Inspection·January 30, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 04/17/24 at 9:45 A.M. of Resident #26's wound care, rendered by LPN #304 revealed LPN #304 did not use a clean field when she placed the wound care supplies, including an extra pair of gloves, onto Resident #26's bed with no bag or container in the vicinity to discard the old dressing or soiled supplies. The old dressing LPN #304 removed from Resident #26's wound was dated 04/15/24 (two days prior to the observation). LPN #304 was observed changing her gloves between removal of the old dressing and performance of wound care, but no hand hygiene was performed between glove changes. Once the dressing change was completed, LPN #304 removed the used supplies from the bed with her right hand, removed her right glove from the inside out to cover the bottom half of the used supplies, then handed the glove with half of the used supplies hanging out to Resident #26 to dispose of. At this time, normal saline solution was noted squirting out of the saline bullet from inside the used glove onto Resident #26's bed as he disposed of soiled dressing supplies into the trash can at the head of his bed, where the soiled dressing and supplies remained. Interview with LPN #304 at the time of the wound care observation (04/17/24 at 9:45 A.M.) confirmed the dressing she removed was dated 04/15/24. A follow-up interview on 04/17/24 at 9:55 A.M. with LPN #304 confirmed she did not set up a clean field for the dressing supplies, did not use a barrier to protect Resident #26's bedding, did not have a bag or trash receptacle nearby for disposal of soiled dressing and supplies, and did not perform hand hygiene between glove changes. LPN #304 said she typically did not use anything to lay underneath the gathered dressing supplies to use as a clean field. During the interview, LPN #304 confirmed nurses who completed the dressing changes should sign-off the dressing change had been completed on the MAR or TAR and that refusals should be documented as well. Interview with Resident #26 on 04/17/24 at 11:45 A.M. revealed he was supposed to get daily dressing changes, but the nurses did not always complete the dressing changes daily. Resident #26 said he was getting his dressing changed every morning at approximately 5:00 A.M., but lately they have been missing it. Resident #26 went two to three days in a row without a dressing change at least once in the past month and other days here and there, also indicating some agency staff on night shift did not attempt to change his dressing and then it just did not get done at any point that day because nobody checked or asked him. Resident #26 confirmed his dressing was not changed one other day this week but could not confirm which day. He further confirmed the dressing change observed at 9:45 A.M. was the only time his dressing was changed on this date (04/17/24). An interview with LPN #304 on 04/17/24 at 10:25 A.M. confirmed Resident #26's wound care was signed-off on 04/16/24 and 04/17/24 on the TAR although the dressing she removed on this date was dated 04/15/24. LPN #304 further confirmed if a resident refused treatment, the nurse was responsible for indicating the refusal on the TAR by using codes 2 for refused or a 9 for other/see nurses notes but the TAR did not contain any such documentation for the dates of 04/03/24, 04/07/24, 04/08/24, or 04/09/24. Interview on 04/17/24 at 1:25 P.M. with the Director of Nursing (DON) confirmed documentation of wound care orders should be charted on the MAR or TAR and nurses should document if the resident refused medications or treatments. Further interview confirmed no documentation was present on the TAR or in the progress notes that wound care was provided to Resident #26 on 03/29/24, 03/30/24, 04/07/24, 04/08/24, and 04/09/24, or that he refused wound care on these dates. Review of an email from LPN #392 confirmed she signed that Resident #25 received wound care on 04/16/24, but she had not performed the ordered dressing change. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365859 If continuation sheet Page 2 of 11 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 365859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Merriman 209 Merriman Rd Akron, OH 44303 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 Review of the policy last reviewed August 2023 titled Wound Care revealed the following: Level of Harm - Minimal harm or potential for actual harm Step one in the wound care procedure required use of a disposable cloth or paper towel to establish a clean field on the resident's overbed table where all dressing supplies should be placed prior to completing the ordered wound care. Residents Affected - Few Step three required staff to place a disposable cloth under the wound or next to the resident to serve as a barrier to protect the bed linen and other body sites. Gloves were to be changed after removal of the old dressing, then hands should be washed and dried thoroughly before donning new gloves to clean the wound and apply the ordered treatment and dressing. Disposable items were to be disposed of in a designated container. Treatments were to be documented in the medical record. Refusals and reason for refusal should be documented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365859 If continuation sheet Page 3 of 11 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 365859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Merriman 209 Merriman Rd Akron, OH 44303 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure Resident #44's pressure ulcer wound care was completed as ordered and failed to ensure the accuracy of Resident #44's medical record. This finding affected one (Resident #44) of one resident reviewed for pressure wounds. Residents Affected - Few Findings include: Review of Resident #44's medical record revealed the resident was admitted on [DATE] with diagnoses including essential hypertension, chronic kidney disease and hypothyroidism. Resident #44 was admitted with a stage four pressure wound (wound which extends below the subcutaneous fat into deep tissues, including muscle, tendons, and ligaments) to the coccyx (gluteal cleft) identified as full thickness and a unstageable (unable to stage pressure wound due to necrosis) pressure wound of the right, upper buttock identified as full thickness. Review of Resident #44's Clinical admission form dated 01/19/24 revealed the resident had a buttocks (generalized) pressure wound which measured 2 centimeters (cm) length by 4 cm width by 0.8 cm depth and a right buttock deep tissue injury (DTI) which measured 8 cm by 5 cm. Review of Resident #44's physician orders revealed an order dated 01/19/24 (discontinued 01/30/24) to cleanse the sacrum wound, pat dry, apply calcium alginate and cover with a foam dressing. Per staff, this order applied to both the right hip and coccyx. Review of Resident #44's medication administration records (MARS) and treatment administration records (TARS) from 01/19/24 to 01/30/24 revealed the wound care was completed as ordered. Review of Resident #44's Initial Wound Evaluation and Management Summary form dated 01/24/24 revealed the resident had a stage four pressure wound to the coccyx (full thickness) measuring 4.6 centimeters (cm) length by 1.5 cm width by 1.0 cm depth with 90% (percent) slough and 10% granulation tissue. The wound was debrided on this date. The form indicated the Dressing Treatment Plan included to apply quarter strength Dakins-moistened gauze to the wound bed and a gauze island with border dressing twice daily for thirty days. Apply zinc ointment to the peri wound twice daily for 30 days. Review of Resident #44's Initial Wound Evaluation and Management Summary form dated 01/24/24 revealed an unstageable pressure wound of the right, upper buttock (full thickness) measuring 7.8 cm length by 5.4 cm width by 0.1 cm depth. The wound was debrided on this date. The form indicated the Dressing Treatment Plan included to apply quarter strength Dakins-moistened gauze to the wound bed and a gauze island dressing with border twice daily for thirty days. Apply zinc ointment to the peri wound twice daily for 30 days. Review of Resident #44's physician orders revealed an order dated 01/24/24 to current was to cleanse the right upper buttock with Dakins, apply Dakins moistened gauze, apply zinc to the peri-wound, cover with a dry border dressing and an order dated 01/24/24 to cleanse the coccyx with Dakins, apply Dakins moistened gauze, apply zinc to the peri-wound, cover with a dry border dressing. Review of Resident #44's progress note dated 01/29/24 at 5:23 A.M. authored by Licensed Practical Nurse (LPN) #805 indicated the wound care was done on the coccyx, cleansed with Dakins, apply moistened gauze, apply zinc to the peri-wound, cover with a border dressing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365859 If continuation sheet Page 4 of 11 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 365859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Merriman 209 Merriman Rd Akron, OH 44303 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 01/29/24 at 6:40 A.M. with LPN #805 and State Tested Nursing Assistant (STNA) #804 of Resident #44's pressure ulcer wound care revealed the staff rolled the resident to the right side and removed the resident's incontinence brief. LPN #805 removed the dressing to the right upper buttock pressure wound (no dressing was observed on the coccyx), removed her gloves and washed her hands. LPN #805 put on new gloves, cleansed the right upper buttock and coccyx with half strength Dakins solution and replaced a foam dressing to the right hip. LPN #805 did not place a dressing on the coccyx and did not change her gloves between cleansing the right upper buttock pressure wound and the coccyx pressure wound. LPN #805 did not apply zinc oxide cream to the peri wound areas of the right hip or the coccyx pressure wounds. The incontinence brief was replaced and the staff left the room. Interview on 01/29/24 at 6:50 A.M. with LPN #805 confirmed Resident #44 did not have a pressure wound dressing to the coccyx upon first examination of the resident's sacral wounds. LPN #805 confirmed she did not apply the dressing to the right upper buttock pressure wound as ordered because the facility did not have quarter strength Dakins solution, did not have the zinc oxide cream for the peri wound and did not have the right foam dressing to cover the resident's right upper buttock pressure wound. LPN #805 also confirmed she did not place a dressing to the coccyx pressure wound because she could not find the correct dressing for the coccyx wound. She also confirmed she did not place zinc oxide cream to the peri wound of the coccyx as ordered. Interview on 01/29/24 at 9:37 A.M. with LPN Wound Nurse #810 indicated the facility had the supplies but the nursing staff do not go to the central supply room in the basement for the supplies. Interview on 01/30/24 at 10:59 A.M. with LPN #806 confirmed she placed new orders for Resident #44's right upper hip/buttock pressure wound and coccyx pressure wound on 01/24/24 and staff were signing off both the order for the calcium alginate order from 01/24/24 to 01/30/24 in error which should have been discontinued. She confirmed Resident #44's current physician orders was for the Dakins solution to the coccyx and right hip/buttock area. Interview on 01/30/24 at 11:48 a.m. with LPN Minimum Data Set (MDS) #820 confirmed Resident #44 had both the coccyx and right upper hip/buttocks wounds upon admission which did not deteriorate and remained at the same staging and size. Review of the Wound Care policy reviewed 08/23 indicated the purpose of the procedure was to provide guidelines for the care of wounds to promote healing and stated to verify the physician's order for the procedure and gather the equipment and supplies as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365859 If continuation sheet Page 5 of 11 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 365859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Merriman 209 Merriman Rd Akron, OH 44303 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review and interviews, the facility failed to ensure registered nurse coverage at least eight hours per day, seven days per week. This finding had the potential to affect all 54 residents residing in the facility. Findings include: Review of the staffing schedules from 12/24/23 to 12/30/23 with Human Resources (HR) #811 revealed no evidence of registered nurse (RN) coverage on 12/25/23 for at least eight hours as required. Interview on 01/29/24 at 10:07 A.M. with HR #811 confirmed the facility did not have RN coverage of at least eight hours on 12/25/23. This deficiency represents non-compliance investigated under Complaint Number OH00149612. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365859 If continuation sheet Page 6 of 11 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 365859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Merriman 209 Merriman Rd Akron, OH 44303 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. Based on interview, medical record review, and policy review the facility failed to ensure a complete and accurate medical record for one resident (#43) of three residents reviewed for wound care. The facility census was 49. Findings include: Review of the medical record for Resident #43 revealed an admission date of 01/19/24 with diagnoses including metabolic encephalopathy, moderate protein-calorie malnutrition, stage three chronic kidney disease, type two diabetes mellitus, stage four pressure ulcer of sacral region, unstageable pressure ulcer of right buttock, pressure-induced deep tissue damage of other site, unstageable pressure ulcer of other site, and pressure-induced deep tissue damage of left heel. Review of the Minimum Data Set (MDS) assessment completed on 03/08/24 revealed Resident #43 had intact cognition and the presence of one stage four and two unstageable pressure ulcers, which were present