Health inspection·September 29, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of State Tested Nursing Assistant (STNA) #778's witness statement dated 09/17/23 revealed CA #716 used profanity towards Resident #57 and threatened to beat him up. Review of STNA #740's witness statement dated 09/17/23 revealed Resident #57 came down to the kitchen to ask for a grilled cheese sandwich. CA #716 told Resident #57 to get out of the kitchen. Resident #57 started cussing at CA #716 and then CA #716 was mad and cussed at Resident #57. CA #716 stated she was going to beat his (expletive) and Resident #57 stated to come and show him. CA#716 asked for Resident #57's name and stated she could call her dad, since a man shouldn't talk to her like that. Review of Resident #57's witness statement dated 09/17/23 revealed he went to the kitchen for his wife's dinner plate. He stated a kitchen worker used profanity towards him and stated she was going to kick his (expletive). She then tried to come around the food cart, but the aides told him to leave, and he left the kitchen. Review of a 09/18/23 social services progress note revealed Resident #57 stated he felt safe and had no issues. Interview with Resident #57 on 09/18/23 at 10:37 A.M. revealed a staff member from the kitchen threatened him the previous night when he went to the kitchen, and the staff person ended up walking off the job. He declined wanting to complete a police report. Interview on 09/21/23 at 11:48 A.M. with STNA #740 revealed witnessing an incident involving Resident #57 who was disrespectful first to CA #716 and CA #716 had used profanity toward Resident #57. Interview on 09/21/23 at 11:55 A.M. with STNA #778 revealed on 09/17/23 between 5:30 P.M. and 6:00 P.M. Resident #57 came down to the kitchen and was upset that his wife did not receive grilled cheese on her plate. Resident #57 then got smart and CA #716 who told Resident #57 to get out of the kitchen and told the resident she was going to call her mom and dad up to the facility. CA #716 threatened to beat him up. STNA #778 confirmed CA #716 used profanity towards Resident #57. There was no physical contact between CA #716 and Resident #57. Interview on 09/21/23 at 12:38 P.M. with CA #713 revealed on 09/17/23 she was cooking that night in the kitchen. Resident #57 had brought down a paper earlier in the day stating his wife, who was also a resident in the facility, wanted grilled cheese that night. CA #713 stated she had grilled cheese made for Resident #57's wife but had not seen her tray go by for dinner and missed putting the grilled cheese on her plate. She stated she was getting ready to send the grilled cheese down to the unit when Resident #57 arrived in the kitchen. He stepped in the door and said shame, shame, shame. CA #716 told Resident #57 he had been coming down to the kitchen all the time and there was no need to give them attitude. CA #713 heard Resident #57 use profanity toward CA #716 and CA #716 used profanity towards Resident #57. CA #716 stated she didn't have time for this and had dads. The STNAs were able to get Resident #57 to go back to his room. CA #716 was sent home pending the investigation. Interview on 09/25/23 at 1:21 P.M. via phone with CA #716 revealed on 09/17/23 Resident #57 was not supposed to be in the kitchen. She stated it was her first interaction with him and he was being disrespectful and saying unnecessary stuff. CA #716 stated Resident #57 was cussing first and she confirmed she cussed back at him. CA #716 stated she wasn't going to be threatened by him and she told Resident #57 she had a dad if he was going to be aggressive toward her. CA #716 confirmed she was unable to finish her shift that night and was sent home pending an investigation. She then told the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 2 of 35 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 09/29/2023 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 facility to take her name off the schedule. Level of Harm - Minimal harm or potential for actual harm Interview on 09/25/23 at 4:50 P.M. with Regional Director of Clinical Operations #809 revealed she was aware of the 09/17/23 incident between Resident #57 and CA #716. She confirmed it didn't matter if Resident #57 used profanity towards CA #716 because the culinary aide should never use profanity toward the resident. Residents Affected - Few Review of facility policy Ohio Abuse, Neglect, and Misappropriation, revised 04/01/19, revealed verbal abuse was the use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families, and it was the intent of the facility to prevent abuse, mistreatment, or neglect of residents. This deficiency represents non-compliance identified during the investigation of Complaint Number OH00146473 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 3 of 35 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 09/29/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on record review and interview, the facility failed to complete level two Preadmission Screening and Resident Review ( PASRR) for Resident #42's new diagnosis of schizoaffective disorder. This affected one (Resident #42) of two residents reviewed for PASRR. The facility census was 66. Findings include: Review of medical record for Resident #42 revealed an admission date of 05/26/21. Diagnoses included chronic obstructive pulmonary disease (COPD), vascular dementia with other behavioral disturbance, adult failure to thrive, solitary pulmonary (lung) nodule, cognitive communication deficit, type two diabetes without complications, anxiety disorder, prostate cancer, and post-traumatic stress disorder (PTSD). On 06/28/22 a new diagnosis of schizoaffective disorder was added to Resident #42's diagnoses. Review of the 09/08/23 quarterly Minimum Data Set (MDS) 3.0 assessment revealed Resident #42 was severely impaired cognitively, exhibited no hallucinations or delusions but did exhibit physical and verbal behaviors one to three days during the assessment reference period, required extensive assist of one person for locomotion and personal hygiene, extensive assist of two people for bed mobility, transfer, and toilet use, and total dependence of two people for bathing, and received an antipsychotic seven days during the assessment reference period. Review of the care plan initiated on 12/17/21 and revised on 09/09/22 revealed Resident #42 had noted moods upon reviews. He had a history of alcohol abuse, PTSD, schizophrenia, anxiety, and depression. Moods fluctuated from review to review. The goal was Resident #42 will have emotional distress, remain to follow his daily routine through next review. Interventions included administering medications as ordered, observe and document signs/symptoms of effectiveness and side effects, behavioral health consults as needed, communicate with resident/resident representative regarding mood state and treatment, consult with pastoral care, psychiatry services, and/or support groups, encourage resident to express feelings, encourage resident to participate in activities of choice, encourage to maintain as much independence and control/decision making as much as possible, notify medical provider of increased episodes of mood disturbance, and provide emotional support as needed. Review of the 06/23/21 PASSR Identification screen, under section D: indicators of serious mental illness, revealed Resident #42 was not identified as having a diagnosis of Schizophrenia. Review of both the electronic and hard charts revealed no evidence the appropriate state agency (The Ohio Department of Mental Health) was notified of the new diagnosis for PASRR review as required. Interview on 09/20/23 at 10:03 A.M. with Director of Social Services verified the appropriate agency had not been notified of the new diagnosis as required. She stated she was just recently made aware the state agency needed to be notified of certain new diagnoses and was unaware Resident #42 had a new diagnosis of schizoaffective disorder on 06/28/22. Review of facility policy PASSR, effective date of 01/01/2020, revealed PASSR consisted of two parts which must follow the patient. Part one: Preadmission screen (PAS) for new admits which included a level one screen and a level two evaluation if indicated. Part two included a Resident Review (RR) which would be complete in accordance with the rules and per specified timeframes, which included (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 4 of 35 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 09/29/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete any major decline or improvement in the individual's physical or mental condition which would not be normally resolved without interventions. This included a change in the individual's current diagnosis, mental health treatment, functional capacity, or behavior such that as a result of the change, the individual who did not previously have indications of severe mental disorder now has such indications. Social service or designee as assigned by the executive director would be responsible to track and submit all RRs, which included tracking events that trigger the RR along with key time frames to ensure a resident review was not missed. Event ID: Facility ID: 365972 If continuation sheet Page 5 of 35 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 09/29/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #48 was provided an opportunity to give input into her plan of care. This effected one resident (Resident #48) of two residents reviewed for care planning. The facility census was 66. Findings include: Review of Resident #48's medical record revealed diagnoses including schizoaffective disorder, depression, anxiety disorder, and cognitive communication deficit. An admission assessment dated [DATE] indicated Resident #48 participated in the 48 hour baseline care planning. A social service note dated 08/30/22 at 7:32 