Inspection·January 12, 2023

F 0580 Findings include: Level of Harm - Minimal harm or potential for actual harm 1. Review of the medical record for Resident #15 revealed an admission date of 05/05/20 with diagnoses including congestive heart failure, diabetes, dementia, altered mental status, and hypertension. Resident #15's medical record revealed she had a power of attorney (POA) for medical decisions. Residents Affected - Few Review of the care plan dated 05/10/20 revealed Resident #15 was at nutritional risk due to congestive heart failure and confusion. The care plan revealed on 12/16/22 she triggered for weight loss of 7.8 percent in 30-days due to inadequate oral intake. Interventions included diet as ordered, monitor intake, weight every month, and notify physician of a significant change. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 had impaired cognition. She was independent with eating. Her weight was 154 pounds, and she had no weight loss. Review of the weight record revealed Resident #15 had a significant weight loss as on 11/04/22 her weight was 161.8 pounds and on 12/01/22 her weight was 149.2 pounds (7.8 percent weight loss). Review of the nursing notes dated 11/04/22 to 01/11/23 for Resident #15 revealed no documentation her physician and/ or her POA were notified of her significant weight loss. Review of the Nutrition Follow Up for Significant Weight Change assessment dated [DATE] and completed by Dietitian #415 revealed on 11/04/22 Resident #15's weight was 161.8 pounds and on 12/01/22 her weight was 149.2 pounds. The assessment revealed Resident #15 had a 7.8 percent weight loss in 30 days. The assessment revealed Dietitian #415 recommended Boost Breeze (supplement) every day at breakfast. The assessment revealed no documented evidence Resident #15's Primary Care Physician #900 and/ or Resident #15's POA were notified regarding her significant weight loss. Interview on 01/09/23 at 10:23 A.M. with Resident #15's POA revealed she did not feel the facility notified her regarding Resident #15's change in condition and/ or significant changes. Interview on 01/11/23 at 10:42 A.M. with Dietitian #415 verified Resident #15 had a significant weight loss of 7.8 pounds in 30 days on 12/01/22 and that she recommended a supplement to be provided at breakfast. She revealed she did not notify Primary Care Physician #900 and/ or Resident #15's POA regarding the significant weight loss. She revealed she was unsure of who notified the physician and/ or responsible party regarding significant weight loss. Interview on 01/11/23 at 11:33 A.M. with the Director of Nursing and Assistant Director of Nursing (ADON)/ Licensed Practical Nurse (LPN) #473 revealed the Former Dietitian #512 used to complete the notifications to the physician and/ or responsible party regarding significant weight loss and did not know the current Dietitian #415 was not doing the same. They verified there was no documented evidence Primary Care Physician #900 and/ or Resident #15's POA were notified regarding her significant weight loss on 12/01/22. 2. Review of the medical record for Resident #61 revealed an admission date of 06/28/22 with diagnoses including cerebral infarction, dementia, dysphasia, and diabetes. Resident #61 had a responsible party listed in her medical record. Review of the care plan dated 07/01/22 revealed Resident #61 was at nutritional risk due to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366088 If continuation sheet Page 2 of 8 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 01/12/2023 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 0580 Level of Harm - Minimal harm or potential for actual harm difficulty swallowing and chewing due to recent stroke. Interventions included diet as ordered, monitor meal intake, and weight every month. Review of the weight record for Resident #61 revealed on 08/31/22 Resident #61's weight was 129 pounds and on 09/06/22 her weight was 121.2 pounds (5.9 percent weight loss). Residents Affected - Few Review of the nursing notes dated 09/06/22 to 01/11/23 revealed there was no documented evidence Primary Care Physician #900 was notified regarding Dietitian #415's recommendation on 09/26/22 for a multivitamin with minerals and of her significant weight loss and on 12/14/22 again with the recommendation for a multivitamin with minerals. Review of the quarterly Dietary Review dated 09/26/22 and completed by Dietitian #415 revealed Resident #61 had a 30-day weight loss of 5.9 percent. The review revealed Dietitian #415 recommended to add a multivitamin with minerals. There was no documented evidence the physician and/ or responsible party were notified regarding her weight loss and recommendation. Review of the Nutritional assessment dated [DATE] and completed by Dietitian #415 revealed Resident #61 had a moderate decrease in food intake. The assessment revealed to have the physician consider multivitamin with minerals every day. There was no documented evidence the physician and/ or responsible party were notified regarding the recommendation. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #61 was cognitively impaired. She required extensive assist of one staff with eating. She had no weight loss. Interview on 01/11/23 at 10:42 A.M. with Dietitian #415's verified she recommended Resident #61 receive a multivitamin with minerals on 09/26/22 and on 12/14/22 per her assessments. She revealed she sends the Administrator and Director of Nursing her recommendations and that she thought nursing then notified the physician of her recommendations which would have included for Resident #61 to receive a multivitamin with mineral. She verified Resident #61 did not have an order for a multivitamin with minerals and was unsure if the physician was notified of her recommendations and/ or significant weight loss as she did not notify Primary Care Physician #900. Interview on 01/11/23 at 11:33 A.M. with the Director of Nursing and Assistant ADON/ LPN #473 revealed Former Dietitian #512 used to complete the notifications to the physician of any dietary recommendations and received the order from the physician. They verified there was no documented evidence the physician was notified regarding Resident #61's dietary recommendation on 09/26/22 and 12/14/22 for a multivitamin with minerals and/ or her significant weight loss. They revealed they were not aware Dietitian #415 was not contacting Primary Care Physician #900 regarding her recommendations and obtaining her own orders and/ or notifying the physician and/ or responsible party of significant weight loss. Review of the facility policy labeled Nutritional Plan for Weight Loss, dated January 2022, revealed the dietitian would be responsible for reviewing the weight variance report and making additional recommendations, documenting in the medical records, and discussing weight changes with the weight committee. The policy did not have any information regarding the notification to the physician and/ or responsible party of recommendations and/ or significant weight changes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366088 If continuation sheet Page 3 of 8 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 01/12/2023 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to ensure accurate and timely weights were obtained for Residents #52 and #171, who were both on feeding tubes. This affected two residents (#52 and #171) of three residents reviewed for weights. The facility census was 74. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #171 was admitted to the facility on [DATE] with diagnoses including diseases of intestine, atrial fibrillation, dysphasia, bacterial pneumonia, non-Hodgkin's lymphoma, iron deficiency anemia secondary to blood loss (chronic), and unspecified protein-calorie malnutrition. Review of the Medicare 5-Day Minimum Data Summary (MDS) 3.0 assessment of 12/28/22 revealed Resident #171 was cognitively intact, required extensive assist of two for most activities of daily living (ADL), was totally dependent for eating and received 51 percent (%) or more of his total calories through a feeding tube. Review of Resident #171's care plan of 12 23/22 identified a care area for treatment of a urinary tract infections and the need for ADL assistance. Review of the census revealed Resident #171 was discharged to the hospital on [DATE] and readmitted on [DATE]. The care plan was revised on 01/11/23 to include a care area for increased nutrient needs (related to weight loss in the last year and compared to hospital weight, a 6.6 % loss in nine days though unclear of weighing technique used during hospitalization with a history of brain cancer status post (s/p) chemotherapy, aspiration pneumonia, s/p nasogastric (NG) tube, underweight and triggering for malnutrition based on a mini nutritional assessment as evidenced by a body mass index (BMI) of 18.23. Review of the weights for Resident #171 revealed the only entries were on 01/06/23 with a weight of 152 pounds (lbs.) and a weight of 142 lbs. on 01/11/23. There were no weights recorded from 12/23/22 through 12/28/22 when the resident was at the facility. Interview on 01/12/23 at 11:20 A.M. with the Director of Nursing (DON) verified Resident #171 was not weighed after his admission on [DATE] and that residents were usually weighed within 24 hours of admission and monitored, usually with weekly weights upon admission for four weeks and monthly weights after that. Review of the April 2021 policy for Residents at Nutritional Risk revealed nutritionally at-risk residents included tube feed residents and those with below acceptable body weight range. Timely assessment and implementation of a plan, including monitoring, were essential for proper care of a resident at risk. 2. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] with diagnoses including cerebral infarction weakness, unspecified dementia, dysphasia, encephalopathy, and alcohol abuse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366088 If continuation sheet Page 4 of 8 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 01/12/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Diet orders included a mechanical soft diet with honey thick liquids, enteral nutrition via feeding tube three times a day, and supplemental Magic Cups twice a day. Review of the quarterly MDS 3.0 assessment of 10/03/22 revealed Resident #52 was moderately cognitively impaired, required total dependence of one for eating and received at least 51% of his nutrition from tube feeding. Review of Resident #52's care plan of 10/12/22 revealed care areas included risks of complications due to use of feeding tube, and nutrition/hydration risks. Review of the weights for Resident #52 revealed an invalid weight on 12/19/22 of 145.6 lbs., invalidated by the DON on 01/09/23 and a weight by Registered Dietitian/Licensed Dietitian (RDLD) #513 on 12/19/22 of 116 lbs. A second invalidated weight on 01/09/23 of 153.4 lbs. was reviewed with Assistant Director of Nursing (ADON) #473 on 01/09/23 and a reweigh on 01/09/23 indicated Resident #52 weighed 119 lbs. Interview on 01/11/23 at 10:41 A.M. with RDLD #513 revealed she reviewed all residents identified on the weight variance report as having a significant change. Sometimes she would request a reweigh if a weight seemed inaccurate. Accurate weights were important for those individuals at higher nutritional risk. She was reviewing Resident #52 monthly due to his low BMI/weight, refusal of eating, and tube feedings. Interview on 01/12/23 at 11:58 A. M with ADON #473 revealed the aides weighed the residents and the nurses entered them into the medical record. She verified inaccurate weights were entered for Resident #52 on 12/19/22 and 01/09/23 and the nurse should have questioned the accuracy in comparison with the other weights. She stated the weight on 01/09/23 of 153.4 lbs. included the weight of the resident's wheelchair. Review of the April 2021 policy for Residents at Nutritional Risk revealed nutritionally at-risk residents included tube feed residents and those with below acceptable body weight range. Timely assessment and implementation of a plan, including monitoring, were essential for proper care of a resident at risk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366088 If continuation sheet Page 5 of 8 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 01/12/2023 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 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 interview, record review, and facility policy review the facility did not ensure pharmacy recommendations were addressed. This affected two residents (#11 and #61) out of six residents reviewed for unnecessary medications. The facility census was 74. Findings included: 1. Review of the medical record for Resident #11 revealed an admission date of 01/30/21 with diagnoses including dementia, psychotic disturbance, heart failure, hypertension, and acute kidney failure. Review of the pharmacy Consultation Report dated 04/07/22 revealed Pharmacist #901 recommended to consider changing the immediate release formulation of Metoprolol (medication to treat high blood pressure, chest pain, and heart failure) to the extended-release formulation. The pharmacy recommendation was not addressed. Review of the pharmacy Consultation Report dated 08/13/22 revealed Pharmacist #901 recommended discontinuing acetaminophen- hydrocodone (opioid pain medication) as she had not used the medication since 11/14/21. The pharmacy recommendation was not addressed. Review of the pharmacy Consultation Report dated 12/06/22 revealed Pharmacist #901 reviewed the medical record due to Resident #11 had a fall on 11/30/22 and identified medications that contributed to falls that included: Lorazepam (antianxiety), Remeron (antidepressant), Zoloft (antidepressant), tolterodine extended release (antispasmodic), metoprolol and acetaminophen-hydrocodone. Pharmacist #901 recommended the physician evaluate the medications as they possibly contributed to the fall and look at decreasing the lorazepam to 0.5 milligram (mg) in the morning and 1 mg at night. She also recommended to discontinue the acetaminophen-hydrocodone due to non-use. The pharmacy recommendation was not addressed. Review of the January 2022 physician orders for Resident #11 revealed she continued to have an order for acetaminophen-hydrocodone 5-325 mg given by mouth every six hours as needed for pain and lorazepam 1 mg twice a day. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had impaired cognition. Interview on 01/11/23 at 10:10 A.M. with the Director of Nursing revealed the Former Director of Nursing #511 had not followed up on the pharmacy recommendations as she verified the recommendations dated 04/07/22, 08/13/22, and 12/06/22 were not addressed for Resident #11. 