Inspection·April 21, 2022

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure an accurate Minimum Data Set (MDS) 3.0 assessment to address Resident #9's tobacco use. This affected one (Resident #9) of six residents reviewed for MDS accuracy. The facility census was 70. Findings include: Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including Dementia, Parkinson's, muscle weakness and dysphagia. Review of the comprehensive MDS 3.0 dated 11/15/21 revealed Resident #9 did not use tobacco. Subsequent quarterly MDS assessments dated 12/14/21 and 01/11/22 and the comprehensive assessment dated [DATE] further revealed no evidence of tobacco use. Review of the smoking assessment dated [DATE] revealed the resident required a smoking apron due to tremors, when smoking. Observation on 04/13/22 at 10:28 A.M. revealed Resident #9 was escorted outside by Housekeeping Supervisor #221 who placed a smoking apron on her, gave her a cigarette and lit it for her. Resident #9 then proceeded to smoke two cigarettes. On 04/13/22 at 2:25 P.M., an interview with the Regional Manager of Clinical Services verified Resident #9's MDS assessments did not address Resident #9's tobacco use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366214 If continuation sheet Page 2 of 19 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 366214 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Villa of Alliance 1785 Freshley Avenue Alliance, OH 44601 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop an individualized and comprehensive care plan related to Resident #9's tobacco use. This affected one resident (#9) of six residents reviewed for care planning. Findings include: Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including Dementia, Parkinson's, muscle weakness and dysphagia. Review of the smoking assessment dated [DATE] revealed the resident required a smoking apron due to tremors, when smoking. Review of the resident's comprehensive care plan dated 11/28/21, revealed no evidence of the resident's tobacco use. Observation on 04/13/22 at 10:28 A.M. revealed Resident #9 was escorted outside by Housekeeping Supervisor # who placed a smoking apron on her, gave her a cigarette and lit it for her. Resident #9 then proceeded to smoke two cigarettes. On 04/13/22 at 2:25 P.M. interview with the Regional Manager of Clinical Services verified the facility had not developed an individualized and comprehensive plan of care related to the resident's tobacco use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366214 If continuation sheet Page 3 of 19 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 366214 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Villa of Alliance 1785 Freshley Avenue Alliance, OH 44601 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 0685 Assist a resident in gaining access to vision and hearing services. 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 proper treatment to aide one resident (Resident #24) in her ability to hear adequately. The affected one (Resident #24) of one resident reviewed for ancillary services. Residents Affected - Few Findings include: Review of the medical record for Resident #24 revealed an admission date of 05/26/20 with diagnoses of Alzheimer's Disease, dementia, emphysema, hyperlipidemia and pulmonary fibrosis. Observation and interview on 04/11/22 at 11:44 A.M. with Resident #24 revealed she did not have any assistive devices to aid in hearing. She repeatedly asked this surveyor to repeat herself so she could hear what was being asked. Resident #24 confirmed she could not hear well and thought she would benefit from having her hearing checked. Interview on 04/13/22 at 9:12 A.M. revealed Resident #24 needed questions and sentences repeated at least twice at a higher volume during conversation with this surveyor. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 12 out of 15. Resident #24 had adequate hearing and did not use an assistive device to aid in hearing. Review of the progress note from an audiologist appointment on 02/01/22 revealed the reason for the visit was an ear care exam and hearing loss. The note indicated Pt was noted to have a complete build up of cerumen (ear wax). Resident #24 refused any treatment at time of the appointment. The physician recommended Debrox 5 drops twice a day for three days with a gentle warm water rinse on the fourth day, or a referral from the Primary Care Physician (PCP) for other treatment options. Review of the Physician's orders from 02/01/22 through 04/13/22 did not reveal any evidence of ear drops being ordered or the PCP making any further recommendations for treatment for Resident #24's ear care. Interview on 04/13/22 at 10:36 A.M. with the Director of Nursing (DON) confirmed no action was taken to address recommendations for Resident #24 after her appointment with the audiologist on 02/01/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366214 If continuation sheet Page 4 of 19 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 366214 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Villa of Alliance 1785 Freshley Avenue Alliance, OH 44601 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and policy review the facility failed to ensure medications requiring refrigeration were stored appropriately. This had the potential to affect all 70 residents currently residing in the facility. Findings include: Observation made with Registered Nurse (RN) #262 on 04/11/22 at 12:02 P.M. of the medication storage room revealed one refrigerator containing medications. The refrigerator also contained four cups of pudding, three cups of applesauce and two gallons of juice one of which was ¼ full and the other was almost empty. At the time of observation RN #262 verified the refrigerator was to be used for medications only and no food should have been placed inside. Review of the facility policy for medication storage dated 07/23/19 revealed medications should be stored separately from juices, applesauce and other foods. