Inspection·October 31, 2022

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of self-reported incident (SRI), review of the facility investigation, staff interviews and facility policy review, the facility failed to ensure one resident (#73) was free from physical and verbal abuse. This affected one of one resident reviewed for abuse. The facility census was 76. Findings Included: Review of the medical record for Resident #73 revealed an initial admission date of 02/02/22 with the admitting diagnoses including chronic obstructive pulmonary disease, cervicalgia, generalized weakness, difficulty in walking, repeated falls, reduced mobility, chronic respiratory failure, low back pain, arthritis, asthma, hypertension, fecal impaction, hypothyroidism, hyperlipidemia and personal history of COVID-19. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #73 had no cognitive deficit as indicated by a Brief Interview for Mental Status of 15. The resident required extensive assistance of two staff for bed transfer, bed mobility and ambulation. The assessment indicated the resident was frequently incontinent of both bowel and bladder. Review of SRI tracking number 220857 and dated 04/27/22 revealed Resident #73 had reported Former State Tested Nursing Assistant (FSTNA) #200 was rough when providing care and made an inconsiderate verbal statement to the resident. The SRI indicated the resident felt FSTNA #200 could have been nicer. The resident reported to unidentified nurse that FSTNA #200 was not nice to her. The resident revealed the FSTNA told her she was unable to get her job done because she was always taking care of her. The resident revealed the FSTNA was rough with her legs when assisting her. The resident revealed the FSTNA had been nicer recently and was doing a good job but now isn't again. The resident was assessed with no signs of redness or bruising related to rough treatment. Other residents were interviewed with residents (#12, #26, #29, #39, #52 and #60) stating the State Tested Nursing Assistant (STNA) was not nice, was lazy and acted like providing care to residents was a burden. Those residents who were not interviewable were assessed with no signs of redness or bruising indicating rough treatment. FSTNA #200 was suspended pending the outcome of the investigation. The witness's initial statement on 04/28/22 indicated no abuse had occurred while the witness's statement on 04/29/22 verified the resident's allegation. The facility immediately terminated FSTNA #200 from employment on 04/29/22. The witness was reeducated on the facility's abuse prevention policy. The facility substantiated the allegation of physical abuse and emotional/verbal abuse. Review of STNA #150's witness statement dated 04/29/22 revealed the STNA entered Resident #73's room with FSTNA #200 to provide incontinence care. The STNA revealed the resident rolled towards FSTNA #200 and rolled her leg a little to far off of the edge of the bed. STNA #150 revealed she instructed the resident to roll back to her and FSTNA #200 shoved the resident's leg back and the resident started crying. The statement indicated STNA #150 was afraid to report the allegation while the FSTNA #200 was on duty but felt FSTNA #200 was intentionally trying to hurt Resident #73. Interview on 10/27/22 at 3:01 P.M. with the Director of Nursing (DON) revealed STNA #150 reported FSTNA #200 was rough with Resident #73 when they were turning her. The DON revealed STNA #150 and Resident #73 reported the same allegation. The DON also revealed through interview with residents and staff members the allegation of abuse was substantiated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 2 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy titled, Abuse, Neglect and Misappropriation of Resident Property, dated 11/16 revealed it was the facility's policy to investigate all alleged violations involving abuse, neglect, mistreatment of a resident or misappropriation of resident property, including injury of unknown origin. If a staff member is accused or suspected of abuse, neglect, mistreatment of a resident or misappropriation of resident property, the facility should remove that staff member from the facility and the schedule pending the outcome of the investigation. all incidents and allegations of abuse, neglect, mistreatment of a resident or misappropriation of resident property shall have evidence that alleged violations are thoroughly investigated. If the alleged violation is verified appropriate corrective action must be taken. Event ID: Facility ID: 365721 If continuation sheet Page 3 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, staff interview and facility policy review, the facility failed to ensure one resident (#66) was free from restraints. This affected one of one resident reviewed for restraints. The facility census was 76. Residents Affected - Few Findings Include: Review of the medical record for Resident #66 revealed an initial admission date of 06/21/22 with the latest readmission of 08/15/22 with the admitting diagnoses including dementia with severe agitation, protein calorie malnutrition, fracture of the sacrum, fracture of the rim of the right pubis, schizoaffective disorder, fracture of fifth lumbar, hyperlipidemia, chronic atrial fibrillation, anxiety disorder, gastro-esophageal reflux disease, low back pain, fracture of left pubis, nondisplaced fracture of zone one of sacrum, encephalitis, anemia, vascular dementia, herpes virus vesicular dermatitis, hypothyroidism, major depressive disorder, allergic rhinitis, osteoarthritis and hypertension. Review of the plan of care dated 08/17/22 revealed the resident used a physical restraint, tilt-n-space wheelchair related to comfort, bed/chair alarm and stop sign to door. Interventions included discuss and record with the resident/family/caregivers the risks and benefits of the restraint, when the restraint should/will be applied, routines while restrained and any concerns or issues regarding restraint use. Monitor/document/report as needed any changes regarding effectiveness of restraint, less restrictive device, if appropriate, any negative or adverse effects noted, including decline in mood, change in behavior, decrease in activities of daily living self performance, decline in cognitive ability or communication, skin breakdown and increased agitation. Review of the resident's medical record revealed a hand written physician's order dated 10/26/22 may be up in merry-walker as tolerated. Further review revealed the physician discontinued the merry-walker on 10/26/22 and wrote discontinue above order until evaluated. Review of the resident's medical record revealed no evidence assessments were completed addressing the use of the merry-walker as a restraint. Review of the resident's medical record revealed no documented evidence the resident's family provided consent for the use of the merry-walker. On 10/26/22 at 10:06 A.M., observation of Resident #66 revealed the resident was sitting in a merry walker at the nurses station with Licensed Practical Nurse (LPN) #15 while at medication cart. The resident was observed standing then sitting continuously. The resident was also observed trying to remove the straps between her legs. Interview with LPN #15 at the time of the observation revealed the staff alternate the resident from her wheelchair to the merry-walker so she can walk. Interview on 10/27/22 at 12:20 P.M. with the Director of Nursing (DON) revealed the physician visited the facility on 10/26/22. She revealed during the visit, the nurse had requested an order for the merry-walker for the resident. She revealed the physician had given the order so they placed her in the merry-walker. She revealed once she saw the resident in the merry-walker she educated the nurse on the assessments and the process of the implementation of the merry-walker. She revealed the order was then discontinued. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 4 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy titled, Use of Restraints, dated 04/17 revealed restraints shall only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. Prior to placing a resident in restraints there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions that may improve the symptoms. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. the order shall include the following, the specific reason for the restraint (as it relates to the resident's medical symptom), how the restraint will be used to benefit the resident's medical symptom and the type of restraint, and period of time for the use of the restraint. Event ID: Facility ID: 365721 If continuation sheet Page 5 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #63's medical record revealed she was admitted on [DATE]. Diagnoses included dementia, severe calorie malnutrition, cognitive communication deficit, anxiety. Residents Affected - Few Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed her cognition was not intact. She required extensive assistance with assistance of two or more staff for bed mobility, transfers, dressing, and personal hygiene. She required total dependence of two or more staff members for toileting. A fall was identified with no injury, injury (except major) and major injury. Review of the physician's orders for 10/22 revealed orders for a mat to the floor on the left side of bed, and the right side of the bed against the wall. Review of the plan of care revealed Resident#63 was at risk for falls with interventions of a mat to the floor on the left side of bed, and the right side of the bed against the wall, call light in reach, bed in low position and a DPM (Defined Perimeter Mattress). Review of the progress notes revealed Resident #63 had a fall on 02/02/22 and on 05/27/22. No injuries were noted with either fall. On 10/26/22 at 10:56 A.M. interview with Registered Nurse (RN) #80 verified the quarterly MDS dated [DATE] is incorrect in Section J. Based on record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately in the areas of active diagnoses, falls, and range of motion. This affected three (Resident #40, #46, and #63) of 24 residents reviewed for assessments. Findings include: 1. A review of Resident #46's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included protein- calorie malnutrition. The diagnosis was added to her diagnoses list on 09/07/22. A review of Resident #46's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed section (I.) coded the resident's active diagnoses. The section for nutritional diagnoses (I 5600) included a place to code malnutrition (protein or calorie) as an active diagnosis, but it was not marked despite the resident having that diagnosis since 09/07/22. On 10/27/22 at 10:02 A.M., an interview with the Director of Nursing (DON) was held and she was informed Resident #46's quarterly MDS assessment was not completed accurately as her active diagnoses did not include the diagnosis of protein- calorie malnutrition. She acknowledged the diagnosis of protein- calorie malnutrition was given on 09/07/22 and should have been indicated on the quarterly MDS assessment completed on 09/14/22. 