Inspection·October 18, 2021

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was told she did not speak to Resident #19 in a verbally abusive manner, and that she was talking to another staff member when she was using curse words. She stated the NA was talking to another staff member, who was STNA #135. She stated when she interviewed STNA #135, she was informed NA #600 had told the resident a derogatory statement (statement provided with explicit language), which was a conflict of NA #600's statement. She stated NA #600 was subsequently terminated for poor customer care and using vulgar language in the workplace. Attempts to reach STNA #135 on 10/14/21 at 10:30 A.M. and 10:45 A.M. were unsuccessful. Review of the facility investigation, revealed a written statement from STNA #135. The statement revealed on 05/14/21, she was exiting another resident's room that morning and heard NA #600 state to Resident #19, sit the (explicit) down and shut the (explicit) up. I can't stand you and you need to go meet Jesus. Review of an Employee Disciplinary Report for NA #600 revealed the employee was terminated on 05/18/21 following investigation of this incident. The date of the violation was 05/14/21. The report revealed the employee was suspended immediately and upon results of the investigation, witness statements confirmed the employee was speaking to the resident inappropriately in violation of the Code of Conduct Policy. Review of facility Abuse policy, with an issue date of 8/2016 and a revision date of 11/01/17 revealed all patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation. It also revealed all providers, employees, volunteers, and students shall communicate with each other and patients with the utmost respect and compassion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365998 If continuation sheet Page 2 of 20 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 365998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614 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 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm Based on record review, review of a facility self reported incident (SRI) , facility policy and procedure review and interview the facility failed to prevent the misappropriation of narcotic pain medication. This affected 13 residents (#3, #5, #9, #11, #12, #20, #24, #26, #244, #246, #247, #248 and #250) of 18 residents identified to receive narcotic medications. Residents Affected - Some Findings include: Review of a facility self reported incident, tracking number 206725 revealed on 05/27/21 the facility reported an allegation of misappropriation to the State agency. A brief description of the incident revealed a nurse allegedly misappropriated medication. The initial SRI included nine residents identified by the facility to have been affected. On 10/14/21 at 1:30 P.M. interview with the Administrator revealed she had conducted an investigation of an incident of theft of narcotic medication involving Licensed Practical Nurse (LPN) #200. The Administrator revealed a concern was brought to her attention in May 2021 when another nurse alleged LPN #200 was falsely signing his name on the narcotic sheet indicating he dropped a narcotic pill and wasted the dropped medication. The reporting LPN also alleged a narcotic sheet was missing. The Administrator said she and the Director of Nursing (DON) interviewed LPN #200 at the facility on 05/27/21 regarding the dropped narcotics and the missing narcotic sheet. The Administrator informed the LPN he had 45 dropped narcotic pills for seven different residents at the time of the investigation/interview. The LPN denied any misappropriation of narcotics. The LPN stated he had a difficult time hitting the cup when punching the pill from the blister back. The LPN was suspended on 05/27/21 pending an investigation and subsequently resigned his position on 05/28/21. Review of the facility investigation determined the facility reported 45 doses of narcotic pain medication as stolen and 14 narcotic cards and controlled narcotic count sheets. The facility identified 13 residents, Resident #3, #5, #9, #11, #12, #20, #24, #26, #244, #246, #247, #248 and #250 who were affected by the stolen medications. The facility investigation determined LPN #200 had been taking the narcotic pain medications from 12/31/20 to 05/25/21. Review of the facility policy titled, Controlled Substances, dated 04/2019 revealed the facility complied with all laws, regulations and other requirements related to handling, storage, disposal and documentation of controlled medications. Medication that were opened and subsequently not given (refused or only partly administered) were to be destroyed. Waste and/or disposal of controlled medication were to be done in the presence of the nurse and a witness who also signed the disposition sheet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365998 If continuation sheet Page 3 of 20 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 365998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614 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 staff interview the facility failed to ensure a new Pre-admission Screening and Resident Review (PASARR) was completed Resident #6, who had a mental illness diagnosis added after his initial PASARR was completed. This affected one resident (#6) of one resident reviewed for PASARR. Findings include: A review of Resident #6's medical record revealed a documented admission date of 04/30/12 with diagnoses including major depressive disorder and anxiety disorder. The resident's diagnoses list was updated to reflect the addition of delusional disorder on 01/01/13, unspecified psychosis on 09/13/13, and schizophrenia on 07/16/15. A review of a PASARR screen, dated 11/23/10 revealed the resident's pre-admission screen determination was not applicable. The screening form did not mark the resident had indications of serious mental illness at the time the PASARR was completed. The medical record was absent for evidence of a new PASARR being completed on or after 07/16/15, when Resident #6 was given the diagnoses of schizophrenia. Findings were verified by the Administrator. A review of an annual Minimum Data Set (MDS) 3.0 assessment, dated 05/07/21 indicated Resident #6 was not