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366214 If continuation sheet Page 5 of 19 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 366214 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Villa of Alliance 1785 Freshley Avenue Alliance, OH 44601 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and review of facility the facility failed to dispose of garbage and refuse properly. This had the potential to affect all 70 residents currently residing in the facility. Residents Affected - Many Findings include: Observations made on 04/11/22 from 10:00 A.M. through 10:30 A.M. revealed six red biohazard trash bags on the ground around the red biohazard trash can with two red bags on top of the lid which was located outside of the exit door (door two) from the COVID-19 unit. There were multiple trash items including used Personal Protective Equipment (PPE) such as surgical masks, gloves, and two N95 masks scattered throughout the grounds of the facility. There were also multiple trash items spread throughout the large, wooded area behind the facility including used PPE, clear trash bags in trees and other trash items. There were soiled gloves laying on the ground around the two dumpsters located in the back of the facility. Further biohazard bins located in the back of the facility had soiled gloves on the ground. There was a trash can located at the front door of the facility overflowing with used surgical masks hanging over the side. Observation on 04/11/22 at 10:35 A.M. with Laundry Aide (LA) #200 verified all biohazard trash bags, used PPE, and other trash items on the ground surrounding the entire facility and in the large, wooded area behind the facility. Interview on 04/12/22 at 1:00 P.M. with the Maintenance Director (MD) #216 revealed they do not do routine grounds clean up and would start this in the spring since it was getting warmer outside. Interview 04/18/22 2:40 P.M. with the Administrator revealed there was no cleaning schedule for the outside grounds. Review of facility policy dated 10/18/01 titled, Infectious Waste, Handling revealed any infectious waste including used PPE, items contaminated with secretions or excretions from residents believed to be infectious must be placed in red plastic bags and sealed and stored in a secured area until removal from the premises by an authorized vendor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366214 If continuation sheet Page 6 of 19 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 366214 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Villa of Alliance 1785 Freshley Avenue Alliance, OH 44601 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 - Immediate jeopardy to resident health or safety Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Centers for Medicare and Medicaid Services (CMS) memoranda, review of Centers for Disease Control and Prevention (CDC) guidelines, review of the facility's COVID-19 line list, review of facility infection control policies, interviews with staff, observations, interview with the local health department (LHD) and medical record review, the facility failed to implement appropriate infection control practices including appropriate use of personal protective equipment (PPE), social distancing with residents who tested positive for COVID-19 and failed to ensure residents who were exposed to COVID-19 were encouraged to wear appropriate PPE while visiting with other residents. Residents Affected - Many This resulted in Immediate Jeopardy on 04/11/22 when State Tested Nursing Assistant (STNA) #213 was observed smoking and monitoring smoking outside the exit door of the COVID-19 Unit with Resident #52 who tested positive for COVID-19 on 04/07/22. Neither STNA #213 nor Resident #52 were social distancing, wearing a mask, eye protection, gown, or gloves. Interview with STNA #213 and review of the facility staffing schedule revealed STNA #213 was scheduled to work with residents throughout the facility who did not have COVID-19 during the week of 04/11/22 through 04/17/22. In addition, Resident #25 tested positive for COVID-19 on 04/11/22 exposing his roommate, Resident #46. After exposure to COVID-19, Resident #46 visited his spouse, who resided in a different room, and the spouse's roommate, multiple times a day for extended periods of time without wearing appropriate PPE or social distancing. Review of the facility timeline from 04/05/22 through 04/17/22 revealed between 04/05/22 and 04/17/22, 21 Residents #54, #48, #44, #53, #3, #50, #52, #37, #57, #26, #25, #61, #2, #62, #49, #14, #46, #36, #28, #6, and #60 tested positive for COVID-19. Between 04/07/22 and 04/16/22, seven staff members, STNA #233, #259, Registered Nurse (RN) #231, #235, Housekeeper #249, #222, and Therapy #269 tested positive for COVID-19. This deficient practice of infection control placed all residents at risk for serious life-threatening harm, complications and/or death. The facility census was 70. On 04/12/22 at 3:15 P.M. the Administrator, Director of Nursing (DON), and Corporate Nurse #267 were notified that Immediate Jeopardy began on 04/11/22 when the facility did not implement appropriate infection control practice when residents exposed to COVID-19 did not wear appropriate PPE when with non-exposed residents and did not implement appropriate infection control measures while monitoring smoking of a resident that was positive for COVID-19. The Immediate Jeopardy was removed on 04/13/22 when the facility implemented the following corrective actions: • On 04/12/22 at 5:00 P.M. STNA #213, who was monitoring smoking with a COVID-19 positive resident, Resident #52, without wearing PPE or social distancing outside the COVID unit, was removed from the schedule, and quarantined for 14 days. • On 04/12/22 at 5:00 P.M., the Administrator and DON began education of all staff that when within six feet of a resident who is on transmission-based precautions for COVID-19, the staff member must wear PPE that includes an N95 mask, gown, gloves and eye protection. This education was completed on 04/13/22 by the Administrator and/or DON. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366214 If continuation sheet Page 7 of 19 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 366214 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Villa of Alliance 1785 Freshley Avenue Alliance, OH 44601 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 - Immediate jeopardy to resident health or safety On 04/12/22 at 6:10 P.M., Resident #46 was assessed for symptoms of COVID-19 and tested for COVID-19 by the DON. Resident #46 did not have signs/symptoms of COVID-19 and the COVID-19 test was negative. Resident #46 will continue to be monitored daily by the licensed nurse for an indefinite period. Residents Affected - Many • On 04/12/22 at 7:00 P.M., Corporate Nurse #267 reviewed the facility's Novel Coronavirus Prevention and Response policy for identification, contact tracing, monitoring and quarantine of individuals exposed to COVID-19. 1) The facility will follow the CDC guidelines which includes placing residents who had close contact with someone with COVID-19 infection in quarantine after exposure, even if viral testing is negative, and staff caring for them will use full PPE that includes gowns, gloves, eye protection and N95 respirators. 2) These residents will be removed from Transmission-Based Precautions after day 10 following the exposure (day 0) if they do not develop symptoms. The facility may also remove these residents from Transmission-Based Precautions after day seven following the exposure (day 0) if a viral test is negative for COVID-19 and they do not develop symptoms. The specimen will be collected and tested within 48 hours before the time of planned discontinuation of Transmission-Based Precautions. 3) For residents who are up to date with all recommended COVID-19 vaccine doses and residents who have recovered from COVID-19 infection in the prior 90 days who have had close contact with someone with COVID-19 infection, staff are required to wear a well fitted mask when caring for them and are required to encourage that the resident is wearing a well fitted mask when engaging with other residents for 10 days but will not be quarantined, restricted to their room, or cared for by staff using the full PPE recommended for the care of a resident with COVID-19 infection unless they develop symptoms of COVID-19, are diagnosed with COVID-19 infection, or the facility is directed to do so by the Alliance City health department. If these residents are moderately to severely immunocompromised, the facility will place the resident in Quarantine as stated above. • On 04/13/22 at 9:00 A.M. Corporate Nurse #267 began a house-wide audit of all residents to ensure that high risk residents who had close contact to someone with COVID were placed in quarantine. Six residents (#61, #7, #2, #12, #4, #46) were considered to have close contact as defined by the CDC as less than 6 feet away for a combined total of 15 minutes or more over a 24-hour period of an infected individual within 48 hours of the positive test or start of symptoms. All six residents were up to date with COVID vaccinations and not moderately to severely immunocompromised. One (#61) of the six began symptoms on 4/11/22, was isolated, tested and moved to the COVID unit due to positive test results. A second, Resident #2, was up to date, asymptomatic and tested on positive on 04/12/22 and was immediately moved to the COVID unit. The remaining four residents, (#7, #12, #4, and #46) are asymptomatic and not immunocompromised and not quarantined per CDC guidance (encourage mask use, monitor signs and symptoms). Corporate Nurse #267 completed the audit at 12:00 P.M. on 04/13/22. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366214 If continuation sheet Page 8 of 19 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 366214 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Villa of Alliance 1785 Freshley Avenue Alliance, OH 44601 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 - Immediate jeopardy to resident health or safety On 04/13/22 at 9:30 A.M., Corporate Nurse #267 provided education to the Administrator and DON on smoking procedures, managing residents with close contact (including symptomatic or immunocompromised), Novel Coronavirus Prevention and Response, donning and doffing personal protective equipment (PPE), initiating transmission-based precautions, and Coronavirus surveillance. • Residents Affected - Many On 04/13/22 at 10:00 A.M., the Administrator and Human Resource Director (HR) #245 began all staff education on smoking procedures, managing residents with close contact (including symptomatic or immunocompromised), Novel Coronavirus Prevention and Response, donning and doffing of PPE, initiating transmission-based precautions, and Coronavirus surveillance. Training was completed on 04/13/22 for all staff. • On 04/13/22 at 6:00 P.M., Corporate Nurse #267 reviewed the facility's Novel Coronavirus Prevention and Response policy for outbreak testing and managing residents who have close contact with someone with COVID-19 infection and revised to refer to current CMS guidelines. The facility will follow CMS guidelines for testing (e.g., facility testing requirements), including but not limited to: 1) Testing Residents with Symptoms or Signs of COVID-19 Staff with symptoms or signs of COVID-19, regardless of vaccination status, must be tested immediately and are expected to be restricted from the facility pending the results of COVID-19 testing. In accordance with CDC guidance, appropriate actions are taken based on the results. Residents who have signs or symptoms of COVID-19, regardless of vaccination status, must be tested immediately. While test results are pending, residents with signs and symptoms should be place in transmission-based precautions in accordance with CDC guidance and appropriate actions taken based on the results. 