Health inspection·November 22, 2023

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of policy and interviews, the facility failed to ensure gastrostomy tube (G-tube) medications were administered using proper technique. This effected one resident (Resident #49) of three residents reviewed for G-tube medication administration. The facility census was 65. Findings include: Review of Resident #49's medical record revealed an admission date of 12/29/22. Diagnoses included acute respiratory failure with hypoxia, atrial fibrillation, major depressive disorder, moderate protein-calorie malnutrition, dysphagia and hypertension. Review of Resident #49's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 had severely impaired cognition and required maximal assistance by one to two staff members for all Activities of Daily Living (ADLs). All medications were provided through his G-tube. Review of Resident #49's physicians orders revealed orders for all medications to be given via G-tube including an order for Hydralazine 25 milligrams (mg) every eight hours for hypertension. Observation of medication administration on 11/21/23 at 2:00 P.M. by Licensed Practical Nurse (LPN) #427 for Resident #49 of administration of Hydralazine 25 mg via gastrostomy tube (G-tube) revealed LPN #427 used ice water from the nursing cart to dissolve medication for administration and used ice water to flush G-tube before and after medication administration. Interview on 11/21/23 at 2:15 P.M. with LPN #427 revealed he confirmed he used ice water to dissolve the medication and used ice water to flush the G-tube before and after medication administration. LPN #427 confirmed the water was ice cold and he was supposed to use tepid or room temperature water for administration and flush. Interview on 11/21/23 at 2:30 P.M. with the Director of Nursing (DON) revealed staff were to use room temperature or tepid water to dissolve medications and with flushes before and after each medication. She stated they are not to use ice water. Review of the undated facility policy titled Medication Administered by Enteral Tube, revealed under the procedure section letter I stated to dilute medication with 10-30 milliliters of tepid (not hot or cold) water. Under section III titled Administration of Medications via G-tube letter J revealed 15 milliliters of tepid water to be used to flush before and after medication administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365732 If continuation sheet Page 2 of 5 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 365732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Austintown Healthcare Center 650 S Meridian Road Youngstown, OH 44509 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 0851 Level of Harm - Potential for minimal harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review, the facility failed to submit complete and accurate staffing information for the Payroll-Based Journal (PBJ) report to Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all 65 residents in the facility. Findings include: Review of [NAME] PBJ Staffing data report revealed facility triggered for low weekend staffing and one star staffing for fiscal year quarter two of 2023. Interview on 11/21/23 at 5:05 P.M. with the Administrator revealed they submit the facility staffing data to the corporate office who then reports the data to CMS. The Adminstrator revealed the way the facility staffing data was transposed from the coporate office who submitted the data to CMS was late and/or not accurate which resulted in the trigger of low weekend staffing and one star for staffing for Quarter Three of 2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365732 If continuation sheet Page 3 of 5 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 365732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Austintown Healthcare Center 650 S Meridian Road Youngstown, OH 44509 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 Based on interview, observations, and record review the facility failed to ensure appropriate infection control practices were followed in regard to oral suctioning of respiratory secretions for Resident #4, and hand hygiene and glove use with wound care for Resident #3. This affected two residents ( #4 and #3) of five residents reviewed for infection control practices. The facility census was 65. Residents Affected - Few Findings include: 1. Record review for Resident #4 revealed an admission date of 07/22/23. Diagnoses included cerebral palsy, dysphagia, unspecified psychosis, convulsions and anxiety. Review of Resident #4's quarterly Minimum Data Set (MDS) 3.0 assessment dated for 10/31/23 revealed the resident had severe cognitive impairment. Resident #4 was dependent for all care including Activities of Daily Living. Review of Resident #4's physician orders dated 11/10/23 revealed orders to change suction tubing and canister once per week on Sundays and as needed. Nursing staff to suction resident orally as needed. Observation on 11/20/23 at 10:20 A.M. of the suction canister used to hold mucus secretions removed from the residents mouth and throat appeared as three-fourth full of yellow mucus. On the top of the mucus, there was a thick layer of green, bubbly or foamy textured substance that had the appearance of a green mold or biofilm. Interview on 11/20/23 at 10:35 A.M. with Licensed Practical Nurse (LPN) #427 verified the canister was almost full, undated, and the contents of container was yellow mucus. On the top of the mucus, there was a thick layer of green, bubbly or foamy textured substance that had the appearance of a green Interview on 11/20/23 at 10:38 A.M. with the Director of Nursing revealed she confirmed the canister was full, undated, and almost full of yellow mucus. On the top of the mucus, there was a thick layer of green, bubbly or foamy textured substance that had the appearance of a green. She could not confirm when the canister was last changed due to the canister and tubing were undated. 2. Review of the medical record for Resident #3 revealed an admission date of 05/08/23. Diagnoses included multiple sclerosis, cellulitis of the left lower limb, quadriplegia, type two diabetes mellitus, and peripheral vascular disease. Review of physician orders for Resident #3 revealed an order dated 11/01/23 that stated wound care for right heel included to cleanse with wound cleanser, apply iodosorb (medicated wound ointment) to wound base, cover with abdominal pad and wrap with kerlix. The dressing was to be changed three times a week on Monday, Wednesday and Friday. Observation of wound care for Resident #3's right heel wound on 11/22/23 at 7:50 A.M. was completed by Licensed Practical Nurse (LPN) #404 and LPN #453. Observation revealed LPN #404 and #453 performed hand hygiene, donned personal protective equipment (PPE) and entered the room. The gathered wound dressing supplies were placed on the cleaned bedside table on a barrier. LPN #404 then removed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365732 If continuation sheet Page 4 of 5 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 365732 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Austintown Healthcare Center 650 S Meridian Road Youngstown, OH 44509 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 - Few soiled dressing. LPN #453 then cleansed the wound with wound cleanser. Once completed cleansing wound, LPN #453 then doffed the dirty gloves and donned clean gloves without performing hand hygiene. LPN #453 then applied a new clean wound dressing to Resident #3's right heel. LPN #404 and #453 then discarded supplies, doffed PPE and washed hands prior to exiting resident's room. Interview on 11/22/23 at 8:20 A.M. with LPN #453 confirmed when she doffed the dirty gloves after she had cleaned Resident #'3 wound bed, she did not perform hand hygiene before donning a clean pair of gloves to apply the new dressing. Review of facility policy titled Personal Protective Equipment Gloves dated 07/01/17 revealed staff were to perform hand hygiene before donning and after doffing gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365732 If continuation sheet Page 5 of 5