Inspection·December 5, 2019

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A witness statement per Resident #49 dated 09/10/19 revealed STNA #600 found the coin purse and asked Resident #49 if she wanted her coin purse with her money locked up with the nurse. Resident #49 agreed and then checked on 09/08/19 to see if she had enough money to get lunch and the nurse gave her the coin purse and there was money missing. A witness statement per STNA #600 dated 09/10/19 revealed she gave LPN #601 Resident #49's coin purse that contained $38.00 dollars. She revealed she counted the money in front of LPN #601 and LPN #601 put the purse and money inside the medication cart. A witness statement per LPN #601 dated 09/15/19 revealed STNA #600 brought her Resident #49's coin purse and LPN #601 and STNA #600 counted the money inside the coin purse and there was $38.00 dollars. LPN #601 wrote on a piece of tape the resident's name and $38.00 dollars and placed the tape on the coin purse. LPN #601 placed the coin purse inside the B wing medication cart inside the narcotic drawer. Interview on 12/03/19 at 2:49 P.M. with LPN #602 verified Resident #49 had asked for her change purse with money out of the narcotic drawer on 09/08/19. She verified the change purse contained $2.00 dollars inside. She verified they did not have accounting records of Resident #49's money as they did not count her money in the narcotic drawer shift to shift. Interview on 12/03/19 at 3:06 P.M. STNA #600 verified on 09/02/19 Resident #49 agreed to not keep her change purse with money in her room. She verified she gave LPN #601 the change purse and they counted the money together and Resident #49 had $38.00 dollars inside the change purse. She verified LPN #601 placed the change purse with the money in the medication cart inside the narcotic drawer. Interview on 12/04/19 at 1:48 P.M. with the Administrator verified Resident #49 had personal money missing from the medication cart inside the narcotic drawer. She verified she had a personal funds account at the facility and revealed Resident #49's personal money should not have been maintained in the narcotic drawer instead should have been put into her personal account. Review of facility policy titled Abuse, Neglect, Misappropriation of Resident's Property and Injury of Unknown Source, dated 10/17/17 revealed misappropriation was defined as deliberate, depriving, defrauding, or otherwise obtaining the real or personal property of a resident. Review of facility policy titled Protection and Management of Resident Funds, dated 03/01/19 revealed if a resident presented written authorization, the facility shall hold, safeguard and manage and account for the resident's personal funds deposited with the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 2 of 13 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 12/05/2019 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 observation, record review and interview the facility failed to accurately code alarms on the Minimum Data Set (MDS) 3.0 assessment for Resident #29, Resident #63, Resident #96 and Resident #99. This affected four residents (#29, #63, #96 and #99) of four residents reviewed for alarms. Residents Affected - Some Findings include: 1. Record review for Resident #99 revealed an admission to the facility on [DATE]. Resident #99's current diagnoses included unspecified dementia with behavioral disturbance, major depressive disorder, generalized osteoarthritis, and primary hypertension. A fall risk assessment dated [DATE] revealed that Resident #99 was a high risk of falls. Review of the physician's orders for Resident #99 revealed an order, dated 10/30/19 for motion [NAME] alarm for bathroom, an order dated 09/22/19 for self releasing alarm belt to wheelchair, a motion [NAME] to the residents bed, and an order for bed tender alarm dated 06/05/18. A care plan relative to fall risk revealed individualized interventions for falls including: motion sensor beside bed, a motion sensor to bathroom door, and a self release alarmed seatbelt to wheelchair. The MDS 3.0 assessment, dated 11/08/19 revealed Resident #99 had a with a brief interview mental status (BIMS) score of of 99 indicating resident was unable to complete the assessment due to severe cognitive impairment. There was no reference to the use of alarms. Review of Resident #99's MDS 3.0 assessments, dated 10/11/19 and 11/08/19 under Section P-0200 Alarms, revealed the MDS indicated that (A) a bed alarm was not used, (B) a chair alarm was not used, (C ) a floor mat alarm was not used and (D) motion [NAME] alarm were not used. Interview with MDS Coordinator RN #606 at 3:36 P.M. revealed the MDS section verified Section P indicated that a bed alarm (marked 0) was not used, a chair Alarm (marked 0) was not used, a floor mat alarm (marked 0) not used, and a motion [NAME] alarm (marked 0) was not used. 2. Record review revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, unspecified dementia without behavioral disturbance and a history of falling. Review of the physician's orders revealed an order dated, 03/15/16 for bilateral half side-rails up when in bed, an order, dated 04/11/19 for a chair alarm to wheelchair and recliner for safety and an order dated 04/24/19 for a personal body alarm (PBA) at all times. Review of the MDS 3.0 dated 09/20/19 revealed the resident was moderately cognitively impaired, required extensive assist of two staff for transfers and toileting, used a wheelchair for mobility, had no falls, and had no use of physical restraints or alarms. Review of the care plan, dated 10/01/19 included a care area for falls with interventions including a chair alarm (01/07/19) and a PBA (04/12/19). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 3 of 13 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 12/05/2019 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 Level of Harm - Minimal harm or potential for actual harm Observations of Resident #29 on 12/03/19 at 10:56 A.M. and 12/05/19 at 9:44 A.M. revealed the resident was seated in a wheelchair with the PBA and chair alarms in place. Interview on 12/04/19 at 2:31 P.M. with the Director of Nursing verified if a resident had active orders for an alarm, the alarm use should be reflected on the MDS assessment. Residents Affected - Some Interview on 12/04/19 at 3:34 P.M. with Registered Nurse (RN) #606 verified Resident #29 had a chair alarm and PBA in place but the alarm section of the MDS for Resident #29 was not accurate to reflect the use of the alarming devices. RN #606 revealed this may have been overlooked. Review of the Alarm policy, dated 01/11/13 revealed alarms were utilized for the purpose of safety, providing an audible notification to the staff of a resident's need for assistance or an audible reminder to the resident of their need receive or request assistance from staff. Need for alarm intervention and type of alarm was determined by or through the Fall Risk Assessment, the admission assessment, a post fall assessment, the interdisciplinary team and/or the interdisciplinary team and/or the resident's physician. 3. Record review revealed Resident #96 was admitted to the facility on [DATE] with diagnoses including unspecified dementia without behavioral disturbance, aphasia (loss of ability to understand or express speech) after a stroke. Physician orders included an order, dated 07/02/18 for bilateral half side-rails up when in bed, an order,dated 05/07/19 for a motion sensor to the left side of the bed to alert staff on unassisted transfers and an order for chair alarm on at all times to alert staff of unassisted ambulation. Review of the MDS 3.0 assessment, dated 11/08/19 revealed the MDS did not reflect the use of alarms. Review of the care plan, dated 11/18/19 included a care area for risk of falls with interventions including a chair alarm and motion sensor to bedside. Observation and interview on 12/02/19 at 9:10 A.M. with State Tested Nursing Assistant (STNA) #608 verified Resident #96 had a motion sensor and chair alarm to help prevent falls. Interview on 12/04/19 at 2:31 P.M. with the Director of Nursing verified if a resident had active orders for an alarm, the alarm(s) should be reflected on the MDS assessment. Interview on 12/04/19 at 03:34 P.M. with Registered Nurse (RN) #606 verified the alarm section of the MDS for Resident #96 was not complete and the use of alarms might have been overlooked. 4. Record review revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including dementia, major depressive disorder, and chronic kidney disease stage 3. Review of the care plan dated 06/09/19 included a care area of high risk for falls related to risks including immobility and dementia. The care plan was revised on 08/20/19 to initiate a chair tender alarm and again on 09/24/19 to initiate an alarming floor mat per doctor's order. Physician's orders included an alarming floor mat to left side of bed dated 09/03/19 and a chair tender while up to alert staff of unassisted transfers dated 09/13/19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 4 of 13 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 12/05/2019 