2. Review of the medical record for Resident #40 revealed an initial admission date of 04/07/21 with the admitting diagnoses of dementia, reduced mobility, schizoaffective disorder, allergic rhinitis, dysphagia, personal history of COVID-19, pseudobulbar affect, hypertension, obesity, anemia, polyneuropathy, anxiety disorder, bipolar disorder, major depressive disorder and generalized muscle (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 6 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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 0641 weakness. Level of Harm - Minimal harm or potential for actual harm Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive impairment. The resident was dependent on two staff for activities of daily living. The assessment indicated the resident had no deficits in range of motion to upper or lower extremities. The assessment indicated the resident received passive range of motion (PROM) and splint/brace restorative nursing services seven days a week. Residents Affected - Few Review of the plan of care dated 04/07/21 revealed the resident had an ADL self-care performance deficit and potential for fluctuations in ADL due to dementia. Interventions included resting splints to bilateral upper extremities with morning care, remove with bedtime care, perform range of motion and hand care prior to applying hand splints daily for 15 minutes, check splints every two hours and restorative passive range of motion to all extremities daily for 15 minutes. Review of the monthly physician's orders for October 2022 identified orders dated 03/29/22 for restorative PROM to all extremities daily for 15 minutes, restorative palm protector to bilateral upper extremities with the special instructions to apply with bed time care and remove with morning care. Perform range of motion and skin care prior to applying palm protector daily for 15 minutes and check every two hours, 04/14/22 resting hand splints to bilateral upper extremities with the special instructions to apply with morning care and remove with bedtime care. Perform range of motion and skin care prior to applying hand splints daily for 15 minutes, check every two hours. Review of the physical therapy (PT) evaluation and treat dated 05/23/22 revealed the resident had impaired ROM to the bilateral lower extremities. On 10/26/22 at 3:25 P.M., interview with the Director of Nursing (DON) verified the inaccurate MDS related to impaired ROM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 7 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Review of Resident #23's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included chronic congestive heart failure (CHF), chronic kidney disease, hypertensive heart disease, diabetes, A-fib and major depression and schizoaffective disorder. Review of the minimum data set (MDS) assessment 08/22/22 revealed his cognition was intact, he required extensive assistance of two or more staff members for bed mobility, transfers, dressing, and toilet use. He required extensive assistance of one staff member for personal hygiene. Resident #23 was admitted with Schizoaffective Disorder, however PASARR dated 08/17/22 revealed the resident was not identified as having had any mental illness diagnoses at the time the assessment was completed. Mood disorder was not marked despite the resident having the diagnoses of schizoaffective disorder and major depressive disorder at the time the PASARR was completed. On 10/25/22 at 1:34 P.M. interview with Social Service Designee #205 revealed she does not do PASARR's, the previous admission person did those, however this one was not updated. On 10/26/22 at 10:22 A.M., an interview with Registered Nurse (RN) #80 revealed the facility did not have a policy specific to PASARR's. They followed the Ohio Administrative Code and she provided a copy of that but it only included the definitions. Based on record review and staff interview, the facility failed to ensure new Pre-admission Screening and Resident Review (PASARR's) were completed for residents receiving new mental illness diagnoses after their admission into the facility. This affected six (Resident #14, #23, #28, #40, #46, and #65) of six residents reviewed for PASARR's. Findings include: 1. A review of Resident #46's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses at the time of her admission included anxiety disorder and bipolar disorder. Her diagnoses list was updated to include the diagnoses of major depressive disorder on 09/13/19 and schizo-affective disorder on 10/26/21. A review of Resident #46's PASARR Identification Screen dated 09/13/18 revealed the resident was not identified as having had any mental illness diagnoses at the time the assessment was completed. A mood disorder was not marked despite the resident having the diagnoses of major depressive disorder and bipolar disorder at the time the PASARR was completed. The PASARR review results dated 10/10/18 revealed the Preadmission Screen (PAS) Determination was not applicable and an in- person assessment was not required. Resident #46's medical record was absent for any evidence of a new PASARR being completed after the resident was diagnosed with schizo-affective disorder on 10/26/21. On 10/26/22 at 10:22 A.M., an interview with Registered Nurse (RN) #80 revealed the facility did not have a policy specific to PASARR's. She reported they followed the Ohio Administrative Code regarding PASARR's. She provided a copy of the Ohio Administrative Codes that pertained to PASARR's but it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 8 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some only included the definitions. She stated she would check Resident #46's medical record to see if she could find evidence another PASARR being completed, after the resident's initial admission into the facility. On 10/26/22 at 10:50 A.M., a follow up interview with RN #80 revealed she was not able to find any evidence of the resident having a new PASARR completed since the initial PASARR was completed on 09/13/18. She confirmed a new PASARR should have been submitted after a new mental illness diagnosis of schizo-affective disorder was provided on 10/26/21. 2. A review of Resident #65's medical record revealed she was admitted to the facility on [DATE]. The resident's diagnoses included major depressive disorder. The diagnoses list was updated to reflect a new mental illness diagnosis of schizo-affective disorder was added on 01/26/22. A PASARR Identification Screen dated 01/22/19 revealed Section (D.) identified indications of serious mental illness. The screener was to mark any of the seven mental disorders (schizophrenia, mood disorder, delusional/ paranoid disorder, panic/ severe anxiety disorder, personality disorder or other psychotic disorders) included in that section the resident was known to have. There was an eighth option to mark another mental disorder other than mental retardation that may lead to a chronic disability. The screener marked to reflect Resident #65 had recurrent major depressive disorder. Resident #65's medical record was absent for any evidence a new PASARR Identification Screen was completed, after 01/22/19, despite the resident receiving the diagnosis of schizo-affective disorder on 01/26/22. On 10/25/22 at 11:45 A.M., an interview with Social Service Director (SSD) # 205 and the Director of Nursing (DON) revealed the facility's Admissions Director was the one who ensured PASARR's were completed for new admissions. If a resident received a new mental illness diagnosis (after they were admitted to the facility), the facility's previous Admissions Coordinator/ social worker was responsible for the completion of a new PASARR Identification Screen. They reported the Admission's Coordinator/ social worker no longer worked at the facility and the facility's Administrator was trying to keep up with those new PASARR's that needed to be completed. They stated they would look to see if they could find evidence of a more recent PASARR Identification Screen being completed. On 10/25/22 at 1:03 P.M., a follow up interview with the DON revealed they were not able to find evidence of Resident #65 having a new PASARR Identification Screen completed, after the diagnosis of schizo-affective disorder was added on 01/26/22. She acknowledged a new PASARR Identification Screen should have been completed after the diagnosis of schizo-affective disorder was added on 01/26/22. 