfield Rd Columbiana, OH 44408 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some behaviors towards staff and other residents and was not easily redirected. The staff attempted one on one with her when she was being aggressive. She indicated she had witnessed Resident #19 hit other residents. Review on the facility policy, Resident Abuse Prevention Practices, dated October 2017 revealed it was the policy of the company to protect all residents from mistreatment, neglect, abuse, and misappropriation of resident property. This included protection of all residents from verbal, mental, physical, emotional, or financial abuse by staff, families, visitors or outside ancillary service employees or in any situation that would be harmful to the resident. This also included protection against corporal punishment, involuntary seclusion, or exploitation of residents. Abuse was defined as knowingly causing physical harm or recklessly causing physical harm to a resident by use of physical contact with the resident or chemical restraint, medication, or isolation as punishment, for staff convenience, excessively, as a substitute for treatment, or in amounts that preclude habilitation and treatment. Abuse was also defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, mental anguish, or deprivation by an individual, including a caretaker, of goods or services necessary to attain physical, mental, and psychosocial well-being. (Willful: the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm). The assessment and care plan process would identify and address residents with needs and behaviors which may lead to conflict or abuse. Abuse could be identified through reviewing and monitoring unusual incidents, bruising, skin tears, or behavior changes and monitoring events for patterns or trends such as shift, staff assignment, unit/location, etc. Monitoring staff for signs of stress, burnout, personal problems, or the inability to manage stress. Alleged, suspected, or observed abuse, neglect, and/or mistreatment of a resident and/or their belongings would be thoroughly investigated by the Administrator and the Director of Nursing or the designee. Alleged and suspected violations were to be reported immediately to the Department of Health using the Enhanced Information Dissemination Collection (EIDC) for on-line submission of self-reported incident and to the Corporate Quality Assurance Performance and Improvement department and/or the Corporate Attorney. In the case of any employee being suspected of allegedly abusing, neglecting, or mistreating a resident, the Administrator, Director of Nursing, Assistant Director of Nursing (where applicable), or Nursing Supervisor, in that order would suspend that individual of his/her duties until the investigation was complete. The investigation would begin immediately after receiving a complaint of abuse. The resident would be examined for injury at the time of complaint, and appropriate medical attention given as necessary. Written statements would be taken from anyone involved or witnessing the event. A plan of support for the resident would be initiated. The residents and/or their representative would be notified of the allegation and would be updated on the investigation and the final results of the investigation. 2. Record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, Parkinson's disease, anxiety disorder and psychotic disorder with hallucinations. The Minimum Data Set assessment dated [DATE] revealed Resident #12 had severe cognitive impairment and physically aggressive behaviors towards others. He required limited assistance by staff for bed mobility, transfers and extensive assistance by staff for dressing, toileting and hygiene. Review of the Progress Notes from 01/05/19 to 07/13/19 revealed Resident #12 had acted out aggressively toward his room mate on 01/05/19 by putting a blanket over his head; on 02/24/19 he made statements he was going to kill someone; on 03/07/19 he was looking to fight someone; 03/21/19 showed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365715 If continuation sheet Page 17 of 23 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 365715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Mary's Alzheimer's Center 1899 Garfield Rd Columbiana, OH 44408 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 0609 Level of Harm - Minimal harm or potential for actual harm aggression toward others; and on 06/27/19 he was sent to a psychiatric hospital for punching Resident #59 in the face with a closed fist ejecting her glasses from her face causing abrasions, discoloration and facial pain. Resident #12 returned to the facility on [DATE] with an order to be on every 15 minute checks. On 07/12/19 he made verbal threats to hit another resident and on 07/13/19 he made statements he was going to kill others. Residents Affected - Some Record review revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including vascular dementia with behavioral disturbance. The