Inspection·March 31, 2022

F 0584 hallucinations, delusions or behaviors during the review period. Level of Harm - Minimal harm or potential for actual harm Review of work order #14692 revealed the work order was created on 01/06/22 and indicated the door handle to Resident #61's room was loose and was not latching. The comment section of the work order stated a new door was measured and was being installed. Resident #61 will have a whole new door soon. Residents Affected - Few During an observation and interview with Resident #61 on 03/28/22 at 9:48 A.M. it was visualized there was a bath towel stuffed in the resident's door jam to keep the door closed. The door was knocked on to enter the room and the resident stated come in, the door was opened and the towel was was placed over the top of the door as the door handle was hanging down toward the floor on both sides of the door and could not hold the towel. Resident #61 stated the door will not latch and staff use a towel to make sure the door stays closed. Resident #61 stated about two months ago his/her room door would not open when the staff attempted to bring him/her their medication. Resident #61 stated the staff had to break the door to gain entry. Resident #61 verified during the time his door would not open he/she was not in any distress, danger or in need of any services, stating if an emergency had happened he/she would have called 911. Resident #61 stated the staff informed him/her the door would be replaced but it had not happened yet. During an interview with State Tested Nursing Assistant (STNA) #692 on 03/28/22 at 9:50 A.M., it was verified the door handle was broken, part of the door itself was pulled away from the door and the door was being held closed by a bath towel being shoved in the door jam between the wall and the door. The STNA stated he/she worked for an agency and was not sure how long the door had been in that condition. During an interview with Maintenance Worker #800 on 03/29/22 at 8:11 A.M., it was revealed the facility uses the Tels system to track and complete work orders. MW #800 stated the staff put in a work order into the Tels system and it populates to the maintenance workers cell phones in the Tels app. MW #800 stated the app tracks when the work order was put in, who put it in, and there was a a space for the maintenance worker to document when it was worked on and completed in the app. MW #800 stated after work orders were complete, they were still saved in the Tels system and can be viewed. It was asked if he/she was aware of Resident #61 having a broken room door and MW #800 stated he/she had called the vendor yesterday to come out and replace the door. MW #800 stated the work order would need to come from an employee of the health care building as MW #800 was not over healthcare, but assisting with the health care building needs as the maintenance worker over the health care center was on vacation. MW #800 stated he/she did not know when the door initially became broken. During an observation of Resident #61's door on 03/29/22 at 8:40 A.M. it was visualized the door had a door reinforcer (a U-shaped piece of metal that is approximately nine inches tall that goes around the front and back of the door at the location of the door knob to repair the door or prevent forced entry) placed around the door handle hole which allowed the door handle to function properly and the door to be closed and stay closed without the use of a towel being placed in the door jam. During an interview with the Administrator on 03/29/22 at 9:50 A.M. it was confirmed the door in Resident #61's room had broken in January 2022. The Administrator verified a temporary fix to the door was put in place on 03/28/22 which allowed the door to latch and stay closed without the use of a towel. The Administrator verified this was the first time a temporary fix had been initiated for the resident's door. The Administrator stated the facility had a vendor come out to the facility in January to measure and order a new door for the resident but the new door was not yet available. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 If continuation sheet Page 2 of 16 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Care Center 500 Community Drive Avon Lake, OH 44012 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 0584 Administrator stated they were unaware the door was being held closed by a towel being placed in the door jam and said it must be by resident preference the staff are doing that. