Health inspection·December 5, 2022

F 0558 Reasonably accommodate the needs and preferences of 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, medical record review, review of the facility's policy, and staff interview, the facility failed to ensure the call lights were within reach and accessible for the residents. This affected two (Residents #37 and #242) of 26 residents observed for call lights within reach. The facility census was 80. Residents Affected - Few Findings include: 1. Record review for Resident #242 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, type II diabetes mellitus, and hypertensive heart disease. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #242 was severely cognitively impaired and required extensive assistance of two for activities of daily living. Review of the care plan dated 11/22/22 revealed Resident #242 was at risk for falls with an intervention to have a call light within reach. Observation on 11/28/22 at 8:44 A.M. revealed Resident #242 was in her room, sitting in tilt-in-space wheelchair and appeared teary-eyed. The call light was noted to be located behind Resident #242's wheelchair, wrapped around the back of nightstand, and placed in the top draw adjacent to, and out of reach of Resident #242. Interview with Registered Nurse (RN) #865 on 11/28/22 at 8:47 A.M. verified the call light was out of reach for Resident #242. 2. Record review for Resident #37 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease and spinal stenosis. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #37 was alert and oriented and required extensive assistance of one for activities of daily living. Observation on 11/28/22 at 9:18 A.M. revealed Resident #37 was in her room, sitting in tilt-in-space wheelchair. Resident #37's call light was noted to be on the floor and out of reach. Interview on 11/28/22 at 9:22 A.M. with State Tested Nurse Assistant (STNA) #894 verified Resident #37's call light was out of reach. STNA #894 stated Resident #37 would be able to use the call light if it was within reach. Review of the facility's policy titled Call Light Response Time Policy, revised February 2022, revealed the facility had a policy in place to ensure resident needs and request were responded to in a timely manner by utilizing the call light. Review of the document revealed the facility did not implement the policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365924 If continuation sheet Page 2 of 13 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 365924 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amherst Manor Nursing Home 175 N Lake Street Amherst, OH 44001 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on medical record review, review of the facility's policy, and staff interview, the facility failed to ensure cognition and mood were assessed on the comprehensive Minimum Data Set (MDS) assessments for three (#23, #41, and #70) of 20 residents reviewed for cognition and mood. The facility census was 80. Findings include: 1. Review of Resident #41's medical record revealed an admission date of 10/19/22. Diagnoses included respiratory failure and chronic kidney disease. Review of the admission Minimum Data Set (MDS) assessment, dated 10/26/22, revealed Resident #41's cognition and mood were not assessed. The resident was marked as resident is rarely/never understood. The resident's preferred language was Spanish and the resident was noted to need or want an interpreter to communicate with a doctor or health care staff. Interview on 11/29/22 at 2:30 P.M. with Registered Nurse (RN) #846 verified Resident #41's cognition and mood were not assessed on the comprehensive assessment. RN #846 reported Resident #41 was marked as being rarely or never understood due to the language barrier. 2. Review of Resident #23's medical record revealed an admission to the facility occurred on 08/17/22. Diagnoses included Alzheimer's disease, dementia, and stroke. Review of the admission MDS assessment, dated 08/24/22, revealed the assessment was not completed fully. The sections identified C that assessed mental status and section D that assessed mood were not completed. Interview with RN/MDS Coordinator #846 on 11/29/22 at 2:35 P.M. confirmed two of the sections on the MDS assessment were not completed for Resident #23 and should have been. The RN/MDS Coordinator #846 stated Licensed Social Worker (LSW) #872 and herself were working on a system to ensure sections C and D were completed. 