Inspection·August 8, 2023

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 08/03/23 at 3:25 P.M. of Family Member (FM) #295 revealed she was Resident #96's Power of Attorney for medical and health. FM #295 stated she was not notified about the medication Resident #96 received to decrease his sexuality. FM #295 stated she received a letter from the insurance company stating Lupron Depot inject kit was limited due to the expense. FM #295 indicated she called the insurance company and was told they issued it and the copay was 500.00 dollars. FM #295 stated she was not contacted by the facility to make her aware Lupron Depot was ordered and administered to Resident #96. FM #295 stated she should have been notified and the medication chemically castrated Resident #96. FM #295 indicated the order was written as an emergency drug given for hypersexuality and she was kind of notified her brother was touching residents inappropriately but the facility did not clearly communicate exactly what that meant. FM #295 revealed Resident #96 had dementia and Parkinson's Disease, was impulsive, but giving Lupron Depot was a very severe approach to take. FM #295 stated she asked Assistant Director of Nursing (ADON) #278 to tell her what behaviors her brother displayed. FM #295 stated she was upset she was never called about the Lupron Depot because she makes the medical decisions due to Resident #96 was unable to make his own decisions. FM #295 stated she was told Resident #96 needed to stay away from women, but she was not told he was inappropriately touching anyone. FM #295 indicated Resident #96 received Haldol before he was administered Lupron Depot. Observation on 08/03/23 at 4:30 P.M. revealed Resident #96 sitting quietly in his wheelchair in the common area. Resident #96 was unable to be interviewed. Interview on 08/07/23 at 2:10 P.M. of the Director of Nursing (DON) and ADON #278 revealed ADON #278 spoke with FM #295 after the Lupron Depot was ordered and administered to Resident #96. ADON #278 stated she touched base with FM #295 afterwards when FM #295 called the facility regarding insurance coverage for the Lupron depot. ADON #278 stated FM #295 was not notified Resident #96 had Lupron Depot ordered and administered and she should have been notified. ADON #278 stated FM #295 said she wished someone had told her about the Lupron Depot. ADON #278 stated she never witnessed Resident #96 inappropriately touching another resident. DON stated Resident #96 did not have major incidents of extreme sexual advances, but would rub other residents legs, rub their arms, and would roll his wheelchair into their room. The DON indicated Resident #96 received Finasteride and Haldol previous to the Lupron Depot for sexual behaviors. ADON #278 stated the order written on 07/04/23 for Lupron Depot stated for hyposexuality, but should read hypersexuality. This deficiency represents non-compliance investigated under Complaint Number OH00144610. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility activity calendar the facility failed to ensure activities were consistently provided for residents on the memory care unit. This affected two residents (Resident's #15 and #96) and had the potential to affect all 25 residents (Resident's #1, #3, #7, #11, #12, #15, #17, #23, #29, #46, #47, #53, #54, #55, #56, #60, #66, #71, #73, #74, #76, #81, #85, #88, #96) residing on the memory care unit. The facility census was 100. Residents Affected - Some Findings include: 1. Review of Resident #15's medical record revealed an admission date of 10/29/21 and diagnoses included Alzheimer's Disease, dementia with other behavioral disturbances, and atrial fibrillation. Review of Resident #15's admission Activity assessment dated [DATE] included Resident #15's hobby was gardening. Resident #15's religion was Catholic, and she participated in church and religious activities. Resident #15 preferred to keep herself busy with a variety of individual and group activities of her choice when she was not involved in activities. Preferred participation was morning, afternoon, evening. Family interview revealed Resident #15 enjoyed spending time and visiting with family and friends, having her meal served in a social setting, pet therapy, resting and relaxing and a variety of individual and group activities of her choice. Review of Resident #15's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 had severe cognitive impairment. Resident #15's mood was not assessed. Review of Resident #15's activities schedule dated 07/07/23 through 07/31/23 revealed no arts and crafts activities were documented, cooking and food activity revealed on 07/21/23 she received juice from the juice cart, and on 07/28/23 Resident #15 received a snack, current event activity revealed on 07/20/23 Resident #15 watched television. Review of the game, puzzle activity revealed on 07/28/23 Resident #15 played bingo, the type of music attended on 07/21/23 was dinner music and on 07/23/23 musical guest was attended. Resident #15 did not have any one on one visits, activities or other activities documented. Resident #15 did not have any party, holiday activities documented. Resident #15 did not have any religious activities attended documented, even though the activity calendar stated they were offered every Sunday in July, 2023. Resident #15 did not have a visit activity including pet visit documented. There were no other activities documented. 