2) Testing of Staff and Residents During an Outbreak Investigation. A new COVID-19 infection in any staff or any nursing home-onset COVID-19 infection in a resident triggers an outbreak investigation. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further viral transmission. A resident who is admitted to the facility with COVID-19 does not constitute a facility outbreak If the facility has the ability to identify close contacts of the individual with COVID-19, they could choose to conduct focused testing based on known close contacts. If the facility does not have the expertise, resources, or ability to identify all close contacts, they should instead investigate the outbreak at a facility-wide or group-level (e.g., unit, floor, or other specific area(s) of the facility). Broader approaches might also be required if the facility is directed to do so by the jurisdiction's public health authority, or in situations where all potential contacts are unable to be identified, are too numerous to manage, or when contact tracing fails to halt transmission. • On 04/13/22 at 7:00 P.M., Corporate Nurse #267 educated the Administrator and DON on CMS guidance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366214 If continuation sheet Page 9 of 19 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 366214 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Villa of Alliance 1785 Freshley Avenue Alliance, OH 44601 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 for COVID-19 testing. Level of Harm - Immediate jeopardy to resident health or safety • Residents Affected - Many Beginning 04/13/22, daily audits will be conducted by the Infection Preventionist (IP) #239, DON, Administrator or designee for four weeks, or until otherwise directed by the Quality Assurance (QA) committee, to ensure that when staff are within six feet of a resident who is on transmission-based precautions for COVID-19 and smoking, the staff member is wearing PPE that includes an N95, gown, gloves and eye protection. • Beginning 04/14/22, daily audits will be conducted by the IP, DON, Administrator or designee for four weeks, or until otherwise directed by the QA committee, to ensure that: • 1) Residents who have close contact with a resident who tested positive for COVID-19 and have are not up to date on COVID vaccination, are moderately or severely immunocompromised or are showing symptoms of COVID-19 are placed in quarantine. 2) Regardless of vaccination status, testing of staff and residents occurs for those who had a higher-risk exposure with a COVID-19 positive individual. 3) Facility wide or group level testing occurs for staff and residents when a positive case is identified if the facility is not able to identify all close contacts. 4) Staff and residents with symptoms or signs of COVID-19, regardless of vaccination status, will be tested immediately, with symptomatic staff being restricted from the facility pending the results of the COVID-19 testing and symptomatic residents being placed in transmission-based precautions for COVID-19 pending the results of COVID-19 testing. 5) Monitoring will be completed every shift for residents with close contact to COVID-19 positive resident. • Beginning 04/20/22, a weekly QA committee meeting will be held for four weeks to review the internal action and audit plan and make any new recommendations, which will be implemented immediately. Although the Immediate Jeopardy was removed on 04/13/22, the facility remained out of compliance at Severity Level 2 (no actual harm with harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: 1. Observation on 04/11/22 at 3:54 P.M. revealed STNA #213 was standing outside the COVID-19 Unit exit door with Resident #52. Both STNA #213 and Resident #52 were smoking cigarettes. STNA #213 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366214 If continuation sheet Page 10 of 19 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 366214 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Villa of Alliance 1785 Freshley Avenue Alliance, OH 44601 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 - Immediate jeopardy to resident health or safety standing directly in front of Resident #52, within two to three feet of Resident #52, while conversing and smoking. Neither STNA #213 nor Resident #52 were wearing PPE including face masks. Interview on 04/11/22 at 3:54 P.M. with STNA #213 and Resident #52 confirmed they were smoking together, were not social distancing or wearing PPE, and Resident #52 had been diagnosed with COVID-19 and resided on the COVID Unit. Residents Affected - Many Observation and interview on 04/11/22 at 3:55 P.M. with Licensed Practical Nurse (LPN) #229 confirmed STNA #213 was outside the COVID-19 Unit exit door with Resident #52, both smoking cigarettes, not social distancing or wearing any PPE including masks. LPN #229 confirmed Resident #52 was diagnosed with COVID-19. LPN #229 instructed STNA #213 she should not be smoking with the resident and should be social distancing and wearing PPE. Interview on 04/11/22 at 4:35 P.M. with Resident #52 revealed when staff took him out to smoke, if they were smokers, they smoked with him without wearing PPE or social distancing. Interview on 04/11/22 at 4:59 P.M. with STNA #213 revealed she had been educated on COVID-19 and proper use of PPE. STNA #213 confirmed she routinely smoked with Resident #52 while he was on his smoke breaks. STNA #213 confirmed she would not wear PPE while smoking with Resident #52, stating, When I go outside, I need to remove it, sometimes it's my only break. 