Health inspection·April 13, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Review of an admission MDS assessment dated [DATE] for Resident #35 revealed Resident #35 was cognitively intact and required extensive assist for ADLs. Review of call light times for Resident #35 revealed a call time of 65 minutes and 34 seconds on 04/09/23 at 4:17 P.M. Residents Affected - Few Interview on 04/13/23 at 9:33 A.M. with Resident #35 stated the staff are busy and get to the call lights in order, but sometimes the residents have to wait. Interview on 04/13/23 at 10:13 A.M. with Director of Nursing (DON) verified call lights for Resident #5, Resident #21, and Resident #35 were not answered in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365911 If continuation sheet Page 2 of 14 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 365911 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winchester Terrace 70 Winchester Rd Mansfield, OH 44907 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and resident and staff interviews, the facility failed to bathe residents per their preference. This affected one (#2) of seven residents reviewed for bathing. The census was 37. Findings include: Review of Resident #2's medical record identified admission to the facility occurred on 02/07/23 with medical diagnoses including quadriplegia, high blood pressure, and pressure ulcers. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was cognitively intact. Review of section F of the MDS identified under the question how important it was for the resident to choose between a tub, shower, or bed bath, Resident #2 rated it was somewhat important on scale of one to five, with one being most important. The assessment further identified Resident #2 was totally dependant on staff for bathing. Review of Resident #2's written plan of care for activities of daily living (ADLs) dated 02/07/23 revealed he was totally dependent on staff for bathing, showers, and hygiene. The plan identified for staff to allow for choices whenever able. Interview with Resident #2 on 04/12/23 at 4:13 P.M. stated he was scheduled for two showers a week, on Tuesday and Saturdays, during the day shift. Resident #2 confirmed he was usually only getting one shower a week and a bed bath the other days. Resident #2 stated he preferred to get showers at a minimum of twice a week. Resident #2 identified the staff would do the bed baths because it was faster and not providing showers as scheduled. Resident #2 confirmed on 04/11/23 he missed his shower, and was given a bed bath because he was told a staff member called off. Review of Resident #2's shower and bathing records completed the last 14 days revealed Resident #2 received a shower on 04/05/23 and a bed bath the other days. Interview with the Director of Nursing (DON) on 04/13/23 at 7:52 A.M. confirmed Resident #2 was only provided an actual shower on 04/05/23 in the past 14 days. The DON confirmed Resident #2's listed preference was for a shower and not a bed bath. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365911 If continuation sheet Page 3 of 14 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 365911 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winchester Terrace 70 Winchester Rd Mansfield, OH 44907 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 0567 Honor the resident's right to manage his or her financial affairs. 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 funds management system, and resident, family and staff interviews, the facility failed to obtain written authorization prior to opening resident personal needs accounts. This affected four (#8, #16, #19, and #28) of four resident personal needs accounts reviewed. The facility identified Resident #8, #16, #19, and #28 as the only residents with personal needs accounts. The census was 37. Residents Affected - Some Findings include: 1. Review of Resident #8's medical record identified admission to the facility occurred on 06/02/22. Review of Resident #8's Minimum Data Set (MDS) dated [DATE] revealed Resident #8 was assessed with severely impaired cognition. Resident #8's payer source was listed as Medicaid. Review of Resident #8's personal needs account (PNA) revealed a balance on 03/31/23 of $700.15. There was no written authorization provided that indicated Resident #8 or a legal representative authorized for personal funds to be deposited in an account with the facility. 2. Review of Resident #16's medical record identified admission to the facility occurred on 06/15/22. Resident #16 was identified as a Medicaid payer source. Review of Resident #16's PNA revealed a balance on 03/31/23 of $600.30. There was no written authorization provided that indicated Resident #16 or a legal representative authorized for personal funds to be deposited in an account with the facility. 3. Review of Resident #19's medical record revealed an admission date of 06/11/21. Resident #19 was identified as a Medicaid payer source. Review of Resident #19's PNA revealed a balance on 03/31/23 of $951.28. There was no written authorization provided that indicated Resident #19 or a legal representative authorized for personal funds to be deposited in an account with the facility. 