Health inspection·February 12, 2020

F 0623 Resident #71 went to the hospital on [DATE] and no written notification of transfer was available for review. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy, Transfer and Discharge Policy reviewed 05/28/19 revealed no guidance regarding providing written notification of transfer to residents. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365862 If continuation sheet Page 2 of 10 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 365862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pines Healthcare Center 3015 17th Street NW Canton, OH 44708 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure care was planned with the input of the resident and responsible party. This affected three residents (#50, #39, and #122) of four reviewed for care planning. The facility census was 71. Findings include: 1. Medical record review revealed Resident #39 was admitted on [DATE] with diagnoses including intellectual disabilities, cognitive communication deficit, cerebral palsy, cerebral infarction (stroke), Alzheimer's dementia, diabetes mellitus, convulsions and depression. An interview with Resident #39's guardian on 02/09/20 at 11:14 A.M. indicated she had contacted the facility by phone to speak to someone about Resident #39's care needs. Resident #39's guardian wanted a list of Resident #39's medications and assistance with making funeral arrangements to be prepared in the event Resident #39's health deteriorated. Resident #39's guardian had left several messages with the facility and had not received a return phone call. Resident #39's guardian indicated she was not contacted by the facility to attend a plan of care conference. A review of resident #39's clinical record indicated the facility had not scheduled a plan of care conference for Resident #39 since 07/26/19. An interview with the Minimum Data Set (MDS) Registered Nurse (RN) on 02/11/20 at 3:22 P.M. verified the facility had not conducted a plan of care conference as required after her quarterly MDS assessment was completed. The MDS RN verified the above findings at the time of the interview. 2. Resident #122 was admitted on [DATE] with diagnoses including respiratory, heart, digestive and liver disease, depression, dementia, anxiety and mild cognitive impairment. An interview with Resident #122's guardian on 02/09/20 at 11:22 A.M. indicated she had contacted the facility by phone to discuss Resident #122's care needs and other issues. Resident #122's guardian indicated she had not received a return phone call and was not asked to attend a plan of care meeting to discuss his care needs. A review of Resident #122's clinical record dated 01/2019 to 02/2020 indicated the facility had not conducted a plan of care conference for Resident #122. An interview with the MDS RN on 02/11/20 at 3:30 P.M. indicated Resident #122 had no evidence in the clinical record a plan of care meeting had been conducted quarterly in the past 12 months. 3. Review of Resident #50's medical record revealed the resident was admitted on [DATE] with diagnoses including cerebral infarction, hemiplegia and hemiparesis, chronic kidney disease, type two diabetes mellitus, and aphasia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was not cognitively intact for making decisions, extensive two person assist with bed mobility, transfers, toileting, and dressing. Resident #50's spouse was responsible party/representative. There was no documentation related to care conference meetings including Resident #50 and/or his authorized representative since the resident's initial admission on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365862 If continuation sheet Page 3 of 10 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 365862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pines Healthcare Center 3015 17th Street NW Canton, OH 44708 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Further review of the medical record revealed the facility performed MDS quarterly assessments on 11/05/20 and 01/28/20. The medical record contained no evidence the resident or spouse were invited to or declined participation in the review of the care plan after the scheduled assessments. Interview on 02/11/20 at 3:22 P.M. with the MDS Coordinator verified no care conferences were completed since Resident #50's initial admission and indicated one should be offered after admission and quarterly. Event ID: Facility ID: 365862 If continuation sheet Page 4 of 10 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 365862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pines Healthcare Center 3015 17th Street NW Canton, OH 44708 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide the restorative program for Resident #30's left hand splint. This affected one out of one resident reviewed for the restorative splint program. Findings include: Medical record review revealed Resident #30 was admitted on [DATE] with diagnoses