2. Interview on 04/11/22 at 9:10 A.M. with the DON revealed the facility was currently in outbreak status as of 04/05/22. There were 10 residents, Resident #54, #48, #44, #53, #3, #50, #52, #37, #57 and #26 who tested positive for COVID-19 between 04/05/22 and 04/10/22 who resided in the COVID-19 unit. Observation on 04/11/22 at 9:48 A.M. revealed five residents, Residents #28, #123, #36, #15, and #25, were sitting in the lounge. Residents #28, #123, #36, #15, and #25 were not social distancing or wearing any face masks. Interview on 04/11/22 at 9:49 A.M. with RN #262 confirmed Residents #28, #123, #36, #15, and #25 were not social distancing or wearing any face masks. RN #262 revealed there were no residents with COVID-19 on her unit so no residents needed to social distance or wear face masks. Interview on 04/11/22 at 1:45 P.M. with Infection Preventionist (IP) #239 revealed two additional residents, Resident #61 and #25 tested positive for COVID-19 on 04/11/22. Both residents were transferred to the COVID Unit. Resident #25 had a roommate prior to being transferred to the COVID Unit, Resident #46 who was fully vaccinated. Interview on 04/11/22 between 2:06 P.M. and 2:22 P.M. with STNA #238 and RN #262 confirmed Resident #46 was not on quarantine precautions. Resident #46 came out of his room frequently, visited and ate all meals with his wife, (Resident #43) and did not wear PPE. Resident #43 resided in the room next door and had a roommate, Resident #119. Observation on 04/11/22 at 2:26 P.M. revealed Resident #46 came out of his room and walked up the hall. Resident #46 did not have a face mask on. Observation on 04/11/22 at 2:41 P.M. revealed Resident #46 was standing at the nurses' station talking with RN #262. Resident #46 was not wearing any face mask or any type of PPE. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366214 If continuation sheet Page 11 of 19 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 366214 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Villa of Alliance 1785 Freshley Avenue Alliance, OH 44601 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 - Immediate jeopardy to resident health or safety Residents Affected - Many Interview on 04/11/22 at 2:44 P.M. with RN #262 confirmed Resident #46 was not on quarantine precautions and did not wear PPE. RN #262 revealed she was not sure of the facility policy but was not instructed to do anything. RN #262 revealed Resident #46, looked more fatigued today for him, but he did not have a fever. RN #262 confirmed the resident would not be placed in quarantine or isolation unless he had a fever. Observation on 04/12/22 between 12:00 P.M. and 5:00 P.M. revealed Resident #46 sitting in his wife's room (Resident #43) directly across from her with the bedside table between them. The roommate, Resident #119 was sitting in her chair. Residents #46, #43, and #119 were not social distancing, or wearing any face masks or PPE. Record review revealed Resident #46 tested positive for COVID-19 on 04/14/22. Phone interview on 04/14/22 at 3:42 P.M. with Local Health Department (LHD) Infection Control Nurse #315 revealed the facility had not reached out to the health department related to recommendations on what PPE needed to be worn by residents who were exposed to COVID-19 but not quarantined during the outbreak. Review of the facility policy titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes updated 02/02/22 revealed residents who are up to date with COVID-19 vaccine doses and residents who have recovered from SARS-COV-2 infection in the prior 90 days who have had close contact with someone with SARS-COV-2 infection should wear source control and be tested as described in the testing section. Interviews conducted on 04/18/22 from 11:20 A.M. through 4:45 P.M. with RN #262, LPN #274, #275, STNAs #208, #225, #238, #270, #206, and #273 and Housekeeper #221 confirmed although currently all residents were supposed to be wearing masks, they did not know how to identify a resident who was exposed to COVID-19 or actions to take place. On 04/18/22 at 2:30 P.M. during interview the DON was made aware staff were unable to identify residents who were exposed to COVID-19 and were not placed on isolation or quarantine precautions. Interview on 04/18/22 at 4:00 P.M. with the DON revealed there would be a posting in each residents' room, who was exposed to COVID-19 and not placed on quarantine, with a picture of a facemask and included: 1. If a resident was up to date with vaccinations and had close contact with an individual who tested positive for COVID -19 place this sign to the head of the bed. 2. We need to have the resident wear a face mask while providing care. 3. Please do not remove sign. The Administrative Team will review and remove the sign when indicated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366214 If continuation sheet Page 12 of 19 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 366214 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Villa of Alliance 1785 Freshley Avenue Alliance, OH 44601 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 4. Level of Harm - Immediate jeopardy to resident health or safety If the resident exhibits any signs or symptoms of COVID-19 report this immediately to the nurse. Residents Affected - Many Please call to the On Call nurse if you have any questions or concerns or have any known exposure. 