Health inspection·March 20, 2023

F 0578 limitations entailed. Level of Harm - Minimal harm or potential for actual harm Interview on 03/16/23 at 10:48 A.M. of the DON revealed advance directives needed signed by the physician and until it was signed Resident #335 should be considered full code. The DON confirmed Resident #335 did not have a signed advance directive and did not have an order for a full code in his medical record. Residents Affected - Few Review of the nurse report sheet for the nursing unit Resident #335 resided on revealed Resident #335 was listed as a DNR. Review of the facility policy titled Advanced Directives dated, 05/22/13, included the Social Service Director or Designee would determine on admission of the resident if the resident had an advanced directive and if not determine if the resident wished to formulate an advance directive. Along with the provided education regarding advance directives, the resident's decision regarding formulation of an advance directive would be placed prominently in the resident's medical record by the Social Service Director or Designee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 2 of 20 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 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Falls Village Skilled Nursing & Rehabilitation 330 Broadway East Cuyahoga Falls, OH 44221 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #52's medical record revealed he was admitted on [DATE] with diagnoses including hemiplegia, acute respiratory failure and cerebral infarction. Review of Resident #52's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited a memory problem. Residents Affected - Few Review of Resident #52's Wound Evaluation form dated 03/14/23 indicated he had a sacrum stage three (full thickness skin loss, involving damage or death of subcutaneous tissue that may extend down to, but not through, underlying tissues and muscles) pressure wound measuring 4.5 cm length by 4.0 cm depth by at least 0.5 cm depth with 60% (percent) granulation tissue, 20% necrotic tissue (slough). The treatments included to cleanse the wound with wound cleaner, apply anasept gel (antibiotic) then apply dermablue (antimicrobial) or hydrofera blue (antimicrobial), cover with a large sacral foam dressing and change three times a week and as needed. Position side to side only. Observation on 03/16/23 at 7:00 A.M. revealed Resident #52 was lying on his back with his arms positioned at his sides and he was lying on an air mattress. He was not alert and oriented, had a tracheostomy tube and a feeding tube with feeding solution infusing at 75 ml (milliliters) per hour at the time of the observation. Interview on 03/16/23 at 7:30 A.M. with Licensed Practical Nurse (LPN) #858 confirmed Resident #52 was positioned on his back when he should be positioned side to side only to prevent further deterioration of his pressure ulcer wound. Interview on 03/16/23 at 7:34 A.M. with LPN Minimum Data Set (MDS) Coordinator #907 revealed Resident #52's care plans did not include the intervention to only position the resident from side to side and not on his back. Interview on 03/16/23 at 9:10 A.M. with the Director of Nursing (DON) confirmed Resident #52's wound documentation indicating he should be positioned side to side only and she was unsure why it was not care planned as a wound/skin intervention in his medical record. Review of the facility policy titled Pressure Ulcer Prevention and Assessment dated, 12/17/13, included it was the policy of the facility to prevent the development of pressure ulcers to the greatest extent possible and as allowed by the resident's compliance, cognition and or physical function. For a person in bed change position at least every two hours or more frequently as needed, determine if the resident needed a special mattress, raise the head of the bed as little and for as short a time as possible and only as necessary for meals, treatments and medical necessity. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of skin irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor and physician. Place resident on a minimum of every two hour check and change. Impaired mobility, decreased functional ability, cognitive impairment, exposure of skin to urinary and fecal incontinence are additional clinical condition that indicate a resident was at risk for pressure ulcers. This deficiency represents noncompliance investigated under Complaint Number OH00140816 and Complaint Number OH00140473. Based on observation, staff and family interview, record review and review of the facility policy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 3 of 20 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 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Falls Village Skilled Nursing & Rehabilitation 330 Broadway East Cuyahoga Falls, OH 44221 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm Residents Affected - Few Pressure Ulcer Prevention and Assessment the facility failed to ensure Resident #330 was turned and repositioned at least every two hours to relieve pressure on his buttocks, failed to maintain an intact, ordered dressing in place to his sacrum and failed to ensure the setting on his low air loss (LAL) mattress was adjusted to the proper setting demonstrating a lack of care and services to prevent the development of a deep tissue pressure injury (persistent non-blanchable deep red, maroon or purple discoloration intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue). In addition, the facility failed to ensure Resident #335's pressure ulcers and