Health inspection·November 15, 2022

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 11/08/22 at 8:20 A.M., 9:55 A.M., and 12:18 P.M. revealed Resident #25's bilateral hands were contracted with no splinting device in place. Interview on 11/08/22 at 12:34 P.M. with State Tested Nursing Assistant (STNA) #606 revealed Resident #25 was supposed to have carrot splinting devices placed in his bilateral hands but that the carrots had been broken approximately two weeks ago and they did not place anything then in his bilateral hands. She revealed they were unable to place washcloths or any other devices in his hands as the carrots were the only device that could fit inside his hands. STNA #606 revealed she reported to a nurse that the carrot splinting devices were broken but could not remember the date and to who she specifically reported this to. She revealed she did not document anywhere in his medical record regarding the implementation of his splints. Interview on 11/08/22 at 1:02 P.M. with Licensed Practical Nurse (LPN) #604 revealed she was the charge nurse for Resident #25 today, 11/08/22, and was not aware Resident #25 did not have his carrot splinting devices and/ or that they were broke. She revealed they did not document anywhere in his medical record regarding the implementation of his splints. Interview on 11/08/22 at 1:49 P.M. with Rehabilitation Director #607 revealed she was not aware that Resident #25's carrot splinting devices were broken and that they were not utilizing any splinting devices in his bilateral hands. She revealed Central Supply #605 ordered new replacement carrot splinting devices and she was unsure if she was aware they were broken. She revealed per their last Occupational Therapy Discharge summary dated [DATE] revealed Resident #25 was to have bilateral hand rolled wash clothes or carrot splints to his bilateral hands to increase range of motion. She revealed if the carrot splinting devices were broken that the staff should have been using rolled up washed clothes as replacement. Interview on 11/08/22 at 1:52 P.M. with the Director of Nursing revealed she was not aware Resident #25's carrot splinting devices were broken and was not aware how long they had been broken. She revealed the order should have been on the TAR and the nurses documenting that the splints were applied, and she was unsure why the order was not on the TAR for September 2022, October 2022 and November 2022. She verified she had no documentation of the splints being implemented for Resident #25 from 09/01/22 through 11/08/22. Interview on 11/08/22 at 2:04 P.M. with Central Supply #605 revealed she ordered the needed supplied including carrot splinting devices and was not aware Resident #25's carrot splinting devices were broken as she was not notified. She revealed she did not have any back up carrot splinting devices and /or had ordered any replacements. Review of facility policy labeled, Restorative Program dated 11/08/22 revealed the purpose of this policy was to provide direction and guidance to the clinical team to assess and implement a plan of action for resident-specific care to maintain or improve mobility with the maximum practicable independence. The policy revealed based upon the assessment and evaluation necessary equipment including splints or braces should be addressed in the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365991 If continuation sheet Page 2 of 7 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 365991 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addison Healthcare Center 8055 Addison Road SE Masury, OH 44438 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the pharmacy delivered medications in a timely manner to ensure Resident #44 and Resident #99 received intravenous antibiotics as scheduled. This affected two residents (Resident #44 and Resident #99) out of five residents reviewed for medication administration. Findings include: 1. Resident #44 was admitted to the facility at 5:45 P.M. on 10/27/22 with diagnoses including cellulitis of the lower extremities, bacteremia, elevated white blood cell count, heart failure, chronic kidney disease and obesity. A review of a nurse progress note dated 10/27/22 indicated the physician verified the admission medication orders at 6:45 P.M. A review of Resident #44's clinical nurse practitioner (CNP) progress note dated 10/28/22 indicated Resident #44 was admitted from the hospital for intravenous infusion of antibiotics for the lower leg cellulitis with associated bacteremia infection. The CNP progress note indicated Resident #44 had a peripheral intravenous central line (PICC) in the right upper forearm for the intravenous infusion. The CNP note indicated the plan of care included to continue the intravenous antibiotic administration started while in the hospital. A review of the hospital Medication Administration Record (MAR) dated 10/27/22 indicated the last dose of Cefepime (antibiotic) 2 grams was administered intravenously in the hospital at 11:16 A.M. prior to transfer to the facility. Resident #44's admission physician order dated 10/27/22 indicated to administer Cefepime 2 grams intravenously every eight hours for infection. The next dose was due to be administered at 7:16 P.M. on 10/27/22. A review of Resident #44's MAR dated 10/01/22 to 10/31/22 indicated he received the first dose in the facility of Cefepine 2 grams intravenously on 10/28/22 at 4:00 P.M. Electronic medication administration note dated 10/28/22 at 5:51 A.M. and 10:59 A.M. indicated the facility was waiting for delivery of the Cefepime antibiotic medication from pharmacy. An interview with Resident #44 on 11/07/22 at 10:50 A.M. indicated he did not receive his intravenous antibiotic for at least 24 hours after he was admitted to the facility. Resident #44 stated the nursing staff had informed him they had called the pharmacy several