Inspection·September 16, 2025

F 0686 Level of Harm - Actual harm Residents Affected - Few wound healing, signs and symptoms of infection, wound size measurements and stage of wound, obtain and monitor laboratory/diagnostic work as ordered and report results to the physician, and treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. A review of Resident #95's physician's orders revealed an ordered dated 05/19/25 to cleanse coccyx with normal saline, pat dry, apply Allevyn Life dressing (dressing for the prevention and treatment of pressure injuries and other wounds) to the coccyx to pad and protect the area every other day and as needed for preventative treatment every night shift (11:00 P.M. to 7:00 A.M.). The order was noted due to the resident's history of a healed pressure ulcer to this area. The order indicated to sign and date the dressing when completed. A review of Resident #95's medical record revealed a skin evaluation assessment dated [DATE]. The assessment included the area was cleaned with normal saline, pat dried and a dry dressing was applied as ordered to pad and protect. The assessment note included the resident's skin was intact and the dressing remained dry and intact. A review of Resident #95's weekly skin evaluation/assessment dated [DATE], completed by Licensed Practical Nurse (LPN) #100, documented the resident had no new areas of skin breakdown identified, and dressing was intact to the coccyx. The evaluation included the resident's skin was intact with no new issues. The assessment indicated Resident #95 was at risk for the development of pressure ulcers. (However, there was no evidence the dressing that was in place at the time of the assessment on this date (used to pad and protect) was actually removed during this skin evaluation to determine if the resident had skin breakdown to the coccyx). This was the last weekly skin evaluation documented prior to the resident being transferred 07/03/25 hospitalization. A review of Resident #95's progress note dated 07/03/25 revealed at 9:06 A.M. the nurse found Resident #95 moaning in pain and lethargic. Resident #95's blood sugar was obtained, and the result was 36 milligrams/diluent (mg/dL). Orange juice was provided, blood sugar was re-checked, and the reading was 27 mg/dL. Glucagon was administered, the blood sugar was checked and the glucometer read low. The physician was notified and 911 was called. While waiting for emergency medical services (EMS) Resident #95's blood sugar was checked, and the result was 51 mg/dL and moments later was 24 mg/dL. Resident #95 was transferred to the hospital. A review of Resident #95's hospital emergency room documentation dated 07/03/25 revealed the resident had a Stage II pressure ulcer (the top layer of skin (epidermis) is broken; it looks like a shallow open sore. There may be mild swelling, oozing or pus.) the size of a quarter with surrounding erythema (redness), warmth, induration (a hardening or thickening of the tissue surrounding the wound.). A computerized tomography (CT) scan with contrast was obtained which revealed the presence of extensive gas forming soft tissue infection at the lower back extending to the tip of the coccyx measuring 9.0 centimeters (cm) by 2.3 cm by 16.1 cm pressure ulcer at the sacrum with no definitive osteomyelitis. Resident #95's blood sugar continued to drop, and she was administered dextrose 10 percent, antibiotics were started, and the hospital nurse informed the facility Resident #95 would be admitted to the hospital with diagnoses of sepsis with acute hypoxic respiratory failure without septic shock, necrotizing soft tissue infection, acute respiratory failure with hypoxia, pneumonia of the right lower lobe due to infectious organism, acute cystitis without hematuria. The hospital documentation did not state if there was a dressing to Resident #95's sacrum/coccyx upon arrival to the hospital. Resident #95 was hospitalized until 07/12/25, at which time she returned to the facility. The resident was discharged to the hospital again on 07/25/25 due to a low hemoglobin level with no active sign of bleeding and did not return to the facility. An interview with Wound Registered Nurse (WRN) #103, the facility wound nurse, on 09/09/25 at 1:41 P.M. revealed she had assessed the resident upon admission and the resident did not have any pressure ulcers. WRN revealed the floor nurses were then responsible to complete weekly skin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366113 If continuation sheet Page 2 of 6 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 09/16/2025 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 0686 Level of Harm - Actual harm Residents Affected - Few assessments/evaluations and should notify her if a resident developed or had a pressure ulcer develop following admission. During the interview, WRN #103 verified the skin evaluation/assessments dated 06/16/25 and 06/30/25 were incomplete as they failed to include evidence the staff completed the assessments had actually looked at the resident's skin under the dressing that was in place. WRN #103 was unable to provide any information as to when the pressure ulcer had actually developed. WRN #103 agreed the weekly skin assessment dated [DATE] indicated the coccyx dressing was intact but there was no actual skin assessment of the area underneath the dressing documented in Resident #95's medical record. WRN #103 verified on 07/03/25 the resident