Inspection·September 5, 2024

F 0569 including osteoarthritis, iron deficiency anemia, alcoholic myopathy, gout and nicotine dependence. Level of Harm - Minimal harm or potential for actual harm Review of Resident #33's quarterly financial report for April 2024 through June 2024 revealed a balance of $2205.77 on 05/03/24 and a balance of $2883.52 on 06/03/24. Review of available spend-down letters for 2024 revealed one letter on 07/17/24. Residents Affected - Some Interview on 09/04/24 at 12:15 P.M. with BOM #105 and SFBOM #106 revealed SFBOM #106 was assisting in training BOM #105 in her role, including with resident funds. BOM #105 indicated as of this week she realized spend-down letters were to be sent every month a resident was approaching or over the resource limit and confirmed no there were no spend-down letters for Resident #33 for May or June during the interview. Review of the policy, Accounting and Records of Resident Funds, revised April 2018 revealed a representative of the business office will inform the resident if the balance in his/her personal funds account reaches $200 less than the supplemental security income (SSI) resource limit and if the amount in the account reaches the SSI resource limit for one person, the resident may lose eligibility for medicaid or SSI. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366203 If continuation sheet Page 2 of 13 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 366203 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orrville Pointe 230 South Crown Hill Road 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Many Based on record review and staff interview, the facility failed to maintain registered nurse (RN) coverage in the facility at least eight consecutive hours a day seven days a week as required. This had the potential to affect all 45 residents who reside in the facility. Findings include: Review of the nursing staff punch detail, nursing staff schedule, and payroll based journal (PBJ) submission for 12/22/23, 12/23/23, and 12/25/24 revealed no registered nurses were present working in the facility. Interview on 09/05/24 at 10:39 A.M. with Human Resources (HR) #105 verified the identified findings. The deficient practice was corrected on 04/01/24 when the facility implemented the following corrective actions: • Beginning 03/01/24 Director of Nursing (DON)/Designee reviewed the current number of RN's employed by the facility and update the roster intermittently. • Beginning 03/01/24 the facility would advertise for RN's on job recruitment sites and review daily. • Beginning 03/01/24 the facility would audit daily scheduling sheets to ensure 8-hour RN covered was provided. • Beginning 03/01/24 the DON would provided the 8 hour coverage in the event there was a call off to ensure the facility met state and federal regulation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366203 If continuation sheet Page 3 of 13 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 366203 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orrville Pointe 230 South Crown Hill Road 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and staff interview the facility failed to ensure the daily nursing staff information was posted. This had the potential to affect all 45 residents who reside in the facility. Residents Affected - Many Findings include: Observation on 09/05/24 between 11:32 A.M. and 2:05 P.M. revealed no posted nursing staff information was identified throughout the facility. Interview on 09/05/24 at 2:34 P.M., Human Resources (HR) #105 verified no posted nursing staff information was posted in a prominent area within the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366203 If continuation sheet Page 4 of 13 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 366203 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orrville Pointe 230 South Crown Hill Road 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on record review, interview, and review of the facility policy and procedure, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected one resident (#17) of five residents. The facility census was 45. Findings include: Review of the medical record for Resident #17 revealed an admission date of 04/05/24. Diagnoses included anxiety disorder, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, depression, and schizoaffective disorder. Review of the physician orders for September 2024 for Resident #17 revealed an active order for Olanzapine (antipsychotic) oral tablet 5 milligrams (mg). Give one tablet by mouth at bedtime related to dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety with a start date of 04/05/24. Review of the consultant pharmacist medication regimen reviews dated 04/01/24, 05/01/24, 06/01/24, and 08/01/24 revealed a recommendation, noting for the resident is receiving the antipsychotic agent Olanzapine, but lacks an allowable diagnosis to support its use. Please verify why the patient was started on this medication and update their diagnosis list on PCC or consider asking the provider