3. Review of the medical record for Resident #40 revealed an initial admission date of 04/07/21 with the admitting diagnoses of dementia, reduced mobility, allergic rhinitis, dysphagia, personal history of COVID-19, pseudobulbar affect, hypertension, obesity, anemia, polyneuropathy, anxiety disorder, bipolar disorder, major depressive disorder and generalized muscle weakness. Further review revealed on 10/26/21 the diagnoses of schizoaffective disorder was added. Review of the medical record revealed the most recent PASARR was completed on 04/12/21. On 10/26/22 at 10:36 A.M. interview with Registered Nurse (RN) #80 verified the significant change PASARR for the schizoaffective disorder added on 10/26/21 was not completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 9 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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 0644 Level of Harm - Minimal harm or potential for actual harm 4. Review of Resident #14's medical record revealed she was initially admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, chronic kidney disease stage one, cardiomyopathy (disease that makes it difficult for the heart to pump blood), and nonrheumatic aortic stenosis (narrowing of the heart's aortic valve). The diagnoses of major depressive disorder and unspecified psychosis not due to a substance or known physiological condition were added on 12/03/19. Residents Affected - Some Review of Resident #14's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively independent and had active diagnoses of depression and psychotic disorder. Review of Resident #14's most recent PASARR dated 11/25/19 revealed in Section D no boxes marked for diagnoses of the mental disorders listed: schizophrenia, mood disorder, delusional disorder, panic or other severe anxiety disorder, somatoform disorder, personality disorder, or other psychotic disorder. An interview on 10/25/22 at 1:46 P.M. with Social Services Designee (SS) #205 verified she does not do the PASARRs, the previous admission person did those and at the time of the survey the Administrator was doing the PASARRs. SS #205 verified the most recent PASARR for Resident #14 was the one dated 11/25/19 and it was not accurate based on current diagnoses. An interview on 10/26/22 at 10:25 AM with Registered Nurse (RN) #80 reported the facility does not have a PASARR policy and they refer to the Ohio Revised Code for guidance. 5. Review of Resident #28's medical record revealed he was admitted to the facility on [DATE] with the diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, essential hypertension, hypothyroidism, and dysphagia. The diagnosis of major depressive disorder was added 09/17/19, delusional disorders diagnosis was added 11/01/20, and schizoaffective disorder, depressive type diagnosis was added 10/26/21. Review of Resident #28's quarterly MDS dated [DATE] revealed he was not cognitively independent and had active diagnoses of depression, psychotic disorder, and schizophrenia. Review of Resident #28's most recent PASARR dated 05/29/14 revealed in Section D no boxes marked for diagnoses of the mental disorders listed: schizophrenia, mood disorder, delusional disorder, panic or other severe anxiety disorder, somatoform disorder, personality disorder, or other psychotic disorder. An interview on 10/25/22 at 1:46 P.M. with SS #205 verified she does not do PASARRs, the previous admission person did those and at the time of the survey the Administrator was doing the PASSARs. SS #205 verified the most recent PASARR for Resident #28 was the one dated 05/29/14 and it was not accurate based on current diagnoses. An interview on 10/26/22 at 10:25 AM with RN #80 reported the facility does not have a PASARR policy and they refer to the Ohio Revised Code for guidance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 10 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview and facility policy review, the facility failed to ensure one resident's (#233) baseline plan of care addressed Clostridium difficile infection (c-diff) and isolation to prevent the potential spread of c-diff. This affected one of 24 sampled residents. Findings Included: Review of the medical record for Resident #233 revealed an admission date of 10/20/22 with the admitting diagnoses of acute post-hemorrhagic anemia, hemorrhage of anus and rectum, atrial fibrillation diabetes mellitus, chronic kidney disease, congestive heart failure, hyperlipidemia, gastro-esophageal reflux disease, depression, anxiety, hypothyroidism and presence of cardiac pacemaker. Review of the admission nursing assessment dated [DATE] revealed the resident was admitted to the facility following an acute care hospital stay with the diagnoses of gastro-intestinal bleed, anemia and c-diff. The assessment indicated the resident was continent of bowel. Review of the resident's baseline plan of care and comprehensive plan of care revealed the resident had no care plan addressing the diagnoses of c-diff and isolation status. Review of the monthly physician's orders for October 2022 identified an order for transmission based precautions for 14 days from admission. Further review revealed no isolation precautions addressing the resident's c-diff diagnoses. Review of the resident's discharged orders revealed a discontinued order for Vancomycin 125 milligrams by mouth four times a day for one day for c-diff. Observation on 10/26/22 at 10:03 A.M. of Resident #233 revealed she was quiet at bedrest with television on. A plastic three drawer cart was outside the door and contained personal protective equipment (PPE). A sign was hung outside the resident's door alerting visitors to see the nurse prior to entry and the resident was on contact isolation. On 10/26/22 at 12:16 P.M., interview with Licensed Practical Nurse (LPN) #61 verified the resident had no plan of care addressing the diagnoses of c-diff and isolation status. Review of the facility policy titled, Baseline Care Plans, dated 03/22 revealed a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight hours of admission. The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan. The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 11 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure a comprehensive care plan was developed for a resident with the diagnosis of schizo-affective disorder. This affected one (Resident #46) of 24 residents reviewed for care plans. Findings include: A review of Resident #46's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included schizo-affective disorder (a mental health condition including schizophrenia and mood disorder symptoms). A review of Resident #46's active care plans revealed the resident did not have a care plan in place to address her diagnosis of schizo-affective disorder. None of the existing care plans addressed any behaviors related to her diagnosis of schizo-affective disorder. On 10/27/22 at 10:10 A.M., an interview with State Tested Nursing Assistant (STNA) #105 revealed Resident #46 was known to yell out when needing to go to the bathroom or after she already did and needed to be changed. She denied the resident was known to have any other behaviors that she was aware of. She then stated the resident could be confused at times and could become irritable she thought was possibly related to a dementia diagnosis. She denied the resident was known to be combative nor had she known her to have any hallucinations or delusions. She denied the aides were responsible for documenting behaviors and just reported them to the nurse when they occurred. She was asked what behaviors she would report to the nurse when the resident displayed them. She just stated she would report anything out of the norm for the resident. She denied she was aware of any specific behaviors for which she should be monitoring the resident for that was associated with her schizo-affective disorder. On 10/27/22 at 10:13 A.M., an interview with Registered Nurse (RN) #39 revealed she was not familiar with any behaviors Resident #46 had related to her diagnosis of schizo-affective disorder. She had to refer to the physician's orders and the medication administration record to see what the resident's target behaviors were. She reported they were monitoring the resident for sad/ worried facial expressions, decreased appetite and agitation. She confirmed those target behaviors were the same for the antidepressant and the antipsychotic the resident was receiving. She was then asked what behaviors the resident had that were associated with her schizo-affective disorder diagnosis. She reported the resident was known to have hallucinations and delusions. The resident was known to see things and talked to people who were not there. She denied they were monitoring the resident for those behaviors. On 10/27/22 at 10:50 A.M., an interview with RN #80 revealed Resident #46's active care plans did not address her diagnosis of schizo-affective disorder or any behaviors she was known to have associated with that diagnosis. She acknowledged the active care plans should have a care plan in place that addressed that diagnosis and the behaviors associated with it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 12 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the care plan of Resident #14 was revised with changes in physician's orders. This affected one Resident (#14) of five residents reviewed for respiratory concerns. The facility census was 76. Findings included: Review of Resident #14's medical record revealed she was initially admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, chronic kidney disease stage one, cardiomyopathy (disease that makes it difficult for the heart to pump blood), and nonrheumatic aortic stenosis (narrowing of the heart's aortic valve). Review of Resident #14's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively independent and received oxygen therapy. Review of Resident #14's physician order dated 10/21/22 revealed administer oxygen at two liters/minutes via a nasal cannula for shortness of breath or when her pulse oximetry is below 90%, check pulse oximetry in one or 30 minutes, discontinue oxygen when the pulse oximetry is 90% or greater. Review of Resident #14's current care plan revealed a focus of altered respiratory status