Inspection·August 25, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record, and interview with staff, the facility failed to ensure a wound treatment order was obtained and transcribed in the medical record for Resident #35. This affected one resident (Resident #35) of three residents reviewed for wounds. Findings Include:Review of the medical record revealed Resident #35 was admitted to the facility on [DATE]. Diagnoses included diabetes, dementia, bacteremia, chronic obstructive pulmonary disease, hypertension, anxiety disorder, depression, Alzheimer's disease, intermittent explosive disorder, dysphagia, and absence of part of the right foot.Review of the nurses note dated 10/16/25 at 6:45 P.M. revealed Resident #35 arrived with two emergency medical technicians (EMT) via an ambulance from the hospital. Resident #35 received a head to toe assessment upon admission and it was observed he had lost his right great toe.Review of the admission assessment dated [DATE] revealed Resident #35 had moderately impaired cognition and no open areas.Review of the nurses note dated 10/26/25 at 6:21 P.M. revealed Resident #35 was screaming in his room and saying he wanted to kill himself and he was unable to calm down and he was throwing items at staff. The resident was sent to the local hospital. Review of the nurse's note dated 10/31/25 at 5:30 P.M. revealed Resident #35 was readmitted from the hospital with a one by one (no standard unit listed) scab, dark in color with no drainage noted. The top of the right foot had a dry dressing. Review of the November 2025 physician's orders revealed Resident #35 did not have an order for a treatment to his right foot. Review of the November 2025 Treatment Administration Record revealed no documentation of a treatment being completed to the right foot of Resident #35.An observation on 11/03/25 at 1:00 P.M. revealed Resident #35 was sitting at the nurses station with a border foam dressing on the top of the right foot dated 11/01. Licensed Practical Nurse #101 stated she did not know why it was there. She checked the orders and verified there was no order for him to have a dressing to the top of his right foot. An interview on 11/04/25 at 10:35 A.M. with Regional Director of Clinical Operations (RDCO) #100 revealed the dressing to the right foot was placed for a pad and protect. She stated they notified the nurse practitioner on 11/01/25; However, the nurse did not put the order in the computer, but it was just a pad and protect, she stated the resident did not have any open areas or scabbed areas to the right foot. She stated they would have caught it when they completed his weekly skin check. Observation on 11/04/25 at 11:00 A.M. of Resident #35's right foot, with the Director of Nursing (DON) and RDCO #100, revealed the resident had a border foam dressing to the area of his right foot where his great toe used to be. The DON pulled the dressing back halfway to just expose his healed surgical incision. When the dressing was completely removed it exposed a dime sized scabbed area to the top of his foot, close to the second toes, and three pea sized scabs to the top of the second toe. The DON stated they did not have a treatment to the scabs because they were closed wounds. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366096 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 366096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Salem West Healthcare Center 2511 Bentley Drive Salem, OH 44460 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm Based on medical record review, interview and policy review the facility failed to ensure complaints of new onset pain were addressed in a timely manner. This affected one (Resident #34) of three residents reviewed for injuries. The facility census was 81. Actual harm occurred beginning on 06/11/25 when Resident #34, who had a diagnosis of dementia and required assistance with care, complained of pain in the right thigh and lower extremity and demonstrated increased agitation during therapy that was not comprehensively assessed or treated. On 06/12/25, Resident #34 was unable to stand and had ongoing complaints of pain affecting therapy participation and mobility. Facility staff did not notify the resident's medical provider until 06/26/25 at 11:40 P.M. when the resident again complained of right hip pain to the day shift nurse resulting in an x-ray order and it was determined the resident had a pathological fracture to the right femur. The resident was subsequently transferred to the hospital for evaluation and returned to the facility the same day with hospice services at the request of family. Findings include: Review of Resident #34's medical record revealed diagnoses including type two diabetes mellitus with diabetic polyneuropathy, bipolar disorder, pseudobulbar affect, contractures of bilateral knees, pain in bilateral knees, dementia with behavioral disturbance, need for assistance with personal care, schizophrenia, post-traumatic stress disorder, neurosyphilis, persistent mood disorder, anxiety disorder, emotional lability and psychosis. Review of physician orders revealed on 04/17/23, an order was written to monitor for pain every shift. Review of a Physical Therapy (PT) evaluation dated 05/14/25 indicated Resident #34 was referred to PT for recent decline in function and bilateral knee flexion contractures. Resident #34 presented with decreased lower extremity strength, bilateral knee flexion contractures, decreased sitting balance requiring increased assistance with bed mobility and Hoyer lift for transfers. There was