Minimum Data Set assessment dated [DATE] revealed Resident #59 had severe cognitive impairment and needed extensive assistance by staff for bed mobility, transfers and toileting and total staff assistance for hygiene. An interview on 08/22/19 at 1:33 P.M. with Licensed Practical Nurse (LPN) #965 verified Resident #12 was on every 15 minute checks due to known physical aggression towards staff and other residents. LPN #965 indicated Resident #12 had a history of physically attacking other residents but had not done so for several weeks. Review of a Progress Note dated 06/25/19 authored by LPN #967 at 10:10 A.M. revealed Resident #59 was punched in the face by a closed fist of Resident #12 resulting in swelling and dark discoloration area measuring four centimeters (cm) by two cm and a one cm by one cm abrasion to the bridge of her nose where glasses were ejected from her face. Review of a Progress Note dated 06/25/19 at 5:31 P.M. authored by LPN #967 revealed Resident #59 was experiencing pain during manipulation of her head for an x-ray and was medicated with Tylenol. Review of a Progress Noted dated 06/25/19 at 10:32 P.M. authored by LPN #967 revealed Resident #39's x-rays of nasal and facial bones were negative for fractures. An interview on 08/22/19 at 1:24 P.M. with Registered Nurse (RN) #810 revealed the facility had not considered physical attacks as reportable incidents due to the nature of dementia and the facility did not consider it willful physical aggression. RN #810 verified Resident #59 had been punched in the face by Resident #12 and did sustain injuries requiring head x-rays and pain medication. Review of the facility document titled Summary Report, dated 06/26/19, authored by LPN #806 revealed at 10:10 A.M. it was noted Resident #12 was involved in a resident to resident altercation with a female resident (Resident #59) where he drew his arm back and struck Resident #59 in the face with a closed fist. Review of the document titled Resident Abuse Prevention Practices, dated October 2017 revealed it was the policy of the company to protect all residents from mistreatment, neglect, abuse, and misappropriation of property. 3. Record review revealed Resident #3 was admitted on [DATE] with diagnoses including but not limited to dysphasia, delusional disorder, generalized anxiety disorder, Alzheimer's disease and major depressive disorder. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was severely cognitively impaired with no behaviors, required extensive assist of two for activities of daily living and supervision only for ambulation. Review of the progress note of 03/19/19 revealed Resident #3 was found by staff on the hallway by the south unit shower room hitting another female resident (Resident #54) repeatedly in the head. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365715 If continuation sheet Page 18 of 23 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 365715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Mary's Alzheimer's Center 1899 Garfield Rd Columbiana, OH 44408 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some When staff tried to intervene, the other resident hit Resident #3 in the face. Staff separated the residents. Neither resident sustained any injury. Review of the progress note dated 04/26/19 revealed Resident #3 was in the south hallway with her arms around another resident squeezing the other resident's hand aggressively and yelling. There was no injury to the other resident. Review of the progress note dated 04/30/19 revealed Resident #3 was found yelling in the south hallway and being verbally and physically aggressive with staff and another resident (Resident #78). Resident #3 scratched the other resident. Review of the care plan dated 08/12/19 revealed care areas for behaviors, wandering, and communication problem due to cognitive loss. Interview on 08/22/19 at 1:20 P.M. with Registered Nurse #120, the director of nursing and the administrator revealed the corporate policy was not to report resident to resident altercations between dementia residents. The facility staff did an internal incident report on altercations but was under the impression they did not need to be reported as a self-reported incident since the dementia residents were not capable of willful actions due to their cognitive status. Review of the document titled Resident Abuse Prevention Practices, dated October 2017 revealed it was the policy of the company to protect all residents from mistreatment, neglect, abuse, and misappropriation of property. This document stated, under section V-Investigation, alleged, suspected, or observed, and/or mistreatment of a resident and or their belongings are thoroughly investigated by the Administrator and the Director of Nursing or the designee. Alleged and suspected violations are reported immediately to the Department of Health using EIDC (Enhanced Information and Dissemination and Collection) for on-line submission of self-reported incidents (SRI). Review