to choose alternate therapy. Interview on 09/05/24 10:09 A.M. with Minimum Data Set (MDS) Nurse #103 stated she talked to the physician and told him that pharmacy recommendations were made but was not sure when that was. MDS Nurse #103 stated he referred to psych to address and when psych saw Resident #17 on 08/05/24, she was diagnosed schizoaffective disorder. MDS Nurse #103 verified the pharmacy recommendations dated 04/01/24, 05/01/24, 06/01/24, and 08/01/24 were all the same recommendation regarding the diagnosis for the use of the Olanzapine. MDS Nurse #103 verified the recommendations were addressed late due to the order being changed on 09/04/24 for the use of the Olanzapine for schizoaffective disorder. Review of the facility policy titled Medication Regimen Reviews, revised May 2019 revealed if the physician does not provide a timely or adequate response or the consultant pharmacist identifies that no action has been taken, he/she contacts the Medical Director or (if the Medical Director is the physician of record) the Administrator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366203 If continuation sheet Page 5 of 13 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 366203 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orrville Pointe 230 South Crown Hill Road 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to monitor residents using anticoagulant medications. This affected one resident (#27) out of five residents reviewed for medications. The facility census was 45. Residents Affected - Few Findings include: Review of Resident #27's medical record revealed an admission date of 12/07/23 and diagnoses including bipolar disorder, hypertension, vitamin D deficiency, depression, generalized anxiety disorder, mild protein-calorie malnutrition and dementia with other behavior disturbance, schizoaffective disorder-bipolar type. Review of Resident #27's quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #27 had moderate cognitive impairment, was dependent on staff for bathing utilized a wheelchair for mobility and received antipsychotic medications, antidepressant medications and anticoagulants. Review of Resident #27's physician's orders revealed an order dated 04/17/24 for Eliquis (anticoagulant or blood thinning medication) oral tablet five milligrams (mg) with directions to give by mouth twice a day for cardiovascular disease. Continued review revealed the facility had no orders in place to monitor the resident for side effects related to her high-risk medication. Continued review of Resident #27's medical record revealed there was no side-effect monitoring in the Point of Care system. Review of Resident #27's care plan dated 12/18/23 and revised 12/27/23 revealed residents taking medications in high-risk drug classes are at risk of side effects that can adversely affect their health, safety and quality of life. The resident is currently prescribed medications from the following high-risk drug class(es): Anticoagulant, Antidepressant, Antipsychotic, Hypoglycemic. A listed intervention dated 12/18/23 revealed monitor resident for adverse effects of medications. Review of a second care plan dated 12/18/23 revised 12/27/23 revealed Resident #27 was at risk for decreased cardiac output and abnormal lab values related to Cardiac Arrhythmias, Hypertension, Use of anticoagulation medication. A listed intervention dated 12/28/23 revealed monitor for adverse affects of anticoagulant medications: abnormal bleeding, blood in stool, urine, emesis, mucous & gums, c/o abdominal pain, back pain, severe headaches; check skin for bruises, cuts, scratches. Interview on 09/04/24 at 10:41 A.M. with Licensed Practical Nurse (LPN) #116 revealed Resident #27 was on an anticoagulant so they had to monitor her for bleeding but this was not documented anywhere in the medical record. Interview on 09/04/24 at 3:27 P.M. with the Director of Nursing (DON) and MDS/LPN #103 revealed there was not an order in place relative to medication monitoring for Resident #27's anticoagulant and confirmed there was no evidence the facility was monitoring for side effects relative to Resident #27's medication. Follow-up interview on 09/04/24 at 3:37 P.M. with the DON verified the facility did not have an anticoagulation policy to provide for review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366203 If continuation sheet Page 6 of 13 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 366203 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orrville Pointe 230 South Crown Hill Road 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 0838 Level of Harm - Potential for minimal harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on facility assessment review and interview, the facility failed to ensure the facility assessment was complete and accurate. This finding had the potential to all 45 residents who reside in the facility. Findings include: Review of the facility assessment form dated 08/2024 under Part 3: Facility Resources Needed to Provide Competent Support and Care for the Resident