Health inspection·May 8, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some receive knives with their meals. Resident Care Coordinator #327 reported the previous dietary manager had made the decision but in the future residents will receive a knife starting with the next meal except the residents on the memory care unit because they are not in their right mind. Interview on 05/05/24 at 2:38 P.M., with STNA #367 verified most of the memory care residents would be appropriate and capable of using a knife to cut their meals if a knife was provided. STNA #367 verified the aides are not provided a knife either to assist residents in cutting their food. Interview on 05/05/24 at 2:45 P.M., with Resident #36's family member revealed Resident #36 would be capable of using a knife with her meal and added that she is not a risk to herself or anyone else. Resident #36 is in the memory care unit. Interview on 05/07/24 at 10:12 A.M., with STNA #341 in the memory care unit verified residents do not receive a butter knife with meals and aides are not provided one to assist with cutting up food either. STNA #341 stated she uses a spoon and fork to cut up their food when needed and stated it is effective. Review of a facility resident diet list revealed 15 residents (#1, #3, #6, #18, #23, #24, #27, #30, #32, #34, #37, #41, #47 #48, and #198) who did not receive food by mouth and residents with a puree or mechanical soft diet. Review of policy titled, Sharp Utensils, dated November 2019, revealed the facility has determined that knives and other sharp utensils will not be given to the residents on [NAME] (memory care) to protect the safety on the unit. The STNA will have access to sharp utensils to cut up food as needed for residents. Review of policy titled, Resident Rights, revised December 2016, verified residents have the right to a dignified existence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365936 If continuation sheet Page 2 of 27 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 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 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 medical record review, observation, resident interview, staff interview, and policy review, and facility policy the facility failed to reasonably accommodate a resident's requests. This affected one (#197) of one resident reviewed for choices. The census was 51. Residents Affected - Few Findings include: Review of the medical record revealed Resident #197 was initially admitted on [DATE] with re-entry on 05/01/24. Diagnoses included other acute osteomyelitis left shoulder, neuromuscular dysfunction of bladder, bipolar disorder, quadriplegia, colostomy status, primary osteoarthritis, hypothyroidism, and adult failure to thrive. Review of the Minimum Data Set (MDS) assessment, dated 04/14/24, revealed the resident was cognitively intact. Resident #197 required substantial/maximum assistance for eating and dependent on staff for bed mobility. Review of the most recent care plan revealed the resident had a care plan for activities of daily living (ADL) care and required weight bearing assistance by staff to eat, the facility was to provide the diet as ordered and offer favorite foods as available and food alternatives as appropriate/available. If the resident refuses a meal the facility is to provide finger foods as appropriate/available when the resident has difficulty using utensils. Observation on 05/06/24 at 2:16 P.M., revealed Resident #197's call light was on. Upon entering the room Resident #197 verified her call light was on stating she had refused her lunch tray. Resident #197 stated she requested State Tested Nursing Assistant (STNA) #342 at approximately 1:20 P.M., to microwave instant macaroni and cheese. Resident #197 stated STNA #342 agreed and took the lunch tray and the instant macaroni and cheese package with her. Resident #197 stated she put her call light on approximately 10 minutes ago to inquire about the status of her lunch because it had been so long (approximately one hour). Observation on 05/06/24 at 2:28 P.M., revealed Licensed Practical Nurse (LPN) #302 entered Resident #197's room and the resident explained she was waiting for her instant macaroni and cheese. LPN #302 informed the resident she would let STNA #342 know. LPN #302 was observed to come out to the nurse's station and make a verbal observation the instant macaroni and cheese cup was on the counter sealed. Observation on 05/06/24 at 2:43 P.M., revealed STNA #342 coming back from break. LPN #302 informed STNA #342 that Resident #197 was waiting for her instant macaroni and cheese. STNA #342 stated Resident #197 said she wanted her instant macaroni and cheese later, so she went on break and stated it had not been more than 20 minutes. STNA #342 took the instant macaroni and cheese and left the unit. Interview on 05/06/24 at 2:45 P.M., with LPN #302 verified STNA #342 had just come back from break. Observation on 05/06/24 at 3:01 P.M., revealed STNA #342 came back to the unit with the instant macaroni and cheese and set it on the nurse's station counter. Interview with STNA #342 verified she used the microwave to cook instant macaroni and cheese. At 3:03 P.M., STNA #342 took the instant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365936 If continuation sheet Page 3 of 27 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 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 0558 Level of Harm - Minimal harm or potential for actual harm macaroni and cheese to the resident's room and informed Resident #197 it needed to cool down (approximately 1 hour and 40 minutes since initial request and over 30 minutes since follow-up request). Observation on 05/06/24 at 3:10 P.M., revealed Resident #197 was assisted with eating the instant macaroni and cheese. Residents Affected - Few Review of policy titled, Homelike Environment, revised February 2021, revealed staff provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365936 If continuation sheet Page 4 of 27 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 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 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Potential for minimal harm Based on resident interviews, staff interview, and observation, the facility failed to prominently post where state survey results were located for residents to view. This had the potential to affect all 51 residents. The facility census was 51. Residents Affected - Many Findings include: Interview on 05/07/24 at 2:19 P.M., with Residents (#2, #4, #26, #29, and #35) who attended the resident group meeting denied knowing where to find the state survey results. Observation on 05/07/24 at 2:55 P.M., of hallway posting board revealed no mention of where to find the state survey results. Observation of the postings on the front desk where you enter the facility revealed no documentation regarding the location of the state survey results book. Interview on 05/07/24 at 2:58 P.M., with the Director of Nursing (DON) verified there was no posting for the residents or their families for locating the state survey results. DON produced the state survey results book that was