currently considered by the State Level II PASARR process to have a serious mental illness. Section (I.) of the MDS listed the resident's active diagnoses and schizophrenia was included as one of the resident's diagnoses. On 10/14/21 at 9:35 A.M. an interview with Registered Nurse (RN) #100 revealed Resident #6 had been admitted to the facility prior to 04/30/12 (the date of admission identified on the admission Record). RN #100 revealed that date was when the facility started using an electronic health record. She reported the resident had been in the facility since 2010, which was why the PASARR had been completed on 11/23/10, around the time the resident was originally admitted . On 10/14/21 at 2:30 P.M., an interview with the Administrator confirmed the facility was not able to find evidence of any additional PASARR screens being completed for Resident #6 (other than the one from 11/23/10). The Administrator acknowledged there should have been a new PASARR screen completed, after the resident was given the diagnosis of schizophrenia, to determine the need for any level II services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365998 If continuation sheet Page 4 of 20 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 365998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614 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 Based on observation, record review and interview the facility failed to ensure Resident #23 was positioned properly and safely to consume his meal. This affected one resident (Resident #23) randomly observed during the initial dining observation. The facility census was 37. Residents Affected - Few Findings include: Review of Resident #23's medical record revealed an admission date of 03/22/16 with diagnoses including unspecified dementia with behavioral disturbances, dysphagia, abnormal posture, gastro-esophageal reflux disease and debility. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/31/21 revealed Resident #23 was cognitively impaired and required supervision of one person with physical assistance for eating and two person extensive physical assistance for bed mobility. Review of the plan of care, dated 09/08/21 revealed the resident required assistance as needed with eating and assistance with bed mobility. Review of the physician orders for 10/2021 revealed Resident #23 was on a regular, mechanical soft textured diet. On 10/12/21 at 11:45 A.M. observation of the lunch meal revealed Resident #23 was in bed with his upper body positioned leaning to the left. The head of the bed was elevated approximately 90 degrees and the resident had slid down in the bed. The resident's head was bent over to to the right side. State Tested Nursing Assistant (STNA) #162 placed the residents lunch tray on the over the bed table, and removed the lid. The STNA set up the meal for the resident, encouraged him to eat and left the room. The over the bed table and meal tray were eye level to the resident and he was unable to reach his food or feed himself safely. An interview with the Assistant Director of Nursing (ADON) on 10/12/21 at 12:14 P.M. confirmed the resident needed to be repositioned in order to eat safely. On 10/12/21 at 12:15 P.M. the ADON and STNA #162 were observed to reposition Resident #23 in his bed by lifting him up towards the head of the bed, straightening his body and head, and elevated the head of the bed to 90 degrees. The resident then began to feed himself after positioning was corrected. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365998 If continuation sheet Page 5 of 20 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 365998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614 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 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 Based on observation, record review and interview the facility failed to provide ensure Resident #5, who was totally dependent on staff for personal hygiene/bathing was provided timely and adequate nail care. Resident #5's fingernails were observed to be long and jagged. The jagged edges of the nails were observed cutting into the resident's skin due to a contracture of the left hand. This affected one resident (#5) of 19 residents observed for activities of daily living. Residents Affected - Few Findings include: Review of the medical record for Resident #5 revealed an admission date of 07/06/20 with diagnoses including metabolic encephalopathy, unspecified dementia without behavioral disturbances and depression. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 07/14/21 revealed the resident was cognitively impaired and was totally dependent on staff for personal hygiene and bathing. Review of the plan of care, dated 07/16/21 revealed the resident required assistance with personal hygiene and bathing. The plan of care revealed to ensure the resident's nails were clean and trimmed. On 10/12/21 at 11:01 A.M. and 10/13/21 at 8:01 A.M. observation of Resident #5 revealed the resident's fingernails were long with jagged edges. The jagged edges were cutting into the resident's skin due to contracture of the left hand. An interview on 10/13/21 at 8:07 A.M. with Licensed Practical Nurse (LPN) # 102 confirmed Resident #5 fingernails were long with jagged edges. The LPN also confirmed the jagged nails on the resident's left hand were cutting into the resident's skin. The resident had a contracture of the left hand. An interview on 10/14/21 at 3:00 P.M. with the Director of Nursing (DON) revealed the facility did not have a policy for nail care. The DON said nail care was an assumed standard of care with bathing or showering. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365998 If continuation sheet Page 6 of 20 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 365998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm Based on observation, record review, facility policy and procedure review and interview the facility failed to implement interventions to prevent the development of a pressure ulcer for Resident #10. Residents Affected - Few Actual harm occurred on 10/07/21 when Resident #10, who was severely cognitively impaired was identified to have a Stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer to the ball of his left foot. There was no evidence the facility had adequate interventions in place to prevent the development of the ulcer and to promote healing once the ulcer was identified. The facility failed to ensure the pressure ulcer was timely identified prior to being found as a Stage III and failed to ensure a treatment was initiated at the time the ulcer was first identified. This affected one resident (#10) of four residents reviewed for pressure ulcers. Findings include: Review of Resident #10's medical record revealed an admission date of 04/09/21 with diagnoses including shortness of breath, chronic obstructive pulmonary disease, hypertension, osteoarthritis, underweight, cachexia and dementia with behavioral disturbances. Review of the resident's physician's orders, revealed an order dated 04/09/21 for a pressure reduction mattress to bed, cushion to wheelchair, body audit weekly every Monday, encourage to turn and reposition every two hours and as needed, barrier cream to buttocks every shift and as needed for prevention and incontinence care every two hours and as needed. Review of the plan of care, dated 04/15/21 revealed the resident was at risk for pressure ulcer development or skin integrity complications. Interventions included skin prep to bilateral heels twice daily and as needed, encourage to turn every two hours, barrier cream to buttocks every shift as needed, foam cushion to my chair of choice, nurse to provide complete body audit weekly, shower twice weekly as needed and pressure reduction mattress to bed. Review of the resident's Braden Scale dated 07/13/21 revealed a score of 15 indicating a low risk for skin breakdown. Review of the resident's Minimum Data Set (MDS) 3.0 assessment, dated 07/17/21 revealed the resident had clear speech, understood others, made himself understood and had a severe cognitive deficit as indicated by a BIMS score of three. The assessment revealed the resident was independent with bed mobility, transfers and ambulation. The resident was identified as being at risk for skin breakdown and had no unhealed skin breakdown at that time. The MDS identified the facility implemented a pressure reducing device to bed/chair and applications of ointments/medications other than to feet. Review of the resident's skin profile document, dated 10/07/21 revealed the resident acquired a Stage III pressure ulcer to his left outer foot (the ball of the left foot) measuring 2.0 centimeters (cm) in length by 2.0 cm width with 0.1 cm depth and yellow slough to the wound bed. Comments included: Weekly wound assessment complete. No odor present at this time. Denies any pain to area. Tolerated assessment and dressing change well. On 10/07/21 an order for a nutritional supplement, Juven (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365998 If continuation sheet Page 7 of 20 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 365998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 twice daily for wound healing was obtained. Level of Harm - Actual harm Review of the plan of care, dated 10/12/21 revealed the resident had an actual Stage III pressure area on his left foot related to history of ulcers (the resident had been admitted with a pressure ulcer to the buttocks that had healed after admission). Interventions included assess wound, record/monitor status weekly and don't put shoes on left foot. Residents Affected - Few On 10/12/21 at 2:28 P.M. observation of the resident revealed he was positioned on his left side with the Stage III pressure ulcer directly on the bed. The resident was very thin in appearance and there was no evidence of any type of pressure reduction to the resident's feet. On 10/13/21 (six days after the pressure ulcer was first identified) an order was obtained to cleanse wound to left foot with wound cleanser, pat dry, apply Medihoney and cover with an Allevyn. Review of the resident's October 2021 Treatment Administration Record (TAR) revealed no treatment was documented to have been completed until 10/13/21. Review of the resident's progress noted failed to provide evidence a treatment was administered for the pressure ulcer from 10/07/21 until 10/13/21. On 10/13/21 at 9:23 A.M. observation of the resident revealed he was positioned on his back with his left foot resting directly on the foot board of the bed. There was no evidence of any type of pressure reduction to the resident's feet. Although, the MDS from July 2021 identified the resident was independent with bed mobility and ambulation, the resident was not observed during any observations on 10/12/21 or 10/13/21 to be out of bed and was not observed to be able to reposition himself in bed. At multiple times the ball of the resident's left foot was observed either directly pressing against the foot board of the bed or resting on his right foot. The resident was tall and appeared to be too long for the bed with the foot board which created additional pressure to the ball of the left foot when it pressed again the foot board and resulted in the pressure ulcer development. On 10/13/21 at 2:25 P.M. observation of Licensed Practical Nurse (LPN) #128 provide the physician ordered treatment to the Stage III pressure ulcer to the ball of the left foot revealed the resident was positioned on his left side with the ball of his left foot resting on his right foot. The LPN entered the room in personal protective equipment (PPE) and set-up the required supplies on a barrier on the resident's bedside table. The LPN had to assist the resident to position on his back at which time the resident's foot rested against the foot board of the bed. The LPN then exited the room to obtain wound cleanser. The LPN entered the room with PPE, washed her hands and applied gloves. She cleansed the wound with wound cleanser and four by four dressing. The LPN then placed Medihoney on the wound and covered the pressure ulcer with an Allevyn patch. She placed a pillow over the resident's right leg but the left foot continued to touch the resident's right foot. The LPN verified the current pressure ulcer interventions were ineffective and the Stage III pressure ulcer continued to have direct pressure to it. On 10/13/21 at 4:12 P.M. interview with the Director of Nursing (DON) revealed she believed a pressure ulcer treatment had been ordered on 10/07/21 at the time the ulcer was discovered but the order was not put in the resident's electronic medical record. The DON verified the resident's medical record contained no evidence of a treatment until 10/13/21. Review of the facility policy titled, Prevention of Pressure Ulcers, dated 04/2020 revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365998 If continuation sheet Page 8 of 20 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 365998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm purpose of the procedure was to provide information regarding identification of pressure injury risk factions and interventions for specific factors. Inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living and reposition resident as indicated on the care plan. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365998 If continuation sheet Page 9 of 20 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 365998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614 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 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. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to provide adequate and necessary care and services to prevent the development of hand contractures for two residents (#5 and #25). Actual harm occurred when Resident #25 who was severely cognitively impaired was not provided range of motion services or the application of splint/ orthotic devices resulting in the development of bilateral hand contractures. Actual Harm also occurred for Resident #5 when the facility failed to provide range of motion and/or hand roll/splinting care for the resident's left hand to prevent a decline in range of motion and development of a contracture to the hand. This affected two residents (#5 and #25) of three residents reviewed for positioning/ mobility. Findings include: 1. A review of Resident #25's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, muscle wasting and atrophy, polyosteoarthritis and dementia with behavioral disturbances. The resident's diagnoses list was updated to reflect a diagnosis of a contracture of the right hand, which was added on 06/23/21. A review of Resident #25's nursing admission assessment completed on 06/24/20 revealed no indication of any contracture or limitations to range of motion at the time of her admission. A review of Resident #25's Occupational Therapy (OT) Recertification/ Progress Report/ Updated Therapy Plan for a certification period of 02/08/21 to 03/08/21 revealed the resident's diagnoses included muscle wasting and atrophy, Parkinson's disease, abnormal posture, stiffness of an unspecified joint, muscle weakness and abnormalities of gait and mobility. Contractures were not included in the resident's diagnoses at that time. The goals for the resident's treatment were to increase her bilateral upper extremity (BUE) strength and to improve her activities of daily living (ADL) self care ability and her ability to perform self dressing of her upper and lower extremities. The assessment did not include anything about limitations in range of motion (ROM) or the resident having any known contractures. A review of Resident #25's OT Discharge Summary, for date of service of 01/12/21 to 03/19/21 revealed the resident's discharge recommendations included a restorative ROM program. The ROM program established/ training included bilateral upper extremity (BUE) ROM in all planes three times a week as tolerated. A review of Resident #25's OT Recertification/ Progress Report/ Updated Therapy Plan for a certification period of 03/15/21 to 04/13/21 revealed the resident was having issues with her ring finger (fourth digit) of her right hand. Listed diagnoses did not include contractures as one of the resident's diagnoses for treatment. The resident was assessed to be experiencing deficits in ROM and strength. The short term goal was for the resident to increase her right ring finger metacarpophalangeal (MCP)/ proximal interphalangeal (PIP) joint extension to -15 degrees to increase her grasp for self (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365998 If continuation sheet Page 10 of 20 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 365998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614 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 feeding. Level of Harm - Actual harm A review of Resident #25's physician's progress note, dated 06/24/21 revealed the resident was noted to have bilateral hand contractures. The physician's plan for the bilateral hand contractures was for her to have occupational therapy. Residents Affected - Few A review of Resident #25's OT Recertification/ Progress Report/ Updated Therapy Plan for a certification period of 06/23/21 to 07/21/21 revealed the resident's diagnoses added contractures of the right and left hand that were not previously identified. The onset date of the contractures were noted to be 06/23/21. The reason for the OT referral was for BUE digit contractures increasing the resident's risk for skin breakdown. Her right upper extremity (RUE) and left upper extremity (LUE) ROM was noted to be impaired. An assessment of the RUE and LUE ROM revealed the resident's wrists, hands, middle finger, ring finger and little fingers were impaired. Recommendations were made for the resident to use hand rolls to decrease her risk for skin breakdown and to assist with extension of her digits (fingers). A review of Resident #25's OT Discharge Summary for date of service of 06/23/21 to 08/19/21 revealed discharge recommendations included the use of hand rolls to the resident's BUE and a hand roll schedule to decrease the resident's risk for skin breakdown. Restorative programs recommended by OT were a restorative splint and brace program. The resident was to wear hand rolls in her BUE four hours on and four hours off to decrease the risk for skin breakdown. A review of a Therapy to Restorative Nursing Communication form, dated 08/20/21 revealed the resident had been discharged from physical therapy (PT) and OT. OT recommendations included BUE hand stretching/ passive range of motion (PROM) in all planes daily as tolerated. Adaptive equipment/ orthotic devices issued with schedule included BUE hand rolls four hours on/ four hours off daily as tolerated. A review of Resident #25's