Health inspection·May 24, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to ensure the resident and resident representative were notified of changes in medication and test results. This affected two (#5 and #19) of two residents reviewed for notification of change. The facility census was 28. Findings include: 1. Review of the medical record revealed Resident #5 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease, spinal stenosis lumbar region, essential hypertension, fibromyalgia, ulcer of esophagus without bleeding, dysphagia, mixed hyperlipidemia, major depressive disorder, generalized anxiety disorder, chronic kidney disease stage three, and chronic diastolic (congestive) heart failure. Review of the Minimum Data Set (MDS) assessment, dated 05/05/23, revealed the resident was cognitively intact. Review of a pharmacy recommendation, dated 05/02/23, revealed Resident #5 was prescribed the antidepressant Doxepin by mouth every night at bedtime for depression and anxiety and also took the antidepressant Zoloft 50 milligrams (mg) by mouth daily. The recommendation was to re-evaluate the continued use of Doxepin and consider if the medication can be discontinued as it was an anticholinergic and high risk medication in the elderly. On 05/08/23 the physician accepted the recommendation to discontinue the medication. Review of Resident #5's physician orders revealed an order dated 03/17/23 for Doxepin oral capsule 10 mg. The order was discontinued on 05/08/23. The medical record was silent of resident notification. Review of a nursing progress note, dated 05/11/23, revealed Resident #5 was noted, during a care conference, with shortness of breath, a loose productive cough, and lung sounds were noted with inspiratory and expiratory wheezes. A rescue inhaler was given as ordered with some relief and the physician was notified and waiting a response. Review of a nursing progress note, dated 05/11/23, revealed a new order received for a chest x-radiation (x-ray) and the diuretic Lasix 20 mg for three days. Resident #5 was updated on the order. Review of Resident #5's nursing progress note, dated 05/12/23, revealed x-ray results revealed no acute cardiopulmonary process. The medical record was silent for resident notification of the results. Interview on 05/21/23 at 9:27 A.M. with Resident #5 revealed she was not informed of medication changes stating one medication was discontinued with no explanation. Resident #5 stated she wanted to be involved in her health status updates as she did prior to living in a facility. Resident #5 further stated she recently had a x-ray and never received an update of the results. 2. Review of the medical record revealed Resident #19 was admitted on [DATE]. Diagnoses included major depressive disorder, Alzheimer's disease with late onset, unspecified dementia with other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366181 If continuation sheet Page 2 of 14 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 366181 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand Rapids Care Center 24201 W 3rd St Grand Rapids, OH 43522 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 0580 behavioral disturbance, and gastro-esophageal reflux disease without esophagitis. Level of Harm - Minimal harm or potential for actual harm Review of the MDS assessment, dated 04/13/23, revealed the resident was severely cognitively impaired. Residents Affected - Few Review of Durable Power of Attorney documentation, dated 11/03/14, revealed Resident #19 had two named durable power of attorneys-in-fact. Review of a physician progress note, dated 02/15/23, revealed Resident #19 wandered, exhibited irritability, and reported lack of interest in food. The note stated the facility would start the cognition-enhancing medication Aricept five (5) milligrams (mg) by mouth nightly for management of behavioral and psychological symptoms associated with dementia. The medical record was silent for notification to Resident #19's representative of notification. Review of a physician order, dated 02/15/23 and continued on 04/05/23, revealed Resident #19 had an active order for Aricept oral tablet 5 mg by mouth. Interview on 05/22/23 at 5:17 P.M. with Resident #19's representative reported they were notified by pharmacy on an unknown date that Resident #19's insurance approved Resident #19 to receive Aricept. Resident #19 representative stated she never was notified of the new medication and it would not have been a medication Resident #19 would have wanted. Interview on 05/23/23 at 3:18 P.M., with the Director of Nursing (DON) verified there was no documentation of notification for Resident #5 and Resident #19's medication changes and Resident #5's x-ray results. Review of the policy titled, Resident Change in Condition, revised 07/02/21, revealed the resident/physician or the provider/family/responsible party will be notified when there has been a need to alter the resident's medical treatment including a change in provider orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366181 If continuation sheet Page 3 of 14 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 366181 