injuries were accurately and thoroughly evaluated, measured, and documented in the medical record and Resident #52 was adequately repositioned to provide pressure relief to his wound areas. This affected three residents (Resident's #52, #330, #335) out of four residents reviewed for pressure ulcers. The facility census was 80. Actual Harm occurred to Resident #330 on 03/14/23 when Resident #330, who returned to the facility from a hospitalization on 03/07/23 with a documented excoriated buttocks and groin area with barrier cream in place, was assessed and observed by Wound Nurse Practitioner (WNP) #925 and found to be laying on a hard, LAL mattress not properly adjusted to the required settings, and Resident #330 had developed a deep pressure injury on his coccyx radiating to the right buttock. Findings include: 1.Review of Resident #330's medical record revealed an admission date of 01/14/23 and a re-entry date of 03/07/23 after being in the hospital with the diagnoses of urinary tract infection and clostridium difficile (a bacteria that can cause diarrhea and inflammation of the bowel) . Resident #330's additional diagnoses included enterocolitis due to clostridium difficile (C Diff), acute kidney failure and dehydration. Review of Resident #330's Braden Scale for Predicting Pressure Sore Risk, dated 01/14/23, revealed Resident #330 was at low risk for developing a pressure ulcer, injury. Review of Resident #330's hospital Physician Orders and Transfer of Care Form, dated 02/28/23 through 03/07/23, included Resident #330 was incontinent of bladder and bowel. Resident #330 was alert, oriented and cooperative. Resident #330's skin was intact, he had excoriation (an abraded area of the skin) on his bottom and groin, and barrier cream was applied. Review of Resident #330's physician orders, dated 03/07/23, revealed protective barrier cream ointment topically to peri-area (perineal area) after each incontinent episode. This order was discontinued on 03/08/23 and a new order written dated 03/08/23 at 8:15 A.M. for a treatment to buttocks and perineal area, cleanse with wound cleanser, apply Triad (adheres to wet skin, keeping the wound covered and protected from incontinence) and cover buttocks with a large sacral dressing for protection, change three times a week and as needed. Review of Resident #330's Initial Wound Assessment Documentation dated, 03/07/23 at 7:44 P.M., included Resident #330's buttocks and groin were excoriated with no open areas. Review of Resident #330's admission Minimum Data Set (MDS) 3.0 assessment, dated 03/07/23, revealed Resident #330 had moderate cognitive impairment. Resident #330 required extensive assistance of one staff member for bed mobility and toilet use and required extensive assistance of two staff members for transfers. Resident #330 was frequently incontinent of urine and occasionally incontinent of bowel. Resident #330 did not have a pressure ulcer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 4 of 20 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 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Falls Village Skilled Nursing & Rehabilitation 330 Broadway East Cuyahoga Falls, OH 44221 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm Residents Affected - Few Review of Resident #330's physician orders, Medication Administration Record (MAR) and Treatment Administration Record (TAR), State Tested Nursing Assistant (STNA) charting, care plan, and progress notes dated 03/07/23 through 03/14/23, did not reveal documentation Resident #330 had physician orders to be turned and repositioned every two hours or evidence Resident #330 was turned and repositioned every two hours. Further review of the progress notes did not reveal documentation Resident #330 refused to be turned and repositioned. Review of Resident #330's TAR, dated 03/08/23, revealed he did not receive the treatment orders dated 03/08/23 at 8:15 A.M. for a treatment to buttocks and perineal area, cleanse with wound cleanser, apply Triad and cover buttocks with a large sacral dressing for protection, change three times a week and as needed. Review of Resident #330's care plan, dated 03/08/23, included Resident #330 had impaired skin integrity with risk of pain and infection related to fragile skin and incontinence MASD (moisture associated skin damage) to buttocks due to loose stools from clostridium difficile. Resident #330 would have pain managed as evidenced by no complaints of pain, Resident #330 would have wound resolved, Resident #330's wound would be without signs and symptoms of infection, Resident #330's wound would decrease in size as noted measurements. Care plan Interventions dated 03/08/23 included to apply barrier cream after each incontinence cleansing, check skin with showers/baths and report abnormalities to the physician as indicated; a low air loss mattress, notify physician and resident, resident representative of change in condition, positioning interventions, appliances, wound treatments per protocol and physician orders. Review of Resident #330's general progress notes and assessments, dated 03/10/23 through 03/13/23, revealed no documentation of characteristics of a wound or reddened area on Resident #330's coccyx, sacral area or buttocks including measurements, color, drainage. Review of Resident #330's skilled progress notes dated, 03/10/23 at 11:09 A.M., revealed Resident #330 had no change to skin or current impairments. Review of Resident #330's STNA charting for skin observation, dated 03/10/23 at 11:38 A.M., revealed Resident #330 had a new skin impairment, red area. The