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 If continuation sheet Page 3 of 16 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Care Center 500 Community Drive Avon Lake, OH 44012 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 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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, family interview, and staff interview, the facility failed to implement physician orders for Resident #94) and failed to assess for a device in use for Resident #48). This affected two (Resident #48 and #94) of 28 residents reviewed for devices. The facility identified six residents with wanderguards. The facility census was 98. Residents Affected - Few Findings include: 1. Review of Resident #94's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, dementia with behavioral disturbance, weakness, falls, and fatigue. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 was cognitively intact. Resident #94 required extensive assistance with bed mobility, dressing, transfers, and toileting. Review of the physician's orders dated 03/02/22 revealed Resident #94 had an order in place for hip protectors/hipsters when out of bed. Review of Resident #94's treatment administration order (TAR) revealed the staff had initialed the hip protectors/hipsters indicating the device was in place every shift starting on 03/02/22, on the night shift. Observation on 03/28/22 at 11:43 A.M. revealed Resident #94 was sitting in his wheelchair and no hip protectors or hipsters were noted to be in place. Subsequent observation of Resident #94 on 03/31 22 at 7:54 A.M. revealed the resident was in the dining room and no hip protectors or hipsters were noted to be in place. On 03/31/22 at 8:45 A.M., an observation of Resident #94 was in a common area outside the 200 hallway and no hip protectors or hipsters were noted to be in place. Interview on 03/31/22 at 7:54 A.M. with Resident #94's wife confirmed the resident wears incontinent care products, but does not wear any hip protector device. Interview on 03/31/22 at 8:38 A.M. with Registered Nurse (RN) #658 confirmed he/she was the nurse who usually works on Resident #94's hallway. The RN verified Resident #94 does not wear hipsters but has a bed and chair alarm used in his/her care. Interview on 03/31/22 at 2:00 P.M. with the Administrator stated the facilities documentation was lacking and the documentation was not where it should be. 2. Review of medical record for Resident #48 revealed an admission date of 10/29/21. Diagnoses included Alzheimer's disease, dementia with behavioral disturbance, and encounter for palliative care. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48 had severely impaired cognition and had wandered four to six days of review period. Review of current physician's orders revealed no order to address Resident #48's placement of wanderguard. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 If continuation sheet Page 4 of 16 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Care Center 500 Community Drive Avon Lake, OH 44012 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the elopement risk assessment dated [DATE] revealed Resident #48 was known to wander aimlessly and was ambulatory. Resident #48 was confused and resided on secured unit for safety. There was no assessment or care plan in the resident's medical record for the use of the wanderguard. Observation on 03/28/22, 03/29/22, and 03/31/22 revealed Resident #48 had wanderguard secured around right ankle. Resident #48 resided on the secured unit. Interview on 03/31/22 at 11:42 A.M. with License Practical Nurse (LPN) #637 confirmed Resident #48 had wanderguard secured around the right ankle. Follow up interview on 03/31/22 at 11:46 A.M. with LPN #637 verified lack of physician's order, assessment, and care plan for Resident #48 regarding a wanderguard placement on the right ankle. Review of the facility's policy Person/Elopement Policy revised January 2022 revealed residents at risk for elopement will have wander guard bracelet applied and assessed daily by licensed nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 If continuation sheet Page 5 of 16 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Care Center 500 Community Drive Avon Lake, OH 44012 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's policy, record review, resident interview, and staff interview the facility failed to assess and monitor the dialysis access site for one (#40) of one resident reviewed for dialysis. The facility identified two current residents receiving dialysis services. The facility census was 98. Residents Affected - Few Findings include: Review of Resident #40's medical record revealed the resident was admitted on [DATE] with most recent re-admission on [DATE]. Diagnoses included depression, hypothyroidism, anxiety, end stage renal disease, type two diabetes, headache, schizophrenia, psychosis, and dependant on renal dialysis. Review of the care plan dated 01/2022 revealed Resident #40 was to have the dialysis access bruit and thrill checked. Review of the discharge return anticipated Minimum Data Set (MDS) dated [DATE] revealed