Inspection·February 6, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to ensure the physician was notified when residents had a change of condition. This affected three residents (Resident #14, #49 and #69) out of three reviewed for change of condition. The facility census was 74. Findings include: 1. Review of the open medical record for Resident #69 revealed an admission on [DATE]. Diagnoses included multiple sclerosis, chronic pain syndrome and neuromuscular dysfunction of bladder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent on toileting and needed assistance with repositioning. The assessment indicated Resident #69 had four stage 3 pressure ulcers (extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) on admission. Review of the admission nursing assessment dated [DATE] revealed a pressure ulcer to the right gluteal fold (right buttock) that measured 7 centimeters (cm) by 5 cm, a right hip pressure ulcer that measured 5 cm by 5 cm and a right heel pressure ulcer that measured 7 cm by 5 cm. There were no wound depths documented for any of the three pressure ulcers. There were no other wound measurements documented in the resident's record. Review of the plan of care dated 11/24/23 revealed Resident #69 is at risk for impaired skin integrity related to pressure ulcers, eczema and osteomyelitis wound. Interventions included assess/record/monitor wound healing, measure length, width, and depth. Assess and document status of wound perimeter, wound bed and healing progress. Review of physician orders revealed no orders for Resident #69 to be seen by the wound clinic for the pressure ulcer on the right hip or right buttock. Orders dated 11/26/23 included wound care to evaluate right hip treatment and skin condition as soon as possible (ASAP). Interview on 01/29/24 at 11:05 A.M. with Resident #69 revealed he was having more pain on his left hip/buttock area and that he has not been seen by the wound doctor for wounds on his bottom since he has been in the facility, and he had not seen the wound doctor for his right foot pressure ulcer since 12/18/23. Observation on 01/29/24 at 12:18 P.M. of Resident #69's coccyx wounds with RN #349 revealed the right buttock pressure ulcer measured 12.1 cm by 8 cm by 2 cm. The wound bed was necrotic with serosanguinous drainage (thin, watery, pale, red/pink drainage). The necrotic tissue was located from 10 O'clock to 2 O'clock with undermining of 2 cm from 10 O'clock to 2 O'clock. The old dressing was saturated with a moderate amount of serosanguinous drainage. The wound was cleansed, wet to dry dressing, moistened with Dakin's solution was applied and absorbent bandage dressing (ABD) dressing applied. The right hip dressing was removed and revealed a stage 3 pressure ulcer wound that measured 3.8 cm by 1.8 cm by 0.8 cm. The wound bed had granulation with serosanguinous drainage, and no odor noted. The resident was rolled to the right side and under a dressing to left buttocks was a stage 2 pressure ulcer (partial-thickness skin loss into but no deeper than the dermis) measuring 4 cm by 3 cm by 0.1 cm with moderate serosanguinous drainage with no odor. The wounds were cleansed with normal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 2 of 17 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 365837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Grove Manor 1670 Crider Rd Mansfield, OH 44903 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 0580 saline and a wet to dry dressing was applied and covered with an ABD. Level of Harm - Minimal harm or potential for actual harm Interview on 01/29/24 at 4:00 P.M. with RN #349 verified the right buttock pressure ulcer appeared to have gotten worse since admission. RN #349 verified there was no order for the left buttock treatment. RN #349 stated she had not seen the left buttock wound prior to the dressing change. She stated she did not know when this wound was identified. RN #349 verified she has not measured any of Resident #69's wounds and thought the wound clinic was following these wounds. Residents Affected - Some Interview on 01/29/24 at 4:15 P.M. with Regional Nurse Coordinator (RNC) #384 verified there was no order for the wound on Resident #69's left buttock and did not know when this wound appeared. RNC #384 verified the physician had not been notified of the new pressure ulcer on Resident #69's left buttock. RNC #384 verified Resident #69 had not been seen by any wound doctor for his pressure ulcers on his buttock or right hip since he was admitted to the facility on [DATE]. RNC #384 verified Resident #69 was being seen at an outside wound clinic for his right heel but had not seen the wound doctor since 12/18/23. RNC #384 verified no physician was notified of the worsening of the pressure ulcers to Resident #69's right buttock or the right hip, since he was admitted to the facility. Interview on 01/30/24 at 10:00 A.M. with STNA #361 revealed she has taken care of Resident #69 over the weekend, and he had bandages on both sides of his buttock that needed to be changed and the nurse changed the dressing. Interview on 01/30/24 at 10:45 A.M. with STNA #363 revealed she had seen the wound on Resident #69's left buttock a little over two weeks ago while assisting an agency nurse to change Resident #69's dressing. STNA #363 stated there was an open area on the left buttock. Interview on 01/30/24 at 11:00 A.M. with RN #380 revealed she is the nurse for Resident #69, and she has taken care of his wounds on his bottom. RN #380 stated she just thought the right buttock wound was getting bigger and the pressure ulcer on the left buttock had been identified and the physician had been notified. 