located at the front desk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365936 If continuation sheet Page 5 of 27 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 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. Based on observation, record review, policy review and staff interviews, the facility failed to ensure code status documentation was addressed timely. This affected one (#247) of 19 reviewed for advanced directives. The facility census was 51. Findings included: Review of medical record for Resident #247 revealed admission date of 04/29/24. The resident was admitted with diagnoses including chronic obstructive pulmonary disease, malignant neoplasm of left breast, secondary malignant neoplasm of brain, depression and anxiety. The resident remained at the facility. Observation and interview on 05/05/24 at 3:36 P.M., with Registered Nurse (RN) #354 verified there was no code status information in Resident #247's hard chart. The side of the hard chart and paper behind the advance directive tab was labeled as Comfort Care (CC). There was an order for Do Not Resuscitate Comfort Care Arrest (DNR-CCA) dated 04/29/24 in the electronic charting. RN #354 explained sometimes the resident information will not be placed in the hard chart until after therapy reviews the chart. Interview on 05/07/24 at 10:10 A.M., with Licensed Practical Nurse (LPN) #319 revealed the facility had an electronic Do Not Resuscitate (DNR) Comfort Care Arrest (CCA) order from discharging hospital. LPN #319 provided an Ohio DNR CC form signed by Resident #247 only, the physician section was blank. LPN #319 verified the facility did not obtain a copy of the signed DNR form from the discharging hospital, or ensure the medical director signed the current form. Review of the policy titled, admission Assessment and Follow Up: Role of the Nurse, last revised September 2012 revealed to determine if the resident had an existing advance directive and if so initiate obtaining a copy for the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365936 If continuation sheet Page 6 of 27 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 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 medical record review, observation, resident interview, nurse practitioner interview, staff interview, and policy review, the facility failed to implement interventions to prevent skin impairment timely for a resident with stage 4 pressure ulcers and ensure would measurements were completed upon readmission. This affected one (#197) of three residents reviewed for pressure ulcers. The facility census was 51. Residents Affected - Few Findings include: Review of the medical record revealed Resident #197 was initially admitted on [DATE] with re-entry on 05/01/24. Diagnoses included other acute osteomyelitis left shoulder, neuromuscular dysfunction of bladder, bipolar disorder, quadriplegia, colostomy status, primary osteoarthritis, hypothyroidism, and adult failure to thrive. Review of the Minimum Data Set (MDS) assessment, dated 04/14/24, revealed the resident was cognitively intact. Resident #197 was dependent on staff for bed mobility, upper and lower body extremity dressing. Review of the most recent care plan revealed Resident #197 had an activities of daily living care plan due to quadriplegia, muscle spasms, and spinal cord injury. The resident was totally dependent on staff for repositioning and turning in bed. The resident had pressure ulcer development and interventions included to encourage and assist the resident to turn and reposition frequently. The care plan noted the resident is resistive to care and will refuse to let staff turn and reposition her. Review of the weekly wound observation tool, dated 04/23/24, revealed Resident #197 had abrasion on the rear right lower leg measuring 1.0 centimeter (cm) in length by 0.4 cm in width by 0.3 cm in depth; stage IV pressure ulcer to the sacrum measuring 1.5 cm in length by 1.5 cm in width by 0.1 cm in depth; stage IV pressure ulcer to the left gluteal fold measure 2.0 cm in length by 1.5 cm in width by 0.1 cm in depth; stage IV pressure ulcer to the right gluteal fold measuring 0.5 cm in length by 0.5 cm in width by 0.1 cm in depth; excoriation on left back measuring 4 cm in length by 1 cm in width by 0.1 cm in depth; and a stage III pressure ulcer to the left upper posterior thigh measuring 0.5 cm in length by 0.5 cm in width by 0.5 cm in depth. Review of the admission Assessment, dated 05/01/24, revealed a skin assessment verifying Resident #197 had current skin conditions present upon (re)admission. The assessment identified a surgical incision on the abdomen, abrasion on the rear right lower leg, pressure on the sacrum, pressure on the left gluteal fold, pressure on the right gluteal fold, and pressure on the left upper back. No measurements of the wounds were noted. Review of the weekly wound observation tool, dated 05/07/24, revealed Resident #197 had stage IV pressure ulcer to the sacrum measuring 1.0 cm in length by 1.5 cm in width by 0.5 cm in depth; stage IV pressure ulcer to the left gluteal fold measure 3.5 cm in length by 2.0 cm in width by 0.1 cm in depth; stage IV pressure ulcer to the right gluteal fold measuring 1.5 cm in length by 1.0 cm in width by 0.1 cm in depth; excoriation on the left posterior thigh measuring 2.5 cm in length by 1 cm in width by 0.1 cm in depth; shearing on the right upper back measuring 4.0 cm in length by 3.0 cm in width by 0.1 cm in depth; and a stage III pressure ulcer to the left back measuring 1.0 cm in length by 1.0 cm in width by 1.0 cm in depth. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365936 If continuation sheet Page 7 of 27 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 05/05/24 at approximately 2:00 P.M., with Resident #197 revealed she is rarely repositioned and the last time she was repositioned was when she had her dressing changed on third shift. Resident #197 stated the facility staff do not offer to reposition her and she has not recently refused. Observation on 05/06/24 at 8:31 A.M., of Resident #197, revealed the resident was observed to be in bed with positioning noted. The resident was on her back with heel boots on, pillow on the left side tucked under her shoulder to her torso and a blue wedge on the right side. Resident #197 stated she was last repositioned during the dressing change last night. Observation on 05/06/24 at 10:36 A.M., of Resident #197 revealed the resident was observed to be in bed with positioning noted. The resident appeared to be in the same position as previously observed on her back with heel boots on, pillow on the left side tucked under her shoulder to her torso and a blue wedge on the right side. Resident #197 stated she has not been repositioned and no staff had offered. Observation on 05/06/24 at 2:16 P.M., Resident #197 revealed the resident was observed no changes to the resident's positioning in bed. Resident #197 reported no staff have offered to reposition her during this shift. Interview on 05/06/24 at 2:43 P.M., with State Tested Nursing Assistant (STNA) #342 verified providing care to Resident #197 throughout the shift. STNA #342 verified