Inspection·March 10, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure a resident who was dependent for personal hygiene received the necessary care and services to ensure secretions from a tracheostomy were managed to prevent the accumulation of dried mucous on the resident's gown, bed linens, and a washcloth placed beneath the tracheostomy tube. This affected one resident (#3) of three residents observed who required assistance with activities of daily living. The facility census was 74. Residents Affected - Few Findings include: Review of Resident #3's medical records revealed an admission date of 07/31/24. Diagnoses included respiratory failure, muscle weakness and need for personal care assistance. Review of the care plan dated 02/18/25 revealed an intervention to provide Resident #3 assistance with activities of daily living (ADL) care per orders. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #3 was rarely understood and was dependent for toileting, bathing and personal hygiene. Observation on 03/06/25 at 10:24 A.M. with Licensed Practical Nurse (LPN) #849 revealed Resident #3 was sleeping in bed. Resident #3 and had tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube. A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. Breathing is done through the tracheostomy tube rather than through the mouth and nose). Further observation revealed brownish/red colored dried debris on a washcloth that had been placed below Resident #3's tracheostomy. The same brownish/red colored dried debris was also observed on Resident #3's gown, pillowcase and sheets. LPN #849 confirmed the observations and stated she would have the aides come in and provide Resident #3 with ADL care. While in the room speaking to LPN #849, Certified Nursing Assistants (CNAs) #831 and #836 entered the room. CNAs #831 and #836 stated Resident #3 was dependent for all ADLs and confirmed Resident #3's gown and bed linens were soiled. CNAs #831 and #836 proceeded to roll Resident #3 onto his right side revealing Resident #3's sheets, mattress pad and reverse side of his pillow case were soiled and had a foul odor. CNA #831 and #836 stated the resident's gown and bedding should be changed daily and as needed. This deficiency represents noncompliance investigated under Complaint Number OH00163187. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365995 If continuation sheet Page 2 of 6 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 365995 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Lawn Ctr for Rehab 10608 Navarre Road SW Navarre, OH 44662 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. Based on record review, observation and interview the facility failed to ensure documentation in the medical record was accurate. This affected one resident (#3) of three residents whose medical record were reviewed. The facility census was 74. Findings include: Review of Resident #3's medical records revealed an admission date of 07/31/24. Diagnoses included respiratory failure, throat cancer, and percutaneous endoscopic gastrostomy (PEG) tube. Review of the care plan dated 02/18/25 revealed Resident #3 received tube feeding related to having a nothing by mouth (NPO) status. Interventions included administer skin treatments to PEG tube site as ordered. Review of Resident #3's physician orders for February 2025 through March 2025 revealed an order to cleanse tube (PEG) site with normal saline and apply a T-sponge twice daily. Observation on 03/06/25 at 10:24 A.M. with Licensed Practical Nurse (LPN) #849 revealed Resident #3 had a PEG tube with nutritional formula infusing. Observation of the PEG tube insertion site revealed a split gauze dressing that was dated 02/28/25. Interview with LPN #849 at time of observation confirmed the split gauze dressing was dated 02/28/25. LPN #849 stated the dressing was to be changed daily. At 11:10 A.M. the Director of Nursing (DON) entered Resident #3's room to assist with care and also confirmed the split gauze dressing was dated 02/28/25. Review of Resident #3's Treatment Administration Record (TAR) revealed from 02/28/25 though 03/05/25 staff had documented the PEG tube site was cleansed with normal saline and a T-sponge dressing was applied twice daily. Interview on 03/10/25 at 10:37 A.M. with the DON confirmed Resident #3's TAR had documentation indicating the PEG tube insertion site was cleansed with normal saline and a T-sponge dressing was applied twice daily from 02/28/25 through 03/05/25. The DON indicated staff should not document treatments as being completed when they had not been done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365995 If continuation sheet Page 3 of 6 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 365995 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Lawn Ctr for Rehab 10608 Navarre Road SW Navarre, OH 44662 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, policy review and Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure appropriate personal protective equipment (PPE) was worn while providing direct care when there was a risk of splash or spray, failed to ensure appropriate glove use and