new skin impairment, red area was reported to the nurse. This charting did not indicate what area of the body the STNA noted the red area of skin impairment. Review of Resident #330's skilled progress notes dated, 03/11/23 at 5:47 P.M. revealed Resident #330 had no change to skin or current impairments, dressing on left buttock wound. Review of Resident #330's skilled progress notes dated, 03/12/23 at 5:59 P.M., revealed Resident #330 had no change to skin or current impairments, wound on sacrum, coccyx, dressing present. Review of Resident #330's skilled progress notes dated, 03/13/23 at 6:48 P.M., revealed no change to skin or current impairments. Review of Resident #330's Wound Evaluation, dated 03/14/23, and completed by WNP #925 included findings that Resident #330 had a pressure injury, Deep Tissue Injury, on his coccyx radiating to the right buttock. The measurements were a length of 15 centimeters (cm), width seven cm, and depth at least 0.1 cm. Resident #330 had a red, open area directly over the coccyx with a reddish-purple linear (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 5 of 20 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 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Falls Village Skilled Nursing & Rehabilitation 330 Broadway East Cuyahoga Falls, OH 44221 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm Residents Affected - Few discoloration radiating from the right buttock to the right ischial area, area was all measured as one. Eighty percent of the measured area was intact but discolored. Treatments to consider included to turn and reposition every two hours, pressure reducing mattress, alternating, pressure redistribution cushion to all seated surfaces. Treatment for the pressure ulcer was to cleanse with wound cleanser, apply xeroform to the open area over the coccyx. Then apply a large sacral foam dressing. Change three times a week and as needed. Ensure static mode was turned off and weight was consistent with patient's weight. Further review of the wound evaluation included resident was admitted to the facility to undergo rehab and family was present during the exam. Wife #950 stated resident was having some discomfort and a pillow was placed underneath Resident #330's buttocks. It was explained to Wife #950 the pillow negated the offloading properties of the specialized mattress that Resident #330 was on, and the pillow could be used to help position him so he was offloaded on his buttocks but should not come in contact with the wound itself. Resident #330 had a dark, purplish red linear line along the right buttock consistent with possible pillow coming in contact with this area or folded bedding. There was a small superficial area directly over the coccyx, the entire area was measured as one given the discoloration throughout. The above treatment would be applied using the large sacral foam to incorporate the entire area. Resident #330 was currently treated for clostridium difficile (C Diff) and this placed him at a greater risk of further tissue breakdown and posed a barrier to resolution. The large sacral foam should help protect the area from exposure. The facility would ensure the low air loss mattress was not set on static position and coincided with his current weight which was 204 pounds. Recommend limiting time in chair to less than two-hour intervals and Resident #330 could rotate back and forth between the bed and chair frequently throughout the day. Review of the manufacturer instructions for Resident #330's LAL mattress included the pump and mattress system was indicated for the prevention and treatment of any and all stage pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program. The instructions included to determine the patient's weight and set the control knob to that weight setting on the control unit. Further review included to press the static button to shift between alternating mode and static mode. In alternating mode, the air cells will alternate in ten-minute cycles. When in static mode, the mattress provides a firm surface that makes it easier for the patient to transfer or reposition. The static mode will help ensure the patient does not bottom out when in a sitting position. Observation on 03/13/23 at 8:22 A.M. revealed Resident #330's wife called surveyor to Resident #330's room. Wife #950 stated Resident #330's incontinence brief was not changed and now his rear end was raw. Wife #950 stated she registered a complaint with Resident #330's nurse and aide, but she did not know what their names were. Wife #950 stated this happened on 03/08/23 and 03/10/23, and Wife #950 stated she did not know who the nurse was those days. Wife #950 stated the aide and Licensed Social Worker (LSW) #881 reported it to the nurse. Wife #950 indicated Resident #330 was very restless and his incontinence brief was not changed timely during the night. Observation on 03/13/23 at 8:30 A.M. of Resident #330's buttock and sacral area with Registered Nurse (RN) #910 revealed Resident #330's incontinence brief was wet with urine. Resident #330 did not have a dressing on his sacral or buttock area. Observation of Resident #330 revealed he had an open area with a pink wound bed on his coccyx which was approximately the size of a nickel, and a dark red and purple line extending down his right buttock. Further observation revealed Resident #330's buttocks were excoriated, had open areas, and barrier cream was noted on buttocks. Observation on 03/13/23 at 9:48 am revealed Resident #330 lying on his back in bed. There was no observation of staff turning and