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 Level of Harm - Minimal harm or potential for actual harm Review of the MDS 3.0 assessment dated [DATE] indicated chair and bed alarms were coded as not used for the resident. Observations of Resident #63 on 12/03/19 at 11:58 A.M. and 12/04/19 at 2:14 P.M. revealed the resident was seated in her wheelchair with the chair tender in place. Residents Affected - Some Observations of Resident #63 on 12/03/19 at 1:48 P.M., 12/04/19 at 8:48 A.M. and 12/04/19 at 12:41 P.M. revealed an alarm floor mat in place under the left side of the bed while resident was sitting in a nearby reclining chair. Interview on 12/04/19 at 2:30 P.M. with Licensed Practical Nurse #613 verified Resident #63 used a chair alarm when in the wheelchair and bed alarm when in bed. Interview on 12/04/19 at 2:31 P.M. with the Director of Nursing verified if a resident had active orders for an alarm, that alarm should be reflected on the MDS. Interview on 12/04/19 at 3:15 P.M. with State Tested Nursing Assistant (STNA) #615 verified Resident #63 used a chair alarm when in the wheelchair and bed alarm when in bed. Interview on 12/05/19 at 11:22 A.M. with STNA #614 verified Resident #63 used a chair alarm when in the wheelchair and bed alarm when in bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 5 of 13 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 12/05/2019 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview the facility failed to ensure Resident #62, who had a diagnosis of diabetes mellitus received insulin injections in accordance with the physician's order for administration and to meet the resident's needs. This affected one resident (#62) of six residents observed for medication administration. Residents Affected - Few Findings include: Review of the medical record for Resident #62 revealed an admission date of 03/02/18 with diagnoses including diabetes mellitus type 2, dementia and chronic kidney disease. Record review revealed the resident had a physician's order, dated 09/18/19 for NovoFine Lantus Solostar KwikPen Insulin Needles, inject one applicator subcutaneously every morning and at bedtime. The order included to rotate sites, use arms not abdomen for injection. During medication administration observation on 12/03/19 at 7:42 A.M., Licensed Practical Nurse (LPN) #610 entered Resident #62's room with the prepared Lantus Solostar Kwikpen and exposed the resident's abdomen which revealed two small blue, red, and purple colored bruises to the right upper quadrant. Resident #62 inquired of LPN #610 why she was getting bruises and LPN #610 responded she believed it was from her insulin shots but she would check. LPN #610 then wiped an area of Resident #62's abdomen in the left upper quadrant of the abdomen and proceeded to inject six units of Lantus insulin using the Kwikpen. Interview on 12/03/19 at 3:27 P.M. with Resident #62 and LPN #610 confirmed Resident #62 had three bruises on the abdomen. LPN #610 verified two bruises coincided with previous insulin injections on the abdominal right upper quadrant and the third was new from the insulin injection she gave that morning. Interview on 12/03/19 at 3:49 P.M. with the Director of Nursing verified Resident #62 had a physician's order, dated 09/18/19 to use her arms and not the abdomen for insulin injections. She further confirmed Resident #62 received insulin injections in the abdomen on multiple occasions from 09/19/19 to 12/03/19. Review of Medication Administration Records for September through December 2019 revealed Resident #62 received the Lantus Solostar insulin injection in the abdomen on 09/19/19 at 9:15 P.M., 09/20/10 at 7:23 A.M. and at 8:23 P.M., on 09/21/19 at 7:46 A.M. and at 8:08 P.M., on 09/22/19 at 7:56 A.M. and at 8:06 P.M., on 09/23/19 at 7:14 A.M. and at 9:15 P.M., on 09/24/19 at 7:12 A.M. and at 8:01 P.M., on 09/25/19 at 7:47 A.M. and at 8:33 P.M., on 09/26/10 at 7:19 A.M. and at 8:25 P.M., on 09/27/10 at 7:34 A.M. and at 8:51 P.M., on 09/28/19 at 8:41 P.M., on 09/29/19 at 7:33 A.M. and at 8:07 P.M., on 09/30/19 at 6:49 A.M. and at 8:07 P.M., on 10/01/19 at 7:13 A.M. and at 8:55 P.M., on 10/02/19 at 7:06 A.M. and at 08:18 P.M., on 10/03/19 at 7:25 A.M. and at 8:08 P.M., on 10/04/19 at 9:21 A.M. and at 8:09 P.M., on 10/05/19 at 7:04 A.M. and at 8:09 P.M., on 10/06/19 at 7:11 A.M. and at 8:35 P.M., on 10/07/19 at 7:35 A.M. and at 8:43 P.M., on 10/08/19 at 7:08 A.M. and at 8:35 P.M., on 10/09/19 at 7:20 A.M. and at 8:58 P.M., on 10/10/19 at 7:11 A.M. and at 8:08 P.M., on 10/11/19 at 7:27 A.M. and at 8:11 