Population Every Day and During Emergencies, Section 3.1 Staff Type, revealed the staffing included the Administrator and administrative support staff; Director of Nursing (DON); Minimum Data Set (MDS) Coordinator; Social Service/Designee; Environmental Services; Registered Nurses; Licensed Practical Nurses; State Tested Nursing Assistants; Culinary Personnel; Activities Staff; Therapy Personnel and Registered Dietitian. The list also included contracted staff and volunteers. Review of the facility assessment form dated 08/2024 under Part 3: Facility Resources Needed to Provide Competent Support and Care for the Resident Population Every Day and During Emergencies, Section 3.2 Staff Plan, indicated the facility required 24 to 48 hours of licensed nurses providing direct care; 30 to 60 hours of nursing assistants; 8 to 16 hours of other nursing personnel (e.g. those with administrative duties); 24 hours of administration; 4 hours of dietitian or other clinically qualified nutrition professional; 24 hours of food and nutrition services staff members; and n/a for respiratory care services staff members. Interview on 09/05/24 at 10:01 A.M. with Assistant Administrator #100 confirmed the facility assessment did not list the infection preventionist role in the facility assessment under the Staff Type or Staff Plan to determine the amount of hours required of the infection preventionist to assess, develop, implement, monitor, and manage the facility infection control program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366203 If continuation sheet Page 7 of 13 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 366203 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orrville Pointe 230 South Crown Hill Road 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 0851 Level of Harm - Minimal harm or potential for actual harm Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Many Based on record review and interview, the facility failed to completely and accurately report staff hours worked in Payroll Based Journal (PBJ). This had the potential to affect all 45 residents residing in the facility. Findings include: Review of facility time punches revealed no Registered Nurse (RN) and no Director of Nursing (DON) punches were recorded on 12/23/23, 12/24/23 and 12/25/23. Review of PBJ data revealed on 12/23/23, eight RN hours and eight DON hours were submitted; on 12/24/23, eight RN hours and eight DON hours were submitted and on 12/25/23, no RN hours or DON hours were submitted. Interview on 09/05/24 at 10:39 A.M. with Business Office Manager (BOM) #105 revealed she was responsible for submitting PBJ data and while it was checked over by the Administrator, she was the only one who input the staffing data for submission. BOM #105 was unaware the PBJ reporting did not reflect the staffing as recorded on 12/23/23 and 12/24/24 as of the time of the interview. The deficient practice was corrected on 03/01/24 when the facility implemented the following corrective actions: • Beginning 03/01/24 Director of Nursing (DON)/Designee reviewed the number of RNs employed and updated the roster intermittently • Beginning 03/01/24 DON advertised for RNs on job recruitment sites and reviewed applicants daily • Beginning 03/01/24 the facility audited daily scheduling sheets to ensure 8-hour consecutive RN coverage was provided, and the DON provided the RN coverage in the event that there was a call off to ensure facility meets state and federal regulations. These action steps have been ongoing to ensure consistent and future compliance. • Review of PBJ data from 04/01/24 through 06/30/24 showed accurate data submission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366203 If continuation sheet Page 8 of 13 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 366203 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orrville Pointe 230 South Crown Hill Road 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure appropriate personal protective equipment (PPE) was maintained while providing care for Resident #41 who was in isolation precautions related to a COVID-19 diagnosis. This finding affected one resident (Resident #41) and had the potential to affect an additional 26 residents who reside on the second floor including Residents #1, #2, #12, #13, #14, #15, #16, #17, #18, #22, #24, #28, #29, #30, #31, #33, #34, #35, #36, #37, #39, #40, #42, #43, #47 and #96. The facility census was 45. Residents Affected - Some Findings include: Review of Resident #41's medical record revealed the resident was admitted on [DATE] with diagnoses including spastic quadriplegic cerebral palsy, COVID-19 and impulse disorder. Review of Resident #41's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #41's progress note dated 08/30/24 at 10:18 A.M. authored by Licensed Practical Nurse (LPN) #113 revealed the resident complained of not feeing well, was sneezing and had congestion. The resident had tested positive for COVID-19. Strict isolation precautions were started. The physician and power-of-attorney (POA) were updated. Review