related to chronic obstructive pulmonary disease, shortness of breath when flat, on exertion and at rest. One of the interventions was administer oxygen two to four liters/minute via nasal cannula and titrate (adjust) to maintain an oxygen saturation greater than 88 %. This intervention was not accurate based the Resident #14's physician order dated 10/21/22. On 10/27/22 at 7:30 A.M. an interview with Registered Nurse (RN) #80 revealed the respiratory care plan was not accurate and therefore would not guide the nurses to the proper care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 13 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 facility policy and procedure, the facility failed to follow physician orders in regard to obtaining daily weights . This affected one (Resident #23) of 24 resident records reviewed. The census was 76. Residents Affected - Few Findings include: Review of Resident #23's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included chronic congestive heart failure (CHF), chronic kidney disease, hypertensive heart disease, diabetes, A-fib and depression and schizoaffective disorder. Review of the minimum data set (MDS) assessment 08/22/22 revealed his cognition was intact, he required extensive assistance of two or more staff members for bed mobility, transfers, dressing, and toilet use. He required extensive assistance of one staff member for personal hygiene. Review of physician orders revealed an order dated 09/04/22 for daily weights due to congestive heart failure (CHF) and notify physician if greater than three pounds. Further review revealed no documentation of weights on 09/16/22, 09/19/22, 10/12/22, and 10/23/22. On 10/26/22 at 2:05 P.M. interview with Licensed Practical Nurse (LPN) #25 revealed that she puts the daily weights in the computer, they are not documented any other place. On 10/26/22 at 2:07 P.M. interview with Registered Nurse (RN) #80 verified missing weights and the lack of physician notification with weight gain. Review of the facility policy and procedure Change in a Resident's Condition or Status (dated 2001 and revised 02/21) revealed the nurse will notify the resident's attending physician when or physician on call when there has been a(an) specific instruction to notify the physician of changes in a resident's condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 14 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to ensure a resident was seen by an ophthalmologist for treatment of cataracts as referred by the optometrist. This affected one (Resident #65) of three residents reviewed for vision/ hearing. Residents Affected - Few Findings include: A review of Resident #65's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included cataract extraction status of an unspecified eye. A review of Resident #65's Medicare (MCR) 5 day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. Her vision was indicated to be adequate with the use of corrective lenses. No behaviors or rejection of care was noted. A review of Resident #65's active care plans revealed she had a care plan in place for having impaired peripheral visual function related to a stroke and left sided vision loss. She required large print to be able to see/ read. Interventions included arranging consultation with eye care practitioners as required, monitor/document/report as needed any signs and symptoms of acute eye problems (sudden visual loss, pupils dilated, gray or milky, complaints of halos around lights, double vision, tunnel vision, and blurred or hazy vision). A review of Resident #65's optometry consult notes revealed the resident was not seen on 06/07/21 and again on 09/13/21 by the optometrist when visiting the facility as the resident was pending laser treatment for the removal of a cataract. The resident was to be seen by the optometrist post procedure. A review of an optometry order form for a date of service 12/22/21 revealed Resident #65 was referred to an ophthalmologist for laser treatment on the implant of the right eye secondary to a cataract. Resident #65's medical record was absent for any evidence she had been seen by the ophthalmologist for cataract removal as was referenced with the optometry consults on 06/07/21 and 09/13/21 and as was re-ordered on 12/22/21. On 10/25/22 at 1:39 P.M., an interview with Resident #65 revealed she had cataracts to both her eyes and was in need of surgery to have them removed. She stated an appointment had been made but it was canceled by the nurse. She denied she had any eye procedures done after the re-order was given on 12/22/21 for the resident to be referred to an ophthalmologist. The resident reported she had work done on them years ago but nothing in the past year or two. She was told by the optometrist it could help her vision by 50% or better if she had the procedure done. On 10/25/22 at 1:48 P.M., an interview with Social Service Designee (SSD) #205 revealed she was the one responsible for setting up ophthalmology consults if they were ordered. She was informed Resident #65 was supposed to have a laser procedure done on her right eye cataract as indicated on a optometry order form dated 12/22/21 with no evidence that procedure had ever been completed. She stated she started as the facility's SSD mid May 2022. She would have to look to see if that referral was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 15 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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 0685 ever made or if there was documentation to support why it had not been completed. Level of Harm - Minimal harm or potential for actual harm On 10/25/22 at 3:55 P.M., a follow up interview with SSD #205 revealed she was not able to find any evidence that an ophthalmology referral was made as indicated in the optometrist consult notes for 06/07/21 and 09/13/21. She stated they thought the original appointment was canceled but they were working on finding the documentation to support that. She returned on 10/25/22 at 4:10 P.M. and reported there was no documentation to show why the ophthalmology appointment was not followed through with. She stated the Director of Nursing (DON) had contacted a day shift nurse that typically worked the 200 hall and was informed the transportation company canceled on them when they were supposed to transport Resident #65 to her ophthalmology appointment. She denied they had documentation to support nor did they have evidence that appointment was rescheduled after being canceled. The original appointment was allegedly scheduled sometime in December 2021. She made an appointment for the resident to be seen by an ophthalmologist for 11/29/22 at 10:40 A.M. since it still had not been completed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 16 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview , the facility failed to ensure interventions were in place for pressure ulcers. This affected one (Resident #29) of five residents reviewed for pressure ulcers. The census was 76. Residents Affected - Few Findings include: Review of the medical record revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses included ASHD, gastroesophageal reflux disease (GERD), osteoporosis, and chronic pain syndrome. Review of the minimum data set (MDS) assessment 09/06/22 revealed her cognition was not intact. She required limited assistance of one staff member for transfers, dressing and personal hygiene. She required supervision with set up help only for bed mobility and toileting. Review of the physician orders revealed an order dated 07/25/22 for heel float boot to the left foot while in bed. Resident #29 has a Stage 2 (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) pressure ulcer to the left heel. Observations on 10/26/22 at 12:30 P.M. and 2:48 P.M. revealed Resident #29 was in bed and did not have the heel float boot in place. On 10/27/22 at 7:45 A. M, 9:55 A.M. and 10:35 A.M. Resident #29 was in bed and the heel float boot was not in place. On 10/27/22 at 10:35 A.M. interview with Registered Nurse (RN) #7 verified the heel float boot was not in place . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 17 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and facility policy review, the facility failed to ensure one resident's (#40) contracture prevention devices were implemented as physician ordered. This affected one of five residents reviewed for limited range of motion. Findings Included: Review of the medical record for Resident #40 revealed an initial admission date of 04/07/21 with the admitting diagnoses of dementia, reduced mobility, schizoaffective disorder, allergic rhinitis, dysphagia, personal history of COVID-19, pseudobulbar affect, hypertension, obesity, anemia, polyneuropathy, anxiety disorder, bipolar disorder, major depressive disorder and generalized muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive impairment. The resident was dependent on two staff for activities of daily living. The assessment indicated the resident had no deficits in range of motion to upper or lower extremities. The assessment indicated the resident received passive range of motion (PROM) and splint/brace restorative nursing services seven days a week. Review of the plan of care dated 04/07/21 revealed the resident had an ADL self-care performance deficit and potential for fluctuations in ADL due to dementia. Interventions included resting splints to bilateral upper extremities with morning care, remove with bedtime care, perform range of motion and hand care prior to applying hand splints daily for 15 minutes, check splints every two hours and restorative passive range of motion to all extremities daily for 15 minutes. Review of the monthly physician's orders for October 2022 identified orders dated 03/29/22 for restorative PROM to all extremities daily for 15 minutes, restorative palm protector to bilateral upper extremities with the special instructions to apply with bed time care and