Health inspection·March 21, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including overactive bladder, acute and chronic respiratory failure, chronic obstructive pulmonary disease, multiple sclerosis, type two diabetes, schizophrenia, unspecified severe protein malnutrition, nutritional marasmus, anxiety, gastrostomy status, and dysphagia. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #35 had severe cognitive impairment. Resident #35 was dependent for oral hygiene, toilet hygiene, upper body dressing, and personal hygiene. There was no known weight loss or gain, and the resident had one stage four pressure ulcer (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling). Review of the plan of care dated 02/24/24 revealed Resident #35 had potential for alteration in nutrition and hydration related to alternative nutrition by feeding tube. Interventions included assessing signs and symptoms of aspiration, assessing tube feeding tolerance, elevated head of bed as ordered, flushes as ordered, medication as ordered, monitor labs as ordered, and weights as ordered. Review of the physician's orders dated 11/15/23 at 7:00 A.M. revealed an order for weekly weights related to percutaneous endoscopic gastrostomy (PEG) tube in the morning every Wednesday. Review of the Treatment Administration Report (TAR) revealed missing weekly weights for the month of January 2024 on 01/03/24, 01/17/24, and 01/31/23; missing weekly weights for the month of February 2024 on 02/07/24, 02/14/24, and 02/28/24; and missing weekly weight for the month of March 2024 on 03/13/24 and 03/20/24. Interview on 03/20/24 at 4:59 P.M. with the DON revealed Resident #35 had paper documentation for monthly weights but weekly weights were not documented as ordered by the physician. 3. Review of the medical record revealed Resident # 31 was admitted on [DATE] with diagnoses including hemiplegia, severe protein calorie malnutrition, type two diabetes, adult failure to thrive, and acute kidney injury. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #31 had moderate cognitive impairment. Resident #31 required extensive assistance with bed mobility and transfers. Supervision was required while eating. The resident had known weight loss. Review of the plan of care dated 02/06/24 revealed Resident #31 had a diagnosis of malnutrition, prescribed Marinol supplement for appetite, and readmission with Remeron medication added for appetite. Interventions included obtaining and monitoring labs as ordered, obtaining and monitoring vital signs per order, and obtaining and monitoring weights per routine or as indicated. Review of the physician's orders dated 02/29/24 at 7:00 A.M. revealed an order for weekly weights for four weeks in the morning every Thursday for wound healing for thirty days. Review of the TAR dated for March 2024 revealed missing weekly weights on 03/07/24, 03/14/24, and 03/20/24. Interview on 03/20/24 at 3:25 P.M. with the DON verified Resident #31's weekly weights were not documented as obtained per the physician's orders. The weight documented on 03/14/24 was a monthly weight. The DON verified the weekly weights should be documented in the electronic medical record for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365831 If continuation sheet Page 2 of 9 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 365831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505 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 all disciplines to see. 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: 365831 If continuation sheet Page 3 of 9 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 365831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and interview, the facility did not ensure all medication carts in the facility were maintained to secure all drugs in their proper packaging. This had potential to affect all 38 residents residing in the facility who received medications from three of three medication carts. The facility census was 45. Findings include: Observation of medication carts completed on 03/20/24 at 2:30 P.M. revealed there were a total of 11 loose medications observed. There were five loose medications observed in the 100-hall medication cart, as well as five loose medications observed in the 300-hall medication cart, and one loose medication observed in the 400-hall medication cart. The facility had a total of four medication carts. Interview on 03/20/24 at 2:45 P.M. with Licensed Practical Nurse (LPN) #724 revealed she confirmed there were five loose medications observed in the 100-hall medication cart, as well as five loose medications observed in the 300-hall medication cart. Interview on 03/20/24 at 3:00 P.M. with LPN #721 revealed she confirmed there was one loose medication observed in the 400-hall medication cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365831 If continuation sheet Page 4 of 9 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 365831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, 2019 Food Code - Chapter 3717-1-03 Reference Guide review, and facility policy review the facility did not ensure food was served at a palatable temperature. This had the potential to affect 44 residents who received food from nutrition services. The facility identified