Health inspection·September 14, 2023

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a medication error rate of less than 5%. A total of 26 medications were administered with five medication errors for a medication error rate of 19.23%. This finding affected three residents (Residents #32, #53 and #66) of six residents observed for medication administration. Residents Affected - Few Findings include: 1. Review of Resident #32's medical record revealed the resident was admitted on [DATE] with diagnoses including heart failure, fibromyalgia and diabetes. Review of Resident #32's physician orders revealed an order dated 06/18/20 for Cymbalta give 60 mg (milligrams) by mouth in the morning for major depression and give 60 mg by mouth at bedtime for depression; an order dated 11/11/22 for Lasix 20 mg (diuretic) give one tablet by mouth in the morning for edema; and an order dated 01/05/23 for artificial tears instill one drop in both eyes every morning and at bedtime for dry eyes. Observation on 09/11/23 at 9:57 A.M. with Licensed Practical Nurse (LPN) #801 of Resident #32's medication administration revealed twelve medications were administered. LPN #801 did not administer Resident #32's Cymbalta, Lasix and artificial tears as ordered; however, she documented on the MAR that she had administered the medications. Interview on 09/11/23 at 12:13 P.M. with LPN #801 confirmed she did not administer Resident #32's Cymbalta, Lasix and artificial tears for a total of three medication errors. 2. Review of Resident #53's medical record revealed the resident was admitted on [DATE] with diagnoses including hypertensive heart disease, heart failure and diabetes. Review of Resident #53's physician orders revealed an order dated 08/10/23 for NovoLog fast acting insulin inject 8 units subcutaneously before meals for diabetes. Observation on 09/11/23 at 1:52 P.M. with LPN #803 revealed she administered two medications to Resident #53 including NovoLog insulin via a FlexPen. LPN #803 administered 8 units of NovoLog insulin via a FlexPen and did not prime the pen with two units of insulin prior to dialing up 8 units of insulin and administering the insulin to the resident. Interview on 09/11/23 at 2:22 P.M. with LPN #803 confirmed she did not prime Resident #53's NovoLog FlexPen as required prior to dialing up 8 units of the insulin and administering the insulin to the resident for a total of one medication error. Review of the undated NovoLog Insulin Using Your FlexPen prescriber instructions indicated to wash and dry your hands, remove the pen cap, gently roll the pen ten times between the hands, wipe the rubber end of the pen with an alcohol swab, remove the seal from the new pen needle and screw it onto the end of the pen, remove the outer needle cap and set aside, remove the inner needle cap and throw away, turn the knob on the pen to a dose of 2 units, hold the pen with the needle straight up, tap the side of the pen to get rid of any air bubbles, push the injection button until you see zero in the dose window, turn the knob on the end of the pen to the desired dose, use an alcohol swab to (continued on next page) 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 09/14/2023 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few clean the skin, insert the needle straight into the skin so that it reaches the fatty lay, use your thumb to slowly press the button on the end of the pen all the way in and hold it for 10 seconds to allow time for the insulin to get into the body. 3. Review of Resident #66's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including hypothyroidism, anxiety disorder and epileptic syndromes with complex partial seizures. Review of Resident #66's physician orders revealed an order dated 08/22/23 for Zonisamide oral capsule 100 mg give three capsules by mouth every morning and at bedtime for convulsion. Observation on 09/11/23 at 10:16 A.M. with LPN #802 of Resident #66's medication administration revealed eleven medications were administered. LPN #802 did not administer Resident #66's Zonisamide anticonvulsant as ordered. Interview on 09/11/23 at 12:00 P.M. with LPN #802 confirmed she did not administer Resident #66's Zonisamide anticonvulsant as ordered for a total of one medication error. A total of 26 medications were administered with five medication errors for a medication error rate of 19.23 percent. Review of the undated Medication Administration policy revealed the facility would properly assess residents and plan their care to meet these needs. Medications which were ordered by the physician for a specific time will be given as such. Utilization of the liberalized medication administration structure does not imply that any time frame parameter was acceptable for providing medications. Specific medications may still require strict parameters determined by the physician. 