Inspection·January 30, 2020

F 0641 Level of Harm - Minimal harm or potential for actual harm Review of the December 2019 Medication Administration Record (MAR) for Resident #29 revealed she received a Mantoux injection to the right forearm on 12/09/19. Interview on 01/30/20 at 1:45 P.M. with RN #600 revealed the admission MDS dated [DATE] data was inaccurately coded and did not reflect the Mantoux injection. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366088 If continuation sheet Page 2 of 9 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 366088 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Austinburg Nsg and Rehab Ctr 2026 State Route 45 Austinburg, OH 44010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the care plan for Resident #2 was accurate and did failed to ensure a care plan was implemented for Resident #29 related to a a blood thinning medication. This affected two residents of 25 residents reviewed for care plans. Findings Include: 1. Review of Resident #2's medical record revealed an admission date of 05/28/19 with diagnoses including chronic lung disease, diabetes, tricuspid insufficiency (valve in the heart does not work properly), and endocarditis (infection in the heart). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/10/19 revealed Resident #2's cognition was intact. Review of the plan of care for Resident #2 revealed a care plan dated 06/10/19 stating Resident #2 required oxygen therapy for chronic lung disease. Review of the physician orders for Resident #2 revealed no order for oxygen therapy. Observation on 01/27/20 at 9:58 A.M. revealed no oxygen equipment in Resident #2's room. Interview with the Administrator on 01/30/20 at 3:17 P.M. revealed Resident #2 never received oxygen while a resident in the facility. Registered Nurse (RN) #600 was interviewed on 01/30/20 at 2:24 P.M. and verified the care plan was inaccurate. 2. Review of the medical record for Resident #29 revealed an admission date of 12/09/19 with diagnoses including atrial fibrillation, right leg fracture, and chronic lung disease. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #29's cognition was intact. Review of the physician's orders for Resident #29 revealed an order dated 12/09/19 for Resident #29 to receive Warfarin (a blood thinning medication), 4 milligrams (mg) daily. Review of the Medication Administration Record for Resident #29 revealed she received Warfarin, 4 mg each evening. Review of the plan of care for Resident #29 revealed no care plan addressing the use of a blood thinning medication. Interview with RN #600 on 01/30/20 at 1:58 P.M. verified Resident #29 did not have a care plan in place for the blood thinning medication and one should have been implemented. Review of the policy, Resident Assessment Comprehensive Care Plans, updated 11/28/17, stated the comprehensive care plan must describe the resident's medical, nursing, physical, mental and psychosocial needs and preferences and how the facility will assist in meeting these needs and preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366088 If continuation sheet Page 3 of 9 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 366088 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Austinburg Nsg and Rehab Ctr 2026 State Route 45 Austinburg, OH 44010 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews the facility failed to collaboratively provide meaningful, individualized activities to meet the personal preferences of Resident #23. This affected one of 24 residents screened for activities. Residents Affected - Few Findings included: Record review was conducted for Resident #23 who was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, chronic fatigue, [NAME]-[NAME] virus, rheumatoid arthritis, anxiety, hypothyroidism and anemia. The plan of care, initiated 09/21/18, revealed her preferences for everyday living activities included painting, sewing, drawing, caring for plants and gardening, reading books, newspapers and gardening magazines, going for walks for exercise, being around pets and watching documentaries and the cooking channel. There were no revisions made to Resident #23's preferences since the initial care plan date of 09/21/18. The annual, comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was alert, oriented and cognitively intact, exhibited no mood problems, no behaviors and no rejection of care. Resident #23 completed the preferences for activities section and indicated the activities very important or somewhat important to her were reading books, newspapers and magazines, listening to music and being around animals. She did not prefer group activities. Review of the Daily Participation Records for December 2019 and January 2020 revealed Resident #23 was provided one-to-one visits, did independent activities of choice and her mom and husband visited daily. There were no other activities listed as provided to Resident #23 and no record of the content of the one-to-one activities. Interview and observation was conducted on 01/28/20 from 9:57 A.M. to 10:10 A.M. with Resident #23 