most recent quarterly Minimum Data Set (MDS) assessment, dated 07/09/21 revealed the resident did not have any communication issues but her cognition was severely impaired. She was not known to display any behaviors during the assessment reference period (seven days) but was known to reject care one to three days during the seven day assessment period. The resident was totally dependent on two for transfers and an extensive assist of two staff for dressing. Ambulation did not occur. The resident had functional limitations in range of motion on both sides of her upper and lower extremities. Contracture of the right hand was listed as an active diagnosis and OT and PT minutes were indicated to have been provided. A review of Resident #25's active care plans revealed she did not have a care plan in place to address her contractures. There was no indication in the care plans the resident was to receive any type of restorative nursing program for ROM/ hand stretching or the use of BUE hand rolls/ splints to help prevent contractures. A review of Resident #25's Kardex, used by the State tested Nursing Assistants (STNAs) to identify a resident's care needs, revealed there was no indication the resident was to receive any type of ROM programming. The Kardex also failed to include the use of hand rolls that had been recommended by OT, to be on for four hours and off for four hours (per schedule). A review of Resident #25's active physician's orders revealed there were no orders in place for the resident to receive any ROM services or hand rolls/ orthotic devices to help manage her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365998 If continuation sheet Page 11 of 20 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 365998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614 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 contractures. Level of Harm - Actual harm Resident #25's electronic health record was absent for any evidence of her receiving any type of restorative nursing services as part of a program to provide her with PROM exercises. It also did not include evidence of hand rolls being used on the on for four hours/ off for four hours schedule recommended by OT. Residents Affected - Few On 10/12/21 and 10/13/21 ongoing observations at various times each day, including specific observations on 10/12/21 at 10:38 A.M. and 10/13/21 at 9:37 A.M., 10:55 A.M. and 1:42 P.M. revealed no evidence of Resident #25 having any hand rolls in place to her bilateral hands. Contractures were noted to her bilateral hands. It was not until 10/14/21, when the facility was asked to provide information on the resident's development of her contractures, that she was observed to have hand rolls put in place. An observation on 10/14/21 at 8:45 A.M., was the first observation in the previous three days of the resident having hand rolls in place. The hand rolls had Velcro straps wrapped around the resident's posterior hands to hold them in place. On 10/14/21 at 8:59 A.M. interview with STNA #145 revealed Resident #25 required extensive assistance/total dependence from staff for personal care. The STNA initially reported the resident had full ROM to her arms and legs and then reported the resident's legs had limited ROM. The STNA was then asked about the resident's hands and indicated staff were putting hand rolls in them. The STNA revealed they had black hand rolls to use that were given to them by therapy. The STNA reported staff (the STNAs) knew what the care needs of each resident were based on the kardex they had for reference. The STNA was not aware the resident's kardex did not include the need for ROM to be provided or the use of hand rolls for the resident. She stated she knew the resident needed those things but could not speak to whether or not the other staff would know as well. She reported she had been off work the past couple of days and last worked with the resident this past Saturday. On 10/14/21 at 9:10 A.M. interview with the Director of Nursing (DON) revealed the facility did have a restorative nursing program but not all programs were being implemented by a restorative aide. She stated if the need arose, the facility might pull the restorative aide to work the floor due to a call-off. The DON revealed things like ROM would still be provided during a resident's bath or during other personal care. She reported, if ROM was provided as part of a restorative program, it should be documented in the electronic health record under the task tab so the minutes provided could be recorded. She denied ROM or the use of hand rolls would be in the physician's orders as she stated that was a nursing measure. The DON acknowledged Resident #25's plan of care did not address her contractures as there was not a care plan in place for it and the Kardex that was used by the STNAs to direct the resident's care did not include the need to provide range of motion or use of hand rolls to prevent worsening of her existing contractures. The DON was not able to explain why that information was not included on the Kardex or why a care plan had not been developed. The DON revealed this must have been missed. She acknowledged without it being included on the Kardex and no documented evidence range of motion and hand rolls were being used, it was hard to show staff were providing the care and services to prevent the resident's contractures from developing. She agreed contractures were considered avoidable, if those types of interventions weren't being implemented on a routine basis. 2. Review of the medical record for Resident #5 revealed an admission date of 07/06/20 with diagnoses including metabolic encephalopathy, unspecified dementia without behavioral disturbance and depression. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365998 If continuation sheet Page 12 of 20 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 365998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614 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 Review of the admission nursing assessment, dated 07/07/20 for Resident #5 revealed no impairment with range of motion to the left upper extremity including the shoulder, elbow, wrist and hand. Level of Harm - Actual harm Residents Affected - Few Review of the Occupational Therapy (OT) notes and OT plan of care revealed Resident #5 received OT services from 07/07/20 through 08/04/20 to increase bilateral upper extremity strength to facilitate participation in activities of daily living. The assessment, dated 07/07/20 revealed the resident had range of motion within functional limits to left hand with no diagnosis of left hand contracture. Review of the OT services provided 01/11/21 through 02/08/21 revealed the resident was seen to increase bilateral upper extremity strength to facilitate participation in activities of daily living/self care tasks and to increase metacarpophalangeal joint of the hand extension to increase functional abilities. The assessment, dated 01/11/21 revealed the resident had range of motion within functional limits to the left hand and no diagnosis of left hand contracture. Review of the OT services provided 05/26/21 through 07/22/21 revealed the resident was seen to increase active range of motion to left middle finger and left ring finger to improve dexterity skills and improve function grasp/release skills. The OT notes revealed the resident would safely wear a hand roll on the left fingers and hand for up to four hours daily. A diagnosis of contracture to the left hand was first noted on 05/26/21. The assessment dated [DATE] revealed the resident had impaired range of motion to left hand. Review of the annual MDS 3.0 assessment, dated 07/14/21 revealed Resident #5 was cognitively impaired and was totally dependent on staff for personal hygiene needs and bathing. The resident was receiving occupational therapy services three to five times per week and was not identified to have limited range of motion to bilateral upper extremities including shoulder, elbow, wrist or hand. Review of a Restorative Nursing Communication form for Resident #5 dated 07/22/21 recommended left upper extremity hand roll, four hours on, four hours off as tolerated. Review of the 10/2021 physician orders for Resident #5 revealed there were no orders for restorative nursing care or a device to the left hand to prevent decreased range of motion or contracture. Observations on 10/12/21 and 10/13/21 at various times including on 10/12/21 at 11:05 A.M. and 2:03 P.M. and on 10/13/21 at 8:01 A.M. and 11:15 A.M. revealed the resident's left hand was contracted with very limited range of motion. The resident was not observed with a hand splint, hand roll or device in place to prevent further decline during any of the observations made. On 10/12/21 at 12:48 P.M. interview with the Assistant Director of Nursing (ADON) revealed the communication form from therapy for restorative nursing care would be given to the ADON, who would write the order and inform the restorative STNA of the orders. The ADON confirmed there was no order in Resident #5's medical record for restorative nursing care or splint to left hand. An interview on 10/13/21 at 8:07 A.M. with Licensed Practical Nurse (LPN) # 102 confirmed Resident #5's left hand was contracted and the resident did not have a splint, hand roll or device in place to prevent further decline. An interview on 10/13/21 at 8:18 A.M. with Occupational Therapist (OT) #164 revealed the resident was discharged from therapy approximately two months ago and was placed on a restorative program for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365998 If continuation sheet Page 13 of 20 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 365998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614 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 a hand roll to be in place every four hours as tolerated. OT #164 confirmed the resident did not have a contracture of the left hand upon admission to the facility but had subsequently developed the contracture. Level of Harm - Actual harm Residents Affected - Few On 10/13/21 at 10:35 A.M. interview with STNA #145 revealed Resident #5 was to receive restorative care daily including range of motion to hands and apply a left hand splint/brace. However, the STNA could not find a hand roll or splint in the resident's room at that time. A review of the facility's policy on Restorative Nursing Services, revised July 2017 revealed residents would receive restorative nursing care as needed to help promote optimal safety and independence. Restorative nursing care consisted of nursing interventions that may or may not be accompanied by formalized rehabilitation services (e.g., physical, occupational or speech therapies). Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. Restorative goals and objectives were individualized and resident-centered, and were outlined in the resident's plan of care. Restorative goals may include supporting and assisting the resident in developing, maintaining, or strengthening his/ her physiological and psychological resources. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365998 If continuation sheet Page 14 of 20 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 365998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614 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 and interview the facility failed to have ensure psychoactive medications were justified and administered to residents only with an acceptable clinical indication for use. This affected two residents (#36 and #19) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of the medical record for Resident #36 revealed an admission date of 06/04/21 with diagnoses including anxiety, depression and dementia without behavioral disturbances. Review of the plan of care for Resident #36, dated 06/16/21 revealed the resident used psychotropic medication. Review of the interventions revealed no evidence of non pharmacological approaches for staff to attempt prior to medication administration or when the resident had signs and symptoms of anxiety. Review of the physician's orders for Resident #36 revealed an order, dated 06/27/21 for the anti-psychotic medication, Risperidone 0.5 milligrams (mg) by mouth two times daily for anxiety. Review of the pharmacy recommendation, dated 07/20/21 revealed a recommended dose reduction of the resident's psychotropic medications, including Risperidone. The physician declined, stated the resident came to the facility on the medications and was still adjusting to the environment. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 09/21/21 revealed Resident #36 was cognitively impaired with trouble sleeping, tiredness and a poor appetite. The MDS revealed the resident had no behaviors. The MDS revealed the resident received antianxiety and antidepressant medications. Interview on 10/14/21 at 10:11 A.M. with the Assistant Director of Nursing (ADON) revealed Resident #36 was not receiving psychiatric care services and there was no plan of care in place to provide any type of non pharmacological interventions for the resident's diagnosis of anxiety. The ADON revealed the physician had signed off on the use of Risperidone for the resident's diagnosis of anxiety and would not confirm that anxiety was not a justified diagnosis for the routine administration of the anti-psychotic medication. Interview on 10/14/21 at 1:14 P.M. with State Tested Nursing Assistant (STNA) #145 revealed Resident #36 had not had any behaviors or symptoms of anxiety in the last two weeks. STNA #145 said when Resident #36 was first admitted to the facility she would have episodes of anxiety and the staff would talk to her, offer food and or fluids to calm her down. Interview on 10/14/21 at 1:10 P.M. with STNA #148 revealed when Resident #36 was first admitted she would become anxious, cry and wring her hands. The STNA said the staff would try to calm the resident by talking with her, offering food or addressing toileting needs. The STNA stated she would document this information in the task section on the electronic kiosk for the resident. 2. Review of Resident #19's medical record revealed an original admission date of 08/25/20 with diagnoses including Parkinson's disease, muscle weakness, depression, dementia, anxiety, COVID-19, cognitive communication deficit, hypertension, Alzheimer's dementia, hyperlipidemia, cellulitis and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365998 If continuation sheet Page 15 of 20 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 365998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614 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 edema. Level of Harm - Minimal harm or potential for actual harm Review of the resident's quarterly MDS 3.0 assessment, dated 08/13/21 revealed the resident had unclear speech, rarely/never understood others, rarely/never made himself understood and had severe cognitive deficit. Residents Affected - Few Review of current physician's orders revealed Resident #19 was receiving Seroquel 50 mg, one tablet by mouth daily for unspecified dementia and Seroquel 25 mg, one tablet by mouth daily for Alzheimer's dementia. These medications were ordered on 07/19/21 and 07/27/21 respectively. Interview with the Director of Nursing on 10/13/21 at 11:02 A.M. verified Resident #19 was currently receiving two doses of an antipsychotic for a diagnosis of dementia with behavioral disturbance and Alzheimer's dementia. The Director of Nursing verified these are not appropriate medications for these diagnoses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365998 If continuation sheet Page 16 of 20 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 365998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614 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 record review, facility policy and procedure review and interview the facility failed to ensure laboratory testing was obtained as ordered for Resident #12. This affected one resident (#12) of five residents reviewed for unnecessary medication use. Residents Affected - Few Findings include: Review of Resident #12's medical record revealed an original admission date of 12/26/19 with the latest readmission of 04/13/21. Resident #12 had diagnoses including major depressive disorder, muscle wasting, schizophrenia, peripheral vascular disease, stiffness of joint, diabetes mellitus, anxiety disorder, COVID-19, dysphagia, atrial fibrillation, seizures, hyperlipidemia, chronic kidney disease, gastroesophageal reflux disease and hypertension. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/21/21 revealed the resident had clear speech, understood others, usually made himself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of three. Review of the resident's monthly physician's orders for October 2021 identified an order (initiated 06/24/21) for laboratory testing; a complete blood count (CBC), basic metabolic panel (BMP) and HgbA1c every three months in March, June, September and December. Review of the medical record revealed no documented evidence the physician ordered CBC, BMP and HgbA1c were obtained as ordered. On 10/14/21 at 10:59 A.M. interview with Licensed Practical Nurse (LPN) #102 verified the September 2021 physician ordered CBC, BMP and HgbA1c were not completed as ordered. Review of the facility policy titled, Lab and Diagnostic Test Results, dated 11/2018 revealed the physician would identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff would process test requisitions and arrange for tests. The laboratory, diagnostic radiology provider or other testing source would report test results to the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365998 If continuation sheet Page 17 of 20 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 365998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614 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, record review, facility policy and procedure review and interview the facility failed to ensure appropriate personal protective equipment (PPE) was worn by nursing staff when providing direct care to Resident #340, who was on droplet precautions for a 14 day quarantine period for COVID-19 following a recent admission. They also failed to ensure nursing staff properly disinfected their face shields when leaving the resident's room before moving on to provide care to other residents to prevent the potential spread of COVID-19. This had the potential to affect all 37 residents residing in the facility. Residents Affected - Many Findings include: A review of Resident #340's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy, abnormalities of gait and mobility, unsteadiness on feet and osteoarthritis. A review of Resident #340's active physician's orders revealed an order for droplet precautions for COVID-19 for 14 day monitoring every