Health inspection·September 16, 2021

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few evidence Resident #339 was provided notification prior to the move or that Resident #339's sister was notified. On 09/16/21 at 10:20 A.M. Resident #339's sister was interviewed and stated when Resident #339 was admitted to the facility he was placed on a quarantine unit. After being in the same room for more than a month, he was moved. Resident #339's sister stated she was not made aware of the move and when she asked Resident #339 about the move, he indicated he was not given notice either. Interview on 09/16/21 at 1:10 P.M., the DON verified she was unable to find documented evidence of notification prior to the room change. Review of the policy for room change, reviewed 02/14/17, revealed notification of room change requirements were considered part of the resident's rights and should be respected as any other resident right. This deficiency substantiates Master Complaint Number OH00115881 and Complaint Number OH000114133. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 2 of 21 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 365972 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canfield Healthcare Center 2958 Canfield Rd Youngstown, OH 44511 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on medical record review, review of personnel files, review of facility reported incidents, review of the facility's Abuse policy, review of the employee handbook and interview, the facility failed to ensure staff did not misappropriate resident property. This affected one (Resident #340) of five residents reviewed for misappropriation. The facility census was 78. Findings include: Review of Temporary Nurse Aide #121's personnel file revealed she was hired 01/27/20 as a hospitality aide. The employee became a Temporary Nurse Aide on 09/18/20. The personnel file contained a statement from Business Office Manager #3 which indicated on 11/10/20, Counselor #122 reported Temporary Nurse Aide #121 asked Resident #340 for money (and received money) on several occasions. Temporary Nurse Aide #121 promised to repay Resident #340 on pay day. Temporary Nurse Aide #121 would not repay the money. A statement by Licensed Practical Nurse (LPN) #19 dated 11/14/20 indicated Resident #340 indicated Temporary Nurse Aide #121 had borrowed from her more than once but never repaid the last $25 she borrowed. Resident #340 reported Temporary Nurse Aide #121 would go to her crying she needed money. LPN #19 indicated Resident #340 had already reported this to Business Office Manager #3. The personnel file also contained communication from Counselor #122 which indicated Resident #340 reported to the counselor that Temporary Nurse Aide #121 borrowed $20.00 from her once and $25.00 from her on five different occasions. Resident #340 told the counselor the last time Temporary Nurse Aid #121 borrowed money it was not repaid. Resident #340 was upset as she had a limited income. Counselor #122 indicated she reported the information to Business Office Manager #3. Review of Facility Reported Incidents submitted by the facility revealed no report of Resident #340 alleging Temporary Nurse Aide #121 was borrowing money from and not repaying it. Review of the facility's Ohio Abuse, Neglect and Misappropriation policy, reviewed 05/30/19, revealed exploitation was identified as taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats or coercion. Misappropriation of resident property was identified as deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Interview on 09/15/21 at 11:05 A.M., the Administrator stated while he was investigating an allegation of unauthorized use of a different resident's debit card by Temporary Nurse Aide #121, she was suspended. When the facility contacted Temporary Nurse Aide #121 about Resident #340's concerns about not being repaid, reported she had been unable to repay her because she was not permitted in the facility. With permission, Temporary Nurse Aide #121 dropped the payment off in the facility parking lot. The Administrator indicated he did not identify this as misappropriation of Resident #340's property because she was paid back. Interview on 09/15/21 at 4:14 P.M., the Administrator stated he would understand the concern about Temporary Nurse Aide #121 borrowing money from Resident #340 if the resident was confused. The Administrator reported Temporary Nurse Aide #121 was suspended indefinitely 11/20/20. Review of Resident #340's medical record revealed diagnoses of psychosis, post-traumatic stress disorder, depression, mood affective disorder, and anxiety disorder. Review of Minimum Data Set (MDS) 3.0 assessments during the timeframe of Temporary Nurse Aide #121's employment revealed on 04/01/20 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 3 of 21 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 365972 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canfield Healthcare Center 2958 Canfield Rd Youngstown, OH 44511 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and 07/02/20 Resident #340 was assessed as being moderately cognitively impaired. On 10/02/20 Resident #340 was assessed as cognitively intact. Interview on 09/16/21 at 11:36 A.M., Business Office Manager #3 stated after Counselor #122 reported to her that Temporary Nurse Aide #121 was borrowing money from Resident #340 without it being repaid, she spoke to Resident #340 who confirmed the report. Business Office Manager #3 stated she reported the information to the Administrator. Business Office Manager #3 stated she believed if Temporary Nurse Aide #121 was borrowing money from Resident #340, it was a concern regardless of whether it was repaid. Interview on 09/16/21 at 11:39 A.M., LPN #19 verified Resident #340 told her Temporary Nurse Aide #121 had been borrowing money from her but had not paid her back the last time she borrowed money. LPN #19 stated she provided the information to the Administrator as she was concerned a staff member was borrowing money from a resident. Review of the employee handbook, revised 03/01/18, revealed on page 15 , under a section labeled Gratuities, under no circumstances should an employee solicit a gratuity from a resident or family member, nor should an employee ever borrow money from a resident or his/her family members. This deficiency substantiates Complaint Numbers OH00111375 and OH110759. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 4 of 21 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 365972 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canfield Healthcare Center 2958 Canfield Rd Youngstown, OH 44511 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on medical record review, review of personnel files, review of facility reported incidents, review of the facility's Abuse policy, review of the employee handbook and interview, the facility failed to ensure allegations of a staff potentially misappropriating a resident's property were reported to the State Agency. This affected one (Resident #340) of five residents reviewed for misappropriation. The facility census was 78. Findings include: Review of Temporary Nurse Aide #121's personnel file revealed she was hired 01/27/20 as a hospitality aide. The employee became a Temporary Nurse Aide on 09/18/20. The personnel file contained a statement from Business Office Manager #3 which indicated on 11/10/20 Counselor #122 reported Temporary Nurse Aide #121 asked Resident #340 for money (and received money) on several occasions. Temporary Nurse Aide #121 promised to repay Resident #340 on pay day. Temporary Nurse Aide #121 would not repay the money. A statement by Licensed Practical Nurse (LPN) #19 dated 11/14/20 indicated Resident #340 indicated Temporary Nurse Aide #121 borrowed from her more than once but never repaid the last $25 she borrowed. Resident #340 reported Temporary Nurse Aide #121 would go to her crying she needed money. LPN #19 indicated Resident #340 had already reported this to Business Office Manager #3. The personnel file also contained communication from Counselor #122 which indicated Resident #340 reported to the counselor that Temporary Nurse Aide #121 borrowed $20.00 from her once and $25.00 from her on five different occasions. Resident #340 told the counselor the last time Temporary Nurse Aid #121 borrowed money it was not repaid. Resident #340 was upset as she had a limited income. Counselor #122 indicated she reported the information to Business Office Manager #3. Review of Facility Reported Incidents submitted by the facility revealed no report of Resident #340 alleging Temporary Nurse Aide #121 was borrowing money from and not repaying it. Review of the facility's Ohio Abuse, Neglect and Misappropriation policy, reviewed 05/30/19, revealed exploitation was identified as taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats or coercion. Misappropriation of resident property was identified as deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Interview on 09/15/21 at 11:05 A.M., the Administrator stated while he was investigating an allegation of unauthorized use of a different resident's debit card by Temporary Nurse Aide #121, she was suspended. When the facility contacted Temporary Nurse Aide #121 about Resident #340's concerns about not being repaid, Temporary Nurse Aide #121 reported she was unable to repay her because she was not permitted in the facility. With permission, Temporary Nurse Aide #121 dropped the payment off in the facility parking lot. The Administrator indicated he did not identify this as misappropriation of Resident #340's property because she was paid back. Therefore, it was not reported to the State Agency. Interview on 09/15/21 at 4:14 P.M., the Administrator stated he would understand the concern about Temporary Nurse Aide #121 borrowing money from Resident #340 if the resident was confused. The Administrator reported Temporary Nurse Aide #121 was suspended indefinitely 11/20/20. Review of Resident #340's medical record revealed diagnoses of psychosis, post-traumatic stress (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 5 of 21 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 365972 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canfield Healthcare Center 2958 Canfield Rd Youngstown, OH 44511 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few disorder, depression, mood affective disorder, and anxiety disorder. Review of Minimum Data Set (MDS) 3.0 assessments during the timeframe of Temporary Nurse Aide #121's employment revealed on 04/01/20 and 07/02/20 Resident #340 was assessed as being moderately cognitively impaired. On 10/02/20 Resident #340 was assessed as cognitively intact. Interview on 09/16/21 at 11:36 A.M., Business Office Manager #3 stated after Counselor #122 reported to her that Temporary Nurse Aide #121 was borrowing money from Resident #340 without it being repaid, she spoke to Resident #340 who confirmed the report. Business Office Manager #3 stated she reported the information to the Administrator. Business Office Manager #3 stated she believed if Temporary Nurse Aide #121 was borrowing money from Resident #340 it was a concern regardless of whether it was repaid. Interview on 09/16/21 at 11:39 A.M., LPN #19 verified Resident #340 told her Temporary Nurse Aide #121 had been borrowing money from her but had not paid her back the last time she borrowed money. LPN #19 stated she provided the information to the Administrator as she was concerned a staff member was borrowing money from a resident. Review of the employee handbook, revised 03/01/18, revealed on page 15, under a section labeled Gratuities, under no circumstances should an employee solicit a gratuity from a resident or family member, nor should an employee ever borrow money from a resident or his/her family members. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 6 of 21 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 365972 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canfield Healthcare Center 2958 Canfield Rd Youngstown, OH 44511 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview, the facility failed to ensure treatments for a wound were implemented in a timely manner. This affected one (Resident #339) of two residents reviewed for non-pressure related skin impairment. The facility census was 78. Residents Affected - Few Findings include: Review of Resident #339's medical record indicated an admission date of 06/12/20. Diagnoses included complications of gastric band procedure and anoxic brain damage. Hospital discharge instructions revealed instruction to continue to change midline wound dressing daily. A collagen dressing was to be changed daily and covered with dry gauze. A hand-written nurse to nurse report indicated Resident #339 had a midline incision from an old surgery which had healed but had two open areas. Review of the admission assessment indicated Resident #339 had a surgical incision on the abdomen (no indication of a size or appearance) and a rash. The assessment indicated there was not a treatment order in place for each area noted. There was no documented evidence the physician was contacted for a treatment order and the order on the hospital discharge instructions was not transcribed onto Resident #339's orders or treatment administration records. On 06/19/20, an order was written for a weekly skin evaluation. No skin evaluation was documented at that time. A wound doctor note dated 06/24/20 indicated Resident #339 had a persistent abdominal wound related to his original surgery so the doctor was asked by nursing to see Resident #339 to evaluate his wound for treatment recommendations and management. The wound doctor note indicated the wound had five areas with scarred epithelial bridges in between. All the