2. Review of Resident #96's medical record revealed an admission date of 10/28/22 and diagnoses included schizophrenia, Parkinson's Disease and type two diabetes mellitus. Review of Resident #96's Preferences for Everyday Living Inventory dated 10/29/22 included it was very important to Resident #96 to spend time by himself, to meet new people, to attend entertainment events in the facility, to do outdoor tasks, to watch sports, to play games, and to listen to music. Review of Resident #96's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #96 had severe cognitive impairment. Resident #96 required extensive assistance of one staff member for bed mobility, transfers, and locomotion on the unit. Resident #96's mood was not assessed. Review of the Activity Calendar for the Memory Care Unit dated 07/2023 revealed four to seven activities were provided each day, but activities actually documented for Resident's #15 and #96 were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some minimal. Resident #96 had eight activities documented from 07/07/23 through 07/31/23 and Resident #15 had six activities documented for the same time period. Review of Resident #96's activities dated 07/07/23 through 07/31/23 revealed no arts and crafts activities were attended. Review of the game, puzzle activity revealed balloon toss was attended on 07/26/23 and 07/27/23. Resident #96 attended cooking on 07/27/23, and received a snack on 07/28/23. Resident #96 received mail on 07/12/23. Resident #96 attended dinner music on 07/21/23 and musical guest on 07/23/23. Further review did not reveal any one on one visit, activity, or other activity was attended. Resident #96 did not attend any outside, community activity or any party, holiday activity. Resident #96 did not attend any type of religious activity. Resident #96 attended a pet visit on 07/11/23. No other activities were documented. Observation on 08/03/23 at 12:05 P.M. revealed Resident #15 sitting quietly at a table in the common area waiting to be served the lunch meal. Interview on 08/03/23 at 4:22 P.M. of Anonymous Individual (AI) #301 revealed the memory care nursing unit had very few activities conducted during 07/2023. AI #301 stated residents just sat with nothing to do. Observation on 08/03/23 at 4:30 P.M. revealed Resident #96 sitting quietly in his wheelchair in the common area. Resident #96 was unable to be interviewed. Interview on 08/07/23 at 11:38 A.M. of Social Services Designee (SSD) #280 revealed she recently changed positions in 06/2023 and was the facility Activity Director previous to the change. SSD #280 stated the Memory Care nursing unit (400 hall) had a separate activity calendar from the other nursing units in the facility. SSD #280 stated the facility had one Activity Director (AD #202) and one Activity Assistant (AA#200). SSD #280 stated all activities the residents' attended were documented in the resident's electronic medical record. SSD #280 stated documentation should be accurate because the activity staff were able to keep up with the documentation on a daily basis. Interview on 08/07/23 at 11:55 A.M. of State Tested Nursing Assistant (STNA) #255 revealed there was a change of activity staff recently, and activities in Memory Care were not as often for awhile and there was a bit of a gap due to changes. STNA #255 stated activities for sure suffered for a few weeks in 07/2023 during the transition of activities from SSD #280 to AD #202. Interview on 08/07/23 at 12:30 P.M. of AD #202 revealed she became the Activity Director about two weeks ago and before that was an STNA on the Memory Care nursing unit. AD #202 stated she made sure activities were done every day, but was not sure if activities were getting charted, and she was going to make sure they were documented every day going forward. Interview on 08/07/23 at 3:02 P.M. of the Administrator and AA #200 revealed AA #200 worked on a part time basis until a week or two ago when she became a full time Activity Assistant. The Administrator stated an Activity Director was hired and started working in the facility around the beginning of 07/2023, worked a week and quit. The Administrator stated activities were always done in the Memory Care unit. Interview on 08/09/23 at 3:45 P.M. of Family Member (FM) #300 revealed she was unhappy with the activities Resident #15 attended while residing in the facility. FM #300 stated Resident #15 was not stimulated and was provided minimal if any activities. FM #300 stated she was supposed to have once a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 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 0679 Level of Harm - Minimal harm or potential for actual harm week face times which were frequently missed, and she was sad when the face times were missed because she very much enjoyed seeing her mother during the face time encounters. FM #300 indicated even if Resident #15 was at the end of life stage she should still be stimulated and have activities provided. Resident #15 stated when family visited they rarely saw activities conducted, and Resident #15 was usually sitting with no stimulation. Residents Affected - Some Review