remove with morning care. Perform range of motion and skin care prior to applying palm protector daily for 15 minutes and check every two hours, 04/14/22 resting hand splints to bilateral upper extremities with the special instructions to apply with morning care and remove with bedtime care. Perform range of motion and skin care prior to applying hand splints daily for 15 minutes, check every two hours. On 10/24/22 at 1:14 P.M. observation of Resident #40 revealed the resident's contracture devices (resting hand splints) were off and laying on the bed side table. On 10/26/22 at 10:04 A.M., observation of Resident #40 revealed the resting hand splints or palm protectors were not in place. Observation on 10/26/22 at 1:10 P.M. of Resident #40 revealed the resident was sitting up in a tilt and space wheelchair with the bilateral resting hand splints in place. The left resting hand splint was applied correctly. The right hand splint was Velcroed to the resident hand and arm with her hand out of the resting splint and in a fist. Interview with State Tested Nursing Assistant (STNA) #173 at the time of the observation revealed the splints were to be applied from 9:00 A.M. to 1:00 P.M. daily. STNA #173 revealed she applied the splints at approximately 10:30 A.M. STNA #173 revealed she had not provided range of motion (ROM) to the resident's upper and lower extremities as therapy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 18 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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 0688 provides all ROM. Level of Harm - Minimal harm or potential for actual harm On 10/26/22 at 3:25 P.M., interview with the Director of Nursing (DON) verified the resting hand splints were not in place as physician ordered. Residents Affected - Few Review of the facility policy titled, Resident Mobility and ROM, dated 07/17 revealed residents will not experience an avoidable reduction in ROM. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 19 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident #69's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia with psychotic disturbance, encounter for palliative care, obesity, dysphagia (difficulty swallowing), need for assistance with personal care, heart failure, and chronic kidney disease. Residents Affected - Few A review of Resident #69's physician's orders revealed the resident was to receive a chocolate Boost (nutritional supplement) with every meal with the need to place it in a cup with a straw. The order had been initiated on 09/12/22. She was also to receive a Mighty Shake twice a day beginning on 10/24/22. A review of Resident #69's admission/ 5 day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was severely impaired. Mood indicators were present, which included a poor appetite. She required supervision with one person physical assist with eating. Her height was 63 inches and her weight was 169 pounds. She was not identified as having had a significant weight loss. A review of Resident #69's active care plans revealed she had a care plan in place for at risk for malnutrition. The care plan indicated she was at risk due to poor intakes and being palliative care. The care plan was updated to reflect the resident was placed on Boost and a Magic Cup (high calorie ice cream) and was to receive them as ordered. The goal was for no significant weight changes to occur. The interventions included the need to administer supplements as ordered. The care plan did not reflect the Magic Cup had been discontinued on 10/24/22, when Mighty Shakes were ordered to be given twice daily. A review of Resident #69's weights revealed she was known to weigh 168.7 pounds on 09/09/22. Her last weight on 10/13/22 revealed her weight was down to 153.9 pounds (14.8 pound loss in 30 days reflecting a significant weight loss). A review of Resident #69's dietary notes revealed a dietary note dated 10/15/22 at 1:48 P.M., that indicated the resident was noted to have had a significant weight loss. She was noted to have poor intakes and was being offered a Magic Cup and Boost. A dietary note dated 10/19/22 at 1:57 P.M. revealed she continued to have poor intakes and Remeron was in place for an appetite stimulant. She was to continue to receive Boost as ordered and the note specified the resident liked chocolate. The Magic Cup continued to be offered. A review of Resident #69's medication administration record (MAR) for October 2022 revealed the nurses were documenting the resident receiving Magic Cup twice a day until it was discontinued on 10/14/22. Mighty Shakes were documented as having been given beginning 10/24/22, after it had been ordered. The nurses were not documenting the chocolate Boost to show if it was being offered to the resident or what percentage of the supplement was consumed despite it having been ordered on 09/12/22. On 10/26/22 at 12:29 P.M., an observation of Resident #69's meal process revealed she was served her lunch meal in her room while in bed. An aide attempted to feed the resident but she became agitated when they tried to get her to eat. She began yelling at the aide when she was trying to get her to eat. The resident was provided a pureed diet as ordered and a 4 ounce (oz) Mighty Shake was sent on her tray. She did not drink the Mighty Shake either. There was no evidence of a chocolate boost being given as ordered with every meal. A review of the resident's meal ticket that was sent with her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 20 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tray identified her proper diet and indicated she was to receive Mighty Shakes, but it did not mention the chocolate Boost that should be given with every meal. Findings were confirmed with State Tested Nursing Assistant (STNA) #79. On 10/26/22 at 12:31 P.M., an interview with STNA #79 confirmed Resident #69's meal tray did not include a chocolate Boost as ordered with every meal. She reported she had been off for about a week, but the last time she worked she thought the resident was getting chocolate Boost as far as she could recall. On 10/27/22 at 3:52 P.M., an interview with Registered Nurse (RN) #39 revealed Resident #69's order for the chocolate Boost was put into the computer wrong, which was why it did not show up on the MAR's. She stated an agency nurse worked that day when the order was given and put the order in under other. She stated as a result, it did not show up on the MAR to be given or for the staff to document any percentages of the supplement consumed. She confirmed the chocolate Boost had been ordered since 09/12/22 and they did not have documentation to show it had been given. She stated the Mighty Shake would have come from the kitchen and the nurses would have been passing out the chocolate Boost during their medication passes. She acknowledged a meal observation of Resident #69's lunch meal served on 10/26/22 at 12:29 P.M. revealed she was not provided a chocolate Boost with her meal as ordered. Based on observation, interview, record review, and policy review the facility failed to ensure dietary intake was accurately measured and documented and failed to ensure nutritional supplements were administered as ordered . This affected two Resident (#48 and #69) of seven residents reviewed for nutrition. The facility census was 76. Findings included: 1. Review of Resident #48's medical record revealed he was initially admitted on [DATE] with a readmission on [DATE] with the diagnoses of quadriplegia contracture right hand, essential hypertension, dysphagia, contracture left knee, and unspecified intracranial injury without loss of consciousness. Review of Resident #48's annual Minimum Data Set (MDS) dated [DATE] revealed severely impaired cognition and an abdominal gastrostomy tube. Review of Resident #48's weights revealed on 04/26/2022, the resident weighed 154.6 pounds (lbs.) and on 07/18/2022, the resident weighed 149 pounds which was a -3.62 % Loss. Review of Resident #48's nutrition progress note dated 07/20/22 revealed an increase in his Jevity tube feed from 57 milliliters per hour to 60 milliliters per hour and a request for daily weights due to a decrease in weight. Review of Resident #48's physician orders revealed an order dated 07/21/22 for Jevity 1.5 calorie at 60 milliliters an hour per pump day and night shift and an order dated 10/05/22 for Jevity 1.5 calorie at 62 milliliters an hour per pump every day and night shift. On 07/22/22 there was an order to record the amount of tube feed infused per shift and the pump was to be cleared every shift. Review of Resident #48's current care plan for nutrition had an intervention to monitor and document the amount of tube feed infused each shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 21 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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 0692 Level of Harm - Minimal harm or potential for actual harm Review of Resident #48's Medication Administration Record (MAR) for 10/22 revealed Resident #48 was receiving more tube feeding in a twenty-four-hour period than he should have based on the physician order. Tube feeding running at 62 milliliters an hour per pump would be a total of 1,488 milliliters in twenty-four hours. Review of the October MAR revealed the intake for twenty-four hours: Residents Affected - Few 10/05/22: 1286 milliliters in 24 hours 10/06/22: 2054 milliliters in 24 hours 10/07/22: 1147 milliliters in 24`hours 10/08/22: 1324 milliliters in 24 hours 10/09/22: 1258 milliliters in 24 hours 10/10/22: 1544 milliliters in 24 hours 10/11/22: 1709 milliliters in 24 hours 10/12/22: 2064 milliliters in 24 hours 10/13/22: 1358 milliliters in 24 hours 10/14/22: 1954 milliliters in 24 hours 10/15/22: 1879 milliliters in 24 hours 10/16/22: 1954 milliliters in 24 hours 10/17/22: 1896 milliliters in 24 hours 10/18/22: 1366 milliliters in 24 hours 10/19/22: 1974 milliliters in 24 hours 10/20/22: 2167 milliliters in 24 hours 10/21/22: 1846 milliliters in 24 hours 10/22/22: 1330 milliliters in 24 hours 10/23/22: 1046 milliliters in 24 hours 10/24/22: 2054 milliliters in 24 hours 10/25/22: 2154 milliliters in 24 hours Observation on 10/24/22 at 9:41 A.M. revealed Resident #48 receiving Jevity 1.5 calorie tube feeding at 62 cc/hour via a pump. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 22 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 10/25/22 at 8:17 A.M. revealed Resident #48 receiving Jevity 1.5 calorie tube feeding at 62 cc/hour via a pump. On 10/26/22 at 1:13 P.M. an interview with Registered Nurse (RN) #80 revealed she believed the nurses were adding tube flushes into the total amount for tube feed intake documentation. She acknowledged this was not correct due to the order was for documentation of tube feed intake and not tube feed and flush intake. She verified the information documented would not be accurate for the dietitian when monitoring tube feed intake and weights for the nutritional plan of care for Resident #48. Review of policy titled, Food and Nutrition Services, undated, revealed nursing personnel, with the assistance of the food and nutrition services staff, will evaluate (and document as indicated) food and fluid intake of residents with, or at risk for, significant nutritional problems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 23 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record revealed Resident #31 was initially admitted to the facility on [DATE] with the admitting diagnoses including chronic obstructive pulmonary disease (COPD), dysphagia, malignant neoplasm of colon, drug or chemical induced diabetes mellitus, anemia, anxiety, retinal edema, congestive heart failure and atrial fibrillation. Residents Affected - Few Review of the plan of care dated 01/12/22 revealed the resident had an alteration in respiratory status related to COPD, shortness of breath on exertion and laying flat. Interventions included administer medications as ordered and elevate head of bed or assist resident out of bed in an upright chair during episodes of difficulty breathing. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment. Review of the monthly physician's orders for October 2022 identified an order dated 01/11/22 for Ipratropium-Albuterol Solution 0.5-2.5 milligrams (mg)/3 milliliters (ml) with the special instructions to inhale one application by mouth every six hours for COPD. On 10/24/22 at 1:04 P.M., observation of the resident's respiratory equipment revealed the resident's nebulizer administration set was stored in the top drawer of the resident's night stand without being contained or in a bag. On 10/25/22 at 11:34 A.M., observation of the resident's respiratory equipment revealed the resident's nebulizer administration set was stored in the top drawer of the resident's night stand without being contained or in a bag. On 10/25/22 at 11:35 A.M. interview with Registered Nurse (RN) #185 confirmed the resident's nebulizer administration set was stored in the top drawer of the resident's night stand without being contained or in a bag. Review of the facility's policy titled, Medication Administration Nebulizer, revealed when equipment is completely dry, store in a plastic bad with the resident's name and the date on it. Based on observation, interview, and record review the facility failed to ensure resident oxygen was delivered at the flow rate ordered by the physician and respiratory equipment was stored properly. This affected two Resident (#14 and #31) of five residents reviewed for respiratory concerns. The facility census was 76. Findings included: 1. Review of Resident #14's medical record revealed she was initially admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, chronic kidney disease stage one, cardiomyopathy (disease that makes it difficult for the heart to pump blood), and nonrheumatic aortic stenosis (narrowing of the heart's aortic valve). Review of Resident #14's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively independent and received oxygen therapy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 24 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #14's physician order dated 10/21/22 revealed administer oxygen at two liters/minutes via a nasal cannula for shortness of breath or when her pulse oximetry is below 90%, check pulse oximetry in one or 30 minutes, discontinue oxygen when the pulse oximetry is 90% or greater. Review of Resident #14's pulse oximetry results revealed she had only one room air pulse oximetry since the 10/21/22 order. The room air pulse oximetry was on 10/21/22 and the result was 98% oxygenation on room air. This would warrant Resident #14 to not be administered oxygen. Review of Resident #14's Treatment Administration Record (TAR) for 10/22 revealed she has been receiving oxygen at two liters/min as ordered since 10/21/22. Observation on 10/24/22 at 5:04 P.M. revealed Resident #14 lying in bed with oxygen being administered at four and one-half liters/minute via a nasal cannula. Observation on 10/25/22 at 7:38 A.M. revealed Resident # 14's oxygen being administered at four liters/minute via a nasal cannula. This was verified at the time by Licensed Practical Nurse (LPN) #75. LPN #75 turned the oxygen down to three liters/minute. LPN #75 reported Resident #14's oxygen was ordered to be administered at two to four liters/minute via nasal cannula. Observation on 10/25/22 at 10:24 A.M. revealed Resident #14 lying in bed with oxygen being administered at three liters/minute via a nasal cannula. On 10/25/22 at 2:31 P.M. an interview with LPN #75 verified that Resident #14 should only be on oxygen at two liters/minute and only if needed. LPN #75 reported Resident #14's oxygen saturation last evening was 95% and therefore, she should not be receiving oxygen. LPN #75 verified that he documented this morning that Resident #14 was receiving two liters/minute of oxygen when he had the oxygen set at three liters/minute. Review of facility policy titled, Oxygen Administration, revised 10/10, revealed adjust the oxygen delivery devise so the proper flow of oxygen is being administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 25 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #67 revealed she was admitted to the facility on [DATE]. Diagnoses include bipolar disorder, protein calorie malnutrition, schizophrenia, morbid obesity, anxiety, major depression and Alzheimer's disease. Review of the annual minimum data set assessment (MDS) dated [DATE] revealed her cognition was moderately impaired. She required extensive assistance of two or more staff members for bed mobility, dressing, toilet use and personal hygiene and total dependence of two or more staff assistance with transfers. Resident received anti-psychotics and anti-anxiety medication , Review of the physician orders revealed an order since 12/20/19 for Cymbalta (anti-depressant) 60 mg (milligrams) everyday, since 01/11/22 for Seroquel (anti-psychotic) 50 mg two tabs at bedtime, since 01/12/22 for Seroquel 25 mg everyday and since 10/07/21 Wellbutrin ([NAME]-depressant) XR (extended release) 150 mg everyday Pharmacy review dated 05/27/22 revealed the resident has been taking the antidepressant Cymbalta since December 2019. Please evaluate the current dose and consider a dose reduction. The Physician response was Resident with good response, maintain the current dose. Pharmacy review dated 05/27/22 revealed the resident has been taking the antipsychotic Seroquel 25 mg every morning and Seroquel 100 mg every night since November 2019. Please evaluate the current dose and consider a dose reduction. The Physician response was Resident with good response, maintain the current dose. Pharmacy review dated 09/28/22 revealed the resident has been taking the antidepressant Wellbutrin XL 150 mg since October 2021. Please evaluate the current dose and consider a dose reduction. The Physician response was Resident with good response, maintain the current dose. There were no rationale or information to support the reasoning why gradual dose reductions were not attempted. On 10/27/22 at 9:48 A.M. this was verified during interview with Registered Nurse (RN) #80 . Based on record review and interview the facility failed to ensure the physician responded with a rationale for no action taken on recommendations made by the pharmacist in the Medication Regimen Review (MRR). This affected two Residents (#28 and #67) of five residents reviewed for unnecessary medications. The facility census was 76. Findings included: 1. Review of Resident #28's medical record revealed he was admitted to the facility on [DATE] with the diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, essential hypertension, hypothyroidism, and dysphagia. Review of Resident #28's quarterly MDS dated [DATE] revealed he was not cognitively independent and had an active diagnoses of depression, psychotic disorder, and schizophrenia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 26 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Note to Attending Physician/Prescriber dated 09/29/21 for Resident #28 revealed the resident had been taking the antipsychotic Zyprexa 5 milligrams every evening since October 2021. The physician was asked to please evaluate the current dose and consider a dose reduction. Resident #28's physician marked the box Resident with good response, maintain the current dose. There was no documentation on the form with a rationale for why no action was to be taken. The form was signed by Resident #28's physician on 10/06/21. Review of Note to Attending Physician/Prescriber dated 09/29/21 for Resident #28 revealed the resident had been taking the antidepressant Effexor XR 75 milligrams every day since October 2019. The physician was asked to please evaluate the current dose and consider a dose reduction. Resident #28's physician marked the box Resident with good response, maintain the current does. There was