and her mom in the resident's room. Resident #23 was standing and verbally greeted the surveyor. She was very thin with a flat affect and was pacing during the interview and observation period. The room had an impersonal appearance with only a cell phone, television and electronic tablet, in addition to the standard room furniture. There were no pictures, decorations, books, magazines, newspapers, library materials, wall hangings, crafting materials, plants, therapeutic stuffed animals or any other sensory items for Resident #23, who primarily spent her time in her room. Resident #23 and her mom were asked if there were any concerns about the care and services at the facility. Resident #23's mom shared that her daughter was an anxious person who constantly stood or paced most of the day and said the facility was not thinking outside the box to find activities to engage her daughter's interests. When Resident #23 was asked if she thought she had enough activities, she quickly answered no and said she would like more things to do in her room. Her mother said someone from activities would come in now and then to invite Resident #23 to a group activity but when her daughter refused the group activity, the activity staff would just give up and not try anything else for the day. Her mom expressed concern for her daughter's mental health and felt adding some therapeutic activities would help her. On 01/29/20 at 1:01 P.M., Activity Director (AD) #602 was interviewed regarding her knowledge of Resident #23's involvement in activities. AD #602 said Resident #23 preferred to stand in her door way (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366088 If continuation sheet Page 4 of 9 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 366088 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Austinburg Nsg and Rehab Ctr 2026 State Route 45 Austinburg, OH 44010 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and people watch so AD #602 encouraged group activities, but also had her on the calendar for one-to-one staff visits. AD #602 said Resident #23's mother and husband visited her daily in her room. Interview was conducted on 01/29/20 at 2:30 P.M. with Resident #23 who was found standing in the doorway of her room. When asked if she went out side to take walks or garden with the staff she said no, but said she would like to do those activities. She said a lady brought in a dog once in a while but she did not get to spend time with the dog. She said her television only got three channels and she would like to watch the cooking channel, but it would not come in. She demonstrated by turning on the television and only three channels were available. The cooking channel was not available for her to watch. She said she would like to have her hair done but said it was not comfortable going to the salon in the facility. She said she did not want her nails painted and did not enjoy group activities. She said she enjoyed coloring, painting and looking at magazines. None of these items were available to her in her room. Interview was conducted on 01/29/20 at 3:13 P.M. with AD #602 who verified Resident #23's preferences for everyday living activities remained accurate as listed on the plan of care initiated 09/21/18 and she had been the person to collect that information from Resident #23. When asked about the content of the one-to-one visits for Resident #23, AD #602 shared she personally stopped by her room and talked to her, offered to comb her hair, do her nails, lotion to her hands and invite her to group activities or the beauty shop. AD #602 said they do have a dog coming to the facility visiting three weekends in a two month period when the owner (Activity Aide #900) comes in to do group activities with the residents. AD #602 said it was not a one-to-one activity and visiting with the dog was not offered to Resident #23. AD #602 verified Resident #23 did not get taken out for walks, did not do gardening or keep plants, did not receive regular pet visits, and had no preferred magazines, newspapers, crafts, library books, movies or art materials available in her room that she could work with if and when she preferred. AD #602 said Resident #23 did have cable television in her room consisting of 29 channels but said it may only get three channels if the resident did not use the remote correctly. Interview on 01/30/20 at 9:18 A.M. with Activity Aid #603 said one-to-one visits typically lasted 15 to 20 minutes and included an invitation to the group activity and discussion about daily events or interests. Activity Aid #603 verified Resident #23's preferred interests listed in the plan of care. Activity Aid #603 said Activity Aid #900 came to the facility today and took the dog specifically into visit Resident #23 and said she lit up and interacted very well with the dog. Interview was conducted on 01/30/20 at 11:34 A.M. with Social Service Director (SSD) #604 who revealed Resident #23 did see the facility psychologist for support but there had been no discussions between herself, the psychologist and the rest of the