repositioning Resident #330 or encouraging Resident #330 to turn and reposition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 6 of 20 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 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Falls Village Skilled Nursing & Rehabilitation 330 Broadway East Cuyahoga Falls, OH 44221 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm Residents Affected - Few Interview on 03/13/23 at 9:48 A.M. with Wife #950 revealed on 03/09/23 or 03/10/23 the aides changed Resident #330's incontinence brief and reported the red and raw areas to the nurse. Wife #950 stated when she arrived on 03/10/23 Resident #330's buttocks was very red and sore, and it was reported to the nurse. Wife #950 stated the nurse did not come to the room to evaluate Resident #330's buttocks. Wife #950 indicated Resident #330's incontinence brief was changed, and his red buttocks addressed only after she arrived on 03/10/23. Wife #950 stated today (03/13/23) Resident #330's buttocks was still very red and very sore. Wife #950 indicated Resident #330 did not have a bed sore when he was admitted to the facility. Wife #950 stated cream was put on Resident #330's buttocks when he was changed. Wife #950 stated she was pretty pissed off about the way Resident #330's buttocks looked now. Observation on 03/13/23 at 11:00 A.M., 12:00 P.M., 2:00 P.M. revealed Resident #330 lying on his back in bed. There was no observation of staff turning and repositioning Resident #330 or encouraging Resident #330 to turn and reposition. Observation on 03/14/23 at 10:09 A.M. revealed Resident #330 lying on his back in bed. There was no observation of staff turning and repositioning Resident #330 or encouraging Resident #330 to turn and reposition. Observation on 03/14/23 at 10:09 A.M. of Resident #330 with Wound Nurse Practitioner (WNP) #925 revealed Resident #330's coccyx had an open area with a pink wound bed. Resident #330 had a dark purple line approximately one-half inch wide and one and one-half inch long along his right buttock and ischial area which did not blanche. WNP #925 stated the purple area was due to some kind of pressure injury. Wife #950 was at the bedside and stated the staff did not turn and reposition Resident #330 and he was always lying on his back. Wife #950 stated staff got Resident #330 up for a little bit on 03/13/23, but otherwise he was lying on his back all the time. Observation revealed Resident #330 was lying on his back with a pillow under his buttocks. WNP #925 stated the pillow was causing pressure to the area and should not be under the buttocks. WNP #925 noted the LAL mattress setting was at 350 which was the highest level, and the static button was on which prevented the LAL mattress from redistributing the pressure. WNP #925 stated the LAL mattress setting should be according to weight and should be set at 180 and not 350 and the static button should be off. WNP #925 felt the bed and stated the bed was very hard under Resident #330's buttock and sacral area. The surveyor confirmed the bed was very hard under Resident #30's buttock and sacral area. WNP #925 stated the staff needed to be educated on the proper settings for the LAL mattress. Interview on 03/15/23 at 3:55 P.M. with Registered Nurse (RN) #910 revealed Resident #330 was admitted at the end of her shift and his buttocks and groin were excoriated, a little red, but Resident #330 had no open areas on his bottom. RN #910 stated Resident #330 was admitted with C Diff and his wife was in the room when the admission skin assessment was completed. RN #910 stated Resident #330's wife arrived every day at 8:00 A.M. and stayed until about 6:00 P.M. Interview on 03/16/23 at 4:38 P.M. with Wife #950 revealed she did not know who put the pillow under Resident #330 when WNP #925 visited her husband. Wife #950 stated one of the aides placed the pillow under Resident #330's buttocks. Wife #950 stated she did not place the pillow under Resident #330 to relieve pain he was having on his bottom. Interview on 03/20/23 at 8:07 A.M. of State Tested Nursing Assistant (STNA) #826 revealed she often was assigned to care for Resident #330. STNA #826 stated she was not working when Resident #330 was admitted but following a night shift she changed Resident #330's incontinence brief and his bottom (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 7 of 20 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 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Falls Village Skilled Nursing & Rehabilitation 330 Broadway East Cuyahoga Falls, OH 44221 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm Residents Affected - Few was red and bleeding. STNA #826 stated she did not remember which day this occurred but it happened within the first week Resident #330 was re-admitted to the facility on [DATE]. STNA #826 stated Resident #330's incontinence brief was soaked, the bed was soaked, his bottom was red and bleeding and it was horrible. STNA #826 indicated she reported the situation to the nurse and the Director of Nursing (DON), and the night shift aide was written up. STNA #826 stated she could not remember the aides name but did not think the aide still worked at the facility. STNA #826 stated she put pillows under Resident #330's side and buttocks to keep the pressure off. Interview on 03/20/23 at 8:21 A.M. with LSW #881 confirmed he spoke with Wife #950 and the nurse supervisor (Licensed Practical Nurse (LPN) #884) regarding Resident #330's diarrhea and his bottom being red and raw. LSW #881 confirmed Wife #950 was upset about Resident #330's red and