P.M. indicated a call was placed to Resident #48's brother to schedule a care conference meeting. A voice message was left for a return call. A social service note dated 08/31/22 at 4:00 P.M. indicated a call was placed to Resident #48's brother. A care conference via phone was scheduled for 09/07/22 at 11:00 A.M. A social service note dated 08/31/22 at 4:09 P.M. indicated Resident #48's son was notified of the care conference meeting. A quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #48 was cognitively intact and was able to understand others. Resident #48 was able to make herself understood. There was no evidence of any further care conferences offered since the care conference meeting for 09/07/22 was scheduled. During an interview on 09/18/23 at 10:08 A.M., Resident #48 stated she was not involved in providing input into her care. Resident #48 stated she knew her son had attended a meeting in the past but she was not invited to attend. During an interview on 09/20/23 at 5:33 P.M., Social Service Designee (SSD) #719 stated care conferences were supposed to be provided on admission and quarterly thereafter. SSD #719 stated residents and resident representatives were supposed to be invited. A request was made for any additional information she could locate regarding any care conference invitations/meetings for Resident #48. The request was repeated on 09/21/23 at 9:00 A.M. and no additional information was provided by SSD #719. During an interview on 09/25/23 at 1:41 P.M., the Director of Nursing (DON) verified care conferences were supposed to be offered a minimum of quarterly. The DON stated social services was responsible for making notifications of care plan meetings. The DON was unable to respond as to why there was no evidence of quarterly care conferences being offered for Resident #48. Review of the facility's Plan of Care Overview policy (not dated) indicated residents/representatives would be informed of their plan of care in the most understandable manner possible. The resident/representative would have the right to participate in the development and implementation of his/her own plan of care including but not limited to a right to request meetings, right to identify individuals or roles to be included in the planning process, right to request revisions to the care plan, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 6 of 35 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 09/29/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete right to participate in goal establishment and outcomes, right to the type, amount, frequency and duration of care or other factors related to the effectiveness of the plan of care, right to be informed in advance of changes to the plan of care, right to see the care plan (including the right to sign after significant changes to the plan of care), and right to refuse specific treatments or care. The facility would review care plans quarterly and/or with significant changes in care, provide a summary of the baseline care plan to the resident and their representative, support the resident's right to participate in treatment and care planning, and support and encourage resident/representative participation including but not limited to helping residents/representatives to understand the comprehensive care planning process, holding meetings at a time when the resident was functioning at his/her best, scheduling meetings to accommodate a representative that might include conference calls, video conference sessions or live sessions, and planning adequate meeting time for decision making and discussion. Care plan meeting attendees would sign and date care plan meeting agendas/documents. Event ID: Facility ID: 365972 If continuation sheet Page 7 of 35 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 09/29/2023 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to initiate a dressing and grooming restorative program for one resident, Resident #48, of twenty five residents screened for activities of daily living. The facility census was 66. Residents Affected - Few Findings include: Review of Resident #48's medical record revealed diagnoses including schizoaffective disorder, depression, anxiety disorder, hypertension, obesity, difficulty in walking, generalized muscle weakness and osteoporosis. An annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48 was moderately cognitively impaired. Extensive assistance was required with bed mobility, dressing, and personal hygiene. Review of an Occupational Therapy (OT) evaluation dated 07/20/23 indicated Resident #48 had been referred to OT after a recent decline in activities of daily living and weakness. An OT Discharge summary dated [DATE] indicated at the time of discharge from OT, Resident #48 required stand by assistance for hygiene and grooming tasks and minimum assistance with upper body dressing. To facilitate the resident maintaining her level of performance and in order to prevent decline, development of and instruction in a Restorative Nursing Program (RNP) had been completed with the interdisciplinary team for dressing and grooming. During an interview on 09/20/23 at 2:00 P.M., Licensed Practical Nurse (LPN) #706 stated the facility had no consistent restorative program. LPN #706 stated Resident #48 had refused to participate in a Range of Motion (ROM) restorative nursing program (RNP) that was recommended by Physical Therapy (PT) during the same time frame. During an interview on 09/21/23 at 7:33 A.M., Therapy Director #821 stated after residents were finished with therapy a copy of the referral to restorative was placed in the restorative binder and a copy was provided to the Director of Nursing (DON). Restorative was responsible for placing the information into the electronic health record. On 09/21/23 at 8:11 A.M., Therapy Director #821 verified he was unable to locate the referral for RNP for dressing and grooming as recommended in the OT discharge notes. Review of an OT evaluation dated 09/21/23 indicated Resident #48 had been seen for therapy in the past with good progress to the point of limited assistance being required. The evaluation indicated Resident #48 demonstrated a slight decline in activities of daily living and slight increased weakness. Resident #48 was near functional status of her previous discharge not indicating a need for immediate therapy. The evaluation indicated due to the documented physical impairments and associated functional deficits, Resident #48 was at risk for increased dependency on caregivers. Review of the facility's Restorative Program policy (no implementation date recorded) revealed resident evaluation for consideration of the restorative treatment plan would include but was not limited to cognitive abilities to participate independently or with assistance and medical conditions to participate independently or with assistance. The assessment/evaluation would determine the services (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 8 of 35 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 09/29/2023 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 0676 necessary. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 9 of 35 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 09/29/2023 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** Based on medical record review and interview, the facility failed to initiate a Range of Motion (ROM)Restorative Nursing Program (RNP) for one resident , Resident #40, of twenty residents screened for range of motion. The facility census was 66. Findings include: Review of Resident #40's medical record revealed diagnoses including flaccid hemiplegia (one side of the body loses motor function and becomes weak or paralyzed) affecting the left non-dominant side, stroke and generalized muscle weakness. Review of a Physical Therapy (PT) evaluation dated 08/17/23 revealed Resident #40 had limitations in ROM. A Discharge summary dated [DATE] indicated recommendations for a RNP for transfers and range of motion. During an interview on 09/18/23 at 11:20 A.M., Resident #40 stated she was unable to voluntarily move her left side. Resident #40 used her right arm and moved her left arm stating she was able to do ROM to her left arm. However, she was unable to move her left leg and ROM was not provided. On 09/20/23 at 2:00 P.M., Licensed Practical Nurse (LPN) #706 stated the recommendation for a RNP for transfers and ROM was not communicated to nursing. On 09/21/23 at 8:11 A.M., Therapy Director #821 verified he could locate no evidence the PT recommendation for transfers and ROM RNPs were communicated to nursing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 10 of 35 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 09/29/2023 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 record review, observations and interviews, the facility failed to eliminate hazard risk when a cognitively and physically impaired resident with fall risk was able to leave the secured courtyard smoking area due to an unsecured gate. This affected one resident ( Resident #31) of eight residents reviewed for accidents/hazards. The facility census was 66. Findings include: Review of medical record revealed Resident #31 was admitted to the facility on [DATE]. Diagnosis included malignant neoplasm of unspecified part of bronchus or lung and brain, secondary malignant neoplasm of unspecified lung, cachexia, unspecified protein calorie malnutrition, muscle weakness, need for assistance for personal care, lack of coordination, adult failure to thrive, alcohol abuse. A niece was listed as resident representative durable power of attorney for care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #31 could make himself understood, was able to understand others, had impaired vision and severely impaired cognition per a Brief Interview for Mental Status (BIMS) score of three out of 15. Resident #31 had no symptoms of delirium, hallucination, no