2. Review of the open medical record for Resident #49 revealed an admission date 12/26/23. Diagnoses included pressure ulcer and cellulitis. Review of the progress note dated 01/08/24 at 3:54 P.M. revealed around 2:20 P.M. the resident was seen on the floor next to the bed on the floor mat. The resident had an abrasion to the right elbow. Resident #49 was currently on neuro checks from previous fall on 01/07/24, so neuro checks will be continued. The family and Assistant Director of Nursing (ADON) #336 were notified. There was no documentation the physician had been notified of the fall on 01/08/24. Interview on 01/29/24 at 10:45 A.M. with the Administrator verified the physician had not been notified when Resident #49 fell on [DATE]. 3. Review of the medical record for Resident #14 revealed an admission date of 01/22/20 and a readmission date of 11/13/22 with diagnoses including but not limited to diabetes mellitus, cognitive communication deficit, unspecified psychosis, and unspecified intellectual disabilities. Review of Resident #14's comprehensive care plan dated 08/22/23 revealed Resident #14 was an elopement risk but there were no interventions documented to address outside appointments. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 3 of 17 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 365837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Grove Manor 1670 Crider Rd Mansfield, OH 44903 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 was cognitively intact and was independent for walking with the use of a walker. The MDS also revealed that Resident #14 had verbal behaviors, rejected care, and wandered one to three days during the look back period. Review of the health status note dated 12/15/23 at 9:45 A.M. revealed Resident #14 left out for an appointment to the gynecologist, transported by a transportation company. Review of the health status note dated 12/15/23 at 12:00 P.M. revealed Resident #14 returned to the facility soiled. Transportation Driver (TD) #378 reported finding the resident walking down the road. Resident #14 told TD #378, I was heading back here. The Administrator, ADON #336, and Medical Director (MD) #391 were notified. MD #391 ordered to send the resident out to the psychiatric hospital to be further evaluated. Review of the health status note dated 12/15/23 at 8:29 P.M. revealed the psychiatric hospital wanted more documentation and the nurse faxed over the requested information. There was no further documentation regarding the resident being transferred to the psychiatric hospital or returning to the facility from the psychiatric hospital. Interview on 01/24/24 at 9:15 A.M. with the Administrator revealed that there was no documentation that the resident was accepted at the psychiatric hospital or that the doctor was notified that Resident #14 was not sent to the psychiatric hospital. A phone interview on 01/29/24 at 3:49 P.M. with MD #391 revealed that if he was notified there would be a progress note and since there is no progress note, he was not notified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 4 of 17 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 365837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Grove Manor 1670 Crider Rd Mansfield, OH 44903 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, staff interviews, resident interview, and record review, the facility failed provide ongoing assessment and monitoring of existing pressure ulcers, failed to complete treatments as ordered by the physician, and failed to notify the physician of the need to alter treatment when pressure ulcers increased in size and when new pressure ulcers developed. This affected two (Resident #63 and #69) of three residents reviewed for skin breakdown. Residents Affected - Few Actual harm occurred when Resident #69 did not have any ongoing assessments of existing pressure ulcers and did not have treatments applied as ordered which resulted in the Stage 3 pressure to the resident's right buttock increasing in size from 7 centimeters (cm) by 5 cm to 12.1 cm by 8 cm by 2 cm. The facility census was 75. Finding include: 1. Review of the open medical record for Resident #69 revealed admission on [DATE]. Diagnoses included multiple sclerosis, chronic pain syndrome and neuromuscular dysfunction of bladder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent on toileting and needed assistance with repositioning. The assessment indicated Resident #69 had four stage 3 pressure ulcers (extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) on admission. Review of the admission nursing assessment dated [DATE] revealed a pressure ulcer to the right gluteal fold (right buttock) that measured 7 centimeters (cm) by 5 cm, a right hip pressure ulcer that measured 5 cm by 5 cm and a right heel pressure ulcer that measured 7 cm by 5 cm. There were no wound depths documented for any of the three pressure ulcers. There were no other wound measurements documented in the resident's record. Review of the plan of care dated 11/24/23 revealed Resident #69 is at risk for impaired skin integrity related to pressure ulcers, eczema and osteomyelitis wound. Interventions included to administer antibiotic medication, apply barrier cream/ointment after each incontinent episode as needed, inspect skin during routine daily care, pressure reduction devices as needed and wound vac to right heel wound with treatment per physician orders. Resident #69 had a pressure ulcer or