2. Review of the medical record for Resident #61 revealed an admission date of 06/28/22 with diagnoses including cerebral infarction, dementia, dysphagia, and diabetes. Review of the care plan dated 07/13/22 revealed Resident #61 was at risk for complications related to diabetes. Interventions included administer medications as ordered, monitor blood glucose levels as ordered, and monitor for signs of hypoglycemia and hyperglycemia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366088 If continuation sheet Page 6 of 8 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 01/12/2023 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 0756 Level of Harm - Minimal harm or potential for actual harm Review of the pharmacy Consultation Report dated 11/04/22 revealed Pharmacist #901 recommended to discontinue Glimepiride (diabetic medication) 1 mg daily and after reevaluation of blood glucose levels initiate alternative therapy with glipizide (diabetic medication) as long- acting sulfonylureas are not recommended in older adults due to prolonged hypoglycemia. The pharmacy recommendation was not addressed. Residents Affected - Few Review of the pharmacy Consultation Report dated 01/06/23 revealed Pharmacist #901 noted on the report Repeated Recommendation from 11/04/22 and to respond promptly to assure facility compliance with federal regulation as Resident #61 continued to receive Glimepiride 1 mg daily. The pharmacy recommendation was not addressed. Review of the Medication Administration Record (MAR) for January 2022 revealed Resident #61 continued to have an order for Glimepiride 1 mg once a day from 01/01/23 to 01/11/23. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #61 was cognitively impaired. Interview on 01/09/23 at 11:29 A.M. with Resident #61's responsible party revealed he was concerned that Resident #61 took too many medications that were not necessary and at times he felt Resident #61 appeared overmedicated. Interview on 01/11/23 at 10:10 A.M. with the Director of Nursing revealed the Former Director of Nursing #511 had not followed up on the pharmacy recommendations as she verified the recommendations dated 11/04/22 was not addressed for Resident #61 and that she continued to receive Glimepiride. Review of the facility policy labeled; Medication Regimen Review, dated 12/01/07, revealed the facility should ensure that the facility physicians/ prescribers were provided with copies of the medication regimen reviews. The policy revealed the facility should then encourage the physician receiving the medication regimen review to act upon the recommendations or reject with an explanation as to why the recommendation was rejected. The facility should maintain copies of medical regimen reviews. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366088 If continuation sheet Page 7 of 8 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 01/12/2023 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 interview, observation, record review, and facility policy review the facility failed to ensure insulin was dated when opened. This affected two residents (#9 and #28) out of three residents observed during the medication storage review. This had the potential to affect eight residents (#6, #9, #10, #28, #38, #62, #174, and #219) that received insulin. The facility census was 74. Findings included: 1. Review of the medical record for Resident #28 revealed an admission date of 03/10/17 with diagnoses including diabetes with unspecified diabetic retinopathy without macular edema, and long-term insulin use. Review of the January 2023 Physician Orders revealed Resident #28 had an order for Novolin Regular U-100 solution (insulin) inject 10 units twice a day. Observation on 01/11/23 at 12:11 P.M. with Licensed Practical Nurse (LPN) #474 of 200-Back Hall medication cart revealed Resident #28's Novolin Regular U-100 insulin vial was opened and undated in the cart. Interview on 01/11/23 at 12:13 P.M. with LPN #474 verified Resident #28's insulin was not dated when it was opened. She revealed the insulin was dispensed from the pharmacy on 08/20/22 and she stated, I have no idea when it was opened. 2. Review of the medical record for Resident #9 revealed an admission dated of 11/14/19 with diagnoses including diabetes, dementia, and acute respiratory failure. Review of the January 2023 Physician Orders revealed Resident #9 had an order for Humalog U-100 insulin per sliding scale before meals and at bedtime. Observation on 01/11/23 at 12:18 P.M. with LPN #460 of the 300-Long Hall medication cart revealed Resident #9's insulin was opened and undated. Interview on 01/11/23 at 12:18 P.M. with LPN #460 verified Resident #9's insulin was opened and undated in the medication cart. Interview on 01/12/23 at 11:26 A.M. with the Director of Nursing verified all insulins were to be dated upon opening. Review of the facility policy labeled Maintenance of Medication Storage Areas, dated May 2019, revealed insulins, eye drops, saline solution multi-dose were to be dated when opened. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366088 If continuation sheet Page 8 of 8