3. Review of Resident #70's medical record revealed an admission to the facility occurred on 08/26/22. Diagnoses included Parkinson's disease and Lewy body dementia. Review of the admission MDS assessment, dated 09/02/22, revealed the assessment was not completed fully. The sections identified C that assessed mental status and section D that assessed mood were not completed. Interview with RN/MDS Coordinator #846 on 11/29/22 at 2:35 P.M. confirmed two of the sections of the MDS were not completed for Resident #70 and should have been. RN/MDS Coordinator #846 stated Licensed Social Worker (LSW) #872 and herself were working on a system to ensure sections C and D were completed. Review of the facility's policy titled MDS 3.0 Policy, dated May 2017, revealed it was the facility's policy to follow the guidelines and requirements set forth in the MDS 3.0 Manual including, but not limited to, completion, coding, storage and submission of MDS assessments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365924 If continuation sheet Page 3 of 13 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 365924 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amherst Manor Nursing Home 175 N Lake Street Amherst, OH 44001 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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, review of the facility policy, and staff interviews, the facility failed to provide a resident with an effective restorative ambulation program. This affected one (Resident #23) of four residents reviewed for restorative programs. The facility census was 80. Residents Affected - Few Findings include: Review of Resident #23's medical record revealed an admission to the facility occurred on 08/17/22. Diagnoses included Alzheimer's disease, COVID-19 (11/26/22), dementia, stroke, falls, and generalized weakness. Review of Resident #23's quarterly Minimum data set (MDS) assessment dated [DATE] revealed Resident #23 was severely impaired cognition. Resident #23 was able to ambulate with one person assistance, with the use of a walker. Review of the occupational therapy (OT) notes revealed Resident #23 received services from 08/23/22 through 09/19/22. The OT therapy notes revealed discharge instructions included Resident #23's prognosis to maintain current level of functioning (CLOF) was good with consistent staff follow through. The notes revealed to encourage the use of rollator during activities of daily living (ADLs). Review of the physical therapy (PT) notes dated 09/29/22 revealed Resident #23 received services from 09/01/22 through 09/29/22. The notes revealed recommended discharge instructions included a restorative nursing program for ambulation with forward wheeled walker (rollator). Review of the facilities physician orders for Resident #23 revealed on 09/16/22, a Floor Maintenance Program (FMP) which encouraged the resident's ambulation with rollator and assist with one person as tolerated, every shift. The physician order did not include the specific time or duration for the resident to be ambulating with the rollator walker. Review of the facilities restorative nursing documentation was completed for the month of November 2022. The report revealed Resident #23 was ambulated six times for the month of November. The records revealed all other days were marked as non-applicable. Observation of Resident #23's room on 11/28/22 at 8:08 A.M. revealed Resident #23 was observed to be sitting in a wheelchair and a red walker (rollator) was noted folded against the wall. Interview with State Tested Nursing Assistants (STNAs) #840 and #861 on 11/29/22 at 7:36 A.M. revealed they worked 6:00 A.M. to 6:00 P.M. (day shift). The staff were asked if Resident #23 ambulates with them. STNA #840 and #861 revealed Resident #23 was currently in isolation (COVID-19 positive) but has not been walking for about the last two months, since they have worked on the unit. The STNAs confirmed there was no specified time or duration of when to ambulate Resident #23. The STNAS stated they document in the facility's electronic medical record system for Resident #23 if they ambulate her. Interview with Registered Nurse/Restorative Nurse (RN) #828 on 11/30/22 at 7:49 A.M. confirmed there was a lack of specific measurable goals and specified approaches for Resident #23's ambulation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365924 If continuation sheet Page 4 of 13 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 365924 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amherst Manor Nursing Home 175 N Lake Street Amherst, OH 44001 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few program. RN #828 confirmed most days in the month of November 2022 were marked not applicable for ambulation for Resident #23. Review of the facilities restorative nursing policy, dated 10/2014, revealed services will be provided to any residents who had been revealed as having a need for such service. These services will include consistent and structured programs designed by Restorative Nurse and carried out by floor nursing assistants and specialized trained restorative aides on a day to day basis. The purpose of the program is to restore each resident to his or her fullest capacity in functioning at a level of independence consistent with his or her wishes or capabilities. The plan should include definition of the problem, measurable goals, and specific approaches. The policy revealed the floor aides will implement the program and document on a daily basis. This deficiency represents non-compliance investigated under Master Complaint OH00135938. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365924 If continuation sheet Page 5 of 13 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 365924 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amherst Manor Nursing Home 175 N Lake Street Amherst, OH 44001 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** 4. Review of Resident #292's medical record revealed the resident was admitted to the facility on [DATE]. Resident #292 died in the facility on 07/28/22. Diagnoses included chronic pancreatitis, chronic obstructive pulmonary disease (COPD), muscle weakness (generalized), unsteadiness on feet, history of falling, and presence of right artificial hip joint. Residents Affected - Some Review of the significant change MDS assessment dated [DATE] revealed Resident #292 had moderate cognition impairment. Resident #292 required extensive assistance of one staff for bathing. Review of the hospice documentation revealed hospice provided baths to Resident #292 on 07/19/22, 07/21/22, and 07/26/22. Review of the bathing task sheet from 05/13/22 to 07/27/22 revealed Resident #292 did not get a bath or shower on 05/17/22, 05/20/22, 05/24/22, 05/27/22, 06/24/22, 06/28/22, 07/08/22, and 07/12/22. There were 22 scheduled opportunities for Resident #292 to receive a bath or shower and Resident #292 did not receive eight of the 22 scheduled baths or showers. There was no documentation Resident #292 refused any baths or showers. Interview on 12/01/22 at 10:15 A.M. with the Director of Nursing (DON) verified there was no documentation proving Resident #292 was bathed every Tuesday and Friday per schedule. Review of the facility's policy titled Bathing Protocol, revised January 2021, revealed all residents were assigned to receive a bath/shower twice per week, residents would be interviewed on preference of frequency and time of day upon admission, the preference would be indicated in the resident specific task, the bathing scheduled would be altered according to resident preference as needed, and documentation of the bath/shower would be noted. This deficiency represents non-compliance investigated under Complaint Number OH00133892. Based on observations, medical record reviews, review of the facility policies, and resident, family and staff interviews, the facility failed to ensure residents who were dependent on staff for assistance with Activities of Daily living (ADLs) received assistance with eating, bathing, and dressing. This affected four (#18, #42, #62, and #292) of five residents reviewed for ADLs. The facility revealed 79 residents required assistance from staff with one or more ADLs. The facility census was 80. Findings include: 1. Review of Resident #18's medical record revealed an admission to the facility occurred on 12/07/18. Diagnoses included stroke, dementia/Alzheimer's disease, protein calorie malnutrition, dysphasia and COVID-19 (tested positive on 11/25/22). Resident #18 was admitted to hospice services for end of life care starting on 10/17/22. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 required supervision from one person with eating. Review of Resident #18's written plan of care revealed to assist with meals and feed the resident as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365924 If continuation sheet Page 6 of 13 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 365924 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amherst Manor Nursing Home 175 N Lake Street Amherst, OH 44001 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the physician progress notes dated 10/04/22 revealed Resident #18 has had a continual decline in health since the hip fracture in August 2022. Observation of the meal services on 11/28/22 at 8:19 A.M. revealed staff were delivering meals to residents throughout the unit. Resident #18 was provided her meal tray, inside her room. The tray was placed on her bedside table that was over her bed. Resident #18 was alone in her room and attempting to eat. Resident #18 was trying to open a container of applesauce that she was not able to open. Resident #18 was able to get food onto the spoon; however when attempting to take a bite, the food was mostly dropping off the spoon. Observation of Resident #18 on 11/29/22 at 8:29 A.M. revealed Resident #18 was in her bed, eating alone with her breakfast tray, and a towel was placed over her chest. Resident #18 was attempting to eat scrambled eggs and the eggs kept dropping off the spoon before she could get them to her mouth. Resident #18 was also observed to pick up a glass of juice and spilled the entire cup down the front of her before she could drink it. Resident #18 was observed to toss the spoon down on the plate in what appeared to be frustration. Interview with Registered Nurse (RN) #828 on 11/29/22 at 8:42 A.M. confirmed Resident #18 was not able to feed herself alone in bed. RN #828 confirmed staff were going to have to assist the resident when needed. Interview and observation with State Tested Nursing Assistant (STNA) #861 on 11/29/22 at 8:43 A.M. revealed Resident #18 would typically eat in the main dining room of the facility. However, Resident #18 was in isolation due to being positive for COVID-19 and Resident #18 had to eat her meals in her room alone. STNA #861 confirmed Resident #18 really needed some staff assistance while she was eating in bed due to the amount of food that was sitting on the towel of Resident #18's chest. 