Health inspection·January 16, 2020

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure written notification of transfer to the hospital was provided to Resident #68 and Resident #76. This affected two of two residents reviewed for transfers and had the potential to affect all 75 residents currently residing in the facility. Findings include: 1. Resident #68's medical record revealed an admission date of 04/10/19 with diagnoses including cardiomyopathy, end stage renal disease, chronic congestive heart failure, and chronic obstructive pulmonary disease. Nurses notes revealed on 08/21/19 at 11:06 A.M. Resident #68 sent was to a hospital for treatment of chronic renal failure and was admitted . Resident #68 was hospitalized from [DATE] through 08/22/19 and was then re-admitted to the facility. The medical record lacked evidence of written notification of the transfer provided to Resident #68 or their representative. 2. Resident #76's medical record revealed an admission date of 09/05/19 with diagnoses including atrial fibrillation, end stage renal disease, respiratory failure, and cirrhosis of the liver. Nurses notes revealed on 12/05/19 at 2:45 P.M. Resident #76 was sent was to a hospital for evaluation and treatment related to critical laboratory levels including a prothrombin time (PT) level greater than 120, and Internationalized Normalized Ratio (INR) level greater than 12 (indicators of the blood clotting time and risk factor for bleeding). Both lab results were in the critical ranges. Resident #76 was sent to the hospital via ambulance and did not return to the facility. The medical record lacked evidence of written notification of the transfer provided to Resident #76 or their representative. Interview with Social Worker #500 on 01/15/20 at 4:33 P.M. confirmed this concern, she reported was not aware of the regulation and indicated the facility currently had no established procedures to ensure written notification was being completed for hospital transfers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366095 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 366095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glenwood Care and Rehabilitation 836 West 34th Street NW Canton, OH 44709 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 accurately complete and submit a Preadmission Screening and Resident Review (PASARR) for Resident #48. This affected one of one resident reviewed for PASARR assessments. Residents Affected - Few Findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, type two diabetes, and cognitive communication deficit. Review of Resident #48's hospital paperwork revealed a Hospital Exemption form, JFS 07000, dated 11/18/19, which stated the anticipated length of Resident #48's skilled nursing facility stay was anticipated as less than 30 days. The Hospital Exemption form stated Resident #48 had a diagnosis of mental retardation and did not evidence of a severe mental illness. Review of the PASARR assessment completed 12/12/19 by Licensed Social Worker (LSW) #500 revealed Resident #48 had a diagnosis of developmental disability. The diagnosis manifested before the age of 22, and did not result in functional limitations prior to the age of 22. The PASARR assessment was blank regarding whether or not Resident #48 received services from the local county Board of Developmental Disabilities, however, was marked yes indicating Resident #48 had indications of developmental disabilities or a related condition. Phone interview with Resident #48's family on 01/15/20 at 9:30 A.M. revealed Resident #48 did not have a diagnosis of developmental delay and did not receive services from the local county Board of Developmental Disabilities. Resident #48's family stated Resident #48 did not start having any cognitive difficulties until approximately six years ago at the age of 62. Interview with LSW #500 on 01/15/20 at 11:00 A.M. revealed she was not aware Resident #48 did not receive services from the local county Board of Developmental Disabilities and was also not aware Resident #48 did not have a diagnosis of development delay. LSW #500 verified she did not speak with the resident's family to confirm a diagnosis of developmental delay as indicated in the hospital paperwork, the PASARR assessment she completed was inaccurate and she did not submit the PASARR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366095 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 366095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glenwood Care and Rehabilitation 836 West 34th Street NW Canton, OH 44709 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 0760 Ensure that residents are free from significant medication errors. 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 review of facility policy the facility failed to ensure Resident #48 was not given an antibiotic (Tetracycline) which she was allergic to. This affected one resident (Resident #48) of six residents reviewed for unnecessary medications. The facility census was 75. Residents Affected - Few Findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, urinary tract infection, urine retention, type two diabetes, and depression. Review of the resident's electronic record revealed the resident profile listed Tetracycline (an antibiotic) as an allergy. Review of the Minimum Data Set (MDS) 3.0 revealed Resident #48 had a Brief Interview for Mental Status (BIMS) score of nine which indicated mild cognitive impairment, and required extensive assistance with care. Review of the progress notes dated 12/26/19 revealed Resident #48 had a change in condition at 12:58 A.M. Resident #48 was short of breath, using accessory muscles for breathing, and her oxygen saturation was 89 percent (below normal range of 90 - 100 percent). Oxygen was administered at three liters per minute via nasal cannula and her saturation rose to 95 to 98 percent. Resident #48 was sent to the emergency room at the local hospital and was admitted with