Health inspection·February 13, 2019

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #87's privacy was maintained during an insulin injection. This affected one resident (Resident #87) of two residents observed during insulin injection administration. Residents Affected - Few Findings include: Record review revealed Resident #87 was admitted to the facility on [DATE] with diagnoses including vascular dementia and aphasia. Record review revealed the resident was not interviewable due to her cognitive deficits and diagnoses. During an observation of medication administration with Licensed Practical Nurse (LPN) #460 on 02/11/19 at 5:12 P.M., LPN #460 prepared two insulin injections for Resident #87. Her room was very close to the nurse's station and as LPN #460 turned from the medication cart, Resident #87's roommate was trying to enter the room in her wheelchair. She was assisted into the room by an unidentified nurse who stayed in the room briefly to talk with the roommate. Several other staff members were directly outside the resident's door, speaking with another resident. LPN #460 commented on the number of people in the hall as she entered Resident #87's room with the insulin injections. Upon entering the room, Resident #87 was observed in a wheelchair in direct view of the door. LPN #460 entered the room, and did not pull a privacy curtain or close the door. She pulled up the resident's top and pulled her elastic waist pants down slightly, and gave the injections. The procedure was visible to anyone in the hall, based on the location of the resident in the wheelchair. LPN #460's body did not obscure the procedure when she was giving the injections. After leaving the room, LPN #460 verified that she had not provided privacy for Resident #87 during the injections. An interview with assistant director of nursing, Registered Nurse (RN) #470 on 02/11/19 at 5:45 P.M. confirmed LPN #460 should have provided privacy for Resident #87 prior to giving the insulin injections. Review of the facility undated policy on subcutaneous injections revealed that privacy should be provided prior to completing an injection procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366078 If continuation sheet Page 2 of 18 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 366078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Massillon, The 2000 Sherman Circle NE Massillon, OH 44646 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were accurately coded for dialysis and antipsychotic medications for Resident #45 and related to falls for Resident #49. This affected two residents (Resident #45 and #49) of 30 residents whose assessments were reviewed. Residents Affected - Few Findings include: 1. Record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses of end stage renal disease, atrial fibrillation, malignant neoplasm of the breast, acute respiratory failure with hypoxia, hypertension, dependence on renal dialysis, gastro-esophageal reflux disease, major depressive disorder, constipation, anorexia, nausea with vomiting, kidney failure, pleural effusion, weakness, diabetes, asthma, and anxiety. Record review revealed the resident had received hemodialysis treatments. Review of a physician's orders, dated 11/27/18 revealed Resident #45 was to receive hemodialysis on Monday, Wednesday, and Friday. Review of a physician's orders, dated 11/27/18 revealed Resident #45 was to receive Zyprexa five milligrams twice a day for chemotherapy related nausea. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident#45 had intact cognition and did not receive dialysis. Further review of the MDS assessment revealed in section N0410 Resident #45 had been coded as receiving an antipsychotic medication for six days, however section N0450 on the MDS indicated Resident #45 had not received an antipsychotic medication since the last review date. An interview on 02/13/19 at 10:12 A.M. with Registered Nurse #452 revealed Resident#45 was receiving hemodialysis at the time of the assessment and the MDS was coded incorrectly, she indicated she had done a modification. During the interview Registered Nurse #452 also indicated Resident #45 was receiving an antipsychotic medication at the time of the assessment and the MDS was coded incorrectly, she indicated she had done a modification. 2. Review of Resident #49's medical record revealed the resident was admitted to the facility on [DATE] after hip surgery for a fracture, dementia, anxiety and unsteadiness on his feet. Review of the record revealed Resident #49 sustained falls on 11/03/18, 11/16/18, 12/04/18 and 12/12/18. The fall on 12/12/18 resulted in back pain. Review of the resident's MDS 3.0 assessment revealed a Medicare 60 day assessment dated [DATE]. The assessment indicated the resident had not had a fall since the last assessment (10/16/18 which was a Medicare 30 day assessment). Review of the next assessment that addressed resident falls, a Medicare 90 day assessment dated [DATE], revealed the resident had only had one fall since the last assessment, and the fall was not marked as resulting in an injury. An interview with the assessment nurse, Registered Nurse, RN #452, on 02/13/18 at 1:50 P.M. verified the above information. She verified the assessment on 11/14/18 should have recorded the fall on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366078 If continuation sheet Page 3 of 18 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 366078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Massillon, The 2000 Sherman Circle NE Massillon, OH 44646 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 0641 Level of Harm - Minimal harm or potential for actual harm 11/03/18, which did not have an injury. She also indicated the assessment completed on 12/18/18 should have recorded three falls, 11/16/18, 12/04/18 and 12/12/18) and although two falls did not have injury reported or observed, the fall on 12/12/18 did result in pain, which would have been recorded as a fall with injury. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366078 If continuation sheet Page 4 of 18 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 366078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Massillon, The 2000 Sherman Circle NE Massillon, OH 44646 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observations on 02/10/19 at 9:13 A.M. and 2:23 P.M. and on 02/12/19 at 11:53 A.M. revealed Resident #102 was observed to have long, ragged and unclean fingernails. The resident's right hand was observed to be flaccid (limited movement) and her right hand nails were observed to be starting to dig into the palm of her right hand. Residents Affected - Few An interview on 02/12/19 at 11:53 A.M. with Resident #102 revealed it had been awhile since her nails had been cut and they needed to be trimmed. An interview on 02/12/19 at 11:57 A.M. Licensed Practical Nurse (LPN) #300 revealed the nursing assistants were to trim the resident's nails when providing showers unless the resident had diabetes and then the nurses were to trim the nails. An interview on 02/12/19 at 12:00 P.M. with State Tested Nursing Assistant (STNA) #312 revealed activity staff would trim the resident's nails on nail days. She stated the STNA staff very rarely cut nails unless they were long, and the nurses do the nails of the residents who had diabetes. An interview on 02/12/19 at 1:10 P.M. with the Director of Nursing revealed there was not a specific day or time the resident's fingernails were to be trimmed, it was done as needed by the nurses. The STNA staff could file and clean the nails but not trim the nails. During an interview on 02/12/19 at 1:30 P.M. with LPN #300, the LPN indicated there was no documentation of Resident #102 having her fingernails trimmed. Observation of Resident #102 at the time of interview verified the resident's nails were long, ragged, and dirty and also noted the nails on the resident's right hand had the potential to be digging into the palm of her hand. LPN #300 verified Resident #102 required staff assistance to clean and cut/trim her fingernails. Based on observation, record review and interview the facility failed to ensure Resident #103, who required extensive assistance from staff for toileting received adequate and timely assistance to the bathroom and failed to ensure Resident #102, who required staff assistance for activities of daily living was provided adequate and timely nail care. This affected two residents (Resident #102 and #103) of two residents reviewed for activities of daily living. Findings include: 1. Review of Resident #87's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including hypertension, muscle weakness, abnormal posture and unsteadiness on her feet. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was moderately cognitively impaired and required extensive assistance from two staff for her activities of daily living including bed mobility, transfers and toileting. The assessment revealed she was frequently incontinent of bowel and bladder. An observation and interview with Resident #103 at 11:55 A.M. on 02/10/19 revealed the resident was sitting in her wheelchair in her room, socializing with her roommate. Both residents were alert and oriented, said they ate lunch in their room and were waiting for their lunch trays. Resident #103 said she had asked a staff person about 25 minutes ago for help to go to the bathroom but the staff member had said she had to get the sit to stand to stand lift and would come back with it, since it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366078 If continuation sheet Page 5 of 18 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 366078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Massillon, The 2000 Sherman Circle NE Massillon, OH 44646 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was not in the hall. Resident #103 said the staff member had not returned and she had waited about 25 minutes. The resident's roommate verified the conversation and the time frame since the request was made, and said to the resident if I were you, I would call again, she probably forgot. The surveyor left the room and observed the sit to stand lift sitting in the hall about four doors away. There were no staff in the hall. At 12:09 P.M., a meal cart arrived from the kitchen and two staff members began passing trays to residents in their rooms. Resident #103 and her roommate were the last residents served meals on the hall, and a State Tested Nursing Assistant (later identified as STNA #400) was noted to take a tray into the room for Resident #103. She spoke briefly with the resident, but the surveyor could not hear the conversation. After the STNA left, the surveyor entered the room and Resident #103 said the STNA who brought her lunch was the staff member who had answered her call light