Inspection·June 18, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Interview on 06/17/25 at 9:27 A.M. with ADON/RN #266 stated the indwelling urinary catheter collection bag which the resident had come back from the hospital with hadn't had a privacy covering attached. He stated normally the facility would change the collection bag to one with a privacy cover on it, but the facility hadn't gotten around to changing Resident #8's collection bag until he changed the collection bag on 06/17/25. Residents Affected - Few Interview on 06/17/25 at 12:19 P.M. with family members of Resident #8 revealed the catheter collection bag hadn't been covered until 06/16/25 when it was covered with a pillowcase. They stated on 06/17/25 the indwelling urinary catheter collection bag had been changed to one with a privacy covering. Review of facility policy/procedure Foley Catheter Care Procedure, dated January 2025, revealed there was nothing in the policy/procedure indicating the indwelling urinary catheter drainage bag should have a privacy covering. Review of the undated facility policy Resident Rights revealed the resident had the right to be treated at all times with courtesy, respect, and full recognition of dignity and individuality. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365855 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 365855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview and facility policy review, the facility failed to ensure residents' wishes regarding end-of-life measures were signed by the physician. This affected two (Residents #6 and #47) of three residents reviewed for Advanced Directives. The facility census was 56. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 01/08/24. Diagnoses included dementia, depression, diabetes and kidney failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was severely cognitively impaired. She required set up help for eating, oral and personal hygiene, partial assistance for showering and substantial assistance for toileting. Review of the physicians' orders for June 2025 for Resident #6 revealed an order for Do Not Resuscitate, Comfort Care only, comfort care will be provided, even before a cardiac or respiratory arrest occurs (DNRCC). Review of the Do Not Resuscitate (DNR) form dated 01/08/24 revealed no evidence that the required signature of the physician had been obtained. 2. Review of the medical record for Resident #47 revealed an admission date of 12/20/24. Diagnoses included cirrhosis of the liver, repeated falls, congestive heart failure and depression. Review of the quarterly MDS assessment dated [DATE] revealed Resident #46 was cognitively intact. She required set up help for eating, oral and personal hygiene, supervision for toileting and dressing and partial assistance for showering. Review of the physician' orders for June 2025 for Resident #47 revealed an order for a DNRCC. Review of the DNR form dated 12/20/24 revealed no evidence the required signature of the physician had been obtained. Interview on 06/17/25 at 8:50 A.M. with Certified Nurse Aide (CNA) #205 confirmed neither DNR form for Resident #6 or #47 had been signed by the physician. Review of the facility policy titled Advance Directives, dated 08/01/22, did not address the completion of the DNR form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365855 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 365855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, tray ticket and facility policy reviews, the facility failed to ensure fluid restrictions were followed as ordered for Residents #26 and #158. This affected two (Residents #26 and #158) out of four residents reviewed for nutrition and had the potential to affect one additional (Resident #36) identified by the facility as being on a fluid restriction. Additionally, the facility failed to ensure weekly weights were obtained as ordered for Residents #26. This affected one (Residents #26) out of four residents reviewed for nutrition. The facility census was 56. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #158 revealed an admission date of 05/12/25 and a reentry date of 06/07/25. Diagnoses included acute on chronic combined systolic and diastolic heart failure (CHF), Non-ST elevation (NSTEM) myocardial infarction (heart attack), cardiomyopathies (disease of the heart muscle), hypertension (high blood pressure), and hyperlipidemia. Review of Resident #158's history and physical dated 05/13/25 revealed the resident was admitted to the facility after being hospitalized from [DATE] to 05/12/25 for new onset of CHF. During hospitalization, a CHF nurse was consulted and completed education with the resident. Due to new onset CHF, dyspnea (shortness of breath) on exertion, and lower extremity edema, the physician ordered a fluid restriction for the resident along with the resident being weighed three times a week. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #158 was cognitively intact, did not reject care, required setup or cleanup assistance from staff for eating, and was on a therapeutic diet. Review of the physician orders revealed an order dated 05/13/25 for an 1800 ml (milliliter)/day fluid restriction due to CHF with nursing giving 120 ml each medication pass (480ml/day) and dietary providing 1320 ml/day. The 1800 ml fluid restriction order was discontinued on 06/07/25, and a 2000 ml fluid restriction was started on 06/07/25 with nursing providing 250 ml each medication pass (1000 ml/day) and dietary providing 1000 ml/day. Review of Resident #158's care plan dated 05/13/25 revealed the resident was at risk for fluid volume excess due to CHF and edema. Interventions included fluid restriction as ordered, encourage fluids within fluid restriction, and observe for edema and report to physician as needed. Observation on 06/17/25 at 8:06 A.M. revealed there was one large white Styrofoam cup with a lid full of water and ice on Resident #158's over bed table. At the time of observation, Resident #158 stated she was not aware she was on any special diet or fluid restriction, and the Styrofoam cup was full of ice water, which had just been brought to her by a staff member. Interview on 06/17/25 at 8:25 A.M. with Activity Aide #325 and Activity Supervisor #277 revealed the activity department would pass water to residents every day. They stated they were made aware of who was on a fluid restriction via the dashboard of the electronic medical record (EMR), which would show any changes, or by the nurses verbally telling them. They stated they were unaware Resident #158 was on a fluid restriction and Activity Aide #325 confirmed she had given Resident #158 a full cup of ice water, which was a 20-ounce cup (591 ml). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365855 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 365855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 06/17/25 at 11:06 A.M. with Dietary Supervisor #224 revealed for residents who were on a fluid restriction, nursing would let him know how much fluids dietary were allowed in a day, and he would divide that number by three and then put on the dietary ticket how much fluids a resident was allowed for each meal. He stated the tray tickets would go down with the beverage cart prior to the meal so the aides could take the meal orders and would know who was on a fluid restriction. After the beverages were passed and meal orders were taken, the aides would return the meal tickets with the meal orders written on them. Interview on 06/17/25 at 11:28 A.M. with Certified Nurse's Aide (CAN) #206, who normally worked the day shift on the unit where Resident #158 resided, revealed she believed there wasn't anyone on the unit who was on a fluid restriction, and if a resident was on a fluid restriction, the resident shouldn't have a water pitcher in the room. She indicated she wasn't always able to see in the EMR if a resident was on a fluid restriction, and if she had a question about a fluid restriction, she would ask the nurse. Interview on 06/17/25 at 2:37 P.M. with CNA #263, who normally worked afternoon shift on the unit where Resident #158 resided, revealed she was unaware Resident #158 was on a fluid restriction. Review of Resident #158's lunch meal ticket dated 06/17/25 revealed there was nothing noted on the meal ticket indicating the resident was on a fluid restriction. An additional interview on 06/18/25 at 8:07 A.M. with Dietary Supervisor #224 confirmed after reviewing Resident #158's lunch meal ticket dated 06/17/25 there was nothing noted on Resident #158's meal ticket to indicate the resident was on a fluid restriction. He stated normally he would note the fluid restriction at the bottom of the ticket, which he stated he hadn't done. He went on to state the CNAs used the tray tickets as a means of knowing who was on a fluid restriction. Interview on 06/12/25 at 9:05 A.M. with Dietitian #270 stated a fluid restriction should be noted on a resident's tray ticket. 2. Review of the medical record for Resident #26 revealed a date of admission of 09/26/24 with diagnoses including cerebral infarction due to embolism of an unspecified cerebral artery, hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side, congestive heart failure and prediabetes. Significant orders included reduced concentrated sweets diet, mechanical soft texture, thin liquid consistency, weights three times a week on Monday, Wednesday, and Friday for CHF dated 02/17/25, 1800 ml in 24 hours fluid restriction, 480 ml nursing (120 ml each medication pass) and 1320 ml dietary dated 04/17/25, and Bumex (a diuretic to remove excess water from the body) one milligram (mg), one tablet daily for CHF dated 02/13/25. Review of the nurse practitioner note dated 02/12/25 revealed Resident #26 was noted to have a weight gain. The assessment and plan within the note revealed a diagnosis of CHF with weight gain. The plan was to continue weights three times a week as well as adding a fluid restriction of 1800 ml daily. Review of the quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating Resident #26 was cognitively intact. The MDS further revealed a weight gain of 5% or more while not on a physician prescribed weight gain regimen. Review of the care plan dated 05/09/25 revealed Resident #26 had the potential for fluid volume (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365855 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 