of the facility census revealed Resident's #1, #3, #7, #11, #12, #15, #17, #23, #29, #46, #47, #53, #54, #55, #56, #60, #66, #71, #73, #74, #76, #81, #85, #88, #96 resided on the memory care unit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 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 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 observation, interview, record review and review of the facility policy, the facility failed to ensure appropriate hand hygiene was completed for Resident #2 who was in isolation and contact precautions for suspected clostridium difficile (C Diff), failed to ensure stool specimen's for Resident's #2 and #30 were collected timely and failed to ensure Resident #30's stool specimen was sent to the lab accurately labeled. This affected two resident's (Resident's #2 and #30) out of three residents reviewed for infection control and had the potential to affect all 22 residents (Resident's #2, #6, #8, #18, #20, #21, #22, #24, #25, #30, #33, #40, #42, #50, #65, #70, #79, #84, #86, #91, #92, #97) residing on the facility's 200 nursing unit. The facility census was 100. Residents Affected - Some Findings include: 1. Review of Resident #2's medical record revealed an admission date of 05/25/23 and diagnoses included diffuse large B-cell lymphoma, intrathoracic lymph nodes, hypertension and major depressive disorder. Review of Resident #2's admission Minimum Data Set (MDS) 3.0 assessment revealed Resident #2 was cognitively intact. Resident #2 required extensive assistance of one staff member for bed mobility, limited assistance of one staff member for transfers and toilet use. Resident #2 was always continent of urine and bowel. Review of Resident #2's care plan dated 06/07/23 included Resident #2 had the potential for impairment of skin integrity. Skin interventions were maintained, and Resident #2 would have no avoidable skin breakdown. Interventions included to turn and reposition every two hours while in bed; apply moisture barrier after each incontinent episode. Further review of the care plan did not reveal a care plan related to C Diff (inflammation of the colon caused by the bacterial clostridium difficile). Review of Resident #2's progress notes dated 08/02/23 at 1:30 P.M. written by Licensed Practical Nurse (LPN) #236 revealed orders put in for stool sample to rule out C Diff. Resident and family notified. Review of Resident #2's physician orders dated 08/02/23 at 1:36 P.M. revealed orders for a stool specimen, diagnosis ICD 10 code (International Classification of Diseases, tenth revision), A04.7 (enterocolitis due to clostridium difficile), one time only for diarrhea. Review of Resident #2's physician orders dated 08/03/23 at 9:50 A.M. revealed orders for a stool specimen, diagnosis ICD 10 code A04.7. Observation on 08/03/23 at 10:55 A.M. revealed Resident's #2 and #65 resided in the same room. There was no observation of a contact precautions sign on the door or wall outside room [ROOM NUMBER] and no PPE supplies were noted on the door or in a plastic cart outside of the room. Review of Resident #2's progress notes dated 08/03/23 at 12:16 P.M. revealed Resident #2 and family notified of room move. Resident #2's clinical needs required the change. Review of Resident #2's progress notes dated 08/03/23 at 1:36 P.M. revealed orders for a stool sample collected on 08/03/23 and was in the refrigerator awaiting pick up on 08/04/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Review of Resident #2's physician orders dated 08/03/23 at 2:02 P.M. revealed single room isolation, contact precautions to rule out C Diff, every shift for three days. Review of Resident #2's lab results collected on 08/03/23 at 12:00 P.M. and reported on 08/04/23 at 3:16 P.M. revealed stool for occult blood (hidden blood) was negative. Residents Affected - Some Observation on 08/03/23 at 4:40 P.M. of Resident #2 revealed he resided in a new room. Resident #2 stated he was moved from his previous this morning around 12:00 P.M. Resident #2 stated he was under observation for C Diff. Resident #2 stated he had loose stools and C Diff. Review of Resident #2's physician orders dated 08/04/23 at 7:22 P.M. revealed stool specimen for C Diff, diagnosis ICD 10 code A04.7., until 08/07/23 at 11:59 P.M. Review of Resident #2's progress notes from 08/03/23 through 08/07/23 did not reveal notes a stool specimen was collected and sent to the lab to rule out C Diff. Review of Resident #2's lab results from 08/04/23 through 08/07/23 did not reveal a lab result for stool collected and checked for C Diff. Observation on 08/07/23 at 9:15 A.M. revealed Resident #2's breakfast tray was brought to his room on a cart with wheels and the cart was placed outside his room. The Director of Nursing (DON) picked up the breakfast tray from the cart, walked into Resident #2's room and delivered Resident #2's breakfast tray to him. The DON exited the room, did not wash her hands, used hand sanitizer and left the area. Observation on 08/07/23 at 9:18 A.M. of State Tested Nursing Assistant (STNA) #250 revealed she used hand sanitizer, and walked into Resident #2's room to give him a drink for breakfast, walked out of the room, did not wash her hands, used hand sanitizer, and walked to the drink cart. STNA #250 prepared a drink for