of the Department of Health website for on-line submission of a SRI was silent to any evidence of the alleged abuse related to Resident #3 and the three identified events of physical altercations and resident to resident abuse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365715 If continuation sheet Page 19 of 23 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 365715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Mary's Alzheimer's Center 1899 Garfield Rd Columbiana, OH 44408 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of the facility's abuse policy the facility failed to thoroughly investigate resident to resident abuse. This affected one (Resident #19) of six residents reviewed for resident to resident abuse. Residents Affected - Few Findings included: 1. Review of the medial record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of dementia with behavioral disturbance, Alzheimer's disease, pseudobulbar, hypertension, muscle weakness, urinary tract infections and bipolar schizophrenic disorder. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #19 had severely impaired cognition and wandering behaviors. Review of discontinued orders revealed Resident #19 had a discontinued order dated 06/12/19 for 15 minutes checks for one week, an order dated 06/13/19 for a urinalysis and culture and sensitivity (C&S), and an order discontinued on 11/09/18 for Haldol (antipsychotic) five milligram (mg) at 4:00 P.M. and start 2 mg daily. Review of a physician's telephone order dated 01/13/19 revealed to hold Resident #19's Nuedexta (mood stabilizer) until available, an ordered dated 02/17/19 to hold the Nuedexta until it was available from the pharmacy. The Neudexta was discontinued on 02/21/19. Review of progress notes dated 04/10/19 at 10:36 P.M. revealed Resident #19 and another resident were seen in south hallway slapping each other with open hands in the arms and shoulders. The residents were separated, and their safety maintained. Resident #19 stated she was slapped on the right cheek. She had no apparent injuries and denied pain. The Power of Attorney (POA) was unable to be reached because he did not have an answering machine set up. A message was left at an alternate contact. Review of a progress note dated 04/26/19 at 11:30 A.M. revealed Resident #19 was observed by a staff member pushing another resident in their wheelchair, when the other resident asked Resident #19 to stop pushing her Resident #19 slapped the other resident on the right side of the face. The residents were separated, and their safety was maintained. Resident #19 was brought to the south nurse's station. Review of a progress note dated 04/26/19 at 5:05 P.M. revealed Resident #19 and another resident grabbed onto each other's hands squeezing aggressively facing each other. The residents were separated to maintained safety. Review of the progress note dated 06/13/19 at 11:50 A.M. revealed Resident #19 walked up to another female resident, who was sitting in a wheelchair. The resident screamed and Resident #19 struck the seated resident on the left cheek with open hand. The residents were immediately separated without difficulty. Review of a progress note dated 06/13/19 at 1:42 P.M. revealed the physician was updated regarding Resident #19's behavioral issues and he was updated on most recent encounter with another resident. The physician ordered to obtain a urine for culture and sensitivity (C&S). The son was unable to be reach because he had no voicemail set up. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365715 If continuation sheet Page 20 of 23 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 365715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Mary's Alzheimer's Center 1899 Garfield Rd Columbiana, OH 44408 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a progress notes dated 06/30/19 at 6:15 P.M. revealed Resident #19 was observed by staff hitting another resident in the face with an open hand. The residents were separated, and their safety was maintained. There were no apparent injuries. The POA for Resident #19 was updated. Review on a progress note dated 06/30/19 at 9:54 P.M. revealed Resident #19 walked over to another resident who was sitting in a chair and smacked the resident on the hand. The residents were separated, and their safety was maintained. The family and physician were notified. Review of a progress note dated 07/15/19 at 2:36 P.M. revealed Resident #19 was pushing another resident in her wheelchair and the other resident told the resident to stop and she would not. The residents began swinging at each other and Resident #19 hit the other resident on top of the head. The residents were separated, and their safety was maintained. A message was left for the POA and the physician was notified. Review of a progress note dated 07/16/19 at 11:21 A.M. revealed Resident #19 had a new order for Depakote (mood stabilizer) 125 milligrams three times a day. Review of physician orders revealed Resident #19 had an order dated 07/16/19 for Depakote sprinkles 125 mg three times a day for dementia with behavioral disturbance. Review of the Physician's progress note dated 07/21/19 revealed during the last week Resident #19 was having episodes of aggressive behavior towards others, slapping. At this time, she is very docile. She has no evidence of a urinary tract infection. She was on Depakote 125 mg and we will check her level soon. Haldol was to be continue. Review on a Plan of Care dated 07/22/19 revealed Resident #19 had a potential to be physically aggressive towards other residents due to her dementia. The resident had altercations with other residents. Interventions included: 15 minutes checks; administer medications as ordered; analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document; assess and anticipate resident's needs; provide physical and verbal cues to alleviate anxiety; give positive feedback; assist verbalization of the source of the agitation; assist to set goals for more pleasant behavior; encourage seeking out of staff member when agitated; give the resident as many choices as possible about care and activities; monitor and document observed behavior and attempted interventions in behavior log; and when the resident becomes agitated intervene before agitation escalates, guide the resident away from the source of distress, engage calmly in conversation and if the response was aggressive the staff was to calmly walk away and re-approach later. Review of a progress note dated 07/22/19 at 1:19 P.M. revealed Resident #19 was observed by staff standing over another female resident in main dining room, who was in a wheelchair. Resident #19 was slapping the other female resident repeatedly on both sides of her face and head. There were no visible signs of injury to either resident. The residents were separated, and their safety was maintained. The resident's POA and physician were notified. The physician ordered for Resident #19 to have 15-minute checks due to her behaviors. Review of physician orders revealed an order dated 07/23/19 for 15-minutes checks. Review of a progress note dated 07/25/19 at 10:49 A.M. revealed the physician was updated on the incident between Resident #19 and another resident. New orders were received to increase her Haldol dosage to twice daily. The son does not give consent for psychiatric services. A message was left for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365715 If continuation sheet Page 21 of 23 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 365715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Mary's Alzheimer's Center 1899 Garfield Rd Columbiana, OH 44408 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 0610 the son to update him on the new orders. Level of Harm - Minimal harm or potential for actual harm Review of a progress note dated 07/25/19 at 1:01 P.M. revealed Resident #19 slapped another resident and there were no injuries to either resident. Residents Affected - Few Review of physician orders dated 07/25/19 revealed an order for Haldol two mg twice daily. Review of a progress note dated 07/28/19 at 5:56 P.M. revealed Resident #19 was seen coming out of another resident's room with another resident. Resident #19 was punching the other resident repeatedly in the back. The residents were separated. There were no apparent injuries to Resident #19 and Resident #19 denied pain. When the resident was asked what happened the resident replied, she pounded on me, so I pounded on her. A message was left for the resident's POA. Review of a progress note dated 07/29/19 at 4:25 P.M. revealed Resident #19 walked up to another female resident who was sitting in a chair and slapped the resident in the face. The residents were separated, and their safety maintained. There were no injuries to either residents. Review on a behavior note dated 08/01/19 at 5:31 P.M. revealed Resident #19 slapped another resident on the hand, the resident's hand was sitting on the table. The residents were separated, and safety was maintained. The interventions were effective. A message was left for the POA and the physician was notified. Review of the behavior note dated 08/07/19 at 7:05 P.M. revealed Resident #19 had physical aggression towards other residents. Interventions attempted were redirection and one on one which were slightly effective. The physician was notified, and a message was left for the resident's POA to return the call to the facility. Review of a progress note dated 08/07/19 at 10:13 P.M. revealed Resident #19 had a new order for Nuedexta 20/10 mg every day. Review of physician orders dated 08/07/19 revealed an order for Nuedexta 20/10 mg at bedtime related to dementia with behavioral disturbance. Review of the progress note dated 08/08/19 at 11:15 A.M. revealed the son of Resident #19 reported he has had some significant health problems and was in hospital for several weeks. He was updated on the incidents that had occurred over the last couple months