including hemiplegia, hemiparesis following a cerebral infarction (stroke), cognitive communication deficit, dysphagia, urethral stricture, anemia and inguinal hernia. Review of physician orders revealed an order dated 08/14/19 for a restorative program. The restorative program indicated to apply a left hand splint in the morning, remove in the evening and remove the splint during hygiene care once a shift. Resident #30's plan of care initiated on 10/11/18 indicated Resident #30 required a restorative nursing program related to risk for contractures. The restorative program indicated a left hand splint be donned in the morning, off at night and remove the hand splint for hygiene care once a shift. On 02/10/20 at 4:18 P.M. an observation and interview with Resident #30 indicated the staff rarely assisted him to don his left hand splint. Resident #30 usually asked the staff to assist him with the application of his splint. Resident #30 indicated the splint had not been applied for several days and he had not asked anyone to assist him today. Resident #30 was not wearing his splint at the time of the interview. On 02/10/20 at 4:20 P.M. an interview with State Tested Nursing Assistant (STNA) #55 indicated she was assigned to care for Resident #30 and was unaware of his restorative program to wear a splint on his left hand. STNA #55 indicated she could ask the nurse or the therapy staff about the restorative program. STNA #55 was unaware the restorative program was documented on the STNA [NAME] (A medical information system used by nursing staff as a way to communicate important information on their residents. It is a quick summary of individual resident needs that is updated at every shift change.) in the electronic system the STNAs used to document their care of the residents. STNA #55 verified the splint was not applied to Resident #30's left hand at the time of the interview. An interview with Director of Nursing (DON) on 02/11/20 at 4:55 P.M. verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365862 If continuation sheet Page 5 of 10 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 365862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pines Healthcare Center 3015 17th Street NW Canton, OH 44708 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure fall interventions were communicated to staff and failed to ensure falls were thoroughly investigated to determine the root cause. This affected one resident (Resident #41) of six residents reviewed for falls. The facility census was 71. Findings include: 1. Review of Resident #41's medical record revealed an admission date of 05/12/19 and diagnoses including osteoporosis, heart disease, anemia, dysphagia, moderate protein-calorie malnutrition, dementia with behavioral disturbance, restlessness and agitation and major depressive disorder. Review of a minimum data set (MDS) assessment dated [DATE] revealed Resident #41 was cognitively impaired with a brief interview for mental status (BIMS) score of three, required the extensive assistance of one staff for toileting, extensive assistance of two staff for bed mobility and extensive assistance of one staff for transfers. Resident #41 sustained two or more falls since the previous MDS assessment. Resident #41 was not steady and could only stabilize with staff assistance. a. Review of a care plan for Resident #41 related to falls initiated 05/13/19 and revised 01/31/20 revealed Resident #41 was impulsive, would at times transfer self without assistance and without walker. On 10/29/19 Resident #41 sustained a fracture to her right hip. Listed goals included Resident #41 transferring with staff daily without injury and to be free of falls. Listed interventions included: bed in lowest position while occupied, bilateral bed canes (06/13/19); before exiting room ask if she would like lights on or off (01/06/20); encourage to wait for staff assistance/use four wheel walker (08/20/19); ensure call light in reach (05/13/19); ensure proper footwear if ambulating (07/19/19); walker within reach (10/29/19); perimeter mattress (12/10/19); personal items within reach (07/19/19); sign in bathroom to ask for assistance (01/24/20); remove leg rests for all transfers (06/13/19); transfer one assist four wheeled walker (08/20/19) and up in common areas while awake (07/19/19). Review of the [NAME] (care card) for Resident #41 current as of 02/11/20 and printed by the facility revealed safety measures in place including encourage to wait for staff assistance and use four wheel-walker; before exiting room, ask if she would like lights on or off; bed in lowest position while occupied, bilateral bed canes; ensure call light is within reach and encourage resident to use it for assistance as needed; provide prompt response to all requests for assistance; ensure resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair; perimeter mattress; provide a safe environment with even floors free from spills and