Inspection·October 23, 2018

F 0550 Level of Harm - Minimal harm or potential for actual harm furnished by the facility revealed they identified nursing concerns were raised in the meetings and what was done by the facility in response. Neither month's documentation identified any raised concerns or interventions regarding cell phone or personal music use by staff. The 09/05/18 supplemental documentation did note social media presence with no context of whether it was a resident concern or whether any corrective action was taken. Residents Affected - Few The above findings were reviewed with RN #703 on 10/19/18 at 12:25 P.M. RN #703 revealed the reference to social media presence on the supplemental documentation was not related to the concern regarding personal music. Review of the facility undated cell phone policy revealed cell phone use was prohibited in resident care areas. Professional conduct was expected from all employees at all times. 2. Record review for Resident #42 revealed an admission date of 07/05/18 with diagnoses that included congestive heart failure, respiratory failure with hypoxia, neuromuscular dysfunction of the bladder, and diabetes. Resident #42 had a physician order with a revision date of 10/09/18 for an indwelling urinary (Foley) (a thin sterile tube inserted into the bladder to drain urine) catheter number 18 French (a measurement system used to measure the size of a catheter) to continuous drainage. Review of Resident #42's care plan with a revision date of 07/18/18 revealed Resident #42 had a Foley catheter related to neurogenic bladder. The care plan revealed an intervention for staff to store the urine drainage bag inside a protective dignity pouch. Review of quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/03/18 revealed Resident #42 required extensive assist with bed mobility and transfers and walking did not occur. The MDS revealed Resident #42 had an indwelling catheter in place. Observation on 10/15/18 at 9:45 A.M. revealed Resident #42 was in bed with her catheter drainage bag hanging on the side of the bed without a protective dignity pouch. From the hallway, the urine drainage bag was observed to be three fourths full of urine. Observation on 10/15/18 at 5:23 P.M. revealed Resident #42 was in bed with her urine drainage bag hanging on the side of the bed without protective dignity pouch and it was visible from the hallway. Observation on 10/16/18 at 6:14 P.M. revealed Resident #42 was in bed with her urine drainage bag hanging on the side the bed facing the doorway without a protective dignity pouch and the urinary drainage tubing was lying on the floor. Interview and observation on 10/16/18 at 6:22 P.M. with Licensed Practical Nurse #600 verified the indwelling catheter drainage bag and tubing were on the floor without a protective dignity pouch. Interview on 10/18/18 at 9:52 A.M. with Resident #42 revealed that she used to work as a nursing assistant as her profession. She said her catheter was a personal thing and it bothered her and she thought it should be covered. She said sometimes the staff forgot to put the drainage bag inside a cover to provide privacy. Review of facility policy dated 05/2017 labeled, Placement of the Foley Drainage Bag, revealed when a resident was in bed, the drainage bag on the bed frame should be below the level of the bladder to provide straight gravity drainage, yet not on the floor. Staff were to place the catheter bag in a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 2 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashtabula County Nursing Home 5740 Dibble Road Kingsville, OH 44048 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 0550 cover provided by the laundry department or central supply. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 3 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashtabula County Nursing Home 5740 Dibble Road Kingsville, OH 44048 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the Ombudsman's office was notified when Resident #6 and Resident #19 were discharged to the hospital. This affected two residents (Resident #6 and #19) of two residents reviewed for transfer/hospitalization. Findings included: 1. Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE] and transferred to the hospital for an acute illness on 08/28/18. Resident #6 was readmitted to the facility on [DATE]. Resident #6's medical record contained no evidence the Ombudsman's office was notified of the transfer to the hospital. An interview was conducted on 10/19/18 at 1:51 P.M. with Ombudsman #800 who revealed that neither she nor the Ombudsman's office received any notification that Resident #6 had been transferred to the hospital on [DATE]. An interview was conducted on 10/19/18 with the Administrator and Corporate Consultant #40 who verified that there was currently no system in place to notify the Ombudsman's office of any resident transfers to the hospital. Corporate Consultant #40 said he and the facility were working on a process to make a monthly compilation of all facility initiated discharges to send to the Ombudsman's office to be in compliance with the regulation. The facility's undated policy titled, Notice of Transfer to Hospital, revealed a copy of the facility initiated discharge would be sent to the Ombudsman's office monthly. 2. Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE] and transferred to the hospital for an acute illness on 08/17/18. Resident #19 was readmitted to the facility on [DATE]. Resident #19's medical record contained no evidence that the Ombudsman's office was notified of the transfer to the hospital. An interview was conducted on 10/19/18 with the Administrator and Corporate Consultant #40 who verified that there was currently no system in place to notify the Ombudsman's office of any resident transfers to the hospital. Corporate Consultant #40 said he and the facility were working on a process to make a monthly compilation of all facility initiated discharges to send to the Ombudsman's office to be in compliance with the regulation. The facility undated policy titled, Notice of Transfer to Hospital, revealed a copy of the facility initiated discharge would be sent to the Ombudsman's office monthly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 4 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashtabula County Nursing Home 5740 Dibble Road Kingsville, OH 44048 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** Based on record review and interview the facility failed to ensure Resident #10's Minimum Data Set (MDS) 3.0 assessment was accurate related to weight loss. This affected one resident (Resident #10) of six residents reviewed for nutrition. Residents Affected - Few Findings include: Medical record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia without behavioral disturbance, tremor, anxiety disorder, bipolar disorder, vitamin D deficiency, hypothroidism, major depression, unspecified fracture of left acetabulum and left ischium (hip) and left hip osteoarthritis. A significant change Minimum Data Set (MDS) 3.0 assessment, dated 05/13/18 was completed for Resident #10 after she suffered a left hip fracture following a fall on 04/28/18. An MDS 3.0 assessment, dated 10/02/18 indicated Resident #10 had severely impaired cognition and was dependent on staff for activities of daily living including meal tray set up and supervision for eating. Section K indicated that Resident #10 was 63 inches tall, 138 pounds and had not had any significant weight