interdisciplinary team regarding ideas for or implementing therapeutic activities for Resident #23. She added Resident #23 would get severe anxiety over going out of the facility and preferred to stay in her room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366088 If continuation sheet Page 5 of 9 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 366088 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Austinburg Nsg and Rehab Ctr 2026 State Route 45 Austinburg, OH 44010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, record review, and staff interview, the facility failed to ensure residents who smoked were free from accident hazards. This affected two (Resident #2 and Resident #14) of three residents reviewed for smoking. Findings include: 1. Review of Resident #2's medical record revealed an admission date of 05/28/19 with diagnoses including diabetes, tricuspid insufficiency (valve in the heart does not work properly), and endocarditis (infection in the heart). Review of the smoking care plan for Resident #2, dated 08/05/19, revealed he was at risk for injury related to smoking with interventions including for all lighters to be maintained at the nurse's station or other designated area. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/10/19, revealed Resident #2's cognition was intact. Review of the Safe Smoking Assessment for Resident #2 dated 12/17/19 revealed the resident was determined to be a safe smoker. Interview on 01/27/20 at 9:58 A.M. with Resident #2 revealed he smoked independently. He said he kept his cigarettes and lighter in his room. Resident #2 was observed on 01/29/20 at 9:06 A.M. smoking in the smoking room. No staff members were present during the observation. Resident #2 was observed independently returning to the 100 unit where he resided at 9:19 A.M. Resident #2 was asked to show his smoking paraphernalia at that time. Resident #2 removed a flip top carton of cigarettes from his sweatshirt pocket. The carton contained two cigarettes and a lighter. Licensed Practical Nurse (LPN) #601 verified the observation on 01/29/19 at 9:19 A.M. LPN #601 was interviewed immediately following the observation and stated Resident #2 kept his lighter and cigarettes in his room. The Director of Nursing (DON) was interviewed on 01/30/20 at 11:09 A.M. and stated she had only been with the facility for three months and was not yet familiar with the smoking policy. The DON reviewed the smoking policy at the time of the interview and stated residents were not to be in possession of smoking paraphernalia. On 01/30/20 at 1:43 P.M. the DON approached this surveyor and stated all lighters had been taken from residents who smoked independently. Review of the Smoking Policy, dated 03/2018, procedure #3, stated, Residents are not permitted to have lighters or other smoking paraphernalia on their person during non-smoking times. This includes both safe and unsafe smokers. 2. Review of Resident #14's medical record revealed an admission date of 12/04/10 with diagnoses that included diabetes, schizophrenia, and emphysema. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366088 If continuation sheet Page 6 of 9 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 366088 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Austinburg Nsg and Rehab Ctr 2026 State Route 45 Austinburg, OH 44010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the smoking care plan for Resident #14, dated 10/22/13, revealed he was at risk for injury related to smoking with interventions including all lighters were to be maintained at the nurse's station or other designated area. Review of the Safe Smoking Assessment for Resident #14, dated 12/16/19, revealed the resident was determined to be a safe smoker. Review of the quarterly MDS 3.0 assessment, dated 01/04/20, revealed Resident #14's cognition was intact. Resident #14 was interviewed on 01/30/20 at 10:25 A.M. and stated he was an independent smoker and showed this surveyor the lighter he kept on his person. LPN #607 was interviewed on 01/30/20 at 10:25 A.M. and verified Resident #14 kept his lighter and cigarettes in his room. The DON was interviewed on 01/30/20 at 11:09 A.M. and stated she had only been with the facility for three months and was not yet familiar with the smoking policy. The DON reviewed the smoking policy at the time of the interview and stated residents were not to be in possession of smoking paraphernalia. On 01/30/20 at 1:43 P.M. the DON approached this surveyor and stated all lighters had been taken from residents who smoked independently. Review of the Smoking Policy, dated 03/2018, procedure #3, stated, Residents are not permitted to have lighters or other smoking paraphernalia on their person during non-smoking times. This includes both safe and unsafe smokers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366088 If continuation sheet Page 7 of 9 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 366088 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Austinburg Nsg and Rehab Ctr 2026 State Route 45 Austinburg, OH 