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand Rapids Care Center 24201 W 3rd St Grand Rapids, OH 43522 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure resident rooms were maintained in good repair. This affected one (#6) of 28 residents reviewed. The facility census was 28. Findings include: Review of the medical record revealed Resident #6 was admitted on [DATE]. Diagnoses included schizophrenia, chronic obstructive pulmonary disease, and bilateral primary osteoarthritis. Review of the Minimum Data Set (MDS) assessment, dated 04/25/23, revealed the resident was moderately cognitively impaired. Observation on 05/21/23 at 8:30 A.M. revealed a wall in Resident #6's room had large scrapes and holes in the wall measuring approximately three feet long by one foot wide. Interview on 05/23/23 at 1:35 P.M. with Licensed Practical Nurse (LPN) #206 indicated she was not aware how long the scrapes and holes were present and appeared alarmed at the size of the wall damage. Interview on 05/23/23 at 1:42 P.M. with Maintenance #236 verified the holes in Resident #6's room started off as a small poke of a hole and became worse over time. Maintenance #236 reported the hole was there for an unknown amount of time but at least three months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366181 If continuation sheet Page 4 of 14 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 366181 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand Rapids Care Center 24201 W 3rd St Grand Rapids, OH 43522 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a self-reported incident, resident representative interview, staff interview, and facility policy review, the facility failed to timely report allegations of misappropriation to the State Survey Agency. This affected one (#19) of one resident reviewed for misappropriation. The facility census was 28. Findings include: Review of the medical record revealed Resident #19 was admitted on [DATE]. Diagnoses included major depressive disorder, Alzheimer's disease with late onset, unspecified dementia with other behavioral disturbance, and gastro-esophageal reflux disease without esophagitis. Review of the Minimum Data Set (MDS) assessment, dated 04/13/23, revealed the resident was severely cognitively impaired. Review of self-reported incident (SRI) #235054, dated 05/16/23, revealed Resident #19's family reported Resident #19 was missing a ring. The facility searched for the ring and could not find it. The report stated Resident #19 had dementia and could have taken the ring off anywhere, but the facility would continue to look for the ring. Social Services #206 was notified on 05/14/23 at 10:45 A.M. of the missing ring and notified the Administrator. The SRI was not created and submitted to the State Survey Agency until 05/16/23. Interview on 05/22/23 at 5:17 P.M. with Resident #19's representative reported while visiting Resident #19 on Sunday, 05/14/23, it was noticed that Resident #19's sapphire ring was not on her finger. Resident #19's representative reported the ring had high sentimental value and was monetarily valued at $2,500.00 over 20 years ago. It was reported a physician order was put in place every shift as a safety net to monitoring the ring, and the last time Resident #19's representative observed the ring was in March 2023. Interview on 05/23/23 at 9:51 A.M. with the Administrator verified the facility did not initiate a SRI within 24 hours related to Resident #19's ring. It was reported initially the facility considered the ring missing, and after a couple of days considered it under possible misappropriation. Review of the policy titled, Ohio Resident Abuse Policy, revised 10/03/22, verified all allegations of abuse, neglect, involuntary seclusion, injuries of unknown source, and misappropriation of resident property must be reported immediately to the Administrator, Director of Nursing, and to the applicable state agency. This deficiency represents non-compliance investigated under Complaint Number OH00143098. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366181 If continuation sheet Page 5 of 14 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 366181 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand Rapids Care Center 24201 W 3rd St Grand Rapids, OH 43522 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 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure interventions were implemented to prevent pressure ulcer development or worsening of a current pressure ulcer. This affected one (#28) of two residents reviewed for pressure ulcers. The facility census was 28. Residents Affected - Few Findings include: Review of Resident #28's medical record revealed an admission date of 02/20/23 with the diagnosis including, encephalopathy, diabetes mellitus type II, stage three sacral pressure ulcer, COVID-19, necrotizing fasciitis, neuropathic bladder, malnutrition, prothrombin gene mutation, dysphagia, anemia, thrombophilia, nephrotic syndrome, hypertension, and cerebral infarction. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #28 was assessed with severely impaired cognition, was dependent on staff for the completion of activities of daily living including bed mobility and transfers, was incontinent of bowel, had an indwelling urinary catheter, received all nutrition via tube feeding, and was at risk for pressure ulcer development with a stage IV pressure ulcer (full-thickness skin and tissue loss) present on admission. Review of a pressure ulcer risk assessment completed on 05/03/23 scored Resident #28 at very high risk for pressure ulcer development. Review of a nursing plan of care developed on 02/22/23 to address Resident #28 potential for skin breakdown related to immobility, diabetes mellitus type II, and incontinence revealed interventions included to turn and reposition as indicated, use pressure relieving devices as indicated, bilateral heel protectors as tolerated while in bed, bilateral pressure relieving boots as tolerated, elevate heels off the mattress per routine and/or as needed as resident allows, a specialty air mattress with bed bolsters as ordered, and a specialty wheelchair cushion as ordered. Review of wound specialist evaluation documentation on 05/15/23 revealed Resident #28 was evaluated for a stage IV pressure ulcer to the coccyx present on admission of 02/21/23. The wound description included measurements 6.5 centimeters (cm) long by 4.5 cm wide by 2.0 cm deep with undermining tissue measuring 3.0 cm at the 9:00 o'clock position. The wound was documented as improving. The wound specialist interventions included off loading heels, pressure reducing cushion, barrier cream each shift, plan of care discussed with nursing, reposition every two hours, limit time in the chair, and a low air loss mattress. On 05/21/23 at 10:07 A.M., Resident #28 was observed in bed with off loading boots placed to the overbed table in the corner of the room. Observation on 05/22/23 at 7:40 A.M., 8:55 A.M., and 9:29 A.M. noted Resident #28 in bed and positioned to the left with both legs in the fetal position (legs flexed toward chest) without offloading boots or interventions in place to bilateral heels. Resident #28's pressure relieving boots remains in the chair in his room. On 05/22/23 at 9:50 A.M., interview with State Tested Nurse Aide (STNA) #229 stated she assumed care for Resident #28 at 6:00 A.M. and had not checked the resident for incontinence not had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366181 If continuation sheet Page 6 of 14 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 366181 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand Rapids Care Center 24201 W 3rd St Grand Rapids, OH 43522 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 - Minimal harm or potential for actual harm Residents Affected - Few repositioned him. STNA #229 stated Resident #28 was to be checked every two hours due to frequent loose stools and current skin breakdown. STNA #229 also stated the off going staff was observed exiting the residents room at 6:00 A.M. On 05/22/23 at 9:58 A.M. observation noted STNA #229 and Licensed Practical Nurse (LPN) #200 to provide care to Resident #28. STNA #229 verified the resident was positioned in the same position for approximately four hours and had not been checked for incontinence or repositioned during her shift. STNA #229 proceeded to remove Resident #28 adult incontinence brief and discovered the resident incontinent of a large amount of liquid stool. Further observation confirmed stool was dried to the resident's buttocks. STNA #229 cleansed the stool from the resident and confirmed no barrier cream was in place. The resident's bilateral buttocks was observed with reddened tissue. Interview with LPN #200 at the time of observation on 05/22/23 at 9:58 A.M. verified no barrier cream was observed in place. Observation at that time revealed LPN #200 proceeded to remove a soiled pressure ulcer dressing to Resident #28's coccyx and replaced it with a clean dressing as ordered. Following the treatment the resident was positioned to the right side. Observation of the residents skin revealed indentation of bed linens to the resident's skin. On 05/22/23 at 11:05 A.M. interview with the Director of Nursing verified Resident #28 was required to be repositioned every two hours with pressure relief interventions implemented. Additional observations on 05/23/23 at 6:15 A.M. and 7:30 A.M. noted Resident #28 in bed without off loading boot or interventions to the bilateral heels. Resident #28's pressure relieving boots were observed in the room on the chair. Observation on 05/23/23 at 7:31 A.M. revealed LPN #206 assessed Resident #28's coccyx wound and it measured 6.2 cm long by 3.5 cm wide by 2.0 cm deep with 3.2 cm undermining. There were no observed pressure ulcers on Resident #28's heels. Review of the facility skin and wound care best practices, revised 06/10/22, revealed skin care and pressure injury prevention for residents at risk included to offload or suspend heels for at risk residents and reposition at a frequency determined by risk assessment to avoid pressure to bony prominence's. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366181 If continuation sheet Page 7 of 14 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 366181 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand Rapids Care Center 24201 W 3rd St Grand Rapids, OH 43522 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure physical therapy treatments and range of motion interventions were consistently implemented for a resident to prevent contracture and decreased joint mobility. This affected one (#28) of one residents reviewed for range of motion. The facility census was 28. Findings include: Review of Resident #28's medical record revealed and admission date of 02/20/23 with the diagnosis including, encephalopathy, diabetes mellitus type II, stage three sacral pressure ulcer, COVID-19, necrotizing fasciitis, neuropathic bladder, malnutrition, prothrombin gene mutation, dysphagia, anemia, thrombophilia, nephrotic syndrome, hypertension, and cerebral infarction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was assessed with severely impaired cognition, was dependent on staff for the completion of activities of daily living including bed mobility and transfers, was incontinent of bowel, had an indwelling urinary catheter, received all nutrition via tube feeding, and was at risk for pressure ulcer development with a stage IV pressure ulcer (full-thickness skin and tissue loss) present on admission. Review of admission progress notes dated 02/25/23 at 1:11 A.M. revealed Resident #28 was assessed with unequal strength to bilateral arms and the resident was unable to squeeze hands due to unresponsiveness and unable was to follow command. Review of a nursing plan of care dated 03/31/23 revealed a plan was implemented to address Resident #28's provision of activities of daily living due to a self care deficit related to a cerebral vascular accident. Interventions included to evaluate needs for adaptive equipment, educate and direct the use of assistive devices, and refer to physical therapy (PT), occupational therapy (OT), and speech therapy (ST) as needed. Review of a progress note on 04/12/23 revealed Resident #28 returned from a hospitalization and the assessment noted Resident #28 had abnormal hand-grasps, contractures, and was unable to follow commands. Review of PT discharge summary documentation dated between 04/18/23 and 05/16/23 noted the reason for was Resident #28 achieved the highest practical level. Resident #28's PT included a goal to increase left elbow, bilateral knee, and hip extension by 10 degrees and implement a stretching program to reduce skin breakdown and preserve muscle length to not impair ability to achieve sitting and lying positions. On 04/18/23 Resident #28's baseline was assessed as dependent, and on 05/16/23 a discharge assessment documented Resident #28 improved to tolerating 15 degrees at the knees and hips. Discharge recommendations for a home exercise program with a prognosis to maintain current level of function was listed as good with consistent staff follow through. There was no documentation provided which indicated the specific exercises to implement, if staff was trained to perform the exercises, or assistive devices to utilize to prevent potential contractures. Observation on 05/21/23 at 10:07 A.M. noted Resident #28 in bed with lower extremities in the fetal position (legs to chest) and hands with washcloth rolls. On 05/22/23 at 7:40 A.M. the resident was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366181 If continuation sheet Page 8 of 14 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 366181 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand Rapids Care Center 24201 W 3rd St Grand Rapids, OH 43522 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 0688 in bed with no washcloth rolls in hands with his left hand closed and legs in the fetal position. Level of Harm - Minimal harm or potential for actual harm On 05/22/23 at 10:05 A.M. interview with State Tested Nurse Aide (STNA) #229 and Licensed Practical Nurse (LPN) #200, while observing resident care, revealed no knowledge of Resident #28 being provided with specific exercises including range of motion or a home exercise program. Staff also confirmed no assistive devices were in place to address contractures, and staff indicated washcloth rolls or foam balls were placed to the resident's bilateral hands at the family direction. Residents Affected - Few On 05/22/23 at 11:00 A.M. interview with Certified Occupational Therapy Assistant, identified as Therapy Director (TD) #400, revealed when Resident #28 was discharged from therapy an unidentified STNA was informed of the exercise program. TD #400 confirmed the staff's lack of knowledge regarding Resident #28's home exercise program. TD #400 was unable to provide evidence indicating which STNA was provided education on the resident's exercise program. TD verified the resident was noted with progressive decrease in range of motion; however, no physical device to implement was determined at the time of therapy discharge. On 05/22/23 at 11:05 A.M. interview with the Director of Nursing was unable to provide information confirming staff was provided with education regarding Resident #28's exercise program or interventions to address the resident's range of motion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366181 If continuation sheet Page 9 of 14 