Inspection·August 26, 2021

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review, review of liability notices and staff interview, the facility failed to ensure residents received the appropriate liability notices and timely notification when their skilled services ended. This affected three (Residents #15, #23 and #50) of three residents reviewed for liability notices. Facility census was 52. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 05/24/21 with diagnoses including multiple myeloma (cancer), hypertension, muscle weakness and lack of coordination. Resident #15 remained in the facility after discontinuation of Medicare A services. However, the facility did not provide the resident with the Advanced Beneficiary Notice (ABN) which would have informed him of the daily rate to remain in the facility along with other options. Interview on 08/24/21 at 4:57 P.M. with Admissions #573 verified Resident #15 did not receive the ABN prior to services ending. 2. Review of the medical record for Resident #23 revealed an admission date of 10/01/18 with diagnoses including diabetes mellitus, chronic obstructive pulmonary disease and difficulty walking. Resident #23 remained in the facility after discontinuation of Medicare A services. However, the facility did not provide the resident with the ABN which would have informed him of the daily rate to remain in the facility along with other options. Also, the Notice of Medicare Non-Coverage (NOMNC) was signed by the resident but was not dated by his signature. Interview on 08/24/21 at 4:57 P.M. with Admissions #573 verified Resident #23 did not receive the ABN prior to services ending. Admissions #573 also verified the NOMNC was signed by the resident but was not dated by his signature. 3. Review of the medical record for Resident #50 revealed an admission date of 07/08/21 with diagnoses including congestive heart failure, diabetes mellitus and difficulty walking. Resident #50 was discharged from the facility on 08/03/21. Review of the NOMNC indicated her last covered day was 08/02/21. However, Resident #50 received the notice on 08/01/21. The NOMNC also did not indicate what services were being discontinued or who to contact for an appeal. Interview on 08/24/21 at 4:57 P.M. with Admissions #573 verified Resident #50 did not receive the NOMNC greater than 48 hours of being cut from Medicare A services. Admissions #573 also verified the NOMNC did not indicate what services were being discontinued or who to contact for an appeal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366123 If continuation sheet Page 2 of 7 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 366123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accord Care Community Orrville LLC 1980 Lynn Drive Orrville, OH 44667 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to provide privacy during family visits. This affected two (Resident #28 and Resident #32) of five residents observed for visitation. The census was 52. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including schizophrenia, major depressive disorder, and agoraphobia with panic disorder. The resident's brother was listed as his next of kin and durable power of attorney. Review of the annual comprehensive minimum data set assessment (MDS) dated [DATE] indicated Resident #28 was moderately impaired in daily decision-making ability and it was somewhat important to the resident to be able to use the telephone in private. Interview and observation on 08/24/21 at 2:12 P.M. revealed Resident #28 in the front lobby visiting with his brother, both were seated at a table six feet apart. Resident #28's brother stated that the visits were difficult due to the front lobby noise created by delivery services, staff entering and leaving, and the receptionist taking calls. 2. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, cognitive communication deficit and diabetes. His spouse was his emergency contact. Review of the care plan initiated 07/17/21 indicated Resident #32 was at risk for psychosocial well-being concerns related to medically imposed restrictions related to COVID 19 precautions. The interventions indicated to provide/offer alternative means of communication with families/visitors to prevent feelings of social isolation. Review of the admission MDS dated [DATE] indicated Resident #32 was moderately cognitively impaired in daily decision-making ability and it was very important to him to be able to use the telephone in private. Interview and observation on 08/25/21 at 9:38 A.M. revealed Resident #32 in the front lobby with his spouse. Resident #32's spouse stated that they visit for only a half hour and there was no privacy when visiting. The spouse stated that she tried to do an outside window visit but the weeds were too high to get to the windows. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366123 If continuation sheet Page 3 of 7 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 366123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accord Care Community Orrville LLC 1980 Lynn Drive Orrville, OH 44667 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations, record review and interview, the facility failed to maintain a clean and sanitary environment and ensure bed linens were clean. This affected three (Residents #28, #29 and #38) of 52 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #38 revealed an admission date of 04/23/19. Diagnoses included unspecified dementia, anxiety disorder, excoriation (skin-picking) disorder, atopic dermatitis, and pruritis. Observations on 08/23/21 at 12:05 P.M. revealed Resident #38 was dressed, lying her head on the pillowcase which had spots of dry blood. The resident also had two bandages on her left forearm. The resident verified the blood on the pillowcase and stated the pillowcase was changed a couple of days ago. Observations on 08/23/21 at 1:41 P.M. revealed Resident #38 was lying her head on the same pillowcase. On 08/23/21 at 1:57 P.M. Licensed Practical Nurse (LPN) #500 verified the blood on the pillowcase and stated he would change the pillowcase immediately. 