Health inspection·July 1, 2025

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Potential for minimal harm Based on record review and staff interview. the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) in a timely manner to the residents. This affected two (Residents #1 and #17) of three residents reviewed for NOMNC. The facility census was 73. Residents Affected - Some Findings include: Review of Resident #1's NOMNC revealed the last covered day was 06/10/25. It was signed and dated on 06/09/25. Review of Resident #17's NOMNC revealed the last covered day was 06/12/25 and signed on 06/12/25. Review of the Advance Beneficiary Notice of Non-Coverage notice was dated 06/11/25. Interview on 07/01/25 at 8:10 A.M. with Social Service Designee (SSD) #416 verified Resident #1 and #17 did not receive two days notice before the end of a Medicare covered Part A stay or when all all of Part B therapies were ending. SSD #416 stated he was not aware NOMNC required at least a two-day notice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 2 of 14 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 07/01/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 resident and staff interviews, the facility failed to complete a treatment for Resident #12. This affected one of one resident reviewed for wound treatments. The facility census was 73. Residents Affected - Few Findings include: Review of the medical record for Resident #12 revealed an admission date of 06/03/25. Resident #12 was hospitalized from [DATE] through 06/11/25. Resident #12 was readmitted [DATE]. Diagnoses included unspecified fracture of upper end of left tibia, diabetes mellitus, and adult failure to thrive. Review of the care plan initiated 06/05/25 and revised on 06/17/25 revealed he had an open area on his right hand related to gout. One intervention was to assess, monitor and record wound healing. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 was cognitively intact and received treatments and ointments to areas other than feet. Review of the Medication Administration Record (MAR) from June 2025 revealed an order to cleanse area to back of right hand with wound cleanser and apply a dry dressing daily and as needed starting 06/17/25. It was signed off daily except for 06/19/25. Observation and interview on 06/29/25 at 10:30 A.M. revealed Resident #12's dressing on his hand was dated 06/25/25. Resident #12 stated it was ordered to be changed daily but staff were not changing it daily. Interview on 06/29/25 at 10:50 A.M. with Certified Nursing Assistant (CNA) #392 verified the date of 06/25/25 on the dressing on Resident #12's hand. Review of the facility policy titled Wound Care dated 08/2023 revealed to apply the treatment as indicated. Dress the wound and mark tape or dressing with initials, date and time. Document in the electronic medical record. Indicate if the resident refused. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 3 of 14 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 07/01/2025 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Ohio Board of Nursing Administrative Code, and staff interview, the facility failed to ensure they had sufficient nursing staff with the appropriate skills to complete the resident's central venous line therapy procedures. This affected one (Resident #122) of one resident reviewed for intravenous (IV) access. Findings include: Review of Resident #122's medical record revealed the resident was admitted on [DATE] with diagnoses including osteomyelitis and chronic kidney disease. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #112 exhibited intact cognition. Review of Resident #122's hospital discharge documentation dated 06/13/25 revealed an central venous catheter (CVC) double lumen (DL) tunneled left internal jugular (IJ) was placed on 06/06/25 and a hemodialysis central line access permanent catheter left internal jugular was placed on 06/03/25. Review of Resident #122's physician orders revealed an order dated 06/11/25 to use 10 milliliters (ml) of normal saline (NS) intravenously (IV) as needed for an IV flush; flush each IV catheter lumen with 10 ml NS after each intermittent IV administration; use 10 ml IV every six hours for IV flush; flush each IV catheter lumen with 10 ml saline after each intermittent IV administration. The IV flushes were ordered at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. Review of Resident #122's medication administration records (MARs) from 06/12/25 to 06/30/25 revealed Licensed Practical Nurse (LPN) #306 had documented the nurse flushed the resident's left chest CVC DL tunneled IJ IV access on 06/22/25 at 12:00 A.M. and 6:00 A.M.; 06/23/25 at 12:00 A.M. and 