one resident (#35) that received nothing by mouth. The facility census was 45. Residents Affected - Many Findings include: Observation was conducted on 03/20/24 at 11:28 A.M. of the tray line temperatures at meal service. The food temperatures were taken with a calibrated digital thermometer as follows: beef pepper patty 169.4 degrees Fahrenheit (F), mashed potatoes 168 degrees F, roasted zucchini 184 degrees F, milk 39 degrees F. The tray line's start time was11:30 A.M. The system being used to retain hot food temperatures was a plate warmer and thermal dome cover. The test tray was placed on the 100/200 hall cart at 12:05 P.M. where staff would pass on the 100 unit then the 200 unit. At 12:11 P.M. a test tray was passed to Dietary Manager #725 who proceeded to take the food temperature with the same digital thermometer used on the tray line. The test tray temperatures were as follows: the roasted zucchini 145.8 degrees F, beef pepper patty 127.6 degrees F, mashed potatoes 148.3 degrees F, and milk 48.2 degrees F. The surveyor tasted the foods and found the milk to be barely cold and the beef pepper steak to be barley warm. The overall flavor and portions of the food were appropriate for the meal. Review of the 2019 Food Code - Chapter 3717-1-03 Reference Guide revealed cold temperature controlled (TCF) for safety cold food should be 41 degrees F or less and TCF hot food should be 130 degrees F or above. Review of an undated facility policy titled Tray Line Checklist revealed food should be on the steam table no more than one half hour prior to start of service, and hot food should be 135 degrees or hotter. Cold food should be 41 degrees or lower and, in a refrigerator, or ice bath. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365831 If continuation sheet Page 5 of 9 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 365831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and facility policy review the facility failed to ensure food was stored in a sanitary manner. This had the potential to affect 44 residents receiving meals from the kitchen. The facility identified one resident (#35) who received nothing by mouth. The census was 45. Findings include: Observation on 03/18/24 at 6:53 P.M. the kitchen dry storage revealed two open undated Potato Pearls containers with no use by date. These findings were verified by the Dietary Manager (DM) #725 at the time of the observation. Observation on 03/20/24 at 1:00 P.M. revealed the resident's refrigerator on the 200-unit had a white plastic bag with three take out containers. The plastic bag did not have a resident name or date. A paper bag with an employee's name on it with perishable food inside the bag was undated, and a gallon of ice cream in the freezer with no resident name or date. This was verified by DM #725 at the time of the observation. Interview with the Administrator on 03/20/23 at 1:12 P.M. revealed the unit-200 refrigerator should not have any food in it. Interview on 03/20/24 at 1:38 P.M. with Licensed Practical Nurses (LPNs) #721 and #724 revealed the facility staff would place resident food from visitors in the 200-unit refrigerator. Interview on 03/21/24 at 8:35 A.M. with the Administrator revealed the 200-unit refrigerator was moved into the employee breakroom. The facility currently had no place to keep food for residents brought in by visitors. Review of the facility policy titled Food Brought in by Family or Visitors, dated October 2017, revealed food brought in by family and visitors that was left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility prepared food. Perishable foods must be stored in re-sealable containers with tight fitting lids in a refrigerator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365831 If continuation sheet Page 6 of 9 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 365831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure restorative nursing services were accurately documented in the medical record. This affected one resident (#37) of one resident reviewed for mobility. The facility census was 45. Findings include: Review of the medical record for Resident #37 revealed an admission date of 06/14/23 with diagnoses including injury to the cervical spinal cord, paralytic syndrome, chronic pain syndrome, polyneuropathy, and paraplegia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was cognitively intact. Review of the care plan dated 02/29/24 revealed Resident #37 had a risk for limited mobility related to decreased range of motion, pain, weakness, and paraplegia. Intervention included therapy as ordered. Review of the physician orders dated 09/01/23 indicated an order for splinting for contractures of the hands: patient to wear left hand splint on in evening and off during the night. Right hand splint to be donned when left doffed and removed in A.M. Patient may verbalize to staff his preference of times. Check skin prior to application and after removal. A second physician order dated 02/06/24 indicated splinting: patient to wear bilateral had splints on at H.S. (hours of sleep) and off in the A.M. Check skin prior to application and after removal. Review of the Treatment Administration Record (TAR) revealed both orders present with their respective dates. There