Resident #40's had no memory deficit, had behaviors one to three days of the review period, and was independent with daily cares. The 01/21/22 quarterly MDS assessment dated [DATE] revealed Resident #40 received dialysis services. Review of the medical record revealed Resident #40 had a hospital stay from 03/11/22 to 03/15/22. The medical record did not have evidence the staff were monitoring Resident #40's thrill and bruit from 03/15/22 through 03/29/22. There was no physician order to monitor Resident #40's thrill and bruit from 03/15/22 through 03/29/22. Interview with Resident #40 on 03/28/22 at 9:17 A.M. stated the staff sometimes felt or listened to his dialysis fistula site, but it was not all the time. Interview on 03/30/22 at 3:15 P.M. with the Director of Nursing (DON) confirmed the medical record did not have evidence of the staff monitoring the Resident #40's thrill and bruit from 03/15/22 to 03/29/22. Review of the policy titled Dialysis, dated July 2013, revealed the policy was to ensure the resident receiving dialysis treatment receives safe and appropriate treatment related to dialysis care. The procedure included to develop a plan of care which addresses the following items as appropriate to the individual resident and monitoring of the access site. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 If continuation sheet Page 6 of 16 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Care Center 500 Community Drive Avon Lake, OH 44012 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and staff interview, the facility failed to ensure posted nursing staff was up to date as required. This had the potential to affect all 98 residents residing in the facility. Residents Affected - Many Findings include: Observation of the posted nursing staff information on 03/28/22 at 6:45 A.M. revealed the posted nursing staff information was from 03/24/22. Interview on 03/28/22 07:11 AM with Minimum Data Set Nurse #688 verified the posted nursing staff information was from four days ago on 03/24/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 If continuation sheet Page 7 of 16 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Care Center 500 Community Drive Avon Lake, OH 44012 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical record review for Resident #48 revealed an admission date of 10/29/21. Diagnoses included Alzheimer's disease and dementia with behavioral disturbance. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 had impaired cognition. Resident #48 received antipsychotic medications for seven days of seven-day review period. Review of the physician's orders dated 02/01/22 revealed an order for Ativan 0.5 milligrams (mg) every four hours as needed for anxiety with no stop date noted. Interview with Director of Nursing (DON) on 03/29/22 at 4:30 P.M. verified there was no stop date for Resident #48's as needed Ativan order. The DON stated she didn't know that they needed a stop date. Review of the facility's policy titled Psychoactive Medication Reduction Policy, dated August 2021, revealed PRN psychoactive medications will be discontinued after 14 days from start date. If long term use is required then the physician must document reason for continued use. Non-pharmacological interventions will be used prior to administration of PRN psychoactive medication and interventions will be documented in residents' electronic medication record. 3. Review of the medical record for Resident #10 revealed an admission date of 07/02/21. Diagnoses included dementia with behavioral disturbances, psychosis, anxiety disorder, and major depressive disorder. Review of the physician orders dated 07/02/21 revealed an order for Xanax (antianxiety) tablet 0.5 mg and to give one tablet by mouth every four hours as needed for anxiety for 14 days with no stop date. Interview on 03/29/22 at 4:30 P.M. with Director of Nursing (DON) verified there was no stop date for Resident #10's as needed Xanax order. The DON stated she didn't know that they needed a stop date and contacted the resident's nurse practitioner. 2. Review of Resident #29's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, psychotic disorder, and bipolar disorder. Review of the MDS assessment dated [DATE] revealed Resident #29 was severely cognitive impaired. Review of the physicians orders dated 05/28/21 revealed an order for Lorazepam (antianxiety medication) 0.5 mg every eight hours PRN for anxiety/agitation. There was no stop date for the use of Lorazepam. Interview with the Director of Nursing on 03/29/22 at 2:15 P.M. verified the PRN order for Lorazepam was not limited to 14 days as required and did not have a stop date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 If continuation sheet Page 8 of 16 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Care Center 500 Community Drive Avon