Resident #87, did not wash her hands, walked into Resident #87's room, and delivered the drink to him. Interview on 08/07/23 at 9:33 A.M. of STNA #250 confirmed she did not wash her hands after giving Resident #2 a drink and leaving his room. Observation on 08/07/23 at 9:51 A.M. of Licensed Practical Nurse (LPN) #236 revealed she prepared medications to be administered to Resident #2. LPN #236 donned an isolation gown and gloves, picked up the medications which were in a plastic cup and walked into Resident #2's room. LPN #236 administered the medications to Resident #2, and walked out of the room to the medication cart. After arriving at the medication cart LPN #236 removed her isolation gown and gloves and placed them in the trash bin located on the side of the medication cart. LPN #236 used hand sanitizer, but did not wash her hands after removing her isolation gown and gloves. LPN #236 confirmed she placed her isolation gown and gloves in the trash bin on the medication cart, stated she should not have done that, and closed the trash bag with the soiled isolation gown and gloves and took it to the dirty utility room. LPN #236 used hand sanitizer, but did not wash her hands. LPN #236 proceeded to prepare medications for Resident #86, did not wash her hands and walked into Resident #86's room and administered the medications. LPN #236 confirmed she did not wash her hands after administering medications to Resident #2 and removing her isolation gown and gloves. LPN #236 confirmed she did not wash her hands before administering medications to Resident #86. LPN #236 stated she should have washed her hands. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Interview on 08/07/23 at 2:26 P.M. of the DON confirmed staff did not wash their hands after walking out of Resident #2's room who had suspected C Diff. Observation on 08/08/23 at 10:30 A.M. of Resident #2 revealed he was back in his old room. Observation did not reveal a contact precaution sign outside his room or PPE supplies. Residents Affected - Some Interview on 08/08/23 at 10:30 A.M. of Resident #2 revealed he was suspected to have C Diff, the staff took a stool sample and sent it to the lab. Resident #2 indicated the lab ran the wrong test, checked his stool for blood but not C Diff. Resident #2 stated he was put in isolation in a new room because his stools were soft, and he told the nurse's he did not need a laxative because he had multiple bowel movements during the day. Resident #2 stated he was moved back to original this morning under the assumption he did not have C Diff, but he was not sure because a second stool specimen was never collected. Resident #2 indicated he told staff he could give another specimen, but was told no, another stool specimen was not needed. Resident #2 stated he did not know why a second stool specimen was not collected, how could the follow up be so bad, and lets get another sample, check it and then we would know for sure if he had C Diff or not. Resident #2 stated it was terrible being confined to his room and he could not leave the room or go outside the whole time. Interview on 08/08/23 at 11:15 A.M. of the DON and Assistant Director of Nursing (ADON) #278 revealed Resident #2 was placed in isolation on 08/03/23. ADON #278 stated she did not know why Resident #2 was not put in single room isolation with contact precautions on 08/02/23 when his progress notes stated orders were put in for a stool specimen to rule out C Diff. ADON #278 stated on 08/03/23, as soon as she was aware Resident #2 was suspected for C Diff he was moved to a single room and placed on contact precautions. ADON #278 stated she did not know why Resident #2's physician order dated 08/02/23 at 1:36 P.M. did not specify diarrhea for C Diff instead of stool for diarrhea. ADON #278 stated the ICD 10 code of A04.7 was correct, but the lab ran the test for occult blood instead of C Diff. ADON #278 stated a second specimen was not obtained because Resident #2 was not having diarrhea, his stool was formed, and he was taken off contact precautions. ADON #278 stated she was not sure why the Nurse Practitioner was not contacted before 08/07/23 to let her know the second stool specimen was not collected. The DON and ADON #278 stated they were aware staff were not washing their hands after they were in Resident #2's room who had suspected C Diff. Interview on 08/08/23 at 11:44 A.M. of LPN #236 revealed Resident #2 brought it to her attention that he was having soft stools for the past couple weeks and he did not need laxatives. LPN #236 stated Resident #2's roommate told her he was having diarrhea and because another resident (Resident #22) was being treated for C Diff and resided in the same hall with the same STNA we were afraid of cross contamination and a stool specimen for C Diff was ordered. LPN #236 stated when she arrived for work on 08/06/23 she thought Resident #2 needed a test for C Diff, checked the lab results and found out the lab ran the wrong test (occult blood) on the specimen collected on 08/03/23. LPN #236 indicated the lab was not called on 08/06/23 when the mistake was found because the lab staff did not work on Sunday. LPN #236 stated the lab was contacted on 08/07/23 and it was confirmed the wrong test was completed on Resident #2's stool