Health inspection·August 29, 2023

F 0759 Level of Harm - Minimal harm or potential for actual harm carbidopa-levodopa as the family provided the medication until the pharmacy supplied it. The DON further stated that the starter box was not utilized as it did not have the medications needed for Resident #35. This deficiency represents noncompliance investigated under Complaint Number OH00145599. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366113 If continuation sheet Page 2 of 4 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 366113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Health Care Center Inc 1355 Churchill Hubbard Rd Youngstown, OH 44505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review the facility failed to maintain acceptable infection control practices during blood glucose monitoring and medication administration to prevent the spread of infection. This affected five residents (#22, #26, #34, #56 and #68) out of five residents observed for medication administration. The facility census was 97. Residents Affected - Some Findings include: 1. Review of medical record for Resident #26 revealed an admission date of 02/10/22 with diagnoses including Alzheimer's disease, peripheral vascular disease, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26's cognition was moderately impaired. Review of the physician orders for August 2023 revealed Resident #26 was ordered Novolog injection (insulin Aspart) per sliding scale as follows: if 200 to 250 inject two units, if 251 to 300 inject four units, if 301 to 350 inject six units, if 351 to 400 inject eight units, if greater than 400 call primary care physician, to be given subcutaneously before meals and at bedtime for type two diabetes mellitus. On 08/28/23 at 11:05 A.M. Licensed Practical Nurse (LPN) #260 was observed while gathering supplies to check Resident #26's blood sugar. LPN #260 placed the glucometer and lancet device on top of medication cart without placing a barrier prior to putting the items down. Without performing hand hygiene, LPN #260 donned gloves, cleansed Resident #26's finger with an alcohol prep pad and performed a finger stick. LPN #260 then placed used lancet device on medication cart with no barrier and picked up glucometer to get a blood sugar reading. While waiting for the glucometer to result, LPN #260 placed the glucometer with no barrier underneath, on a notebook on top of the medication cart. With the same gloves on, LPN #260 proceeded to prepare insulin pen and administered Novolog per physician orders. LPN #260 threw supplies away in sharps container. LPN #260 doffed gloves and did not perform hand hygiene. LPN #260 then cleansed glucometer with an alcohol wipe before putting glucometer in designated drawer in medication cart. 2. Observation on 08/28/23 at 11:10 A.M. of medication administration for Resident #22 with LPN #260 revealed LPN #260 prepared medications without performing hand hygiene. LPN #260 entered Resident #22's room and watched while Resident #22 then took all the medications. LPN #260 then exited room without performing hand hygiene. Interview on 08/28/23 at 11:13 A.M. with LPN #260 confirmed the glucometer and lancet devices were placed on top of medication cart without a barrier underneath. LPN #260 also confirmed at this time that hand hygiene was not performed during blood sugar check for Resident #26 and medication administration for Resident #22. LPN #260 stated that she cleansed the glucometer with an alcohol prep pad because she thought she could. 3. Observation on 08/29/23 at 7:37 A.M. of medication administration for Resident #34 with LPN #208 revealed LPN #208 prepared medications without performing hand hygiene. LPN #208 entered Resident #34's room and gave Resident #34 the medication. LPN #208 observed to ensure all medications were taken, then exited the room without performing hand hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366113 If continuation sheet Page 3 of 4 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 366113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Health Care Center Inc 1355 Churchill Hubbard Rd Youngstown, OH 44505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 08/29/23 at 7:35 A.M. with LPN #208 confirmed no hand hygiene was performed before medication preparation, or before or after medication administration. 4. Observation on 08/29/23 7:37 A.M. of medication administration for Resident #68 with LPN #245 revealed LPN #245 began preparation of medications without performing hand hygiene. LPN #245 entered Resident #68's room and gave medications to resident. LPN #245 observed the resident take all medications prior to exiting room. LPN #245 then exited resident room and went to the medication cart to sign off given medications. No observation of hand hygiene was made after medication administration. 5. Observation on 08/29/23 7:48 A.M. of medication administration for Resident #56 with LPN #245 revealed LPN #245 began preparation of medications without performing hand hygiene. LPN #245 entered Resident #68's room and gave medications to resident. LPN #245 observed the resident take all medications prior to exiting room. LPN #245 then exited resident room and went to the medication cart to sign off given medications. No observation of hand hygiene was made after medication administration. Interview on 08/29/23 at 7:59 A.M. with LPN #245 confirmed no hand hygiene was performed before medication preparation, or before or after mediation administration for Residents #56 and #68. Review of the policy titled Medication Administration, dated 07/23, revealed staff are to use a sanitizing solution between residents. For oral medications staff are to wash hands with soap and water every three to five residents and if soiled. Hands are to be washed with soap and water after removal of gloves for injectable medications. Review of the policy titled Blood Glucose Monitoring, dated 07/23, revealed the glucometer is to be cleaned with and disinfected between each resident tested using EPA approved germicidal disinfectant effective against Blood Borne Pathogens. The glucometer will be visibly wet per EPA approved germicidal recommendations for Blood Borne Pathogens. The glucometer is to have a one-minute contact time with Oxivir wipe. This deficiency is an incidental finding discovered during the complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366113 If continuation sheet Page 4 of 4