no documentation on the form with a rationale for why no action was to be taken. The form was signed by Resident #28's physician on 10/06/21. Review of Note to Attending Physician/Prescriber dated 09/28/22 for Resident #28 revealed the resident had been taking the antidepressant Effexor XR 75 milligrams every day since October 2019. The physician was asked to please evaluate the current dose and consider a dose reduction. Resident #28's physician marked the box condition is not well controlled. There was no documentation on the form with a rationale for why no action was to be taken. The form was signed by Resident #28's physician on 10/04/22. On 10/27/22 at 9:49 A.M. an interview with Registered Nurse (RN) #80 verified the physician was to provide a rationale if no action was taken regarding a dose reduction of psychotropic medications during the MRR process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 27 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure a resident receiving an antipsychotic medication was monitored for resident specific target behaviors. This affected one (Resident #46) of five residents reviewed for unnecessary medications. Findings include: A review of Resident #46's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included schizo-affective disorder, bipolar disorder, anxiety disorder, and major depressive disorder. A review of Resident #46's physician orders revealed the resident had an order to receive Seroquel (an antipsychotic medication) 25 milligrams (mg) by mouth (po) every morning and 50 mg po at bedtime for schizo-affective disorder. The order had been in place since 01/18/22. She also had an order to receive Lexapro (an antidepressant) 10 mg po ever night at bedtime for depression. The orders indicated the resident's target behaviors for the antidepressant was sad/ worried facial expressions, decreased appetite and agitation. The target behaviors for the antipsychotic was also sad/ worried facial expressions, decreased appetite and agitation. A review of Resident #46's active care plans revealed the resident did not have a care plan in place to to address her diagnosis of schizo-affective disorder. None of the existing care plans identified any behaviors the resident was known to have associated with the diagnosis of schizo-affective disorder. A review of Resident #46's medication administration record (MAR) for October 2022 revealed the resident was receiving her Seroquel and Lexapro as ordered. The MAR also included a place for the nurses to document target behaviors for the antidepressant and antipsychotic when they occurred. The target behaviors were the same (sad/ worried facial expression, decreased appetite, and agitation) for both medications. On 10/27/22 at 10:10 A.M., an interview State Tested Nursing Assistant (STNA) #105 revealed Resident #46 was known to yell out when she needed to go to the bathroom. She would also yell out if she already went and was in need of being changed. She denied she had known the resident to display any other behaviors. She then stated the resident could be confused at times and could become irritable which she thought was from dementia. She denied the resident was known to be combative and had not known her to have any hallucinations or delusions. She denied the aides documented any behaviors and just reported them to the nurse when they occurred. She was asked what behaviors she would report to the nurse when they occurred and indicated that she would report anything out of the norm for the resident. She denied she was made aware of any resident specific target behaviors to monitor for for each resident. On 10/27/22 at 10:13 A.M., an interview with Registered Nurse (RN) #39 revealed she was not familiar with what behaviors Resident #46 was being monitored for. She had to reference the resident's physician's orders to see what the target behaviors were. She confirmed they were monitoring the resident for sad/ worried facial expressions, decreased appetite and agitation and those target behaviors (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 28 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm were the same for the antidepressant and the antipsychotic the resident was receiving. She confirmed the target behaviors they were monitoring for were not specific to a particular behavior for which the resident was receiving those medications. She reported the resident was known to have hallucinations and delusions as she seen things and talked to people who were not there. She denied they were monitoring the resident for those resident specific target behaviors. Residents Affected - Few A review of the facility's policy on Behavioral Assessment, Intervention and Monitoring (revised March 2019) revealed the facility would comply with regulatory requirements related to the use of medications to manage behavioral changes. Under monitoring, if the resident was being treated for altered behavior or mood, the interdisciplinary team (IDT) would seek and document any improvements or worsening in the individual's behavior, mood, and function. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 29 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview and review of facility policy and procedure, the facility failed to ensure the facility medication error rates were not 5% or greater, with 30 opportunities for error and two actual observed errors resulting in a medication administration error rate of 6.67% . This affected two (Resident #2 and Resident #36) of three residents observed for medication administration. The census was 76. Residents Affected - Few Findings include: 1. Observation on 10/25/22 at 7:24 A.M. revealed Licensed Practical Nurse (LPN) #27 administer the following medications to Resident #2, Amlidopine 10 mg (milligrams), ASA (aspirin) 81 mg, Cranberry 500 mg tablet, Colace 100 mg, Flovent (asthma therapy)110 mcg (Micrograms) two puffs, Magnesium Oxide (mineral supplement) 400 mg, Potassium 10 meq(milliequivalent), Memantine 10 mg and Vitamin C (supplement) 500 mg . LPN #27 administered Flovent two puffs, one right after the other without waiting in-between. LPN #27 failed to instruct resident on holding breath in and failed to instruct him to rinse his mouth after administration of the medication. This was verified during interview with LPN #27 on 10/25/22 at 7:40 A.M. 2. Observation on 10/26/22 at 7:30 A.M. revealed Registered Nurse (RN) #113 administered the following medications to Resident #36, ASA 81 mg, Buspirone (antidepressant) 5 mg, Calcium 600 mg with Vitamin D, Oxybutynin (smooth muscle relaxant) 2.5 mg, Dilantin (seizure medication)100 mg, Potassium 10 meq, Vitamin D 3 (supplement) 50 meq, Celexa 10 mg (anti-depressant), Primidone (seizure medication) 100 mg and Lasix (diuretic) 20 mg. Review of the medical record for Resident #36 revealed physician orders for 10/22 for Lasix 40 mg. This was verified during interview on 10/26/22 at 8:20 A.M. with RN #113. Review of the policy and procedure oral inhalations dated 05/16 revealed have resident hold breath for 5-10 seconds or as long as possible to allow medication to reach deeply into lungs. If another puff of the same medication or different medication is required follow the manufacturers product information for administration instructions including the acceptable wait time between inhalations. For steroid inhalers, provide a cup of water and instruct the resident to rinse mouth and spit water back into cup. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 30 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain laboratory tests ordered by the physician. This affected two (Resident #44 and #67) of five residents reviewed for unnecessary medications. Findings include: 1. Review of Resident #44's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, cognitive communication disorder, dementia, anxiety, insomnia and depression. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed his cognition was not intact. He required supervision of one staff members physical assistance for bed mobility, extensive assistance of one staff members physical assistance for transfers, dressing and toileting and limited assistance of once staff members physical assistance for personal hygiene. Review of the Physician orders revealed an order on 09/15/22 for PT/INR weekly (Resident receives Coumadin which is a blood thinning medication). Review of the lab results revealed they were obtained on 09/15/22, 09/21/22, 09/27/22 (refused), 10/04/22 (no results), 10/13/22 (hold for two days then recheck on 09/15/22) this was not obtained until 10/18/22. On 10/26/22 at 10:33 A.M. interview with Registered Nurse #80 verified Resident #44's physician ordered labs were not completed as ordered. 