365855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few excess or decreased fluid volume related to diet and medicine use. Interventions included, dietary to review meal intakes, weights, and fluid needs as needed, fluid restrictions as ordered, weights as ordered, observe for edema and report to the physician as needed. The care plan further revealed Resident #26 was at risk for altered nutrition related to medical diagnosis including diabetes mellitus type two, risks and weight fluctuations associated with diuretic use, daily fluid restriction, variable meal intakes and significant weight variances. Interventions included providing and serving diet as ordered, obtaining weights as ordered, and providing fluid restrictions as ordered. Review of the medication administration records (MARs) dated 02/01/25 through 06/17/25 revealed no orders on the record for the nursing staff for weights three times weekly on Monday, Wednesday and Friday. A review of the MARs dated 04/01/25 through 06/17/25 revealed no orders on the records for 1800 ml fluid restrictions. Review of the dietician progress note dated 06/05/25 revealed a current weight of 175 pounds reflecting a continued weight gain. Significant weight gain noted for three and six months. The note further revealed potential for weight fluctuations related to the history of edema and diuretic therapy. Recommendations were to continue weights on Monday, Wednesday, and Friday per order, and 1800 ml daily fluid restriction. A review of documented weights for Resident #26 revealed the following: • 02/14/25: 166.0 pounds • 02/17/25: 165.0 pounds • 02/21/25: 166.1 pounds • 02/28/25: 162.0 pounds • 03/03/25: 158.4 pounds • 04/01/25: 171.6 pounds • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365855 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 365855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 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 0692 04/16/25: 176.0 pounds Level of Harm - Minimal harm or potential for actual harm • 04/21/25: 178.2 pounds Residents Affected - Few • 05/02/25: 173.4 pounds • 06/03/25: 175.0 pounds The weights were documented as being taken on a seated scale. A review of the facility diet list dated 06/17/25 revealed Resident #26 was not listed for a dietary fluid restriction. On 06/17/25 at 4:00 P.M. an interview with the Director of Nursing (DON) verified the MARs dated 02/01/25 through 06/17/25 had no orders for weights three times weekly on Monday, Wednesday and Friday. The DON further verified the MARs dated 04/01/25 through 06/17/25 had no orders for the 1800 ml fluid restrictions. The DON stated the orders were entered incorrectly and therefore not carried out resulting in Resident #26 not having weights three times weekly on Monday, Wednesday and Friday and no fluid restriction of 1800ml. A review of the policy titled; Weight Management Program and Weight Loss Policy, revised 11/29/24, revealed all residents will be weighed monthly and as ordered. The policy further revealed weights will be reviewed by the dietitian and designated nurse monthly and as needed. The DON or designee will maintain a list of residents in the weekly weight program and the dietitian weekly reports. The DON or designee will review the dashboard for high-risk weight changes progress notes daily and address accordingly. The dietitian will review all residents' monthly weight reports during the weight committee meeting. Any issues or trends in resident weights will be discussed and documented. The interdisciplinary team will meet weekly to discuss all resident weight issues, including dietitian recommendations. The team will ensure all recommendations have been implemented. A review of the policy titled; Nutrition/Hydration, revised 06/17/25, revealed a resident's diet will be recorded on the physician orders and dietary communication form to the kitchen. Any changes must be reflected in a physician order and written communication to the dietary department. The policy further revealed upon admission the residents baseline weight and height will be obtained and recorded in point click care period new residents and readmitted residents will be weighed weekly for four weeks. Weekly weights may be continued according to the recommendation of the dietician. Nutritional meetings will be held weekly with the dietitian. All recommendations will be communicated as soon as possible to the physician and new orders will be implemented. The policy also stated all residents will be reviewed at least quarterly by the facility dietitian and more often as needed based on skin changes, changing condition, changing intakes, weight concerns or other clinical changes. Recommendations may be generated and will be communicated as soon as possible to the physician and new orders will be implemented. