Health inspection·March 7, 2023

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few order directly from a prescriber. RN #28 indicated he planned to re-write Resident #151's order for vitamin B12 for 1000 mcg every day and re-write Resident #45's order for Calcium-Magnesium for 600-400 mg tablet because that is all he had available to give to Resident #45. When asked if the DON had prescribing authority for RN #28 to accept an order from her he stated she did not, but he trusted her, so he would re-write the orders. After again asking if it was appropriate to change an order based on something told to him by the DON or another nurse who was not a certified nurse practitioner who could act as a prescriber he verified it was not and stated he would check with the physician about the orders. On 03/01/23 at 11:14 A.M., RN #72 verified a nurse should never instruct another nurse to write an order or give a change in medication orders absent the legal authority to prescribe medications. At 12:12 P.M. RN #72 stated although the DON was given an order approving the change to the original orders it was not appropriate for another nurse to write orders he or she had not personally received from the physician. Review of the OAC 4729:5-5 for prescription processes stated a prescription, to be valid, must be issued for a legitimate medical purpose by an individual prescriber acting in the usual course of the prescriber's professional practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365855 If continuation sheet Page 2 of 6 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 365855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurie Ann Nursing Home 2200 Milton Boulevard Newton Falls, OH 44444 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 - Minimal harm or potential for actual harm Based on medical record review and interview, the facility failed to ensure appropriate treatments were applied to a pressure ulcer for one resident (Resident #5) of five residents reviewed for pressure ulcers. The facility census was 42. Residents Affected - Few Findings include: Review of Resident #5's medical record revealed diagnoses included left hip fracture, diabetes mellitus, and macular degeneration. An order dated 02/21/23 indicated the wound bed on the coccyx was to be irrigated with normal saline then covered with calcium alginate (a treatment for wounds) and a foam dressing every day and as necessary. A wound consultant note dated 02/27/23 indicated Resident #5 had a stage three pressure ulcer on the coccyx (full thickness tissue loss without bone, tendon or muscle being exposed). Instructions revealed to continue calcium alginate to aid in autolytic debridement of the wound. On 03/02/23 between 11:00 A.M. and 11:20 A.M., Licensed Practical Nurse (LPN) #22 was observed gathering supplies to complete Resident #5's dressing change to the pressure ulcer on her coccyx. LPN #22 gathered normal saline, gauze, a tube of santyl (an ointment used to debride a wound), a cotton applicator, and a foam dressing. When asked if Resident #5 had an order for santyl, LPN #22 stated she would have to check with Registered Nurse (RN) #28 because she was not sure of the order. The orders were not in view and LPN #22 was not heard asking RN #28 for verification of the orders. When the old dressing was removed LPN #22 observed there was a piece of calcium alginate on the wound and she sent RN #28 to obtain calcium alginate from the cart. When placing the new dressing on the pressure ulcer site, LPN #22 placed santyl on a piece of calcium alginate and applied it to the pressure ulcer then covered it with a foam dressing. On 03/02/23 at 1:40 P.M., LPN #22 verified she had applied santyl and calcium alginate to the wound bed. LPN #22 verified she had not reviewed the treatment order before applying the dressing, stating she did it on the fly. LPN #22 stated she figured RN #28 would tell her if the order was incorrect. Review of the facility's Wound and Skin Care policy, revised 06/07/16 revealed treatments would be initiated as ordered by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365855 If continuation sheet Page 3 of 6 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 365855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurie Ann Nursing Home 2200 Milton Boulevard Newton Falls, OH 44444 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, interview and policy review, the facility failed to ensure a resident's complaints of constant pain with ineffective pain interventions were addressed in a timely manner. This affected one (Resident #32) of four residents reviewed for pain. The facility census was 42. Residents Affected - Few Actual harm occurred to Resident #32 on 03/01/23 when Resident #32 informed Licensed Practical Nurse (LPN) #39 he had constant pain and ordered Tylenol was ineffective in managing the pain. The resident described the pain as a shocking/stabbing sensation to the left hip/leg/feet. LPN #39 failed to report the pain to the physician and no changes were made to pain management until 03/02/23 which resulted in a lack of effective pain relief and suffering for the resident for an extended period of time. Findings include: Review of Resident #32's medical record revealed diagnoses including cerebral infarction, neuropathy, type two diabetes mellitus, and osteoarthritis. The admission nursing assessment did not have any documentation in the pain section indicating whether he did or did not have pain. An admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated a pain assessment interview should be done but the interview was not completed. A care plan initiated 01/06/23 indicated Resident #32 had an alteration in musculoskeletal status related to osteoarthritis, generalized muscle weakness, dorsalgia (ache, strain, discomfort in the back), abnormal posture, hemiplegia (paralysis of one side of the body) and neuropathy (a group of diseases resulting from damaged or malfunctioning of nerves that causes weakness, numbness and pain in hands and feet). The goal was for Resident #32 to remain free from pain or at a level of discomfort acceptable to the resident. Interventions included administering analgesics (pain medication) as ordered by the physician and monitoring and documenting for side effects and effectiveness. On 03/01/23 between 8:10 A.M. and 8:16 A.M., LPN #39 was observed administering routinely