shift for 14 days. The order was initiated on 10/06/21 and was to end on 10/20/21. On 10/12/21 at 11:49 A.M. an observation during the dining process for the lunch meal revealed Resident #340 was served her lunch tray by State Tested Nursing Assistant (STNA) #143. STNA #143 had applied all the appropriate PPE equipment (N95 mask, gown, gloves and face shield) and provided set up help to the resident who was initially going to eat her meal while sitting up in bed. STNA #143 was noted to remove her disposable gloves and washed her hands in the resident's bathroom before she prepared to exit the room. As she was heading towards the resident's door to exit, the resident verbalized the desire to eat her meal while sitting up in her wheelchair. STNA #143 proceeded to assist the resident out of her bed and into her wheelchair for her meal as the resident requested. STNA #143 failed to apply a new pair of disposable gloves before assisting the resident into her wheelchair. The STNA was observed to come into contact with the resident, her wheelchair, the bedside table, the resident's oxygen tubing and the resident's call light with her ungloved hands. She did finish removing her PPE, after she assisted the resident, and disinfected her hands with hand sanitizer before leaving the resident's room. STNA #143 did not disinfect her face shield upon leaving the room and was proceeding down the hall to assist passing trays to other residents on the hall. The PPE cart in the hall outside of Resident #340's room did not have disinfectant wipes present on top of the cart or in one of it's drawers. Findings were verified by STNA #143. On 10/07/21 at 11:59 A.M., an interview with STNA #143 confirmed she did not apply a new pair of disposable gloves, when Resident #340 asked for additional assistance to get up in her wheelchair for her meal, after she had already removed her gloves. She acknowledged she touched the resident, her wheelchair, the bedside table, oxygen tubing and call light with her ungloved hands. She agreed she should have applied a new pair of gloves when the resident requested additional direct care. She also acknowledged she was not observed to disinfect her face shield with a disinfectant wipe after leaving the resident's room before heading down the hall to assist other residents during the meal service. She stated she knew she should disinfect her face shield when leaving the room of a resident on droplet precautions as part of a 14 day quarantine for COVID-19 following a new admission. She reported the PPE cart in the hall did not include disinfectant wipes to be used. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365998 If continuation sheet Page 18 of 20 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 365998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614 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 A review of the facility undated COVID-19 guidelines revealed there were guidelines for providing care to new residents that were within the stated quarantine period. Once residents were placed in isolation, they were to ensure adherence to standard, contact and airborne precautions while providing any care needs. Under PPE, eye protection was to be worn in areas indicated. Face shields should be cleaned after caring for each resident. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365998 If continuation sheet Page 19 of 20 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 365998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holzer Senior Care Center 380 Colonial Drive Bidwell, OH 45614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on record review, review of Food and Drug Administration (FDA) information, review of a HealthDay News Study and interview the facility failed to provide adequate justification for the use of antibiotics for those residents who tested positive for the COVID-19 virus. This affected 21 residents (#6, #7, #8, #17, #23, #26, #28, #29, #30, #32, #39, #41, #35, #39, #40, #241, #242, #243, #244, #245, #249) of 27 residents prescribed antibiotics. The facility census was 37. Residents Affected - Some Findings include: Review of Resident #6, #7, #8, #17, #23, #26, #28, #29, #30, #32, #39, #41, #35, #39, #40, #241, #242, #243, #244, #245 and #249's medical records, dated 12/01/20 to 01/31/21 revealed each residents had been prescribed and administered Azithromycin (an antibiotic used to treat bacterial infections) after testing positive for COVID-19 virus. When reviewing these resident's medical records at the time the antibiotic were initially ordered, there was no evidence to support McGeer's criteria had been met indicating an infection was present for the antibiotics to be prescribed and administered. On 10/14/21 at 1:57 P.M. interview with the Director of Nursing (DON) revealed the facility medical director (MD) had prescribed all residents who tested positive for the COVID-19 virus the antibiotic Azithromycin. Review of information on the FDA website (https://www.fda.gov) revealed the following FDA response to the question, Are antibiotics effective in preventing or treating COVID-19? No. Antibiotics do not work against viruses; they only work on bacterial infections. Antibiotics do not prevent or treat COVID-19, because COVID-19 is caused by a virus, not bacteria. Some patients with COVID-19 may also develop a bacterial infection, such as pneumonia. In that case, a health care professional may treat the bacterial infection with an antibiotic. In addition, an article from HealthDay News, dated 08/04/20 revealed the following: Early in the U.S. coronavirus pandemic, many people landing in the hospital may have been given unnecessary antibiotics, a new study suggests. The findings come from one of the hard-hit hospitals in New York City, the initial epicenter of the U.S. pandemic. Researchers there found that of COVID-19 patients admitted between March and May, just over 70% were given antibiotics. That's despite the fact that COVID-19 is caused by a virus, and very few of those patients actually had a coexisting bacterial infection. Antibiotics kill bacteria, but are useless against viral infections such as the common cold, the flu and COVID-19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365998 If continuation sheet Page 20 of 20