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 366181 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand Rapids Care Center 24201 W 3rd St Grand Rapids, OH 43522 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure dependent residents received timely care and services to address bowel incontinence. This affected one (#28) of one residents reviewed for incontinence. The facility identified eleven residents as occasionally or frequently incontinent of bowel. The facility census was 28. Findings include: Review of Resident #28's medical record revealed an admission date of 02/20/23 with the diagnosis including, encephalopathy, diabetes mellitus type II, stage three sacral pressure ulcer, COVID-19, necrotizing fasciitis, neuropathic bladder, malnutrition, prothrombin gene mutation, dysphagia, anemia, thrombophilia, nephrotic syndrome, hypertension, and cerebral infarction. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #28 was assessed with severely impaired cognition, was dependent on staff for the completion of activities of daily living including bed mobility and transfers, was incontinent of bowel, had an indwelling urinary catheter, received all nutrition via tube feeding, and was at risk for pressure ulcer development with a stage IV pressure ulcer (full-thickness skin and tissue loss) present on admission. Review of a nursing plan of care dated 02/22/23 revealed the facility developed a plan to address Resident #28's bowel movement pattern. The plan of care goal included Resident #28 would receive assistance with toileting, would be comfortable, clean, and dry, and free from skin breakdown. Interventions included to administer medications per physician order, assess resident pattern of bowel movement and episodes of incontinence, monitor rectal area for redness, irritation, skin excoriation or breakdown, barrier cream or ointment after incontinence as needed, and provide incontinence care as needed. Review of a late entry progress note on 02/24/23 at 6:00 P.M. revealed Resident #28 was incontinent of bowel. The resident's assessment revealed his abdomen was non-tender with loose stools and bowel sounds in all four quadrants. Review of a physician order noted on 05/09/23 revealed the physician ordered a general surgery consult for Resident #28 for a diverting colostomy (a piece of the colon is surgically diverted to an artificial opening in the abdominal wall) due to a stage four pressure ulcer and loose stools. Further review of Resident #28's medical record lacked documentation indicating a frequency established to monitor bowel patterns and episodes of bowel incontinence. Observation on 05/22/23 at 7:40 A.M., 8:55 A.M., and 9:29 A.M. noted Resident #28 in bed and positioned to the left with both legs in the fetal position (legs drawn up to the chest). On 05/22/23 at 9:50 A.M. interview with State Tested Nurse Aide (STNA) #229 revealed she assumed care for Resident #28 at 6:00 A.M. and had not checked the resident for incontinence. STNA #229 stated the resident was to be checked every two hours due to frequent loose stools and the off going staff was observed exiting the resident's room at 6:00 A.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366181 If continuation sheet Page 10 of 14 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 366181 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand Rapids Care Center 24201 W 3rd St Grand Rapids, OH 43522 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 05/22/23 at 9:58 A.M., observation noted STNA #229 and Licensed Practical Nurse (LPN) #200 to provide care to Resident #28. STNA #229 verified the resident was positioned in the same position for approximately four hours and had not been checked for incontinence during her shift. STNA #229 proceeded to remove Resident #28 adult incontinence brief and discovered the resident was incontinent of a large amount of liquid stool. Further observation confirmed stool was dried to the resident's buttocks. STNA #229 cleansed the stool from the resident and confirmed no barrier cream was in place. The residents bilateral buttocks was observed with reddened tissue. Interview with LPN #200 at the time of observation verified no barrier cream was observed in place. On 05/22/23 at 11:05 A.M. interview with the Director of Nursing (DON) verified Resident #28 required frequent incontinence care due to frequent loose stools and skin breakdown. The DON confirmed no documentation contained in the medical record indicated a specific schedule or pattern related to the resident's bowel habits was established. Review of an undated policy related to identifying incontinence, revealed the licensed nurse will instruct nursing assistants to fill out the 72 hour diary using their observations. The nursing assistants fill out the bowel and bladder continence evaluation for after providing care. The resident is monitored hourly and findings are documented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366181 If continuation sheet Page 11 of 14 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 366181 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand Rapids Care Center 24201 W 3rd St Grand Rapids, OH 43522 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Potential for minimal harm Based on review of employee personnel files and staff interview, the facility failed to complete performance reviews for state tested nurse aides (STNAs) at least once every 12 months. This affected two (#230 and #240) of two STNAs reviewed for annual performance evaluations. This had the potential to affect all 28 residents in the facility. The census was 28. Residents Affected - Many Findings include: 1. Review of STNA #230's employee personnel record revealed a hire date of 11/21/17. Further review of the employee personnel file revealed a performance evaluation had not been completed since November 2021. 