areas were irregular ovoid-shaped hyper granulated wounds with mild serosanguinous drainage. The wound doctor assessed Resident #339 with an abdominal post-surgical grade one dehiscence (surgical wound dehiscence is the separation of the margins of a closed surgical incision that had been made in skin, with or without exposure or protrusion of underlying tissue, organs, or implants. Grade one indicated only the dermal layer was involved) that would benefit from debridement of the hyper granulation tissue to facilitate wound closure. The wound doctor ordered initiated treatment. Interview on 09/15/21 at 2:05 P.M., the Director of Nursing (DON) verified discharge orders from the hospital contained instructions for wound care which were not transcribed or implemented. The DON verified she was unable to locate assessments from the time of admission until the wound doctor saw Resident #339 on 06/24/20. The DON verified there was no evidence of a treatment initiated until 06/25/20. This deficiency substantiates Complaint Number OH000114133. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 7 of 21 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 365972 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canfield Healthcare Center 2958 Canfield Rd Youngstown, OH 44511 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #339's medical record revealed diagnoses including anoxic brain injury, need for assistance with personal care, and generalized muscle weakness. On 07/28/20 an order was written for restorative active ROM to the right upper extremity, active assisted ROM to both lower extremities six to seven days a week to total 15 minutes a day to maintain Resident #339's current function. The order indicated Resident #339 required moderate assistance and verbal and tactile cues. Review of an August 2020 Treatment Administration Record (TAR) revealed nurses initialed the range of motion order as completed but did not indicate the time spent providing the services. Interview on 09/16/21 at 12:19 P.M., LPN #46 stated nurses did not perform the restorative ROM program but were supposed to check with the aides to determine if the ROM was performed. Aides performed and documented the ROM program when it was performed. Review of documentation by nursing assistants revealed between 08/02/20 and 08/08/20 ROM was provided two days. Between 08/09/20 and 08/15/20 ROM was provided a minimum of 15 minutes three days with two days marked as not applicable. Interview on 09/16/21 at 3:12 P.M., the DON verified restorative records did not reveal services were provided with the ordered frequency. This deficiency substantiates Complaint Number OH000114133. Based on record review, interviews, observation and policy review, the facility failed to ensure restorative therapy was performed per the resident's physician's orders and plan of care. This affected two (Resident's #12 and #339) of four reviewed for activities of daily living (ADL). The facility census was 78. Findings include: 1. Record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (MS), quadriplegia, spondylolysis, and radiculopathy of lumbar and cervical region. Interview on 09/13/21 at 11:20 A.M., with Resident #12 revealed she had MS and spinal cord injuries that have left her a quadriplegic. The resident reported her bilateral hand contractures and knee (leg) contractures had worsen and she could not raise her arms as far as she could after receiving therapy months ago. The resident confirmed she has not received restorative therapy since she had completed therapy months ago. She stated she only received therapy for approximately two weeks. Further observation and interview with Resident #12 on 09/13/21 at 11:20 A.M., revealed the resident was not able to extend or stretch her fingers to a neutral position. The resident reported she could not extend her legs to a neutral position or raise her bilateral shoulders to a neutral position. The resident reported she was able to extend bilateral hands and legs after therapy, however since she was not receiving therapy or restorative for months her range of motion (ROM) worsened. The resident reported she was dependent on staff prior and was still dependent on staff for all her ADL's, however she had noticed she was getting weaker in her upper body strength. The resident reported she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 8 of 21 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 365972 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canfield Healthcare Center 2958 Canfield Rd Youngstown, OH 44511 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was able to smoke with an adaptive device and she had noticed she was getting weaker and not able to lift arms as high. The resident demonstrated she could not lift arms and extended fingers. Review of Resident #12's undated therapy referral to restorative communication form revealed the resident was ordered a ROM program to maintain her current level of function. The ROM program included Active ROM to bilateral upper extremities (BUE), elbows and shoulders, and passive ROM to BUE, wrist and fingers, and bilateral lower extremity (BLE) active ROM and passive ROM. Review of Resident #12's task and orders dated 07/13/21 to present revealed the resident was ordered restorative active ROM and passive ROM BUE. Staff were to perform active ROM on BUE elbow to shoulder and passive ROM on bilateral wrist and fingers, may use 1/4-pound weights if requested. Restorative performed six to seven days a week for at least 15 minutes to maintain current function. Allow for periods of rest as needed, reported complaints of pain to the nurse. There was no evidence of BLE active and passive ROM. Further review of Resident #12's tasks revealed no evidence that restorative therapy had been administered for performed from 07/13/21 to present. Review of the facilities list of residents receiving restorative therapy dated 09/15/21 revealed Resident #12 was to receive active ROM and passive ROM to BUE. Perform active ROM on BUE elbow to shoulder, and passive ROM on BUE wrist and fingers, may use 1/4-pounds weights if requested. Perform six to seven days a week at least 15 minutes to maintain current function. Allow for periods of rest as needed, reported complaints of pain to the nurse. The was no evidence of restorative program for BLE. Review of Resident #12's Minimum Data Set (MDS) 3.0 dated 06/24/21 revealed the resident brief interview for mental status (BIMS) score was 15 (cognition intact), no rejection of care, total dependence for transfers, toilet use, and personal hygiene. The resident used a wheelchair for mobility. The resident and direct care staff believe the resident was capable of increase independence in at least some of her ADL. The resident did not receive the restorative therapy program. Review of Resident #12's ADL self-care performance deficit plan of