times to have them deliver the intravenous antibiotic but they failed to deliver the antibiotic until the next day. An interview with Licensed Practical Nurse (LPN) #500 on 11/08/22 at 3:30 P.M. and with LPN #501 and LPN #502 on 11/09/22 at 6:15 A.M. indicated they had worked for the facility for more than two years and the the pharmacy routinely failed to deliver medications in a timely manner after residents were admitted to the facility. LPN #500 stated she often had to wait 24 hours or more for medications to be delivered from the pharmacy after a resident arrived to the facility. LPN #500 stated some medications were stocked in the facility and could be signed out to administer to the residents as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365991 If continuation sheet Page 3 of 7 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 365991 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addison Healthcare Center 8055 Addison Road SE Masury, OH 44438 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few needed. If the facility did not stock a particular medication then the resident had to wait an extended period of time to have their prescription medications administered. An interview with Assistant Director of Nursing (ADON) on 11/08/22 at 11:29 A.M. verified the above findings and indicated she was unaware if the administrative personnel had contacted the pharmacy to implement changes to ensure the residents received their medications from the pharmacy in a timely manner. ADON stated the nurses had called the pharmacy several times to have Resident #44's intravenous antibiotic delivered immediately on 10/27/22 but did not receive the antibiotic until the following day. An interview with Physician #503 on 11/09/22 at 7:15 A.M. indicated the staff notified him of the failure of the pharmacy to deliver the intravenous (IV) antibiotics for Resident #44 within the first few hours after their admission. Physician #503 stated when the staff notified him the intravenous antibiotics were not available to administer the staff were informed by the pharmacy the intravenous antibiotics would be delivered by the pharmacy buy the next morning. Physician #503 stated this had been an ongoing problem and should have been addressed by the facility. Physician agreed residents should receive IV antibiotics as soon as possible to treat their specific infections. An interview with Administrator on 11/09/22 at 8:00 A.M. indicated upon admission to the facility the physician ordered medications were faxed to the pharmacy after verified with the physician. If a resident's medication was not available when scheduled to administer the staff could withdraw the medication from the facility stock if available. If the facility did not have the medication stocked, the nurse would call the pharmacy and inquire of the time of delivery for the resident's medication. The nurse would then notify the physician of the missing medication. Administrator indicated she had informed the corporation of the problem and there had been no resolution. An interview on 11/09/22 at 9:12 A.M. with the Quality Assurance Pharmacist (QAP) from the pharmacy the facility used to provide the medications to the residents in the facility revealed she was recently notified of the problem with timeliness of delivery of Resident #44's intravenous antibiotics to the facility on [DATE]. QAP indicated the pharmacy should be able to deliver intravenous medications immediately to the facility when needed. QAP agreed it was unacceptable for the pharmacy to delay the delivery of intravenous antibiotics and could not identify the root cause of the problem. An interview with Director of Nursing (DON) on 11/09/22 at 10:52 A.M. indicated the pharmacy was expected to deliver IV antibiotic medications to the facility as soon as possible after receiving the physician order. DON indicated the expectation was the resident would receive the IV antibiotic with in four to six hours after their admission to the facility. DON verified the pharmacy was contacted by the facility staff and continued to fail to deliver the IV antibiotic in a timely manner. A review of the Ohio Pharmacy Information (undated) from the pharmacy company who provided services to the facility indicated resident's medications would be delivered at 12:00 P.M. and 12:00 A.M. from Monday through Friday and 12:00 P.M. and 5:00 P.M. on Saturday, Sunday and holidays. New order requests received before 12:00 P.M. would arrive with the first scheduled delivery. Order requests after 12:00 A.M. would be delivered on the first scheduled delivery the following day. 2. Resident #99 was admitted on [DATE] with diagnoses including chronic kidney disease with kidney cancer, bacteremia, enterococcus as the cause of diseases classified elsewhere, heart disease and anemia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365991 If continuation sheet Page 4 of 7 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 365991 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addison Healthcare Center 8055 Addison Road SE Masury, OH 44438 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 0755 Level of Harm - Minimal harm or potential for actual harm Resident #99's nursing progress note dated 11/04/22 at 6:19 P.M. indicated Resident #99 was admitted and had a right chest single lumen central venous line port for intravenous infusion. A review of Resident #99's physician order dated 11/05/22 indicated to administer Ampicillin 1 gram intravenously every eight hours for bacterial infection. Residents Affected - Few Review of nursing progress note dated 11/05/22 at 1:46 A.M., 10:57 P.M., revealed the Ampicillin intravenous antibiotic had not arrived from the pharmacy and the physician was aware. Review of Resident #99's MAR dated 11/01/22 to 11/20/22 revealed the Ampicillin antibiotic was not administered until 