loss or gain in the last one or six months. A review of the monthly vitals section which included height and weight indicated that on 04/01/18 Resident #10's weight was 159 pounds and her height was 63 inches. On 07/04/18, Resident #10's weight was 142 pounds, on 09/02/18 Resident #10's weight was 138 pounds and on 10/02/18 Resident #10's weight was 135 pounds. From 04/01/18 to 10/02/18 Resident #10 lost 24 pounds, a 15% weight loss, in six months. According to the MDS any weight loss of 10% or more in six months should be coded for a significant weight loss on the MDS. Section K of the 10/02/18 MDS indicated a weight of 138 pounds and no significant weight loss in one or six months. The signature section indicated that Dietary Manager #628 completed section K of that MDS on 10/04/18. The MDS section K was completed incorrectly and did not capture the six month significant weight loss. An interview was conducted on 10/17/18 at 1:12 P.M. with Dietary Manager (DM) #628 who verified she used the 09/02/18 weight of 138 pounds for the MDS assessment date of 10/02/18 which was not an accurate representation of the 10/02/18 weight of 135 pounds, and it did not capture the 15% weight loss in six months for Resident #10. DM #628 explained that she was responsible for completing the MDS section K for Resident #10. DM #628 also said that she was responsible for completing all of the nutritional assessments except for the goals and interventions sections which are completed by Dietitian #625. DM #628 verified that she provided wrong weight information on the 10/02/18 nutrition assessment by listing a weight for 10/02/18 as 138 pounds instead of 135 pounds. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 5 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashtabula County Nursing Home 5740 Dibble Road Kingsville, OH 44048 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview the facility failed to develop and implement a comprehensive and individualized activity program designed to meet the total care needs of Resident #79. This affected one resident (Resident #79) of one resident reviewed for activities. Residents Affected - Few Findings include: Review of Resident #79's medical record revealed an admission date of 08/03/18 with diagnoses including fracture of left fibula, a pressure ulcer and major depressive disorder. Review of the activities initial review dated 08/03/2018 revealed the resident wanted to participate in activities and was not interested in independent activities such as reading or puzzles. Review of the 60-day Minimum Data Set (MDS) 3.0 assessment, dated 10/15/18 revealed the resident was cognitively intact. Resident #79 required extensive assistance from staff for bed mobility and dressing. The resident was totally dependent on staff for transfers and locomotion. Record review revealed no plan of care had been developed for Resident #79 related to her activity needs or preferences. In addition, record review revealed no activity progress notes had been completed for the resident. Review of the Activities Task Sheets for 10/2018 revealed Resident #79 was coded to have participated in the following activities from 10/01/18 to 10/18/18: one pet visit, television twice and range of motion exercise once. There were no other activity records or task sheets available to review. Written statements, provided and done on 10/18/18 by Activities Staff #643 and Activities Staff #644 revealed one to one visits were provided to the resident on 09/03/18, 09/11/16, 09/19/18 and 10/08/18 and a visit with the bunnies (as noted on the activities task sheet) was provided on 10/05/18. On 10/16/18 at 8:51 A.M., interview with Resident #79 revealed she would love to have a puzzle to work on in the room. No puzzles or other activities were observed in the room at that time. On 10/19/18 at 2:10 P.M. a telephone interview with Activities Director #623 revealed she had spoken with Resident #79 on the evening of 10/18/18. The Director indicated the resident told her she enjoyed getting lotion/hand therapy, loved visiting with the bunnies and liked classical music. The resident reported she wanted to come to more activities but didn't always feel up to it because she was frequently in pain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 6 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashtabula County Nursing Home 5740 Dibble Road Kingsville, OH 44048 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #74 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, dementia, and unspecified hemiplegia (paralysis on one side of the body). Review of Resident #74's MDS 3.0 assessment, dated 03/18/18 revealed the resident required extensive assistance from two staff for bed mobility and toileting. Record review revealed Resident #74 sustained a fall on 06/11/18 when STNA #705 was providing bowel incontinence care. The post-fall investigation revealed one witness statement had been made concerning the event (done by STNA #705), which revealed STNA #705 rolled the resident in bed onto their side. Resident #74 rolled over the side of the bed when STNA #705 turned away to get a washcloth from the table. The investigation contained no other witness statements. Resident #74 received a contusion (bruise) to the face and was sent to the emergency room. On 10/17/18 at 6:51 P.M. interview with the Director of Nursing (DON) revealed she was involved in the post-fall investigation for Resident #74. The DON verified only one STNA was present in the resident's room and providing care at the time of the fall. The DON verified the resident was assessed to require two staff for bed mobility. Based on observation, record review and interview the facility failed to ensure adequate assistance was provided to Resident #64 and Resident #74 to prevent falls. Actual harm occurred on 05/03/18 at 11:15 A.M. when Resident #64, assessed as requiring supervision with bathing, was left unattended by State Tested Nurse Aide (STNA) #626 in the shower room and fell to the floor while reaching for his clothing. The resident sustained an injury to his arm which subsequently became infected, requiring hospitalization and surgical intervention. The resident also reported difficulty with using his arm following the incident. Actual harm occurred on 06/11/18 when Resident #74, assessed as requiring two staff for bed mobility and toileting, rolled out of bed sustaining a facial contusion and emergent hospital visit, while being provided care by only one STNA. This affected two residents (Resident #64 and #74) of four residents reviewed for falls. Findings include: 1. Record review revealed Resident #64 was admitted to the facility on [DATE] with diagnoses that included unsteadiness on feet, generalized osteoarthritis, chronic obstructive pulmonary disease and anxiety. A diagnoses of infective bursitis of the left elbow was added to the list of diagnoses after Resident #64 was hospitalized on [DATE]. A plan of care was initiated on 01/26/15 and revised on 02/21/18 and identified Resident #64 was at risk for falls. A fall risk assessment completed on 02/08/18 revealed Resident #64 was at risk for falls. The fall interventions included bed locked and in low position during transfers, fall risk assessment and safety checks per policy, and nonskid strips to the floor on the right side of the bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 7 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashtabula County Nursing Home 5740 Dibble Road Kingsville, OH 44048 