physical or verbal behaviors, no rejection of care and no wandering behavior during the assessment period. He required limited assistance with bed mobility, extensive assistance needed with transfers, one person assistance with locomotion and one-person physical assistance with toilet use. Resident #31 used a wheelchair for mobility and was always incontinent of bowel and urinary. There was no pain present during the assessment and resident #31 was in Hospice care. Review of the plan of care for Resident #31 with a date initiated of 10/20/22 revealed he was at risk for falls related to impaired balance, cognitive deficit, impaired safety awareness, malnutrition and Hospice services for brain and lung cancer. The care plan indicated a BIMS of three (severe cognitive impairment) which fluctuated from review to review. Record review of a smoking assessment dated [DATE] at 7:08 P.M. completed by the Director of Nursing (DON) revealed Resident #31 was assessed as independent for smoking. Record Review of a Fall Risk Observation tool dated 07/24/23 at 1:56 P.M. completed by Clinical Unit Manager #706 identified Resident #31 as a potential risk for falls related to diminished safety awareness, wheelchair/ambulation assistance needed and non-ambulatory gait and balance. Review of a nursing note dated 09/21/23 at 2:00 A.M. written by Licensed Practical Nurse (LPN) #728 revealed Resident #31 was observed outside in the grass on the side of the building at 2:00 A.M. by another resident. State Tested Nurse Aid (STNA) and nurse went outside and assessed resident #31 and put him back in his wheelchair. Record review of the facility investigation, dated 09/21/23, revealed Resident #31 had been found outside in the grass at 2:00 A.M. on 09/21/23 by another resident. Resident #31 had gotten out of the back gate because it was not locked as it should have been, and no alarm had sounded to alert staff he had gotten out of the back gate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 11 of 35 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 09/29/2023 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 Review of the witness statement dated 09/21/23 at 2:00 A.M. authored by LPN #728 revealed she was notified at 1:40 A.M. by staff Resident #31 was not able to be located and there was no alarm sounding in the facility. STNA #755 revealed Resident #31 was not in his room at 1:00 A.M. during rounds. Resident #31 was found outside in the front of the building sitting in the grass. The secured smoking area gate was open, so no alarm had sounded. STNA #779 witness statement revealed the back gate was open, no alarm had sounded, and Resident #31 was found outside in the front of the building in the grass. STNA #771's witness statement revealed the alarm never sounded, and Resident #31 got out the back gate as it was open. Review of the facility investigative elopement report #1159120 completed on 09/21/23 at 6:04 P.M. by Licensed Practical Nurse (LPN) #728 revealed LPN #728 was alerted by a State Tested Nurse Aid (STNA) Resident #31 was not in his room. LPN #728 and the STNA immediately began searching the facility interior and exterior for the resident. Approximately 15 to 20 minutes later, another resident alerted this nurse to Resident #31's location. LPN #728 observed Resident #31 sitting upright with his back to the front of his wheelchair, in the grass in front of building beside the window to room [ROOM NUMBER] or 108. A Smoking assessment dated [DATE] at 10:42 A.M. completed by the Director of Nursing (DON) revealed Resident #31 needed supervision when smoking. A BIMS assessment dated [DATE] at 2:37 P.M. completed by Director of Social Services (DSS) #719 revealed a new BIMS score of 13. Review of the medical record revealed on 09/21/23 at 7:00 P.M. Nurse Practitioner (NP) #810 issued an order for a Wander Guard to right ankle. Interview and observation on 09/21/23 at 3:50 P.M. with Resident #31 revealed he was alert and oriented to person and place. When asked about the incident on 09/21/23 he stated, fell in grass I was cold it was dark. He couldn't answer how he got outside or who found him. Observation of his right ankle at the time of the interview revealed the resident was wearing a Wander Guard. During an interview and observation on 09/21/23 at 4:14 P.M. with the DON revealed an investigation had been initiated into how Resident # 31 got outside independently. It was believed Resident # 31 had gone out the back gate of the secured smoking courtyard and propelled himself around the front of the facility where he was found. Observations with the DON revealed there was a keypad on the back gate in the courtyard. The DON pushed on the gate for 15 seconds. The gate started alarming when the gate was pushed on. After 15 seconds, the gate released, and the alarm was no longer able to be heard. The DON stated she would have to get the Administrator to reset the gate as the gate did not automatically secure again once it was opened. Interview on 09/21/23 at 4:19 P.M. with the Administrator revealed if a resident went out the courtyard gate the alarm would continue to sound at the nursing station and front desk until the system was reset by staff. The only way to secure the gate after it was opened was to flip a switch from inside the facility. The Administrator stated there were a couple of residents who would open the gate by pushing on it and walk around the facility. At that time the facility assumed that was how Resident #31 exited but the facility was continuing to investigate. Interview on 09/21/23 at 4:39 P.M. revealed Resident #49 verified he found Resident #31 around 2:00 A.M. on 09/21/23. Resident #49 stated Resident #31 was laying outside in the grass area in front of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 12 of 35 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 09/29/2023 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 the building between the building and the parking lot. He stated Resident #31 was laying on the ground with his wheelchair tipped over. Resident #49 stated he noticed staff looking for Resident #31 and wanted to help staff. The last time Resident #49 saw Resident #31 the night of 09/20/23 was 11:00 P.M. in the recreation room. Observation on 09/21/23 at 4:41 P.M. with the Administrator verified Resident #31 had got out the back courtyard gate in his wheelchair and traveled a path to the front of the facility where there were areas of uneven pavement, and limited lighting in the dark. The Administrator pointed to the grassy area near the left side of the parking lot in the row closest to the nursing facility where he believed Resident #31 was found in the grass after falling out of his wheelchair. Observation was conducted with the Administrator on 09/25/23 at 9:22 A.M. of the recorded video surveillance from the night of 09/20/23. It was observed Resident # 45 pushed Resident #31 out the back door in his wheelchair to the smoking courtyard on 09/20/23 at 11:58 P.M. Resident #31 went out of camera range so it was not able to be determined by the video what time Resident #31 left the courtyard. It was observed on the surveillance video staff were in the courtyard at 2:03 A.M. looking around. Interview on 09/25/23 at 10:42 A.M. with Resident #45 stated Resident #31 was jammed in the door leading out into the courtyard on the night of 09/20/23 so she pushed him out the door to help him. Resident #45 verified Resident #31 did not come back into the facility with her. Interview and with Maintenance Director (MD) #718 on 09/25/23 at 10:47 A.M. revealed the gate through which Resident #31 left the courtyard on 09/21/23 can become ajar from a heavy wind or by a person pushing on it for 15 seconds. He stated the alarm to this gate was not sounding the morning of 09/21/23 when he reported to work so he assumed someone silenced the alarm and left the gate open. He stated anytime the alarm sounded staff were to address the alarm and reset it. MD #718 explained once the back gate was open, the only way to secure/lock it up again would be for someone to walk back into the facility, go into a maintenance room, use keys to open a box which had a reset switch and flip the switch to reset the lock on the gate. MD #718 said the gate opened with a 15 second egress in case of a fire or there was a code box next to the gate where a person could punch in the code and open the gate. MD #718 verified the facility was a secured facility, so the residents did not have the codes to get out of the facility unless assisted by staff. MD #718 expressed the gait was working as it should, however, if the gate is left open because staff do not reset the switch, then the building is no longer secured. MD #718 added the doors to get out into the smoking courtyard are always open, so anyone could walk out into the courtyard and leave the courtyard if the gate was not locked. Observation on 09/26/23 at 11:00 A.M. with MD #718 of the secured gate in the back courtyard revealed the gate was locked and there was a keypad to the left side which could open the gate using a code or pushing on the gate for 15 seconds. MD #718 pushed on the back gate for 15 seconds and the gate opened with an alarming sound. MD #718 said there have been several times he has come to work within the last three months and did rounds between 7:00 A.M. and 8:00 A.M. and found the gate open which led him to believe it had been left open all night. MD #718 stated all nursing staff have a key to the maintenance room to reset the back gate alarm. DM #718 stated the gate will not relock unless he comes in and resets the back gate and stated if the back gate is not reset, the gate will stay open all night. MD #718 took the surveyor to the maintenance room, opened a wall mounted box with a key and pointed to the switch that needed to be physically reset to relock the gate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 