earlier. The STNA said she forgot to come back because the trays had come and that she would come back to help the resident to the bathroom after she ate her lunch. The resident said she hoped she could wait that long but also did not want her food to get cold. STNA #400 was observed coming out of a resident room on 02/10/19 at 12:20 P.M. She verified she had answered a call light for Resident #103 earlier and although the resident said she needed to use the bathroom, the sit to stand lift was being used by another resident. She said she meant to come back after the lift was free but lost track of time and then the resident trays came. She verified the resident asked about going to the bathroom when she passed the tray to her and she said she would come back later. She was not sure of the amount of time that had passed since the first request, but said it was possible the resident had requested to use the bathroom around 11:30 A.M., which would be about 50 minutes that the resident had waited. She said she would go to the resident's room after speaking with the surveyor to see if the resident wanted to use the bathroom even though she had her meal already. An interview with the director of nursing on 02/13/19 at 4:30 P.M. revealed she would expect a resident's toileting needs to be met in a timely manner. She was unable to state how quickly a resident should be helped after requests were made, but she did verify waiting 50 minutes to use the bathroom was too long. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366078 If continuation sheet Page 6 of 18 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 366078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Massillon, The 2000 Sherman Circle NE Massillon, OH 44646 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure all falls were thoroughly investigated and failed to ensure comprehensive, individualized and effective fall/safety interventions and increased supervision were in place to prevent falls for Resident #49. The facility also failed to ensure a treatment cart, containing medications and treatment supplies was securely locked when unattended by staff. This affected one resident (Resident #49) of three residents reviewed for falls and had the potential to affect 20 residents, Resident #97, #98, #53, #82, #5, #108, #107, #77, #50, #32, #37, #26, #34, #58, #36, #39, #85, #30, #49 and #17 identified by the facility to be cognitively impaired and independently mobile. The facility census was 109. Findings include: 1. Review of Resident #49's medical record revealed the resident was admitted to the facility on [DATE] after hip surgery for a fracture, dementia, anxiety and unsteadiness on his feet. Record review revealed a fall care plan, dated 09/19/18 and updated through 03/27/19 revealed the resident was at risk for falls due to impaired mobility, potential for fluctuations in blood sugars, impaired cardiovascular status and use of psychotropic medications. Review of a nursing note, dated 11/03/18 at 6:08 P.M. revealed the resident was found on the bathroom floor by a State tested nursing assistant. The call light was within reach but was not on. The resident had not been injured. The facility would not allow the surveyor to independently review the incident report/fall investigation, but the director of nursing (DON) reviewed falls with the surveyor on 02/12/19 at 4:15 P.M. The director of nursing indicated the interventions to prevent future falls after the incident included leaving a urinal at the bedside and starting the resident on a toileting program. Review of a physician's order dated 11/05/18 revealed the resident had been ordered a toileting program which included to toilet the resident upon rising, before and after meals, before bed and as needed. She revealed the investigation did not indicate when the resident had last been taken to the bathroom. Review of a nursing note dated 11/16/18 at 2:31 P.M. revealed the resident was found on the floor in his bedroom beside the bed, with the floor wet with urine. The note indicated the resident said he wanted to go to bed. The resident was not injured. During the interview with the director of nursing on 02/12/19 at 4:15 P.M., the DON indicated the fall had actually occurred at 11:50 A.M. on 11/16/18 and interventions to prevent future falls after the incident included offering to lay the resident down between activities. She revealed the investigation did not indicate when the resident had last been taken to the bathroom even though the resident was found incontinent of urine and the intervention after the previous fall had been to put the resident on a toileting plan. Review of a nursing note dated 12/04/18 at 4:14 P.M. revealed the resident was found on the floor at the bedside. The note indicated he had been in the wheelchair prior to the fall and had attempted to transfer himself into bed. The note indicated the resident's foot was under the edge of the mat, but he did not have an injury. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366078 If continuation sheet Page 7 of 18 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 366078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Massillon, The 2000 Sherman Circle NE Massillon, OH 44646 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During the interview with the director of nursing on 02/12/19 at 4:25 P.M., the DON revealed the resident had not used his call light, although his call light would have been near his bed, with a blue mat also near his bed, which the resident apparently tripped over. The director of nursing stated the physician ordered a urine specimen, which was negative. She stated the interventions included changing the blue mat to a gray mat, which was more secure to the floor. She verified the mat was ordered on 11/19/18 to be in place when the resident was in bed to prevent injury. She verified the resident had been in the wheelchair and the mat on the floor actually was a tripping hazard to the resident and his roommate and should have been stored off the floor when he was not in bed. A nursing note dated 12/12/18 at 1:48 P.M. revealed at 10:45 A.M., the resident attempted to stand at the sink in the bathroom, and when he started to sit back down, he missed his chair, causing him to sit on the floor. The note indicated he had been assisted to the bathroom [ROOM NUMBER] minutes prior and although he initially stated he was not injured, later complained of back pain. During the interview with the director of nursing on 02/12/19 at 4:30 P.M., the DON verified the resident required the extensive assistance of two staff to use the bathroom and to transfer. She stated the intervention for the fall was to put a faucet extender in place so the resident could wash his hands at the sink without standing up. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively impaired, unsteady on his feet and required the extensive assistance of two staff for bed mobility, transfers and using the bathroom Review of a nursing note dated 02/03/19 at 3:43 P.M. revealed the resident was found sitting on the floor in the lobby of the unit. He stated he was trying to transfer from his wheelchair to another chair. The resident was not injured and the fall was not witnessed. During the interview with the director of nursing on 02/12/19 at 4:37 P.M., the DON revealed the above fall happened at 8:45 A.M. She stated the intervention was to order a cushion for the resident's chair, so he would be more comfortable sitting in his wheelchair, instead of wanting to transfer to one of the padded chairs in the unit lobby area. Review of the resident's falls revealed there was no evidence of increased supervision by staff to prevent future falls, despite the fact the resident's falls were unwitnessed. An observation of the faucet extender with the director of nursing on 02/13/19 at 3:00 P.M. revealed the extender allowed the water to flow closer to the edge of the sink but did not affect the distance the resident needed to reach to turn the faucet on. The director of nursing stated the resident was able to wheel his chair under the sink and turn on the faucet even prior to the fall. She verified she was not sure why he was standing at the sink and fell on [DATE] and that the investigation did not provide evidence of why the resident was in the bathroom when staff had just taken him there several minutes prior. She also verified the intervention, the faucet extender, did not specifically address the reason for the fall based on the information in the investigation. 2. An observation on 02/10/19 at 8:00 A.M. revealed a treatment cart was observed on the 300 unit located in the hallway unlocked without a staff member close by. The contents inside the treatment cart included the following: numerous dressing and bandages (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366078 If continuation sheet Page 8 of 18 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 366078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Massillon, The 2000 Sherman Circle NE Massillon, OH 44646 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 three one ounce tubes of petroleum jelly Level of Harm - Minimal harm or potential for actual harm three one ounce tubes of hydrocortisone cream one one ounce tube of bacitracin Residents Affected - Some two one and half ounce tubes of Silvasorb two three ounce tubes of Silvasorb 19 single packs of sani wipes with bleach Three 28 milliliter bottles of skin prep Two eight-ounce bottles of wound cleaner One 16-ounce bottle of isopropyl rubbing alcohol 70 percent (the bottle contained warnings related to if the solution was swallowed) Review of the Material Safety Data Sheet related to 70 percent isopropyl rubbing alcohol revealed if swallowed, call a physician immediately. Rinse mouth and throat thoroughly with water. Do not induce vomiting unless directed to do so by a physician. Handling and storage information included: do not ingest, do not breathe, avoid contact with the eyes, if ingested seek medical advice immediately. Review of the facility policy titled Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles revealed the community should ensure all medications and biologicals, including treatment items, were securely stored in a locked cabinet/cart or locked medication room, inaccessible by residents and visitors. An interview on 02/10/19 at 8:00 A.M. Licensed Practical Nurse #320 verified the treatment was unlocked and should had been locked. The facility identified 20 residents, Resident #97, #98, #53, #82, #5, #108, #107, #77, #50, #32, #37, #26, #34, #58, #36, #39, #85, #30, #49 and #17 who were cognitively impaired and independently mobile. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366078 If continuation sheet Page 9 of 18 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 366078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Massillon, The 2000 Sherman Circle NE Massillon, OH 44646 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure weight monitoring was completed as ordered for Resident #45 who received hemodialysis. This affected one resident (Resident #45) of three residents reviewed for dialysis. Residents Affected - Few Findings include: Review of Resident #45's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of end stage renal disease, atrial fibrillation, malignant neoplasm of the breast, acute respiratory failure with hypoxia, hypertension, dependence on renal dialysis, gastro-esophageal reflux disease, major depressive disorder, constipation, anorexia, nausea with vomiting, kidney failure, pleural effusion, weakness, diabetes, asthma, and anxiety. Review of a physician's order, dated 11/27/18 revealed Resident #45 was to have her weight done prior to dialysis days on Monday, Wednesday, and Friday. Weights were to be done pre-dialysis on Tuesday, Thursday, and Sunday. Review of the December 2018 Medication Administration Record (MAR) revealed no documentation of pre-dialysis weights as ordered on 12/16/18, 12/18/18, and 12/23/18. Review of the January 2019 MAR revealed no documentation of pre-dialysis weights as ordered on 01/17/19, 01/22/19, 01/24/19, and 01/31/19. An interview on 02/13/19 at 12:06 P.M. the Director of Nursing verified Resident #45's weights had not been obtained as ordered on 12/16/18, 12/18/18, 12/23/18, 01/17/19, 01/22/19, 01/24/19, and 01/31/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366078 If continuation sheet Page 10 of 18 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 366078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Massillon, The 2000 Sherman Circle NE Massillon, OH 44646 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to timely address a pharmacy recommendation for Resident #45. This affected one resident (Resident #45) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #45's medical record revealed the resident was admitted to the facility on [DATE] with the diagnoses of end stage renal disease, atrial fibrillation, malignant neoplasm of the breast, acute respiratory failure with hypoxia, hypertension, dependence on renal dialysis, gastro-esophageal reflux disease, major depressive disorder, constipation, anorexia, nausea with vomiting, kidney failure, pleural effusion, weakness, diabetes, asthma, and anxiety. Review of the physician's order, dated 11/28/18 revealed Resident #45 had an order for 400 milligrams of Amiodarone HCL once daily for atrial fibrillation. Review of a pharmacy recommendation dated 12/07/18 revealed the pharmacist indicated Resident #45 had been receiving Amiodarone 400 milligrams every day since 11/26/18 and this was a higher than recommended maintenance dose. The pharmacist recommended decreasing the Amiodarone to 100 milligrams daily and to monitor the residents blood pressure and apical pulse weekly. The rational for the recommendation was due to Amiodarone had a boxed warning about substantial toxicities and the inappropriate dosing of amiodarone could lead to life threatening adverse effects. Record review revealed the recommendation was not addressed until 02/01/19 by the Certified Nurse Practitioner (CNP). Review of a physician's telephone order dated 02/01/19 revealed the CNP wrote an order for the cardiologist be notified regarding the pharmacy recommendation to decrease Resident #45's Amiodarone due to currently being on a higher than recommended maintenance dose. An interview on 02/13/19 at 9:08 A.M. with the Director of Nursing (DON) revealed pharmacy recommendations were to be addressed as soon as possible but no later than two weeks. She verified Resident #45's pharmacy recommendation dated 12/07/18 had not been addressed by the CNP until 02/01/19 at which time it was referred to the cardiologist. However, there was no written evidence the cardiologist had been notified or contacted as of this date. During an interview on 02/13/19 at 1:30 P.M. the DON indicated the cardiologist had been notified of the recommendation and they were waiting on a return call. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366078 If continuation sheet Page 11 of 18 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 366078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Massillon, The 2000 Sherman Circle NE Massillon, OH 44646 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #49's medial record revealed the resident was admitted to the facility on [DATE] after hip surgery for a fracture, dementia, anxiety and unsteadiness on his feet. Residents Affected - Few Review of the resident's physician orders for January 2019 revealed on 01/10/19, the physician ordered the resident's blood pressure and pulse to be checked prior to administration of Metoprolol, a blood pressure medication. The medication was to be held if the resident's diastolic blood pressure was less than 60. Review of the medication administration record revealed the resident's blood pressure was 106/54 on 01/13/19 and 106/45 on 02/04/19 prior to the 8:00 A.M. dose, but the medication was marked as administered. The record also did not indicate the resident had his blood pressure checked or received the Metoprolol on 01/29/19. Further review of the resident's record revealed a pharmacy recommendation dated 01/18/19, which