6:00 A.M.; 06/28/25 at 12:00 A.M. and 6:00 A.M.; 06/29/25 at 12:00 A.M. and 6:00 A.M. Review of Resident #122's MARS revealed the Director of Nursing (DON) had documented the nurse had completed the resident's flushes on 06/30/25 at 12:00 A.M. and 6:00 A.M. Interview on 06/30/25 at 6:27 A.M. with LPN #306 revealed Resident #122's left CVC DL IJ IV access was to be flushed four times per day including two on the nightshift at 12:00 A.M. and 6:00 A.M. LPN #306 confirmed she flushed Resident #122's IV access outside of the scope of practice for LPNs in Ohio on 06/22/25, 06/23/25, 06/28/25 and 06/29/25 at 12:00 A.M. and 6:00 A.M. because Registered Nurse (RN) coverage was not available to complete the task and the nurse did not want complications for the resident. Interview on 06/30/25 at 8:30 A.M. with the DON confirmed the Ohio Board of Nursing allows LPNs to flush peripheral access lines only and LPN #306 could not provide care to Resident #122's left CVC DL IJ IV. A second interview on 07/01/25 at 9:32 A.M. with the DON revealed she had flushed Resident #122's left DL IJ on 06/30/25 at 6:00 A.M. and confirmed the MAR shows she completed the left DL IJ on 06/30/25 at 12:00 A.M. The DON said she was was not sure why it was signed off as completed on 06/30/25 at 12:00 A.M. by the DON because she didn't complete it. An additional interview on 07/01/25 at 11:20 A.M. with the DON revealed she had documented Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 4 of 14 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 07/01/2025 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 0726 #122's left DL IJ FLUSH on 06/30/25 at 12:00 A.M. in error. Level of Harm - Minimal harm or potential for actual harm Review of Rule 4723-4-02 of the Ohio Board of Nursing Administrative Code titled Intravenous Therapy Procedures for Licensed Practical Nurses revealed except as provided in paragraph (B) of this rule, a licensed practical nurse shall not perform any of the following intravenous therapy procedures including solutions administered through any central venous line or arterial line or any other line that does not terminate in a peripheral vein. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 5 of 14 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 07/01/2025 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Potential for minimal harm Based on review of personnel files and staff interview the facility failed to ensure certified nursing assistants (CNA) received regular performance reviews as required. This had the potential to affect all 73 residents residing in the facility. Residents Affected - Many Findings include: Review of the personnel file for CNA #1106 revealed a date of hire of 10/25/23 and there was no annual performance review. Review of the personnel file for CNA #1108 revealed a date of hire of 06/07/23 and there was no annual performance review. Interview with Human Resources Director (HRD) #415 on 07/01/25 at 10:59 A.M. verified there were no annual performance reviews completed for CNA #1106 and CNA 1108. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 6 of 14 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 07/01/2025 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 0759 Ensure medication error rates are not 5 percent or greater. 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, facility policy review, and staff interview, the facility failed to ensure the medication error rate did not exceed medication error rate of five percent (%) or greater. Two errors occurred within 28 opportunities for an error rate of 7.14%. This affected two (Residents #35 and #41) of four residents observed for medication administration. Residents Affected - Few Findings include: 1. Review of Resident 41's medical record revealed the resident was admitted on [DATE] with diagnoses including type two diabetes mellitus and edema. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #41 had intact cognition. Review of Resident #41's physician orders dated [DATE] revealed an order for potassium chloride powder give 20 milliequivalents (meq) by mouth one time a day for a supplement. Observation on [DATE] at 8:15 A.M. revealed Licensed Practical Nurse (LPN) #308 administered Resident #41's morning medication administration. LPN #308 revealed she administered nine medications including a potassium 20 meq tablet. Interview on [DATE] at 11:55 A.M. with LPN #308 confirmed she administered a potassium tablet to Resident #41 instead of the potassium powder as ordered. Review of the facilities Administering Medications policy revised 12/2012 revealed medications shall be administered in a safe and timely manner, and as prescribed. 