care dated 07/01/21 revealed the resident was to receive a restorative program for active ROM and passive ROM to BUE. Perform active ROM on BUE elbow to shoulder, and passive ROM on BUE wrist and fingers, may use 1/4-pounds weights if requested. Perform six to seven days a week at least 15 minutes to maintain current function. Allow for periods of rest as needed, reported complaints of pain to the nurse. The was no evidence of restorative program for BLE. Further review of Resident #12's paper medical record revealed no evidence restorative therapy was provided per orders and plan of care. Interview on 09/15/21 at 10:34 A.M., with the Director of Nursing (DON) confirmed there was no documented evidence in the electronic or paper medical record from 07/13/21 to present that Resident #12 was provided restorative therapy per order and plan of care. The DON confirmed the floor staff were responsible for performing restorative services. There was no one person designated to provided restorative therapy. Restorative therapy should be documented in the electronic medical record under the task tab. Interview on 09/15/21 at 1:47 P.M., with Occupational Therapist (OT) #62 revealed she recommended (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 9 of 21 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 365972 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canfield Healthcare Center 2958 Canfield Rd Youngstown, OH 44511 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the resident to be transferred to a restorative program after she was discharged from therapy on 06/29/21. The discharge recommendation was for the ROM program including active ROM to BUE (elbows and shoulders) and passive ROM to BUE (wrist and fingers) and bilateral lower extremity (BLE) active ROM and passive ROM. Review of the facility policy titled Restorative Program, dated 07/26/18, revealed active ROM was the performance of an exercise to move a joint without any assistance or effort of another person to the muscles or surrounding the joint. Passive ROM was the movement of a joint through the range of motion with no effort from the patient. The purpose of the policy was to implement a plan of action for resident-specific care to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable. The medical director, director of nursing, and therapy would be accountable and have oversight of the program. The staff would be trained and competent and there would be sufficient staff to meet the needs of the program and resident care. Event ID: Facility ID: 365972 If continuation sheet Page 10 of 21 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 365972 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canfield Healthcare Center 2958 Canfield Rd Youngstown, OH 44511 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 medical record review, review of facility smoking list, observation, interview, and policy review the facility failed to ensure residents were provided adequate supervision while smoking and failed to ensure accurate comprehensive smoking assessments were completed. This affected two (Resident #12 and #62) of four reviewed for accidents. The facility census was 78. Findings included: 1. Record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including cigarette nicotine dependence, multiple sclerosis (MS), quadriplegia, spondylolysis, and radiculopathy of lumbar and cervical region. Review of the facility smoking list dated 09/01/21 revealed Resident #12 was listed as supervision with and a smoking apron. Review of Resident #12's smoking assessment dated [DATE] revealed the resident had dexterity problems, smoked six to 10 times daily, could light her own cigarette, required a cigarette holder, and could dispose of a cigarette appropriately. The assessment did not include the use of a smoking apron or required supervision. Interview and observation on 09/13/21 at 11:24 A.M., revealed Resident #12 was outside smoking without supervision or a smoking apron in place. The resident had a ring noted on her right index finger that held the cigarette. The resident reported staff must assist her outside, and they usually light her cigarette and then leave. The staff does not stay outside with her or supervise her while she smokes. Resident #12 reported the facility had smoking aprons, but staff does not give her one. The smoking aprons were observed hanging on the pavilion. The smoking aprons were in disrepair and had black mold on them. The resident confirmed she was unable to get a cigarette out of the package or light a cigarette due to medical conditions and contractures. She stated she lets the cigarette burn to the end and usually another resident would dispose of it for her. She was noted to be disposing ashes by taping the cigarette off her wheelchair, and the ashes were landing on the concrete floor. The other unidentified residents present reported they do not keep their smoking materials in the locked mailbox outside by the smoking pavilion. Resident #12 confirmed she keeps her smoking material on her because she cannot use the mailbox due to her medical condition. Interview and observation on 09/14/21 at 10:23 A.M., the Resident #12 was observed outside smoking without supervision or a smoking apron. The findings were confirmed by Social Service (SS) #91. SS #91 verified Resident #12 should be supervised and wearing a smoking apron. Observation on 09/14/21 at 10:53 A.M., revealed Resident #12 was still outside smoking without supervision or a smoking apron. Observation on 09/14/21 at 1:40 P.M., Resident #12 was observed outside with two other residents unsupervised and no smoking apron. Observation on 09/14/21 at 2:06 P.M. of Resident #12 with the Director of Nursing (DON) revealed the resident was outside smoking unsupervised and no smoking apron. The DON confirmed findings and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 11 of 21 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 365972 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canfield Healthcare Center 2958 Canfield Rd Youngstown, OH 44511 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 confirmed the resident was not safe to smoke independently and required supervision. The DON could not answer why residents were smoking unsupervised. The resident reported the burn marks on her legs were prior to her admission in the facility. The resident reported she had no feelings in her legs. The one scar was from sitting a bowl of hot food on her legs and she didn't feel it was burning her. When her caregiver removed the bowl from the lap, her skin was attached to the bottom of the bowl. The residents have a mailbox outside where they were supposed to store their smoking materials. Each resident had their own key for the box. The DON confirmed Resident #12's smoking assessment was inaccurate to reflect the resident able to light cigarette and