indicated correctly that the resident was ordered routine doses of Tylenol 1000 milligrams (mg) twice a day as well as a routine dose of Percocet, a narcotic pain medication which contained 325 mg of Tylenol to be given at a dose of two tablets at bedtime, for another dose total of 650 mg of Tylenol. The pharmacy recommendation also correctly identified the resident had orders for Tylenol 650 mg every six hours as needed and that he could have two tablets of Percocet as needed every four hours for pain. The recommendation indicated the maximum recommended dose of Acetaminophen (Tylenol) should be 3000 mg per day, to prevent serious liver injury. Review of physician orders revealed the routine Tylenol dose order was modified on 01/28/19 to indicate the maximum dose of 3 gms (grams or 3000 mg) every 24 hours. Review of the medication administration record revealed the resident received an as needed dose of Percocet on 02/03/19, which would have provided a total Acetaminophen dose for that day of 3300 milligrams. An interview with the assistant director of nursing, Registered Nurse (RN) #470, on 02/12/19 at 3:30 P.M. verified the above concerns about the resident's blood pressure and Metoprolol administration. She also verified the resident had received over the recommended dose of acetaminophen on 02/03/19 and the order for the maximum dose was not written clearly, as it was only marked on the routine Tylenol order. She verified any nurse who would consider giving the resident an as needed dose of Acetaminophen would not see the order for the maximum dose recommendation. Based on record review and interview the facility failed to ensure parameters for blood pressure monitoring were followed related to medication administration for Resident #45 and Resident #49 and failed to ensure Resident #49 did not receive more than the maximum dosage of Acetaminophen in a 24 hour period. This affected two residents (Resident #45 and #49) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #45's medical record revealed the resident was admitted to the facility on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366078 If continuation sheet Page 12 of 18 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 366078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Massillon, The 2000 Sherman Circle NE Massillon, OH 44646 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few [DATE] with diagnoses of end stage renal disease, atrial fibrillation, malignant neoplasm of the breast, acute respiratory failure with hypoxia, hypertension, dependence on renal dialysis, gastro-esophageal reflux disease, major depressive disorder, constipation, anorexia, nausea with vomiting, kidney failure, pleural effusion, weakness, diabetes, asthma, and anxiety. Review a physician's order dated 01/31/19 revealed Resident #45 had an order for 12.5 milligrams of Metoprolol Tartrate at bedtime daily and give another daily dose every Sunday, Tuesday, and Thursday. The order indicated to hold the medication if the resident's systolic blood pressure (SBP) was less than 100. Review of the January 2019 Medication Administration Record (MAR) revealed the Metoprolol Tartrate for Resident #45 was not held for systolic blood pressure (SBP) less than 100 for the daily dose on 01/24/19 (SBP 97/42), for the bedtime dose on 01/01/19 (SBP 85/40) or on 01/15/19 (SBP 98/60). Review of the February 2019 MAR revealed Metoprolol Tartrate for Resident #45 was not held for SBP less than 100 for the bedtime dose on 02/01/19 (SBP 90/40). During an interview on 02/13/19 at 9:08 A.M. the director of nursing (DON) verified the Metoprolol Tartrate for Resident #45 should have been held on 01/01/19, 01/15/19, 01/24/19 and 02/01/19 for SBP less than 100. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366078 If continuation sheet Page 13 of 18 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 366078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Massillon, The 2000 Sherman Circle NE Massillon, OH 44646 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, record review and interview the facility failed to ensure pots and pans were stored in a sanitary manner to prevent contamination. This had the potential to affect all 109 residents residing in the facility. Findings include: Observation on 02/10/19 at 9:00 A.M. of the kitchen, with Certified Dietary Manager (CDM) #500 revealed there seven pots and pans that were observed to be wet on the storage rack. Interview on 02/10/19 at 9:10 A.M. with CDM #500 revealed pots and pans were not to be stacked wet and were to be air dried before putting away. CDM #500 verified the seven pots and pans as observed above had not been properly dried before being put away. Review of the facility policy, titled Dish Machine Practices, dated 04/2010 revealed dishes shall be air-dried and never stored wet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366078 If continuation sheet Page 14 of 18 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 366078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Massillon, The 2000 Sherman Circle NE Massillon, OH 44646 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 and interview the facility failed to maintain acceptable infection control practices to prevent the spread of infection during wound care for Resident #49 and Resident #27 and during medication administration for Resident #87. This affected two residents (Resident #27 and #49) of three residents reviewed for wound care and one resident (Resident #87) of two residents observed for insulin administration. Residents Affected - Few Findings include: 1. Review of Resident #49's medical record revealed the resident was admitted to the facility on [DATE] after right hip surgery. Review of the record revealed the resident developed an unstageable area to his right heel on 10/08/18 and a current treatment order, dated 01/03/19 revealed the resident was to have his right heel cleansed with normal saline, with santyl (a debriding agent) applied to wound, covered with alginate (another debriding agent) and then covered with a foam dressing every day. Review of the most recent wound measurements dated 02/07/19 revealed the wound was 0.6 centimeter wide by 0.6 centimeter long. Observation of a dressing change for Resident #49 with Registered Nurse (RN) #450 was made on 02/11/19 at 2:05 P.M. Licensed Practical Nurse (LPN) #451 was also present in the room to assist during the treatment. RN #450 had all the supplies for the dressing change in small plastic garbage bag when she entered the room and had also said she had the supplies needed to measure the wound per the surveyor's request. After cleaning the resident's bedside table and laying a clean, waterproof field, RN #450 removed items needed for the dressing change from the bag with her hands. She laid them on the clean field and after washing her hands and putting on gloves, removed the old dressing and cleansed the wound. After washing her hands again, she put on gloves and used a clear piece of plastic with a wound grid imprinted to measure the length and width of the open area. She then opened the package of the foam dressing, dropping it on the field and used the edge of the wrapper of the package, which had ruler printed on it, to measure the wound. The edge of the wrapper touched the surface of the wound. After measuring the wound area, RN #450 washed her hands and put on clean gloves. She picked up a small tube of Santyl with her right hand and opened a tongue depressor, applying a small amount of the Santyl onto the tongue depressor and then applied the Santyl to the wound. She then picked up the Calcium alginate fabric with her gloved hands, cut a piece of it with the scissors and holding the alginate in her right hand/fingers, picked up the foam dressing. She patted the alginate into the wound and covered it with the foam dressing. After completing the dressing change, RN #450 washed her hands and put on clean gloves. She put the lid on the Santyl, used a bleach wipe to clean the tube of Santyl, put it back in box which was in a zip lock bag and then using the same gloved hands, replaced the alginate back into the wrapper to be reused another time, putting it into the zip lock bag. After completing the dressing change, LPN #451 replaced the resident's socks and covered him with a blanket. Both nurses left the room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366078 If continuation sheet Page 15 of 18 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 366078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Massillon, The 2000 Sherman Circle NE Massillon, OH 44646 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview with RN #450 immediately after the dressing change, on 02/11/19 at 2:30 P.M. verified the resident's pressure area on his heel had been present since October 2018. She verified she had used a package wrapper to measure the depth of the wound for Resident #49. She also verified she had touched the calcium alginate that was applied to the wound with the same gloved hands that had touched the Santyl tube and the wrapper of the tongue depressor. Although she cleaned the tube of Santyl after the dressing change with a wipe, she verified she had touched the alginate after touching the tube, lid, and box as well as the zip lock bag that contained all the dressing supplies. She verified she could not ensure the cleanliness of the wrappers and outside of the tube and the alginate which was touched with her gloved hands after touching these items was to be put directly into the wound. Review of the facility dressing change policy, revised June 2009, revealed after washing hand, cleaning a surface for the dressing change equipment and donning gloves, dressing supplies were to be opened and placed on the surface. After the wound was cleansed, the clean dressing was to be placed over the wound, being careful not to touch the portion of the dressing that will touch the wound. 2. Record review revealed Resident #87 was admitted to the facility on [DATE] with diagnoses including vascular dementia and aphasia. Review of the record revealed the resident was ordered a routine dose of insulin, Humulin 70/30 and a sliding dose of insulin, Humalog based on a finger stick blood sugar. An observation of medication administration was conducted with LPN #460 on 02/11/19 at 5:12 P.M. for Resident #87. After checking the resident's blood sugar, LPN #460 determined that she needed to administer a sliding scale dose of insulin as well as a routine dose of insulin for that medication pass. She removed two insulin pens from the medication cart drawer and removed the caps from the pens. She attached a needle from a sterile package to each of the pens and drew up the amount of insulin required. She did not cleanse the insulin pens prior to attaching the