5. Review of the staff education dated 04/18/22 completed by DON revealed facility staff was educated on the posting to be placed above the bed of residents who were exposed to COVID-19 but not placed on quarantine or isolation. The education included: 1. If a resident was up to date with vaccinations and had close contact with an individual who tested positive for COVID -19 place this sign to the head of the bed. 2. We need to have the resident wear a face mask while providing care. 3. Please do not remove sign. The Administrative Team will review and remove the sign when indicated. 4. If the resident exhibits any signs or symptoms of COVID-19 report this immediately to the nurse. 5. Please call to the On Call nurse if you have any questions or concerns or have any known exposure. Observation on 04/18/22 at 4:45 P.M. revealed the posting for residents not on quarantine or isolation, but was exposed to COVID-19 was in place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366214 If continuation sheet Page 13 of 19 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 366214 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Villa of Alliance 1785 Freshley Avenue Alliance, OH 44601 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 0885 Report COVID19 data to residents and families. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interviews, and review of facility policies and Centers for Medicare and Medicaid (CMS) guidance the facility failed to inform residents, their representatives, and families of those residing in facilities by 5:00 P.M. the next calendar day following the occurrence of either a single confirmed infection of COVID-19 or three or more residents or staff with new on-set of respiratory symptoms occurring within 72 hours of each other. This affected six (Residents #27, #29, #46, #55, #170, and # 319) of seven residents interviewed and had the potential to affect all residents currently residing in the facility. The facility census was 70. Residents Affected - Many Findings include: Review of resident and staff COVID 19 testing information revealed on 04/05/22 Resident #54 tested positive for COVID-19. Additionally, on 04/06/22 Resident #48 and #44 tested positive for COVID-19, on 04/07/22 Resident #53, #3, #50, #52, #37, and #57 tested positive for COVID-19, on 04/08/22 Resident #26 tested positive for COVID-19, on 04/11/22 Resident #25, and #61 tested positive for COVID-19 on 04/12/22 Resident #2 tested positive for COVID-19, on 04/13/22 Resident #62 and #49 tested positive for COVID-19, on 04/14/22 Resident #14, #46 and #36 tested posited for COVID-19. On 04/16/22 Resident #28 and #60 tested positive for COVID-19. Additionally, between 04/07/22 and 04/16/22 State Tested Nurse Aide (STNA) #233, STNA #259, Registered Nurse (RN) #231, RN #235, housekeepers #249, and #222, and Therapy #269 all tested positive for COVID-19. 1. Record Review for Resident #46 revealed an admission date of 02/22/22. Medical diagnoses included COVID-19 dated 04/14/22. Review of Resident #46's admission Minimum Data Set (MDS) 3.0 dated 03/01/22 revealed Resident #46 had impaired cognition. On 04/11/22 Resident #46 was exposed to COVID-19 by his roommate Resident #25. Review of Resident #46's care plan (CP) dated 02/22/22 revealed the resident was at risk for impaired respiratory function or respiratory infection related to potential exposure to COVID-19. Goals included the resident would remain free of any community acquired respiratory illness. Interventions included, COVID-19 testing as needed, monitoring of labs, and x-rays as needed, staff to educate Resident #46 on infection control practices, and to monitor for signs and symptoms of infection including for COVID-19 such as cough, increased or new onset of shortness of breath and fever, new loss of taste and smell, nausea, vomiting and diarrhea. Review of Resident #46's progress notes from 04/04/22 through 04/11/22 revealed no documentation of notification to the resident, resident representative or guardian of new COVID-19 cases in the facility. Interview on 04/14/22 at 10:40 A.M. with Resident #46 revealed he was not updated on positive COVID-19 cases in the facility. Interview on 04/18/22 at 12:12 P.M. with Resident #46's representative revealed she was not notified when Resident #46 was exposed on 04/11/22 to COVID-19 and was not notified of each new case of COVID-19 in the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366214 If continuation sheet Page 14 of 19 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 366214 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Villa of Alliance 1785 Freshley Avenue Alliance, OH 44601 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 0885 2. Medical record review for Resident #27 revealed an admission dated of 01/18/17. Level of Harm - Minimal harm or potential for actual harm Review of the quarterly MDS dated [DATE] revealed Resident #27 had intact cognition and was able to make all needs known. Residents Affected - Many Review of Resident #27's progress notes from 04/05/22 through 04/13/22 revealed no notification made to the resident or her family of the COVID-19 positive cases in the facility. Interview on 04/14/22 at 10:35 A.M. with Resident #27 revealed she had not received any information or updates about the positive COVID-19 cases in the facility of residents and staff. Interview on 04/19/22 at 10:00 A.M. with Resident #27's representative revealed she was not notified of new cases of COVID-19 in the facility. 