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 0689 Level of Harm - Actual harm Review of the Minimum Data Assessment (MDS) 3.0 assessment, dated 02/09/18 revealed the resident was alert and oriented with no cognitive impairment and required the extensive assistance of one person for bed mobility, transfers, dressing, and toileting. Resident #64 required supervision and set up for both hygiene and bathing. Residents Affected - Few Review of the nursing progress note, dated 05/03/18 at 3:23 P.M. revealed the nurse found Resident #64 on his knees holding onto his wheelchair. Resident #64 had a skin tear on the left forearm and small cut on his right second toe. The nursing progress note indicated STNA #626 told the nurse the resident had been left alone in the shower room (prior to being found on his knees on the floor). Review of an incident report revealed Resident #64 sustained a fall on 05/03/18. The incident report indicated Resident #64 was left alone in the shower room, fell onto his knees and hands while reaching for his clothing, was bleeding from his left arm and had cut his second toe on his right foot. As part of the investigation, STNA #626 provided a statement indicating she did leave Resident #64 alone in the shower. Following the incident, STNA #626 was in-serviced on not leaving residents alone in the shower room. Review of the MDS 3.0 assessment, dated 05/07/18 revealed Resident #64 was cognitively intact, required one person assistance for bed mobility, transfers and dressing. For personal hygiene Resident #64 was assessed to require set up and supervision. Review of the nursing progress notes from 05/09/18 through 06/05/18 revealed on 05/09/18 Resident #64 began complaining of pain and swelling in his left elbow region. The physician was notified and started him on the steroid medication, Prednisone 50 milligrams (mg) at bedtime. On 05/14/18 the pain and swelling increased, the physician was notified and came to see Resident #64. The physician expressed concern the arm was infected and planned for him to see an orthopedic physician the next morning. On 05/15/18 Resident #64 was started on the antibiotic Rocephin for a left elbow infection. On 05/16/18 nursing notes revealed that pain and redness was spreading in the left elbow region so his primary care physician at the facility wanted him evaluated at the hospital. Resident #64 was admitted to the hospital on [DATE] and had surgery during the stay for a diagnosis of septic olecranon bursitis of the left elbow and cellulitis. He returned to the facility on [DATE] and was placed in contact isolation for the Methicillin Resistant Staphylococcus Aureus (MRSA) in his elbow being treated with two antibiotics Ceftin and Bactrim DS. Resident #64 remained in contact isolation until 06/05/18. An interview was conducted on 10/15/18 at 4:04 P.M. with Resident #64 who revealed STNA #626 was assisting him in the shower, finished washing his back and told him she had to step out. Resident #64 said he was left on the shower bench with no towel and his dry clothing were on his wheelchair at least two to three feet out of reach. After ten to fifteen minutes had gone by he stated he was cold and reached for his clothing. He stated he managed to get his shorts on and when he reached a second time for his shirt he fell to the floor landing on his left forearm, which was cut during the fall. Resident #64 said that he was left handed and never had problems using his left arm until the fall on 05/03/18. Resident #64 explained that he had to go to the hospital because the cut he sustained on his left forearm got infected and he had to have surgery due to an infection and pain. He said his arm has not worked the same since the accident. An interview was conducted on 10/17/18 at 5:50 P.M. with the director of nursing who verified Resident #64 fell in the shower room and sustained an injury to his left arm as a result of STNA #626 leaving him unattended. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 8 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashtabula County Nursing Home 5740 Dibble Road Kingsville, OH 44048 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 0689 The facility policy titled Shower/tub bath policy, dated 10/2010, revealed employees were to stay with residents throughout the bath and never leave the resident unattended in the bath or shower. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 9 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashtabula County Nursing Home 5740 Dibble Road Kingsville, OH 44048 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** Based on observation, record review and interview the facility failed to ensure comprehensive nutritional assessments were completed and/or timely and adequate nutritional interventions were implemented to prevent weight loss. This affected six residents (Resident #269, #46, #57, #10, #79 and #70) of six residents reviewed for weight loss. Residents Affected - Some Findings include: 1. Review of Resident #70's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including amyotrophic lateral sclerosis (ALS), cognitive communication deficit, dysphasia, acute and chronic respiratory failure with hypoxia, anxiety disorder and major depressive disorder. The resident was ventilator dependent and received nutrition/hydration via a gastrostomy tube. Review of the admission nursing assessment identified Resident #70 was admitted with a weight of 166 pounds. The resident's height was six feet. Review of the 14-day Minimum Data Set (MDS) 3.0 assessment, dated 09/24/18 revealed the resident had intact cognition. Rejection of care had not been exhibited. The resident was dependent for eating. The assessment indicated the resident had a weight of 145 pounds and had no or unknown weight loss on a feeding tube. Review of the 30-day Minimum Data Set (MDS) 3.0 assessment which was in progress and dated 10/08/18 revealed the resident had intact cognition. Rejection of care had not been exhibited. The resident was dependent for eating. The assessment indicated the resident had a weight of 138 pounds and had no or unknown weight loss on a feeding tube. Review of the nutrition risk assessments dated 09/19/18, 08/16/18 and 06/06/18 revealed the resident was at low risk for nutritional deficits. The amount of calories, protein and fluids the tube feeding was supplying was documented. However, none of the completed assessments reflected what Resident #70's calorie, protein, fluid or other nutritional needs were calculated to be to ensure his needs were being met via the enteral tube feedings. Review of the plan of care revealed the resident was at risk for weight loss due to the multiple diagnoses and the resident's refusal of the tube feeding at times. Interventions included obtain weight per doctor's order, notify the doctor and the dietitian of significant changes, monitor intake, tolerance, residuals and record. Dietitian to evaluate and make tube feeding, flush and supplement change recommendations. Review of nutrition notes from 06/11/18, 06/22/18 and 6/23/2018 revealed Resident #70 was complaining of feeling full and uncomfortable and frequently asked to have the tube feeding shut off. An intermittent tube feed schedule was attempted. However, the resident was not agreeable to that tube feed schedule. The resident wanted the tube feeding held during the night. A more concentrated tube feeding formula was tried. Reducing the tube feeding rate was tried. A third tube feeding formula was then started