2. Review of Resident #62's medical record revealed an admission to the facility occurred on 08/15/22. Diagnoses included dementia, stroke affecting her right side, and insomnia. Review of the admission MDS assessment dated [DATE] revealed Resident #62 required extensive assistance of one staff person for dressing, due to her limited range of motion on the right side of her body. Observations of Resident #62 on 11/29/22 at 8:58 A.M. and 1:11 P.M. revealed Resident #62 was wearing a solid pink sweatshirt and solid grey sweatpants. Resident #62 was observed to ambulate with a cane and had white Tennis shoes one. Subsequent observation of Resident #62 on 11/30/22 at 7:44 A.M. revealed Resident #62 was wearing a solid pink sweatshirt and solid grey sweatpants, with what appeared as the same clothing she had on the day prior (11/29/22). Observation of Resident #62 on 12/01/22 at 7:39 A.M. revealed Resident #62 was sitting in the dinning room Resident #62 had the same solid pink sweatshirt and solid grey sweatpants that she had on 11/29/22 and 11/30/22. Interview with Registered Nurse (RN) #828 on 12/01/22 at 7:45 A.M. stated Resident #62 was moved into another room temporally due to COVID-19 outbreak within the facility. RN #828 confirmed Resident #62's clothing may not have been moved during the room change. RN #828 confirmed Resident #62 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365924 If continuation sheet Page 7 of 13 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 365924 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amherst Manor Nursing Home 175 N Lake Street Amherst, OH 44001 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some not capable of dressing herself and Resident #62 was wearing a solid pink sweatshirt and grey sweatpants. RN #828 confirmed staff should be assisting her to change clothing and she should not be wearing the same clothing for three days in a row. 3. Review of Resident #42's medical record revealed the resident was admitted to the facility on [DATE]. The resident was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Diagnoses included Parkinson's disease, muscle weakness, rheumatoid arthritis, and adult failure to thrive. Review of the admission MDS assessment, dated 10/07/22, revealed Resident #42 had intact cognition. Resident #42 required physical assistance of one staff for bathing. Resident #42 did not refuse or resist care. Review of the plan of care, dated 11/01/22, revealed Resident #42 had a self-care deficit related to Parkinson's, underlying disease, and weakness. Interventions included assisting with hygiene. The plan of care did not mention Resident #42 refused care. Review of the shower schedule revealed Resident #42 was to receive assistance with bathing on Tuesdays and Fridays on first shift. Review of the facility's task records for showers/baths for 11/01/22 through 11/28/22 revealed no evidence that Resident #42 was offered or received assistance bathing on 11/04/22, 11/08/22, 11/15/22, 11/25/22, or 11/28/22 as scheduled. Resident #42 was not documented as refusing on any of these dates. Resident #42 was documented as receiving two showers and refusing two showers within this time period. Interview with Resident #42 and Resident #42's family member on 11/28/22 at 9:44 A.M. revealed Resident #42 was supposed to receive showers twice per week and only had around three showers since residing in the facility. Interview on 11/29/22 at 3:38 P.M. with Licensed Practical Nurse (LPN) #837 verified Resident #42 only received two showers between 11/01/22 and 11/28/22 and there were no documented refusals for 11/04/22, 11/08/22, 11/15/22, 11/25/22, or 11/28/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365924 If continuation sheet Page 8 of 13 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 365924 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amherst Manor Nursing Home 175 N Lake Street Amherst, OH 44001 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 Based on observations, medical record review, and staff interviews, the facility failed to ensure the resident's wound dressing changes were completed as physician ordered and were accurately documented in the resident's medical record. This affected for one (Resident #18) of two residents reviewed for pressure ulcers. The facility identified 11 residents with pressure ulcers. The facility census was 80. Residents Affected - Few Findings include: Review of Resident #18's medical record revealed an admission to the facility occurred on 12/07/18. Diagnoses included stroke, dementia/Alzheimer's