needles. After completing the medication pass, LPN #460 was asked if the pens should be cleaned before putting the needle on the end to administer insulin. She stated that she should have cleaned the end of the pen with an alcohol pad, but verified she had not done this. Review of the undated facility policy on subcutaneous injections, revealed before drawing up medication from a multi-use vial, such as the insulin vial, the vial's rubber stopper should be cleaned with an antiseptic pad using friction and then allowed to dry. An interview with the facility assistant director of nursing, RN #470, on 02/11/19 at 5:45 P.M. confirmed the insulin vial should have been cleaned with alcohol prior to withdrawing the insulin from the vial. 3. Record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, hypothyroidism, gastro-esophageal reflux disease, major depressive disorder, hypertension, anxiety disorder, diabetes, right foot contracture, right knee pain, Vitamin D deficiency, visual field defects, abnormal posture, feeding difficulties, and left-hand contracture. Review of a significant change Minimum Data Set (MDS) 3.0 assessment revealed Resident #27 had severely impaired cognition, required total to extensive assist from staff for all activities of daily living and had a Stage III pressure ulcer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366078 If continuation sheet Page 16 of 18 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 366078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Massillon, The 2000 Sherman Circle NE Massillon, OH 44646 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a physician's order, dated 01/21/19 revealed Resident #27 had an order to cleanse her coccyx with Dermal Wound Cleanser (DWS) and pat dry, apply silver AG to the wound bed, cover with a border foam dressing. The dressing was to be changed every seven days and as needed. An observation of incontinence care on 02/11/19 at 2:04 P.M. revealed Resident #27 had soiled the dressing to her coccyx with feces. State Tested Nursing Assistant (STNA) #312 provided incontinence care with no concerns. STNA #312 had asked LPN #310 to change Resident #27's dressing because it had become soiled with feces. STNA #312 had not cleaned the over-bed table after providing incontinence care. Observation of a dressing change on 02/11/19 at 2:20 P.M. with LPN #310 and RN #470 for Resident #27 revealed LPN #310 had placed her clean dressing supplies on a washcloth on the overbed table without first cleaning the table. At the time of the observation, she verified she had not cleaned the overbed table prior to placing the clean dressing supplies on the table. LPN #310 then retrieved new dressing supplies as RN #470 cleaned the overbed table with a bleach Sani-Wipe. LPN #45 cleaned scissors with a bleach Sani-Wipe. LPN #310 proceeded to cut a piece of Maxorb, applied the Maxorb to the wound bed and covered with an Allevyn border foam dressing without first cleaning the wound. LPN #310 verified she had not cleaned the wound prior to applying the new dressing. An interview at this time with RN #470 also verified LPN #310 had not cleaned the wound prior to applying the new dressing. LPN #310 then removed the dressing, cleaned the wound, and reapplied a new Maxorb and Allevyn, after surveyor intervention. Review of the facility policy dated 06/2009, titled Dressing Change-Clean Technique, revealed aseptic dressing changes would be performed by a licensed nurse according to a physician order. Step three of the procedure guide stated the overbed table would be cleared and cleaned. Step eight indicated dressing supplies would be opened and placed on the overbed table. Step 16 indicated the wound would be cleansed with four by four gauze pads soaked with normal saline or wound cleanser outward from the wound, cleaning from the top to the bottom. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366078 If continuation sheet Page 17 of 18 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 366078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of Massillon, The 2000 Sherman Circle NE Massillon, OH 44646 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview the facility failed to maintain an effective pet control program to prevent gnats in the kitchen. This had the potential to affect all 109 residents residing in the facility. Residents Affected - Many Findings include: Observation on 02/10/19 at 9:00 A.M. of the kitchen with the Certified Dietary Manager (CDM) #500 revealed when CDM #500 picked up the juice nozzle gnats flew out around the nozzle tray. CDM #500 verified the gnats flying around and stated she did not know were they came from. Observation on 02/11/19 at 10:28 A.M. with CDM #500 of the kitchen revealed gnats flying around the dishwasher area. CDM #500 verified the presence of the gnats at that time. On 02/12/19 at 11:45 A.M. gnats were observed flying around the juice machine in the kitchen area. CDM #500 verified the presence of the gnats and indicated the facility had a pest control come to the facility yesterday evening. Interview on 02/13/19 at 11:50 A.M. with CDM #500 verified gnats should not be flying around in the kitchen. Review of a pest control service work sheet, dated 02/11/19 at 5:52 P.M. revealed the kitchen was treated for gnats and fruit flies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366078 If continuation sheet Page 18 of 18