11/06/22 at 6:00 A.M. An interview with Resident #99 on 11/07/22 at 10:09 A.M. indicated he was admitted to receive intravenous antibiotics and the pharmacy did not deliver the intravenous antibiotic until approximately 48 hours after he was admitted to the facility. An interview with Physician #503 on 11/09/22 at 7:15 A.M. indicated the staff notified him of the failure of the pharmacy to deliver the IV antibiotics for Resident #99 with in the first few hours after their admission. Physician #503 stated when the staff notified him the intravenous antibiotics were not available to administer the staff were informed by the pharmacy the intravenous antibiotics would be delivered by the pharmacy buy the next morning. Another nurse called and notified him the antibiotic was not available the next morning and the pharmacy told the staff the IV antibiotic would be delivered in the afternoon. Physician #503 stated this had been an ongoing problem and should have been addressed by the facility. Physician agreed residents should receive IV antibiotics as soon as possible to treat their specific infections. An interview with Administrator on 11/09/22 at 8:00 A.M. indicated upon admission to the facility the physician ordered medications were faxed to the pharmacy after verified with the physician. If a resident's medication was not available when scheduled to administer the staff could withdraw the medication from the facility stock if available. If the facility did not have the medication stocked, the nurse would call the pharmacy and inquire of the time of delivery for the resident's medication. The nurse would then notify the physician of the missing medication. Administrator indicated she had informed the corporation of the problem and there had been no resolution. An interview on 11/09/22 at 9:12 A.M. with the QAP from the pharmacy the facility used to provide the medications to the residents in the facility revealed she was recently notified of the problem with timeliness of delivery of Resident #44's intravenous antibiotics to the facility on [DATE]. QAP indicated the pharmacy should be able to deliver intravenous medications immediately to the facility when needed. QAP agreed it was unacceptable for the pharmacy to delay the delivery of intravenous antibiotics and could not identify the root cause of the problem. An interview with DON on 11/09/22 at 10:52 A.M. indicated the pharmacy was expected to deliver IV antibiotic medications to the facility as soon as possible after receiving the physician order. DON indicated the expectation was the resident would receive the IV antibiotic with in four to six hours after their admission to the facility. DON verified the pharmacy was contacted by the facility staff and continued to fail to deliver the IV antibiotic in a timely manner. A review of the Ohio Pharmacy Information (undated) from the pharmacy company who provided services to the facility indicated resident's medications would be delivered at 12:00 P.M. and 12:00 A.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365991 If continuation sheet Page 5 of 7 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 365991 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addison Healthcare Center 8055 Addison Road SE Masury, OH 44438 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 0755 Level of Harm - Minimal harm or potential for actual harm from Monday through Friday and 12:00 P.M. and 5:00 P.M. on Saturday, Sunday and holidays. New order requests received before 12:00 P.M. would arrive with the first scheduled delivery. Order requests after 12:00 A.M. would be delivered on the first scheduled delivery the following day. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365991 If continuation sheet Page 6 of 7 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 365991 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addison Healthcare Center 8055 Addison Road SE Masury, OH 44438 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 0851 Level of Harm - Potential for minimal harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review, the facility failed to submit complete and accurate staffing information for the Payroll-Based Journal (PBJ) report to Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all 51 residents in the facility. Findings include: Review of emails of 05/11/22 and 07/30/22 between the Administrator and the corporate office revealed missing nursing hours for the PBJ reports for 01/01/22 to 03/31/22 and 04/01/22 to 06/30/22. The DON or the Assistant DON provided direct care on 01/09/22, 01/15/22, 02/12/22, 02/13/22, 02/26/22, 03/13/22, 03/20,22, 03/26/22, 03/27/22, 07/02/2022, 07/09/2022, 07/10/2022, 07/16/2022, 07/17/2022, 07/23/2022, 07/24/2022, 07/30/2022, 07/31/2022, 08/06/2022, 08/07/2022, 08/13/2022, 08/20/2022, 08/21/2022, 08/27/2022, 09/03/2022, 09/04/2022, 09/17/2022 and 09/18/2022. Interview on 11/14/22 12:45 P.M. with the Administrator revealed the Director of Nursing (DON) provided direct care to ensure facility staffing was not low, particularly on the weekends. The hours when the DON provided direct care were not entered into the PBJ since she was salary. The Administrator reported she provided those hours to the corporate office when requested but they were not entered in time and the PBJ report did not accurately reflect the staffing data. Interview on 11/1422 at 1:10 P.M. with the DON verified she provided direct care on the dates reported to the corporate office. Interview on 11/15/22 at 1:44 P.M. with Corporate Manager (CM) # 801 revealed staffing hours cannot be entered beyond a certain date. He verified the facility triggered for low weekend staffing and a one-star staffing rating because not all hours were reported to CMS in the PBJ report for 04/01/22 to 06/30/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365991 If continuation sheet Page 7 of 7