potential for pressure ulcer development related to stage 3 pressure ulcers to right hip, sacrum, and right heel. Interventions included assess/record/monitor wound healing, measure length, width, and depth. Assess and document status of wound perimeter, wound bed and healing progress. Review of physician orders revealed no orders for Resident #69 to be seen by the wound clinic for the pressure ulcer on the right hip or right buttock. Orders dated 11/26/23 included weekly skin checks on Friday, the right hip pressure ulcer was to be cleansed with normal saline, pat dry with non-sterile gauze, apply wet to dry dressing with Dakin's (sodium hypochlorite solution) (1/4 strength) and cover with foam, wound vac to right heel and changed on Monday, Wednesday and Friday, wound care to evaluate right hip treatment and skin condition as soon as possible (ASAP). Wound treatments orders changed on 01/12/24 to include right hip apply Prisma (semi-occlusive dressing, like a foam, to maintains a moist wound environment) to entire wound bed, cover with absorbent bandage dressing (ABD) daily, buttock and sacral wound apply triad cream (zinc oxide-based hydrophilic paste to adheres to moist wound beds and protects skin), cover with ABD daily, wound clinic to evaluate wounds/orders (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 5 of 17 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 365837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Grove Manor 1670 Crider Rd Mansfield, OH 44903 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 Level of Harm - Actual harm Residents Affected - Few on 12/04/23. On 01/22/24 orders changed to cleanse with Normal Saline (NS), pat dry and apply wet to dry dressing daily and as needed. On 01/23/24 orders changed for right hip to cleanse with normal saline, pat dry, apply wet to dry dressing daily and as needed. Review of the Treatment Administration Record (TAR) for January 2024 revealed dressing changes for right hip and buttock/sacral wound was not documented as being completed 01/01/24, 01/09/24, 01/15/24, 01/19/24, 01/21/24, and 01/22/24. Interview on 01/22/24 at 11:47 A.M. with Resident #69 revealed he was to have a wound vac on his right heel but there were no new canisters for the wound vac after it was removed two days ago. A dressing was applied but has not been changed since it was put on two days ago. Observation on 01/22/24 at 1:45 P.M. of the pressure ulcer on Resident #69's right foot with Registered Nurse (RN) #377 revealed the wound vac was not on the right heel as ordered. An undated ABD dressing that was saturated with serosanguinous drainage (thin, watery, pale, red/pink drainage) was observed on the resident's right heel. The wound bed gauze that packed the wound had to be soaked to be removed. The wound was beefy red and covered with 25% slough (often presents as a soft, mucinous or stringy material in granulated wounds). The wound was cleansed with normal saline and gauze, wet with Dakin's quarter-strength solution was applied and covered with an ABD. The nurse did not take any measurements when the dressing was removed. Interview on 01/22/24 at 4:00 P.M. with RN #377 verified she did not have an order for the wet to dry dressing to the right heel. The order is for a wound vac to the right heel. Interview on 01/25/24 at 8:45 A.M. with RN #349 revealed she was the nurse that notified the physician that Resident #69 did not have wound vac supplies and needed an order for his right heel pressure ulcer. She verified the wet to dry dressing was not put in Resident #69's orders. Interview on 01/29/24 at 11:05 A.M. with Resident #69 revealed he was having more pain on his left hip/buttock area and that he has not been seen by the wound doctor for wounds on his bottom since he has been in the facility. Observation on 01/29/24 at 12:18 P.M. of Resident #69's coccyx wounds with RN #349 revealed the right buttock pressure ulcer measured 12.1 cm by 8 cm by 2 cm. The wound bed was necrotic with serosanguineous drainage. The necrotic tissue was located from 10 O'clock to 2 O'clock with undermining of 2 cm from 10 O'clock to 2 O'clock. The old dressing was saturated with a moderate amount of serosanguineous drainage. The wound was cleansed, wet to dry dressing, moistened with Dakin's solution was applied and ABD dressing applied. The right hip dressing was removed and revealed a stage 3 pressure ulcer wound measured 3.8 cm by 1.8 cm by 0.8 cm. The wound bed had granulation with serosanguineous drainage, and no odor noted. The resident was rolled to the right side and under a dressing to left buttocks was a stage 2 pressure ulcer measuring 4 cm by 3 cm by 0.1 cm with moderate serosanguineous drainage with no odor. The wounds were cleaned with normal saline and a wet to dry dressing was applied and covered with ABD. Interview on 01/29/24 at 4:00 P.M. with RN #349 verified the right buttock pressure ulcer appeared to have gotten worse since admission. RN #349 verified there was no order for the left buttock treatment. RN #349 stated she had not seen the left buttock wound prior to the dressing change. She stated she did not know when this wound was identified. RN #349 verified she has not measured any of Resident #69's wounds and thought the wound clinic was following these wounds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 6 of 17 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 365837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Grove Manor 1670 Crider Rd Mansfield, OH 44903 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 Level of Harm - Actual harm Residents Affected - Few Interview on 01/29/24 at 4:15 P.M. with Regional Nurse Coordinator (RNC) #384 verified there was no order for the wound on Resident #69's left buttock and did not know when this wound appeared. RNC #384 verified Resident #69 had not been seen by any wound doctor for his pressure ulcers on his buttock or right hip since he was admitted to the facility on [DATE]. RNC #384 verified the facility was not measuring wounds weekly and the skin assessment dated [DATE] did not identify the new pressure ulcer on his left buttock. RNC #384 verified Resident #69 was being seen at an outside wound clinic for his right heel, but no other wounds. Resident #69 had not been to the wound clinic for his right heel since 12/18/23. RNC #384 verified no physician was notified of the worsening of the pressure ulcers to Resident #69's right buttock or the right hip, since he was admitted to the facility. RNC #384 verified the physician had not been notified of the new pressure ulcer on Resident #69's left buttock. Interview on 01/30/24 at 9:52 A.M. with State Tested Nursing Assistant (STNA) #356 via phone revealed she has taken care of Resident #69 on 01/20/24 and 01/21/24. STNA #356 stated Resident #69 has bandages covering both sides of his buttock and the nurse was changing the dressing. Interview on 01/30/24 at 10:00 A.M. with STNA #361 revealed she has taken care of Resident #69 over the weekend, and he had bandages on both sides of his buttock that needed to be changed and the nurse changed the dressing. Interview on 01/30/24 at 10:45 A.M. with STNA #363 revealed she had seen the wound on Resident #69's left buttock a little over two weeks ago while assisting an agency nurse to change Resident #69's dressing. STNA #363 stated there was an open area on the left buttock. Interview on 01/30/24 at 11:00 A.M. with RN #380 revealed she is the nurse for Resident #69, and she has taken care of his wounds on his bottom. RN #380 stated she just thought the right buttock wound was getting bigger and the pressure ulcer on the left buttock had been identified and the physician had been notified. 2. Review of the open medical record for Resident #63 revealed an admission date on 11/22/23. Diagnoses included sepsis, pressure ulcer to the right buttock, sacral pressure and kidney failure. Review of a wound evaluation dated 01/16/24 revealed a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) to the sacrum that measured 11.7 cm x 10.4 cm x 3.7 cm, a stage 4 pressure ulcer to the left ischium that measured 9.5 cm by 10.5 cm by 2.5 cm, and a stage 4 pressure ulcer to the right ischium measuring 8.5 cm by 8.4 cm by 2.2 cm. Further review revealed a new order to apply quarter-strength Dakin's-moistened Kerlix to the wound beds and ABD pad twice a day for 16 days (01/16/24 - 02/01/24) (sacrum stage 4 pressure ulcer, stage 4 left ischium pressure ulcer, stage 4 right ischium pressure ulcer.) Review of January 2024 physician orders revealed orders for the coccyx and bilateral buttocks pressure ulcers to be cleansed with Dakins, apply Dakin's-soaked gauze and ABD secured with tape twice a day for wound healing for seven days, started on 01/16/24 and discontinued on 01/23/24. Review of the TAR for January 2024 revealed no order for the coccyx and bilateral buttocks pressure ulcers after 01/23/24, which should have continued until 02/01/24. Interview on 01/24/24 at 12:15 P.M. with Resident #63 revealed he does not see a wound doctor. His dressing was supposed to be changed twice a day but is only changed daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 7 of 17 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 365837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Grove Manor 1670 Crider Rd Mansfield, OH 44903 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 Level of Harm - Actual harm Residents Affected - Few Observation on 01/24/24 at 12:18 P.M. of Resident #63's dressing change to his coccyx wounds with RN #349 and LPN #328 revealed three stage four pressure ulcers. The old dressings that were removed were saturated with serosanguinous drainage and the pad underneath the resident had bloody discharge from the wound. The wounds were cleansed with normal saline and packed with normal saline-soaked Kerlix and then covered with ABDs. Interview on 01/24/24 at 1:00 P.M. with RN #349 verified the order was to use Dakins solution but she did not have any and used the normal saline instead. RN #349 stated she has never used the Dakins solution when providing wound care. This deficiency represents non-compliance investigated under Complaint Number OH00150105, OH00150034, OH00150030 and OH00149650. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 8 of 17 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 365837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Grove Manor 1670 Crider Rd Mansfield, OH 44903 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility Elopement/Unauthorized Absence policy and procedure and interviews with staff and the transportation driver, the facility failed to provide adequate supervision and comprehensive individualized interventions to prevent Resident #14, who was identified at risk for elopement, from leaving the building when on an outside doctor's appointment, unaccompanied by facility staff or family, and prior to the transportation company picking her up and returning her to the facility after the appointment had concluded. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, negative health outcomes, and/or death when Resident #14, who was assessed to be at risk for elopement, exited the doctor's office without staff knowledge when the appointment was completed. This affected one (#14) of two residents reviewed for elopement. The facility identified 11 residents (#7, #14, #19, #28, #31, #39, #42, #46, #51, #56, and #60) who were assessed as elopement risks that currently reside in the facility. Additionally, the facility failed to conduct a thorough investigation by doing a root cause analysis, and have evidence that neuro checks were completed, after Resident #49 fell on two consecutive days (01/07/24 and 01/08/24) in an effort to identify and implement measures to reduce the hazards/risks, including adequate supervision and assistive devices, as much as possible; and/or monitor the effectiveness of the interventions and modify the care plan as necessary to prevent further falls from occurring, placing the resident at risk for the potential for more than minimal harm that is not Immediate Jeopardy. This affected one (Resident #49) of three residents reviewed for falls. The facility census was 75. On 01/24/24 at 10:30 A.M., the Administrator, Regional Nurse Consultant (RNC) #384, Interim Director of Nursing (IDON) #390 and Assistant Director of Nursing (ADON) #336 were notified Immediate Jeopardy began on 12/15/23 at approximately 10:35 A.M. when Resident #14 left an outside doctor's office appointment, unsupervised and without staff knowledge, and prior to the transportation company picking her up and returning her to the facility following the appointment. Transportation Driver (TD) #378 reported to the facility that he was taking a person, who did not reside at the facility, to an appointment and as he was driving down the road he saw the resident walking on the sidewalk, pushing a rollator walker, next to a four-lane highway approximately 0.3 miles from the doctor's office with feces running down her leg, so he turned around and picked her up. TD #378 then returned her to the nursing home at 12:00 P.M. and talked to the Administrator. TD #378 stated that Resident #14 usually had an escort or staff would meet her at outside appointments. TD #378 stated that on 12/15/23, Resident #14 had neither. The Immediate Jeopardy was removed on 01/26/24 when the facility implemented the following correction actions: • On 12/15/23 at 11:45 A.M., TD #378 called the facility and spoke to Business Office Manager #301 and explained that he picked up Resident #14 when he saw her walking from the appointment, and she had feces down her leg so he may need some help when Resident #14 arrives at the facility. • On 12/15/23 at12:00 P.M., Resident #14 returned to the facility from her appointment with TD #378. ADON #336 walked Resident #14 and TD #378 to the nurses' station. The Administrator interviewed TD (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 9 of 17 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 365837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Grove Manor 1670 Crider Rd Mansfield, OH 44903 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 #378. TD #378 explained that he saw her walking on the road, stopped and asked her where she was going, and she told him that she was walking back to the facility. Level of Harm - Immediate jeopardy to resident health or safety • Residents Affected - Few On 12/15/23 at 12:10 P.M., Resident #14 was taken to the shower room by State Tested Nurses Assistant (STNA) #377 because she had feces on her legs, and at that time Licensed Practical Nurse (LPN) #329 did a skin assessment to check for any injuries and no new skin issues were noted. • On 12/15/23 at 12:20 P.M., the Administrator spoke to RNC #384 regarding Resident #14. RNC #384 instructed the Administrator to document the skin assessment, ensure elopement care plan is in place, verify elopement risk assessment was previously completed and review care plan for previous elopement risk. Transportation policy was updated to include transportation form process noting if the resident needs accompanied to an appointment. RNC #384 also instructed the Administrator to complete education with nurses, State Tested Nursing Assistants (STNAs), and department heads on the transportation form process and transporting residents with wanderguard to outside appointments and being accompanied by a staff member or family member. • On 12/15/23 from 12:30 P.M. to 4:00 P.M., the Administrator in serviced nursing staff on the first shift in the building on the transportation form process and transporting residents with wanderguard to outside appointments and being accompanied by a staff member or family member. • On 12/15/23 at 12:36 P.M., Medical Director (MD) #391 was notified of the resident leaving the doctor's office and walking down the street. He gave the order to send the resident for a psychiatric evaluation at the psychiatric hospital. • On 12/15/23 at 1:30 P.M., the Administrator reviewed the Elopement Binder to ensure Residents #14 and #19, who were assessed as an elopement risk and previously ordered a wander guard, were included. The Administrator added the education about the new transportation form to the Elopement Binder. • On 12/15/23 at 1:45 P.M., the Administrator added Wander Guard/Appointment Education to the Agency Binder/Nursing Staff book FYI for first shift staff. • On 12/18/23 at 9:30 A.M., audits began to monitor if anyone had a wanderguard and has an appointment that there was someone to accompany them. These audits will continue five times a week for four weeks. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 10 of 17 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 365837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Grove Manor 1670 Crider Rd Mansfield, OH 44903 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 - Immediate jeopardy to resident health or safety On 12/26/23 from 10:40 A.M. to 4:56 P.M., the DON and/or Designee completed new elopement assessments for all current residents. Residents #7, #28, #31, #39, #42, #46, #51, #56, and #60 were identified as an elopement risk and assessed that no wanderguard is needed at this time. Residents Affected - Few • On 01/24/24 at 5:10 P.M., the Administrator and/or Designee updated the elopement book to reflect which residents were identified as an elopement risk with the criteria that these residents will be accompanied to future outside appointments. • On 01/25/24 at 11:04 A.M., LPN #337 updated care plans to reflect elopement risk for Residents #7, #14, #19, #28, #31, #39, #42, #46, #51, #56, and #60. The facility ensured appropriate interventions were put in place if needed. • On 01/25/24 from 5:30 P.M. through 8:00 P.M., the Administrator in serviced all staff in the building on both shifts including facility Transportation Driver #320 on the transportation form process and transporting residents with elopement risk to outside appointments. Residents with an elopement risk would be accompanied by a staff member or family member. Daily, the off going nurse will inform incoming nurse to review the Nursing FYI binder for any updates. • On 01/25/24 at 7:45 P.M., the Administrator conducted an elopement drill with no issues noted and the process was evaluated with no concerns identified. • On 01/26/24, the Administrator educated Agency staff via Clipboard messaging application and will continue to educate any new Agency staff working at the facility regarding the transportation form process and transporting residents with elopement risk to outside appointments and being accompanied by a staff member or family member. • Ongoing, elopement assessments will be completed quarterly and as needed. The Elopement Binder will be updated as needed. Although the Immediate Jeopardy was removed on 01/26/24, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 11 of 17 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 365837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Grove Manor 1670 Crider Rd Mansfield, OH 44903 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 - Immediate jeopardy to resident health or safety 1. Review of the medical record for Resident #14 revealed an admission date of 01/22/20 and a readmission date of 11/13/22 with diagnoses including but not limited to diabetes mellitus, cognitive communication deficit, unspecified psychosis, and unspecified intellectual disabilities. Review of Resident #14's comprehensive care plan dated 08/22/23 revealed Resident #14 was an elopement risk but there were no interventions documented to address outside appointments. Residents Affected - Few Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 was cognitively intact and was independent for walking with the use of a walker. The MDS also revealed that Resident #14 had verbal behaviors, rejected care, and wandered one to three days during the look back period. Review of the physician's orders for January 2024 revealed Resident #14 had an order for a wanderguard to be placed on the right wrist with a start date of 09/19/23. Review of the elopement assessment dated [DATE] revealed Resident #14 was at moderate risk for elopement. Review of the health status note dated 11/03/23 at 12:14 P.M. revealed Resident #14 was transported to an outside appointment by the transportation company and was accompanied by Former Central Supply #405 to her appointment. Review of the health status note dated 11/03/23 at 4:28 P.M. revealed STNA #403 reported to the nurse (LPN #329) the resident was packing up a few belongings. STNA #403 reported talking resident out of leaving facility. Physician aware, the nurse will continue to monitor resident for the rest of this shift. Review of the health status note dated 12/01/23 at 10:38 A.M. revealed Resident #14 expressed concerns with going to an appointment alone and requested that someone attend the appointment. This nurse (LPN #329) requested a staff nurse (LPN #327) to accompany the resident to the appointment. Staff nurse (LPN #327) meeting resident at scheduled appointment. Resident #14 transported to appointment by transportation company. Review of the health status note dated 12/04/23 at 10:49 A.M. revealed Resident #14 had packed up items on her wheeled walker. Resident #14 stated, I want to leave could someone cut this wrist band off of my arm please. This nurse (LPN #329) encouraged Resident #14 to stay and get unpacked and educated resident on the reasoning of the wander guard on her wrist. Resident #14 stated, I want to leave, no one wants me here, and I'm tired of the voice. This nurse (LPN #329) will continue to monitor Resident #14 for the rest of this shift. Review of the health status note dated 12/11/23 at 9:30 A.M. revealed Resident #14 threatened to remove her wanderguard band. ADON #336 assisted Resident #14 back to her room and reassured the resident that the facility would be the safest place to stay. Resident #14 is currently in room watching television with wanderguard in place. Fifteen-minute checks are in place. MD #391 notified. Review of the health status note dated 12/15/23 at 9:45 A.M. revealed Resident #14 left out for an appointment to the gynecologist, transported by transportation company. Review