3. Medical record review for Resident #170 revealed an admission date of 03/24/22. Review of the admission MDS assessment dated [DATE] revealed Resident #170 had intact cognition and was able to make needs known. Review of Resident #170's progress notes from 04/05/22 through 04/13/22 revealed neither the resident, their representative, nor guardian had received an update from staff about the positive COVID-19 cases in the facility of residents and staff. Interview on 04/14/22 at 10:40 A.M. with Resident #170 revealed the resident was not updated regarding new positive cases of COVID-19. Interview on 04/19/22 at 10:05 A.M. with Resident #170's representative revealed she was had not received any updates about the positive cases of COVID-19 in the facility. 4. Medical record review for Resident #29 revealed an admission date of 11/01/19. Review of the quarterly MDS dated [DATE] revealed Resident #29 had intact cognition and was able to make all needs known. Review of Resident #29's progress notes from 04/05/22 through 04/13/22 revealed neither the resident, their representative, nor guardian had received an update from staff about the positive COVID-19 cases in the facility of residents and staff. Interview on 04/14/22 at 10:45 A.M. with Resident #29 revealed neither she nor her representative had received an update from staff about the positive COVID-19 cases in the facility of residents and staff. Interview on 04/19/22 at 10:10 A.M. with Resident #29's representative revealed she was not updated on the positive cases of COVID-19 in the facility. 5. Medical record review for Resident #55 revealed an admission date of 02/23/21. Review of the annual MDS assessment dated [DATE] revealed Resident #55 had intact cognition and was able to make needs known. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366214 If continuation sheet Page 15 of 19 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 366214 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Villa of Alliance 1785 Freshley Avenue Alliance, OH 44601 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 0885 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of Resident #55's progress notes from 04/05/22 through 04/14/22 revealed the resident had not received an update from staff about the positive COVID-19 cases in the facility of residents and staff. Interview on 04/14/22 at 10:50 A.M. with Resident #55 revealed neither the resident, nor their representative had received an update from staff about the positive COVID-19 cases in the facility of residents and staff. Interview on 04/19/22 at 10:23 A.M. with Resident #55's representative revealed she was not updated on the positive cases of COVID-19 in the facility. 6. Medical record review for Resident #319 revealed an admission date of 03/28/22. Review of the five-day MDS assessment dated [DATE] revealed Resident #319 had intact cognition and was able to make all needs known. Review of Resident #319's progress notes dated 04/06/22 through 04/14/22 revealed neither the resident, nor their representative had received an update from staff about the positive COVID-19 cases in the facility of residents and staff. Interview on 04/14/22 at 10:55 A.M. with Resident #319 and their representative revealed he was not informed of new COVID-19 case in the facility since 04/05/22. Interview on 04/14/22 at 10:25 A.M. and 10:27 A.M. with Registered Nurse (RN) #262 and Licensed Practical Nurse (LPN) #246 revealed they did not know who was designated to inform the residents, their guardians, their representatives, or the staff of new staff or resident positive COVID-19 cases. They did state it was not the staff nurse's job. Interview on 04/14/22 at 10:28 A.M. with the Infection Preventionist (IP)/RN #239 revealed she did not notify residents or personally go around and notify staff and residents, but someone does. They do not document the notification and the IP/RN #239 only reviews the positive COVID-19 cases. Interview on 04/14/22 at 10:29 A.M. with the Corporate RN #267 revealed the nursing staff was to notify the other facility staff and the residents of new positive COVID-19 cases. Interview on 04/14/22 at 10:30 A.M. with the Director of Nursing (DON) #240 revealed they thought the Marketing Department notified the residents, their guardians, their representatives, or the staff of new staff or resident positive COVID-19 cases. Interview on 04/14/22 at 10:31 A.M. with the Marketing Personnel (MP) #256 revealed they do not do any notification of COVID-19 cases. They thought the nursing staff did all the notifications. Interview on 04/14/22 at 10:32 A.M. with Medical Records (MR) #250 revealed they believed nursing staff did the notifications and they were to document the notification in the resident's progress notes. Interview on 04/14/22 at 10:33 A.M. with the Activity Director (AD) #236 revealed they did do some notifications a few times however they thought it was the responsibility of the Social Service Designee (SSD) to do all the notifications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366214 If continuation sheet Page 16 of 19 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 366214 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Villa of Alliance 1785 Freshley Avenue Alliance, OH 44601 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 0885 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 04/14/22 at 11:02 A.M. with the Corporate Nurse RN #267 verified no one was doing the notifications to resident and staff of new positive COVID-19 cases. Review of the undated facility policy titled Resident Notification of COVID-19 Outbreaks revealed the administrator was to call a special resident council meeting through the activities department to inform residents present of the outbreak situation. The facility Administrator, or designee, will also compose a memo/letter to the residents informing them of the situation. Activity staff were responsible for the distribution of the letter, and the staff designated to notify the staff and residents families, or representatives of new COVID-19 cases were the SSD, MR, IP, and the Activity Aide (AA). Review of CMS guidance QSO-20-29-NH revealed the facility was to inform residents, their representatives, and families of those residing in facilities by 5:00 P.M. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366214 If continuation sheet Page 17 of 19 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 366214 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Villa of Alliance 1785 Freshley Avenue Alliance, OH 44601 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 0886 Perform COVID19 testing on residents and staff. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interviews, review of facility policy, and review of Centers for Medicare and Medicaid (CMS) guidance and Centers for Disease Control (CDC) guidance in QSO memo 20-38-NH dated 03/10/22 the facility failed to ensure testing residents and staff immediately after identification of each new positive COVID-19 case. This affected six (Resident #27, #29, #46, #55, #170, and #319) of six residents reviewed for testing and had the potential to affect all residents currently residing in the facility. The facility census was 70. Residents Affected - Many Findings include: Review of the COVID-19 positive testing log for residents revealed on 04/05/22 Resident #54 tested positive. On 04/06/22 Resident #48 and #44 tested positive. On 04/07/22 Resident #53, #3, #50, #52, #37, and #57 tested positive. On 04/08/22 Resident #26 tested positive. On 04/11/22 Resident #25, and #61 tested positive. On 04/12/22 Resident #2 tested positive. On 04/13/22 Resident #62 and #49 tested positive. On 04/14/22 Resident #14, #46 and #36 tested positive. On 04/16/22 Resident #28 and #60 tested positive. Additionally, between 04/07/22 and 04/16/22 State Tested Nursing Assistant (STNA) #233, STNA #259, Registered Nurse (RN) #231, RN #235, housekeepers #249, and #222, and Therapy #269 tested positive for COVID-19. Review of the Resident testing schedule revealed a whole facility testing of all residents did not occur until 04/14/22. Review of the testing schedule for staff confirmed testing was not initiated for all staff until 04/07/22. The next all staff testing occurred on 04/12/22 then again on 04/14/22. Review of facility staff testing revealed Dietary Manager (DM) #234 was not tested on [DATE]. Interview on 04/14/22 at 8:55 A.M. with DM #234 confirmed she was not tested on [DATE]. DM #234 asked if she should have been tested and then confirmed she worked on 04/12/22 and 04/13/22. Interview on 04/14/22 at 1:30 P.M. with the Infection Preventionist (IP) Registered Nurse (RN) #239 and the Director of Nursing (DON) confirmed the COVID-19 outbreak began on 04/05/22. RN #239 and the DON confirmed initial staff testing began on 04/07/22 for COVID-19 and would be completed every Tuesday and Thursday. All resident testing for COVID-19 began on 04/14/22 and would continue every Thursday unless the resident became symptomatic. Medical record review for Resident #46 revealed an admission date of 02/22/22. Review of Resident #46's care plan (CP) dated 02/22/22 revealed the resident was at risk for impaired respiratory function or respiratory infection related to potential exposure to COVID-19. Interventions included, COVID-19 testing as needed. Review of Resident #46's progress notes from 04/04/22 through 04/11/22 revealed there was no documentation of a completed test for COVID-19 until 04/12/22. Review of nurse progress notes from 04/05/22 through 04/13/22 for Resident #27, #29, #46, #55, #170 and #319 revealed no documentation for COVID-19 testing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366214 If continuation sheet Page 18 of 19 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 366214 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Villa of Alliance 1785 Freshley Avenue Alliance, OH 44601 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 0886 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interviews completed on 04/18/22 from 12:00 P.M. through 4:45 P.M. with State Tested Nurse Aides (STNAs) #238, #270, #257, #273, #271, and #225, Registered Nurse (RN) #262 and Housekeeper #221 revealed their initial testing for COVID-19 outbreak for April 2022 was completed on 04/07/22. Staff confirmed they worked in the facility on 04/05/22, 04/06/22 and 04/07/22. Interviews completed on 04/18/22 from 12:40 P.M. through 1:25 P.M. with Residents #4, #5, #20, #22, #29, #38, #42 and #55 confirmed they were not tested until 04/14/22. Interviews on 04/18/22 between 1:30 P.M. and 2:30 P.M. with STNAs #273, #271, and #225 confirmed they were not tested during the whole staff testing dated on 04/14/22. Review of the facility policy titled Coronavirus Surveillance dated, 04/09/20 revealed the facility was to test all residents and staff immediately following the identification of a positive case of COVID-19 for residents or staff. Review of the CMS guidance in QSO memo 20-38-NH dated 03/10/22 revealed the facility was to test all residents and staff regardless of vaccination status immediately after exposure or identification of a positive case of COVID-19. If test results are negative, it should be repeated in five to seven days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366214 If continuation sheet Page 19 of 19