13 of 35 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 09/29/2023 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Review of logbook documentation provided by MD #718 revealed that six days from the dates of 07/03/23 to 09/24/23 the gate was found open in the morning with no alarm sounding. Review of Elopement Prevention and Management Overview Policy #NS 1124-00 stated any resident admitted who was cognitively impaired was considered an elopement risk until determined otherwise. Environmental modification to prevent undetected exits such as door alarms or wander guards will be initiated for interventions. Event ID: Facility ID: 365972 If continuation sheet Page 14 of 35 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 09/29/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on policy review, interview, review of an article from the American Journal of Health-System Pharmacy, and observation, the facility failed to ensure staff appropriately flushed a feeding tube during medication administration . This effected one (Resident #22) of one resident reviewed for medication administration via feeding tube. Findings include: On 09/20/23 between 11:06 A.M. and 11:15 A.M., Licensed Practical Nurse #732 was observed administering medication to Resident #22 via a feeding tube. Among the medications administered were famotidine (a gastric acid secretion reducer), allopurinol (helps prevent increase or decreases uric acid levels), provera (hormone), sertraline (antidepressant), cimetidine (gastric acid secretion reducer) and cod liver oil (liquid). All the pills were crushed. Approximately five milliliters (ml) of water were added to the cups with the medications before they were emptied into the feeding tube. No flushes with water were conducted between the medications. On 09/20/23 at 11:29 A.M., LPN #732 verified although she flushed the feeding tube before she began and after she finished administering medications, she did not flush the feeding tube between medications. Review of the facility's policy, Medication Administered by Enteral Tube (implementation date not designated) revealed mixing medications might result in a drug interaction that may include occlusion of the tube and did not comply with medication administration practices of administering medication separately. Administer medication one at a time and follow with a minimum of 15 ml of water between medications unless other directed to do so which prevents clogging of the tube with drug to drug interactions. Review of a Medscape article from the American Journal of Health-System Pharmacy titled Medication Administration through Enteral Feeding Tubes revealed when multiple medications are scheduled for administration at the same time, each should be given separately, and the feeding tube should be irrigated with 5-10 ml of water between each medication. When delivering any medication through an enteral access device, the appropriate flushing technique is essential to reduce the risk of tube occlusion and to maintain patency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 15 of 35 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 09/29/2023 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of controlled drug administration records, review of facility policy and interviews, the facility failed to develop and implement a comprehensive and individualized pain management program, including assessment/monitoring of pain and administration of narcotic pain medication (Percocet) to meet Resident #45's needs and prevent severe pain. Residents Affected - Few Actual harm occurred on 09/18/23 when as needed (PRN) Percocet 5-325 milligrams (mg) was not available to administer to Resident #45 as requested and as ordered by the physician. On 09/18/23 at 10:21 A.M. Resident #45 rated her pain level an eight on a scale of zero (no pain) to 10 (severe pain). Resident #45 was administered a dose of Percocet on 09/19/23 at 12:23 P.M. for severe pain rated at a level nine out of 10 after having gone over 48 hours without receiving the Percocet as requested. The resident verbalized she was in excruciating pain during this time-period with facial grimacing with movement of her legs and difficulty with ambulation related to the severe pain This affected one resident (#45) of two residents reviewed for pain management. The facility census was 66. Findings include: Review of medical record for Resident #45 revealed an admission date of 03/30/23. Diagnoses included unilateral primary osteoarthritis of the right knee, pain in unspecified knee, unspecified abnormalities of gait and mobility, uncomplicated psychoactive substance abuse, and major depressive disorder. Review of a care plan initiated 03/31/23 revealed Resident #45 had complaints of acute/chronic pain disease process related to substance use disorder and osteoarthritis. The goal was for Resident #45 to verbalize relief of pain. Interventions included provide medications per orders, monitor for signs and symptoms of side effects, and evaluate effectiveness of medication. The care plan revealed to observe for pain every shift, administer non-pharmacological interventions, and notify medical provider, resident representative if interventions were unsuccessful, or if current complaint was a significant change from resident's experience of pain. There were no new interventions added after the initial care plan date of 03/31/23. Review of Resident #45's physician's orders revealed an order dated 04/04/23 for one 600 milligram (mg) Ibuprofen Oral Tablet (non-steroidal anti-inflammatory drug) by mouth every six hours as needed for pain and an order dated 05/07/23 for one 500 mg Acetaminophen Extra Strength (non-narcotic pain reliever) tablet by mouth every six hours as needed for mild pain. Review of the facility Pain Observation Tool V5-V2, dated 06/29/23 revealed Resident #45 did not verbalize and/or exhibit non-verbal symptoms of pain, did not receive scheduled or as needed pain medication, and the resident stated deep relaxation and frequent position changes would help relieve pain. Pain management intervention was not necessary and there was no need for a change in interventions in the care plan. There was no additional Pain Observation Tool V5-V2 completed after 06/29/23. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #45 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and required supervision with set up for bed mobility, transfers, and locomotion. Resident #45 during the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 16 of 35 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 09/29/2023 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 0697 reference period of the assessment was not on any routine or as needed pain medications and was not receiving any non-pharmacological pain-relieving interventions. Level of Harm - Actual harm Residents Affected - Few Review of an 08/11/23 physician progress note, authored by Physician #850, revealed Resident #45 was complaining of continued pain in the knees, was having difficulty walking, and was not getting any pain medications. The physical exam revealed pain in the right knee with movement and positive crepitus (a cracking or popping sound) of the knee. The plan was to consult orthopedics to evaluate for knee replacement and to start Percocet for pain. Record review revealed a physician order, dated 08/11/23 for Percocet (Oxycodone with Acetaminophen) 5-325 mg one tablet by mouth every eight hours as needed for pain. Review of a 09/12/23 physician progress note, authored by Physician #850, revealed Resident #45 was complaining of continued pain in the knees but was improving with pain meds. The resident was having difficulty walking and there was pain in the right knee with movement. Review of the nursing progress notes between 09/13/23 and 09/27/23 revealed the notes did not contain any assessment of Resident #45's pain, request for pain medication and use of non-pharmacological interventions for pain management during this time period. Review of the controlled drug administration record for Resident #45 revealed a script for 26 tablets of Percocet was filled on 08/31/23, the last tablet was signed out on 09/17/23 at 9:00 A.M, and a new script for 30 tablets Percocet written and filled on 09/19/23. Review of the pain level vital section documentation of the medical record for 09/17/23 revealed no pain assessments were completed on 09/17/23. There was no documentation by nursing to reflect why the Percocet ran out on 09/17/23, whether or not the as-needed Acetaminophen was offered while waiting for the Percocet to be re-filled until 09/19/23 nor any documentation to reflect if the nurses attempted to get a Percocet from the facility starter box (which was a secured medication containment system at the facility where various medications including narcotics supplied from the pharmacy could be pulled until the medications arrived from the pharmacy). Review of the September 2023 MAR revealed pain levels were to be assessed every shift. On 09/17/23 Resident #45's pain level was not documented on the MAR nor was any Percocet, Ibuprofen or Acetaminophen documented as being administered to Resident #45. The next pain level was assessed on 09/18/23 at 10:21 A.M. and was assessed to be rated a level eight. On 09/18/23 at 5:02 P.M. the resident continued to rate pain at a level eight. On 09/19/23 at 10:43 A.M. the resident's pain was assessed to be a nine (out of 10 as the most severe pain). Further review of September 2023 Medication Administration Record (MAR) for Resident #45 confirmed she also did not receive any Percocet on 09/18/23 but did receive on 09/18/23 Ibuprofen at 10:21 A.M. for pain at a level rated an eight out of 10 and again received Ibuprofen at 5:02 P.M. with pain rated a level eight. On 09/19/23 she received Ibuprofen at 10:43 A.M with a pain level rated nine and finally received the Percocet on 