disease, fractured right femur, and protein calorie malnutrition. Resident #18 was admitted to hospice services for end of life care starting on 10/17/22. Review of the physician progress note dated 11/07/22 revealed Resident #18 had unstageable pressure ulcers (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar) to her right heel and buttock. Review of the facilities wound assessments dated 11/22/22 revealed Resident #18 had a pressure ulcer to the right heel. The wound was noted to be unstageable and it was developed on 11/07/22. Review of the physician orders dated 11/07/22 revealed an order to apply skin prep and pad and protect with ABD (thick dressing) and Kerlix (wrap dressing), every day shift Monday, Wednesday and Friday to the right heel. Observation of Resident #18 on 11/28/22 at 9:35 A.M. revealed Resident #18's feet were sticking out of the bottom of her blankets. Resident #18's right heel was observed with a dressing in place. The dressing had a piece of tape to secure the dressing in place that was dated 11/22/22. Observation and interview with Licensed Practical Nurse (LPN) #853 of Resident #18's right foot dressing occurred on 11/28/22 at 10:08 A.M. LPN #853 confirmed the dressing to Resident #18's foot was dated 11/22/22, and it was the last time the wound was measured. LPN #841 confirmed she had signed off the treatment had been completed on 11/23/22 and 11/25/22 and confirmed it was actually not completed on 11/23/22 and 11/25/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365924 If continuation sheet Page 9 of 13 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 365924 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amherst Manor Nursing Home 175 N Lake Street Amherst, OH 44001 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, staff interview, medical record review, and review of the facility policy, the facility failed to ensure an indwelling urinary catheter was stabilized and maintained in a manner to prevent urinary tract infection (UTI). This affected one (Resident #83) of two residents reviewed for an indwelling urinary catheter. The facility identified eight residents with an indwelling or external catheter. The facility census was 80. Findings include: Review of the medical record for Resident #83 revealed an admission date of 10/21/22. Diagnoses included type II diabetes mellitus, lack of coordination, muscle weakness, and retention of urine. Review of Resident #83's admission Minimum Data Set (MDS) 3.0 assessment, dated 10/28/22, revealed Resident #83 was cognitively intact. Resident #17 required the extensive assistance of two staff members for bed mobility, transfers, and toileting. Resident #17 had an indwelling catheter for urine and was always incontinent of bowel. Review of the plan of care, dated 10/28/22, revealed Resident #83 had an indwelling urinary catheter due to urinary retention. Interventions included catheter care per policy and after each incontinent episode of bowel, maintaining patency of elimination equipment, and keep catheter bag below level of bladder at all times. Review of the physician orders for November 2022, revealed an orders for Foley catheter 16 French with five cubic centimeter (CC) balloon to continuous drainage, and catheter care per policy every shift. Observation on 11/29/22 at 10:52 A.M. revealed Resident #83 was lying in bed and the foot of the bed was elevated. Resident #83's urinary catheter bag was lying on the foot of the bed, was unsecured, and was located above the resident's bladder. Observation and interview on 11/29/22 at 10:53 A.M. with Licensed Practical Nurse (LPN) #855 verified the unsecured urinary catheter bag was lying on the foot of Resident #83's bed. LPN #855 stated she was not sure why it was placed that way and proceeded to move and secure the catheter drainage bag on the side of Resident #83's bed. Observation on 12/01/22 at approximately 7:10 A.M. revealed Resident #83 was lying in bed and stating she had to go to the bathroom. Resident #83's urinary catheter drainage bag was unable to be seen. Observation and interview on 12/01/22 at approximately 7:12 A.M. with State Tested Nurse Aide (STNA) #893 revealed Resident #83's urinary catheter tubing and drainage bag were lying on the foot of the bed, located underneath of the resident's sheet and blanket. Once STNA #893 secured the urinary catheter drainage bag on the side of the bed, urine began flowing out and down the urinary catheter's tubing. STNA #893 reported another staff member was providing care to Resident #83 and a call light went off so the staff member must have left the catheter in the bed. Review of the facility's policy titled Catheters: Infection Control Methods, revised September (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365924 If continuation sheet Page 10 of 13 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 365924 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amherst Manor Nursing Home 175 N Lake Street Amherst, OH 44001 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 3013, revealed the urinary catheter drainage bag would remain below the bladder. 