hand hygiene, and failed to prevent the possibility of cross contamination when using a soiled washcloth to clean an oxygen mask and around a tracheostomy. This affected one resident (#3) of one resident observed for tracheostomy care. The facility census was 74. Residents Affected - Few Findings include: Review of Resident #3's medical records revealed an admission date of 07/31/24. Diagnoses included respiratory failure, throat cancer and dysphasia (difficulty swallowing). Review of the care plan dated 02/18/25 revealed Resident #3 had a potential for complications related to tracheostomy. Interventions included provide tracheostomy care every shift. Review of the physician orders for March 2025 revealed an order for trach care each shift and use enhanced barrier precautions (EBP). Observation on 03/06/25 at 10:24 A.M. revealed Resident #3 was resting in bed and had a tracheostomy and PEG (feeding) tube. There was a sign indicating Resident #3 was in EBP. At the time of observation Licensed Practical Nurse (LPN) #849 entered Resident #3's room to provide tracheostomy care. LPN #849 was not wearing a mask or face shield. LPN #849 proceeded to remove a soiled washcloth from underneath Resident #3's tracheostomy and used it to clean the inside of Resident #3's oxygen mask. Resident #3 began coughing expelling a large amount of thick green colored sputum from his tracheostomy and LPN #849 used the same washcloth to wipe away the mucus and clean around Resident #3's tracheostomy. Without changing her gloves or washing her hands, LPN #849 proceeded to fill the water canister, used for humidification for Resident #3's oxygen, with a gallon of distilled water. Immediately after this observation LPN #849 exited Resident #3's room. At 11:10 A.M. the Director of Nursing (DON) entered Resident #3's room and was notified of the observation. The DON stated LPN #849 should have been wearing a mask while performing tracheostomy care and stated LPN #849 should not have used a soiled washcloth to clean Resident #3's oxygen mask and around his tracheostomy site. Review of facility's undated Tracheostomy Care policy revealed tracheostomy care was to be performed every shift or per physician orders. Staff were to wear a gown, mask and face shield and use sterile gauze pads dipped in peroxide solution to clean around the tracheostomy site, wiping in one direction with each pad until area was clear. Review of facility's Infection Control Protocol for all Nursing Procedures revised November 2019, revealed standard precautions were to be used in the care of residents regardless of their infection status. Standard precautions applied to body fluids and secretions and/or mucus membranes, staff were to wear personal protective equipment as necessary to prevent exposure to body fluids, and wash hands before any procedure and after completion of procedure. Review of the CDC EBP guidance dated 04/02/24 revealed residents with any of the following should be on EBP. Infection or colonization with a Multi Drug Resistant Organism (MDRO) when Contact Precautions do (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365995 If continuation sheet Page 4 of 6 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 365995 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Lawn Ctr for Rehab 10608 Navarre Road SW Navarre, OH 44662 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 not apply. Level of Harm - Minimal harm or potential for actual harm Wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. Residents Affected - Few PPE used for these situations: During high-contact resident care activities including dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator Wound care: any skin opening requiring a dressing. Gloves and gown prior to the high-contact care activity Face protection may also be needed if performing activity with risk of splash or spray This deficiency represents non-compliance investigated under Complaint Number OH00163187.Review of the CDC EBP guidance dated 04/02/24 revealed residents with any of the following should be on EBP. • Infection or colonization with a Multi Drug Resistant Organism (MDRO) when Contact Precautions do not apply. • Wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. PPE used for these situations: • During high-contact resident care activities including dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting. • Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator • Wound care: any skin opening requiring a dressing. • Gloves and gown prior to the high-contact care activity (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365995 If continuation sheet Page 5 of 6 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 365995 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Lawn Ctr for Rehab 10608 Navarre Road SW Navarre, OH 44662 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 Face protection may also be needed if performing activity with risk of splash or spray This deficiency represents non-compliance investigated under Complaint Number OH00163187. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365995 If continuation sheet Page 6 of 6