09/19/23 at 12:23 P.M. for pain level of seven. There was no documentation she received any Acetaminophen on 09/17/23, 09/18/23, 09/19/23, or 09/20/23. Interview on 09/19/23 at 8:28 A.M. with Licensed Practical Nurse (LPN) #722 verified the supply of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 17 of 35 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 09/29/2023 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 0697 Level of Harm - Actual harm Percocet for Resident #45 had run out on 09/17/23 and the facility was waiting for the script to be signed to re-order it. LPN #722 said some Percocet could be pulled from the starter box, but she did not do that because she had to wait for a prescription to pull a Percocet from the starter box. LPN #722 verified Resident #45 had a pain level rated a nine during this time period. Residents Affected - Few Interview on 09/19/23 at 8:52 A.M. with Resident #45 revealed she was in excruciating pain and rated her pain at a level a seven out of 10. She stated the facility had run out of her Percocet, which was why she hadn't received any of her Percocet medication. Observation at the time of interview revealed Resident #45 was laying down in her bed and when she moved her legs to the side of the bed to sit up, she grimaced in pain as she moved her legs. Interview on 09/19/23 at 11:59 A.M. with Resident #45 revealed she was currently rating her pain level a seven and it was difficult to walk because the pain was excruciating. Observation at the time of the interview revealed Resident #45 was walking slowly while holding onto the handrails on the wall as she walked. Resident #45 had facial grimacing with the movement of her legs. Interview on 09/20/23 at 7:54 A.M. with Resident #45 revealed she had received Percocet last night and stated the plan was to get knee replacements in December2023 because her knee problems were causing the pain. Observation at the time of the interview revealed she was not physically exhibiting any signs or symptoms of being in pain and said her pain had been relieved with the administration of Percocet. Interview on 09/21/23 at 1:55 P.M. with LPN #732 revealed it took some time to get pain medications re-ordered at the facility and the normal process was to ask for a re-order before the medication ran out. Interview on 09/21/23 at 2:03 P.M. with Resident #45 revealed on 09/17/23 and 09/18/23, she had difficulty walking and sleeping due to increased pain when her Percocet medication was not given to her. The resident stated when she turned in bed on those days, she would get a jolt of pain and would see stars from the severity of the pain. The resident reported when she received the Percocet on 09/19/23, she was able to get a better night's sleep and the pain level became more tolerable. She stated she did take the Ibuprofen when there was no Percocet, but the pain remained rated between a seven and nine. Resident #45 was visibly upset about having to wait for the Percocet order to be refilled and stated with tears I feel like I don't matter. I am a person and I do matter. Interview on 09/21/23 at 2:26 P.M. with Nurse Practitioner #810 revealed the normal process to ensure residents had their Percocet would be when the prescribed medication was getting low, the facility would reach out to the provider to see if the prescription could be refilled. The time it took for the provider to re-order varied and depended on various factors. She stated she was not sure what happened and why there was a delay in the prescription getting re-filled for Resident #45. Interview on 09/21/23 at 2:31 P.M. with Pharmacy Representative #851 revealed the new script for Percocet was written, filled, and delivered on 09/19/23. Interview on 09/21/23 at 3:30 P.M. with State Tested Nursing Assistant (STNA) #775 revealed on 09/18/23 Resident #45 seemed to be in more pain and was moving slower. Interview on 09/21/23 at 3:38 P.M. with STNA #740 revealed Resident #45 was walking slower earlier in the week (no date provided) due to pain in her knees. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 18 of 35 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 09/29/2023 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 0697 Level of Harm - Actual harm Residents Affected - Few Interview on 09/25/23 at 2:29 P.M. with the Director of Nursing (DON) revealed the normal procedure to ensure Resident #45 had her Percocet would be to ask for a re-order when there were seven pills left. The floor nurse was responsible for re-ordering the medication. The DON said she had not been made aware the Percocet medication for Resident #45 had run out before it could be refilled, and she was not aware Resident #45 had been in pain as a result. The DON had no explanation of why the medication had not been ordered earlier to prevent the facility from running out of medication. Interview on 09/27/23 at 2:26 P.M. with Physician #850 revealed he was the physician for Resident #45 and was familiar with her condition of pain and a history of substance abuse. Physician #850 stated Resident #45's pain was valid, she was not attention seeking pain medication due to her history of substance abuse, and if she did not receive the Percocet, she would absolutely be in pain. Review of the undated facility policy Pain Management and Assessment revealed the facility provided resident centered care that would meet the psychological, emotional, and physical needs and concerns of the residents and, regarding pain management considerations, pharmacological interventions would be provided. Review of facility policy Non-Controlled Medication Orders, dated September 2018, revealed medications would be administered only upon the receipt of a clear, complete, and signed order of a person lawfully authorized to prescribe. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 19 of 35 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 09/29/2023 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review and staff interview the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 66 residents residing in the facility. Findings include: Review of schedules and punch detail for Registered Nurses from 09/01/23 to 09/24/23 revealed there was no RN coverage for eight consecutive hours on 09/02/23, 09/03/23, 09/04/23, 09/16/23, 09/17/23, and 09/23/23 as required. Interview on 09/25/23 at 10:56 A.M. with the Director of Nursing (DON) revealed one of the registered nurses, who had been out on maternity leave, just came back to work the previous week. Interview on 09/26/23 at 12:52 P.M. with the Administrator confirmed the facility had not had eight-hour consecutive RN coverage on a daily basis on the dates reviewed above. This deficiency represents non-compliance identified during the investigation of Complaint Number OH00146473 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 20 of 35 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 09/29/2023 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. Based on record review, facility policy review and interview the facility failed to ensure Resident #29's medication regimen was free of unnecessary medication. The facility failed to ensure a psychotropic medication was discontinued timely following a pharmacy recommendation and nurse practitioner approval. This affected one resident (#29) of five residents reviewed for unnecessary medication. The facility census was 66. Findings include: Medical record review revealed Resident #29's initial admission to the facility was 06/30/23. Diagnoses included infection of the skin and subcutaneous tissue, unspecified severe protein calorie malnutrition, ulcer of sacral region unspecified stage, paraplegia, neuromuscular dysfunction of bladder, anxiety disorder, depression, muscle weakness, psychoactive substance abuse, opioid dependence, unspecified mood affective disorder, Viral Hepatitis C, asymptomatic Human Immunodeficiency Virus infection status. Review of the Comprehensive Minimum Data Set Assessment ( MDS) 3.0 dated 07/11/23, revealed the resident's cognition was intact. Review of physician's orders revealed on 07/11/23 the resident was ordered Trazodone HCL oral tablet 50 milligrams (an antidepressant) and Zolpidem tablet 5 milligrams (a sleep aid). Review of Communicare Regional Consultant Pharmacist monthly medication review note on 07/12/23 revealed a recommendation to discontinue Trazodone since Resident #29 was ordered Zolpidem for sleep. Nurse Practitioner (NP) #810 agreed with the recommendation to stop the Trazadone on 08/15/23. Review of Medication Administration Record (MAR) revealed the resident received Zolpidem 10 milligrams (mg) by mouth at bedtime for insomnia from 09/01/23 to 09/20/23 and Trazodone HCL tabled 50 mg by mouth at bedtime for depression on 09/09/23, 09/10/23, 09/11/23, 09/14/23, 09/15/23, 09/18/23, 09/19/23 and 09/20/23. Interview on 09/21/23 at 11:00 A.M. with NP #810 verified she agreed with the pharmacy recommendation to discontinue the Trazadone medication as noted above. The NP verified the medication had not been discontinued and continued to be administered. Interview on 09/21/23 at 11:08 A.M. with Resident #29 revealed he had asked nursing staff many times to discontinue the Trazadone because he stated he felt too tired. Interview with the Director of Nursing (DON) on 09/21/23 at 11:09 A.M. revealed she found the recommendation this morning to discontinue the Trazadone medication in her folder. The DON indicated she wrote the order to discontinue the Trazadone on 09/21/23. Review of Medication Regimen Review Policy and standard Procedure #NS 1218-01 revealed the director of nursing or designee will be responsible for addressing all medication irregularity reports with the attending physician or non- physician practitioner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 21 of 35 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 