ordered medication to Resident #32. After returning to the medication cart to sign the administration of the medications, LPN #39 asked Resident #32 if he was having pain. Resident #32 responded he had pain all the time. When asked to rate the pain, Resident #32 rated it at a severity of eight on a scale of zero to ten (zero being no pain at all and 10 being severe pain). LPN #39 recorded the response but offered no means of pain relief at that time. LPN #39 proceeded to prepare and administer medication to Resident #29 at 8:28 A.M. At 8:32 A.M., LPN #39 was asked by the surveyor whether Resident #32 had anything ordered for pain as LPN #39 had not been observed offering pain medication or non-pharmacological interventions for pain rated severity of eight out of ten. LPN #39 looked at the medication orders and stated Resident #32 had orders for Tylenol on an as necessary basis. LPN #39 offered Resident #32 Tylenol to which he responded it did not help in relieving pain. LPN #39 reported the physician was going to be making rounds that same day and she would have the pain addressed. On 03/02/23 at 9:06 A.M., Registered Nurse (RN) #74 stated the pain interview section of the MDS was not completed because the staff member who had been assigned to do the interview did not have it completed by the assessment reference date. On 03/02/23 at 9:14 A.M., LPN #22 verified she did rounds with the physician on 03/01/23 but she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365855 If continuation sheet Page 4 of 6 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 365855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurie Ann Nursing Home 2200 Milton Boulevard Newton Falls, OH 44444 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 0697 Level of Harm - Actual harm was not told by LPN #39 that Resident #32 was complaining of constant pain and that ordered Tylenol was not effective in helping relieve pain. LPN #22 stated pain was assessed every shift but did not know about comprehensive pain assessments. At 9:22 A.M. LPN #22 stated pain assessments were completed on admission but verified the admission assessment was blank for pain. Residents Affected - Few On 03/02/23 at 9:27 A.M., LPN #22 interviewed Resident #32 and he reported he had constant pain, describing it as a shocking/stabbing sensation. The pain was in the left hip/leg/feet. LPN #22 informed Resident #32 she would contact the physician. At 9:58 A.M. LPN #22 stated she spoke with the physician and he gave an order for Ultram 50 milligrams (mg) every six hours as needed for pain. Review of the facility's Pain Management policy, revised 06/12/17, indicated staff nurses were to complete the initial admission nursing assessment within 24 hours and initiate a pain flow record for all new admissions. All residents would be reviewed upon admission, quarterly and as necessary for acute, chronic, or no pain. On an individual basis, each resident was assessed every shift to evaluate new onset pain or effectiveness of pain management interventions. The nurse would use a numeric pain distress scale or the Wong-Baker faces pain scale for recorded pain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365855 If continuation sheet Page 5 of 6 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 365855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurie Ann Nursing Home 2200 Milton Boulevard Newton Falls, OH 44444 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 record review and interview, the facility failed to thoroughly and consistently record bowel movements for assessment of constipation for Resident #9. This affected one (Resident #9) of 12 residents interviewed regarding constipation. The facility census was 42. Findings include: Review of Resident #9's medical record revealed an admission date of 02/03/23 and diagnoses including right hip fracture, traumatic subarachnoid hemorrhage, arthritis, pain in the right leg and neuropathy. An admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #9 was able to make herself understood. Resident #9 was dependent for toilet use. A plan of care initiated 02/15/23 indicated Resident #9 had potential for constipation related to decreased mobility and medications. The stated goal was for Resident #9 to have a bowel movement at least every three days. Interventions included observing for and documenting bowel movements, observing for complaints of abdominal discomfort and abdominal distention, and administering medications as ordered. Resident #9 had an order for psyllium husk powder one unit every day for constipation. Review of bowel movement records revealed no record of a bowel movement from 02/04/23 through 02/11/23. No bowel movement was recorded between 02/16/23 and 02/23/23. Review of the February 2023 Medication Administration Record (MAR) revealed the following orders for treatment of constipation with start dates of 02/03/23: Colace (stool softener) 100 milligrams (mg) every 12 hours as needed, one Dulcolax suppository as needed if no results were achieved within eight hours of administration of Milk of Magnesia (MOM). If there were no results within 15 to 20 minutes of administration of the Dulcolax suppository, it could be repeated; one Fleet enema as needed if no results were achieved from administration of the suppository, and MOM 30 milliliters as needed if there was no bowel movement within six shifts. The February MAR nor the progress notes revealed administration of any of the medications ordered on an as necessary basis for constipation. There was no documentation of Resident #9 being interviewed or assessed related to the extended periods without documentation of a bowel movement. During an interview on 02/27/23 at 10:00 A.M., Resident #9 verified she did have constipation and had not received any medications to promote bowel movements. On 03/03/23 at 1:15 P.M., Registered Nurse (RN) #72 stated the electronic health record provided an alert to the nurse when a resident did not have a bowel movement. If alerted, nurses should check with aides to ensure they had documented bowel movements for each resident and if they had not, the nurse should offer something for constipation in accordance with the orders. On 03/03/23 at 1:45 P.M. RN #72 verified the lack of documentation of bowel movements for Resident #9. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365855 If continuation sheet Page 6 of 6