P.M., on 10/12/19 at 8:45 A.M. and at 8:04 P.M., on 10/13/19 at 7:25 A.M. and at 8:03 P.M., on 10/14/19 at 8:49 A.M. and at 8:31 P.M., on 10/15/19 at 7:59 A.M. and at 8:05 P.M., on 10/16/19 at 11:19 A.M. and at 8:42 P.M., on 10/17/19 at 7:20 A.M. and at 8:04 P.M., on 10/18/19 at 8:02 A.M. and at 8:29 P.M., on 10/19/19 at 9:02 A.M. and at 8:54 P.M., on 10/20/19 at 9:27 A.M. and at 8:07 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 6 of 13 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 12/05/2019 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few P.M., on 10/21/19 at 8:51 A.M., on 10/22/19 at 8:55 A.M. and at 9:04 P.M., on 10/23/19 at 7:22 A.M. and at 8:17 P.M., on 10/24/19 at 8:52 A.M. and at 8:19 P.M., on 10/25/19 at 7:36 A.M. and at 10:45 P.M., on 10/26/19 at 7:48 A.M. and at 8:05 P.M., on 10/27/19 at 7:04 A.M. and at 10:31 P.M., on 10/28/19 at 9:59 A.M. and at 8:26 P.M., on 10/29/19 at 10:25 A.M. and at 8:13 P.M., on 10/30/19 at 7:31 A.M. and at 10:44 P.M., on 10/31/19 at 8:46 A.M and at 8:04 P.M., on 11/01/19 at 7:46 A.M. and at 8:07 P.M., on 11/02/19 at 9:33 A.M. and at 8:20 P.M., on 11/03/19 at 7:58 A.M. and at 8:27 P.M., on 11/04/19 at 8:44 A.M. and at 8:38 P.M., on 11/05/19 at 8:52 A.M. and at 9:24 P.M., on 11/06/19 at 7:40 A.M. and at 8:11 P.M., on 11/07/19 at 9:39 A.M. and at 8:30 P.M., on 11/08/19 at 10:33 A.M. and at 9:12 P.M., on 11/09/19 at 7:12 A.M. and at 8:50 P.M., on 11/10/19 at 7:29 A.M., on 11/11/19 at 7:37 A.M. and at 8:28 P.M., on 11/12/19 at 9:42 A.M. and at 9:22 P.M., on 11/13/19 at 7:00 A.M. and at 8:41 P.M., on 11/14/19 at 7:19 A.M. and at 8:11 P.M., on 11/15/19 at 7:39 A.M. and at 8:52 P.M., on 11/16/19 at 7:27 A.M. and at 8:28 P.M., on 11/17/19 at 9:38 A.M. and at 8:06 P.M., on 11/18/19 at 9:00 A.M. and at 9:06 P.M., on 11/19/19 at 7:39 A.M. and at 9:36 P.M., on 11/20/19 at 10:50 A.M. and at 8:12 P.M., on 11/21/19 at 9:29 A.M. and at 8:00 P.M., on 11/22/19 at 7:03 A.M. and at 8:14 P.M., on 11/23/19 at 8:50 A.M. and at 9:00 P.M., on 11/24/19 at 9:27 A.M. and at 8:34 P.M., on 11/25/19 at 7:10 A.M. and at 8:15 P.M., on 11/26/19 at 9:48 A.M. and at 8:17 P.M., on 11/27/19 at 7:16 A.M and at 9:02 P.M., on 11/28/19 at 7:29 P.M. and at 8:18 P.M., on 11/29/19 at 7:20 A.M. and at 8:04 P.M., on 11/30/19 at 7:57 A.M. and at 8:33 P.M., on 12/01/19 at 7:41 A.M. and 8:12 P.M., and on 12/02/19 at 7:31 A.M and 8:09 P.M. Review of facility undated policy titled Medication Administration revealed medications must be administered in accordance with the orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 7 of 13 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 12/05/2019 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure timely assessments were completed and adequate interventions were implemented to prevent the development of a pressure ulcer for Resident #94. Residents Affected - Few Actual Harm occurred on 10/29/19 when Resident #94, who was quadriplegic and required extensive assistance to total dependence on staff for activity of daily living care, including bed mobility and transfers developed an unstageable/Stage IV (full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar may be present on some parts of the wound bed, often include undermining and tunneling) pressure ulcer to the coccyx. This affected one resident (#94) of two residents reviewed for pressure ulcers. The facility identified eight current residents with pressure ulcers. Findings include: Record review revealed Resident #94 was admitted to the facility on [DATE] with diagnoses including quadriplegia, neurogenic bowel, neuromuscular dysfunction of bladder and diabetes mellitus type 1. Review of Resident #94's care plan initiated 04/10/19 revealed a care focus for total assistance with bed mobility, bowel stimulation for bowel movement daily and risk of impaired skin integrity due to impaired mobility, neuropathy, and quadriplegia. Interventions noted the resident required skin inspection with hands on care and observation for redness and open areas, barrier cream per physician order, pressure reducing cushion in wheelchair, air mattress in bed, and to turn and reposition every two hours and as needed. Review of Resident #94's physician's orders, revealed an order dated 04/09/19 to perform neurogenic bowel management as per orders/instruction sheet every night, a pressure reducing cushion, an air mattress, to turn and reposition with pillows every two hours when in bed to prevent skin breakdown, and on 07/22/19 an order to apply a thin layer of barrier cream to buttocks with morning care one time a day to prevent skin breakdown. Review of the Neurogenic Bowel Management instruction sheet indicated to perform a mini enema along the side of the wall of the rectum/bowel while resident was in bed, then after ten minutes and using one lubricated finger digitally stimulate using a circle along the wall of the bowel for 30 seconds until stool appeared, and repeat the process up to four times. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/16/19 revealed Resident #94 had no pressure ulcers. Review of Resident #94's shower sheets for October 2019 indicated no skin changes to the coccyx area were identified during the shower that occurred on 10/26/19. Review of Resident #94's progress notes revealed an entry dated 10/24/19 which indicated the resident had no significant weight changes, he was eating meals well and his estimated nutritional needs were being met. On 10/29/2019 at 6:12 A.M. a nursing progress note revealed a new Stage IV pressure area was found on the resident's coccyx during bowel care. Review of the wound assessment, dated 10/29/19 revealed Resident #94 had an unstageable pressure ulcer to the coccyx that measured 3.1 centimeter (cm) in length by 1.2 cm width with 70 percent (%) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 8 of 13 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 12/05/2019 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 0686 slough. The assessment revealed the resident had no sensation to the area. Level of Harm - Actual harm Review of quarterly Braden Scale, dated 11/02/19 revealed Resident #94 was at moderate risk for developing pressure ulcers due to the resident being chair fast, having impaired sensory, limited mobility, adequate protein and requiring moderate to maximum assistance in moving. Residents Affected - Few Review of the MDS 3.0 assessment, dated 11/08/19 revealed Resident #94 had no cognitive impairment, required extensive assistance from two staff for bed mobility and was totally dependent on staff for personal hygiene, transfers, dressing, toileting and bathing. The assessment revealed the resident was always incontinent of bowel and had one unstageable wound not coded as present upon entry into the facility. Observation on 12/03/19 at 10:17 A.M. revealed Resident #94 was seated in a specialized wheelchair and was reclined at 46 degrees. Interview with the resident at the time of the observation confirmed the degree of the wheelchair and confirmed the resident currently had a pressure ulcer to the coccyx area. The resident revealed he had little if any feeling in the area and staff changed the dressing daily on night shift after he received bowel stimulation by the nurse and was cleaned up afterward by the state tested nursing assistant (STNA) staff. Observation on 12/04/19 at 12:50 P.M. revealed Resident #94 was fully reclined in a specialized wheelchair at this time. Additional observations on 12/04/19 at 2:20 P.M., 12/04/19 at 4:45 P.M., 12/05/19 at 8:41 A.M. and 12/05/19 at 10:45 A.M. revealed Resident #94 was sitting in up in the specialized wheelchair. Interview on 12/04/19 at 9:56 A.M. with Licensed Practical Nurse (LPN) #612 verified Resident #94's wound was initially discovered while in the facility on 10/29/19 as a Stage IV pressure ulcer. Interview on 12/04/19 at 2:29 P.M. with LPN #613 verified the resident was assessed to have a Stage IV pressure ulcer the morning of 10/29/19 and then it was changed to an unstageable pressure ulcer because the wound bed was covered in slough. She verified Resident #94 received neurogenic stimulation of bowel from the night shift nurses and bowel incontinence care thereafter since admission. She further indicated Resident #94 preferred to stay in the chair and indicated the resident could tilt himself. However, there was no evidence the facility had implemented any interventions to assess the effectiveness of the resident's tilting ability/frequency or included any information in the plan of care related to the resident or staff responsibility for position changes. Interview on 12/04/19 at 3:15 P.M. with STNA #615 revealed Resident #94 stayed up in the chair most of the time. Interview on 12/04/19 at 5:57 P.M. with Registered Nurse (RN) #606 and review of the resident's plan of care revealed Resident #94 received neurogenic stimulation of the bowel which should include a skin inspection. She further indicated if neurogenic stimulation of the bowel was conducted then the entire area would need checked for skin breakdown with the incontinence care thereafter. RN #606 further verified Resident #94's preference