raw bottom. Interview on 03/20/23 at 10:08 A.M. with Licensed Practical Nurse/Unit Manager (LPN/UM) #813 revealed STNA #826 reported Resident #330's incontinence brief and bed were soaked and Resident #330's bottom had an open area. LPN/UM #813 stated she could not remember which day this happened, but it was in the morning. LPN/UM #813 stated she entered Resident #330's room, looked at his bottom, and it was excoriated. LPN/UM #813 stated she looked at the initial wound assessment, and there was nothing else significant. LPN/UM #813 stated Triad cream was applied to Resident #330's buttocks. LPN/UM #813 indicated Resident #330's buttocks were red but not bleeding, and the purple line was not observed on Resident #330's bottom. Interview on 03/20/23 at 1:24 P.M. with LPN/UM #813 and the Director of Nursing (DON) revealed LPN/UM #813 stated she reported the lack of timely incontinence care for Resident #330 to the nurse on the floor but did not remember who she talked to. LPN/UM #813 indicated she told the nurse to pass it on in report to the next shift to make sure the STNAs were providing incontinence care and doing last rounds to check on the residents before going home. LPM/UM #813 stated the aides should be giving report to each other. LPN/UM #813 stated she did not talk to the night shift aide about Resident #330's incontinence care but told the DON about it. The DON stated she did not talk to the aide about Resident #330's incontinence care or write the aide up for customer service because she could not prove Resident #330 was not wet at the beginning of the shift because he was not checked by STNA #826 until 8:30 A.M. 2. Review of Resident #335's medical record revealed an admission date of 03/08/23 and diagnoses including ventricular tachycardia, acute respiratory failure with hypoxia and type two diabetes mellitus. Review of Resident #335's admission Assessment and Baseline Care Plan, dated 03/08/23, revealed Resident #335 arrived via a cot and was alert to self, person, place, and time. Resident #335 required partial or moderate assistance for bed mobility. Resident #335 required assistance of two staff and used a mechanical lift for transfers. Resident #335 was occasionally incontinent of bowel and bladder. Resident #335 had an unstageable pressure ulcer to the sacrum and measurements were length four centimeters (cm) and width of three cm, with slough (necrotic, dead tissue) and MASD (moisture associated skin damage) surrounding. Review of Resident #335's hospital discharge instructions titled Gold Form: Provider Orders, dated 03/08/23, included Resident #335 had an evolving deep tissue pressure injury on his sacrum, buttocks and the wound measured a length of 12 cm, and a width of 10 cm. The form further stated Resident #335 had a wound site of peri wound skin on bilateral ischium and both had intact deep tissue pressure injuries. The right ischium measured length of four centimeters (cm), width of two cm and the left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 8 of 20 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 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Falls Village Skilled Nursing & Rehabilitation 330 Broadway East Cuyahoga Falls, OH 44221 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 ischium measured a length of two cm and a width of two cm. Level of Harm - Actual harm Review of Resident #335's care plan, dated 03/08/23, included Resident #335 had impaired skin integrity with risk of pain and infection. Resident #335 was admitted to the facility with a pressure ulcer on his sacrum. Resident #335's wound would be without signs and symptoms of infection. Resident #335's wound would decrease in size as noted by measurements. Interventions included apply barrier after each incontinence cleansing and wound treatments per protocol and physician orders. Residents Affected - Few Review of Resident #335's physician orders on 03/09/23 revealed treatment, sacrum, cleanse with wound cleanser, apply Triad and then cover with xeroform, cover with sacral dressing, and change three times a week and as needed. Review of Resident #335's physician orders dated 03/08/23 through 03/13/23 did not reveal orders to turn and reposition Resident #335 every two hours or orders for a LAL mattress. Orders on 03/09/23 revealed orders for a pressure redistributing mattress. Observation on 03/13/23 at 3:09 P.M. of Resident #335 with Registered Nurse (RN) #837 revealed Resident #335 was lying on his back in bed and the head of the bed was elevated approximately 45 degrees. Resident #335 stated he had diarrhea and needed cleaned up. RN #837 stated she would make sure that happened. Observation on 03/13/23 at 3:35 P.M. of Resident #335 revealed he was lying in bed on his back and the head of the bed was elevated 45 degrees. Resident #335 stated his incontinence brief had not been changed. Observation on 03/13/23 at 4:13 P.M. of State Tested Nursing Assistant (STNA) #922 revealed STNA #922 exited another resident room at the end of the nursing unit Resident #335 resided on. After surveyor intervention, STNA #922 entered Resident #335's room to provide incontinence care. STNA #922 stated he arrived for work at 3:00 P.M., had been answering resident call lights and had not provided incontinence care for Resident #335. RN #837 walked in Resident #335's room and stated she did not tell STNA #922 that Resident #335 needed his incontinence brief changed. RN #837 stated she told STNA #820 who left at 3:00 P.M. Resident #335 needed his incontinence brief changed. RN #837 assisted STNA #922 to provide