on admission to the facility. Review of physician orders revealed Resident #43 had the following wound care orders to his right upper buttock: From 01/30/24 to 02/05/24 cleanse with ¼ strength Dakins, use clean gauze moistened with Dakins and apply to wound bed, leaving gauze in place (do not remove), apply zinc to peri-wound, cover with dry border dressing twice daily. May use ½ strength Dakins as a substitute. From 02/05/24 to 02/28/24 cleanse with ¼ strength Dakins, use clean gauze moistened with Dakins and apply to wound bed, leaving gauze in place (do not remove), apply zinc to peri-wound, and cover with super absorbent gel dressing twice a day. May use ½ strength Dakins as a substitute. From 02/28/24 to 03/06/24 cleanse with ¼ strength Dakins, pack loosely with one large piece of Alginate calcium with silver, apply zinc to peri-wound, and cover with super absorbent gel dressing twice a day. May use ½ strength Dakins for substitute. From 03/06/24 to 03/14/24 cleanse with ¼ strength Dakins, pack loosely with a collagen sheet, then pack loosely with one large piece of Alginate calcium with silver, apply zinc to peri-wound, and cover with super absorbent gel dressing once a day. May use ½ strength Dakins for substitute. Beginning 03/14/24 cleanse with 1/4 strength Dakins solution, pack loosely with one large piece of alginate calcium with silver, then pack loosely with collagen sheet, apply zinc to peri-wound, and cover with super absorbent gel dressing once daily. May use ½ strength Dakins as a substitute. Review of physician orders revealed from 01/25/24 to 02/05/24 Resident #43 had an order to cleanse the right knee with normal saline (NS), apply Betadine, and cover with a dry border dressing one time a day. Review of physician orders revealed from 01/24/24 to 03/14/24 Resident #43 had an order to apply (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365859 If continuation sheet Page 7 of 11 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 365859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Merriman 209 Merriman Rd Akron, OH 44303 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 Skin prep daily, once a day to right posterior scalp. Level of Harm - Minimal harm or potential for actual harm Review of physician orders revealed from 01/25/24 to 03/14/24 Resident #43 had an order to cleanse left toes and left heel with NS, apply Betadine, cover with abdominal (ABD) pad, and wrap with Kerlix once daily. Residents Affected - Few Review of physician orders revealed beginning 03/26/24 Resident #43 had an order to cleanse left firs toe with NS, apply Betadine, and cover with bordered gauze every night shift for wound treatment. Review of physician orders revealed Resident #43 had the following wound care orders to his left heel: From 03/07/24 to 03/25/24 cleanse with NS, apply Betadine, ABD pad, and Kerlix. once a day. From 03/14/24 to 04/10/24 cleanse with NS, apply sodium hypochlorite gel (if not available, use Betadine), cover with ABD, and wrap with Kerlix once a day. Beginning 04/10/24 cleanse with NS, apply Betadine, cover with an ABD pad, and wrap with Kerlix one time a day. Review of physician orders revealed Resident #43 had the following wound care orders to his coccyx: From 01/30/24 to 02/05/24, between gluteal folds use clean gauze moistened with Dakins ½ strength solution and apply to wound bed, leaving the Dakin's-soaked gauze in place (do not remove), apply zinc to peri-wound, and cover with a dry border dressing twice a day. From 02/0/24 to 02/07/24, between gluteal folds use clean gauze moistened with Dakins ½ strength solution and apply to wound bed, leaving the Dakin's-soaked gauze in place (do not remove), apply zinc to peri-wound, and cover with super absorbent gel dressing two times a day. From 02/07/24 to 03/06/24, between gluteal folds cleanse with Dakins ½ strength, apply alginate calcium silver to wound bed, leave in place (do not remove), apply zinc to peri-wound, and cover with super absorbent gel dressing. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for February 2024 revealed there was no documentation of the following wound care treatments for the following wounds on the following dates: Right upper buttock- missing documentation for ordered treatments on 02/02/24, 02/15/24, 02/16/24, 02/17/24, 02/22/24, 02/23/24 (morning treatments), and 02/29/24 (both treatments). Right knee- missing documentation for ordered treatment on 02/02/24. Right posterior scalp- missing documentation for ordered treatment on 02/08/24. Left toes and left heel- missing documentation for ordered treatments on 02/02/24, 02/15/24, 02/16/24, 02/17/24, 02/22/24, and 02/23/24. Left first toe- missing documentation for ordered treatment on 02/29/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365859 If continuation sheet Page 8 of 11 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 365859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Merriman 209 Merriman Rd Akron, OH 44303 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 Coccyx- missing documentation for ordered treatments scheduled the mornings of 02/15/24, 02/15/24, 02/16/24, 02/22/24, 02/23/24, and 02/29/24, and the scheduled evening treatment on 02/29/24. Review of the progress notes revealed no documentation on 02/02/24, 02/08/24, 02/15/24, 02/16/24, 02/17/24, 02/22/24, 02/23/24, or 02/29/24 regarding Resident #43's wound care. Residents Affected - Few Review of the MAR and the TAR for March 2024 revealed there was no documentation of the following wound care treatments for the following wounds on the following dates: Right upper buttock- missing documentation for ordered treatment on 03/30/24. Right posterior scalp- missing documentation for ordered treatment on 03/01/24, 03/04/24, and 03/05/24. Left great toe- missing documentation for ordered treatment on 03/03/24. Left heel- missing documentation for ordered treatment on 03/11/24. Review of the progress notes revealed no documentation on 03/01/24, 03/03/24, 03/04/24, 03/05/24, 03/11/24, or 03/30/24 regarding Resident #43's wound care. Review of the MAR and TAR for March 2024 revealed there was no documentation of the following wound care treatments for the following wounds on the following dates: Right upper buttock- missing documentation for ordered treatments on 04/05/24 and 04/09/24. Right posterior scalp- missing documentation for ordered treatments on 04/01/24, 04/05/24, 04/08/24, 04/09/24, 04/12/24, and 04/13/24. Left great toe- missing documentation for ordered treatments on 04/01/24, 04/05/24, 04/08/24, 04/12/24, and 04/13/24. Left heel- missing documentation for ordered treatment on 04/01/24, 04/04/24, 04/05/24, 04/08/24, 04/09/24, 04/12/24, and 04/13/24. Review of the progress notes revealed no documentation on 04/01/24, 04/04/24, 04/05/24, 04/08/24, 04/09/24, 04/12/24, or 04/13/24 regarding Resident #43's wound care. Interview on 04/17/24 at 9:45 A.M. with Licensed Practical Nurse #304 revealed nurses who completed wound care and treatments were to sign-off the care and treatments were completed on the MAR or TAR. Resident refusal of wound care was to be documented on the MAR or TAR and in the progress notes. Interview on 04/17/24 at 1:25 P.M. with the Director of Nursing confirmed completed wound care should be documented on the MAR or TAR and nurses should document if the resident refused medications or treatments. Review of the policy last reviewed in August 2023 titled Wound Care revealed treatments were to be documented in the medical record. Refusals and the reason for refusal were also to be documented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365859 If continuation sheet Page 9 of 11 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 365859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Merriman 209 Merriman Rd Akron, OH 44303 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 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and staff interview, the facility failed to ensure their Quality Assurance and Performance Improvement (QAPI) program committee thoroughly evaluated, identified areas in need of improvement, and data related to the issues was being monitored to determine if the plan of correction was being implemented as written and corrections were being sustained, and to determine if revisions were necessary. This had the potential to affect eight residents (Residents #3, #18, #22, #23, #26, #28, #43, and #48) who were receiving wound care treatments. The facility census was 49. Residents Affected - Some Findings include: Review of the facility's survey tracking history revealed the facility had a complaint survey completed on 01/30/24 which resulted in concerns wound care was not being completed as ordered for one resident with a pressure ulcer and inaccuracy of the medical record in relation to the wound care documentation. Review of the facility's written plan of correction (POC) revealed the facility had an approved plan in place, including: Wound care education to facility nurses on 01/29/24 by the Director of Nursing (DON). The wound care doctor that rounded at the facility provided an educational video for facility nurses. The DON or designee was to audit all residents with pressure wounds twice a week for four weeks through observation and chart review to ensure accurate wound care and documentation. Review of the written wound care