was admitted to the hospital and the hospital first identified the resident had an infected Stage II pressure area. She stated the nurses should have removed the dressing to assess the resident's skin prior to have identified this ulcer sooner. WRN #103 revealed staff were documenting they were changing the resident's dressing every other day as ordered; however, there was no documentation of an actual description of the resident's coccyx under the pad and protect dressing during the resident's stay in the facility. During the interview, WRN #103 revealed she did not personally see Resident #95 for wound care because the facility staff had not identified the resident had a Stage II pressure ulcer or that the ulcer was infected prior to the resident being transferred to the hospital on [DATE]. An interview with Physician #102 (Infectious Disease Physician) on 09/09/25 at 4:05 P.M. revealed Resident #95 had a pressure ulcer located on the coccyx upon her arrival to the hospital. Surgery was performed to debride the coccyx area. The physician revealed the pressure ulcer had become infected during the resident's stay at the extended care facility. An interview with LPN #100 on 09/09/25 at 4:25 P.M. revealed she had completed the most recent weekly skin evaluation on 06/30/25 prior to Resident #95's admission to the hospital on [DATE]. During the interview, LPN #100 stated she did not actually remove the pad and protect dressing to Resident #95's coccyx to inspect the area for skin breakdown. LPN #100 stated she was unable to say if Resident #95's coccyx area had developed a pressure ulcer at the time the assessment was completed. An interview with LPN #101 on 09/11/25 at 7:40 A.M. revealed he had completed Resident #95's preventative wound treatment on 06/30/25. During the interview, LPN #101 stated he was unable to remember what the resident's coccyx area looked like at the time. An interview with Quality Assurance Nurse (QAN) #104 on 09/09/25 at 3:00 P.M. verified the above findings and agreed the facility staff failed to ensure adequate and ongoing assessments were being completed for Resident #95. QAN #104 also verified the assessment/evaluation documented on 06/30/25 was not comprehensive or complete to ensure the resident's skin had actually be assessed under the pad and protect dressing that was in place. The facility policy and procedure titled Pressure Ulcer Prevention and Care Protocol revised 1/2025 revealed the licensed nursing staff would use the following criteria as part of the resident's comprehensive assessment to determine risk of pressure ulcer development and development of the resident's plan of care. Risks and complications unique to the resident would be documented on the resident's individualized plan of care. The prevention and care interventions developed through the assessment would be noted on the plan of care and followed by the direct care staff. The risk assessment criteria included: A head-to-toe examination of the skin for Stage I or greater pressure ulcer, scar over a bony prominence (healed pressure ulcers), or non-removable dressing/device and any alteration in skin condition. Review of medical history/medical record for co-morbid conditions Assessment of oxygen transport/tissue perfusion and BP Advanced Age Ability to move, turn, transfer and ambulate Presence of Trauma, Tremors, Spasticity Incontinence/skin moisture Medication review Treatments such as Chemotherapy, Radiation, Dialysis Nutritional status and hydration Hygiene Review laboratory data Cognitive status Psychosocial status Behaviors Refusal of care This deficient practice (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366113 If continuation sheet Page 3 of 6 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 09/16/2025 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 0686 represents noncompliance investigated under Master Complaint Number 2608745 and Complaint Numbers 2604131 and 1334558 (OH00167327). Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366113 If continuation sheet Page 4 of 6 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 09/16/2025 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 Based on record review, observation, interview and facility policy review, the facility failed to ensure staff performed hand hygiene to prevent the cross contamination of germs during Resident #61 and Resident #44's medication administration and Resident #58's incontinence care. This affected two (Residents #61 and #44) out of seven residents observed for medication administration and one (Resident #58) out of three residents reviewed for incontinence care. The facility census was 93. Findings include:1. A review of Resident #61's medical record revealed an admission date of 01/22/25 with diagnoses including dementia, chronic kidney disease, anxiety, gastroesophageal reflux disease, depression, high blood pressure, cerebral vascular disease with stroke, influenza, encephalopathy, high cholesterol, and urinary tract infection. Resident #61's Medication Administration Record (MAR) dated 09/01/25 to 09/30/25 indicated to administer the following medications orally during the evening: Multivitamin one tablet (supplement) Cyproheptadine hydrochloride 4 milligrams (mg) (antihistamine) 2. A review of Resident #44's medical record revealed an admission date of 07/19/25 with diagnoses including atherosclerotic heart disease, aortocoronary bypass graft, cerebral