and the resident's new orders. The facility requested consideration for psychiatric services due to her ongoing behaviors. The son indicated he wished to consult with the physician before approving any psychiatric consult. Review of progress notes dated 08/14/19 at 1:36 P.M. revealed the son of Resident #19 had not reached the physician about psychiatric services and would try again tomorrow. An interview on 08/20/19 at 2:48 P.M. with Licensed Practical Nurse (LPN) #806 indicated there were no witness statements of any of the incidents with Resident #19. An interview on 08/22/19 at 2:15 P.M. with State Tested Nursing Assistant (STNA) #800 indicated one-minute Resident #19 could be so sweet then the next minute she would be beating you. The resident would kick and hit with care. STNA #800 said Resident #19 had hit other residents. They would remove her from the situation and take her to the nurse. She indicated Resident #19 was on 15-minute (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365715 If continuation sheet Page 22 of 23 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 365715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Mary's Alzheimer's Center 1899 Garfield Rd Columbiana, OH 44408 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 0610 checks. Level of Harm - Minimal harm or potential for actual harm An interview on 08/22/19 at 2:18 P.M. with STNA #802 indicated Resident #19 was physically aggressive towards the staff and other residents. She indicated they had two behavior technicians who worked a couple times a week and they would redirect her. Residents Affected - Few An interview on 08/22/19 at 2:20 P.M. with STNA #804 indicated Resident #19 had aggressive behaviors towards staff and other residents and was not easily redirected. The staff attempted one on one with her when she was being aggressive. She indicated she had witnessed Resident #19 hit other residents. Review on the facility policy, Resident Abuse Prevention Practices, dated October 2017 revealed it was the policy of the company to protect all residents from mistreatment, neglect, abuse, and misappropriation of resident property. This included protection of all residents from verbal, mental, physical, emotional, or financial abuse by staff, families, visitors or outside ancillary service employees or in any situation that would be harmful to the resident. This also included protection against corporal punishment, involuntary seclusion, or exploitation of residents. Abuse was defined as knowingly causing physical harm or recklessly causing physical harm to a resident by use of physical contact with the resident or chemical restraint, medication, or isolation as punishment, for staff convenience, excessively, as a substitute for treatment, or in amounts that preclude habilitation and treatment. Abuse was also defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, mental anguish, or deprivation by an individual, including a caretaker, of goods or services necessary to attain physical, mental, and psychosocial well-being. (Willful: the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm). The assessment and care plan process would identify and address residents with needs and behaviors which may lead to conflict or abuse. Abuse could be identified through reviewing and monitoring unusual incidents, bruising, skin tears, or behavior changes and monitoring events for patterns or trends such as shift, staff assignment, unit/location, etc. Monitoring staff for signs of stress, burnout, personal problems, or the inability to manage stress. Alleged, suspected, or observed abuse, neglect, and/or mistreatment of a resident and/or their belongings would be thoroughly investigated by the Administrator and the Director of Nursing or the designee. Alleged and suspected violations were to be reported immediately to the Department of Health using the Enhanced Information Dissemination Collection (EIDC) for on-line submission of self-reported incident and to the Corporate Quality Assurance Performance and Improvement department and/or the Corporate Attorney. In the case of any employee being suspected of allegedly abusing, neglecting, or mistreating a resident, the Administrator, Director of Nursing, Assistant Director of Nursing (where applicable), or Nursing Supervisor, in that order would suspend that individual of his/her duties until the investigation was complete. The investigation would begin immediately after receiving a complaint of abuse. The resident would be examined for injury at the time of complaint, and appropriate medical attention given as necessary. Written statements would be taken from anyone involved or witnessing the event. A plan of support for the resident would be initiated. The residents and/or their representative would be notified of the allegation and would be updated on the investigation and the final results of the investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365715 If continuation sheet Page 23 of 23