of Resident #41's physician orders revealed an order dated 08/30/24 reveled an order for strict isolation precautions to be maintained and all services to be provided in the room. Discontinue when completed. Review of Resident #41's progress note dated 09/03/24 at 11:48 A.M. authored by LPN #113 revealed the resident remained on strict isolation precautions per the facility protocol due to a positive COVID-19 result. The resident stated she was feeling better and requested to be up in her wheelchair in the room. The COVID-19 test for day five was negative. Observation on 09/04/24 at 8:30 A.M. revealed State Tested Nursing Assistant (STNA) #134 donned (put on) an N95 duck bill type respirator mask and gloves. STNA #134 took the resident's breakfast tray into the resident's room, adjusted the resident's bedside table and took the covers off of the food. STNA #134 walked back into the hall and asked STNA #149 to help pull the resident up for the breakfast meal. STNA #149 implemented an isolation gown, gloves and N95 duck bill type respirator mask. STNA #134 at that time implemented an isolation gown while leaving her N95 respirator mask and gloves in place and followed STNA #149 into the room to pull Resident #41 up in the bed. Neither staff member were observed with any type of eye protection. Signage on the door indicated for staff to use an N95 respirator mask and gloves as well as to wash/sanitize their hands upon entry and when leaving the resident's room. Interview on 09/04/24 at 11:37 A.M. with STNA #134 confirmed the plastic bin outside of Resident #41's room had PPE including gowns, gloves and eye protection but she did not don the isolation gown when she had first entered Resident #41's room and she did not implement eye protection at any point during the interaction with Resident #41. She confirmed she was educated on the appropriate PPE while caring for residents on COVID-19 precautions and was aware Resident #41 was COVID-19 positive. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366203 If continuation sheet Page 9 of 13 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 366203 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orrville Pointe 230 South Crown Hill Road 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 09/04/24 at 1:16 P.M. with STNA #149 with Clinical Manager RN #102 (infection preventionist) in attendance confirmed the STNA did not use appropriate PPE which included eye protection while providing care for Resident #41 who was COVID-19 positive. Interview on 09/04/24 at 1:20 P.M. with Clinical Manager RN #102 confirmed the entrance to Resident #41's room had signage for airborne isolation precautions which stated for staff to use an N95 respirator mask, keep the door closed and wash their hands. The signage did not include staff/visitor instructions to don an isolation gown and eye protection while providing care for Resident #41 as required. Review of the Personal Protective Equipment - Contingency and Crisis Use of N-95 Respirators (COVID-19 Outbreak) policy revised 09/21 revealed the policy was to prevent transmission of infectious agents through the inhalation of airborne particles or droplet nuclei and the equipment and supplies including respirator masks and additional PPE as required (gloves, gown and eyewear). Review of the Centers for Disease Control Infection Control (CDC) Guidance titled COVID-19 dated 06/24/24 revealed healthcare providers (HCP) who enter the room of a resident with suspected or confirmed COVID-19 infection should adhere to standard precautions and use a N95 respirator mask, gown, gloves and eye protection (i.e. goggles or a face shield that covers the front and sides of the face). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366203 If continuation sheet Page 10 of 13 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 366203 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orrville Pointe 230 South Crown Hill Road 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 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on observation, Employee Phone List review and interview, the facility infection preventionist (IP) failed to ensure staff were appropriately fit tested for N95 respirator masks to prevent the potential for cross contamination and spread of infectious diseases in the facility. This finding had the potential to affect all 45 residents residing in the facility. Findings include: Review of the Employee Phone List form dated 09/02/24 revealed 3 Registered Nurses (RNs), 13 Licensed Practical Nurses (LPNs) and 27 State Tested Nursing Assistants (STNAs) were employed in the facility. Observation on 09/04/24 at 8:30 A.M. revealed State Tested Nursing Assistant (STNA) #134 donned an N95 duck bill type respirator mask and gloves. STNA #134 took the resident's breakfast tray into the resident's room, adjusted the resident's bedside table and took the covers off of the food. STNA #134 walked back into the hall and asked STNA #149 to help pull the resident up for the breakfast meal. STNA #149 implemented an