Resident #197 has not been repositioned today and stated the resident has refused. Interview on 05/06/24 at 2:46 P.M., with Licensed Practical Nurse (LPN) #302 verified a STNA must report to the nurse if a resident refuses to be repositioned because they would need to document it. LPN #302 stated there were no reports of Resident #197 refusing to be repositioned and added that she had went in the resident room a short time ago and the resident asked to be repositioned. LPN #302 reported she told the STNA and was informed she would provide care to her next. Observation on 05/06/24 at 3:01 P.M., revealed STNA #342 offer to reposition Resident #197 and she agreed. STNA #342 revealed how often a resident is repositioned depends on the resident and if the resident is cognitively intact she will ask and if they are not she will assess and determine how often a resident is to be repositioned. Interview on 05/07/24 at 9:18 A.M., with Resident #197 revealed the resident in bed. Resident #197 stated she had not been repositioned since approximately 2:00 A.M., when her ostomy had leaked. Resident #197 denied any refusals for repositioning. Observation on 05/07/24 at 12:09 P.M., with Registered Nurse (RN ) #37, LPN #319, and Nurse Practitioner (NP) #376 of Resident #197 wound care revealed wound to left shoulder measured one centimeter (cm) in length by 1.0 cm in width by 1.0 cm in depth with 1.5 cm tunneling at 12:00. Wound to sacral are measured 1.0 cm in length by 1.5 cm in width by 0.5 cm in depth. Wound to right gluteal area measured 1.5 cm in length by 1.0 cm in width by 0.1 cm in depth. Wound to left gluteal area measured 3.5 cm in length by 2.0 cm in width by 0.1 cm in depth. Wound to left upper posterior thigh measured 2.5 cm in length by 1.0 cm in width by 0.1 cm in depth. All wounds were observed without any necrotic (dead) tissue, slough (yellow viscous fibrinous tissue), or odors. Peri wound for all wounds observed to be pink and blanchable. No drainage was observed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365936 If continuation sheet Page 8 of 27 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview via telephone, on 05/07/24 at 2:43 P.M., with NP #376 revealed while repositioning could potentially affect Resident #197 wound healing it was more likely the wounds were worsened due to the Vaseline gauze dressings at the hospital. NP #376 reports Resident #197 has chronic conditions and has had numerous wounds that have been there a long time, shut and reopened. Interview on 05/07/24 at 3:58 P.M., with Licensed Practical Nurse (LPN) #379 verified she was not notified of Resident #197 being turned and repositioned today. Interview on 05/07/24 at 4:13 P.M., with STNA #362 verified providing care to Resident #197 throughout the shift. STNA #362 verified she had not offered to reposition Resident #197 during the 12 hour shift stating she had not thought about it. STNA #362 stated she does not think anyone does because when she was trained no one ever offered to reposition Resident #197 and added that with her STNA training she knows better. Resident #197 was repositioned during wound care at 12:09 P.M. Interview on 05/08/24 at 3:15 P.M., with the Assistant Director of Nursing (ADON) #319 verified Resident #197's care plan stated the resident should be repositioned frequently and stated repositioning should be offered every two hours. ADON #319 also verified no wound measurements were completed with the re-admission from the hospital on [DATE]. Review of the policy titled, Repositioning, revised May 2013, verified repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. Repositioning is critical for for a resident who is immobile or dependent on staff for repositioning. A turning/repositioning program includes a continuous consistent program for changing the resident's position and realigning the body. A program is defined as a specified approach that is organized, planned, documented, monitored, and evaluated. Residents who are in bed should be on at least an every two hour repositioning schedule. Use two people and a draw sheet to avoid shearing while turning or moving the resident in bed. Review of the policy titled, Skin Assessment and Documentation. dated November 2017, verified skin assessments are performed at the time of admission or re-admission and daily for three days to identify the presence of pressure areas, deep tissue injury, surgical wounds, lacerations present at admission. An order for skin assessments to be completed for three days and admission or re-admission are entered in the electronic chart and recorded on the treatment record. Review of the policy titled, Clinical Protocol Pressure Ulcers/Skin breakdown, dated April 2018, verified the nursing staff shall describe and document/report the following full assessment of pressure sore including location, stage, length, width, and depth and presence of exudates or necrotic tissue. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365936 If continuation sheet Page 9 of 27 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview and policy review, the facility failed to provide adequate supervision for residents while they were smoking. This affected two (#1 and #6) of two residents reviewed for smoking. The facility identified five residents who smoke. The facility census was 51. Findings include: 1. Review of medical record for Resident #1 revealed admission date of 07/19/18, with diagnoses including multiple sclerosis, chronic obstructive pulmonary disease, seizures, hemiplegia affecting right dominant side, and major depressive disorder. Review of minimum data set (MDS) assessment dated [DATE] revealed a brief interview of mental status (BIMS) score of 15 which indicated cognitively intact. Resident #1 was dependent on staff for activities of daily living. Review of care plan dated 04/04/24 revealed Resident #1 is a smoker and often refuses to wear smoking apron. Interventions included the resident has been assessed and requires supervision while smoking, and smoking apron required while smoking. Review of smoking-safety screen dated 04/04/24 revealed Resident #1 can light their own cigarette, required smoking apron, and supervision. 