education and in-service log for wound care training completed by the DON on 01/29/24 revealed a total of six licensed nurses and one maintenance staff member attended the wound care training. Review of the current nursing staff roster revealed a total of 12 licensed practical nurses (LPNs), including the assistant director of nursing (ADON) and the Minimum Data Set (MDS) Coordinator and five registered nurses (RNs) were employed by the facility. Additionally, the Admissions Director and the Staffing Coordinator were also LPNs. Interview on 04/18/24 at 12:25 P.M. with the DON confirmed the in-service log contained all the signatures of nurses who attended the wound care training and that the training consisted of review of the following three policies: Wound Care, last reviewed 08/21; Pressure Injury risk Assessment, last reviewed 08/2021; and Pressure Injury Treatment, undated. There was no mention of a video and no documentation of a wound care educational video in the binder that contained evidence of the facility's implementation of their POC. Review of the audit tracking forms to ensure the facility completed audits of all residents with pressure wounds twice a week for four weeks through observation and chart review revealed the facility failed to complete wound audits more than once a week and failed to review residents with pressure wounds during week three of the audits. Interview on 04/18/24 at 12:25 P.M. with the DON revealed wound audits were conducted by LPN #304 so she could not speak to how the audits were conducted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365859 If continuation sheet Page 10 of 11 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 365859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Merriman 209 Merriman Rd Akron, OH 44303 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 0865 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 04/18/24 at 1:20 P.M. with LPN #304 revealed she completed an audit on one resident on Wednesdays and one resident on Thursdays, instead of all residents with pressure injuries twice a week. She further confirmed the audits completed in week three were on residents with non-pressure injuries. During the interview, LPN #304 admitted she misunderstood what she was required to do as part of the facility's POC related to wound audits. LPN #304 further confirmed the audits did not capture missing documentation on the medication administration record (MAR) or the treatment administration record (TAR) during week two and week four audits of Resident #43's wound care. Interview with the Administrator on 04/18/24 at 12:35 P.M. revealed the facility held monthly QAPI meetings and the medical director was expected to attend quarterly. The Administrator revealed the last meeting was held on 03/29/24 with the interdisciplinary team and the medical director was not in attendance for that meeting. The Administrator said the team reviewed the facility's progress with audits related to open surveys exited on 01/30/24 and 03/14/24. Regarding wound care audits and wound care training, the Administrator revealed LPN #304 was tasked with completing training and audits. He further stated LPN #304 sent him weekly audits to upload to the Enhanced Information Dissemination Collection (EIDC) system and he trusted that the staff assigned to carry out parts of the POC were doing what they were supposed to be doing and therefore he did not review the information. The Administrator confirmed no problems with the facility's execution of their approved POC were identified during the QAPI meeting held on 03/29/24. Review of the QAPI meeting notes from 03/29/24 revealed no indication any concerns were identified regarding the facility's execution of the written POC. Observations, interviews, medical record reviews, and review of facility policies and procedures on 04/16/24 through 04/18/24 revealed the facility failed to ensure wound care was completed as ordered, treatments provided were rendered according to appropriate standards of care to decrease the risk of infection, and the record accurately reflected care that was provided. Please refer to F684 and F842. Review of the State Operations Manual (SOM), chapter seven, section §7317 titled Acceptable Plan of Correction effective 11-16-18 revealed the facility must develop a plan to monitor their ongoing performance toward compliance and ensure solutions put into place are sustained. Section §7317 also revealed when a plan of correction is approved, it is the facility who is ultimately accountable for managing their own compliance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365859 If continuation sheet Page 11 of 11