no pain at rest. PT notes dated 05/27/25, 05/30/25, 06/02/25, 06/03/25, 06/04/25, 06/05/25, and 06/06/25 revealed therapy included range of motion exercises with weights and standing exercises with no documentation of complaints of pain. A PT note dated 06/09/25 indicated Resident #34 performed bilateral lower extremity exercises seated using three-pound weights. Resident #34 complained of pain when staff assisted with knee extension due to stretch on bilateral knee flexion contractures. A PT note dated 06/11/25 indicated bed mobility with moderate to maximum assistance to roll and to reposition for increased comfort as Resident #34 had complaints of increased pain in the right lower extremity. Resident #34 appeared to demonstrate increased agitation with the therapist when cued for increased assistance with bed mobility. Resident #34 declined to get out of bed to go to the therapy room to attempt stands with the turn stand. A PT note dated 06/12/25 indicated four attempts were made to get Resident #34 to rise to a standing position from a seated position. However, Resident #34 appeared to have difficulty clearing her bottom from the chair. Resident #34 was unable to complete any stands due to complaints of increased pain in her right upper thigh area. Nursing was notified. Resident #34 required prolonged seated rests to recover with complaints of increased fatigue and increased right upper thigh pain. Review of an Occupational Therapy (OT) note dated 06/12/25 indicated Resident #34 was unable to stand to work on balance goals and reported right leg pain. The note indicated nursing and the nurse practitioner were aware. Review of additional PT notes revealed on 06/16/25 Resident #34 complained of pain when her right lower extremity range of motion exercises were completed. The complaints were reported to nursing. A PT note dated 06/17/25 indicated Resident #34 complained of increased right lower extremity pain and screamed out it hurts when range of motion was provided. Standing was not attempted related to complaints of pain. Nursing was notified. A PT note dated 06/19/25 indicated Resident #34 complained of pain when exercising her lower extremities and was unable to complete full range requiring Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366096 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 366096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Salem West Healthcare Center 2511 Bentley Drive Salem, OH 44460 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 0697 Level of Harm - Actual harm Residents Affected - Few staff to assist with her exercises. Nursing was aware of leg pain. A PT progress note dated 06/23/25 indicated sit to stands attempts were made twice at the turn stand with max assist of two. However, Resident #34 was unable to clear her bottom from the chair. Resident #34 demonstrated complaints of increased RLE pain. Nursing was notified. Resident #34 had complaints of increased right lower extremity pain with movement. Nursing was notified of Resident #34's complaints of increased right leg pain. Prolonged rests were required in between sets. A PT note dated 06/24/25 indicated Resident #34 performed active assistive bilateral lower extremities were exercised seated using 2.5-pound weights to improve her strength and increase her ability to perform bed mobility and transfers upon discharge from therapy. Resident #34 continued to complain of pain when her right lower extremity was ranged and bilateral lower extremities were edematous. Nursing was aware. A PT note dated 06/26/25 indicated Resident #34's range was limited in both legs but especially the right due to Resident #34 reporting pain when moved. Nursing was aware. Review of a progress note dated 06/26/25 at 11:40 P.M. revealed Resident #34 complained of right hip pain to the day shift nurse. An x-ray was ordered and results indicated in intertrochanteric fracture (type of hip fracture that occurs in the region between the greater and lesser trochanters (bony projections) of the thigh bone). The Director of Nursing (DON) and physician were notified of the abnormal x-ray and ordered Resident #34 be transferred to the emergency room for fracture evaluation. Resident #34's relative was notified by phone. During an interview on 08/19/25 at 10:04 A.M., Physical Therapy Assistant (PTA) #100 stated Resident #34 had been in the facility for a long time and was able to communicate pain. PTA #100 indicated she had been providing therapy services for Resident #34 and she had been able to stand with assistance at the turn stand. However, she was working with another resident one day when another PTA attempted to get Resident #34 to stand but she was unable. Resident #34 had neuropathy but the quality/severity of her pain prior to the fracture being discovered was different than her usual which was why therapy made sure nursing was made aware of the complaints. During interviews of five certified nursing assistants (dates/times not recorded due to a voiced desire to remain anonymous) who acknowledged familiarity with Resident #34, the following was revealed: One of the nursing assistants stated Resident #34 started complaining of pain every time she was rolled onto her right hip for at least a couple weeks before the x-ray was obtained. The information was shared with nursing. Some nurses would go in and feel her hip and leg but she was unaware of any action taken after that. Resident #34 did not complain of pain while at rest with the exception of a few times when she was sitting up in her chair. Another nursing assistant stated Resident #34 complained of pain for two to three weeks when turned prior to the x-ray being obtained. The nursing assistant stated moving aggravated the pain. Sometimes after transferring to the wheelchair from the bed, Resident #34's appetite would be decreased which she attributed to pain. The nursing assistant stated there was no place for nursing assistants to document information about residents. Notifications were completed verbally. One nursing assistant (third nursing assistant) stated Resident #34 complained of pain for over two weeks before the x-ray was obtained. The nursing assistant reported she had notified five nurses. The nursing assistant stated she was unaware there was an area in the aide documentation to indicate pain. The nursing assistant indicated she did not know if nurses had access to the information so all notifications of the pain were made verbally. Another nursing assistant stated Resident #34 complained of pain for about three weeks prior to the x-ray of her hip being obtained. The nursing assistant stated she reported the pain to nurses (could not recall which ones) that Resident #34 was having pain with movement. A fifth nursing assistant reported Resident #34 was complaining of pain with movement as early as mid-June. Nurses were made aware. On 08/19/25 at 11:14 A.M., the Director of Nursing (DON) was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366096 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 366096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Salem West Healthcare Center 2511 Bentley Drive Salem, OH 44460 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 0697 Level of Harm - Actual harm Residents Affected - Few interviewed regarding the documentation from therapy notes which revealed multiple complaints of pain over multiple days without evidence of physician notification until 06/26/25. The DON stated she might have copies of facsimiles and would research. On 08/19/25 at 12:48 P.M., the DON provided documentation from nursing assistants which indicated no changes were noted in Resident #34's condition in June 2025. The DON also indicated and provided the Medication Administration Record (MAR) from June 2025 indicating Resident #34's pain was assessed every shift with multiple shifts indicating no pain. The DON verified the assessments were completed at a certain point in the shift and may have reflected pain at rest. The DON was unable to provide an explanation of therapy documenting Resident #34's pain was reported to nursing and the lack of physician notification of the ongoing complaints of pain with therapy. On 08/20/25 at 1:17 P.M., Licensed Practical Nurse (LPN) #120 stated she recalled being informed of Resident #34's pain but could not recall dates, stating complaints of pain were an ongoing occurrence. Resident #34 had behaviors and a history of yelling out making it difficult to determine if the yelling out was a behavior or related to pain. LPN #120 was unable to state action, if any, she took in relation to reports of pain. Review of the undated facility policy Pain Management and Assessment revealed acute pain refers to pain that is usually sudden in onset and time-limited with a duration of less than one month and often is caused by injury, trauma, or medical treatments such as surgery. It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety is a primary concern for our residents, staff and visitors. The purpose of this policy is to provide guidance to the clinical staff to support the intent of (the regulatory reference) that based on the comprehensive assessment of a resident, the facility must ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management. There is no objective test that can measure pain. The clinician must accept the resident's report of pain. Clinical observations clarify information from the resident. Site of discomfort may direct the nurse to specific types of pain-relief measures. To the extent possible and in consideration of cognitive abilities, the nurse will provide a thorough assessment by observation of activities and treatment/relief for detection of pain and to attempt to identify location and any limitations imposed by the pain. Clues may include not participating in favorite activities or outings, facial grimaces during care, guarding or protecting a body limb or part, unexplained behaviors when the resident is unable to verbalize. Characteristics of pain, such as: intensity, pattern, location, frequency, duration.Impact of pain on quality of life including but not limited to sleep loss, function abilities, appetite and mood.Physical and psychosocial issues including physical examination of the site of the pain, movement, activity that causes the pain, as well as any discussion with resident about any psychological or psychosocial concerns that may be causing or exacerbating the pain. Pain Scale for Assessing Pain a. The Pain AD Scale1.Use for dementia related, cognitively impaired including but not limited to those with Alzheimer's Dementia that utilizes nurse observations such as breathing, moaning, tenseness, distracted, frightened b.The Verbal-Descriptor Scale1. Used for those residents who may be unable to comprehend numbers such as those with low education levels, English not their primary language; descriptive words (mild, moderate, severe, extreme) correlate to the 1-10 Pain scale For example, severe is a 6 on the 1-10 pain scale c. The 1-10 Pain Scale 1. For residents with intact cognition abilities who can /are willing to determine their worst pain ever ( l0) and no pain (1) range using numbers Pharmological and non-pharmological resident centered interventions for pain management are also documented. This deficiency represents non-compliance investigated under Master Complaint Number 1374425 (OH00167430) and Complaint Number (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366096 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 366096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Salem West Healthcare Center 2511 Bentley Drive Salem, OH 44460 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 0697 1374412 (OH00167460). Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366096 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 366096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Salem West Healthcare Center 2511 Bentley Drive Salem, OH 44460 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 - Some 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 medical record review and interview, the facility failed to ensure accuracy of medical records regarding bathing. This affected four (Residents #4, #5, #51 and #63) of six residents reviewed for provision of showers.Findings include: 1. Review of Resident #51's medical record revealed diagnoses including schizophrenia, bipolar disorder, depression, anxiety disorder, anxiety disorder, obsessive-compulsive disorder and dependent personality disorder. A nursing note dated 07/16/25 at 8:50 A.M. indicated Resident #51 was transferred out for a geriatric psych hospitalization. Review of nurse aide documentation in the electronic health record revealed Resident #51 was not available for showers/bathing on 07/23/25 and 07/27/25. However, shower sheet and body/skin inspection forms dated 07/23/25 and 07/27/25 indicated Resident #51 accepted showers and had skin assessments completed by nurses. Resident #51 was readmitted to the facility on [DATE]. During an interview on 08/21/25 at 11:00 A.M., it was addressed with the Director of Nursing that staff documented showers were given and skin assessments completed for Resident #51 while he was out at the hospital. No valid explanation was provided.2. Review of Resident #63's medical record revealed diagnoses including bipolar disorder, schizoaffective disorder, anxiety disorder, heart disease, congestive heart failure, and atrial fibrillation. Review of bathing records in the electronic health record revealed showers/bathing was not attempted due to medical condition or safety concerns on 07/23/25, 08/06/25 and 08/10/25. Review of shower sheets revealed inconsistencies with documentation in the electronic health record. Shower sheets on 07/23/25, 08/06/25 and 08/10/25 revealed Resident #63 refused showers instead of the shower not being attempted. There was a separate place in the electronic health record to indicate if showers were refused.On 08/18/25 at 2:03 P.M., Resident #63 stated he is told showers could not be offered at times due to staffing issues. Resident #63 denied showers were offered in accordance with the shower schedule.On 08/21/25 at 11:00 A.M. inconsistencies in documentation between the electronic health record and shower sheets were addressed with the DON who indicated she would need to educate nursing assistants on documentation.3. Review of Resident #4's medical record revealed diagnoses including chronic obstructive pulmonary disease, conduct disorder, generalized muscle weakness, contractures of multiple sites, and schizophrenia. A care plan initiated 09/27/22 indicated Resident #4 had activity of daily living (ADL) self-care performance deficit. Resident #4 required a hoyer for all transfers with two assists. Resident #4 was totally dependent on staff for all ADLs including bathing. Aide documentation in the electronic health record revealed between 07/20/25 and 08/17/25 staff documented showers were not attempted due to environmental limitations on 07/27/25 and 08/17/25. A shower was not attempted on 07/20/25 due to medical condition or safety concerns. However, a shower sheet and body/skin inspection form was provided for 07/27/25 indicating a shower was accepted.On 08/21/25 at 11:00 A.M. inconsistencies in documentation between the electronic health record and shower sheets were addressed with the DON who indicated she would need to educate nursing assistants on documentation.4. Review of Resident #5's medical record revealed diagnoses including Parkinson's disease, dementia, psychosis, type two diabetes mellitus, anxiety disorder, and post-traumatic stress disorder. A care plan regarding ADL self care performance deficit initiated 06/19/23 indicated Resident #5 was totally dependent on staff for bathing. Review of bathing records between 07/24/25 and 08/17/25 revealed documentation in the electronic health record indicated bathing was not attempted due to environmental limitations on 07/27/25 and 08/17/25. However, shower sheets were provided indicated a shower was accepted on 07/27/25.On 08/21/25 at 11:00 A.M. inconsistencies in documentation between the electronic health record and shower sheets were addressed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366096 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 366096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Salem West Healthcare Center 2511 Bentley Drive Salem, OH 44460 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 with the DON who indicated she would need to educate nursing assistants on documentation.This deficiency is an incidental finding discovered during the complaint investigation. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366096 If continuation sheet Page 8 of 8