dispose of it properly. The DON also reported the assessment should have included the use of a smoking apron and staff supervision. The nurse completing the form did not document the resident's type of supervision or safety equipment. The DON reported the resident sits outside almost all day and smokes when she was not on a leave of absence. Review of the facility policy titled Nursing Services/Smoking, dated 03/25/18, revealed the smoking apron was a fire resistant apron used to cover the torso or body and lag to aid in preventing cigarette ashes or dropping cigarettes from igniting clothing. A supervised smoker was a resident that was unable to demonstrate safe smoking habits including smoking materials management, lighting, controlling a cigarette ash and extinguishing smoking material and requires staff supervision when smoking. All smoking materials will be maintained by the facility staff and provide to the residents upon request. All smoking materials will be returned to the facility staff upon completion of smoking. Supervised smoking would be performed by staff members. 2. Review of the medical record for Resident #62 revealed an admission date of 08/09/21 with diagnoses including laceration to the left lower leg, history of falls, nicotine use, and a short stature due to an endocrine disorder. The MDS 3.0 assessment dated [DATE] revealed the resident had intact cognition and used tobacco products. Review of the nursing progress note dated 08/11/21 revealed the resident smoked cigarettes and was considered an unsafe smoker. The physician progress note dated 08/19/21 revealed Resident #62 was an unsafe smoker. Observations on 09/13/21 at 12:45 P.M. and on 09/15/21 at 12:55 P.M. of Resident #62 in her room revealed an electronic cigarette and a full pack of cigarettes sitting on her tray table. Observation on 09/16/21 at 11:27 P.M. revealed Resident #62 to have an open pack of cigarettes and a lighter on her tray table. There were no staff present in the room during these observations. Observation on 09/14/21 at 1:53 P.M. revealed Resident #62 to be smoking a cigarette in the designated smoking area outside at the facility. Resident #62 did not have a smoking apron over her clothing during this observation. Resident #62 was observed dropping ashes on her clothing as she was unable to extend her arm out past her body frame to flick the ashes from her cigarette. Hospitality Aide #100 was observed supervising the resident, however, did not intervene to assist the resident with disposing of her ashes properly so that they would not fall on her clothing. The facility document titled Canfield Smokers, dated 09/01/21, revealed Resident #62 needed to be supervised and wear a smoking apron while smoking. The facility policy titled Resident/Patient Smoking, reviewed 05/30/19, stated the facility will secure smoking materials in a locked area when not in use by the resident/patient for both independent and supervised smokers. The policy stated that smoking materials would be returned to the facility staff upon completion of smoking. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 12 of 21 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 365972 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canfield Healthcare Center 2958 Canfield Rd Youngstown, OH 44511 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interview and policy review, the facility failed to ensure Resident #334 received diet ordered by the physician. This affected one (Resident #334) of seven residents reviewed for nutrition. The facility census was 78. Residents Affected - Few Findings include: Record review revealed Resident #334 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, chronic obstructive pulmonary disease, alcohol dependence, vitamin B deficiency, anemia, and chronic peptic ulcer disease. Interview with Resident #334 on 09/14/21 at 8:22 A.M. revealed he was not getting double portion of meals as ordered. The resident reported he had been using his own money to buy snacks. Review of the facility's list of resident diets dated 09/14/21 revealed no evidence Resident #334 was to receive double portion with meals. Review of Resident #334 diet requisition form dated 08/23/21 revealed no evidence of double portions with meals. Review of Resident #334's admission orders from another skilled nursing facility dated 08/06/21 revealed the resident was ordered double entrees. Review of Resident #334's current physician's orders dated 09/15/21 revealed on 08/23/21 (admission) the resident was ordered double portion entrees. Review of Resident #334's plan of care for nutritional problems/potential nutrition problems related to Parkinson disease, chronic obstructive pulmonary disease, alcohol dependence dated 09/01/21 revealed the resident was to receive double portion entrees. Review of Resident #334's nutritional note dated 09/01/21 revealed the resident's order included double portions. Observation on 09/14/21 at 5:46 P.M. of Resident #334's dinner meal revealed no evidence the resident received a double entree. Dietary Manger (DM) #98 confirmed the resident did not receive a double entrée. The DM reported she was not aware the resident was ordered double entree due to the dietary requisition form did not include double entree. The DM confirmed she did not have access to the resident physician's orders and if there would be an error, she would not be aware of it since she did not have access to them. Interview on 09/15/21 at 8:01 A.M., with Licensed Practical Nurse (LPN) #19 and DM #98 confirmed the resident was ordered double entrees, however the dietary requisition form was completed inaccurately, so the resident was not receiving the double portions. Review of the facilities policy titled Therapeutic Diets, dated 09/2017, revealed all residents have a diet order that is prescribed by the attending physician in accordance with applicable regulatory guidelines. The licensed nurse accepts the diet order from the authorized prescriber. The licensed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 13 of 21 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 365972 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canfield Healthcare Center 2958 Canfield Rd Youngstown, OH 44511 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Nurse completes and signs the diet requisition form, including the full diet order, food allergies, and specific food preference request. Diets are prepared in accordance with the guidelines in the approved diet manual and the individualized plan of care. This deficiency substantiates Complaint Number OH00114133. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 14 of 21 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 365972 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canfield Healthcare Center 2958 Canfield Rd Youngstown, OH 44511 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews and policy review, the facility failed to ensure Seroquel (antipsychotic) was prescribed appropriately for Resident #34 who had no approved diagnoses for the antipsychotic medication. This effected one (Resident #34) of five residents reviewed for unnecessary medications. The facility census was 78. Findings include: Review of the medical records for Resident #34 revealed the resident was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus, Parkinson's disease, metabolic encephalopathy, dementia without behavioral disturbances, kidney failure, and bipolar disorder added to diagnoses list on 09/15/21. Review of the September 2021 physician's orders revealed Resident #34 was ordered Seroquel (antipsychotic) 50 milligrams (mg) by mouth at bedtime for antipsychotic, Carbidopa- Levodopa (anti-Parkinson's agent), Mirapex (anti-Parkinson's agent), Jentadueto (diabetes medication), monitoring for antipsychotic medication side effects and adverse reactions, and monitor behaviors. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #34 had severe cognitive impairment. Resident #34 also required extensive two staff assist for bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and extensive one staff assistance for eating and personal hygiene. The resident also received antipsychotic medications with no gradual dose reductions (GDR) or statement of contraindication for GDR. Review of the plan of care dated 05/13/21 revealed Resident #34 had impaired cognitive function related to Alzheimer's dementia with interventions to include administer medications as ordered, encourage resident to be involved in daily decision making and observe for changes in cognitive function. Also, Resident #34 used antipsychotic medication related to disease process with interventions to include consult with pharmacy and medical provider to consider dosage reduction when clinically appropriate. Review of the September 2021 Medication Administration Records (MAR) revealed Resident #34 received Quetiapine (Seroquel) as prescribed and monitoring for antipsychotic side effects and adverse reactions every shift. Review of the monthly pharmacy reviews and recommendations for Resident #34 revealed, on 05/01/21, Resident #34 was ordered Seroquel for hallucinations- yelling. On 06/01/21, the consulting pharmacist monthly review and recommendations revealed the resident was ordered Quetiapine (Seroquel) an antipsychotic without a supporting diagnosis. Recommendation included prescriber review the ongoing need for the antipsychotic and, if continuing, add a supporting diagnosis with a verbal response OK by the nurse practitioner. On 07/01/21, the consulting pharmacist review and recommendation revealed Resident #34 was ordered Quetiapine with no apparent supporting diagnosis noted in the medical record, and the recommendation to reassess ongoing need for the antipsychotic medication and provide a supporting diagnosis for continued use or gradual dose reduction with note to discuss with next meeting pharmacy and therapeutic committee meeting in October or November 2021. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 15 of 21 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 365972 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canfield Healthcare Center 2958 Canfield Rd Youngstown, OH 44511 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Observation on 09/13/21 at 11:48 A.M. revealed Resident #34 lying in bed with eyes closed and not responding when the door was knocked on or when name called. Interview on 09/15/21 at 1:00 P.M. with Registered Nurse (RN) #20 stated Resident #34 has never demonstrated any hallucinations or yelling out at the facility, and Resident #34 routinely slept pretty well. Residents Affected - Few Interview on 09/15/21 at 1:10 P.M. with the Director of Nursing (DON) stated Resident #34 was admitted to the facility on [DATE] with orders for Seroquel for hallucinations and yelling out, and the resident's primary care physician continued the Seroquel order. The DON stated on 06/01/21 she received the pharmacy review and recommendation that Resident #34 was prescribed the antipsychotic medication without approved medical diagnosis for the medications, and she reviewed with Certified Nurse Practitioner (CNP) #111 who responded OK without addressing the pharmacist's recommendations. On 07/01/21, the facility received another consulting pharmacy review and recommendation for Seroquel prescribed for Resident #34 requesting an appropriate diagnosis for the continued use of the antipsychotic medication or a gradual dose reduction with review with CNP #111 that the medication would be reviewed at the pharmacy and therapeutic meeting in October or November 2021. Review of the facility Pharmacy and Therapeutics Committee monthly meeting policy, dated August 2018, revealed the Medical Director, Executive Director, consulting pharmacist, the DON and nursing unit managers would attend monthly meetings to review and address facility medication use patterns or concerns; review and address non-responded to consulting pharmacist drug regimen review recommendations in less than 30 days and perform psychotropic medication evaluations for gradual dose reductions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 16 of 21 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 365972 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canfield Healthcare Center 2958 Canfield Rd Youngstown, OH 44511 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interview, and policy review the facility failed to ensure dental consents were signed in a timely manner. This affected one (Resident #67) of one resident reviewed for dental services. The facility census was 78. Residents Affected - Few Findings include: Medical record review revealed Resident #67 was admitted to the facility on [DATE] with diagnoses including significant weight loss, heart disease, diabetes, and moderate protein-calorie malnutrition. The resident had Medicaid insurance. Interview and observation on 09/13/21 at 10:49 A.M., with Resident #67 revealed the resident was noted to be edentulous (no teeth). The resident reported she was supposed to get dentures a few months ago but never heard back from the anyone, and she would really like to get dentures. The dentist had already fitted her for the dentures. Review of Resident #67's dental notes dated 07/02/21 revealed the resident requested new dentures, and she was edentulous. Review of Resident #67's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was not edentulous and had teeth. Review of Resident #67's dental plan of care dated 03/01/21 and revised today (09/15/21) revealed the resident was edentulous. Review of Resident #67's nutritional plan of care dated 06/25/21 and reviewed 09/13/21 revealed no evidence of the resident's oral status. The resident was noted to be at risk related to therapeutic diet