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365855 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 365855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 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 0692 Level of Harm - Minimal harm or potential for actual harm A review of the policy titled Policies and Procedures Manual Policy/Procedure Dietary, dated 01/22/25, revealed the purpose of the policy is to manage fluid overload in the body, particularly when there is an issue with the heart, kidney or liver. The procedure to divide fluids was stated as follows: • Residents Affected - Few Count the number of medication passes the resident has. • Decide the least amount of fluid the resident needs at each medication pass. If possible try to use only 120 ml at each medication pass. • Add the milliliters from each medication pass to get the total amount of fluid allotted to nursing. • Subtract the amount of nursing milliliters from the total fluid restriction amount to get the amount dietary can use for meals. • Notify the dietary department of the amount of fluid allotted for meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365855 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 365855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and facility policy review, the facility failed to ensure respiratory equipment was dated and monitored for routine replacement. This affected two (Residents #41 and #48) of four residents reviewed for respiratory care but had the potential to affect an additional 10 (Residents #2, #7, #9, #12, #20, #33, #34, #43, #157, and #158) the facility identified as using oxygen. The facility census was 56. Residents Affected - Few Findings include: 1. Review of Resident #41's medical record revealed an admission date of 01/29/25 with diagnoses including pneumonia, atrial fibrillation (irregular heart rhythm), anxiety disorder, vascular dementia, acidosis (too much acid in the body fluids), bradycardia (heart beats more slowly than expected), atherosclerotic heart disease, hypertension (high blood pressure), right bundle branch block (an obstacle in the right bundle branch of the heart that makes the heartbeat late and creates an irregular heart beat), and old myocardial infarction (heart attack). Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was severely impaired cognitively, was dependent on staff for all activities of daily living (ADL) and mobility, was under Hospice services, and used oxygen. Review of Resident #41's physician orders dated 06/06/25 revealed an order for oxygen at three liters via nasal cannula and may titrate to maintain SPO2 (blood oxygen level) greater than 90 percent and an order to change oxygen tubing every week and PRN (as needed). Observation on 06/16/25 at 9:38 A.M. revealed Resident #41's oxygen tubing was not dated. Observation on 06/16/25 at 9:53 A.M. of Resident #41's oxygen tubing and interview with Assistant Director of Nursing Registered Nurse (ADON/RN) #265 revealed ADON/RN #265 confirmed no date was present and should have been dated when oxygen tubing was changed. ADON/RN #265 stated he was just getting ready to go around and date the oxygen tubing. Observation of ADON/RN #265 at time of interview revealed he had a roll of white surgical tape and black marker in hand. 2. Review of Resident #48's medical record revealed an admission date of 06/01/25 with diagnoses including atherosclerotic heart disease, cerebral ischemia (a condition that occurs when there isn't enough blood flow to the brain), chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and dependence on supplemental oxygen. Review of the admission MDS assessment revealed Resident #48 was moderately impaired cognitively, required substantial/maximum assistance from staff for toileting hygiene, bathing, and to transfer from bed/chair to chair, and used oxygen. Review of Resident #48's physician orders dated 06/02/25 revealed an order for continuous oxygen at two liters per minute and an order to change the nasal canula every Thursday. Observation on 06/16/25 at 8:44 A.M. revealed Resident #48's oxygen tubing was not dated. Interview on 06/16/25 at 9:31 A.M. with Registered Nurse (RN) #220 revealed oxygen tubing was to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365855 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 365855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete changed weekly during the night shift, and the tubing should be dated when changed. Observation of Resident #48's oxygen tubing at the time of interview with RN #220 revealed RN #220 confirmed no date was present and should have been dated when the oxygen tubing was changed. Review of the facility policy Oxygen Therapy, revised 08/07/14, revealed oxygen tubing must be dated/initialed and changed weekly. Event ID: Facility ID: 365855 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 365855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and facility policy review, the facility failed to ensure pharmacy recommendations were reviewed and responded to timely by the physician and/or practitioner. This affected two (Residents #17 and #20) of five residents reviewed for unnecessary medications. The facility census was 56. Findings include: 1. Record review revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including acute kidney failure, chronic atrial fibrillation, type two diabetes, hypertension, peripheral vascular disease, lymphedema, benign prostatic hyperplasia, osteoarthritis, hypothyroid, hypomagnesemia, ulcerative colitis, post traumatic disorder, metabolic encephalopathy, major depressive disorder, heart failure, and dementia. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #17 had intact cognition and was receiving antidepressant medication, anticoagulant medication, diuretic medication, antiplatelet medication and hypoglycemic medication during the assessment period. Review of the medication orders revealed on 03/29/25 Resident #17 received an order to administer Remeron oral tablet 15 milligram (mg) (antidepressant) one time a day for sleep. Review of facility document titled Note to Attending Physician/Prescriber dated 04/27/25 revealed a pharmacy recommendation made to the physician to clarify the supporting diagnosis for the medication Aricept so that nursing could update the orders in Point Click Care (PCC), the electronic medical record (EMR). Further review of the physician/prescriber response revealed a prescriber agreed with and wrote changed diagnosis to dementia. A prescriber signature and date were missing from the response. Review of Resident #17 medication records, treatment records, progress notes, physician response documentation and physician orders revealed there was no documentation of a response from the physician to the pharmacy of facility staff regarding the recommendations made by pharmacy on 04/27/25 and 05/29/25. Review of facility document titled Note to Attending Physician/Prescriber dated 05/29/25 revealed the pharmacy stated hypnotic drug have a Gradual Dose Reduction (GDR) attempt quarterly when used routinely. The pharmacy requested an attempt for a dose reduction or trial as needed use to verify the resident was on the lowest possible dose. The pharmacy also stated if a GDR was not appropriate at this time, please document a clinical rational for continuing therapy. Further review of the undated Physician/Prescriber Response revealed a note that Resident #17 would be seen by psych team on next scheduled visit 06/26/25. The document was not signed or dated by the practitioner. Review of Resident #17 medication orders revealed an updated order on 06/17/25 for Aricept oral tablet five mg (improves mental function) one tablet by mouth daily. 2. Record review for Resident #20 revealed the resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia, chronic obstructive pulmonary disease, protein calorie (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365855 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 365855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 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 0756 Level of Harm - Minimal harm or potential for actual harm malnutrition, hypertension, insomnia, chronic pain syndrome, anxiety, atrial fibrillation, hypotension, syncope, hyperlipidemia, Vitamin D deficiency, Vitamin B12 deficiency, history of falling, changes in retinal vascular appearance, drug induced constipation, major depressive disorder, other symptoms and signs concerning food and fluid intake, gastro esophageal reflux, pain in hand, partial intestinal obstruction, muscle weakness, abnormal posture, abnormal gait. Residents Affected - Few Review of the quarterly MDS assessment dated [DATE] revealed Resident #20 had moderately impaired cognition. The resident received antidepressant medication and anticoagulation medication during the seven-day assessment reference period. Review of the physician orders revealed on 11/25/24 Resident #20 was ordered to receive Reglan oral tablet five mg (antiemetic). (Reglan has a black box warning for the serious side effect of tardive dyskinesia, which is a potentially irreversible movement disorder). Review of the facility document the pharmacy monthly medication review dated 04/27/25 for Resident #20 revealed the pharmacy recommended Abnormal Involuntary Movement Scale (AIMS) testing completed upon initiation of Reglan and every six months thereafter. The pharmacy wrote at the time of the review that an AIMS test was not available in PCC and suggested nursing complete an AIMS test at their earliest convenience. It was noted that a boxed warning for Reglan chronic or high dose use had been linked to tardive dyskinesia which continues even after discontinuation of the drug. Those at greatest risk were the elderly and recommended Reglan treatment not to exceed three months. Further review of the document revealed the physician/prescriber did not respond, sign or date the recommendation but a written statement from the Director of Nursing (DON) dated 06/17/25 revealed an AIMS test was performed on 06/17/25. Further review of the medical records for Resident #20 including progress notes, medication orders, and physician progress notes revealed no evidence the physician responded to the pharmacy recommendation dated 04/27/25. Interview on 06/18/25 at 8:36 A.M. with the DON revealed the facility utilized Wellness Director #271 to direct all the pharmacy recommendations and GDR to the physician or practitioner through email, or a folder was given to the practitioner to review upon visits to the facility. Wellness Director #217 ensured the pharmacy recommendations were signed and dated by the practitioner. Interview on 06/18/25 at 9:00 A.M with the DON verified there was not a physician signature or date regarding the pharmacy recommendation dated 