09/29/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation , record review, review of medication information, policy review and interview the facility failed to store medication appropriately. Improper storage was identified on two (Unit II medication cart and Unit I medication room) of three storage units observed. This affected four residents, Resident #12, #24, #57, and #261 of 66 residents residing in the facility. Findings include: 1. On 09/20/23 between 11:30 A.M. and 11:38 A.M., Licensed Practical Nurse (LPN) #732 was observed monitoring Resident #24's blood glucose level and administering insulin. While preparing to administer Resident #24's Humalog via an opened insulin pen, it was noted there was no date indicating when the insulin pen was opened. The label indicated the Humalog pen was delivered 08/22/23. This was verified by LPN #732 at the time of observation. Review of the Medscape website revealed opened Humalog pens could be stored at room temperature up to 28 days. 2. Observations of the 100 hall (Unit I) medication room with LPN #725 on 09/26/23 at 10:38 A.M. revealed there were two refrigerators for storage of medications. One of the refrigerators did not contain a thermometer to monitor the temperature under which the medications were stored and there was no evidence of a temperature log. Medications stored in the refrigerator included intravenous Daptomycin (antibiotic) for Resident #261 and Arformoterol tartrate inhalation solution (bronchodilator) for Resident #12. The lack of a thermometer, lack of evidence of temperature monitoring and presence of the medications was verified by LPN #725 at the time of the observation. Review of Resident #261's Medication Administration Record (MAR) revealed the Daptomycin order was valid through 09/10/23. Review of the Medscape website revealed Arformoterol tartrate solution should be stored in the refrigerator away from light. 3. Observations of the Section II medication cart with LPN #726 on 09/26/23 at 10:40 A.M., revealed a vial of Insulin Glargine for Resident #24 which did not contain information on the date it was opened. There was also a bottle of Cromolyn eye drops for Resident #57 with a label indicating it was delivered 08/22/23 with instructions to use for seven days. At the time of the observation, LPN #726 verified Resident #24's opened Insulin Glargine was not dated and that the eye drops for Resident #57 should have been discarded after the order was completed. Review of manufacturer information for Insulin Glargine revealed bottles in use or stored at room temperature should be discarded after 28 days. Review of Resident #57's MAR revealed the last dose of Cromolyn eye drops was administered on 08/30/23 during the 6:00 A.M. medication pass. Review of the facility's Storage of Medications policy, revised August 2020, revealed refrigerated medication was to be stored at temperatures between 36 degrees and 46 degrees Fahrenheit with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 22 of 35 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 09/29/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete thermometer to allow temperature monitoring. The facility should maintain a temperature log in the storage area to record temperatures at least once a day or in accordance with facility policy. The policy revealed when the original seal of a manufacturer's container or vial was initially broken, the container or vial would be dated. The nurse should place a date opened sticker on the medication and record the date opened and the new expiration date. The expiration date of the vial or container would be 30 days from opening unless the manufacturer recommended another date or regulations/guidelines required different dating. If a vial or container was found without a stated date opened, the date opened would automatically default to the date dispensed and the expiration date would be calculated accordingly, unless otherwise indicated in a facility-specific policy. The nurse would check the expiration date of each medication before administering it. No expired medication would be administered to a resident. All expired medications would be removed from the active supply and destroyed in accordance with facility policy, regardless of the amount remaining. The policy did not address removal of drugs from circulation once the order was completed. Event ID: Facility ID: 365972 If continuation sheet Page 23 of 35 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 09/29/2023 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and interview, the facility failed to obtain laboratory tests as ordered. This affected one resident (#43) of five residents reviewed for unnecessary medication. The facility census was 66. Residents Affected - Few Findings include: Review of Resident #43's medical record revealed diagnoses including type two diabetes mellitus with diabetic peripheral angiopathy, cerebrovascular disease, end stage renal disease, chronic obstructive pulmonary disease, moderate protein-calorie malnutrition, hypercholesterolemia, anemia, and fatty liver. A progress note by a Certified Nurse Practitioner (CNP) dated 09/05/23 indicated Resident #43's chief complaint was increased fatigue. No recent labs were available for review. Orders were written for laboratory tests including a Complete Blood Count (CBC) with differential and Comprehensive Metabolic Panel (CMP) every week for four weeks. Laboratory results from 09/07/23 revealed abnormal CBC results including an elevated [NAME] Blood Count (WBC) of 11.58 (reference range 4.8-10.8) and elevated platelet account of 440 (reference range of 140-400). The red blood count was low at 3.27 (reference range of 4.2-5.4), low hemoglobin of 8.7 (reference range of 12-16), low hematrocrit of 30.1 (reference range of 37-47%. An elevated glucose of 118 (reference range of 61-114) was identified on the CMP. No further CBC or CMP results were available. On 09/25/23 at 1:32 P.M., the Director of Nursing (DON) verified the CBC and CMP were not obtained as ordered. Review of the facility's Laboratory and Radiological Services and Results Reporting policy (no implementation date recorded) revealed the facility was responsible for the quality and timeliness of laboratory services whether services were provided by the facility or an outside resource. There were clinical and physiological risks when laboratory services were not performed in a timely manner or the results of the services were not reported and acted upon quickly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 24 of 35 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 09/29/2023 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 observation, record review and interview the facility failed to provide routine dental services for Resident #39 and Resident #15. This affected two residents (#15 and #39) of 25 residents screened for dental services. The facility census was 66. Residents Affected - Few Findings include: 1. Resident #39 was admitted to the facility on [DATE] with diagnosis of major depressive disorder, alcohol dependence, anxiety disorder, Post-traumatic stress disorder, very low level of personal hygiene, personal history of suicidal behavior, severe protein calorie malnutrition, severe obesity due to excess calories, alcoholic hepatitis without ascites, personality disorder, urinary incontinence, incontinence of feces, atrial fibrillation, cognitive communication deficit, need for assistance with personal care, hypertension, disorder of teeth and supporting structures. The resident had a Managed Medicaid Non-PPS insurance. An encounter note written by Nurse Practitioner (NP) #810 date of service 07/13/23 revealed an acuity visit was done for Resident #39. History of present illness revealed a history of poor oral health, and poor oral hygiene practice. Resident had increased pain over one week located in lower right jaw. The resident was noted to have multiple broken teeth and swelled right lower gum molar broken. The resident was diagnosed with a tooth abscess and started on Amoxicillin (antibiotic) tablet twice a day for 14 days. Resident had poor dentition requiring referral to dentistry due to multiple broken cracked teeth. A referral was made to Mercy Health Dental clinic. Orders were placed and communicated with facility staff on 07/14/23 at 9:26 A.M. Review of [NAME] Healthcare Center order audit report verified an order date of 08/29/23 was completed and was set for Resident #39 to see a dentist on 09/14/23 with pick up details set. Observation of Resident #39 in the hallway on 09/19/23 and 09/20/23 revealed resident holding the side of her cheek in pain. Interview on 09/19/23 at 2:19 P.M. with Social Worker #719 revealed she was notified two weeks ago about the dental appointment for resident #39. Social Worker #719 made an appointment with an outside dentist on 09/14/23 who saw the resident for dental services and stated the facility used to have a receptionist make all the outside appointments. Interview on 09/21/23 at 1:55 P.M. with NP #810 revealed she had made a dental referral and an order was placed in the resident's medical record on 07/13/23. Interview on 09/21/23 at 4:05 P.M. with Resident #39 revealed she had dental pain for a long time and the pain felt like a nine on a scale of one to ten. Resident #39 stated she felt like the nursing home did not try to schedule a dental appointment and was worried her infection would turn to sepsis. Interview on 09/21/23 at 4:37 P.M. with Clinical Manager LPN #706 revealed the front desk employee would make outside physician appointments but the employee quit one month ago. The current procedure was to have the floor nurse make the outside appointment for the resident; if the nurse was unable to make the appointment, the nurse would give it to social work to make the appointment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 25 of 35 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 09/29/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Dental Services Policy #NS 1115-01 stated the facility will assist the resident in obtaining Dental Services by making appointments and arranging transportation to and from dental service locations. 