a diagnosis of acute respiratory distress secondary to chronic obstructive pulmonary disease. Review of Resident #48's hospital progress notes dated 12/26/19 revealed Resident #48 was diagnosed with a deep vein thrombosis (DVT)/pulmonary embolus (PE) and an IVC (inferior vena cava) filter was placed in the right femoral artery. Additional review of the notes revealed Resident #48 had accidentally been given a dose of Tetracycline ordered for another resident (Resident #176) residing in the facility. Review of a Medication Incident Report Form revealed on 12/25/19 at 8:30 P.M. Nurse #501 administered Tetracycline 500 mg by mouth to Resident #48. The error occurred because Nurse #501 was distracted due to a missing resident. On 12/25/19 at 9:30 P.M. Physician #502 was notified of the medication error and ordered Benadryl 25 mg to be given to Resident #48 by mouth Interview on 01/15/20 at 8:48 A.M. with Registered Nurse (RN) #501 revealed it was very busy on the evening of 12/25/19. She was the only nurse working. RN #501 was distracted because a resident was missing, and all staff were looking the missing resident. RN #501 stated she popped a pill out of it's wrapper, put it in a cup and administered it to Resident #48. After the missing resident was found sleeping in a resident room, RN #501 realized she had given Tetracycline to Resident #48 and it should have been given to Resident #176. This was approximately 30 minutes after she administered the medication. RN #501 stated she immediately called Physician #502 and received an order for Benadryl (an antihistamine) 25 milligrams (mg) by mouth. RN #501 stated she administered the Benadryl to Resident #48. RN #501 continued, at 1:00 A.M. Resident #48 became short of breath and was sent to the emergency room at a local hospital. The physician from the hospital called her to find out what happened and told her the labored breathing was probably not due to the medication error. The hospital physician told RN #501 Resident #48 had acute respiratory failure and was diagnosed with a DVT/PE which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366095 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 366095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glenwood Care and Rehabilitation 836 West 34th Street NW Canton, OH 44709 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 0760 most likely caused her symptoms. Level of Harm - Minimal harm or potential for actual harm Phone interview on 01/15/20 at 9:30 A.M. with Family Member (FM) #504 revealed the facility called her on 12/25/19 to inform her a medication (Tetracycline) was administered to Resident #48 and she was allergic to it. FM #504 was also informed Resident #48 was sent to the emergency room on [DATE] due to labored breathing. Residents Affected - Few On 01/15/20 at 9:45 A.M. the Director Of Nursing (DON) verified she had been notified of the medication error on 12/25/19 when Resident #48 was sent to the hospital. Review of facility policy titled, Administering Medications, revised December 2012, stated if medication has been identified as having potential adverse consequences for the resident, the person preparing or administering the medication shall contact the resident's Medical Director to discuss the concerns. The policy further stated allergies to medications must be checked/verified for each resident prior to administering medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366095 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 366095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glenwood Care and Rehabilitation 836 West 34th Street NW Canton, OH 44709 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, interview and review of the facility cleaning schedule for the kitchen the facility failed to ensure meals were prepared under sanitary conditions. This had the potential to affect 74 of 75 residents currently residing in the facility who received meals prepared in the kitchen, with the exception of Resident #49, who did not take food by mouth. Findings include: Observations conducted on 01/13/20 from 10:28 A.M. to 11:52 P.M. of the general kitchen environment revealed the fire suppression hood and metal vents were covered with a moderate to thick amount of black dust. Food preparation, including including mushroom soup, Brussel sprouts, and hot dogs occurred directly under the dust covered hood and metal vents during the observation period. An interview was conducted on 01/15/20 at 12:53 P.M. with the Director Manager (DM #505) who verified the above findings. DM #505 explained that he was not sure about the last time the hood and vents were cleaned but would clean them that day. Review of the daily complete kitchen cleaning assignments for all positions in the kitchen revealed the cleaning schedule did not include the cleaning of the fire suppression hood and vents. Interview on 01/17/20 at 2:20 P.M. with DM #505 confirmed the complete cleaning schedule was the current and only one and it did not include cleaning of the fire suppression hood and vents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366095 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 366095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glenwood Care and Rehabilitation 836 West 34th Street NW Canton, OH 44709 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of facility policy the facility failed to ensure complete and accurate documentation of a physician's order and administered medications Resident #48. This affected one resident (Resident #48) of six residents reviewed for unnecessary medications. The facility census was 75. Findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, urinary tract infection, urine retention, type two diabetes, and depression. Review of the Minimum Data Set (MDS) 3.0 revealed Resident #48 had a Brief Interview for Mental Status (BIMS) score of nine which indicated mild cognitive impairment, the resident required extensive assistance with