04/27/25 for a supporting diagnosis of dementia, additionally the DON verified a practitioner did not sign or date they received the pharmacy recommendation dated 05/29/25 for Resident #17 GDR recommendation. The DON verified she wrote the response Resident #17 would be seen by the psych team on the next scheduled visit with her signature. Lastly, the DON verified the practitioner did not sign or date that they received the pharmacy recommendation dated 04/27/24 regarding Resident #20's recommendation for an AIMS test and the boxed warning regarding long term use of Reglan. The DON verified she wrote an AIMS test was done 06/17/25, and the nurse practitioner assessed Resident #20 on 04/11/25 and 06/04/25. Interview on 06/18/25 at 9:07 A.M. with Wellness Director #271 revealed her responsibility was to email the pharmacy recommendations to the DON and to put the recommendation in a folder to be provided to the practitioner upon their visits to review and sign. Wellness Director #271 stated she did not know why the recommendations for Resident #17 and Resident #20 were missed and not addressed until 06/17/25. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365855 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 365855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 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 0756 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Documentation and Communication of Consultant Pharmacist Recommendation, dated 07/01/21, revealed the consultant pharmacist worked with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapies were communicated to those with authority or responsibility to implement the recommendations , and were responded to in an appropriate timely fashion. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365855 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 365855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to ensure medications had the appropriate diagnosis for administration. This affected one (Resident #28) out of five residents reviewed for unnecessary medications. The facility census was 56. Residents Affected - Few Findings include: Review of the medical record for Resident #28 revealed an admission date of 11/21/22. Diagnoses included Parkinson's disease, delusions, kidney disease, diabetes, paranoid schizophrenia and high cholesterol. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact. He required set up help for eating and personal hygiene, supervision for oral hygiene and toileting and partial assistance for showering. Review of the gradual dose reduction (GDR) form dated 02/28/25 revealed a recommendation by Pharmacist #268 to clarify the diagnosis for Namenda, which had been prescribed for paranoid schizophrenia. The recommendation was made to correct the diagnosis to dementia, which was signed by Nurse Practitioner #269 on 03/05/25. Review of the physician's orders for June 2024 revealed an order for Namenda (used to treat dementia) five milligrams (mg) by mouth two times per day for paranoid schizophrenia. Interview on 06/18/25 at 9:15 A.M. with Licensed Practical Nurse (LPN) #271 confirmed Resident #28 was prescribed Namenda and did not have the appropriate diagnosis for the medication. Review of the facility policy titled Consultant Pharmacist Reports, dated 07/01/21, revealed pharmacy recommendations would be acted upon and documented by the facility staff and/or prescriber. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365855 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 365855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, the facility to ensure Turbersol serum was dated upon opening per manufacturers instruction for efficacy. This had the potential to affect 15 (Residents #15, #19, #21, #51, #52, #106, #107, #156, #157, #206, #207, #208, #209, #256 and #257) identified as new admissions on the 100 unit in the last 30 days. The facility also did not ensure pills were not left at the bedside for Resident #35. This had the potential to affect seven (Residents #11, #24, #43, #106, #157, #208, and #257) who were identified as cognitively impaired and independently mobile on the 100 unit. The facility census was 56. Findings include: 1. On 06/16/25 at 8:20 A.M. an inspection of the medication storage room on the 100 unit revealed a one milliliter vial of Turbersol (a serum used to aid in the diagnosis of tuberculosis) that was opened and undated. The Director of Nursing (DON) verified the opened vial of Tubersol as being undated at the time of the observation. A review of the package inserts for Tubersol revealed a vial of Tubersol which has been opened and in use for 30 days should be discarded. A review of the facility policy titled; Medication Storage in the Facility, dated of 07/01/21, revealed medications and biologicals are stored safely, securely and properly following manufacturers recommendations. The policy further stated certain medications, once opened, require an expiration date shorter than the manufacturers expiration date to ensure medication purity and potency. When the original seal of a manufacturer's container or vial is initially broken, the container or vial shall be dated. 