order, diabetes, urinary tract infection, and significant weight loss. Interview on 09/15/21 at 11:10 A.M., with MDS Nurse #14 confirmed Resident #67's MDS was marked inaccurately, and the resident should have been marked edentulous. The MDS nurse reported she would modify the MDS and updated the plan of care. Interview on 09/15/21 at 10:28 A.M., with Social Service (SS) #91 revealed she called the dental office today to follow up on the resident's dentures. The dental office reported they never received the signed consent back from the facility. The SS had the resident sign the consent today (09/15/21) and she faxed it back to the dental office. The SS confirmed she had received the authorization a few weeks ago, however it got missed. Review of the facilities policy titled Nursing/Dental Service, dated 04/25/18, revealed the facility would assist the resident in obtaining services to meet the resident's needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 17 of 21 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 365972 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canfield Healthcare Center 2958 Canfield Rd Youngstown, OH 44511 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 review of the infection/antibiotic stewardship log, interview, and policy review the facility failed to ensure all antibiotics were appropriate for treatment. This had the potential to affect all 78 residents residing in the facility. Residents Affected - Many Findings include: Review of the infection control log dated 01/2021 to 09/2021 revealed there was no evidence August 2021 and September 2021 infections were logged, trended, and checked to ensure antibiotics met criteria for treatment. Review of the log revealed in January 2021 there were two urinary tract infections (UTI) and only one had a culture with an organism listed. There was also one wound infection, one tooth infection, and one eye infection, however the infections were not noted on the map for trending. The map did not include the organism only the site of the infections. All the infections were treated with antibiotics, however only one antibiotic was checked to ensure the resident met criteria for antibiotic treatment. Review of the log for February 2021 there were three wound infections, four UTI's, and one eye infections. There was only one organism listed and it was for one of the four UTI's. Further review of the map for February 2021 revealed only UTI's were listed on the map (trending). There was no evidence of the organisms on the map only the cite of the infection. All the infections were treated with antibiotics, however only one of infections (UTI) was checked to ensure the resident met criteria for antibiotic treatment. Review of the log for March 2021 there were four UTI's, three unknown infections, one skin, two wounds, one endo, and two upper and lower respiratory infections. There was organism only listed for one of the unknowns and two urine's. Review of the trending map revealed only UTI's, and the respiratory infections were noted on the log. There was no evidence of the organism noted on the map only the sites of the infections. All infections were treated with antibiotics, however only three infections were checked to ensure the residents met criteria for antibiotics. Review of the log for April 2021 there was one UTI, seven unknown infections, two endo, one GI, three upper/lower respiratory infections, one tooth, one toe, two wounds, one abscess, and one antifungal. There were no organisms listed except one wound had yeast the and the three respiratory infection were noted as pneumonia. The map only included trending for UTI, respiratory, and GI. There was no evidence of the organisms only the sites of the infection. All infections were treated with antibiotics, however only four were checked to ensure the resident met criteria for antibiotic treatment. Review of the log for May 2021 there was one upper and log respiratory infection and five UTI's. There was only one organism list for one of the five UTI's. The other UTI's was blank for organisms. All infections were treated with antibiotics, however only two were checked to ensure the resident met criteria for antibiotic treatment. Review of the log for June 2021, there were two wound infections, four UTI's, one lower respiratory infection, one GI, two mouth, one tooth, two skins, and one unknown. There were only two organisms listed. One wound and one yeast for the mouth. Review of the map (trending) revealed only the UTI, respiratory, and GI were noted on the map. There was no evidence of organisms on the map only the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 18 of 21 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 365972 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canfield Healthcare Center 2958 Canfield Rd Youngstown, OH 44511 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many sites. All the infections were treated with antibiotics, however only three were checked to ensure the resident met criteria for antibiotic treatment. Review of the log for July 2021, there were six UTI's, four ear infections, two respiratory, three tooth infections, three wound infections, one skin, two GI, and four unknown infections. There was only organism list for two of six UTI's and the skin was shingles. The trending map only included UTI, respiratory, and GI sites. The other infections were not listed on the trending map, nor was the organisms. All infections were treated with antibiotics, however only two were checked to ensure the residents met criteria for treatment. Interview on 09/16/21 at 1:45 P.M. with Licensed Practical Nurse (LPN) #46 confirmed the infection and antibiotic stewardship log was not comprehensive to include all organisms, trending of all infections, and ensuring all antibiotics met criteria for treatment. The LPN reported if a resident was admitted with an antibiotic, she was not checking the criteria to ensure they met the criteria for treatment. She was only checking criteria for in-house UTI's, GI, and respiratory infections. She was not checking criteria for in-house wounds, skin, teeth, etc. The LPN reported she was not aware McGeer had other criteria's, and she was not aware she had to make sure hospital admission met criteria for antibiotic treatments. LPN #46 reported she has not had time to complete the infection control log or ensure antibiotics were appropriate for the months of August and September 2021 because she had been helping on the floor. Review of the facility policy titled Antibiotics Stewardship Plan, dated 04/20/17, revealed the facility would participate in the antibiotic stewardship program to protect residents and reduce the threat of antibiotic resistance in this setting and as part of an overall national initiative. The infection preventionist will have training, dedicated time, and resources to collect