2. Review of Resident #35's medical record revealed the resident had a re-admission on [DATE] with diagnoses including hyperlipidemia, essential hypertension and constipation. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #35 exhibited moderate cognitive impairment. Review of Resident #35's physician orders revealed an order dated [DATE] to inject Lispro 12 units subcutaneously (sq) before meals for diabetes mellitus and notify the physician of a blood sugar below 50 or greater than 400. Observation on [DATE] at 11:21 A.M. revealed Registered Nurse (RN) #383 obtained Resident #35's blood sugar via a blood sugar device and then administered eight medications including Lispro 12 units to Resident #35. The date written on the vial of Lispro indicated the insulin was opened on [DATE]. Interview on [DATE] at 11:38 A.M. with the Director of Nursing (DON) confirmed staff were to discard insulin once opened after 30 days. Interview on [DATE] at 12:10 P.M. with RN #383 confirmed Resident #35's Lispro insulin was opened on [DATE] and expired on [DATE] and the expired insulin was administered to the resident. Review of the Insulin Lispro Instructions for Use revised 07/2023 verified after insulin vials had been opened, store opened vials in the refrigerator or at room temperature up to 86 degrees (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 7 of 14 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 07/01/2025 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 0759 Fahrenheit for up to 28 days. Keep vials away from heat and out of direct light. Throw away all opened vials after 28 days of use, even if there was insulin left in the vial. 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: 365837 If continuation sheet Page 8 of 14 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 07/01/2025 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to ensure the residents received the correct texture of diet and adaptive equipment as ordered by the physician. This affected one (Resident #53) of three residents reviewed for nutrition. The facility identified 18 residents on a mechanically altered diet. The facility census was 73. Findings include: Review of the medical record for the Resident #53 revealed an admission date of 03/08/25. Diagnoses included dementia and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 had a memory problem and was on a therapeutic mechanically altered diet with no significant weight change. Review of the physician's orders for July 2025 revealed Resident #53 was ordered a regular diet, mechanically altered texture, and honey thick consistency liquids with finger foods as available. Review of Resident 53's diet ticket on 07/01/25 at 12:05 P.M. revealed Resident #53 was on a regular diet, mechanically altered texture, with honey thick consistency liquids. Resident #53 was to receive liquids in a sippy mug and plastic utensils. Observations on 07/01/25 from 12:10 P.M. through 12:25 P.M. revealed Resident #53 was sitting at a table in the dining room. Resident #53 was sitting at the table with a six-ounce regular cup of thin liquids in front of her. Resident #53's plate had ground turkey, scalloped potatoes and green beans. Resident #53 was was observed trying to eat the scalloped potatoes with her fingers. Certified Nursing Assistant (CNA) #309 noticed that Resident #53's liquids were not correct and replaced Resident #53's liquids with the correct consistency and in the appropriate cup. An interview on 07/01/25 at 1:45 P.M. with CNA #309 verified Resident #35 received the incorrect consistency of fluids and did not have the adaptive equipment of a sippy cup. CNA #309 stated she had a concern the newer CNAs not knowing the resident's diets and were not serving the correct juices and adaptive equipment to the residents. Interview on 07/01/25 at 1:55 P.M. with Regional Nurse #500 confirmed Resident #35's diet order and diet ticket included honey thick consistency liquids. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 9 of 14 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 07/01/2025 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 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 observation, staff interview, and policy review, the facility failed to ensure a kitchen did not have expired food, kitchen was clean and sanitary, and opened food items were not labeled or dated. This had the potential to affect all 73 residents residing in the facility who receive food from the kitchen. Findings include: A tour of the kitchen on 06/29/25 from 8:10 A.M. through 8:33 A.M. revealed in the dry storage room, there were 12 bags of raisins that had a best buy date of 07/14/24, red wine