Health inspection·November 8, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review and interview, the facility failed to identify and address an area of skin impairment in a timely manner. This affected one (Resident #25) of ten residents reviewed for quality of care. The facility census was 96. Residents Affected - Few Findings include: Review of Resident #25's open medical record revealed diagnoses including type two diabetes mellitus, hypertension, heart disease and one sided weakness and paralysis following a stroke affecting the right dominant side. Resident #25 was admitted to the facility 11/01/23. There was no documentation of injuries or orders for dressing changes to the right lower arm. On 11/07/23 at 10:10 A.M., Resident #25 nodded toward a bandage on his right lower arm toward the wrist stating he wished somebody would check his arm. The bandage had been on his arm since he was in the hospital when he bumped his arm and it started bleeding. There was no date on the bandage. The bandage had some yellowish discoloration in some areas near the wrist and a dark discoloration in one area. Upon leaving the room, Licensed Practical Nurse (LPN) #102 was interviewed and stated there was no order for a treatment to Resident #25's right arm and she would need to research it. On 11/07/23 at 10:27 A.M., LPN #110 stated she did rounds with the wound physician and she had no knowledge of a dressing or skin impairment. Observations of the dressing change on the right arm revealed a skin tear on the lateral wrist which was scabbed. No signs of infection were noted. On 11/07/23 at 4:38 P.M., the Director of Nursing (DON) verified she was unable to find any assessment or documentation of Resident #25 having a bandage or skin impairment of the right arm or evidence staff had sought orders to remove the dressing and assess the area. This deficiency represents non-compliance investigated under Master Complaint Number OH00147772. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366195 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 366195 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beeghly Oaks Center for Rehabilitation & Healing 6505 Market Street Youngstown, OH 44512 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to timely assess a resident with a history of falls for continued fall risk or need for interventions and failed to ensure another resident's fall interventions were implemented in accordance with physician orders. This affected two (Residents #63 and #98) of four residents reviewed for falls. The facility census was 96. Findings include: 1. Review of Resident #98's medical record revealed diagnoses including displaced fracture of the surgical neck of the right humerus, epilepsy, acquired hemolytic anemia, type two diabetes mellitus, rhabdomyolysis, hypertension (HTN), hyperlipidemia, anxiety disorder, depression, sleep apnea, and alcohol abuse. A nursing note dated 10/19/23 at 6:15 P.M. indicated Resident #98 was admitted into the facility. A medication list was sent to the physician and verified. A nursing note dated 10/19/23 at 9:51 P.M. indicated the nurse was notified Resident #98 was in the bathroom on the floor. Resident #98 was alert and oriented but extremely weak. Resident #98 reported he hit his head. Resident #98 had a sling on his right arm but when the fall occurred the sling was not on. Resident #98 had bruising on his arms and back but verbalized those were due to a previous fall. Resident #98 reported he was transferring himself to the bathroom when he blanked out and fell hitting his head. The ambulance transported Resident #98 to the hospital. The physician was in the facility doing rounds and checked Resident #98. Review of a physician progress note dated 10/19/23 at 10:05 P.M. revealed he had visited the facility to see Resident #98 after being informed of his admission. Resident #98 had a history of seizure disorder. Resident #98 had been admitted to the hospital after having a seizure and falling down stairs and he sustained a right proximal humerus fracture. Resident #98 had been treated for alcohol withdrawal before being admitted to the facility. The physician documented when he saw Resident #98 he was already on the floor and appeared to be having significant pain. Resident #98 would not allow himself to be moved easily. There was concern about Resident #98 not knowing how he fell and he was found face flat on the floor. Resident #98 was immediately sent to the hospital for evaluation. The physician documented he wanted Resident #98 evaluated at the hospital due to concerns he might have had a changing serum level of his anti-seizure drugs. Further review of Resident #98's medical record revealed no admission assessment had been completed to determine immediate needs of Resident #98 or interventions which might be required based on his history of falls. During an interview on 11/07/23 at 2:19 P.M., the Director of Nursing (DON) stated Resident #98 was admitted at the change of shift. The 1100/1200 hall had three admissions that day with two nurses. After Resident #98 arrived at the facility the aide had provided water. Resident #98 asked for his light to be turned off and his door shut so he was seen by staff after his admission. The DON verified there was no assessment documented and the orders had not been transcribed yet. Resident #98 was sent to another facility after leaving the hospital. 