was no documentation for services provided for the months of September 2023, October 2023, November 2023, December 2023, January 2024, February 2024, and 03/01/24, through 03/19/24. On 03/20/24 at 7:46 A.M., an interview with Licensed Practical Nurse (LPN) #712 indicated that nurses document on the TAR when splints are applied as well as refusals by the resident to wear splints. On 03/20/24 at 8:19 A.M., an interview with Director of Nursing (DON) verified there was no documented evidence of splints being applied on the TAR from 08/01/2024 through 03/19/24. On 03/20/24 at 8:34 A.M., an interview with the Director of Rehabilitation #711 indicated the evaluating therapist puts new orders in the queue but current and discontinued are to be added and deleted by nursing staff. The replication of splinting orders on the TAR was most likely due to the first order not being discontinued when the new order was implemented. A review of the Charting and Documentation Policy, dated 07/2017, indicated the following information was to be documented in the resident medical record including: objective observations; medications administered; treatment or services performed; changes in the resident's condition; events, incidents, or accidents involving the resident; and progress toward or changes in the care plan goals and objectives. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365831 If continuation sheet Page 7 of 9 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 365831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505 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, interview, record review, and facility policy review the facility failed to ensure proper hand hygiene and glove use were followed during wound care for Resident #35. This affected one resident (#35) of two residents reviewed for wound care. The facility census was 45. Residents Affected - Few Findings include: Review of the medical record for Resident #35 revealed an admission date of 08/21/23. Medical diagnoses included acute and chronic respiratory failure with hypoxia, multiple sclerosis, type two diabetes mellitus, unspecified sever protein calorie malnutrition, peripheral vascular disease, unspecified dementia without behavioral disturbance, and contracture of right and left hand. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was severely cognitively impaired, utilized an indwelling urinary catheter and was frequently incontinent of bowel. Resident #35 had one unhealed stage four pressure ulcer (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling.) that was present upon admission. Review of Resident #35's care plan dated 08/21/23 revealed Resident #35 was at risk for skin breakdown related to non-ambulatory status, multiple sclerosis, chronic anemia, generalized muscle weakness, sever protein calorie malnutrition, nothing by mouth status with enteral feeding, nutritional marasmus, and refused turning and repositioning at times. Resident #35 was admitted to the facility with chronic sacral ulcer, left heel ulcer, and suspected deep tissue injury (A purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.) of right heel. Resident #35 required total staff dependence with all activities of daily living care, nothing by mouth with enteral feeding, had diagnoses of chronic anemia, diabetes mellitus, obesity, encephalopathy, severe protein calorie malnutrition, and bowel incontinence, as of 10/19/23 left heel resolved. Review of the physician's orders for Resident #35 revealed an order dated 12/28/23 that revealed wound care for sacrum wound included cleansing with wound cleanser, pat dry, applying collagen, and covering with foam dressing. The dressing was to be changed daily and as needed. Observation of wound care on 03/20/24 at 10:20 A.M. for Resident #35 revealed Licensed Practical Nurse (LPN) #74 gathered supplies, knocked on the door and entered the resident room. LPN #74 performed hand hygiene and donned cloves. Resident #35 was incontinent of stool at time of dressing change, LPN #74 cleansed buttocks with a wet washcloth and removed soiled dressing. LPN #74 then proceeded to doff one soiled glove and donned a glove without performing hand hygiene. LPN #74 with soiled gloves placed new clean dressing to Resident #35's coccyx wound. The foam dressing was dated 03/20/24 with LPN #74's initials. LPN #74 removed gloves and performed hand hygiene. Interview on 03/20/24 at 10:45 A.M, with LPN #74 confirmed hand hygiene was not completed between glove changes after cleansing coccyx and removing soiled dressing. Review of the facility policy titled Hand Washing, dated 08/19, revealed that staff wash hands on a regular basis, which included before and after providing care for a resident, when visible soiling (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365831 If continuation sheet Page 8 of 9 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 365831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Danridges Burgundi Manor 31 Maranatha Drive Youngstown, OH 44505 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 is present, before and after the use of gloves, and as needed to assure clean hands. 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: 365831 If continuation sheet Page 9 of 9