4. Review of Resident #28's medical record revealed an admission date of 10/29/21. Review of the MDS assessment dated [DATE] revealed Resident #28 was assessed with moderately impaired cognition. Resident #28 was identified as a Medicaid payer source. Review of Resident #28's PNA revealed a balance on 03/31/23 of $750.78. There was no written authorization provided that indicated Resident #28 or a legal representative authorized for personal funds to be deposited in an account with the facility. Interview with the Administrator on 04/10/23 at 9:10 A.M. stated the facility did not maintain any residents PNA accounts at the facility, and the corporate office maintained the resident funds. Interview with the Administrator on 04/13/23 at 11:04 A.M. confirmed there was no evidence of any written authorization for the facility to manage any resident funds for Resident #8, Resident #16, Resident #19 and Resident #28. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365911 If continuation sheet Page 4 of 14 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 365911 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winchester Terrace 70 Winchester Rd Mansfield, OH 44907 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 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility funds management system, and resident, family and staff interviews, the facility failed to provide quarterly statements of account activity and failed to maintain resident fund records in a clear and understandable manner. This affected four (#8, #16, #19, and #28) of four resident personal needs accounts reviewed. The facility identified Resident #8, #16, #19, and #28 as the only residents with personal needs accounts. The census was 37. Findings include: 1. Review of Resident #8's medical record identified admission to the facility occurred on 06/02/22. Review of Resident #8's Minimum Data Set (MDS) dated [DATE] revealed Resident #8 was assessed with severely impaired cognition. Resident #8's payer source was listed as Medicaid. Review of Resident #8's personal needs account (PNA) revealed Resident #8 had a balance of $700.00 on 01/15/23 and on 03/31/23 was given interest brining the balance to $700.15. Further review of the account document revealed no monthly addition of Resident #8's monthly $50.00 PNA allowance or accounting of any deposits or withdrawals. 2. Review of Resident #16's medical record identified admission to the facility occurred on 06/15/22. Resident #16 was identified as a Medicaid payer source. Review of Resident #16's PNA revealed a balance on 10/01/22 of $600.00, on 12/31/22, a balance of $600.15, and on 03/31/23 a balance of $600.30. Further review of the account document revealed no monthly addition of Resident #16's monthly $50.00 PNA allowance. Interview with Resident #16's sister on 04/13/23 at 1:27 P.M. confirmed confirmed any time herself or Resident #16 asked for some of his PNA account funds the facility informed them it was all done at the cooperate office, and the facility had nothing to do with it. Further interview with Resident #16's sister stated she did not get statements that show where all of Resident #16's personal funds deposits and withdrawals. 3. Review of Resident #19's medical record revealed an admission date of 06/11/21. Resident #19 was identified as a Medicaid payer source. Review of Resident #19's PNA revealed a balance on 06/30/22 of $950.54, a balance on 09/30/22 of $950.78, a balance on 12/31/22 of $951.03, and a balance on 03/31/23 of $951.28. Further review of the account document revealed no monthly addition of Resident #19's monthly $50.00 PNA allowance. 4. Review of Resident #28's medical record revealed an admission date of 10/29/21. Review of the MDS assessment dated [DATE] revealed Resident #28 was assessed with moderately impaired cognition. Resident #28 was identified as a Medicaid payer source. Review of Resident #28's PNA revealed a balance on 06/30/22 of $750.19, a balance of $750.38 on 09/30/22, a balance of $750.58 on 12/31/22, and a balance of $750.78 on 03/31/23. Further review of the account document revealed no monthly addition of Resident #28's monthly $50.00 PNA allowance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365911 If continuation sheet Page 5 of 14 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 365911 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winchester Terrace 70 Winchester Rd Mansfield, OH 44907 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 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with Resident #28 on 04/13/23 at 11:12 A.M. stated he had no idea if he received a monthly PNA allowance or if it was placed into his account. Further interview with Resident #28 stated he did not remember ever getting any statements for his account. Interview with the Administrator on 04/10/23 at 9:10 A.M. stated the facility did not maintain any residents PNA accounts at the facility, and the corporate office maintained the resident funds. Interview with the Administrator on 04/13/23 at 11:04 A.M. confirmed there was no way to determine when the monthly $50.00 PNA allowances for Resident #8, Resident #16, Resident #19 and Resident #28 were deposited since it was not documented. Interview with Business Office Manager (BOM) #56 on 04/13/23 at 12:29 P.M. stated she started her role at the facility on 02/28/23. BOM #56 confirmed she had to contact the cooperate office if any resident asked for monies from their PNA accounts, and confirmed looking at Resident #8, Resident #16, Resident #19 and Resident #28's PNA account records there was no documentation of when their monthly $50.00 allowance was deposited or located. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365911 If continuation sheet Page 6 of 14 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 365911 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winchester Terrace 70 Winchester Rd Mansfield, OH 44907 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital discharge record review, and staff interview, the facility failed to confirmed a resident's code status upon admission to ensure accuracy. This affected one (#37) of 16 sampled residents reviewed for code status. The census was 37. Findings include: Review of Resident #37's medical record identified admission to the facility occurred on [DATE] with medical diagnoses including anemia, weakness, dementia, and history of falling. Review of Resident #37's discharge medical records from the hospital dated [DATE] revealed on [DATE] the hospital physician met with Resident #37's sister, and the hospital records revealed Resident #37 signed papers at the hospital to change his code status to Do Not Resuscitate (DNR) which instructed health care providers not to do cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was assessed with severely impaired cognition. Review of Resident #37's baseline plan of care written at the time of admission identified Resident #37 was listed as a full code (full life saving measures in the event of cardiac or respiratory arrest). The records identified no evidence of the hospital discharge instructions which included Resident #37's DNR code status. Review of care conference notes dated [DATE] revealed Resident #37 was noted to need long term care and had a full code status. The note revealed no evidence any attempts were made to speak with Resident #37 regarding his or his sister's wishes to determine code status. Interview with Social Services Designee (SSD) #62 on [DATE] at 9:08 A.M. stated Resident #37's lived at home with his sister and brother prior to admission to the hospital. SSD #62 stated she had concerns Resident #37's sister was not capable of making decisions for Resident #37, so the facility did not follow the hospital discharge instruction for Resident #37 to be a DNR and placed him as a full code. Interview with SSD #62 confirmed the hospital records did show any evidence the hospital questioned Resident #37's sister's ability to make informed healthcare decisions. Further interview with SSD #62 stated the facility held a care conference for Resident #37 on [DATE] which only facility staff attended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365911 If continuation sheet Page 7 of 14 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 365911 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winchester Terrace 70 Winchester Rd Mansfield, OH 44907 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and resident and staff interviews, the facility failed to provide adequate finger nail care for dependent residents. This affected two (#21 and #36) of four residents reviewed for activities of daily living (ADLs). The census was 37. Residents Affected - Few Findings include: 1. Review of Resident #21's medical record identified the resident was admitted on [DATE] with medical diagnoses including falls, muscle weakness, high blood pressure, and coronary artery disease (CAD). Review of the admission comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was assessed with intact cognition and required extensive assistance of one person with personal hygiene. Review of Resident #21's written plan of care identified she was totally or nearly dependent on staff for bathing, hygiene, and dressing. Observation and interview with Resident #21 on 04/10/23 at 10:01 A.M. revealed Resident #21's finger nails were very long and some were jagged. Interview with Resident #21 at this time confirmed she did not like her finger nails long, and no one cut them or asked if she wanted them cut since her admission. Observation of Resident #21's finger nails occurred with the Director of Nursing on 04/11/23 at 9:58 A.M. confirmed Resident #21's finger nails needed cleaned and cut. 2. Review of Resident #36's medical record identified admission to the facility occurred on 02/25/23 under hospice care services with diagnoses including dementia, anxiety and restlessness. Review of Resident #36's medical record revealed the resident was non-verbal and was dependant on staff for all care. Observation of Resident #36 on 04/11/23 at 7:26 A.M. revealed Resident #36 had both hands in a fist with very long finger nails. The finger nails on both thumbs were extremely long and had dried substances under the nails. Observations on 04/12/23 at 10:31 A.M. of Resident #36 verified her finger nails remain long and unkept. Resident #36 was observed to make tight fists when moved in bed. Observation of Resident #36's hands and interview with the Director of Nursing on 04/11/23 at 10:03 A.M. confirmed Resident #36's finger nails were long and unkept. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365911 If continuation sheet Page 8 of 14 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 365911 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winchester Terrace 70 Winchester Rd Mansfield, OH 44907 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 2. Review of Resident #24's medical record identified admission to the facility occurred on 02/21/23 with medical diagnosis including history of breast cancer, chronic obstructive pulmonary disease, and congestive heart failure. Review of Resident #24's medical record revealed Resident #24 was assessed as cognitively intact. Residents Affected - Few Review of Resident #24's activities participation logs between 03/12/23 and 04/12/23 revealed four days in the past 30 days of activities participation (03/19/23, 03/27/23, 03/28/23, and 04/11/23). Interview with Resident #24 on 04/10/23 at 1:17 P.M. stated the facility activities program was lacking. The interview confirmed there was not a whole lot scheduled for the residents to do, and Resident #24 stated she tried to keep herself busy, but it would be nice to have events scheduled more often. Reviewed the activities calendar for April 2023 revealed the calendar had two events listed daily at 9:00 A.M. and 2:00 P.M. with, The daily Chronicle as the morning event every day. Random observations of the facility on 04/12/23 and 04/13/23 revealed there were no activity staff person and no activities that occurred at all those days. Interview with the Administrator and Director of Nursing on 04/12/23 at 1:59 P.M. confirmed the facility's April 2023 activities calendar consists of activities only at 9:00 A.M. and 2:00 P.M. daily. The interview confirmed there was no one in the facility to complete any activities on 04/12/23. The staff members stated the facility's current activities director was also a licensed state tested nursing assistant (STNA) and was pulled to provide direct resident care at times. The staff members confirmed the facility's activities program was lacking effective activities for the residents, and stated there was no evidence the residents were involved in the decisions about what activities they would like to complete or have scheduled. Based on observation, medical record review, resident and staff interview, and review of an activity calendar, the facility failed to ensure activities met the needs of the residents. This affected two (#10 and #24) of 13 residents reviewed for activities. The census was 37. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 09/10/21 with diagnoses including rheumatoid arthritis, atrial fibrillation, morbid obesity, nonrheumatic mitral valve insufficiency, major depressive disorder, fibromyalgia, osteoarthritis, unspecified psychosis, anxiety, hypertension, and gastroesophageal reflux disease. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 01/12/23 revealed Resident #10 was assessed with intact cognition and required extensive assist for activities of daily living (ADLs). Review of the care plan for Resident #10 dated 01/12/23 revealed the resident was very active in activities. Resident enjoyed BINGO, crafting, and cooking activities. Interventions included encourage ongoing family involvement, invite the resident's family and friends to attend special events, activities, and meals, introduce the resident to other residents with similar background, interest, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365911 If continuation sheet Page 9 of 14 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 365911 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winchester Terrace 70 Winchester Rd Mansfield, OH 44907 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 - Few encourage or facilitate interaction, invite the resident to scheduled activities, provide a program of activities that was of interest, and empower the resident by encouraging and allowing choice, self-expression, and responsibility. Interview on 04/10/23 at 8:52 A.M. with Resident #10 stated the facility did not have activities on the weekend and stated there was only one staff member in activities. Resident #10 stated she would like more activities. Follow up interview on 04/12/23 at 9:09 A.M. with Resident #10 verified she would like to see more activities and would like to go out. Stated she would like to have an exercise class. Follow up interview on 04/13/23 at 11:15 A.M. with Resident #10 verified the facility does not provide activities when the activity director is off work. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365911 If continuation sheet Page 10 of 14 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 365911 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winchester Terrace 70 Winchester Rd Mansfield, OH 44907 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and staff interviews, the facility failed to provide pressure ulcers prevention interventions as indicated. This affected one (#36) of two residents reviewed for pressure ulcers. The census was 37. Residents Affected - Few Findings include: Review of Resident #36's medical record identified admission to the facility occurred on 02/25/23 under the care of hospice services for end of life care. Resident #36 had medical diagnoses including dementia, anxiety, restlessness and agitation. Review of Resident #36's admission Minimum Data Set (MDS) assessment dated [DATE] identified no skin issues at the time of admission; however, Resident #36 was identified at high risk for pressure ulcer development. Review of Resident #36's plan of care included a pressure reducing mattress. Review of Resident #36's medical record revealed on 03/27/23 Resident #36 was seen by a wound consultant for development of a pressure ulcer to the coccyx. The wound consultant note dated 03/27/23 identified Resident #36's physician requested to evaluate and manage Resident #36's wound. The report identified, upon admission on [DATE], Resident #36 was assessed as high risk for pressure ulcer development and the facility was using a barrier cream on the coccyx. The notes identified on 03/27/23 an unavoidable pressure ulcer measuring 1.0 centimeters (cm) long by 3.0 cm wide by 0.1 cm deep developed to Resident #36's coccyx. The notes identified new treatment orders and intervention of a low air loss (LAL) mattress was needed for Resident #36. Review of Resident #36's wound consultant notes dated 04/03/23 identified Resident #36 continued with the coccyx wound and developed two new areas to both heels. The wounds on the heels were identified a black eschar (dead tissue) area that were unstageable (obscured full-thickness skin and tissue loss). The notes identified prevention measures should include a LAL mattress. Observation of Resident #36 on 04/11/23 at 7:26 A.M. revealed Resident #36's bed had a pressure reduction mattress; however, it was not a low air loss mattress. Observation of Resident #36 on 04/12/23 at 10:31 A.M. with State Tested Nurse Aide (STNA) #32 confirmed Resident #36's bed did not have a low air loss mattress. Resident #36 was observed to have dried black eschar skin to both heels. Resident #36 was observed to have a dressing to the coccyx area. Review of a treatment plan for Resident #36's heels revealed the wounds were palliative in nature and identified appropriate protective measures to the heels for comfort for the unavoidable wounds. Interview and observation with Licensed Practical Nurse (LPN) #42 on 04/12/23 at 1:22 P.M. confirmed Resident #36 did not have a low air loss mattress in place at that time. LPN #42 confirmed the wound consultant recommended the LAL mattress on 03/27/23 when Resident #36 developed a pressure ulcer to the coccyx. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365911 If continuation sheet Page 11 of 14 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 365911 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winchester Terrace 70 Winchester Rd Mansfield, OH 44907 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to provide nutritional interventions as ordered. This affected one (#92) of two residents reviewed for nutrition. The census was 37. Residents Affected - Few Findings include: Review of Resident #92's medical record identified admission occurred on 03/22/23. Resident #92 was placed on hospice services on 04/07/23 with medical diagnoses including; COVID-19, dementia, pulmonary nodules, and history of colon cancer. Review of Resident #92's nutritional admission assessment dated [DATE] revealed Resident #92 had a poor appetite and a physician order was placed to provide yogurt daily at breakfast. Further review revealed Resident #92's family indicated Resident #92 liked yogurt and would usually eat it. Review of Resident #92's admission weight on 03/28/23 revealed Resident #92 weighed 98 pounds. Observation of Resident #92 on 04/11/23 at 9:05 A.M. revealed Resident #92 was assisted with eating by State Tested Nurse Aide (STNA) #67 with no yogurt present. Interview at the time of the observation with STNA #67 confirmed Resident #92's meal ticket did not include to send yogurt and none was given to Resident #92 that morning for breakfast. Interview with Dietary Manager #33 on 04/11/23 at 12:19 P.M. confirmed Resident #92 had a current physician order for yogurt at breakfast and it was not documented on her breakfast meal ticket. Observation of Resident #92's on 04/12/23 at 8:22 A.M. revealed she was assisted by STNA #49 with her breakfast tray. Interview with STNA #49 at the time of the observation confirmed Resident #92's daughter filled out her meal tickets at times, and wrote down for Resident #92 to have yogurt for breakfast. The interview confirmed the meal ticket on 04/12/23 did include yogurt; however, it was not provided from the kitchen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365911 