2. A review of medical records for Resident #35 revealed a date of admission of 08/27/24. Significant diagnosis included personal history of malignant melanoma. A review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS of 15 (cognitively intact). A review of a care plan dated 05/05/25 revealed Resident #15 could keep artificial tears at bedside for self-administration. The care plan did not include antibiotic medication to be left at the bedside for self-administration. The care plan also revealed Resident #35 to have inappropriate behaviors at times related to refusal of medications. Interventions included to administer medications as ordered. A review of assessments within the medical record did not reveal a completed self-medication administration assessment (an assessment completed to ensure a resident can safely self-administer medications). Review of the physician's orders for Resident #15 included an order dated 06/12/25 for Cephalexin (an antibiotic used for infection) 500 milligrams (mg), give one by mouth one time a day for infection for seven days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365855 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 365855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the medication administration record (MAR) for June 2025 the Cephalexin was signed off as administered at bedtime on 06/15/25. On 06/16/25 at 8:52 A.M. an observation of the bedside table for Resident #35 revealed a pink capsule in a medication cup. Resident #35 stated they got the pill last night and did not take it as she thought she was to take it in the morning. An interview with Registered Nurse (RN) #239 at the time of the observation revealed the capsule to be the Cephalexin. Resident #35 stated the capsule was given last night, and she did not take it as she thought it was to be taken in the morning. RN #239 then instructed Resident #35 that the Cephalexin was ordered once a day at bedtime. RN #239 removed the pink capsule from the room. On 06/16/25 at 3:32 P.M. an interview with the Director of Nursing (DON) verified the lack of a self-administration assessment within the medical record of Resident #35. There were seven (Residents #11, #24, #43, #106, #157, #208, and #257) who were identified as cognitively impaired and independently mobile on the 100 unit. A review of the facility policy titled; Specific Medication Administration Procedures, dated 07/01/21, revealed once removed from the package or container, unused or partial doses of medication should be disposed of in accordance with the medication destruction policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365855 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 365855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interviews and facility policy review, the facility failed to ensure the garbage and refuse was maintained in a sanitary condition. This had the potential to affect all 56 residents residing in the facility. Residents Affected - Many Findings include: Observation of the facilities outside dumpster area with Dietary Supervisor (DS) #224 on 06/16/25 at 7:26 A.M. revealed there were two dumpsters in the area. The dumpster on the right-hand side had both lids closed on top and both sliding doors on each side were closed. The dumpster on the left side had both lids closed and the sliding door on the right side of the unit was closed. On the left side of the dumpster, there was an opening in the dumpster where the sliding door should have been with the black sliding door located on the ground under the back left-hand corner of the dumpster. Located on the ground around the dumpsters was a buildup of debris which included five white plastic surgical gloves, one clear plastic cup, one empty pudding cup container, two medicine cups, multiple pieces of plastic wrap of various sizes, one brown cardboard box approximately 12 inches wide by nine inches tall and two-inches deep which was labeled fabric softener sheets, three blue surgical gloves, one straw, and numerous plastic spoons. Interview with DS #224 at the time of observation on 06/16/25 verified the above findings. Interview on 06/17/25 at 5:16 P.M. with Maintenance Supervisor #202 revealed he was made aware of the dumpster situation when he got to work on 06/16/25. He stated the door to the dumpster would slide off and people didn't want to pick up the door on the ground after it had slid off the dumpster. He confirmed the area had debris which he helped clean up, and it was the responsibility of the maintenance and housekeeping departments to keep the dumpster area clean. Review of the facility policy Trash/Dumpster Receptacle, dated 08/27/19, revealed all trash dumpsters and receptacles would be kept covered at all times. Employees who took trash and garbage to dumpsters were to close the lids after refuse was deposited, and trash was not to be deposited on the ground for any reason. If for any reason the receptacle lids could not be closed, maintenance would be notified right away for assistance, and maintenance would notify the trash pickup vendor if any problems occurred which impeded the facility's ability to store trash. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365855 If continuation sheet Page 17 of 17