2. Review of Resident #63's open medical record revealed diagnoses including osteoarthritis, delusional disorder, depression, HTN, generalized muscle weakness, schizoaffective disorder/bipolar type, personality disorder and anxiety disorder. A care plan initiated 03/29/16 indicated Resident #63 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366195 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 366195 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beeghly Oaks Center for Rehabilitation & Healing 6505 Market Street Youngstown, OH 44512 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few at an increased risk for falls related to unsteady gait and confusion. Review of physician orders revealed on 02/13/23 orders were written for bed and wheelchair alarms at all times. Placement and function were to be monitored every shift. A nursing note dated 04/03/23 at 2:58 P.M. indicated a state tested nursing assistant (STNA) notified the nurse that Resident #63 had attempted to exit the facility out of the back door and fell onto her buttocks. No injuries were noted. A nursing note dated 04/04/23 at 4:05 P.M. indicated it was an addendum to the nursing note dated 04/03/23 at 2:58 P.M. The note indicated a door alarm was heard at the end of the 1200 hall. A STNA observed Resident #63 standing from the wheelchair and leaning on the exit door inside of the building. The exit door opened and Resident #63 took a step forward and stumbled and fell onto her buttocks in the doorway. Staff assisted Resident #63 back into her wheelchair and she was taken to her room. Review of a fall risk assessment dated [DATE] indicated Resident #63 was at moderate risk for falls. Risk factors included a history of falls within the past six months, memory deficits, and occasional incontinence. On 11/06/23 at 6:30 A.M., Resident #63 was observed sitting in a wheelchair in the doorway of her room. Resident #63 was confused. No wheelchair alarm was observed. On 11/06/23 at 7:18 A.M., Resident #63 was observed lying in bed. No alarms were observed in the bed or wheelchair. On 11/06/23 at 9:21 A.M., Resident #63 was lying in bed watching television. The pressure pad for her bed alarm was observed on the floor with no box to plug the cord into. On 11/06/23 at 11:38 A.M., Resident #63 remained in bed watching television. The pressure pad remained on the floor under the bed. On 11/06/23 at 11:39 A.M., Licensed Practical Nurse (LPN) #100 verified Resident #63 had orders for chair and bed alarms. Resident #63 verified there was no alarm on the wheelchair. LPN #100 retrieved the pressure alarm pad from off the floor under the bed and followed the cord verifying the alarm box was unable to be located. During an interview of the DON on 11/07/23 at 12:24 P.M., the DON verified there was no evidence the wheelchair alarm was sounding or implemented prior to Resident #63's fall on 04/03/23. This deficiency represents non-compliance investigated under Complaint Number OH00147523. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366195 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 366195 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beeghly Oaks Center for Rehabilitation & Healing 6505 Market Street Youngstown, OH 44512 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. Based on observations, medical record review, policy review and interview, the facility failed to monitor and ensure a resident's catheter bag was positioned appropriately to decrease risks associated with urinary tract infections. This affected one (Resident #12) of three residents reviewed for urinary tract infections. Findings include: Review of Resident #12's medical record revealed diagnoses including type two diabetes mellitus, acute kidney failure, and obstructive and reflux uropathy. Resident #12 was sent to the hospital after falling on 09/30/23 and was admitted with a urinary tract infection (UTI). A Nurse Practitioner note dated 10/11/23 indicated Resident #12 had an indwelling foley which was draining a milky, light yellow urine and had just completed treatment for a UTI. A nurse practitioner note dated 11/04/23 indicated Resident #12's urine was clear yellow. On 11/02/23 at 11:30 A.M. when Licensed Practical Nurse (LPN) #102 entered Resident #12's room to administer medication, observations revealed Resident #12's urinary catheter bag was on the floor under the bed. LPN #102 administered the medication and left the room with no evidence she noticed the catheter bag on the floor. On 11/02/23 at 12:05 P.M., Resident #12 was sitting in the bed feeding herself a meal provided by staff. The urinary catheter bag remained under the bed on the floor. On 11/02/23 at 12:23 P.M., the urinary catheter bag remained on the floor under the bed. This was verified by LPN #102 who stated she would take care of it. At 12:27 P.M. LPN #102 returned with a urinary catheter bag cover into which she placed the catheter drainage bag. Review of the facility's Urinary Catheter Care policy (revised September 2014) revealed instructions to follow infection control practices to be sure the catheter tubing and drainage bag were kept off the floor. This deficiency represents non-compliance investigated under Master Complaint Number OH00147772. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366195 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 366195 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beeghly Oaks Center for Rehabilitation & Healing 6505 Market Street Youngstown, OH 44512 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of physician orders, policy review and interview, the facility failed to ensure medications were administered in accordance with physician orders and failed to ensure medications were not expired while preparing them for administration. This affected one (Resident #72) of eight residents observed for medication administration. Three errors were identified out of 33 opportunities resulting in a 9.09% medication error rate. The facility census was 96. Residents Affected - Few Findings include: On [DATE] between 8:45 A.M. and 9:03 A.M., Licensed Practical Nurse (LPN) #102 was observed preparing and administering medication to Resident #72. The following errors were identified: 1. LPN #102 placed a stool softener in the medication cup along with other medication without checking the expiration date. The expiration date on the bottle was February 2023. After this was directed to the attention of LPN #102 she removed the stool softener from the medication cup. 2. Prior to LPN #102 placing a catapres patch 0.2 milligram patch on Resident #72's left arm, she removed a catapres patch dated 10/22. LPN #102 verified the date on the patch removed was dated 10/22. LPN #102 was unable to find another patch. On [DATE] at 9:05 A.M., LPN #102 verified the catapres patch was supposed to be changed every week on Monday. 3. During review of Resident #72's physician orders it was noted Resident #72 had an order for allopurinol which had not been administered. The Medication Administration Record (MAR) revealed the allopurinol was due to be administered at the same time as the previous medications. On [DATE] at 9:45 A.M., LPN #102 verified she had not administered the allopurinol stating she just missed the order. Review of the facility's policy, Administering Medications (revised [DATE]), revealed medications were to be administered in accordance with prescriber's orders. The individual administering the medication was required to check the label three times to verify the right resident, right medication, right dosage, right time and right route before giving the medication. The expiration/beyond use date on the medication label was checked prior to administering. This deficiency represents non-compliance investigated under Master Complaint Number OH00147772 and Complaint Number OH00147366. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366195 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 366195 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beeghly Oaks Center for Rehabilitation & Healing 6505 Market Street Youngstown, OH 44512 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 and interview, the facility failed to ensure a resident's medical record was complete in regard to a fall and unaccompanied exit of the facility and to ensure a resident's orders were transcribed timely. This affected two (Residents #12 and #62) of 14 residents whose medical records were reviewed. The facility census was 96. Findings include: 1. Review of Resident #62's medical record revealed diagnoses including end stage renal disease, anxiety disorder, hypertension, depression, insomnia, bipolar disorder, chronic viral hepatitis B, hepatitis A, and cognitive communication deficit. An elopement risk assessment dated [DATE] indicated Resident #62 was disoriented occasionally or orientation was not determined. Resident #62 was independently mobile. Resident #62 had exit seeking behaviors. On 10/27/23, Resident #62 was assessed as severely cognitively impaired. On 11/01/23, an order was written for a wanderguard to the left ankle at all times. Check the placement and function every shift. A nursing note dated 11/01/23 at 12:28 P.M. indicated family was notified of the fall. There was no documentation regarding what occurred in regard to the fall. During an interview on 11/07/23 at 2:19 P.M., the Director of Nursing (DON) was informed no information was located regarding the circumstances of a fall. The DON stated it was change of shift. The laboratory tech had been in the facility to draw blood. Resident #62 had been sitting in the lobby. When the lab personnel left Resident #62 followed her out the door. The laboratory representative looked back and observed Resident #62 sitting on the pavement outside the door. The DON stated when she spoke to Resident #62 he reported he thought he was leaving the lounge and not exiting the front door. A wanderguard was placed out of precaution. 2. Review of Resident #12's medical record revealed diagnoses including type two diabetes mellitus and acute kidney failure. A Nurse Practitioner note dated 09/23/23 indicated Resident #12's appetite remained fair to poor with some snacks provided by family. The nurse practitioner indicated she would start Marinol 2.5 milligrams (mg) every 12 hours. A Nurse Practitioner note dated 09/25/23 at 6:23 P.M. indicated labs that day included a glucose level of 509. The note indicated the orders sent to the supervisor platform on 09/24/23 were not initiated. New orders were sent to the supervisor platform. On 11/08/23 at 10:36 A.M. the DON provided a list of orders she indicated were the orders the Nurse Practitioner ordered on 09/24/23 but had not been transcribed. The orders were addressed by the Nurse Practitioner on 09/25/23 and transcribed. The orders included monitoring the blood sugars before meals and at bed time started 09/24/23, lantus insulin 3 units every day at bedtime, give a snack prior to insulin administration, decrease metoprolol (cardiac selective beta blocker) to 12.5 mg daily, start amlodipine (drug used for hypertension) 2.5 mg daily, Marinol (appetite stimulant) 2.5 mg every 12 hours and repeat BMP (lab test) on 09/27/23. This deficiency represents non-compliance investigated under Master Complaint Number OH00147772. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366195 If continuation sheet Page 7 of 7