2. Review of medical record for Resident #6 revealed admission date of 03/15/19 with diagnoses including schizoaffective disorder, chronic obstructive pulmonary disease, hypertension, bipolar disorder, tremor, anxiety, and other motor neuron disease. Review of MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated cognitively intact. Resident #6 required supervision/touching assistance for activities of daily living. Review of care plan dated 04/05/24 revealed Resident #6 was a smoker. Interventions included the resident has been assessed and requires supervision while smoking, and smoking apron required while smoking. Review of smoking-safety screen dated 04/05/24 revealed Resident #6 can light his own cigarette and needs a smoking apron. Resident found to have burn holes in his clothing and wheelchair. Resident #6 stated he does not have a problem holding his cigarettes and he is not dropping them. Resident #6 stated the holes were from the wind when it blows the ashes get on him. Smoking apron to be worn while smoking with supervision. Observation on 05/05/24 at 11:05 A.M., revealed Resident #1 and Resident #6 in the smoking area with no staff supervision. No staff was observed in the dining area beside the door as well. Both residents were wearing smoking aprons. Resident #1 was observed to be very shaky while holding her cigarette and when bringing the cigarette up to her mouth. Both residents were able to use the ashtrays. State Testing Nursing Assistant (STNA) #363 who was assisting another resident out to the smoking area at 11:08 A.M., verified that no staff was noted to be out with Resident #1 or Resident #6. STNA #363 stated that an aide probably let them out and the aide did not smoke so they probably went back (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365936 If continuation sheet Page 10 of 27 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 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 0689 inside the facility. Level of Harm - Minimal harm or potential for actual harm Interview on 05/05/24 at 11:08 A.M., with STNA #363 verified that a staff member is to be out with residents while they smoke. STNA #363 verified no staff was providing supervision for Resident #1 and Resident #6. Residents Affected - Few Review of the undated policy titled, Resident Smoking Policy revealed smoking aprons and other safety devices are provided for residents whose assessment shows they require them. Direct supervision will be provided to residents who are assessed to need such supervision. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365936 If continuation sheet Page 11 of 27 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. 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, resident family interview, staff interview, review of the activities calendar, review of the facility brochure, and review of policy, revealed the facility failed to provide appropriate and engaging activities in the memory care unit. This affected five residents (#20, #30, #36, #38, and #43) were reviewed with the potential to affect an additional five (#3, #24, #31, #32, and #34) residents in the memory care unit. The facility census was 51. Residents Affected - Some Findings include: Review of the memory care activity calendar, dated 05/05/24 revealed two scheduled activities including at 12:00 P.M. root beer floats and 2:00 P.M. church. On 05/06/24, there were three scheduled activities including 9:00 A.M. Good Morning, 10:00 A.M. Shopping, and 3:00 P.M. Game Day (cards). On 05/07/24, three activities were scheduled including 9:00 A.M. Good Morning, 12:00 P.M. Book Swap, and 3:00 P.M. Book Read. Review of the facility brochure revealed Memory Care program is highlighted and stated the following: Our philosophy of care focuses on programs designed to keep residents engaged, provide stimulating activities for interaction in our secure unit. This often helps to refuse the need for medication and assists in structuring their time while enhancing their well being by adding purpose and meaning to their everyday life. 1. Review of the medical record revealed Resident #20 was admitted on [DATE]. Diagnoses included type two diabetes mellitus with hyperglycemia, hypothyroidism, schizoaffective disorder, essential primary hypertension, major depressive disorder, atherosclerotic heart disease of native coronary artery without angina pectoris, hyperlipidemia, type two diabetes mellitus without complications, and unspecified dementia. Review of the Minimum Data Set (MDS) assessment, dated 03/04/24, revealed the resident was rarely understood. At the time of the annual assessment fresh air was the only activity determined to be somewhat important. Review of the most recent care plan revealed Resident #20 was dependent on staff for emotional, physical, spiritual, creative, and community activities and social well-being. Interventions include ensure the activities the resident is attending are compatible with physical and mental capabilities, known interest and preferences, adapted as needed, compatible with individual needs and abilities and age appropriate, offer program that is not overly demanding, engage in simple structured activities such as arts and crafts, reminisce, news, and trivia. Observation on 05/06/24 at 10:33 A.M. and 3:09 P.M., revealed Resident #20 sitting in the common area in her wheelchair facing the television with the television on. Interview on 05/07/24 at 10:18 A.M., with State Tested Nursing Assistant (STNA) #341 was not certain what activities Resident #20 liked but stated she likes to talk. 2. Review of the medical record revealed Resident #30 was admitted on [DATE]. Diagnoses included major depressive disorder recurrent, essential (primary) hypertension, unspecified osteoarthritis, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365936 If continuation sheet Page 12 of 27 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 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 0744 schizoaffective disorder bipolar type, and dementia unspecified type. Level of Harm - Minimal harm or potential for actual harm Review of the MDS assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of the annual assessment completed on 10/11/23 revealed no resident or staff interview identified activities preferences. Residents Affected - Some Review of the most recent care plan revealed Resident #20 was dependent on staff for emotional, physical, spiritual, creative, and community activities and social well-being. Interventions include ensure the activities the resident is attending are compatible with physical and mental capabilities, known interest and preferences, adapted as needed, compatible with individual needs and abilities and age appropriate, offer program that is not overly demanding, engage in simple structured activities such as bingo, music, food, spiritual and social programs, and music. Review of quarterly assessments for activities revealed Resident #30 had not had a quarterly activities assessment since 06/15/23. Observation on 05/06/24 and 05/07/24 of Resident #30 throughout the day in the common area watching television. Interview on 05/07/24 at 10:20 A.M., with STNA #341 reported Resident #30 loves television and music, when music is on she will rock back and forth. 3. Review of the medical record revealed Resident #36 was admitted on [DATE]. Diagnoses included other fracture of right femur, Alzheimer's disease, essential primary hypertension, hyperlipidemia, hypothyroidism, type 2 diabetes mellitus without complications, generalized anxiety disorder, chronic gout. Review of the MDS assessment, dated 04/12/24, revealed the resident was severely cognitively impaired. Review of the most recent care plan revealed Resident #20 was dependent on staff for emotional, physical, spiritual, creative, and community activities and social well-being. Interventions include provide with activities calendar and notify resident of any changes to the calendar of activities and resident needs assistance/escort to activity functions. Review of the memory care activity calendar, dated 05/05/24 revealed at 2:00 P.M. church was scheduled. Interview on 05/06/24 at 10:56 A.M., with Resident #36 family revealed the resident was Catholic and would be very interested in attending church services at the facility. Resident #36's family verified visiting yesterday during the church activity time but was not included. 