isolation gown, gloves and N95 duck bill type respirator mask. STNA #134 at that time implemented an isolation gown while leaving her N95 respirator mask and gloves in place and followed STNA #149 into the room to pull up Resident #41. Neither staff member were observed with any type of eye protection. Signage on the door indicated for staff to use an N95 respirator mask and gloves as well as to wash/sanitize their hands upon entry and when leaving the resident's room. Interview on 09/04/24 at 11:37 A.M. with STNA #134 confirmed she was hired 04/2024 and was not fit tested for an N95 respirator mask since hire and prior to providing care for residents on COVID-19 precautions Interview on 09/04/24 at 1:16 P.M. with STNA #149 with Clinical Manager RN #102 (infection preventionist or IP) in attendance confirmed she was not fit tested for an N95 respirator mask since hire and prior to providing care for residents on COVID-19 precautions. Interview on 09/04/24 at 11:15 A.M. with Clinical Manager RN #102 confirmed the facility did not ensure nursing staff were fit tested annually to ensure each staff member had an approved respirator mask when providing care to COVID-19 positive residents to prevent the spread of infectious diseases throughout the facility. Clinical Manager RN #102 also confirmed she was hired 03/23 as a social service designee (SSD) and took on the role of IP in 01/24 and she was not fit tested for an N95 respirator mask since hire. Review of the Centers for Disease Control Infection Control (CDC) Guidance titled COVID-19 dated 06/24/24 revealed N95 respirators should be used in the context of a comprehensive respiratory protection program, which includes medical evaluations, fit testing and training in accordance with the Occupational Safety and Health Administration's (OSHA) Respiratory Protection Standard. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366203 If continuation sheet Page 11 of 13 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 366203 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orrville Pointe 230 South Crown Hill Road 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure influenza and pneumococcal vaccines were adminsitered as required. This finding affected two (Residents #6 and #30) of five residents reviewed for immunizations. Residents Affected - Few Findings include: 1. Review of Resident #6's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified dementia, bipolar disorder and diffuse traumatic brain injury with loss of consciousness of unspecified duration. Review of Resident #6's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #6's Pneumococcal Vaccine Consent form dated 10/25/20 revealed the resident wished to receive the pneumococcal vaccine. Review of Resident #6's Influenza Vaccine Consent form dated 10/25/20 revealed the resident wished to receive the influenza vaccine on an annual basis while he/she was residing in the facility. Review of Resident #6's medical record did not reveal evidence the resident received the influenza vaccine for 2023 or the pneumococcal vaccine during the admission to the facility. Interview on 09/04/24 at 12:57 P.M. with Registered Nurse (RN) Clinical Manager #102 (infection preventionist or IP) confirmed Resident #6's influenza and pneumococcal vaccines were not administered as required. 2. Review of Resident #30's medical record revealed the resident was admitted on [DATE] with diagnoses including diffuse traumatic brain injury with loss of consciousness of unspecified duration, unspecified dementia and late Alzheimer's disease with late onset. Review of Resident #30's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #30's Influenza Vaccine Consent form dated 03/09/20 revealed the resident wished to receive the influenza vaccine on an annual basis while he/she was residing in the facility. Review of Resident #30's medical record revealed the last influenza vaccine was completed on 10/12/22. Interview on 09/04/24 at 12:57 P.M. with RN Clinical Manager #102 confirmed Resident #30's influenza vaccine was not administered for 2023 as required. Review of the undated Prevention and Control of Seasonal Influenza policy indicated antiviral treatment and chemoprophylaxis were adminsitered to residents and staff when appropriate, and in accordance with current Centers for Disease Control (CDC) guidelines. Review of the Clinical Protocol for Pneumonia, Bronchitis and Lower Respiratory Infections policy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366203 If continuation sheet Page 12 of 13 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 366203 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orrville Pointe 230 South Crown Hill Road 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 0883 revised 10/2018 revealed as part of the initial assessment, the physician would help identify residents who have recently had pneumonia or bronchitis and those who were at risk for getting respiratory infections. 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: 366203 If continuation sheet Page 13 of 13