Lake, OH 44012 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Based on record review, review of the facility's policy, and staff interview, the facility failed to have stop dates on as needed (PRN) antianxiety medications for four ( #10, #15, #29, and #48) of five residents reviewed for unnecessary medications. The facility also failed to ensure non pharmacological interventions were attempted prior to the administration of as PRN antianxiety medication which affected one (#15) of five residents reviewed for unnecessary medications. The facility identified 18 residents residents receiving antianxiety medications. The facility census was 98. Findings include: 1. Review of Resident #15's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included depression and anxiety. Review of the physician's orders dated 12/09/21 revealed Resident #15 had an order for Ativan (anti-anxiety medication) 0.5 milligrams (mg) PRN every eight hours for anxiety. There was no stop date for the use of Ativan. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was having hallucinations, delusions, behaviors directed towards others daily, no rejection of care and no wandering. Resident #15 had anxiety and depression and took seven days of antianxiety medications. Review of the medication administration record (MAR) for March 2022 revealed Resident #15 was administered PRN Ativan on 03/02/22 at 11:01 P.M., 03/04/22 at 7:44 P.M., 03/05/22 at 10:07 P.M., 03/06/22 at 7:22 P.M., 03/09/22 at 12:24 A.M. and 8:25 P.M., 03/11/22 at 7:49 P.M., 03/15/22 at 4:42 P.M., 03/16/22 at 12:42 A.M. and 8:55 P.M., 03/19/22 at 8:08 P.M., 03/21/22 at 1:31 A.M., 03/23/22 at 3:45 A.M. and 8:25 P.M., 03/25/22 at 2:38 P.M. and 03/27/22 at 8:17 P.M. There was only documentation of non pharmacological interventions being used prior to the administration of the PRN Ativan for the medication on 03/02/22 at 11:01 P.M., 03/04/22 at 7:44 P.M., 03/15/22 at 4:442 P.M., 03/16/22 at 12:42 A.M., 03/19/22 at 8:08 P.M. 03/23/22 at 3:45 A.M. and on 03/25/22 at 2:38 P.M. and nine doses of medication were administered without non pharmacological interventions being attempted first. Interview with the Director of Nursing (DON) on 03/29/22 at 3:21 P.M. verified there was no stop date for the ativan 0.5 mg every eight hours PRN. The DON verified the physician order was initiated on 12/03/21 and revised on 01/27/22. The DON verified there was only documentation of non pharmacological interventions being used prior to the administration of the PRN Ativan for the medication on 03/02/22 at 11:01 P.M., 03/04/22 at 7:44 P.M., 03/15/22 at 4:442 P.M., 03/16/22 at 12:42 A.M., 03/19/22 at 8:08 P.M. 03/23/22 at 3:45 A.M. and on 03/25/22 at 2:38 P.M. and nine doses of medication were administered without non pharmacological interventions being attempted first. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 If continuation sheet Page 9 of 16 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Care Center 500 Community Drive Avon Lake, OH 44012 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on record review, observations and staff interviews, the facility failed to properly store food and maintain the kitchen and the 200 hall servery in a clean and sanitary manner. This had the potential to affect all residents except one resident (#58) who received nothing by mouth. The facility census was 98. Findings include: During the initial tour of the kitchen on 03/28/22 at 7:03 A.M. revealed Dietary [NAME] (DC) #750 was in the kitchen standing by the prep table across from the stove and not wearing a hair restraint. DC #750 verified the observation and stated she had just taken it off. DC #750 observed getting another hair restraint. Observations on 03/28/22 from 7:10 A.M. through 7:37 A.M. with Dietary Manager (DM) #660 revealed the lower part of the steam table facing the side where the stove was had various splatters and a brown drippings on it. Next to the steam table was the plate warmer that also had various food splatters and crumbs with clean plates loaded on it. The deep fryer and grill both had various food debris and dried food. The floor between the grill and deep fryer appeared with grease spillage and food debris. The steamer was leaking water and caused rust-like stains underneath onto the shelves and a rust-like color stain on the floor. The stove had dried food debris and there was two white plastic buckets full of solidified grease near and across from the stove. There were also a larger bucket that was dirty but empty. DM #660 stated they had to let the grease cool down before emptying it out in the grease trap outside and the empty bucket they used to let the hot water out of the tilt skillet because it didn't reach the drain. DM #660 stated there was a hole at the bottom of the bucket. There were various crumbs and food debris