4. Review of the medical record revealed Resident #38 was admitted on [DATE]. Diagnoses included fracture of unspecified part of neck of right femur subsequent encounter for closed fracture with routine healing, hyperlipidemia, major depressive disorder recurrent, unspecified dementia moderate with psychotic disturbance. Review of the MDS assessment, dated 03/21/24, revealed the resident is severely cognitively impaired. Review of the annual assessment, completed 10/12/23, revealed Resident #38 identified music, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365936 If continuation sheet Page 13 of 27 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some animals, and fresh weather were very important activities, and religious activities were somewhat important. Interview via telephone, on 05/05/24 at 2:16 P.M., with Resident #38's family revealed Resident #38 is a Christian and would like to go to church. It was reported the facility has church on Sunday and they do not include her. Observation on 05/05/24 at 2:30 P.M., revealed church service occurring in the main dining room with four residents present. Observation on 05/05/24 at 2:32 P.M., of Resident #38 revealed the resident was in the memory care unit sitting at the dining room table alone with a cup of water in front of her. Interview on 05/05/24 at 2:40 P.M. with Activities #325 verified church service was offered in the facility main dining room and residents from memory care were not included. Observation on 05/06/24 at 3:10 P.M. revealed Resident #38 sitting across from another resident and next to Activities #325 while Activities #350 stood next to the table. The group was playing the card game Uno with the staff prompting the residents to play. Interview on 05/07/24 at 9:42 A.M. with Activities #350 revealed the Good Morning activity includes walking around saying good morning to everyone. The Shopping activity every Monday at 10:00 A.M. includes asking all residents if they want anything at the store and the Shopping activity on Tuesday includes the staff shopping for requested items if they have money in their account. Interview on 05/07/24 at 10:03 A.M. with Activities #325 reported on 05/06/24 for the shopping activity she had asked the nurse if anyone needed anything like shampoo and snacks and no one from memory care did. Activities #325 reported yesterday for Uno three residents initially participated but one walked away. Activities #325 reported the two residents were able to engage in play mostly with the colors of the cards. Interview on 05/07/24 at 10:12 A.M. with STNA #341 revealed Resident #38 has a laundry basket and likes to fold laundry. 5. Review of the medical record revealed Resident #43 was admitted on [DATE]. Diagnoses included unspecified dementia with behavioral disturbances, Alzheimer's disease, hyperlipidemia, essential hypertension, unspecified diastolic congestive heart failure, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, benign prostatic hyperplasia without lower urinary tract symptoms, malignant neoplasm of prostate, and hypothyroidism. Review of the MDS assessment, dated 04/05/24 revealed the resident is rarely understood. Resident #43 was not interviewed for activity preferences and the staff assessment all indicated no preferences. Review of the care plan, dated 03/26/24, revealed the resident is dependent on staff for meeting emotional, intellectual, physical, and social needs. Interventions included assist with arranging community activities and transportation, invite the resident to scheduled activities, provide a program of activities that are of interest. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365936 If continuation sheet Page 14 of 27 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 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 0744 Level of Harm - Minimal harm or potential for actual harm Review of activities tracking for the last two weeks revealed resident was marked as active for participating in activities category of entertainment. Observations throughout the survey revealed Resident #43 sitting in a chair in front of the television, walking around the memory care unit, or asking staff at the nurse's station to call his wife. Residents Affected - Some Interview on 05/07/24 at 10:03 A.M. with Activity Aide #325 and #350 revealed Resident #43 was marked as participating in Activities/entertainment daily because is active as far as walking around as he pleases, watched television, and got to call his wife several times yesterday. Review of the policy titled, Dementia Care, effective November 2017, revealed the facility provides a secure, specialized memory care unit with trained staff and environmental adaptations. Assessments resulted in the development of individualized care planned activities such as Music and Memory and others appropriate to the residents' level of cognition so they achieve a feeling of success and social interaction. This deficiency represents non-compliance investigated under Master Complaint Number OH00153572. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365936 If continuation sheet Page 15 of 27 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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, staff interview, and review of National Center for Biotechnology Information (NCBI) National Library of Medicine (NLM), the facility failed to monitor medication for potential side effects, toxicity and/or effectiveness. This affected one (#28) of five residents reviewed for unnecessary medications. The facility census was 51. Residents Affected - Few Findings include: Review of medical record for Resident #28 revealed admission date of 07/13/23. The resident was admitted with diagnoses including Parkinsonism, chronic kidney disease, hyperlipidemia and type two diabetes mellitus. Review of the quarterly MDS assessment dated [DATE] revealed he had a Brief Interview Mental Status (BIMS) score of 12 indicating impaired cognition. He required supervision for bed mobility, transfers, toileting and eating. Review of the physician orders revealed an order for Pravastatin (cholesterol) 40 milligrams (mg). Give one tablet at bedtime for hyperlipidemia. Record review of the physician orders for Resident #28 revealed there was no lab work ordered to monitor cholesterol levels, kidney or liver enzymes. Review of https://www.ncbi.nlm.nih.gov/books/NBK551621/#article-59.s7 revealed patients renal function, liver function and lipid panel should be monitored during medication administration. Review of physician orders revealed an order for Ergocalciferol (vitamin D supplement) 50000 units. Give one capsule every Thursday. Record review of the physician orders for Resident #28 revealed there was no lab work ordered to monitor Vitamin D levels. Review of https://www.ncbi.nlm.nih.gov/books/NBK557876 revealed vitamin D levels should be