44010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility did not ensure insulin was dated when opened for Resident #226. This affected one resident (Resident #226) out of eleven residents (Residents #1, #16, #19, #21, #37, #45, #49, #54, #62, #73, and #226) on insulin. The facility census was 82. Findings included: Review of medical record for Resident #226 revealed an admission date of 01/09/20 and diagnoses including diabetes. Observation on 01/28/20 at 3:16 P.M. of medication cart on the 300-hall with Licensed Practical Nurse (LPN) #605 revealed Resident #226's Basaglar insulin, 100 units per milliliter Kwikpen (a disposable single patient pre-filled pen containing insulin), revealed the insulin had been opened, but was not dated with the open date. Interview on 01/28/20 at 3:18 P.M. with LPN #605 verified Resident #226's Basaglar insulin was not dated when the insulin was opened. She confirmed insulin was to be dated when opened. Interview on 01/28/20 at 4:29 P.M. with the Director of Nursing verified insulin was to be dated when opened. She revealed the facility followed the pharmacy insulin storage recommendations on how long different types of insulin were good for after they were opened. Review of facility pharmacy form labeled, Insulin Storage Recommendations, revealed a Basaglar insulin pen was only good for 28 days once opened. Review of facility policy labeled, Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles, dated 10/28/19, revealed once any medication or biological was opened the facility should follow manufacture guidelines and in respect to expirations dates for opened medications. The policy revealed facility staff should record the date opened on the primary container, vial, bottle or inhaler when the medication had a shortened expiration date once opened. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366088 If continuation sheet Page 8 of 9 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 366088 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Austinburg Nsg and Rehab Ctr 2026 State Route 45 Austinburg, OH 44010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview, observation, and record review the facility did not ensure the glucometer meter (a medical device used to measure the concentration of glucose in the blood) was cleaned properly for infection control purposes after Resident #73's blood sugar was obtained. This affected one resident (Resident #7) out of two residents observed for glucometer checks. This had the potential to affect nine residents (Resident #1, #2, #21, #28, #37, #49, #54, #62, and #73) who had orders for blood sugar checks. Residents Affected - Few Findings included: Observation on 01/28/20 at 3:48 P.M. of Licensed Practical Nurse (LPN) #606 for medication administration revealed she obtained Resident #73's blood sugar by piercing the right index finger and applying the blood sample to the test strip in the glucometer. LPN #606 set the glucometer on top of the medication cart after she obtained Resident #73's blood sugar and did not clean the glucometer. Observation on 01/28/20 at 3:58 P.M. revealed LPN #606 then took the same glucometer and obtained Resident #7's blood and applied it to the test strip in the glucometer. Interview on 01/28/20 at 4:00 P.M. with LPN #606 stated as she was walking out of Resident #7's room verified she had not cleaned the glucometer between use for Resident #73 and Resident #7. She said, Oh I forgot, darn it. She verified the glucometer was used for multiple residents and she should have used the bleach wipe to clean the glucometer between residents. She then cleansed the glucometer with a bleach wipe. No blood was observed directly on the glucometer between residents. Interview on 01/28/20 at 04:26 P.M. with the Administrator nurses were to clean the glucometer with the bleach wipe after obtaining a blood sugar for a resident. Review of facility policy labeled, Glucometer Cleaning, dated January 2017, revealed to prevent the transmission of infections the facility required disinfecting blood glucose meters between resident use. The staff, before and after using a blood glucose meter, were to disinfect the meter by cleaning the outside of the meter by using a commercially available Environmental Protection Agency (EPA) registered disinfectant detergent or germicidal wipe. Review of manufacturer guidelines titled, Cleaning and Disinfecting Your Assure Platinum Blood Glucose Meter, dated December 2014, revealed disinfection of the blood glucose meter can be accomplished with a EPA registered disinfectant detergent or germicide that was approved for healthcare settings or a solution of one to ten concentration of bleach. The guidelines revealed the blood glucose meter were at high risk of becoming contaminated with bloodborne pathogens due to contaminated blood. The guidelines revealed cleaning and disinfecting of meters between resident use can prevent the transmission of blood borne pathogens through indirect contact. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366088 If continuation sheet Page 9 of 9