at the bottom of the reach in cooler. The prep sink was dirty with water stains, dirty rag, and food debris in the sink. Next to the prep sink, there was the bread rack that housed a numerous loaves of bread without any dates. At this time, DM #600 stated the bread came frozen and staff were to date it prior to putting it on the bread rack. Observation of the walk-in cooler were two trays of prepared cheese sandwiches with butter on top (for grilled cheese sandwiches) uncovered, unlabeled, and undated. The floor of the walk-in cooler was dirty with food debris. Observation of the walk-in freezer revealed a box of frozen hamburger patties in plastic bag wide open to air and the floor was dirty with various food and debris. In the dry storage area, the floor was also dirty with various debris and there were nine boxed containers of cooking oil stored on the floor. The mixer outside of the dry storage area was uncovered and dirty with various food splatters. At this time, DM #600 stated the mixer guard was stuck on the mixer which made it difficult to be cleaned. The area where the coffee urn was had various food splatter and debris and underneath it were two large clear containers that housed clean serving utensils and scoops. The two clear containers were dirty with food crumbs and debris. The commercial can opener appeared with dried grease, rust, and food debris. The shelves on the side of the steam table side facing the door into kitchen, were dirty with crumbs and food debris. The entire floor throughout the kitchen was dirty with various debris and food. Interview on 03/28/22 between 7:10 A.M. and 7:37 A.M. with DM #660 verified all the above findings. DM #660 stated he had been out sick in the hospital for the one and a half weeks and was not happy with the current condition of the kitchen. Observation on 03/30/22 at 8:51 A.M. of the dish machine revealed a layer of off white lime buildup (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 If continuation sheet Page 10 of 16 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Care Center 500 Community Drive Avon Lake, OH 44012 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many that appeared to be like chipped paint on the inside doors, the inside corners, and along sides inside of the dish machine. Interview at this time with DM #660 verified the findings and stated the lime build up was stuck and he had been trying to get it off but it would will take time. Observation on 03/30/22 at 11:05 A.M. of the 200 hall servery revealed inside of the reach-in freezer had a moderate amount of yellow jello like substance on the bottom of the freezer as well as food crumbs. The reach-in refrigerator had spills and crumbs on the bottom of the refrigerator and on the top of the grill that met the bottom part of the door of there refrigerator. At this time, Certified Dietary Manager (CDM) #693 verified all the above findings. Review of the facility's list of resident's diets revealed Resident #58 was nothing by mouth and did not receive any food from the kitchen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 If continuation sheet Page 11 of 16 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Care Center 500 Community Drive Avon Lake, OH 44012 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 - Potential for minimal harm Based on observation, staff interview, and policy review, the facility failed to maintain its dumpster area in a clean and sanitary condition. This had the potential to affect all 98 residents residing in the facility. Residents Affected - Many Findings include: Observation on 03/30/22 at approximately 9:10 A.M. of the outside dumpsters revealed two dumpsters, one on the right contained card board boxes and the one on the left contained trash. Both lids of the dumpsters were up and open and there was moderate amount of trash, clear trash bags filled with trash and other debris between the dock and the dumpsters. Interview at this time with Dietary Manager (DM) #660 verified the observations and stated when the garbage truck comes to empty the dumpsters, trash falls out. DM #660 stated the garbage truck would then pushed the dumpsters back pushing the trash back making it difficult to clean up the trash. Review of the facility's policy titled Dumpster/Trash Policy revised January 2022 revealed it was the policy of the facility to ensure that the trash dumpster will remain closed at all times and the area around will be free from any debris. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 If continuation sheet Page 12 of 16 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Care Center 500 Community Drive Avon Lake, OH 44012 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and record review, the facility failed to maintain a complete and accurate medical records. This affected three (#18 #94, and #150) of 28 residents reviewed for medical record accuracy. The facility census was 98. Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of 10/30/18. Diagnoses included hemiplegia and hemiparesis following a stroke, major depressive disorder, and weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and required extensive assistance of two staff for bed mobility, total dependence of two staff for transfers, and extensive assistance of one staff for locomotion on and off the unit. Review of Resident #18's medical record from 03/25/22 to 03/28/22 revealed no documentation related to his eye. Observation on 03/28/22 at 3:28 P.M. of Resident #18 revealed bruising under his left eye. Interview at this time with Resident #18 revealed he did not have a fall and he stated he did not know what happened to his eye. Interview on 03/29/22 at 4:30 P.M. with Director of Nursing (DON) stated she knew what happened with the Resident #18's eye. DON stated staff called her either on 03/25/22 or 03/26/22 that Resident #18 had a mark under his eye due to sleeping with his glasses on and had rubbed his eye making it worse. DON stated the physician was made aware. DON verified there was no documentation in the electronic medical record but stated they did an incident report that was entered into the electronic medical record. The DON stated she would log in and print the incident report. Subsequent review of the progress notes dated 03/30/22 at 9:52 A.M. revealed a late entry note for 03/26/22 at 9:43 A.M. revealed Resident #18 came up to nurses station after breakfast to get his medication and the aide asked the resident what happened to his eye. Nurse and another aide turned and look at the resident. He had a discoloration under his left eye. Nurse asked resident did someone hurt him, and the resident stated no. The nurse asked the resident did he go to bed with his glasses on and the resident stated no. The nurse ask resident did he bump his eye or anything like that and resident stated no. Resident #18 stated that he was rubbing his eye and thinks he may have also scratched it. Nurse Practitioner (NP) and resident's daughter were notified. Subsequent interview on 03/30/22 at 2:03 P.M. with the DON stated she had to call the nurse at home when she was unable to find the documentation of the incident related to Resident #18's eye. The DON stated the nurse stated she wrote the note on the day of the incident but didn't save or lock it. The DON stated she had the nurse write the note today (03/20/22) when she came in to work. 3. Review of Resident #150's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included thoracic spinal stenosis, after-care following spinal surgery, Crohn's disease, moderate protein-calorie malnutrition, ileostomy, and depression. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 If continuation sheet Page 13 of 16 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Care Center 500 Community Drive Avon Lake, OH 44012 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 Review of the discharge Minimum Data Set (MDS) assessment, dated 03/29/22 revealed a discharge MDS assessment was initiated but not completed. Review of the Electronic Medication Administration Record dated 03/29/22 indicated Resident #150 was discharged . Residents Affected - Few Review of Resident #150's nurse progress notes dated 03/29/22 through 03/30/22 revealed no information regarding the the reason for the resident's discharge from the facility. A nurse progress note dated 03/31/22 at 9:31 A.M. indicated Resident #150 discharged to hospital for a scheduled surgery. The progress note was not identified as a late entry. Interview on 03/30/22 at 11:15 A.M. with the Director of Nursing (DON) #612 and Wound Nurse #613 confirmed Resident #150 had been discharged from the facility to the hospital for surgery. Interview on 03/30/22 at 11:08 A.M. with the Administrator confirmed Resident #150 had been discharged . The Administrator stated the facility's documentation was sketchy at best and it was their biggest problem. 2. Review of Resident #94's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, dementia with behavioral disturbance, weakness, falls, and fatigue. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 was cognitively intact. Resident #94 required extensive assistance with bed mobility, dressing, transfers, and toileting. Review of the physician's orders dated 03/02/22 revealed Resident #94 had an order in place for hip protectors/hipsters when out of bed. Review of Resident #94's treatment administration order (TAR) revealed the staff had initialed the hip protectors/hipsters indicating the device was in place every shift starting on 03/02/22, on the night shift. Observation on 03/28/22 at 11:43 A.M. revealed Resident #94 was sitting in his wheelchair and no hip protectors or hipsters were noted to be in place. Subsequent observation of Resident #94 on 03/31 22 at 7:54 A.M. revealed the resident was in the dining room and no hip protectors or hipsters were noted to be in place. On 03/31/22 at 8:45 A.M., an observation of Resident #94 was in a common area outside the 200 hallway and no hip protectors or hipsters were noted to be in place. Interview on 03/31/22 at 7:54 A.M. with Resident #94's wife confirmed the resident wears incontinent care products, but does not wear any hip protector device. Interview on 03/31/22 at 8:38 A.M. with Registered Nurse (RN) #658 confirmed he/she was the nurse who usually works on Resident #94's hallway. The RN verified Resident #94 does not wear hipsters but has a bed and chair alarm used in his/her care. During an interview with the Director of Nursing on 03/31/22 at 9:15 A.M. confirmed Resident #94 has hipsters signed off in the TAR indicating the device was in use. The DON stated the facility has hipsters and they do use hipsters in resident care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 If continuation sheet Page 14 of 16 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Care Center 500 Community Drive Avon Lake, OH 44012 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 During an interview conducted on 03/30/22 at 11:08 A.M. the Administrator revealed the facilities documentation was sketchy at best and stated they were calling staff back into the facility to complete documentation. On 03/31/22 at 2:00 P.M., the Administrator verified the facilities documentation was lacking and the documentation was not where it should be. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 If continuation sheet Page 15 of 16 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Main Street Care Center 500 Community Drive Avon Lake, OH 44012 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 0885 Report COVID19 data to residents and families. Level of Harm - Minimal harm or potential for actual harm Based on review of the Centers for Medicare and Medicaid Services (CMS) Quality, Safety and Oversight Memo (QSO-20-29-NH), record review, and staff interview, the facility failed to inform residents, their representatives and families of those residing in the facility by 5:00 P.M. the next calendar day following the occurrence of a confirmed infection of COVID-19 as required. This had the potential to affect all 98 residents residing in the facility. Residents Affected - Many Findings include: Review of the facility's resident testing records revealed a resident test positive for COVID-19 on Friday 01/20/22. Review of the facility's staff testing records revealed the facility had one staff member test positive for COVID-19 on Saturday 02/05/22. Review of the medical record for multiple residents including progress notes revealed no documented evidence of resident notification of the presence of COVID-19 in the facility. On 03/31/21 at 12:45 P.M., review of the facility's scripted e-mail document dated 01/29/22 at 8:54 P.M. revealed the document was e-mailed to the resident's families and responsible parties regarding COVID-19 positive cases in the facility discovered during the week of 01/23/22. During an interview on 03/31/22 at 12:50 P.M., the Administrator indicated the resident's families and responsible parties were notified via e-mail regarding COVID-19 positive cases or suspected cases. Those families or responsible parties without an e-mail were notified by a telephone call. The Administrator provided an e-mail list for review. The Administrator stated residents in the facility were notified in person during testing and when the Social Worker walks around and lets them know. The Administrator indicated the Social Worker keeps a list of the residents she has talked to. The Administrator indicated the scripted e-mails and telephone calls were made weekly and no additional notification/information was sent out by 5:00 P.M. the next day after either a resident or staff member tested positive. Review of the guidance of the Centers for Medicare and Medicaid Services (CMS) released new Quality, Safety and Oversight Memo (QSO-20-29-NH), dated 05/06/20 revealed the facility must inform residents, their representatives, and families of those residing in facilities by 5:00 P.M. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. This information must: (i) Not include personally identifiable information. (ii) Include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered. (iii) Include any cumulative updates for residents, their representatives, and families at least weekly or by 5 p.m. the next calendar day following the subsequent occurrence of either: each time a confirmed infection of COVID-19 is identified, or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 If continuation sheet Page 16 of 16