monitored during administration to avoid toxicity. Interview on 05/07/24 at 3:55 P.M., with the Director of Nursing (DON) revealed no lab work was currently ordered. The last lipid panel was on 08/23/23, the last creatine (kidney) was on 12/13/23 and no liver panel or vitamin D level was documented as completed. She verified the nurses were expected to notify the physician for routine lab work. She stated the expectation would be vitamin levels would be checked when receiving the supplement and kidney monitoring and a lipid and liver panel for cholesterol medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365936 If continuation sheet Page 16 of 27 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 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 0772 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure laboratory (lab) test were completed per physician orders. This affected three (#10, #17 and #26) of five residents reviewed for laboratory test. The facility census was 51. Findings include: 1. Review of medical record for Resident #10 revealed admission date of 11/25/12, with diagnoses including neuropathy, diabetes, cerebral infarction, major depressive disorder, chronic pain, hallucinations, chronic embolism and thrombosis of unspecified vein, and pure hypercholesterolemia. Review of minimum data set (MDS) assessment dated [DATE] revealed a brief interview of mental status (BIMS) score of 12 which indicated moderate cognitive impairment. Resident #10 required extensive assistance to full dependence on staff for activities of daily living. Review of current monthly physician orders for May 2024 revealed orders for Complete Blood Count (CBC), Basic Metabolic Panel (BMP), Hepatic Panel, and Lipid Panel every three months (March, June, September, December), CBC and Complete Metabolic Panel (CMP) yearly in April, and Hemoglobin A1C and Thyroid Stimulating Hormone (TSH) level every six months in March and September dated 06/28/21. Review of laboratory results in the medical record revealed the last CBC/BMP/Hepatic Panel, TSH, and Lipid Panel that was drawn was on 08/17/23. Last Hemoglobin A1C was drawn on 02/19/24 with no TSH level drawn. Interview on 05/07/24 at 11:22 A.M., with Director of Nursing (DON) verified the last CBC, platelet count/CMP, lipid profile, and TSH was drawn for Resident #10 on 08/17/23. DON verified labs were not completed every three months as ordered. DON verified that labs drawn on 02/19/24 did not include TSH level per physician's order. 2. Review of medical record for Resident #26 revealed admission date of 03/24/22, with diagnoses including but not limited to hypothyroidism, type two diabetes, congestive heart failure, chronic kidney disease stage three, and nontoxic goiter. Review of MDS assessment dated [DATE] revealed BIMS score of 15 which indicated the resident was cognitively intact. Resident #26 required supervision/touching to partial/moderate assistance for activities of daily living. Review of current monthly physician orders for May 2024 revealed orders for hemoglobin A1C, microalbumin and BMP to be drawn every three months, dated 10/11/22. Review of laboratory results revealed hemoglobin A1C drawn on 11/17/23 and 02/19/24. CBC, CMP, lipid profile, and TSH drawn on 08/17/23, and BMP, and hemoglobin A1C drawn on 07/13/23. No documentation that a BMP or microalbumin was drawn every three months. Interview on 05/07/24 at 11:22 A.M., with DON verified that BMP and microalbumin for Resident #26 was not drawn every three months per physician order and the last BMP drawn was on 07/13/23. DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365936 If continuation sheet Page 17 of 27 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 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 0772 verified that no microalbumin was drawn. Level of Harm - Minimal harm or potential for actual harm 3. Review of medical record for Resident #17 revealed admission date of 04/05/21. The resident was admitted with diagnoses including seizures, hyperlipidemia, psychotic disorder with delusions, depression, and anxiety. Residents Affected - Few Review of the MDS assessment, dated 04/23/24, revealed he had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. He was dependent for bed mobility, transfers, toileting and extensive one person assistance for eating. Review of the monthly physician orders for May 2024 revealed orders for a Complete Metabolic Panal (CMP), Complete Blood Count (CBC) every six months; lipids, Thyroid Stimulating Hormone and Vitamin D yearly dated 07/20/21. Review of the lab results revealed a CBC and CMP had not been completed since 08/18/23. Interview on 05/07/24 at 3:55 P.M., with the DON verified the CBC and CMP had not been drawn since 08/18/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365936 If continuation sheet Page 18 of 27 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on review of personnel files, review of facility documentation, and staff interviews, the facility failed to employ a qualified dietary manager. This affected all residents who received food from the kitchen. The facility identified two residents (#24 and #48) who did not receive food by mouth. The facility census was 51. Findings include: Review of personnel files revealed Dietary Manager #340 was hired on 06/09/23 and was promoted to the role of Dietary Manager on 04/21/24. Dietary Manager #340 did not have a Servesafe certification. Review of facility provided documentation revealed former Dietary Manager #380 was no longer employed at the facility effective 04/01/24. Interview on 05/05/24 at 12:42 P.M., with Dietary Manager #340 revealed she was in the process of taking the ServeSafe course with plans to complete it by the end of the month. Interview on 05/05/24 at 1:10 P.M., with Resident Care Coordinator #327 verified Dietary Manager #340 did not have the ServeSafe certification. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365936 If continuation sheet Page 19 of 27 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on review of the menu, observation, staff interview, review of census sheet, review of the dietary spreadsheet, and policy review, the facility failed to ensure menus were followed including offering appropriate substitutions for 12 (#5, #21, #28, #27, #33, #40, #42, #47, #197, #198, #199, and #243) residents and serving sizes for 10 (#3, #20, #24, #30, #31, #32, #34, #36, #38, and #43) residents. The facility census was 51. Findings include: 1. Review of the 05/05/25 lunch meal revealed included baked chicken, mashed potatoes, green beans, bread and butter, and fruit. Observation on 05/05/24 at 12:31 P.M., of the lunch meal revealed the 300 and 400 hall resident cart meals included baked chicken, rice, pasta salad, and fruit. Observation revealed 12 (#5, #21, #28, #27, #33, #40, #42, #47, #197, #198, #199, and #243) residents were served the incorrect substitute. Interview on 05/05/24 at 12:35 P.M., with Dietary Aide #313 revealed they had run out of Italian green beans so she served left over pasta salad and they had also run out of mashed potatoes and determined to serve rice instead. Interview on 05/05/24 at 12:42 P.M., with Dietary Manager #340 was not aware of the substitution of pasta salad for green beans and rice for mashed potatoes. Interview on 05/07/24 at 11:31 A.M., with Dietician #381 verified pasta salad was not an appropriate substitution for Italian green beans stating the substitution should have been a vegetable. Dietician #381 reported in the past there was a substitution list she would sign off of once a week. Review of undated policy titled, Menu Substitution revealed menu substitutions will be made after a discussion with the director of food and nutrition services whenever possible. Last-minute substitutions may be needed to be made for uncontrollable circumstances (example: inventory emergency when a food items is temporarily unavailable). Kitchen staff will consult with the director of food and nutrition services or designee on any needed menu substitutions. If the director is unavailable then designated staff will make the substation. 