2. Medical record review for Resident #29 revealed an admission date of 04/20/12 with diagnoses including dysphagia (difficulty swallowing), diabetes mellitus, aphasia (inability to communicate), hemiplegia (paralysis on one side of the body), contractures of left and right wrist, dementia and hypertension. Observations on 08/23/21 at 12:13 P.M. and 4:41 P.M., 08/24/21 at 4:24 P.M. and 08/25/21 at 7:43 A.M., revealed Resident #29's room to have dried brown beige liquid drips on the tube feed pole and base, and large heavily saturated area on the carpet in the front of the tube feed pole. The color of these areas resembled the tube feed that was hanging on the tube feed pole. Interview on 08/25/21 at 7:43 A.M. with State Tested Nurse Aide (STNA) #555 verified dried tube feed on the tube feed pole and on the carpet in front of the tube feed pole. STNA #555 stated she believed the carpet was stained. Review of the Guest Room Cleaning Checklist, undated, revealed staff were to ensure floor was clean. 3. Medical record review for Resident #28 revealed an admission date of 03/01/18 with diagnoses including chronic obstructive pulmonary disease, schizophrenia, depression and lack of coordination. Observations on 08/23/21 at 10:30 A.M., 08/24/21 at 7:59 A.M. and 08/25/21 at 7:42 A.M., revealed Resident #28's room to have trash on the carpet including pieces of candy paper and a used band-aid. Interview on 08/25/21 at 7:43 A.M. with STNA #555 verified the resident's floor had trash on it and needed to be vacuumed. STNA #555 stated housekeeping was supposed to sweep everyday. Review of the Guest Room Cleaning Checklist, undated, revealed staff were to ensure floor was clean. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366123 If continuation sheet Page 4 of 7 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 366123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accord Care Community Orrville LLC 1980 Lynn Drive Orrville, OH 44667 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 0584 This deficiency substantiates Complaint Number OH00125088. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366123 If continuation sheet Page 5 of 7 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 366123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accord Care Community Orrville LLC 1980 Lynn Drive Orrville, OH 44667 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to administer pain medications in a timely manner. This resulted in actual harm for one (Resident #200) of five residents review for medication administration. Resident #200 experienced severe pain when pain medication was not provided for approximately 23 hours after admission. The census was 52. Residents Affected - Few Findings include: Review of Resident #200's medical record revealed an admission date of 08/20/21 at 1:15 A.M. Diagnoses included encounter for surgical orthopedic aftercare and lack of coordination and abnormalities of gait and mobility. Review of the hospital discharge orders dated 08/19/21 revealed Resident #200 was ordered oxycodone (opioid pain medication) 5 milligram (mg) every six hours as needed for pain. Review of the medication administration record (MAR) from the hospital revealed Resident #200 received oxycodone 5 mg at 10:29 P.M. on 08/19/21. Review of the nurse admission screener assessment dated [DATE] at 2:41 A.M. revealed Resident #200 rated his pain level 10 out of 10 (a 10 on the pain scale represents the most severe or worst pain you have ever experienced). Review of the MAR revealed an order for a lidocaine patch daily to the left knee for pain dated 08/20/21, an order for methocarbamol (muscle relaxant) 500 mg every six hours dated 08/20/21, an order for oxycodone 5 mg every six hours for pain dated 08/20/21. Further review revealed Resident #200 did not receive oxycodone 5 mg until 08/21/21 at 12:30 A.M. Review of the nurse's note dated 08/20/21 at 4:00 A.M. revealed Resident #200 would not let the nurse remove bandage on left femur because the hospital just changed it and it was too painful. Resident #200 asked for pain medications, the resident was told no medications for him at that time. Interview on 08/23/21 at 10:15 A.M. with Resident #200 stated that he was admitted to the facility at 1:15 A.M. after having surgery for a fractured hip. Resident #200 stated he asked for pain medications but was told they could not give him any until the next day because they did not have the medications. Review of the plan of care dated 08/24/21 revealed Resident #200 was at risk for pain related to let hip surgery due to fall with fracture. Interventions included to administer analgesia as ordered, give 30 minutes before treatments or care, evaluate the effectiveness of pain interventions every shift, compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results. Monitor/record pain characteristics every shift and as needed. Interview on 08/26/21 at 9:07 A.M. with Licensed Practical Nurse (LPN) #545 stated that Resident #200 asked for pain medications upon admission, but the resident could not receive the medications until the orders were put into the system. LPN #545 stated she called the pharmacy several times between 1:30 A.M. and 6:00 A.M. because the resident was asking for Ativan (antianxiety medication). LPN#545 stated she was in and out of the resident's room throughout the shift and had asked the resident if he was in any pain and Resident #200 stated that he was always in pain. LPN #200 could not state (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366123 If continuation sheet Page 6 of 7 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 366123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accord Care Community Orrville LLC 1980 Lynn Drive Orrville, OH 44667 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 why the oxycodone was not administered as ordered. Level of Harm - Actual harm Interview on 08/26/21 at 9:24 A.M. with the Administrator and Director of Nursing (DON) confirmed Resident #200 was admitted on [DATE] at 1:15 A.M. but neither staff could verify whether staff administered ordered pain medications. The administrator stated the facility had pain medications in the startup box that should have been pulled for Resident #200. Residents Affected - Few Review of the comprehensive Minimum Data Set (MDS) assessment, dated 08/27/21, revealed Resident #200 had intact cognition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366123 If continuation sheet Page 7 of 7