incontinence care for Resident #335. Observation revealed Resident #335's incontinence brief was soaked with urine and a very large diarrhea bowel movement and no dressing was observed when the incontinence brief was removed. Further observation revealed Resident #335's buttocks and sacral area were dark red and purple areas were noted along with a large black area on the left buttock. The large black area measured approximately three inches by one inch. The dark red and purple areas extended across both buttocks and did not blanche in the middle. Large open areas with red wound beds and reddish drainage approximately three inches in diameter were noted across bilateral buttocks, the coccyx area was a dark purple black in color and did not blanche. Further observation revealed a small dark area on right buttock sacral area, the left leg upper thigh had a small open red area with a dark center. These observations were confirmed by RN #837. RN #837 used wound cleanser, applied Triad cream, xeroform, and a foam border dressing to the sacral area. After surveyor intervention RN #837 and STNA #922 cleaned additional diarrhea from the crease of Resident #335's buttocks which was missed when incontinence care was completed. Additional observations revealed Resident #335's upper thigh was red in area of scrotum, scrotum was red and irritated looking, right upper thigh wound revealed a dark wound bed and was approximately a quarter size, red around edges. Resident #335 did not have a LAL mattress on his bed. Additional observations were confirmed by RN #837. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 9 of 20 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 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Falls Village Skilled Nursing & Rehabilitation 330 Broadway East Cuyahoga Falls, OH 44221 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm Residents Affected - Few Interview on 03/13/23 at 5:13 P.M. with the DON revealed she did Resident #335's initial wound assessment. The DON indicated there was one spot that looked like it had MASD surrounding it, and was not macerated, open and bleeding. The DON stated there was some redness and the wound had a lot of slough, slough was pretty yellow, and a little darkened. The DON stated the wound possibly had a small amount of necrotic (dead) tissue. The DON stated she noted Resident #335 had excoriation on the inside of his thighs and scrotum. The DON indicated Resident #335 was admitted from the hospital on [DATE]. The DON stated she did not measure the wounds and she should have. The DON confirmed Resident #335 was on a pressure reducing mattress and not a LAL mattress. Interview on 03/14/23 at 6:54 A.M. with State Tested Nursing Assistant (STNA) #900 revealed she saw Resident #335's bottom when he was admitted . STNA #900 stated Resident #335 had a sacral dressing and she could not see under the dressing, but the wounds around the dressing were present on admission. Observation on 03/14/23 at 10:50 A.M. of Resident #335 with Wound Nurse Practitioner (WNP) #925 and the Director of Nursing (DON) revealed this was her first visit for Resident #335. Observation revealed Resident #335 was lying on his back in bed and his incontinence brief was soaked with urine and a very large liquid bowel movement which was brownish green in color. Resident #335's urine and bowel movement leaked out of the incontinence brief and was noted on the sheets and blanket. Resident #335 did not have a dressing on his sacral area. Resident #335 had a left ischium wound which was measured at a length of 1.5 cm, width of 1.8 cm and depth was unable to be determined. A sacrum wound measured a length of 11.5 cm and a width of 11.5 cm and depth was unable to be determined due to it was unstageable. The DON stated she did the initial assessment when Resident #335 was admitted to the facility, but Resident #335 had a dressing on and she did not pull the dressing all the way down to do a full assessment. The DON stated she did not know if all the wounds were present when Resident #335 was admitted to the facility. The DON stated she changed Resident #335's dressing this morning and he had a dressing on at that time. Further observation revealed Resident #335 had an unstageable pressure ulcer to the right ischium and measured a length of 3.5 cm, width of 2.5 cm and depth was unable to be determined. The DON stated Resident #335's wound changed since she saw it when he was admitted , and she thinks the top part deteriorated. The DON stated when he was admitted she just pushed the dressing down a little bit but did not see the entire wound. The DON stated another nurse started the assessment and she finished it. The DON indicated she did not measure Resident #335's wounds upon admission, used the hospital paperwork as a guide when she filled out the initial assessment. Interview on 03/14/23 at 2:33 P.M. with Licensed Practical Nurse (LPN) #884 revealed he admitted Resident #335. LPN #884 could not remember details about Resident #335's wounds but remembered the wounds were dark in spots, had some redness, purple areas and the wounds were not bleeding. LPN #884 stated he started, and the DON finished up the admission assessment. LPN #884 stated Resident #335 was weak and sore and needed a lot of help with bed mobility and could not do it on his own. Interview on 03/15/23 at 8:42 A.M. and 11:00 A.M. and 4:48 P.M. revealed Resident #335 was lying on his back in bed. There was no observation of staff turning and repositioning or encouraging Resident #335 to turn and reposition. Observations on 03/16/23 at 9:13 AM and 10:50 A.M. revealed Resident #335 was lying on back. No observations of staff turning and repositioning Resident #335. Interview on 03/16/23 at 10:59 A.M. with STNA #960 revealed she had not provided incontinence care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 10 of 20 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 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Falls Village Skilled Nursing & Rehabilitation 330 Broadway East Cuyahoga Falls, OH 44221 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm for Resident #335 or turned and repositioned him. STNA #960 stated she started at the back of her nursing unit and worked her way forward and was going in Resident #335's room in the next few minutes. STNA #960 stated another aide told her Resident #335 was changed around 8:00 A.M. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 11 of 20 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 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Falls Village Skilled Nursing & Rehabilitation 330 Broadway East Cuyahoga Falls, OH 44221 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy the facility failed to ensure Resident's #330 and #335 were provided timely incontinence care. This affected two residents (#330 and #335) out of three residents reviewed for incontinence care. The facility census was 80. Findings include: 1. Review of Resident #330's medical record revealed an admission date of 01/14/23 and a re-entry date of 03/07/23. Resident #330's diagnoses included enterocolitis due to clostridium difficile, acute kidney failure, and dehydration. Review of Resident #330's hospital Physician Orders and Transfer of Care Form dated 02/28/23 through 03/07/23 included Resident #330 was incontinent of bladder and bowel. Resident #330 was alert, oriented, and cooperative. Resident #330's skin was intact, he had excoriation on his bottom and groin, and barrier cream was applied. Review of Resident #330's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #330 had moderate cognitive impairment. Resident #330 required extensive assistance of one staff member for bed mobility and toilet use and required extensive assistance of two staff members for transfers. Resident #330 was frequently incontinent of urine and occasionally incontinent of bowel. Review of Resident #330's physician orders dated 03/07/23 revealed protective barrier cream and ointment topically to peri-area (perineal area) after each incontinent episode. This order was discontinued on 03/08/23. Review of Resident #330's physician orders dated 03/08/23 at 8:15 A.M. revealed treatment to buttocks, perineal area, cleanse with wound cleanser, apply Triad (adheres to wet skin, keeping the wound covered and protected from incontinence) and cover buttocks with a large sacral dressing for protection, change three times a week and as needed. Review of Resident #330's care plan dated 03/07/23 included Resident #330 bowel and bladder incontinence. Resident #330 would have no skin irritation or redness due to incontinence. Interventions included giving good peri-care after each episode of incontinence, apply protective barrier as needed, toilet resident in advance of need as much as possible, and toilet resident promptly upon request. Review of Resident #330's nurse aide charting dated 03/13/23 revealed Resident #330 was incontinent of bowel at 2:17 A.M. and 9:49 A.M. and was incontinent of urine at 2:17 A.M. and continent of urine at 9:49 A.M. There was no further documentation Resident #330 was checked and/or his incontinence brief was changed. Observation on 03/13/23 at 8:22 A.M. revealed Resident #330's wife called surveyor to Resident #330's room. Wife #950 stated Resident #330's incontinence brief was not changed and now his rear end was raw. Wife #950 stated she registered a complaint with Resident #330's nurse and aide, but she did not know what their names were. Wife #950 stated this happened on 03/08/23 and 03/10/23, and Wife #950 stated she did not know who the nurse was those days. Wife #950 stated the aide and Licensed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 12 of 20 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 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Falls Village Skilled Nursing & Rehabilitation 330 Broadway East Cuyahoga Falls, OH 44221 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 Social Worker (LSW) #881 reported it to the nurse. Wife #950 indicated Resident #330 was very restless and his incontinence brief was not changed timely during the night. Observation on 03/13/23 at 8:30 A.M. of Resident #330's buttock and sacral area with Registered Nurse (RN) #910 revealed Resident #330's incontinence brief was wet with urine. Resident #330 did not have a dressing on his sacral or buttocks area. Observation of Resident #330 revealed Resident #330's buttocks were excoriated, had open areas, and barrier cream was noted on buttocks. Interview on 03/13/23 at 9:48 A.M. with Wife #950 revealed Resident #330's rear end was red and raw. Wife #950 stated on 03/09/23 or 03/10/23 the aides changed Resident #330's incontinence brief and reported the red and raw areas to the nurse. Wife #950 stated when she arrived on 03/10/23 Resident #330's buttocks were very red and sore, and it was reported to the nurse. Wife #950 stated the nurse did not come to the room to evaluate Resident #330's buttocks. Wife #950 indicated Resident #330's incontinence brief was changed, and his red buttocks addressed only after she arrived on 03/10/23. Wife #950 stated today (03/13/23) Resident #330's butt was still