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 09/14/2023 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure Resident #39 received the appropriate food items to meet dietary needs identified on meal tickets. This finding affected one (Resident #39) of two residents reviewed for nutrition. The facility census was 71. Findings include: Review of Resident #39's medical record revealed the resident was readmitted to the facility on [DATE] with diagnoses including hemiplegia, unspecified dementia and epilepsy. Review of Resident #39's Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #39's nutritional care plan revealed an intervention dated 05/12/23 to provide meals per the dietary order. Review of Resident #39's physician orders revealed an order dated 07/06/23 for a regular diet, pureed texture and regular consistency. Review of Resident #39's dietary meal ticket dated 09/11/23 for the breakfast meal indicated the resident was to receive pureed bananas foster french toast, pureed breakfast ham with brown gravy, pureed fortified hot cereal of choice, assorted yogurt cup, 2% (percent) milk, hot coffee and orange juice. Observation on 09/11/23 at 9:20 A.M. with Licensed Practical Nurse (LPN) #802 of Resident #39's breakfast meal tray revealed the resident was served pureed bananas foster french toast, pureed breakfast ham, 2% milk, coffee and orange juice. Interview on 09/11/23 at 9:24 A.M. with LPN #802 confirmed Resident #39 was not served the pureed fortified hot cereal of choice and assorted yogurt cup as ordered on her dietary meal ticket. Review of Resident #39's dietary meal ticket dated 09/12/23 for the breakfast meal indicated the resident was to receive pureed baked cheese omelet, pureed sausage patty, pureed oatmeal, pureed English muffin, yogurt cup, 2% milk, hot coffee and orange juice. Observation on 09/12/23 at 8:16 A.M. with State Tested Nursing Assistant (STNA) #804 revealed Resident #39's breakfast tray was delivered which included a pureed cheese omelet, pureed sausage patty with brown gravy, pureed English muffin, 2% milk, hot coffee and orange juice. No yogurt cup or pureed oatmeal cereal were on the tray and STNA #804 indicated she would get the yogurt cup for the resident. Interview on 09/12/23 at 8:43 A.M. with the Administrator confirmed Resident #39's pureed oatmeal and yogurt cup were not on the breakfast tray served to the resident. Review of Meal Distribution policy revised 09/2017 indicated meals were transported to the dining locations in a manner that ensured proper temperature, maintenance, protects against contamination (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete 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 09/14/2023 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 0800 Level of Harm - Minimal harm or potential for actual harm and were delivered in a timely manner and all meals would be assembled in accordance with the individualized diet order, plan of care, and preferences. This deficiency represents non-compliance investigated under Master Complaint Number OH00146369. Residents Affected - Few 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 09/14/2023 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation and interview, the facility failed to have sufficient dietary staff to serve meals timely. This had the potential to affect 70 of 70 resident who received meals from the kitchen, as Resident #60 received no food by mouth. The facility census was 71. Findings include: Review of the facility dining times revealed the lunch meal was to start serving at 11:30 A.M. Interview on 09/11/23 at 8:30 A.M. with Registered Dietician (RD) #900 revealed three dietary staff called off work today including the cook. She stated the Food Service Director (FSD) #867 was acting as the cook. Interview on 09/11/23 at 8:47 A.M. with Social Service Designee (SSD) #805 revealed she was assisting with meal service due to three call-offs. She stated other staff have assisted with dietary in the past due to call-offs or insufficient staffing. Interviews on 09/11/23 from 9:00 A.M. through 11:30 A.M. during the screening process for the annual survey with multiple residents (# 9, #13, #16, #17, #19, #, 26, #36, #38, #45, #58, #64, #171 and #175) revealed multiple concerns with dietary including staffing, temperatures and timeliness of meals. Interview on 09/11/23 at 9:43 A.M. with FSD #867 revealed she was new to the facility, approximately ten days. She stated she had three call-offs and was acting as the cook. She stated she had a meeting with her team the prior week about her expectations as she stated she had a lot of issues in the kitchen and would most likely be terminating everyone and starting with new staff. Observation on 09/11/23 from 11:30 A.M. to 2:37 P.M. revealed the lunch meal was not served until 2:17 P.M. Observation n 09/11/23 at 1:49 P.M. of the dining room revealed Resident #51 was sitting at a table in the dining room. Interview at the time of observation with Resident #51 stated he had been sitting in the dining room since 11:30 A.M. waiting for lunch and he had not yet received lunch. Observation on 09/11/23 at 2:01 P.M. revealed Resident #16 was coming back from her room after making sandwiches for her and her tablemates (#17 and #19) as they were still waiting for lunch. Interview on 09/11/23 at 2:04 P.M. with Licensed Practical Nurse (LPN) #870 verified lunch had not been served yet. She stated the hall trays were usually delivered between 12:00 P.M. and 1:00 P.M. and they were running very late this day. A subsequent interview on 09/11/23 at 3:13 P.M. and on 09/14/23 at P.M. with FSD #867 revealed lunch was late on 09/11/23 due to her being on her own to prepare the meal. Review of a list of resident diets revealed Resident #60 received no food by mouth. Review of the facility policy titled Department Staffing, last revised 09/2017, revealed the dining (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 09/14/2023 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 0802 Level of Harm - Minimal harm or potential for actual harm services department would employ sufficient staff to carry out the functions of food and nutrition services that is safe and effective. This deficiency represents non-compliance investigated under Complaint Number OH00146369. Residents Affected - Many 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 09/14/2023 