If continuation sheet Page 12 of 14 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 365911 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winchester Terrace 70 Winchester Rd Mansfield, OH 44907 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure residents were free from significant medication errors. This affected one (#12) of four residents reviewed for medications. The census was 37. Residents Affected - Few Findings include: Review of the medical record for Resident #12 revealed an admission date of 11/20/12 with diagnoses including cerebral infarction, flaccid hemiplegia affecting right dominant side, aphasia, major depressive disorder, hypothyroidism, anxiety, Bell's palsy, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was assessed with moderately impaired cognition. Review of a nurses note dated 04/06/23 revealed Resident #12 had new orders for the thyroid hormone levothyroxine (Synthroid) 200 micrograms (mcg), the cholesterol-lowering medication fenofibrate 145 milligrams (mg), and laboratory values on 07/06/23. Review of the April 2023 medication administration record (MAR) for Resident #12 revealed levothyroxine 175 mcg was documented as administered on 04/07/23, 04/08/23, 04/09/23, and 04/10/23, and Synthroid 200 mcg was also documented as administered on 04/07/23, 04/08/23, 04/09/23, and 04/10/23. Review of laboratory results dated [DATE] revealed Resident #12's thyroid stimulating hormone (TSH) level was 36.7 microunits per milliliter which was high with a normal range of 0.27 to 4.20 microunits per milliliter. Interview on 04/11/23 at 10:31 A.M. with the Director of Nursing (DON) verified according to the April 2023 MAR both levothyroxine orders were administered to Resident #12 on 04/07/23, 04/08/23, 04/09/23, and 04/10/23. The DON verified the nurse's note on 04/06/23 which revealed a new order for Synthroid 200 mcg, and the DON stated she would get with the nurse practitioner to check the medication cart to ensure levothyroxine 175 mcg was not on the medication cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365911 If continuation sheet Page 13 of 14 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 365911 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winchester Terrace 70 Winchester Rd Mansfield, OH 44907 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 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident, family, and staff interviews, and medical record review, the facility failed to timely follow up with dental services after a resident's dentures were lost. This affected one (#21) of seven residents reviewed for dental services. The census was 37. Residents Affected - Few Findings include: Review of Resident #21's medical record identified admission to the facility occurred on 02/13/23 with medical diagnoses including falls, muscle weakness, chronic obstruction pulmonary disease (COPD), and high blood pressure. Review of Resident #21's admission assessment dated [DATE] revealed Resident #21 had upper and lower dentures. Review of Resident #21's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively intact, required extensive assistance of one person for personal hygiene, and was assessed with no broken or loosely fitting dentures. The assessment identified Resident #21 would not be able to obtain her dentures without assistance from the staff. Observation and interview with Resident #21 on 04/10/23 at 1:06 P.M. revealed Resident #21 was observed with no teeth or dentures in her mouth. Resident #21 stated she had upper and lower dentures, and they were in a white denture cup in the bathroom, but stated the dentures were missing for a few weeks. Resident #21 stated staff were aware they were missing and was looking for them, but had not heard any other news about her teeth. Observation of an interactions between Resident #21 and the Director of Nursing (DON) on 04/11/23 at 9:58 A.M. revealed Resident #21 confirmed to the DON her dentures came up missing about two weeks ago. The DON indicated the facility social services designee (SSD) should be notified by staff when items come up missing. Interview with Resident #21's son on 04/12/23 at 10:06 A.M. stated he brought his mother's dentures in to the facility a few days after admission, and confirmed staff told him they would document it when he arrived. Resident #21's son stated the dentures were in a white denture cup, and Resident #21 told him the dentures were missing a few weeks ago. Resident #21's son stated the staff notified by him as well of the missing dentures, and confirmed there was no further follow up since that time. Interview with Social Service Designee (SSD) #62 on 04/11/23 at 10:09 A.M. stated there was a form that was completed for missing items; however, she could not locate any such form for Resident #21's missing dentures. Review of the missing items log with the Administrator on 04/11/23 at 10:54 A.M., located in the social service office, revealed only one missing item documented since June 2022. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365911 If continuation sheet Page 14 of 14