of the health status note dated 12/15/23 at 12:00 P.M. revealed Resident #14 returned to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 12 of 17 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 365837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Grove Manor 1670 Crider Rd Mansfield, OH 44903 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 - Immediate jeopardy to resident health or safety Residents Affected - Few facility soiled. TD #378 reported finding the resident walking down the road. Resident #14 told TD #378, I was heading back here. The Administrator, ADON #336, MD #391 were notified. MD #391 ordered to send the resident out to the psychiatric hospital to be further evaluated. Interview on 01/23/24 at 1:48 P.M. with TD #378 revealed that he dropped Resident #14 off at her doctor's appointment and gave his number to the office staff to call when she needed to be picked up. The doctor's office did not call TD #378 when Resident #14's appointment was completed. TD #378 stated that he was taking a person, who did not reside at the facility, to an appointment and he was driving down the road and saw her walking on the sidewalk. He turned around and picked her up. She had feces down her leg. TD #378 took her to the nursing home and talked to the Administrator. TD #378 stated that Resident #14 usually had an escort or staff would meet her at outside appointments. TD #378 stated that on 12/15/23, Resident #14 had neither. Review of the policy titled, Transportation Policy, dated 08/2021 with a revision date of 12/15/23, revealed that transportation will be arranged by central supply or designee for appointments. A transport form will be filled out by the nurse and notify central supply if an escort is needed. Review of the policy titled, Wandering and Elopement Policy, dated 08/2021 with a revision date of 08/2023, revealed the facility will identify residents that are at risk of unsafe wandering. Residents who are identified at risk for wandering or elopement, the resident's orders will include strategies and interventions to maintain the resident's safety. 2. Review of the medical record for Resident #49 revealed an admission date of 12/26/23. Diagnoses included pressure ulcer and cellulitis. Review of the plan of care dated 01/02/24 revealed the resident was at risk for falls and potential injury related to impaired cognition, neurological impairment, and unsteady gait. Interventions included bed in lowest position, room moved closer to the nurses' station for safety, mat on floor by bed, and assist resident to toilet. Review of the progress note dated 01/08/24 at 3:54 P.M. revealed around 2:20 P.M. the resident was seen on the floor next to the bed on the floor mat. The resident had an abrasion to the right elbow. Resident #49 was currently on neuro checks from a previous fall on 01/07/24, so neuro checks will be continued. The family and ADON #336 were notified. Review of the medical record identified no fall assessment/investigation was completed on 01/08/24 and no neuro checks were available for the falls on 01/07/24 or 01/08/24. Interview on 01/29/24 at 10:45 A.M. with the Administrator revealed the facility was unable to find any fall investigation for Resident #49's fall on 01/08/24. The Administrator verified she was unable to provide neuro checks being completed on 01/07/24 or 01/08/24 for Resident #49. The Administrator verified that no fall investigation was completed for the fall on 01/08/24 for Resident #49. Review of the facility policy titled, Falls and Fall Risk, Managing, reviewed 08/2022, revealed staff will monitor resident's response to interventions intended to reduce falling or the risks of falling. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 13 of 17 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 365837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Grove Manor 1670 Crider Rd Mansfield, OH 44903 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 This deficiency represents non-compliance investigated under Master Complaint Number OH00150310 and Complaint Number OH00150105. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 14 of 17 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 365837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Grove Manor 1670 Crider Rd Mansfield, OH 44903 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to ensure the medical director was an active participant of the Quality Assurance (QA) Committee. This had the potential to affect all residents. The facility census was 74. Residents Affected - Many Findings include: Review of the facility's sign-in sheet for the QA meeting minutes for the meetings held in September 2023 and November 2023 revealed no evidence the medical director attended the meetings. Interview with the Administrator on 01/29/24 at 3:17 P.M. verified the medical director did not attend the QA meetings as required. The Administrator stated that the last QA meeting that Medical Director (MD) #391 attended was February 2023. A phone interview on 01/29/24 at 3:49 P.M. with Medical Director (MD) #391 revealed that he attended the QA meeting in February and that he runs a full-time clinic. MD #391 stated that since the meetings are in the middle of the day, he can't make it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 15 of 17 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 365837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Grove Manor 1670 Crider Rd Mansfield, OH 44903 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, staff interview, and record review, the