and analyze infection surveillance date to monitor and support the antibiotic stewardship activities. The facility would utilize the McGeer's criteria for monitoring, and reporting infections for surveillance and treatment. The Infection Preventionist (IP) nurse will follow, track, and monitor residents on antibiotic therapy. The IP nurse would ensure timely and appropriate ordering of antibiotic, review culture date, and developing antibiotic monitoring and infection management guidance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 19 of 21 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 365972 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canfield Healthcare Center 2958 Canfield Rd Youngstown, OH 44511 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on review of the infection/antibiotic stewardship log, interview, and policy review the facility failed to ensure all antibiotics were appropriate for treatment. This had the potential to affect all 78 residents residing in the facility. Residents Affected - Many Findings include: Review of the infection control log dated 01/2021 to 09/2021 revealed there was no evidence August 2021 and September 2021 infections were logged, trended, and checked to ensure antibiotics met criteria for treatment. Further review of log revealed in January 2021 there was two urinary tract infection (UTI) and only one had a culture with an organism listed. There was also one wound infection, one tooth infection, and one eye infection, however the infections were not noted on the map for trending. The map did not include the organism only the site of the infections. All the infections were treated with antibiotics, however only one antibiotic was checked to ensure the resident met criteria for antibiotic treatment. The log for February 2021 there was three wound infections, four UTI's, and one eye infections. There was only one organism listed and it was for one of the four UTI's. Further review of the map for February 2021 revealed only UTI's were listed on the map (trending). There was no evidence of the organisms on the map only the cite of the infection. All the infections were treated with antibiotics, however only one of infections (UTI) was checked to ensure the resident met criteria for antibiotic treatment. The log for March 2021 there was four UTI's, three unknown infections, one skin, two wounds, one endo, and two upper and lower respiratory infections. There was organism only listed for one of the unknowns and two urines. Review of the trending map revealed only UTI's, and the respiratory infections were noted on the log. There was no evidence of the organism noted on the map only the sites of the infections. All infections were treated with antibiotics, however only three infections were checked to ensure the residents met criteria for antibiotics. The log for April 2021 there was one UTI, seven unknown infections, two endo, one GI, three upper/lower respiratory infections, one tooth, one toe, two wounds, one abscess, and one antifungal. There were no organisms listed except one wound had yeast the and the three respiratory infection were noted as pneumonia. The map only included trending for UTI, respiratory, and GI. There was no evidence of the organisms only the sites of the infection. All infections were treated with antibiotics, however only four were checked to ensure the resident met criteria for antibiotic treatment. The log for May 2021 there was one upper and log respiratory infection and five UTI's. There was only one organism list for one of the five UTI's. The other UTI's was blank for organisms. All infections were treated with antibiotics, however only two were checked to ensure the resident met criteria for antibiotic treatment. The log for June 2021, there was two wound infections, four UTI's, one lower respiratory infection, one GI, two mouth, one tooth, two skins, and one unknown. There were only two organisms listed. One wound and one yeast for the mouth. Review of the map (trending) revealed only the UTI, respiratory, and GI were noted on the map. There was no evidence of organisms on the map only the sites. All the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 20 of 21 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 365972 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canfield Healthcare Center 2958 Canfield Rd Youngstown, OH 44511 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many infections were treated with antibiotics however only three were checked to ensure the resident met criteria for antibiotic treatment. The log for July 2021, there six UTI's, four ear infections, two respiratory, three tooth infections, three wound infections, one skin, two GI, and four unknown infections. There was only organism list for two of six UTI's and the skin was shingles. The trending map only included UTI, respiratory, and GI sites. The other infections were not listed on the trending map, nor was the organisms. All infections were treated with antibiotics, however only two were checked to ensure the residents met criteria for treatment. Interview on 09/16/21 at 1:45 P.M., with LPN #46 confirmed the infection and antibiotic stewardship log was not comprehensive to include all organism, trending of all infections, and ensuring all antibiotics met criteria for treatment. The LPN reported if a resident was admitted with an antibiotic, she was not checking the criteria to ensure they met the criteria for treatment. She was only checking criteria for in-house UTI's, GI, and respiratory infections. She was not checking criteria for in-house wounds, skin, teeth, etc. The LPN reported she was not aware McGeer had other criteria's and she was not aware she had to make sure hospital admission met criteria for antibiotic treatments. LPN #46 reported she has not had time to complete the infection control log or ensure antibiotics were appropriate for the months of August and September 2021 because she had been helping on the floor. Review of the facilities policy titles Antibiotics Stewardship Plan dated 04/20/17 revealed the facility would participate in the antibiotic stewardship program to protect residents and reduce the threat of antibiotic resistance in this setting and as part of an overall national initiative. The infection preventionist will have training, dedicated time, and resources to collect and analyze infection surveillance date to monitor and support the antibiotic stewardship activities. The facility would utilize the McGeer's criteria for monitoring, and reporting infections for surveillance and treatment. The IP/nurse will follow, track, and monitor residents on antibiotic therapy. The IP nurse would ensure timely and appropriate ordering of antibiotic, review culture date, and developing antibiotic monitoring and infection management guidance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 21 of 21