specimen. After the lab was contacted it was found Resident #2 had soft stool, no diarrhea, no odor to the stool, and he was taken off precautions. Review of the facility policy titled Transmission Based Precautions reviewed 05/2023 included contact precautions: in addition to standard precautions for C Diff residents with pending and or positive for C Diff would be placed in single room isolation. [NAME] PPE prior to contact with the resident. Alcohol based sanitizers were not effective, staff must wash their hands with soap and water before leaving the room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Review of Resident #30's medical record revealed an admission date of 04/02/20 and diagnoses included chronic obstructive pulmonary disease, heart failure and type two diabetes mellitus. Review of Resident #30's Quarterly MDS assessment dated [DATE] revealed Resident #30 was cognitively intact. Resident #30 required supervision for bed mobility, transfers, and toilet use. Resident #30 was always continent of bowel and occasionally incontinent of urine. Review of Resident #30's late entry progress note, effective date 07/31/23 at 12:51 P.M. stated Resident #30 was complaining of diarrhea and weakness. Medical Doctor (MD) #290 was texted, and order was put in for urine culture and sensitivity and a stool sample to rule out C Diff. Resident and family notified. Review of Resident #30's physician orders dated 08/01/23 at 6:45 A.M., 08/03/23 at 2:02 P.M. and 08/07/23 at 9:37 A.M. revealed single room isolation, contact precautions for C Diff, every shift. Review of Resident #30's physician orders dated 08/01/23 at 2:53 P.M. revealed orders for stool for C Diff and urine for urinalysis and culture and sensitivity. Review of Resident #30's physician orders dated 08/02/23 at 3:48 P.M., 08/02/23 at 5:32 P.M., and 08/04/23 at 6:53 P.M. revealed orders for stool for C Diff. Review of Resident #30's progress notes dated 08/04/23 at 5:40 P.M. included Resident #30 was able to provide a stool specimen to be sent out to rule out C Diff. Review of Resident #30's lab results for stool specimen collected on 08/02/23 and reported on 08/04/23 at 12:23 P.M. revealed stool culture was pending and the problem was an incorrect specimen collected by the long term care facility. Review of Resident #30's progress notes from 08/04/23 through 08/07/23 did not reveal a second stool specimen was obtained and sent to the lab to be checked for C Diff. Observation on 08/03/23 at 4:45 P.M. of Resident #30's room revealed a contact precaution sign outside the room and a plastic cart filled with PPE (personal protective equipment) by the door of the room. Resident #30 resided in the room and was lying on his bed with his eyes closed. Review of Resident #30's lab results for the stool specimen collected on 08/07/23 at 4:10 P.M. and reported 08/08/23 at 6:40 A.M. stated C Diff DNA Amplification results were pending. Interview on 08/08/23 at 11:27 A.M. of the DON and ADON #278 revealed on 07/31/23 Resident #30 complained of diarrhea and an order was obtained from MD #290 to collect a stool specimen to rule out C Diff. ADON #278 confirmed on 08/01/23 an order for isolation and contact precautions was placed, and she did not know why Resident #30 was not placed in isolation and contact precautions on 07/31/23 when C Diff was suspected. ADON #278 stated on 08/02/23 a stool specimen was collected by facility staff and picked up by the lab. ADON #278 stated the stool specimen was labeled incorrectly (there was a label on bag which contained the specimen but there was no label on specimen container) and the lab was unable to check the stool specimen for C Diff. ADON #278 stated a second specimen was collected on 08/07/23 and sent to the lab for C Diff, and the results were pending. ADON #278 stated the stool specimen was formed and was sent to lab to be checked for C Diff even though earlier she stated Resident #2's specimen was not sent to the lab to be checked because it was formed. ADON #278 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 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 365865 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some they wanted to be sure Resident #30 did not have C Diff. The DON stated specimen follow up started with the charge nurse assigned to the nursing unit, if a specimen was not followed up by the charge nurse then the night supervisor would follow up, unit managers should follow up with specimens, then ADON #278 and the DON. The DON stated the lab usually did not pick up specimens on the weekend, but would come if the specimen needed to be taken to the lab before Monday. The DON stated she did not know how the specimen was missed and it did not stand out to her when she reviewed lab results. Interview on 08/08/23 at 11:44 A.M. of LPN #236 revealed she knew Resident #30 needed a stool specimen sent for C Diff, but she did not send the specimen to the lab. Review of the facility census revealed Resident #2, #6, #8, #18, #20, #21, #22, #24, #25, #30, #33, #40, #42, #50, #65, #70, #79, #84, #86, #91, #92, #97 resided on the 200 unit. This deficiency represents non-compliance investigated under Complaint Number OH00144952. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365865 If continuation sheet Page 10 of 10