Health inspection·September 30, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with Dietary Aide (DA) #131 revealed CNA #133 directed an expletive word to Resident #15 to describe his behavior and told the resident he was acting like a fool and a toddler. CNA #103 stated CNA #133 told Resident #15 he was acting like a toddler, and that she would treat him that way.Review of the facility's investigation interview with CNA #103, dated 09/12/25, revealed Resident #15 was unplugging his feeding tube and was self-transferring. After Resident #15 unplugging the tube feeding multiple times, the staff left it unplugged and left him in the hallway. CNA #103 stated the staff told Resident #15 to stop unplugging the tube feeding and he would smile and say to call his family. CNA #103 stated that Resident #15 then tried to elope out of the front door. CNA #103 stated that CNA #133 asked Resident #15 if he felt stupid yet and then stated if the resident wanted to act like a kid, she would treat him like one and moved him by her. CNA #103 stated that Resident #15 went with CNA #133 to take the trash out and came back into the dining room and Resident #15 apologized to everyone in the dining room.Review of the facility's investigation interview with DA #131, dated 09/12/25, revealed she was serving dinner in the dining room and CNA #133 called Resident #15 stupid in front of everyone present. DA #131 reported that Resident #15 kept leaving the dining room and CNA #133 became frustrated with the resident. DA #131 stated CNA #133 coached Resident #15 into apologizing to everyone.Review of the facility's investigation interview with Resident #29, dated 09/12/25, revealed Resident #15 was being uncooperative with staff. The staff was saying bad things to Resident #15. Resident #29 stated CNA #133 was talking to Resident #15 like he was an animal when he tried to leave the dining room. Resident #29 stated the way CNA #133 was talking to Resident #15 was like she was making fun of him. Resident #29 stated CNA #133 stated he was acting stupid a couple times, and she pushed him into the dining room and made him apologize to everyone. Resident #29 stated CNA #133 repeated several times that Resident #15 was acting stupid.Review of the facility's investigation interview with CNA #133, dated 09/12/25, revealed she told Resident #15 he was acting like a toddler. CNA #133 stated she took Resident #15 out of the dining room then brought him back in to apologize to everyone.Interview on 09/30/25 at 8:50 A.M. with the Administrator revealed he was notified on 09/11/25 of an incident that occurred in the dining room on 09/09/25 involving CNA #133 and Resident #15 by Resident #26's family member. The Administrator stated the family member was concerned with how CNA #133 was speaking to Resident #15 and reported CNA #133 called Resident #15 an explicative. The Administrator reported Resident #29 was also present at the time of the incident and confirmed the family member's report of what CNA #133 had stated to Resident #15. The Administrator stated that CNA #133 was suspended pending the investigation but resigned on 09/13/25.Interview on 09/30/25 at 1:20 P.M. with Resident #24 confirmed CNA #133 was in the dining room with Resident #15 and stated that Resident #15 was acting a fool, acting like a baby, and stated he needed to apologize to the entire dining room for his behavior.Interview on 09/30/25 at 2:08 P.M. with DA #131 revealed CNA #133 appeared frustrated with Resident #15. DA #131 stated that CNA #133 put Resident #15 across from the dining room and told him to stay put but the resident kept going back and forth from his room to the dining room. DA #131 stated CNA #131 was upset about Resident #15's behavior and confirmed CNA #133 called the resident stupid and made him apologize to the entire dining room. DA #131 stated she felt uncomfortable with the way CNA #133 was speaking to Resident #15.Review of the facility policy titled, Ohio Resident Abuse Policy, revised 07/11/24, revealed verbal abuse was defined as the use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents, or within hearing distance, regardless of their age, ability to comprehend, or disability. The deficiency was corrected on 09/29/25 when the facility implemented the following corrective actions: On 09/12/25, the Director of Nursing (DON) or designee assessed Resident #15, with no negative (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366181 If continuation sheet Page 2 of 5 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 09/30/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete findings. On 09/12/25, CNA #133 was suspended pending an investigation. CNA #133 resigned on 09/13/25. On 09/12/25, The Administrator or designee initiated an investigation, including staff and resident interviews. On 09/12/25, the DON or designee completed skin checks for residents who could not be interviewed, with no negative findings. On 09/12/25, the DON or designee educated all staff on the facility's abuse policy. On 09/12/25, the Administrator or designee completed all staff education on elements of abuse and customer service. Newly hired staff would be educated on abuse via the onboarding procedure. Beginning on 09/12/25, the DON or designee would interview three residents weekly for four weeks to ensure there are no issues related to abuse/neglect/customer service. Results of the audits would be taken to the Quality Assurance and Performance Improvement (QAPI) committee for review and to determine if additional action was needed. Beginning on 09/12/25, the DON or designee would conduct observations of three residents weekly for four weeks to ensure there were no issues related to abuse. Results of the audits would be taken to the QAPI committee for review and to determine if additional action was needed. On 09/30/25, verification was received verifying corrective action was completed and no new concerns were identified.This deficiency represents non-compliance investigated under Complaint Number 2621856. Event ID: Facility ID: 366181 If continuation sheet Page 3 of 5 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 09/30/2025 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** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, review of a facility initiated Self-Reported Incident (SRI), review of the facility incident log, review of witness statements, staff interview, and review of the facility policy, the facility failed to ensure staff reported allegations of staff-to-resident verbal abuse timely. This affected one (#15) of three residents reviewed for abuse. The facility census was 30. Findings include: Review of the medical record for Resident #15 revealed an admission of 08/16/24. Diagnoses included vascular dementia, generalized anxiety disorder, and cerebral infarction (stroke).Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had moderate cognitive impairment. Resident #15 was assessed to require total care for Activities of Daily Living (ADLs).Review of the care plan dated 11/19/24 revealed Resident #15 had behaviors of throwing (incontinence) briefs on the floor, smearing stool on himself and/or the bed, unplugging the bed, disconnecting his feeding tube, anger, irritation, crawling on the floor, kicking/tipping over the bed table, throwing object(s) at others, restlessness, laying on the floor, attempting to sleep on the floor, impulsiveness, eating other people's food, putting himself on the floor for attention, attention seeking behaviors, and making himself-vomit. Interventions included encouraging Resident #15 to express concerns about care and the disease process, clarify misunderstandings, and maintain a calm environment and approach. Review of the facility incident log revealed an entry dated 09/11/25 at 8:45 P.M. related to an allegation of abuse against Resident #15.Review of Resident #26's family member's statement, dated 09/11/25, revealed she was in the dining room and Resident #15 attempted to leave. Certified Nursing Assistant (CNA) #133 was inappropriate, cussing, and saying stop being so stupid. The family member revealed Dietary Aide (DA) #131 was present in the dining room at the time of the incident.Review of the facility submitted SRI, initiated on 09/12/25, revealed a visitor reported an allegation of verbal abuse against Resident #15 that occurred on 09/09/25. The SRI stated Resident #15 was having behaviors of disconnecting his tube feeding multiple times and transferring himself in the room to different chairs without assistance. The visitor reported that CNA #133 used explicit language towards Resident #15. During the investigation, residents who were in the dining room were interviewed. Resident #24 stated that CNA #133 told Resident #15 he better behave and stop acting like a toddler. Resident #29 stated that CNA #133 talked to Resident #15 like an animal when he tried to leave the dining room and CNA #133 was making fun of Resident #15, stating If you want to act like a toddler, I will treat you like one. Interview with Dietary Aide (DA) #131 revealed CNA #133 directed an expletive word to Resident #15 to describe his behavior and told the resident he was acting like a fool and a toddler. CNA #103 stated CNA #133 told Resident #15 he was acting like a toddler, and that she would treat him that way.Review of the facility's investigation interview with DA #131, dated 09/12/25, revealed she was serving dinner in the dining room and CNA #133 called Resident #15 stupid in front of everyone present. DA #131 reported that Resident #15 kept leaving the dining room and CNA #133 became frustrated with the resident. DA #131 stated CNA #133 coached Resident #15 into apologizing to everyone.Interview on 09/30/25 at 8:50 A.M. with the Administrator confirmed he was not notified of the alleged staff to resident verbal abuse that occurred on 09/09/25 until 09/11/25, when Resident #26's family member, who was present at the time of the incident, reported it. The Administrator stated the family member was concerned with how CNA #133 was speaking to Resident #15 and reported CNA #133 called Resident #15 an explicative. The Administrator reported DA #131 and Resident #29 were also present at the time of the incident and confirmed the family (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366181 If continuation sheet Page 4 of 5 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 09/30/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete member's report of what CNA #133 had stated to Resident #15. Interview on 09/30/25 at 2:08 P.M. with DA #131 revealed CNA #133 appeared frustrated with Resident #15. DA #131 stated that CNA #133 put Resident #15 across from the dining room and told him to stay put but the resident kept going back and forth from his room to the dining room. DA #131 stated CNA #131 was upset about Resident #15's behavior and confirmed CNA #133 called the resident stupid and made him apologize to the entire dining room. DA #131 stated she felt uncomfortable with the way CNA #133 was speaking to Resident #15. DA #131 verified she did not report the incident to facility management. Review of the facility policy titled, Ohio Resident Abuse Policy, revised 07/11/24, revealed it was the facility's policy to investigate all allegations, suspicions, and incidents of abuse, neglect, involuntary seclusion, exploitation of residents, misappropriation of resident property and injuries of unknown source. Facility staff must immediately report all such allegations to the Administrator/Abuse Coordinator.The deficiency was corrected on 09/29/25 when the facility implemented the following corrective actions: On 09/12/25, the Director of Nursing (DON) or designee assessed Resident #15, with no negative findings. On 09/12/25, CNA #133 was suspended pending an investigation. CNA #133 resigned on 09/13/25. On 09/12/25, The Administrator or designee initiated an investigation, including staff and resident interviews. On 09/12/25, the DON or designee completed skin checks for residents who could not be interviewed, with no negative findings. On 09/12/25, the DON or designee educated all staff on the facility's abuse policy, including the timely reporting of alleged incidents. On 09/12/25, the Administrator or designee completed all staff education on elements of abuse and customer service. Newly hired staff would be educated on abuse via the onboarding procedure. Beginning on 09/12/25, the DON or designee would interview three residents weekly for four weeks to ensure there are no issues related to abuse/neglect/customer service. Results of the audits would be taken to the Quality Assurance and Performance Improvement (QAPI) committee for review and to determine if additional action was needed. Beginning on 09/12/25, the DON or designee would conduct observations of three residents weekly for four weeks to ensure there were no issues related to abuse. Results of the audits would be taken to the QAPI committee for review and to determine if additional action was needed. On 09/30/25, verification was received verifying corrective action was completed and no new concerns were identified.This deficiency represents noncompliance investigated under Complaint Number 2621856. Event ID: Facility ID: 366181 If continuation sheet Page 5 of 5