2. Review of the menu spreadsheet for 05/07/24 revealed the lunch meal included sloppy joe (#10 (3 ounces) scoop meat, 1 bun), baked French fries (2 ounces), corn (4 ounce spoodle), roll (1 each), and cookie (1 each). Observation on 05/07/24 during the lunch meal serving revealed a #8 scoop/4 ounce scoop used for the sloppy joe and a #16 scoop/2 ounces to be used for the corn. Dietary [NAME] #321 was observed plating one #16 scoop on resident plates. Observations revealed 10 (#3, #20, #24, #30, #31, #32, #34, #36, #38, and #43) residents were served the incorrect serving size. Interview on 05/07/24 at approximately 11:40 A.M., with Dietary Manager #340 revealed the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365936 If continuation sheet Page 20 of 27 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 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 0803 did not have a 3 ounces scoop and used a 4 ounce scoop instead for the sloppy joe. Dietary Manager #340 verified the #16 scoop was half of the portion size identified on the spreadsheet. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365936 If continuation sheet Page 21 of 27 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on review of the menu, observation, review of the recipe, and staff interview, the facility failed to ensure pureed foods were made of appropriate consistency. This affected two (#24 and #48) residents who the facility identified as receiving a pureed diet. The census was 51. Findings include: Review of the lunch menu on 05/06/24 revealed the lunch included meatballs, noodles, mixed vegetables, and bread and butter. Review of the pureed meatloaf recipe revealed the recipe included meatloaf, beef base, hot water, and food thickener. Instructions included to prepare meatloaf in food processer, add broth and process until a smooth texture, add thickener and process briefly until mixed. Measurements of liquid and thickener may be adjusted to achieve desired texture. Observation on 05/06/24 at 10:50 A.M. revealed the facility substituted meatballs for meatloaf. Dietary Aide #321 placed two servings of meatloaf, two spoonsful of thickener, and an unknown amount of hot water (approximately half of a mug) in the blender. The meal was blended for approximately one to two minutes then poured into two individual bowls. Taste test of a spoonful of the pureed meatloaf from the blender revealed a soup like mixture and liquid dripped from the spoon and the texture was gritty. Interview on 05/06/24 at 10:55 A.M., with Dietary Aide #321 revealed they were trained to make purees as a soup like texture. Interview on 05/06/24 at approximately 11:03 A.M., with Director of Therapy #382 verified the pureed meatloaf was gritty and was like a soup. Observation on 05/06/24 at 11:15 A.M., revealed the puree of mixed vegetables. Dietary Manager #340 added the mixed vegetables to the blender and an unknown amount of hot water. The mix was blender for approximately 2 minutes then poured equally into two bowls to serve. Taste test of a spoonful of vegetable from the blender revealed the vegetables were not adequately pureed. A carrot approximately the size of a pencil eraser was in the spoonful. Interview on 05/06/24 at 11:19 A.M., with Dietary Manager #340 verified the pencil eraser size carrot in the pureed meal. Dietary Manager #340 threw away the vegetable puree and made broccoli puree instead. The meatloaf was also remade. Dietary Manager #340 verifed two (#24 and #48) residents who receive a pureed diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365936 If continuation sheet Page 22 of 27 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, review of the dishwasher manual, review of the dishwasher temperature log, and policies review, the facility failed to appropriately store food and ensure the dishwasher was sanitizing. This had the potential to affect all residents who received food from the kitchen. The facility identified two (#24 and #48) residents who do not receive food by mouth. The facility census was 51. Findings include: 1. Observation of the initial kitchen tour on 05/05/24 on 8:33 A.M., revealed a prepackage of frozen meatloaf thawing in the refrigerator with a sticky note on it that stated use for dinner on 04/25/24, hard boiled eggs to be discarded on 04/29/24, and bologna to be discarded on 04/29/24. There were also multiple boxes of keep frozen food such a pork links, meatloaf, and chicken fillets in the refrigerator. In the freezer there was an open to air bag of beef fritters and on the floor were three cracked eggs with no shells in different areas of the freezer. In the storage area were two large trays with unfrosted cupcakes covered with cardboard. The cake was sticking to the cardboard and the cardboard appeared dirty. Interview on 05/05/24 at 8:42 A.M., with Dietary Aide #313 verified the expired items in the refrigerator and the meatloaf was originally to be used on 04/25/24 and was thawed then when not used refrozen and now thawing again. Dietary Aide #313 stated frozen meal items were moved to the refrigerator the day prior to assist with cooking times. The cracked eggs and open beef fritters in the freezer were also verified. Dietary Aide #313 verified the cardboard covering the unfrosted cupcakes and does not know where the cardboard came from. Review of the policy titled, Food Storage, dated March 2023, verified all food should be covered, labeled, and dated and routinely monitored to assure that foods will be consumed by their safe to use date. If thawing frozen meat, poultry, and fish in the refrigerator, allow a minimum of 24 to 48 hours and cook immediately after thawing 2. Observation on 05/06/24 at 11:25 A.M. revealed after running the dishwasher multiple times the high temperature dishwasher final rinse cycle reach a high temperature of 168 degrees Fahrenheit. Interview on 05/06/24 at 11:27 A.M., with Dietary Aide #321 showed the two temperature gages and reported the wash should reach 160 degrees Fahrenheit and the rinse should reach 180 Fahrenheit. Dietary Aide #321 verified the highest temperature of the final rinse was 168 degrees Fahrenheit. Review of the dish machine temperature log, dated 04/17/24 