vinegar was opened and had a best if used 03/13/24, molasses was opened and had a best if used by date of 11/15/24, and ziti, penne and elbow pasta bags were opened with no label or date. In the walk-in refrigerator, the packages of biscuits, waffles, pepperoni, and sliced cheese were not labeled and dated. In the preparation area, there was grease on the floor behind the convection oven and the microwave had dried food on the top of the inside of the microwave. The stand up fan had food splatter on the base of the stand. Interview with Dietary [NAME] #340 on 06/29/25 at 8:34 A.M. verified there were several items including red wine vinegar, molasses, and pasta that had best if used by dates of 2024, there were food packages in the walk-in refrigerator that were no labeled and dated, and there was grease on the floor, a dirty microwave, and dirty fan in the preparation area. Review of the facility policy dated 2021 titled Food Safety and Sanitation revealed kitchen should be cleaned, open food items should be labeled and dated. Foods should be used prior to the use by date on the package. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 10 of 14 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 07/01/2025 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 2. Observation on 06/29/25 at 11:16 A.M. revealed Registered Nurse (RN) #383 obtained a blood sugar using a blood glucose testing (BGT) machine for Resident #66. RN #383 then walked back down the hall and placed the contaminated BGT machine on top of the medication cart before placing the contaminated BGT machine in the top drawer of the medication cart without disinfecting the device. Residents Affected - Some Interview on 06/30/25 at 11:51 A.M. with RN #383 with the Director of Nursing (DON) present revealed RN #383 obtained Resident #12's blood sugar just prior to obtaining Resident #66's blood sugar using the same BGT machine. RN #383 confirmed the multi-use BGT machine was not disinfected or decontaminated between residents because the medication administration cart did not have disinfectant wipes to disinfect or decontaminate the BGT machine to prevent the potential of cross contamination of blood borne pathogens. Interview on 07/01/25 at 9:20 A.M. with the DON confirmed nursing was not disinfecting the BGT machine after each use. The DON confirmed four residents (#34, #66, #223 and #224) shared the BGT machine on the 400-unit. Review of the Assure Prism Multi Blood Glucose Monitoring System Reference Manual dated 02/2026 revealed the meter should be cleaned and disinfected after use on each patient. The Assure Prism multi Blood Glucose Monitoring System may only be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures were followed. The cleaning procedure was needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfection procedure. The disinfection procedure was needed to prevent the transmission of blood-borne pathogens. A variety of the most commonly used environmental protection agency (EPA)-registered wipes had been tested and approved for cleaning and disinfection of the Blood Glucose Monitoring System. Based on observation, interview, review of Centers for Disease Control and Prevention (CDC) guidance, review of manufacturers instructions, policy review, and record review, the facility failed to ensure enhanced barrier precautions (EBP) were in place for residents who had indwelling medical devices or wounds, failed to ensure their infection control surveillance accurately reflected the resident's who required EBP, and failed to ensure blood glucometer machines were appropriately sanitized and disinfected between residents to prevent the potential for cross contamination of blood borne pathogens. This affected nine residents (#2, #48, #63, #65, #66, #122, #171 #172, and #223) reviewed for EBP and had the potential to affect four residents (#34, #66, #223, and #224) who share the same glucometer. The facility census was 73. Findings include: 1. Review of the facilities Order Listing Report dated 06/29/25 at 12:13 P.M. revealed Residents #2, #8, #9, #12, #17, #21, #29, #35, #44, #45, #46, #48, #52, #59, #63, #174, and #221 had orders for enhance barrier precautions (EBP). Tour of the facility on 06/29/25 at 12:36 P.M. revealed Residents #2, #9, #12, #21, #35, and #174 did not have any EBP signage on their doors and personal protective equipment (PPE) in the room or outside the room for staff to don when providing high contact direct care. Observation and interview with Director of Nursing (DON) on 06/29/25 at 1:20 P.M. stated the DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 11 of 14 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 