vascular disease with stroke, heart disease with heart failure, heart arrhythmias, prosthetic heart valve, kidney disease, chronic obstructive pulmonary disease, diabetes mellitus, bone, digestive organ and prostate cancer, anemia, high blood pressure and cholesterol, gastroesophageal reflux disease, vitamin D deficiency, obesity, sleep apnea, reflex uropathy with urinary tract infection. A review of Resident #44's MAR dated 09/01/25 to 09/30/25 indicated to administer the following medications in the evening orally: Tamsulosin 0.4 mg (medication to treat benign prostatic hypertrophy) An observation on 09/08/25 between 3:30 P.M. and 4:00 P.M. of Licensed Practical Nurse (LPN) #100 administer medications to Resident #61 and Resident #44 revealed a failure to perform hand hygiene to prevent the spread of germs. LPN #100 administered medications to Resident #81 and did not perform hand hygiene and approached the medication cart. LPN #100 proceeded to obtain and dispense Resident #61's medications from the medication cart into a medication cup. LPN #100 then entered Resident #61's room and administered the cup of medications to Resident #61. LPN #100 exited Resident #44's room and did not perform hand hygiene and proceeded to obtain Resident #44's medications from the medication cart. LPN #100 was stopped and asked to perform hand hygiene before obtaining the medications from the medication cart. An interview with LPN #100 on 09/08/25 at 4:00 P.M. verified she had failed to perform hand hygiene between Resident #81's, Resident #61's and Resident #44's medication administration task. 3. A review of Resident #97's medical record revealed an admission date of 09/05/25 with diagnoses including heart attack, respiratory failure, obstructive sleep apnea, morbid obesity, venous insufficiency, constipation, heart failure, chronic right/left calf ulcers, dermatophytosis, soft tissue disorder, lymphedema, and plasma-protein disorder. Resident #97's immediate needs plan of care initiated on 09/05/25 indicated Resident #97 had bowel and bladder incontinence, needed two staff to assist her with toileting needs. An observation on 09/10/25 at 7:35 A.M. of Certified Nursing Assistant (CNA) #104 and CNA Supervisor (CNAS) #105 assist Resident #97 with incontinence care revealed a failure to perform hand hygiene to prevent the spread of germs. CNA #104 gathered the supplies needed for the task and placed the items on the over-the-bed table. CNA #104 donned a pair of gloves and proceeded to clean Resident #97's perineal area and buttocks of feces using several wet disposable wipes. CNA #104 did not remove her soiled gloves and perform hand hygiene upon completing the incontinence care task. CNA #104 then proceeded to assist the resident with donning heel protector boots, a pair of pants and placed the Hoyer (mechanical lift) pad under Resident #97 preparing to transfer Resident #97 to her wheelchair using the same soiled gloved hands she used for the incontinence care task. An interview with CNA #104 on 09/10/25 at 8:00 Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366113 If continuation sheet Page 5 of 6 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 09/16/2025 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete A.M. verified the above findings and agreed she should have removed her soiled gloves and performed hand hygiene after completing Resident #97's incontinence care. The facility policy and procedure titled Handwashing/Hand Hygiene dated 11/2024 indicated the policy was all personnel shall follow our established handwashing/hand hygiene procedures to prevent the spread of infection and disease to other residents, personnel and visitors. This policy is based on Centers for Disease Control and Prevention (CDC) guidance for healthcare providers. Employees must perform appropriate fifteen (15) second handwashing using antimicrobial or non-antimicrobial soap and water under the following conditions: a. When hands are visibly dirty or soiled with blood or other body fluids.b. After caring for a person with known or suspected infectious diarrhea.c. After known or suspected exposure to spores, e.g. B. anthracis, c. difficile outbreaks.d. Before eating and after using a restroom If hands are not visibly soiled, use of an alcohol-based hand rub containing 60-95% ethanol or isopropanol is acceptable for all the following situations: a. Before contact with residents.b. Before preparing or handling medications.c. Before handling clean dressings/treatment items. d. Before performing an aseptic task (placing an indwelling catheter or handling invasive medical devices);e. After contact with resident's intact skin. f. After contact with blood, body fluids, secretions, mucous membranes, or contaminated surfaces; (if hands are not visibly soiled). g. After contact with inanimate objects in the immediate vicinity of the resident; and h. Before handling food trays, between trays if touching the resident or other objects other than setting up the meal tray and before feeding the residenti. Immediately after glove removal. J. Before moving from work on a soiled body site to a clean site on the same resident. The purpose of the policy was to reduce the incidence of healthcare associated infections. This deficient practice represents noncompliance investigated under Master Complaint Number 2608745 and Complaint Number 2604131. Event ID: Facility ID: 366113 If continuation sheet Page 6 of 6