2. Review of STNA #240's employee personnel record revealed a hire date of 08/07/19. Further review of the employee personnel file revealed a performance evaluation had not been completed since November 2021. Interview on 05/24/23 at 10:43 A.M., with Office Coordinator #213 confirmed STNA #230 and STNA #240 did not have performance reviews completed in the past 12 months. Office Coordinator #213 stated the former Director of Nursing did not complete performance reviews for STNAs as required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366181 If continuation sheet Page 12 of 14 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 366181 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand Rapids Care Center 24201 W 3rd St Grand Rapids, OH 43522 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 medical record review, resident representative interview, staff interview, review of witness statements, and review of a self-reported incident, the facility failed to maintain accurate documentation in the medical record. This affected one (#19) of 13 resident records reviewed. The facility census was 28. Findings include: Review of the medical record revealed Resident #19 was admitted on [DATE]. Diagnoses included major depressive disorder, Alzheimer's disease with late onset, unspecified dementia with other behavioral disturbance, and gastro-esophageal reflux disease without esophagitis. Review of the Minimum Data Set (MDS) assessment, dated 04/13/23, revealed the resident was severely cognitively impaired. Review of a physician order, dated 04/28/19 to 05/17/23, revealed an order to observe that Resident #19's had a ring (sapphire and diamond) every shift. Review of Resident #19's May 2023 treatment administrative record revealed nursing staff documented the ring was in place on each shift 05/01/23 through first shift on 05/14/23. On 05/14/23, on night shift the ring was not documented as checked, and again on 05/15/23 and 05/16/23, both shifts the ring was documented as observed to be in place by staff. Review of self-reported incident (SRI) #235054, dated 05/16/23, revealed on 05/14/23 Resident #19's family reported Resident #19 was missing a ring. Review of a witness statement, dated 05/17/23, revealed Licensed Practical Nurse (LPN) #211 reported on 05/14/23 Resident #19's daughter came in and asked about a ring the resident did not have on. LPN #211 reported Resident #19 was seen with the ring on and off at times and had not seen the ring in over a month. Review of a witness statement, dated 05/16/23, revealed Registered Nurse (RN) #222 stated she had not seen Resident #19's ring since 05/12/23. Review of a witness statement, dated 05/18/23, revealed LPN #242 had not seen Resident #19's ring and did not recall the last time she saw it. Interview on 05/22/23 at 5:17 P.M. with Resident #19's representative reported when visiting Resident #19 on Sunday 05/14/23 they realized the sapphire ring was not on Resident #19's finger. Resident #19's representative reported the ring had high sentimental value and was monetarily valued at $2,500.00 over 20 years ago. It was reported a physician order was put in place every shift to help ensure the ring was observed. The last time Resident #19's representative observed the ring was in March 2023 when visiting last. Interview via telephone on 05/23/23 at 10:38 A.M. with RN #222 verified a documented check mark on the TAR indicated staff observed the ring was observed on Resident #19's finger. RN #222 stated the last time the ring was observed was on 05/12/23 as indicated on the May 2023 TAR. RN #222 did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366181 If continuation sheet Page 13 of 14 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 366181 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand Rapids Care Center 24201 W 3rd St Grand Rapids, OH 43522 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 observe the ring on Resident #19's finger on 05/15/23 as indicated on the TAR. Level of Harm - Minimal harm or potential for actual harm Interview via telephone on 05/23/23 at 10:02 P.M. with LPN #242 verified the documentation on the May 2023 TAR on 05/14/23 and 05/15/23 on night shift indicated staff observed Resident #19's sapphire and diamond ring. LPN #242 stated staff saw a ring on Resident #19's finger for those days, but did not verify it was a sapphire and diamond ring. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366181 If continuation sheet Page 14 of 14