2. Review of the medical record for Resident #67 revealed she was admitted to the facility on [DATE]. Diagnoses include bipolar disorder, protein calorie malnutrition, schizophrenia, morbid obesity, anxiety, major depression and Alzheimer's disease. Review of the annual minimum data set assessment (MDS) dated [DATE] revealed her cognition was moderately impaired. She required extensive assistance of two or more staff members for bed mobility, dressing, toilet use and personal hygiene and total dependence of two or more staff assistance with transfers. Review of the physician orders revealed orders on 03/04/19 for lipid profile every six months. Further review revealed the only results in the medical record was from 10/05/22. There was no other documentation for 2022 in the medical record. On 10/27/22 at 9:48 A.M. during interview Registered Nurse #80 verified the lipid panels were not obtained every six months as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 31 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and facility policy review the facility failed to store, prepare, and serve food in a sanitary manner and resident refrigerator temps were not monitored and adjusted as needed for increased temperatures. The food storage issue had the potential to affect all 74 residents receiving food from the facility kitchen (Residents #48 and # 276 do not receive food from the kitchen). The preparing and serving of food issue had the ability to affect all ten residents (Residents #6, #20, #25, #28, #31, #32, #40, #46, #51, and #69) who received pureed corn and one Resident (#30) who received a meatloaf sandwich. The resident refrigerator issue affected all thirteen residents (Residents #2, #5, #11, #19, #30, #32, #39, #41, #52, #60, #65, #67 and #68) who had personal refrigerators in their rooms. The nursing unit refrigerator issues had the potential affected all residents receiving items from those refrigerators in the facility. The facility census was 76. Findings included: 1. Observation on 10/25/22 at 11:10 A.M. of the walk-in refrigerator in the facility kitchen revealed a one-gallon container, 1/4 filled, with green beans. The date on the container was to discard by 10/24/22. There was also a plastic bag of bologna with a date on the bag to discard by 10/22/22 and another bag of bologna with a date on the bag to discard by 10/15/22. This was verified at the time of the observation by Dietary Staff #87 that the green beans and two bags of bologna should not be stored in the refrigerator due to having discard dates prior to the date of observation. Review of policy titled, Food Storage, undated, revealed all foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. 2. Observation on 10/25/22 at 11:00 A.M. revealed Dietary Staff #100 touching 5 and 1/2 pieces of bread for pureed corn with her bare hands after touching multiple items in the work area and the bag with the bread in it. Observation on 10/25/22 at 11:20 A.M. revealed Dietary Staff #100 touching the bun for a meatloaf sandwich with her bare hands after touching serving utensil handles and the bag the buns were in. On 10/25/22 at 11:22 A.M. interview with Dietary Staff #100 verified she touched the bread and buns with her bare hands after touching items in the kitchen and the bags the bread and buns came in. Review of policy titled, General Food Preparation and Handling, undated, revealed food should be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact of prepared foods. 3. Review of the October 2022 Refrigerator Logs for Residents #11, #41, #65, and #68 revealed no record of temperature for the 9th or the 12th to the 24th. Review of October 2022 Refrigerator Log for Residents #11 and #65 also revealed temperatures ranging from 46 degrees Fahrenheit to 48 degrees Fahrenheit on multiple occasions and no adjustment to lower the temperature. Review of the October 2022 Refrigerator Logs for Residents #2, #5, #19, #32, #39, #52, and #60 revealed no record of temperature for the 1st, 2nd, 5th, 11th, 14th, and the 19th. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 32 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 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 0812 Level of Harm - Minimal harm or potential for actual harm Review of the October 2022 Refrigerator Log for Resident #67 revealed no record of temperature from the 1st to the 14th and from the 16th to the 24th. Review of the October 2022 Refrigerator Log for Resident #30 revealed no record of temperature for the 9th, 12th, 13th, and 17th to the 24th. Residents Affected - Many Review of the October 2022 Refrigerator Log for the East nursing refrigerator revealed no record of temperature for the dayshift or nightshift on the 13th. Review of the October 2022 Refrigerator Log for the [NAME] nursing refrigerator revealed no record of temperature for the dayshift or nightshift on the 1st, 2nd, 11th, 14th, 16th, or 19th. An interview on 10/25/22 at 4:25 P.M. with Registered Nurse (RN) #39 revealed the nurses on midnights are responsible for the temperature checks on the individual resident refrigerators. She verified the nurses should know proper temperature levels for refrigerators are less than 41 degrees. On 10/25/22 at 4:38 P.M. an interview with RN #80 verified the staff nurses are not consistent with documenting on temperature logs for resident refrigerators or unit refrigerators. She also verified that there was no intervention for the two refrigerators which were consistently out of range for Residents #11 and #65. Observation on 10/25/22 at 4:40 PM with RN #80 of Resident #65's refrigerator revealed a temperature of 50 degrees Fahrenheit and contents of drinks, Jell-O, and fruit. Observation on 10/25/22 at 4:42 P.M. with RN #80 of Resident #11's refrigerator revealed a temperature of 50 degrees Fahrenheit and contents of drinks, Jell-O, and chocolate candies. An interview on 10/25/22 at 5:03 P.M. with the Director of Nursing (DON) verified the nursing staff were to follow the Food Storage policy for resident refrigerators and the temperatures were not being monitored correctly. Review of policy titled, Food Storage, undated, revealed temperatures for refrigerators should be between 35 to 39 degrees Fahrenheit. Thermometers should be checked at least two times each day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 33 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 10/26/22 at 12:11 P.M., an observation of the dining process for the lunch meal served to the residents on the 200 hall noted three State Tested Nursing Assistants (STNA's) passing the lunch trays to the residents eating their meals in their rooms. STNA #47, #79, and #105 were the three STNA's that were passing trays to the 23 residents (Resident #4, #6, #10, #11, #18, #12, #14, #27, #30, #33, #34, #36, #41, #43, #44, #46, #53, #56, #65, #68, #69, #123, #124). None of the three STNA's were noted to perform hand hygiene by washing their hands with soap and water or using alcohol based hand rub (ABHR) between tray passes. The STNA's were noted to assist the residents who needed it with repositioning in bed. They were observed to touch the residents' bed linen and bed controls while providing positioning assistance. They were also noted to come into contact with environmental surfaces such as bedside tables while in the rooms. The STNAs then returned to the food cart to retrieve another lunch tray to be passed to other residents. Several residents required feeding assistance and the STNA's were noted to only don disposable gloves to feed the residents and were not noted to wash their hands first before donning the gloves. Findings were verified by STNA #105. Residents Affected - Some On 10/26/22 at 12:38 P.M., an interview with STNA #105 revealed she had a bottle of hand sanitizer (ABHR) in her pocket that she should be using as part of the meal delivery process. She denied she used the hand sanitizer between tray passes and did contact environmental surfaces, bed controls and bed linen when in resident rooms assisting them with positioning. She also denied washing her hands with soap and water before leaving the residents' room and proceeding to pass the next meal tray. When asked if that was something they should be doing, she confirmed they should be. She stated she was frazzled during the meal delivery process and it has been a week. A review of the facility's policy on Assistance with Meals revised March 2022 revealed all employees who provided assistance with meals would be trained and should demonstrate competency in the prevention of foodborne illnesses. That should include personal hygiene practices and safe food handling. Based on observation, interview and facility policy review the facility failed to maintain proper hand hygiene while providing care services to Resident #48's gastrostomy tube and during dining observation. This affected one Resident (#48) of one resident reviewed for tube feeding and 23 residents receiving meals in their room on the 200 hall (Residents #4, #6, #10, #11, #18, #12, #14, #27, #30, #33, #34, #36, #41, #43, #44, #46, #53, #56, #65, #68, #69, #123, #124). The facility census was 76. Findings included: 1. Review of Resident #48's medical record revealed he was initially admitted on [DATE] with a readmission on [DATE] with the diagnoses of quadriplegia, contracture of the right hand, essential hypertension, dysphagia, contracture of the left knee, and unspecified intracranial injury without loss of consciousness. Review of Resident #48's annual Minimum Data Set (MDS) dated [DATE] revealed severely impaired cognition and an abdominal gastrostomy tube. Observation on 10/25/22 at 10:48 A.M. of Licensed Practical Nurse (LPN) #75 cleaning Resident #48's feeding tube insertion site revealed LPN #75 did not wash his hands or use alcohol-based hand rub prior to donning (putting on) gloves or after doffing (removing) his gloves. After cleaning Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 34 of 35 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 365721 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Overbrook Center 333 Page Street Middleport, OH 45760 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #48's feeding tube insertion site LPN #75 touched the bed controls and the tube feeding pump with his gloved hands. After removing his gloves and not washing his hands, LPN #75 walked down the hallway to the soiled linen room and used the key hanging beside the door to open it. On 10/25/22 at 10:55 A.M. an interview with LPN #75 verified he did not wash his hands prior to donning or after doffing his gloves. He also verified he should have removed his gloves and washed his hands prior to touching the bed controls and touching the tube feed pump. Review of the facility policy titled, Handwashing/Hand Hygiene revised 08/19, revealed alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and waster are used for the following situations: before and after direct contact with residents, after contact with objects (e.g., medical equipment) in immediate vicinity of the resident, and after removing gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365721 If continuation sheet Page 35 of 35