to 05/06/24 revealed the rinse cycle had never been documented as reaching 180 degrees Fahrenheit. Most of the documentation was incomplete however when temperatures were documented the dishwasher rinse cycle ranged from 170 to 175 degrees Fahrenheit, typically 170 degrees Fahrenheit. Review of the undated policy titled, Dishwasher Temperature, revealed the high temperature dishwasher process involves washing the dishware at a specific temperature and sanitizing it at a high temperature. The exact temperatures are not specified in the provided knowledge base. Wash cycle is 150 to 165 degrees Fahrenheit and final rise 180 degrees Fahrenheit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365936 If continuation sheet Page 23 of 27 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 05/06/24 at 1:12 P.M., with Assistant Director of Nursing (ADON) #319 verified the documented dishwasher temperatures. Interview on 05/06/24 at approximately 3:50 P.M., with Resident Care Coordinator #327 revealed a repairman was at the facility and would need to order a part but in the meantime increased the temperature on the dishwasher. Review of the dishwasher manual revealed the electric booster heater is typically used to provide 180 degrees Fahrenheit sanitizing water. This deficiency represents non-compliance investigated under Complaint Number OH00152901. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365936 If continuation sheet Page 24 of 27 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 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 Based on staff interviews, observations, review of Legionella Water Management Plan, and the review of policy, the facility failed to ensure procedures were followed for Legionella prevention and ensure staff properly transported soiled lines in common areas. This had the potential to affect all 51 residents. The census was 51. Residents Affected - Many Findings include: 1. Review of the facility's, Legionella Water Management Plan updated 10/02/23 revealed control measures and monitoring included all sinks/showers/toilets would be visually checked daily, eye wash stations visually checked weekly and ice machines would be visually checked monthly. Upon request for records of the checks being completed, no records were provided. Interview on 05/07/24 at 4:22 P.M., with Maintenance Director #333 verified he was unable to provide documentation the visual checks had been completed. 2. Observation on 05/06/24 at 8:05 A.M., revealed State Tested Nursing Assistant (STNA) #377 carrying soiled linen in a bundle, in one hand, next to her body and a soiled brief in the other hand, down the hallway, into the soiled utility room that was located at the beginning of the dining room. A random resident was observed sitting at the table in the dining room eating breakfast across from the soiled utility area. Interview on 05/06/24 at 8:09 A.M., with STNA #377 verified that linen and soiled briefs are to be bagged prior to transporting in the hallways to the soiled utility rooms. STNA #377 verified she did not have the linen nor the soiled brief in a bag prior to carrying it down the hallway. Review of the policy titled Laundry and Bedding, Soiled, dated October 2018, revealed all soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365936 If continuation sheet Page 25 of 27 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 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 0923 Have enough outside ventilation via a window or mechanical ventilation, or both. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, ombudsman interview, family interview, and policy review the facility failed to ensure pungent smells of urine did not permeate into common areas and dining room. This had the potential to affect all residents. The facility census was 51. Residents Affected - Many Findings include: Observation on 05/06/24 at 7:25 A.M., of 300/400 hall nurses station/common area into the dining room revealed permeating urine odor with no residents in the area. Observation on 05/06/24 at 8:50 A.M., of 600 [NAME] hallway revealed permeating urine smell at the end of the hallway. Observation on 05/06/24 at 10:50 A.M., of 300/400 hall nurses station revealed urine odor was lightly detected. better at this time. When rounding the corner to the common area and dining room urine smell detected. Observation on 05/06/24 at 4:00 P.M., of 300/400 hall common area and dining room revealed faint urine odor. Observation on 05/07/24 at 7:24 A.M., revealed permeating urine odor still present in the 300/400 common area with no residents around in the area. On the way back through the 300/400 hall common area at 7:37 A.M., the urine smell was lightened and the area smelled like air freshener. Observation on 05/07/24 at 10:52 A.M., revealed the pungent urine smell continues in the 300/400 hall common area. The urine smell continues throughout the 600 [NAME] hallway and a feces odor is noted at the end of the hallway. Observation on 05/08/24 at 8:15 A.M., revealed permeating urine smell continues on the 300/300 hallway common area with no residents in the vicinity. Dining room continues with faint urine smell. Observation on 05/08/24 at 9:05 A.M. of Tuscan Way Dining room on 600 hall revealed the room smelled musty with a urine odor. Observation on 05/08/24 at 11:39 A.M., revealed urine odor remained in the dining room and 300/400 hall common area. Tuscan Way dining room continued to have musty urine smell. Interview on 05/05/24 at 2:48 P.M., with Resident #36's family revealed there is a strong urine odor near the nurse's station and dining area outside of the memory care area. Interview on 05/08/24 at 8:18 A.M., with Housekeeper #329 stated they use HDQ C2 (neutral disinfectant cleaner) for cleaning in the facility. Housekeeper #329 stated she will wipe down surfaces, clean the bathrooms, and sweep and mop rooms. Housekeeper #329 stated she uses Odoban spray for urine odors. Housekeeper #329 stated she will spray down the cushions in the common areas sometimes. Interview on 05/08/24 at 9:07 A.M., with Physical Therapy Assistant (PTA #379) verified that the 300/400 common area and dining room have a permeating urine odor. PTA #379 verified the Tuscan Way dining room on 600 hall smelled musty with faint urine odor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365936 If continuation sheet Page 26 of 27 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 365936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Retirement Community of Lima Inc 2440 Baton Rouge Avenue Lima, OH 45805 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 0923 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview via phone communication, on 05/08/24 at 9:55 A.M., with the Ombudsman verified on some visits there has been a strong urine odor. Review of policy titled, Homelike Environment, dated February 2021, revealed the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include pleasant, neutral scents. This deficiency represents non-compliance investigated under Complaint Number OH00152901. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365936 If continuation sheet Page 27 of 27