care, and had an indwelling urinary catheter. Review of the progress notes dated 12/26/19 revealed Resident #48 had a change in condition at 12:58 A.M. Resident #48 was short of breath, using accessory muscles for breathing, and her oxygen saturation was 89 percent (below normal range of 90 - 100 percent). Oxygen was administered at three liters per minute via nasal cannula and her oxygen saturation rose to 95 to 98 percent. Resident #48 was sent to the emergency room at the local hospital and was admitted with a diagnosis of acute respiratory distress secondary to chronic obstructive pulmonary disease and subacute kidney injury. Review of Resident #48's hospital progress notes dated 12/26/19 revealed Resident #48 was diagnosed with a deep vein thrombosis (DVT)/pulmonary embolus (PE) and an IVC (inferior vena cava) filter was placed in the right femoral artery. Additional review of the notes revealed Resident #48 had accidentally been given a dose of Tetracycline ordered for another resident (Resident #176) residing in the facility. Interview on 01/15/20 at 8:48 A.M. with Registered Nurse (RN) #501 revealed it was very busy on the evening of 12/25/19. She was the only nurse working and could not remember if one or two State Tested Nursing Assistants (STNA) were working with her. RN #501 was distracted because a resident was missing, and all staff were looking the missing resident. RN #501 stated she popped a pill out of it's wrapper, put it in a cup and administered it to Resident #48. After the missing resident was found sleeping in a resident room, RN #501 realized she had given Tetracycline (an antibiotic) to Resident #48 and it should have been given to Resident #176. This was approximately 30 minutes after she administered the medication. RN #501 stated she immediately called Physician #502 and received an order for Benadryl (an antihistamine) 25 milligrams (mg) by mouth. RN #501 stated she administered the Benadryl to Resident #48. RN #501 stated she charted the Benadryl on the Medication Administration Record (MAR). RN #501 continued, at 1:00 A.M. Resident #48 became short of breath and was sent to the emergency room at a local hospital. The physician from the hospital called her to find out what happened and told her the labored breathing was probably not due to the medication error. The hospital physician told RN #501 Resident #48 had acute respiratory failure and was diagnosed with a DVT/PE which most likely caused her symptoms. Phone interview with Consulting Pharmacist (CP) #503 revealed she had not received a medication error report. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366095 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 366095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glenwood Care and Rehabilitation 836 West 34th Street NW Canton, OH 44709 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Phone interview on 01/15/20 at 9:30 A.M. with Family Member (FM) #504 revealed the facility called her on 12/25/19 to inform her a medication was administered to Resident #48 and she was allergic to it. FM #504 was also informed Resident #48 was sent to the emergency room on [DATE] due to labored breathing. Interview on 1/15/20 at 9:45 A.M. with the Director Of Nursing (DON) revealed she had not sent a medication error report to CP #503. She wanted to talk to her in person next time she came to the facility. The DON further stated she had been notified of the medication error on 12/25/19 and when Resident #48 was sent to the hospital. Review of Medication Incident Report Form revealed on 12/25/19 at 8:30 P.M. Nurse #501 administered Tetracycline 500 mg by mouth to Resident #48. Error occurred because Nurse #501 was distracted due to a missing resident. On 12/25/19 at 9:30 P.M. Physician #502 was notified of the medication error and ordered Benadryl 25 mg to be given to Resident #48 by mouth Review of Resident #48's progress notes dated 12/25/19 and 12/26/19 did not reveal documentation of the medication error or the administration of Benadryl. Review of Resident #48's MAR did not reveal Tetracycline or Benadryl administration on 12/25/19. Review of the electronic record did not reveal physician orders for administration of Benadryl. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366095 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 366095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glenwood Care and Rehabilitation 836 West 34th Street NW Canton, OH 44709 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview and policy review the facility failed to ensure proper technique for infection control during tracheostomy care. This affected one (Resident #45) of one resident with a tracheostomy who was reviewed for tracheostomy care. Residents Affected - Few Findings include: Observation on 01/15/20 at 3:09 P.M. of tracheostomy (an surgically created opening in the front of the neck for the purpose of facilitating breathing) care for Resident #45 revealed Licensed Practical Nurse (LPN) #507 failed to maintain proper aseptic (sterile) technique during care. LPN #507 applied her sterile glove and proceeded to remove Resident #45's dirty inner cannula from the tracheostomy. LPN #507 then applied clean (non-sterile) gloves and continued tracheostomy care using sterile gauze to clean the tracheostomy. LPN #507 then removed the sterile inner cannula from the package, with the same dirty gloves, and inserted it into the tracheostomy opening. Interview on 01/15/20 at 3:45 P.M. with LPN #507 verified that she handled the new/sterile inner cannula with dirty gloves. LPN #507 verified that tracheostomy care required aseptic technique and she should have used sterile gloves when touching the sterile inner cannula. Review of the facility policy Tracheostomy Care, dated August 2013 revealed aseptic technique must be used during tracheostomy tube changes, either reusable or disposable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366095 If continuation sheet Page 9 of 9