07/01/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was the facilities Infection Preventionist. The DON confirmed there was no EBP signage or PPE cart available for Residents #2, #9, #12, #35 and #174 despite orders in place for EBP. Review of the updated Order Listing Report dated 06/29/25 at 2:49 P.M. revealed Residents #2, #17, #29, #44, #45, #46, #52, #59, #65, #66, #122, #171, #172, #221, and #223 had orders for EBP. Residents #8, #9, #12, #35, #48, #63, and #174 were removed for the updated list as originally provided on 06/29/25 at 12:13 P.M. Residents #65, #66, #122, #171 #172, and #223 were added to the updated list provided at 2:49 P.M. Review of Centers for Disease Control and Prevention (CDC) guidance titled Considerations for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities dated June 2021 revealed EBP was an approach of targeted gown and glove use during high contact resident care activities designed to reduce transmission of multi-drug-resistant organisms (MDROs). EBP should be applied to residents with wounds or indwelling medical devices regardless of MDRO colonization status and if a resident was infected or colonized with an MDRO. Effective implementation of EBP requires staff training on proper use of PPE and availability of PPE with hand hygiene products at point of care. Review of the facility policy titled Enhanced Barrier Precautions dated 04/01/24 revealed EBP was indicated for residents with infection or colonization with a MDRO when contact precautions do not apply, for those with wounds, and for those with indwelling medical devices including central line, urinary catheter, feeding tubes, tracheostomy, nephrostomy, and ventilator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 12 of 14 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 07/01/2025 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 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interview, the facility failed to ensure they implemented their smoking policy by ensuring the facilities grounds were free from discarded cigarette butts. This finding had the potential to affect all 73 residents residing in the facility. Residents Affected - Many Findings include: Observations on 06/29/25 at 1:05 P.M. revealed residents were on a supervised smoke break. Approximately 25 cigarette butts were noted in the rocks surrounding the smoking area. Fire proof receptacles and fire proof ashtrays were located in the smoking area. Interview 06/29/25 at 1:10 P.M. with Medical Records #1121 confirmed approximately 25 cigarette butts were in the rocks in the smoking area which were not cleaned up. A second observation on 06/30/25 at 9:52 A.M. revealed approximately five cigarette butts were lying on the ground surrounded by lint in front of the emergency exit off of the kitchen. Interview on 06/30/25 at 12:05 P.M. with the Administrator revealed it was every staff member's responsibility to pick up cigarette butts from the ground in the smoking areas. Review of the facilities Smoking Policy revised 04/28/25 revealed cigarette butts were to be discarded into the proper containers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 13 of 14 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 07/01/2025 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 0947 Level of Harm - Potential for minimal harm Residents Affected - Many Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on review of personnel files and staff interviews, the facility failed to ensure certified nursing assistants (CNA), who were hired for more than one year, had 12 hours of in-services annually. This had the potential to affect all 73 residents residing in the facility. Findings include: Review of the personnel file for CNA #1106 revealed a date of hire of 10/25/23 and there was no evidence CNA #1106 had 12 hours of annual in-services. Review of the personnel file for CNA #1108 revealed a date of hire of 06/07/23 and there was no evidence CNA #1108 had 12 hours of annual in-services. Interview with Human Resources Director (HRD) #415 on 07/01/25 at 11:25 A.M. verified there was no evidence that CNAs #1108 and #1106 had 12 hours of in-service annually. HRD #415 stated he received an email from Corporate Human Resources (CHR) #700 that stated all employees were scheduled a minimum of 12 hours of in-services in the program. HRD #415 stated he was searching for a report from the software. Interview on 07/01/25 at 1:37 P.M. with the Administrator and Regional Nurse #500 verified they had no further evidence of 12-hour in-services were being completed annually for CNAs #1108 and #1106. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365837 If continuation sheet Page 14 of 14