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: 365924 If continuation sheet Page 11 of 13 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 365924 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amherst Manor Nursing Home 175 N Lake Street Amherst, OH 44001 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, staff interview, review of the temperature logs, and review of the facility policy review, the facility failed to ensure medications were stored with proper temperature controls. This affected two of four medication storage rooms reviewed for medication storage. This had the potential to affect all 80 residents residing in the facility. Findings include: 1. Observation and interview of the medication storage room on the Sandstone Hall on 11/30/22 at 1:33 P.M., with Licensed Practical Nurse (LPN) #855 revealed the temperature log was missing daily temperature recordings. There was no documentation at all for the months of 07/2022 and 08/2022. There were two days (09/02/22 and 09/13/22) with recorded temperatures for the month 09/2022. There was no recorded temperatures at all for the months of 10/2022 and 11/2022. LPN #855 verified there were no temperature recording form the months of 07/2022, 08/2022, 10/2022, and 11/2022 and only two temperatures recorded in 09/2022. Observation and interview of the medication refrigerator on the Sandstone Hall on 11/30/22 at 1:35 P.M. with LPN #855 revealed it was 20 degrees Fahrenheit (F). In the refrigerator, there was a frozen solid 46-ounce (oz) box of lemon-flavored thickened water, a 46 oz box of juice, Narcan (treats narcotic overdose) four milligrams (mg), Ozempic (antidiabetic medication) injection two milligrams (mg), Influenza vaccine opened and not dated, three unopened Tuberculin Purified Protein Derivative (Mantoux) Tuberson multi-dose vial 10 tests five TU. The Mantoux stated to store at 35-46 degrees F and DO NOT FREEZE. There were two new boxes of Influenza vaccine Afluria Quadrivalent five milliliter (ml) multi-dose vial that stated on it: DO NOT FREEZE. There were five Promethegan (treats allergies and motion sickness) 25 mg suppositories. Dronabinol (treats nausea and vomiting) capsules 2.5 mg 59 capsules. One capsule of Dronabinol five mg and stated to keep in the refrigerator and DO NOT FREEZE. There were three Lorazepam Intensol (anti-anxiety medication) oral concentrate United States Pharmaceutical (USP) two mg/ml a total of 30 ml bottles and three Lorazepam injection two mg/ml and were one ml each. LPN #855 verified the refrigerator temperature registered 20 degrees F and should have been between 36 degrees F and 40 degrees F. 2. Observation and interview on 11/30/22 at 2:58 P.M., of the medication room on the 600 Hall with Registered Nurse (RN) #856 revealed the refrigerator did not have a thermometer or temperature log. In the refrigerator, there were Dronabinol capsules 2.5 mg each and a total of 17 capsules. Written on the card was: DO NOT FREEZE. There was one Levemir injection insulin detemir solution pre-injector pen 100, three unopened Enbrel sure click autoinjector (treats autoimmune diseases) 50 mg/ml, Mekinist (a cancer drug) oral tablet two mg bottle 30 tablets unopened and two other bottles, one with 19 tablets and the other with 27 tablets. RN #856 verified there should be a thermometer in the medication refrigerator and a log to record daily readings. Interview with the Administrator on 12/01/22 at 11:30 A.M. revealed the facility did not have a policy pertaining to medication room refrigerator temperatures. Review of the Refrigerator Temperature Chart revealed the temperature must be between 36-40 degrees F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365924 If continuation sheet Page 12 of 13 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 365924 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amherst Manor Nursing Home 175 N Lake Street Amherst, OH 44001 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Potential for minimal harm Based on record review and staff interview, the facility failed to have a policy in place regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This had the potential to affect 80 residents residing in the facility who were able to receive food from outside sources. Residents Affected - Many Findings include: Review of the facility's policy revealed there was no policy in place regarding the use and storage of foods brought to residents by family and other visitors. Interview with Dining Services Director (DSD) #805 on 11/28/22 at 10:45 A.M. verified there was no policy in place regarding the use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Interview with the Administrator on 11/30/22 at 10:11 A.M. revealed residents and/or visitors were able to bring in food from outside sources into the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365924 If continuation sheet Page 13 of 13