and continued. Weight loss was noted for the resident in each of the notes. Review of the Weekly Weight Meeting Notes from 06/15/18 through 10/02/18 revealed Resident #70 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 10 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashtabula County Nursing Home 5740 Dibble Road Kingsville, OH 44048 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 discussed weekly. However, there was no evidence of any new nutritional interventions after 08/17/18 despite Resident #70's weight loss that was identified. Observation on 10/15/18 at 1:19 P.M. revealed the Resident #70 was receiving tube feeding at the ordered rate. The head of the bed was at elevated. The resident appeared cachectic. Residents Affected - Some Interview by phone on 10/17/18 at 10:31 A.M. with registered dietitian, licensed dietitian (RD, LD) #625 revealed Resident #70 had not tolerated several different tube feedings at different rates and schedules. The RD LD indicated the tube feeding was the most well tolerated but the resident occasionally had nursing turn it off. When the resident was in hospital his weight went up, which was possibly because the tube feeding wasn't being turned off. There was no evidence the facility determined why the resident was continuing to lose weight or why he was not tolerating the tube feedings that were being ordered. On 10/18/18 at 2:32 P.M. RD, LD #625 confirmed the resident's nutritional needs had not been calculated to ensure the enteral feeding ordered was meeting his needs prior to 10/17/18. Review of weights revealed on 06/06/18 Resident #70 weighed 166.0 pounds. On 10/17/2018 Resident #70 weighed 136.8 pounds which reflected a total weight loss of 29.2 pounds or 18% from 06/06/18 to 10/17/18 (a four month period of time) for a resident who received all of his nutrition/hydration via gastrostomy tube. 2. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia without behavioral disturbance, tremor, anxiety disorder, bipolar disorder, vitamin D deficiency, hypothyroidism, major depression, unspecified fracture of left acetabulum and left ischium (hip fracture) and left hip osteoarthritis. A nutritional care plan was initiated on 02/07/18 indicating that Resident #10 was at risk for impaired nutrition, weight loss and impaired hydration. Interventions included nutritional supplements would be provided per physician orders. A significant change Minimum Data Set (MDS) 3.0 assessment, dated 05/13/18 was completed for Resident #10 after she suffered a left hip fracture following a fall on 04/28/18. Resident #10 was on a regular diet and as of 05/24/18 and was to receive Med Pass 2.0, a nutritional supplement, twice a day, amount unspecified in the orders. The MDS 3.0 assessment, dated 10/02/18 indicated Resident #10 was severely impaired cognitively and was dependent on staff for activities of daily living including meal tray set up and supervision for eating. Section K of this MDS indicated that Resident #10 was 63 inches tall, weighed 138 pounds and did not reflect a significant weight loss or gain in the last one or six months. Observation conducted on 10/16/18 at 5:11 P.M., 5:17 P.M. and 5:25 P.M. revealed Resident #10 sitting upright in her bed with her dinner tray in front of her. She was able to feed herself with some difficulty due to her hand tremors. There were no staff providing supervision during the meal. She had eaten her meat but left 75% of her meal uneaten. Review of the monthly vitals section which included height and weight indicated on 04/01/18 Resident #10's weight was 159 pounds. On 07/04/18, Resident #10's weight was 142 pounds. On 09/02/18, Resident #10's weight was 138 pounds and on 10/02/18 Resident #10's weight was 135 pounds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 11 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashtabula County Nursing Home 5740 Dibble Road Kingsville, OH 44048 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 From 04/01/18 to 10/02/18 Resident #10 lost 24 pounds which was a 15% weight loss in six months. According to the MDS, any weight loss of 10% or more in six months should be coded for a significant weight loss on the MDS. The 10/02/18 MDS indicated a weight of 138 pounds but was not coded as a significant weight loss in one or six months. The signature section indicated Dietary Manager (DM) #628 completed this section of the MDS on 10/04/18. Residents Affected - Some An interview was conducted on 10/17/18 at 1:12 P.M. with DM #628 who verified she used the 09/02/18 weight of 138 pounds for the MDS assessment completed on 10/02/18. DM #628 said it should have been 135 pounds, and verified it did not capture the 15% weight loss in six months for Resident #10. She explained she was responsible for completing all of the nutritional assessments except for the goals and interventions sections which are completed by Dietitian #625. The nutritional assessments for Resident #10 completed on 02/05/18, 05/13/18, 07/03/18 and 10/02/18 contained no information related to Resident #10's calorie, protein or fluid needs. The nutritional assessment completed on 10/02/18 indicated a weight of 138 pounds and the goals and interventions section completed by Dietitian #625 also indicated there had been no significant weight loss and no new nutritional recommendations were made. An interview was conducted on 10/17/18 at 12:08 P.M. with Dietitian #625. She verified she completed the last two parts of the nutritional assessments, the goals and interventions sections. Dietitian #625 verified these nutritional assessments did not contain an assessment of calorie, protein or fluid needs and did not indicate Resident #10 was high nutritional risk. Dietitian #625 verified Resident #10's calorie, protein and fluid needs would increase after her hip fracture. Dietitian #625 explained that on 05/24/18 she recommended Resident #10 have the Med Pass 2.0 supplement twice a day due to a decline in her meal intakes. She said she assumed the specific amount of 120 milliliters twice a day would be put onto the medication administration record (MAR). Dietitian #625 stated that if the amount was not specified she would not know if a resident's needs were being met. An interview was conducted on 10/17/18 at 10:51 A.M. with Licensed Practical Nurse (LPN) #617. She explained that whenever a resident was ordered Med Pass 2.0 a specific amount to be given was specified in the physician order and it would be entered onto the MAR. LPN #617 verified Resident #10's MAR did not specify how much Med Pass 2.0 she was to receive. LPN #10 said nursing staff should have clarified the order to specify the amount. She said she gave Resident #10 whatever amount she would consume, which was usually four ounces but not always. She said sometimes she drank less or more. LPN #617 said there was no way to tell exactly how much Resident #10 consumed of the Med Pass supplement. Review of the MARs from May 2018 through October 2018 revealed there was no documentation of the amount of Med Pass supplement consumed by Resident #10. Review of the policy titled, Medical Nutritional Supplements, revised 11/05/09 indicated the facility would provide a designated amount of supplement during the routine medications passes. Review of the policy titled Nutritional Assessment, revised December 2011 indicated the dietitian would document an estimate of calorie, protein, nutrient and fluid needs of each resident on the nutritional assessment and whether the resident's current intake was adequate to meet his or her nutritional needs. The policy also indicated the multidisciplinary team shall identify upon a change in condition the resident at increased risk for impaired nutrition and an increased need for calories and/or protein. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 12 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashtabula County Nursing Home 5740 Dibble Road Kingsville, OH 44048 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 - Some 3. In addition, the nutrition risk assessments for four additional residents, Resident #269, Resident #46, Resident #57, and Resident #79 reviewed for weight loss revealed none had an estimate of their calorie, protein, nutrient and fluid needs. On 10/18/18 at 2:32 P.M., Dietitian #625 confirmed the resident nutritional needs had not been calculated and placed on record for the above residents until her progress note dated 10/17/18 which was following a discussion of the need for such information to be available. Review of the policy, Nutritional Assessment revised 12/2011, revealed the dietitian would document an estimate of calorie, protein, nutrient and fluid needs of each resident and whether the resident's current intake was adequate to meet his or her nutritional needs. The policy also indicated the multidisciplinary team shall identify upon a change in condition the resident at increased risk for impaired nutrition and an increased need for calories and/or protein. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 13 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashtabula County Nursing Home 5740 Dibble Road Kingsville, OH 44048 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** Based on record review and interview the facility failed to ensure pharmacy medication recommendations were completed timely for Resident #57. This affected one resident (Resident #57) of ten residents reviewed for unnecessary medication use. Findings include: Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), generalized anxiety disorder and major depressive disorder. Review of Resident #57's pharmacy medication record review dated 03/26/18 revealed the Center of Medicare and Medicaid Services (CMS) guidelines now limited the duration of all as needed psychoactive medication orders to no more than 14 days. The pharmacist recommended to review Resident #57's Ambien, five milligrams (mg) by mouth as needed for insomnia. Resident #57's primary care physician, Physician #801, reviewed and signed the pharmacist medication record review on 06/20/18, almost three months after the recommendation. Physician #801 recommended Ambien 5 mg by mouth as needed for insomnia to continue for six months. Review of Resident #57's pharmacy medication record review dated 04/24/18 revealed Resident #57 received Incruse Ellipta, one puff every day for COPD as well as Ipratropium inhaler two puffs every four hours as needed for shortness of breath. The pharmacist recommendation was to consider changing the Ipratropium to a short acting beta agonist such as Albuterol or Levoalbuterol. Physician #801 reviewed and signed the pharmacy medication record review on 06/28/18, two months after the recommendation was made. Interview with the Director of Nursing (DON) on 10/18/18 at 4:20 P.M. verified Resident #57's pharmacy medication record review for 03/26/18 was reviewed and signed by Physician #801 on 06/20/18. The Director of Nursing also verified Resident #57's pharmacy medication record review for 04/24/18 was signed and reviewed on 06/28/18 by Physician #801. The DON verified Resident#57's primary care physician comes to the facility at least monthly but often during the evening. The DON said it was difficult for the facility to review the pharmacy recommendations with the primary care physician timely. Review of facility policy dated 2016 titled, Consulting Pharmacist Monthly Drug Review, revealed the resident's attending physician must document in the medical record the identified irregularity had been reviewed, and what, if any action had been taken to address the medication drug review recommendation. If there was to be no change in the medication, the attending physician must document his or her rationale in the resident's medical record at the physician's next visit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 14 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashtabula County Nursing Home 5740 Dibble Road Kingsville, OH 44048 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital records, interview with facility staff, review of laboratory testing results, review of the facility policy titled Anticoagulation Clinical Protocol and review of the Nursing Drug Handbook, 38th Edition, the facility failed to ensure adequate monitoring was completed for one resident (Resident #6) who received the oral anticoagulant (blood thinning) medication, Coumadin. This resulted in Immediate Jeopardy when the blood clotting time was not monitored. Actual Harm occurred to Resident #6 on 08/28/18 when the resident was transported to the local emergency room with upper extremity bruising and bleeding evidenced by blood in the urine (indicators of possible increased bleeding due to the Coumadin medication) and was admitted to the hospital with retroperitoneal bleed and perinephric bleed. The resident's International Normalized Ratio (INR) level (blood testing used to monitor therapeutic levels of the medication Coumadin) was significantly elevated with a level over 9 on that date. This affected one of eleven residents reviewed the facility identified as receiving anticoagulant medication. The facility census was 116. Residents Affected - Few On 10/17/18 at 4:12 P.M., the Administrator, Regional Consultant #40, Assistant Director of Nursing (ADON) and Director of Nursing (DON) were notified Immediate Jeopardy began on 08/20/18 when the facility failed to obtain laboratory (INR) testing to monitor Resident #6's Coumadin level. The lack of monitoring resulted in the resident being transferred to the emergency room and admitted to the hospital on [DATE] with bruising and hematuria (blood in urine) with hospital diagnoses of retroperitoneal bleed and perinephric bleed. Resident #6 subsequently received fresh frozen plasma (FFP) and Vitamin K in an attempt to reverse the effects of the Coumadin medication. The Immediate Jeopardy was removed on 10/19/18 when the facility implemented the following corrective actions: • On 08/27/18 at 3:01 P.M. Registered Nurse (RN) #10 identified bruises on Resident #6's arms and notified the physician who ordered an INR and complete blood count lab work to be drawn on 08/27/18. • Laboratory testing results, dated 08/28/18 at 8:30 A.M. revealed Resident #6's INR level was over 9. The physician was notified, and an order was obtained to administer five milligrams (mg) of Vitamin K intramuscularly. Blood was subsequently identified in Resident #6's urine at 9:15 A.M. The facility reported the bloody urine symptom to the physician at 9:15 A.M. who ordered Resident #6 to the hospital for evaluation. At 9:30 A.M. emergency medical services (EMS) was called and at 9:56 A.M. Resident #6 was taken to the hospital emergency room. • A review of a facility investigation revealed Licensed Practical Nurse (LPN) #14 failed to document on the Coumadin log that PT/INR testing for Resident #6 was due on 08/20/18. Review of employee disciplinary action, dated 09/15/18 revealed LPN #14 was issued a three-day working suspension on 09/21/18, 09/22/18 and 09/23/18 for not ordering the PT/INR for Resident #6 on 08/20/18. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 15 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashtabula County Nursing Home 5740 Dibble Road Kingsville, OH 44048 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 0757 Level of Harm - Immediate jeopardy to resident health or safety An emergency meeting of the Quality Assurance committee consisting of the administrator, DON, ADON and management consultants was held on 08/28/18 to direct the following corrective action related to the incident with Resident #6: Ongoing and frequent communication with the hospital and family regarding resident condition. Completion of preliminary audits on all units regarding Coumadin logs and the completion of those logs. Residents Affected - Few • On 08/29/18 Coumadin log audits were completed for the eleven residents receiving Coumadin (Resident #6, #11, #19, #23, #27, #58, #65, #74, #83, #85, and #99) and were set for weekly audit through 12/31/18. The audits were completed by the unit managers, RN #620, RN #621 and RN #622. • On 08/29/18 body audits were completed/reviewed for the remaining ten residents, Resident #11, #19, #23, #27, #58, #65, #74, #83, #85, and #99 receiving Coumadin and found no negative for bleeding or bruising. The body audits were completed by the DON. • On 08/29/18 a plan was implemented for Coumadin log audits to be checked by the DON bi-weekly through 06/30/19. • Staff education regarding the use of anticoagulants, the Coumadin monitoring log and entering lab orders into Point Click Care electronic records was conducted on 09/15/18 for LPN and RN staff by the ADON. There were six LPNs and three RNs as of 09/15/18 who had not received the education. Those six LPNs and three RNs received the education on 10/18/18 by the ADON. Staff education was provided on 10/19/18 by the ADON for eight agency LPNs and any agency nurses who did not receive the education on 10/19/18 were put onto a Do Not Return list. • On 10/19/18 at 12:30 P.M. the DON provided a plan for all new agency staff to receive mandatory training on the same topic (related to the use of anticoagulants) from the ADON before working in the facility. A plan for any newly hired nurses to receive the training as part of the orientation program by the ADON was also implemented. • Nursing staff interviews were conducted on 10/19/18 from 9:06 A.M. to 9:24 A.M. with LPN #615, LPN #617, LPN #618 and LPN #619 who were employed by the facility. All LPN's interviewed verified recent education on anticoagulants including Coumadin, using the monitoring tool to track PT/INR levels, Coumadin orders and lab orders and how to input lab orders into the electronic records system. Although the Immediate Jeopardy was removed on 10/19/18 the facility remained out of compliance at Severity Level 2 (no actual harm with potential for minimal harm that is not Immediate Jeopardy) as the facility remained in the process of implementing their corrective action plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 16 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashtabula County Nursing Home 5740 Dibble Road Kingsville, OH 44048 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 0757 Findings include: Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, major depressive disorder, oropharyngeal dysphagia, poly neuropathy, generalized osteoarthritis, pain in left shoulder, muscle wasting, dementia and cognitive communication deficit. Residents Affected - Few Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was cognitively intact and required extensive assistance from staff for bed mobility, transfers, toileting and hygiene. Record review revealed Resident #6 was unable to make her own financial and health care decisions without input from her son who was identified to be her responsible party. Record review revealed a plan of care, initiated on 07/03/18 and revised on 07/30/18 indicating the resident was on anticoagulant therapy. The goal developed was for the resident to be free from discomfort and adverse reactions related to anticoagulant use. Interventions included to monitor for side effects and effectiveness once a shift and labs as ordered, report abnormal lab results to physician. Review of the physician's orders revealed an order, dated 07/02/18 for the anticoagulant (blood thinning) medication, Coumadin (Warfarin Sodium) two milligrams (mg) once a day every Sunday, Tuesday, Thursday and Saturday for atrial fibrillation. On 07/02/18 an additional Coumadin order was written for a four mg Coumadin once a day every Monday, Wednesday and Friday for atrial fibrillation. The orders were discontinued on 07/16/18 and new orders were obtained. Review of the physician's orders revealed a new order, dated 07/16/18 for Coumadin four mg once a day on Sunday, Monday, Wednesday, Thursday and Saturday. On 07/16/18 a second order for Coumadin was noted for two mg once a day on Tuesday and Friday. Both of those orders were discontinued on 07/30/18 and a new order was written for Coumadin five mg by mouth one time a day for anticoagulant therapy. Review of the laboratory testing results revealed the resident's Coumadin was monitored by checking a Prothrombin Time (PT) and International Normalized Ratio (INR) value. The resident's PT/INR were obtained on 07/06/18, 07/09/18, 07/16/18, 07/23/18, 07/30/18, 08/06/18 and 08/13/18 with changes made to the Coumadin dosage as noted above. The 08/13/18 laboratory testing revealed the resident's PT was 29.6 and INR was 2.9 (within normal limits for the resident) with an order to maintain the same dose and recheck values in one week. However, there was no evidence of any subsequent PT/INR lab values obtained by the facility until 08/28/18 after the resident was assessed with bruising. The results were called to the facility by the lab to report critically high levels of PT at 88.8 and INR over 9.0. Review of the PT/INR Tracking Form for Resident #6 revealed that on 08/13/18 the facility was to draw another PT/INR in one week, however the next draw was not done until 08/28/18 after the resident had shown symptoms of bruising. Review of the nursing progress notes written by RN #10 on 08/27/18 at 3:01 P.M. revealed Resident #6 had three dark bruises on her right and left arm. RN #10 notified the physician and the physician ordered laboratory testing for an INR and complete blood count (CBC) lab work to be done on 08/27/18. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 17 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashtabula County Nursing Home 5740 Dibble Road Kingsville, OH 44048 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 0757 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The nursing progress notes written by LPN #11 on 08/28/18 at 2:47 A.M. revealed Resident #6 had bruises to the underside of both upper arms and the bruising was dark purple/red in color. Review of the nursing progress notes written by LPN #12 on 08/28/18 at 9:58 A.M. revealed that lab called the facility at 8:30 A.M. to report an elevated PT 88.8 and INR over 9. The physician was notified with new orders to give Vitamin K five mg intramuscular, hold the Coumadin, recheck on Thursday. Vitamin K was given at 9:00 A.M. and at 9:15 A.M. Resident #6 urinated a large amount of hematuria (blood in urine). The physician then gave a new order to send Resident #6 to the emergency room. EMS (911) was called at 9:30 A.M. and arrived at 9:56 A.M. to transport Resident #6 to the hospital. Review of the Medication Administration Record (MAR) from August 2018 for Resident #6 revealed the resident received Coumadin as ordered until it was held beginning on 08/28/18. Review of the nursing progress notes dated 08/28/18 at 3:24 P.M. by LPN #12 revealed Resident #6 was admitted to the hospital due to an elevated INR. The nursing progress notes written by RN #13 on 08/30/18 at 8:00 P.M. revealed Resident #6 returned to the facility on [DATE] at approximately 8:00 P.M. A nursing progress note written by LPN #14 on 08/31/18 at 1:37 P.M. revealed Resident #6 was not to be on Coumadin for four to six weeks upon re-admission. Review of the hospital discharge summary indicated Resident #6 was admitted on [DATE] due to significant, elevated INR over 9, and spontaneous bleeding with hematoma to arms and hematuria. Resident #6 was given several units of fresh frozen plasma and Vitamin K. Resident #6 had a computed tomography (CT) scan that showed a retroperitoneal bleed with a perinephric bleed. The discharge summary also recommended that before any Coumadin could be resumed for Resident #6 there would need to be a repeat CT scan. An interview was conducted on 10/17/18 at 7:36 P.M. with RN #10 who verified Resident #6 had dark bruises on both arms on 08/27/18 with no other signs of bleeding. RN #10 indicated she reported the findings to the physician who ordered a PT/INR and CBC to be done on 08/27/18. An interview was conducted on 10/17/18 at 7:48 P.M. with LPN #11 who verified Resident #6 had dark bruises on both arms on 08/28/18 with no other signs of bleeding. An interview was conducted on 10/18/18 at 8:24 P.M. with the DON who revealed the follow-up CT scan on Resident #6 was performed per hospital recommendations on 10/03/18 and found to be improved. Review of the CT scan report of the abdomen and pelvis with intravenous contrast completed on 10/03/18 for Resident #6 revealed bleeding was resolved. A review of physician orders, dated 10/17/18 and 10/18/18 revealed a PT/INR was drawn on 10/17/18 with result of 13.7 and 1.1, the doctor was notified and gave an order to begin Coumadin 2.5 mg once a day to start on 10/18/18. Per review of the MAR, the first dose was scheduled to begin on 10/18/18 at 5:00 P.M. An interview was conducted on 10/18/18 at 10:01 A.M. with the DON and ADON. The DON identified LPN #14 as the LPN who failed to enter the order for the PT/INR check to be done on 08/20/18. The DON and ADON explained that discipline was carried out per the progressive discipline policy of the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 18 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashtabula County Nursing Home 5740 Dibble Road Kingsville, OH 44048 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 0757 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy titled, Anticoagulation Clinical Protocol, dated 10/2010, revealed the physician would order appropriate laboratory testing to monitor anticoagulant therapy and potential complications and the staff should use a monitoring tool to follow trends in anticoagulant dosage and response. Review of the Nursing Drug Handbook, 38th Edition revealed Coumadin was an anticoagulant and used as treatment of deep vein thrombosis, myocardial infarction, pulmonary embolism, rheumatic heart disease with heart valve damage, prosthetic heart valves and chronic atrial fibrillation. The handbook indicated the medication should be used with caution and the most serious risk of therapy was hemorrhage. The dosage was adjusted according to the INR results and elderly tended to require lower dosages to produce a therapeutic level of anticoagulation. Under black box warning it indicated to regularly inspect patient for bleeding gums, bruises on arms or legs, nosebleeds, melena (dark and sticky stools), tarry stool, hematuria and hematemesis. Event ID: Facility ID: 365741 If continuation sheet Page 19 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashtabula County Nursing Home 5740 Dibble Road Kingsville, OH 44048 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on record review and interview the facility failed to ensure psychotropic medications ordered as needed (PRN) were limited to fourteen days or provided with a rationale in the resident's medical record indicating the reason and duration for the as needed psychotropic medication if ordered longer than fourteen days. This affected two residents (Resident #16 and Resident #57) of ten residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #16's medical record revealed an admission date of 02/16/11 with diagnoses that included anxiety disorder and major depressive disorder. Resident #16 had a physician order with a start date of 01/27/18 for Diazepam tablet, 5 milligram (mg), one tablet by mouth every 12 hours as needed for anxiety. No duration was given. Record review of Resident #16's medication record review per the pharmacist dated 07/21/18 revealed the Center for Medicare and Medicaid Services (CMS) guidelines now limited the duration of all as needed psychotropic medication orders to no longer than 14 days. The pharmacist recommended to review the following orders and consider discontinuing therapy for Diazepam, 5 mg by mouth every 12 hours as needed for insomnia and anxiety and Zolpidem, 5 mg, every night as needed for insomnia. The pharmacy medication record review revealed Resident #16's primary care physician, Physcian #800, reviewed the recommendation on 07/30/18 and recommended to discontinue the Zolpidem but to continue Diazepam. No duration for use was given. Review of the August 2018 medication administration record (MAR) revealed Resident #16 received Diazepam tablet, 5 mg as needed on 08/01/18, 08/06/18, 08/08/18, 08/09/18, 08/10/18, 08/11/18, 08/15/18, 08/16/18, 08/17/18, 08/20/18, 08/21/18, 08/23/18, 08/24/18, 08/25/18, 08/26/18, 08/27/18, 08/28/18, 08/29/18, and 08/31/18. Record review of the September 2018 MAR revealed Resident #16 received Diazepam tablet, 5 mg, as needed on 09/03/18, 09/04/18, 09/05/18, 09/06/18, 09/07/18, 09/09/18, 09/10/18, 09/11/18, 09/12/18, 09/13/18, 09/18/18, 09/20/18, 09/21/18, 09/22/18, 09/23/18, 09/25/18, 09/26/18, 09/27/18, and 09/29/18. Record review of October 2018 MAR revealed Resident #16 received Diazepam, 5 mg, as needed on 10/01/18, 10/02/18, 10/05/18, 10/06/18, 10/12/18, and 10/15/18. Interview on 10/16/18 at 5:06 P.M. with the Director of Nursing verified Resident #16's Diazepam order did not have a duration indicated by the physician. Review of facility policy dated 2001, titled Anti-psychotic Medication Use revealed the policy did not include information for nursing staff to ensure as needed orders for psychotropic medications were limited to fourteen days or provide rationale in the resident's medical record indicating the reason and duration for the as needed medication. 