to stay up in the wheelchair which was not reflected in the care plan as well as a lack of evidence of monitoring or assessing the effectiveness of tilting frequency in the chair. Interview on 12/04/19 at 6:12 P.M. with LPN #616 verified Resident #94 stayed up in his chair most of the day unless he asked to lay down, he received bowel protocol every night, and the pressure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 9 of 13 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 12/05/2019 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 0686 reducing cushion he had was built into his wheelchair. She further indicated she believed Resident #94 tilted himself in the wheelchair and was not monitored by staff related to position changes in the wheelchair. Level of Harm - Actual harm Residents Affected - Few Interview on 12/04/19 at 6:27 P.M. with LPN #613 revealed staff did not monitor the resident for position changes in the wheelchair but staff would lay him down if he asked. Interview on 12/05/19 at 2:19 P.M. with STNA #614 revealed Resident #94 spent most of the day up in his chair. The STNA revealed she did not assist with repositioning in the chair, tilting the chair or reminding the resident to change the tilt of the chair. Interview on 12/05/19 at 12:29 P.M. with the Director of Nursing verified Resident #94's pressure ulcer was facility acquired and discovered on 10/29/19 as a Stage IV until reassessed later that same day as unstageable due to the presence of slough tissue. She further verified neurogenic bowel stimulation was provided to Resident #94 every night and was a lengthy procedure, the resident was not able to feel in that area, and he was compliant with nutritional interventions. She also confirmed with these factors staff should be more hypervigilant to ensure skin checks were thorough and completed to find early signs of skin breakdown. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 10 of 13 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 12/05/2019 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 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. Based on observation, record review and interview the facility failed to ensure medications were administered to Resident #59 via gastrostomy tube to decrease the risk of stomach upset/gastrointestinal disturbance. This affected one resident (#59) six residents observed for medication administration. Findings include: Review of the medical record for Resident #59 revealed an admission date of 06/23/04 with diagnoses including heart failure, gastro-esophageal reflux disease, gastrostomy status and chronic bronchitis. Review of the physician's orders, dated 06/27/19 revealed the resident had an order for Potassium chloride solution 20 milliequivalents (meq) per 15 milliliters (ml) 10 percent (%) solution, give 7.5 ml via gastrostomy tube once daily for heart failure. During medication administration observation on 12/03/19 at 9:38 A.M., Licensed Practical Nurse (LPN) #610 prepared the Potassium chloride solution 10% 7.5 ml into a medication administration cup. Observation of the Potassium Chloride medication label revealed a note that stated, must dilute before using. Interview at the time of the observation with LPN #610 revealed she would dilute the medication prior to administering in the gastrostomy tube. LPN #610 prepared five additional medications for administration, entered Resident #59's room, washed hands, applied gloves, disconnected the resident's tube feeding, removed gloves, washed hands, applied new gloves, checked gastrostomy tube placement, then added 15 to 30 ml water to each medication for dilution except for the Potassium chloride. Interview with LPN #610 at the time of the observation confirmed no additional water was added to the Potassium chloride liquid for dilution prior to the administration. LPN #610 then used gravity technique and a piston syringe barrel dated 12/03/19, flushed the gastrostomy tube with 200 ml water, followed by each medication with 30 ml of water flush in between and once for a final flush. Upon completion, LPN #610 disposed of the supplies in the appropriate containers, removed gloves and washed hands. Interview on 12/04/19 at 9:07 A.M. with Pharmacy Consultant #611 revealed liquid potassium was recommended to be diluted with four to six ounces of water when a dilution amount was not specified in the order. He further indicated if administered with less than four ounces of water dilute, a risk existed for stomach upset or gastrointestinal disturbance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 