facility failed to maintain a system to preventing the spread of infections and communicable diseases for nine residents (Resident #5, #6, #12, #27, #59, #60, #67, #70 and #74) identifed as being on isolation precautions. This has the potential to affect all residents. The facility census was 74. Residents Affected - Few Findings include: Observations of the physical environment on 01/22/24 at 5:05 A.M. revealed isolation carts outside of nine resident rooms (Resident #5, #6, #12, #27, #59, #60, #67, #70 and #74). There were no gowns in any of the isolation carts. Additionally, two residents (Resident #59 and #74) did not have a sign posted on the door indicating vistors should see the nurse before entering. Interview on 01/22/24 at 5:40 A.M. with State Tested Nursing Assistant (STNA) #352 stated there was not enough personal protective equipment (PPE) available. She stated she had gloves and masks, but had to go into isolation rooms without a gown because there were not enough available on her shift. Interview on 01/22/24 at 5:31 A.M. with Licensed Practical Nurse (LPN) #332 revealed there is not always enough PPE available. LPN #332 stated sometimes you have to go looking for gowns; you may find them in the laundry room or storage room if we have them. LPN #332 stated there are reusable gowns, but most staff did not wear them. Interview and observation on 01/22/24 at 6:45 A.M. with the Administrator verified the lack of PPE in the isolation carts and that the isolation signs were not posted. The Administrator stated herself and Assistant Director of Nursing #336 do all of the ordering since there is no one working in central supply. Interview on 01/30/24 at 2:00 P.M. with the Administrator revealed the only residents that had isolation carts outside their rooms and were currently on isolation precautions were Resident #59 and #74. Review of the facility policy titled, Transmission-Based Precautions, dated 08/2021, revealed should clearly identify the type of precautions and the appropriate PPE to be used, or a please see the nurse prior to entering sign. Make PPE readily available near the entrance to the resident's room and donning appropriate PPE upon entering into the resident room. This deficiency represents non-compliance investigated under Complaint Number OH00150208. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 16 of 17 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 365837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Grove Manor 1670 Crider Rd Mansfield, OH 44903 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations and interviews, the facility failed to ensure the facility provided a sanitary environment. This affected seven residents (Resident #3, #9, #43, #46, #54, #69 and #80) and had the potential to affect all residents residing in the facility. The facility census was 74. Findings include: Observation of the shower rooms on 01/22/24 at 6:43 A.M. with Assistant Director of Nursing (ADON) #336 revealed the shower room on 200-Hall had dirty linens all over the floor and the trash was overflowing. The shower room on the 400-Hall had mold in the corner of the shower and on the shower chair. The toilet had brown paper towels in it and did not have a flushing handle. ADON #336 stated that that toilet is not in use, and the water is not turned on but there shouldn't be dirty paper towels in it. ADON #336 verified the findings at the time of the observations and verified that the shower rooms are both still being used by residents for their showers. Observation of the physical environment on 01/22/24 at 6:45 A.M. with the Administrator revealed the floor around Resident #3's toilet was dirty with brown buildup. There was a hole behind the toilet on right side. The floor around Resident #9's toilet had brown buildup and there was a hole in the bathroom door approximately one inch by three inches. Small white areas were observed all over the floor where the top layer of linoleum was coming off. Observation of Resident #43's room revealed it was dirty with trash overflowing on the floor. Observation of the floor in Resident #46's room revealed black dirt in all of the grooves in the linoleum. Observation of Resident #80's bathroom revealed dry towels with brown stains on the floor. Observation of Resident #54's trash beside the bed was full and overflowing. Observation of Resident #69's floor revealed a used glove on the floor and the trash was not emptied. The Administrator verified the findings at the time of the observations. Interview on 01/22/24 at 8:11 A.M. with Housekeeper (HK) #315 revealed there are not enough staff to complete work. She stated that she cleans as many rooms as she can but on the weekends, it's really bad. There are usually two housekeepers but, on the weekend there was only one. Interview on 01/29/24 at 3:59 P.M. with HK/Laundry Supervisor #318 revealed that currently there are not enough staff for housekeeping and laundry. HK/Laundry Supervisor #318 stated there used to be a part time laundry person at night but now they don't. Rooms get cleaned but on the weekends it was rough because of a lack of staff. Observations of the shower rooms on 01/29/24 at 7:36 A.M. with Maintenance Supervisor #323 revealed that the toilet in the 400-Hall shower room still paper towels in it. The Maintenance Supervisor #323 verified the findings at the time of the observation. This deficiency represents non-compliance investigated under Complaint Number OH00150212, OH00150105, OH00150030 and OH00149935. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 17 of 17