clutter, adequate glare-free light, personal items within reach and a working and reachable call light. An interview on 02/11/20 at 10:12 A.M. with State Tested Nursing Assistant (STNA) #1 revealed Resident #41 liked to sit across from the nurses' station and listen to the radio. STNA #1 stated staff could not leave Resident #41 alone or she would try to get up. An interview on 02/11/20 at 10:26 A.M. with Licensed Practical Nurse (LPN) #3 revealed staff kept Resident #41 out in the common area so they could keep an eye on her as she was a fall risk. LPN #3 showed the surveyor Resident #41's current [NAME] which showed a fall intervention as perimeter mattress. The intervention regarding keeping Resident #41 up in common areas while awake was not observed on the electronic [NAME]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365862 If continuation sheet Page 6 of 10 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 365862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pines Healthcare Center 3015 17th Street NW Canton, OH 44708 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview on 02/11/20 at 11:56 A.M. with LPN #31 revealed staff kept Resident #41 out in the common area for closer observation. LPN #31 stated for most of Resident #41's stay, she was not allowed to be in her room alone due to fall risk. An interview on 02/11/20 at 2:20 P.M. with LPN #36 revealed Resident #41 could be alone in her room only if she was in bed due to fall risk. LPN #36 was not sure if this was an intervention in place due to Resident #41's falls. An interview on 02/12/20 at 12:42 P.M. with the Director of Nursing (DON) revealed the fall intervention to keep Resident #41 up in the common area while awake was on the care plan since 07/19/19 but was not on the [NAME] for other staff to see. The DON verified this intervention was still in place and should have been on Resident #41's [NAME]. b. Review of data for Resident #41's falls on 07/18/19, 10/25/19, 12/06/19 and 01/03/20 revealed a fall risk observation tool assessment was completed after the resident fell and assessed information including the resident's mental status, mobility, gait, ability to transfer, balance, medications, continence, blood pressure, fall history, external applications, vision, hearing, predisposing conditions and potential fall interventions for the resident. A fall occurrence report dated 01/21/20 at 1:12 P.M. revealed STNA #21 went into the bathroom and found Resident #41 on the floor. The fall was reported by STNA #21 on 01/21/20 at 1:12 P.M. A statement by LPN #3 dated 01/21/20 at 12:15 P.M. revealed Resident #41 was put in the bathroom to have a bowel movement, was told to not get up and pull the string and Resident #41 got up without assistance and fell on her buttocks. The call light was not used. The report did not discern how long Resident #41 was alone in the bathroom for or what time she was placed in the bathroom. Review of Resident #41's medical record revealed no additional fall assessments for the fall dated 01/21/20. Review of Resident #41's nurses notes revealed a late entry note written 01/24/20 at 10:49 A.M. effective for 01/21/20 at 1:12 P.M. The nurse was called to Resident #41's room and observed Resident #41 sitting on the floor in front of the toilet in the bathroom. Resident #41 stated she was done, lost her balance and fell. Vitals were obtained, appropriate notifications were made and a new intervention was put into place of a sign on the wall in the bathroom to use the call light for assistance. An interview was conducted on 02/12/20 at 12:42 P.M. with the DON. When asked about Resident #41's fall on 01/21/20, the DON stated she expected staff to stay with residents for toileting unless the resident asked staff to step out of the bathroom. The DON verified the fall occurrence report did not include information regarding what time Resident #41 was placed in the bathroom, if the resident had asked staff to step out of the bathroom and how long Resident #41 was in the bathroom before she fell. An interview was conducted on 02/12/20 at 12:57 P.M. with STNA #21. STNA #21 stated LPN #3 had taken Resident #41 to the bathroom at some point, told her to pull her call light when she was done and to not get up. STNA #21 stated she was in room [ROOM NUMBER] providing care and had come out of the room when Resident #41's roommate told her the resident was on the floor. STNA #21 stated she never left Resident #41 in the bathroom unattended and the resident had never asked staff to step out during toileting in the past. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365862 If continuation sheet Page 7 of 10 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 365862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pines Healthcare Center 3015 17th Street NW Canton, OH 44708 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 02/12/20 at 1:07 P.M. with LPN #3. LPN #3 stated staff could leave Resident #41 in the bathroom for a few minutes. LPN #3 explained Resident #41 was often in the bathroom for a long time. LPN #3 stated after a resident fell, the nurse would obtain vitals, assess for pain and range of motion and complete a fall assessment. The surveyor showed LPN #3 no other fall assessments were available regarding the fall on 01/21/20. Residents Affected - Few A follow-up interview with the DON on 02/12/20 at 1:34 P.M. revealed no other fall assessment was completed as an assessment was done on Resident #41 for her fall on 01/03/20 and would not have needed to do another one. Review of the facility policy on falls, revised 02/10/19 revealed if a fall occurred, the resident would be assessed and based on findings from the assessment including fall risk, new interventions would be put into place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365862 If continuation sheet Page 8 of 10 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 365862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pines Healthcare Center 3015 17th Street NW Canton, OH 44708 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a toileting program was initiated for Resident #45. This affected one out of two resident reviewed for bladder incontinence. Findings include: Medical record review revealed Resident #45 was admitted on [DATE] with diagnoses including Alzheimer's dementia, dementia with behavioral disturbance, wandering, heart arrhythmia and cognitive communication deficit. A review of Resident #45's Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #45 needed extensive assistance of one staff member for her toileting needs. A review of Resident #45's urinary incontinence assessment dated [DATE] indicated Resident #45 was a candidate for a toileting program. A review of Resident #45's plan of care initiated on 01/29/19 indicated Resident #45 had bladder incontinence and required staff assistance with all toileting needs. Interventions on the plan of care included to establish a voiding pattern, ensure an unobstructed path to the bathroom and monitor for signs and symptoms of a urinary tract infection. A review of the state tested nursing assistant (STNA) documentation dated 01/29/19 to 02/11/20 indicated no toileting program was initiated. The documentation indicated Resident #45 was continent most of the time with incontinent episodes daily. There was no documentation a bladder incontinence tracking log had been completed to assess for patterns of incontinence. An interview with STNA #27 indicated she had cared for Resident #45 frequently. STNA #27 indicated Resident #45 was not on a scheduled toileting program. Resident #27 needed verbal cues and was independent with toilet use. STNA #27 indicated when she happened to walk past Resident #45's room she would ask her if she needed to use the toilet but not according to a particular schedule. An interview with the Director of Nursing (DON) on 02/11/20 at 4:55 P.M. verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365862 If continuation sheet Page 9 of 10 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 365862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pines Healthcare Center 3015 17th Street NW Canton, OH 44708 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and interview, the facility failed to implement their tuberculosis (TB) policy and procedure. This had the potential to affect all residents. Facility census was 71. Residents Affected - Many Findings include: Review of the facility's TB risk assessment dated [DATE] revealed the facility was low risk. Review of the facility's TB policy and procedure, dated 03/01/16, revealed the facility did not knowingly hire employees with active TB. The facility followed the CDC recommendations using the health-care settings for risk assessment, management and prevention. The procedure indicated to perform a two-step tuberculosis skin test (TST) upon hire for new employees; document results in employee health record; a negative result would be documented in employee record, and proceed with hire process. In addition, the policy indicated to perform the individual TB screen annually on employees to assess for active signs and symptoms of TB; document signs and symptoms on the form; for any questions answered, YES a follow up visit to healthcare provider was required, and documentation would be readily accessible for state or other healthcare reporting groups. Review of four state tested nurse aide (STNA) personnel files and health records on 02/12/20 at 1:30 P.M. revealed STNA #35 did not receive the second step of the two-step TST upon hire and STNA #4 did not have an annual TB screening completed. Interview with the human resource manager on 02/12/20 at 1:55 P.M. confirmed STNA #35 did not have the second step of the two-step TST upon hire and STNA #4 did not have an annual TB screening completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365862 If continuation sheet Page 10 of 10