2. Review of medical record for Resident #15 revealed an admission date of 11/10/22. Review of the dental services dental enrollment form revealed on 11/23/22 Resident #15 had signed that she was requesting dental services. Resident #15 was in the hospital 04/12/23 and was discharged from facility on 04/18/23. On 05/15/23 Resident #15 was readmitted to the facility and went back to the hospital on [DATE] and returned to facility on 06/11/23. On 06/12/23 Resident #15 returned to the hospital and was readmitted back to the facility on [DATE]. Diagnoses included hemiplegia (one sided paralysis) and hemiparesis (partial weakness on one side of the body) following unspecified cerebrovascular disease (condition that affects the flow of blood through the brain) affecting right dominant side, severe major depressive disorder with psychotic symptoms, type two diabetes, anxiety disorder, pseudobulbar affect (condition characterized by episodes of sudden uncontrollable and inappropriate laughing and crying), and cognitive communication deficit. Review of progress notes from 05/20/23 to 09/15/23 revealed no dental concerns. Review of 07/12/23 quarterly Minimum Data Set (MDS) assessment revealed Resident #15 could make self-understood and understood others; was cognitively intact; required supervision of one person for personal hygiene; had no pain; had no significant weight changes; no mouth or facial pain; and no discomfort or difficulty with chewing. Review of care plan dated 07/12/23 revealed Resident #15 was at risk for dental complications due to missing and broken teeth with a goal to be free of infection, pain, or bleeding in the oral cavity. Interventions included oral assessment upon admission and as needed, dental consult as needed, educate resident/resident representative on changes in dentition, observe for signs and symptoms of infection, abscess, swelling, fever, pain, and redness; and observe for signs and symptoms of oral/dental pain, debris, cracked lips or bleeding, missing teeth, loose broken decayed teeth, and black, coated, enflamed, or smooth tongue; provide oral care as needed. Review of facility documentation revealed the dentist was in the facility providing dental services on 01/13/23, 05/12/23, 06/27/23, and 08/11/23. Review of census record for Resident #15 revealed she was not a resident in the facility during the 05/12/23 and 06/27/23 dental visits. Review of dental documentation revealed there was no evidence she had been seen by the dentist on 01/13/23 or 08/11/23. Interview and observation on 09/20/23 at 2:43 P.M. with Resident #15 revealed she had many missing teeth and Resident #15 kept pointing to her mouth and kept saying missing teeth. Resident #15 denied having any mouth pain but said yes when asked if she wanted to see a dentist. Interview on 09/21/23 at 9:27 A.M. with Director of Social Services (DSS) #719 revealed the dental office generated the list of which residents would be seen for their visit. If a resident needed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 26 of 35 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 09/29/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few added to the list, she would email the resident's face sheet to the dental office, and they would let her know if the resident could be seen on their next visit. DSS #719 confirmed Resident #15 had signed a dental consult on 11/23/22 and had not been seen by the dentist since admission on [DATE]. DDS #719 could not give an explanation on why Resident #15 had not been seen by the dentist. Interview on 09/21/23 at 10:30 A.M. with a Dental Office Representative revealed the office had not been aware Resident #15 had been a resident at the facility until 09/20/23. At that time, she had been added to the list to be seen on their next visit to the facility on [DATE]. If dental office had known she had been at the facility earlier, she would have already been seen by the dentist. Review of undated facility policy Dental Services revealed the facility would provide resident centered care that met the psychosocial, physical, and emotional needs and concerns of the resident and dental and oral health could impact the physical as well as the mental/emotional and psychological health of a resident. The facility would assist the resident in obtaining routine dental services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 27 of 35 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 09/29/2023 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and review of facility policy, the facility failed to serve palatable meals. This affected 65 residents who received meals from the kitchen. The facility identified Resident #22 as receiving noting by mouth. The facility census was 66. Residents Affected - Many Findings include: Interview on 09/18/23 at 10:56 A.M. with Resident #19 revealed no hot plates were ever used, and the food was cold. Observation of the tray line on 09/21/23 from 11:55 A.M. to 12:10 P.M. revealed no concerns with food quality. Observation was made as dietary staff prepared the lunch meal that consisted of chicken tacos, rice, corn, and watermelon. Cooking temperatures obtained at this time by Culinary Director #856 using a facility thermometer, confirmed the food being served reached temperatures that assured food safety. Further observation continued as dietary staff plated the lunch meal from a steam table in the kitchen. As the tray line neared an end, the surveyor requested a test tray be prepared and placed on the Wing One food cart. Observation was made as the test tray was prepared, placed on the cart at 12:12 P.M., and transported by District Manager #855 to Wing One where it arrived at 12:17 P.M. The test tray remained on the cart in view of the surveyor, until all other trays were distributed to residents. The test tray was removed from the cart at 12:24 P.M. by District Manager #855 who used a facility thermometer that confirmed the temperatures of the chicken taco was 103.2 degrees Fahrenheit (F), rice was 102 degrees F, corn was 107 degrees F, two percent milk was 36 degrees F, coffee was 141 degrees F, and watermelon was 38 degrees F. Immediately following confirmation of the test tray temperatures, the surveyor taste-tested the chicken taco which had good flavor but did not taste hot, the rice had good flavor and was moist but did not taste hot, the corn had good flavor but did not taste hot, the watermelon had good flavor and tasted cold, the milk tasted cold, the coffee tasted warm. The chicken taco, rice, and corn which were found to not be at satisfactory temperatures for palatability. The plate and the metal pellet under the plate were cold to the touch. District Manager #855 at the time of the observation also tasted the taco, rice, and corn and confirmed the items were not warm or palatable. District Manager #855 confirmed the plate and metal pellet under the plate were not warm to the touch. Observation on 09/21/23 at 12:35 P.M. with District Manager #855 of the warming unit in the kitchen that heated the plates and metal pellets revealed the unit was cold to the touch. District Manager #855 confirmed the unit was cold to the touch. Interview on 09/21/23 at 2:07 P.M. with Resident #45 revealed the tacos were cold today. She stated I hate cold food. She stated it was a nice lunch, but it was cold. She stated it could have been an eight and a half out of ten but it was a four out of ten since it was cold. Interview on 09/21/23 at 2:15 P.M. with Resident #49 revealed his lunch was cold today. He stated most of the time the food was cold. He stated his plate was not warm to the touch. Interview on 09/21/23 at 3:36 P.M. with Resident #57 revealed the tacos were cold today. The plate was cold to the touch. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 28 of 35 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 09/29/2023 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 0804 Review of facility policy Food: Quality and Palatability, revised September 2017, revealed food would be palatable, attractive, and served at an appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 29 of 35 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 09/29/2023 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 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, interview and facility policy. The facility failed to ensure the dietary staff members wore appropriate hair covering and failed to ensure the kitchen was clean and sanitary. This affected 65 resident who received meals from the kitchen, the facility identified Resident #22 as receiving nothing by mouth. The facility census was 66. Findings include: Observation of the kitchen on 09/18/23 from 8:06 A.M. to 8:31 A.M. with Dietary [NAME] #707 revealed the following concerns: Culinary Aide #711 was observed on tray line not wearing a proper hair covering. At the time of observation, Culinary Aide #711 confirmed she did not have a hair covering on but had one on earlier in the day. Observation of the three-door reach in freezer located in the dry storage area revealed the bottom of the unit had an accumulation of food debris which included 16 loose peas, one corn kernel and two pieces of diced carrot. Observation of the two-door reach in freezer located in the dry storage area revealed the bottom of the unit an accumulation of food debris around the edges. Observation of the vents above the stove area revealed a buildup of dust and dirt. Observation of the three-door reach in cooler located in the main kitchen area revealed on the bottom of the unit there was an accumulation of food debris around the edges. On the