11 of 13 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 12/05/2019 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 Based on observation, record review and interview the facility failed to maintain adequate infection control practices during the administration of medication for Resident #62 and during meal services to prevent the spread of infection. This affected one resident (#62) of six residents observed during medication administration and six residents (#10, #27, #63, #73, #85 and #87) of ten residents observed for meal service. Residents Affected - Some Findings include: 1. During medication observation on 12/03/19 at 7:19 A.M. Licensed Practical Nurse LPN #610 entered Resident #62's room to obtain a glucometer reading. LPN #610 entered the resident's room, washed her hands, applied gloves and then completed the blood sugar testing. After completing the test, the LPN discarded the items in the appropriate container, removed her gloves and then returned to the medication cart without first performing any hand washing or hand hygiene. The LPN then cleaned the glucometer with a sanitizing wipe and obtained the resident's Lantus Solostar KwikPen from the medication drawer and prepared it for administration. LPN #610 then entered Resident #62's room, applied gloves, administered the insulin, discarded the needle into the designated container, removed her gloves and returned to the medication cart without performing any hand hygiene/washing. Interview with LPN #610 on 12/03/19 at 7:38 A.M. verified she did not perform handwashing after removing her gloves. Review of facility policy titled Handwashing/Hand Hygiene, revised April 2010 revealed employees must wash their hands or use an alcohol-based hand rub after removing gloves. 2. Observation on 12/02/19 at 12:08 P.M. of meal tray service with State Tested Nursing Assistant (STNA) #609 revealed STNA #609 obtained a meal tray and a clean clothing protector, then delivered it to Resident #10. STNA #609 adjusted Resident #10's bed position using the bed remote, then adjusted the overbed tray table, set-up the resident's meal tray by opening containers and lids, cut the resident's food using a fork and knife, and then re-adjusted the overbed tray table before leaving Resident #10's room. STNA #609 then entered Resident #63's room to assist the resident with another staff member without washing her hands. Interview on 12/02/19 at 12:28 P.M. with STNA #609 verified the above observation. Observation on 12/03/19 at 12:04 P.M. of meal tray service with STNA #609 revealed STNA #609 obtained a meal tray and a clean clothing protector from the meal cart and delivered the tray to Resident #85. STNA #609 adjusted the overbed tray table, pushed it toward Resident #85, applied the clothing protector onto Resident #85, cut the resident ' s food and opened condiments before returning to the meal cart. STNA #609 returned and opened the meal cart without first washing her hands, obtained another tray and delivered the tray to Resident #73. STNA #609 returned to the meal cart, obtained a meal tray and a clean clothing protector and delivered it to Resident #27. STNA #609 adjusted the overbed tray table, pushed it toward Resident #27, applied the clothing protector onto Resident #27, removed lids and opened condiments, then turned on the overbed light before leaving the room. STNA #609 then returned to the meal cart and picked up a used clothing protector and placed it into the soiled barrel in the soiled utility room. Without washing her hands, STNA #609 then provided assistance to Resident #87. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 12 of 13 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 12/05/2019 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 Interview on 12/03/19 at 12:25 P.M. with STNA #609 verified the above observation. Level of Harm - Minimal harm or potential for actual harm On 12/04/19 at 12:25 P.M. with Director of Nursing revealed the facility policy was to wash hands or use hand sanitizer after touching resident's personal effects which included resident furniture. Residents Affected - Some Review of facility policy titled Assisting the Resident with In-Room Meals, revised April 2011, revealed it was not necessary to wash hands between each resident tray; however, if there was contact with soiled dishes, clothing or the residents' personal effects, the employee must wash their hands before serving food to the next resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365741 If continuation sheet Page 13 of 13