2. Review of Resident #57's medical record revealed an admission date of 06/09/16 with diagnoses that included generalized anxiety disorder and major depressive disorder. Resident #57 had a physician (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 20 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashtabula County Nursing Home 5740 Dibble Road Kingsville, OH 44048 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 order, with a start date of 07/24/18 for Haloperidol tablet, give 3 milligram (mg) by mouth every two hours as needed for anxiety while on dialysis and a physician order with a start date of 06/09/18 for Ambien tablet 5 mg give one tablet by mouth every hour of sleep as needed for sleeplessness. Record review of Resident #57's pharmacy medication record review dated 03/26/18 revealed the Center of Medicare and Medicaid Services (CMS) guidelines now limited the duration of all as needed psychoactive medication orders to no longer that 14 days. The pharmacist recommended to review Resident #57's Ambien 5 mg by mouth as needed for insomnia. Primary Care Physician #801 reviewed the pharmacist medication record review on 06/20/18 and recommended Ambien 5 mg by mouth as needed for insomnia to continue for six months. Record review of the medication administration record for September 2018 reviewed Resident #57 received Ambien 5 mg give one tablet by mouth as needed for sleeplessness on 09/01/18, 09/03/18, 09/05/18, 09/07/18, 09/10/18, 09/11/18, 09/12/18, 09/18/18, and 09/28/18. Resident #57 did not receive Haloperidol 3 mg by mouth every two hours as needed while on dialysis. Record review of Resident #57's pharmacy medication record review dated 09/22/18 revealed CMS guidelines now limited the duration of all as needed anti-psychotic medication orders to no longer than 14 days unless the prescriber had evaluated the resident for appropriateness of the medication. The pharmacist recommended to review Resident #57's physician order for Haldol 3 mg by mouth every two hours as needed for anxiety while on dialysis. Primary Care Physician #801 reviewed the pharmacy recommendation on 10/18/18 and discontinued the Haldol. Record review of the medication administration record for October 2018 reviewed Resident #57 received Ambien tablet 5 five mg by mouth as needed for sleeplessness on 10/3/18, 10/15/18, and 10/17/18. Resident #57 did not receive Haloperidol 3 mg by mouth every two hours as needed for anxiety while on dialysis. Interview with the Director of Nursing on 10/18/18 at 12:54 P.M. verified Resident #57 had a physician order with a start date of 07/24/18 for Haloperidol 3 mg by mouth every two hours as needed for anxiety while on dialysis without a stop date. The Director of Nursing revealed she would have the physician review the pharmacy medication record review today for the use of Resident #57's Haloperidol. The Director of Nursing also verified Resident #56's Primary Care Physician #801 did not review the pharmacy medication regimen review dated 03/26/18 for Resident #57 until 06/20/18. Review of facility policy dated 2001, titled Anti-psychotic Medication Use revealed the policy did not include information for nursing staff to ensure as needed orders for psychotropic medications were limited to fourteen days or provide rationale in the resident's medical record indicating the reason and duration for the as needed medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 21 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashtabula County Nursing Home 5740 Dibble Road Kingsville, OH 44048 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 observation, record review and interview the facility failed to maintain a medication error rate of less than five percent. The medication error rate was calculated to be 8 percent and included two medication errors of 25 medication administration opportunities. This affected one resident (Resident #70) of five residents observed during medication administration. Residents Affected - Few Findings include: Observation of a medication pass for Resident #70 on 10/16/18 from 8:40 A.M. to 9:13 A.M. by Licensed Practical Nurse (LPN) #612 revealed Resident #70 to be on a continuous enteral feed (tube feed) infusion. The nurse prepared a 50 milligram (mg) tablet of Riluzole, a medication to treat amyotrophic lateral sclerosis, for administration. Review of the Riluzole package revealed instructions from the pharmacy to give on an empty stomach, either an hour before or two to three hours after eating. Interview with LPN #612 at the time of the above observation revealed Resident #70's enteral feeding had not been stopped for an hour or more before the administration of the medications. She confirmed the staff had no current process for ensuring Riluzole was given to Resident #70 on an empty stomach, and that the pharmacy instructions for Riluzole called for it to be given on an empty stomach. LPN #612 also revealed Resident #70 had an order for liquid Docusate, a stool softener, to be administered at this time, which was not available. Following the interview, the LPN administered the prepared medications, including the Riluzole. Interview with LPN #612 on 10/16/18 at 10:28 A.M. revealed Resident #70 had still not received their ordered Docusate medication. Record review for Resident #70 revealed an order dated 09/05/18 for 10 milliliters (ml) of Docusate in a concentration of 50 mg per 5 ml to be administered twice daily at 9:00 A.M. and 9:00 P.M. The above findings were reviewed during an interview with the Director of Nursing on 10/16/18 at 10:50 A.M. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 22 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365741 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ashtabula County Nursing Home 5740 Dibble Road Kingsville, OH 44048 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to maintain Resident #42's indwelling urinary (Foley) catheter tubing and drainage bag in a manner to prevent the spread of infection. This affected one resident (Resident #42) of 15 residents identified to have indwelling (Foley) catheters. Residents Affected - Few Findings include: Record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, respiratory failure with hypoxia, neuromuscular dysfunction of the bladder, and diabetes. Review of Resident #42's care plan with a revision date of 07/18/18 revealed Resident #42 had a Foley catheter related to neurogenic bladder. The care plan revealed an intervention to use universal precautions (safe handling of potentially contaminated equipment or surfaces in the residents environment) and appropriate handling of Foley catheter and tubing. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #42 required extensive assist from staff for bed mobility and transfers and walking did not occur. The MDS 3.0 assessment revealed Resident #42 had a indwelling catheter. Record review revealed Resident #42 had a physician order, with a revision date of 10/09/18 for a Foley (a thin sterile tube inserted into the bladder to drain urine) catheter number 18 French (measurement system to measure size of a catheter) to continuous drainage. Observation on 10/15/18 at 03:49 P.M. of Resident #42 revealed she was up in a wheelchair in front of the nursing station and her indwelling catheter tubing was touching the floor underneath her wheelchair. Observation on 10/16/18 at 06:14 P.M. of Resident #42 revealed she was in bed with her indwelling catheter drainage bag hanging on the side of the bed facing the doorway. The drainage bag and part of the catheter tubing were observed directly on the floor. Interview on 10/16/18 at 06:22 P.M. with Licensed Practical Nurse #600 verified the indwelling catheter drainage bag and tubing were on the floor at that time. Review of facility policy, dated 05/2017 titled Placement of the Foley Drainage Bag revealed when a resident was in bed the drainage bag on the bed frame should be below the level of the bladder to provide straight gravity drainage, yet not on the floor. Staff were to place the catheter bag then in a cover provided by the laundry department or central supply. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 23 of 23