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation and interviews the facility failed to ensure food was served at a palatable temperatures. This had the potential to affect 70 of 70 resident who received food from the kitchen, as Resident #60 received no food by mouth. The facility census was 71. Residents Affected - Many Findings include: Interviews on 09/11/23 from 9:00 A.M through 11:30 A.M. during the screening process for the annual survey with multiple residents (# 9, #13, #16, #17, #19, #, 26, #36, #38, #45, #58, #64, #171 and #175) revealed concerns with dietary including palatability of meals. Observation and interview on 09/12/23 at 11:35 A.M. revealed the hot food on the steam table had temperatures over 165 degrees. A test tray left the steam table at 12:15 P.M. The test tray was served last at 12:34 P.M. The culinary director from sister facility (CD) #910 proceeded to take the temperatures of the meal. The chicken thigh was 123 degrees, the mashed potatoes were 130 degrees and the peas were 127 degrees. CD #910 revealed the food should be over 135 degrees. Review of a list of resident diets revealed Resident #60 received no food by mouth. Review of the facility policy titled Food Preparation, last revised 09/2017 revealed all foods will be held at appropriate temperatures, greater than 135 degrees for hot food holding. This deficiency represents non-compliance investigated under Complaint Numbers OH00146369. 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 09/14/2023 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #58's medical record revealed the resident was admitted on [DATE] with diagnoses including type two diabetes with diabetic neuropathy, chronic pain syndrome and essential hypertension. Review of Resident #58's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #58's physician orders revealed an order dated 08/22/23 for Humalog FlexPen (fast-acting insulin) inject 15 units subcutaneously before meals for diabetes mellitus. Observation on 09/11/23 at 1:52 P.M. revealed Licensed Practical Nurse (LPN) #803 obtained Resident #58's blood sugar with a result of 78. An additional observation on 09/11/23 at 1:55 P.M. revealed Resident #58 refused her Humalog insulin because the meal tray was late and her blood sugar was running low. Interview on 09/11/23 at 2:00 P.M. with LPN #803 confirmed Resident #58 refused her Humalog insulin because her meal tray was late and her blood sugar was low. Review of the facility dining times revealed the lunch meal was to start serving at 11:30 A.M. This deficiency represents non-compliance investigated under Complaint Numbers OH00146369 and OH00145609. Based on observation and interview, the facility failed to serve meals in a timely manner. This had the potential to affect 70 of 70 residents who received food from the kitchen. Resident #60 received no food by mouth. The facility census was 71. Findings include: 1. Review of the facility dining times revealed the lunch meal was to start serving at 11:30 A.M. Interview on 09/11/23 at 8:30 A.M. with Registered Dietician (RD) #900 revealed three dietary staff called off work today including the cook. She stated the Food Service Director (FSD) #867 was acting as the cook. Interview on 09/11/23 at 8:47 A.M. with Social Service Designee (SSD) #805 revealed she was assisting with meal service due to three call-offs. She stated other staff have assisted with dietary in the past due to call-offs or insufficient staffing. Interviews on 09/11/23 from 9:00 A.M. through 11:30 A.M. during the screening process for the annual survey with multiple residents (# 9, #13, #16, #17, #19, #, 26, #36, #38, #45, #58, #64, #171 and #175) revealed multiple concerns with dietary including staffing, temperatures and timeliness of meals. Interview on 09/11/23 at 9:43 A.M. with FSD #867 revealed she was new to the facility, (continued on next page) 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 09/14/2023 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many approximately ten days. She stated she had three call-offs and was acting as the cook. She stated she had a meeting with her team the prior week about her expectations as she stated she had a lot of issues in the kitchen and would most likely be terminating everyone and starting with new staff. Observation on 09/11/23 from 11:30 A.M. to 2:37 P.M. revealed the lunch meal was not served until 2:17 P.M. Observation n 09/11/23 at 1:49 P.M. of the dining room revealed Resident #51 was sitting at a table in the dining room. Interview at the time of observation with Resident #51 stated he had been sitting in the dining room since 11:30 A.M. waiting for lunch and he had not yet received lunch. Observation on 09/11/23 at 2:01 P.M. revealed Resident #16 was coming back from her room after making sandwiches for her and her tablemates (#17 and #19) as they were still waiting for lunch. Interview on 09/11/23 at 2:04 P.M. with Licensed Practical Nurse (LPN) #870 verified lunch had not been served yet. She stated the hall trays were usually delivered between 12:00 P.M. and 1:00 P.M. and they were running very late this day. A subsequent interview on 09/11/23 at 3:13 P.M. and on 09/14/23 at P.M. with FSD #867 revealed lunch was late on 09/11/23 due to her being on her own to prepare the meal. Review of a list of resident diets revealed Resident #60 received no food by mouth. Review of the facility policy titled Frequency of Meals, last revised 09/2017, revealed at least three meals would be provided at regular times comparable to normal mealtimes in the community. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365862 If continuation sheet Page 10 of 10