bottom left of the unit, there was a large circular patch of stuck on brown cardboard and in the middle section there was observed to be a middle size patch of stuck on white cardboard. Observation of the bottom shelf of the steam table revealed dried liquid splashed and accumulation of food debris. Observation of the plate/pellet warmer unit revealed numerous liquid splash marks down the outside of the unit. Observation of the steel three tier serving cart located next to the steam table revealed an accumulation of food debris around the edges of all three tiers. Observation on 09/18/23 at 9:28 A.M. with Culinary Director #852 revealed he was shown all areas of concern. Interview at the time of observation revealed Culinary Director #852 affirmed the areas were dirty and needed cleaning. Culinary Director #852 stated the facility didn't currently have a Culinary Director, and he was helping the facility until a new Culinary Director could be hired. Review of facility dietary policy Environment, revised September 2017, revealed the kitchen would be maintained in a clean and sanitary manner, which included floors, walls, ceilings, lighting and ventilation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 30 of 35 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 09/29/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Review of facility dietary policy Staff Attire, revised September 2017, revealed all staff members would have their hair off the shoulders and confined in a hair net or cap. Review of facility dietary policy Equipment, revised September 2017, revealed all food service equipment would be clean and sanitary. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 31 of 35 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 09/29/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure treatments were documented in the medical record as completed for Resident #43. This affected one resident (#43) of the 31 resident records reviewed for the annual survey. The facility census was 66. Findings include: 1. Review of Resident #43's medical record revealed diagnoses including colostomy status. a. Review of physician orders revealed an order dated 09/12/23 for application of no sting skin prep around the stoma and to red areas when changing the colostomy bag every shift and an order dated 06/27/23 to change the ostomy bag four times a month. Review of the September 2023 Treatment Administration Record (TAR) revealed staff were not documenting when the colostomy bag was changed. On 09/25/23 at 1:24 P.M., interview of Licensed Practical Nurse (LPN) #706 verified the order for skin prep around the ostomy was a FYI (for your information) order so staff were aware to apply it when colostomy care was provided and was reflecting ostomy care was provided every shift. The Director of Nursing (DON) was present and verified the order for colostomy bag changes on a weekly basis had not been placed on the TAR. b. Review of a wound assessment dated [DATE] revealed Resident #43 had a Stage 4 pressure ulcer (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) to the sacrum acquired 05/13/23. Review of the September 2023 TAR revealed between 09/01/23 and 09/14/23 an order indicated the sacral wound was to be cleansed with dakins then the wound packed with dakins wet to dry fluffed gauze and cover with bordered foam twice a day and as needed. The TAR revealed staff did not document the dressing was changed or offered as ordered on day shift on 09/05/23, 09/06/23, 09/11/23, 09/13/23 or 09/14/23. On 09/14/23, the treatment was changed to cleanse the sacrum with dakins then apply calcium alginate and cover with a bordered foam twice a day and as needed. The September 2023 TAR did not reveal staff offered to change the sacral dressing on night shift on 09/19/23. On 09/25/23 at 1:24 P.M., interview of Licensed Practical Nurse (LPN) #706 and the DON were informed of the inconsistent documentation of wound treatments being offered/completed on the TAR. On 09/25/23 at 2:33 P.M. , LPN #706 verified staff were not consistently documenting treatments completed/reason they were not. Review of the facility's Clinical Record Guidelines revealed medication and treatment records were to be documented including date, time, and the person administering the medication/treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 32 of 35 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 09/29/2023 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to have the required participants at the Quality Assurance Performance Improvement ( QAPI) meeting. This had the potential to affect all 66 residents. The facility census was 66. Residents Affected - Many Findings include: Review of Policy and Standards Procedures Quality Assurance Performance Improvement ( QAPI) Plan #NS 1024-00 revealed the QAPI committee will include the Executive Director, Director of Nursing, Medical Director, Infection Preventionist, three other staff members and other state required attendees. Review of QAPI meeting agendas dated 09/02/22, 10/04/22, 11/02/22, 12/02/22, 01/06/23, 02/07/23, 03/03/23, 04/16/23, 05/04/23, 06/08/23, 07/05/23, 08/03/23, 09/01/23, the Executive Director, Director of Nursing, Infection Preventionist #706, and Medical Director attended all the meetings but thirteen of thirteen meetings did not have other staff members attend to meet the required attendance of the committee. Interview on 09/26/23 at 3:26 P.M. the Administrator verified no documented evidence other staff members attended the meeting dates. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 33 of 35 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 09/29/2023 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review the facility failed to ensure adequate infection control measures were implemented during trach care, pressure ulcer bandage changes, and use of the urinary catheter. This affected two residents (#22 and #43). The census was 66. Residents Affected - Few Findings include: 1. On 09/20/23 between 11:15 A.M. to 11:21 A.M., Licensed Practical Nurse (LPN) #732 was observed providing trach care and tracheal suctioning for Resident #22. Clean gloves were applied. LPN #732 opened a sterile package which contained a suction catheter and a pair of sterile gloves. The suction catheter was attached to tubing from the suction machine. The suction catheter was removed from the package with the clean gloves instead of using sterile gloves. The section of the catheter being inserted into the trach was handled with the clean glove. The suction catheter was removed with the end wiped with a tissue then reinserted into the trach. When preparing to change the trach inner cannula shiley, a new set of clean gloves was applied. The inner cannula was handled with the use of the clean gloves. On 09/20/23 at 11:21 A.M., interview after LPN #732 left Resident #22's room she verified she had used clean gloves instead of sterile gloves when performing trach care and suctioning and had not maintained aseptic technique. Review of the facility's Tracheostomy Care policy (implementation date not recorded) indicated prior to replacing the disposable inner cannula sterile gloves should be applied. Review of the facility's Tracheostomy suctioning policy (not dated) indicated sterile gloves were to be donned prior to suctioning and one hand was to be kept sterile. 2. Review of Resident #43's medical record revealed diagnoses including type two diabetes mellitus, acquired absence of the right leg above the knee, chronic pain syndrome, and obstructive and reflux uropathy. a. Review of a wound assessment dated [DATE] revealed Resident #43 had a Stage 4 pressure ulcer (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) to the sacrum acquired 05/13/23. On 09/21/23 between 7:55 A.M. and 8:04 A.M., LPN #735 was observed changing the dressing to the pressure ulcer on Resident #43's sacrum. Wound Nurse Practitioner (Wound NP #820) was present to measure and assess the wound. LPN #735 used the same gloves to remove the old dressing (dated 09/20/23), cleanse the wound, and apply the new dressing with calcium alginate and border gauze. On 09/21/23 at 8:10 A.M., LPN #735 verified she had not washed her hands or changed her gloves between removing the old dressing, cleansing the wound, and handling/applying the clean dressing. LPN #735 indicated she did not know how she was supposed to do that. Wound NP #820 verified it was standard practice to cleanse hands and change gloves between removing old dressings and cleansing the wound and handling/applying new dressings. b. A physician order dated 06/27/23 revealed an order for an indwelling urinary catheter to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 34 of 35 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 09/29/2023 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 - Few straight drainage. Review of an Infection Surveillance Criteria Report and the September 2023 Medication Administration Record (MAR) revealed Resident #43 was treated for a urinary tract infection (UTI) from 09/12/23 to 09/19/23. On 09/18/23 at 11:49 A.M., Resident #43 was observed lying in a low bed. The urinary catheter bag was observed on a dirty mat on the floor to the right side of the bed. On 09/19/23 at 7:08 A.M., Resident #43 was observed lying in a low bed with the urinary catheter bag lying on the floor. At 9:10 A.M. and 9:17 A.M., the urinary catheter bag was observed on the floor. On 09/19/23 at 9:17 A.M., LPN #730 verified the catheter bag was on the floor but should not have been. LPN #730 also verified the mat on the floor on the right side of the bed was dirty. Review of the facility's Catheter Care policy, date of implementation not indicated, indicated the collection bag was to be checked to ensure it was not on the floor and was draining properly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365972 If continuation sheet Page 35 of 35