very red and very sore. Wife #950 stated salve was put on Resident #330's buttocks when he was changed. Wife #950 stated she was pretty [expletive] off about the way Resident #330's buttocks looked now. Interview on 03/15/23 at 3:55 P.M. with RN #910 revealed Resident #330 was admitted at the end of her shift and his buttocks and groin were excoriated, a little red, but Resident #330 had no open areas on his buttocks. RN #910 stated Resident #330 was admitted with clostridium difficile (C Diff) and his wife was in the room when the admission skin assessment was completed. RN #910 stated Resident #330's wife arrived every day at 8:00 A.M., and stayed until about 6:00 P.M. Interview on 03/20/23 at 8:07 A.M. of State Tested Nursing Assistant (STNA) #826 revealed she often was assigned to care for Resident #330. STNA #826 stated she was not working when Resident #330 was admitted but following a night shift she changed Resident #330's incontinence brief and his bottom was red and bleeding. STNA #826 stated she did not remember which day this occurred but it happened within the first week Resident #330 was admitted to the facility. STNA #826 stated Resident #330's incontinence brief was soaked, the bed was soaked, his bottom was red and bleeding and it was horrible. STNA #826 indicated she reported the situation to the nurse and the Director of Nursing (DON), and the night shift aide was written up. STNA #826 stated she could not remember the aides name but did not think the aide still worked at the facility. Interview on 03/20/23 at 8:21 A.M. with LSW #881 confirmed he spoke with Wife #950 and the nurse supervisor (Licensed Practical Nurse (LPN) #884) regarding Resident #330's diarrhea and his bottom being red and raw. LSW #881 confirmed Wife #950 was upset about Resident #330's red and raw bottom. Interview on 03/20/23 at 10:08 A.M. with LPN/Unit Manager (UM) #813 revealed STNA #826 reported Resident #330's incontinence brief and bed were soaked, and Resident #330's bottom had an open area. LPN/UM #813 stated she could not remember which day this happened, but it was in the morning. LPN/UM #813 stated she entered Resident #330's room, looked at his bottom, and it was excoriated. LPN/UM #813 stated she looked at the initial wound assessment, and there was nothing else significant. LPN/UM #813 stated Triad cream was applied to Resident #330's buttocks. LPN/UM #813 indicated Resident #330's buttocks were red but not bleeding. Interview on 03/20/23 at 1:24 P.M. with LPN/UM #813 and the Director of Nursing (DON) revealed LPN/UM #813 stated she reported the lack of timely incontinence care for Resident #330 to the nurse on the floor but did not remember who she talked to. LPN/UM #813 indicated she told the nurse to pass it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 13 of 20 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 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Falls Village Skilled Nursing & Rehabilitation 330 Broadway East Cuyahoga Falls, OH 44221 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on in report to the next shift to make sure the STNA's were providing incontinence care and doing last rounds to check on the residents before going home. LPM/UM #813 stated the aides should be giving reports to each other. LPN/UM #813 stated she did not talk to the night shift aide about Resident #330's incontinence care but told the DON about it. The DON stated she did not talk to the aide about Resident #330's incontinence care or write the aide up for customer service because she could not prove Resident #330 was not wet at the beginning of the shift because he was not checked by STNA #826 until 8:30 A.M. Review of the facility policy titled Perineal Care, dated 04/18/11, included the purpose of this procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. 2. Review of Resident #335's medical record revealed an admission date of 03/08/23 with diagnoses including ventricular tachycardia, acute respiratory failure with hypoxia, and type two diabetes mellitus. Review of Resident #335's admission Assessment and Baseline Care Plan dated 03/08/23 revealed Resident #335 arrived via a cot and was alert to self, person, place, and time. Resident #335 required partial or moderate assistance for bed mobility. Resident #335 required assistance of two staff and used a mechanical lift for transfers. Resident #335 was occasionally incontinent of bowel and bladder. Review of Resident #335's care plan dated 03/08/23 included Resident #335 had bowel and bladder incontinence. Resident #335 would have no skin irritation or redness due to incontinence. Interventions included giving good peri-care after each episode of incontinence, apply protective barrier as needed, toilet resident in advance of need as much as possible, and toilet resident promptly upon request. Observation on 03/13/23 at 3:09 P.M. of Resident #335 with RN #837 revealed Resident #335 was lying on his back in bed, and the head of the bed was elevated approximately 45 degrees. Resident #335 stated he had diarrhea and needed cleaned up. RN #837 stated she would make sure that happened. Observation on 03/13/23 at 3:35 P.M. of Resident #335 revealed he was lying in bed on his back, and the head of the bed was elevated 45 degrees. Resident #335 stated his incontinence brief had not been changed. Observation on 03/13/23 at 4:13 P.M. of STNA #922 revealed he exited a resident room at the end of the nursing unit Resident #335 resided on. After surveyor intervention, STNA #922 entered Resident #335's room to provide incontinence care. STNA #922 stated he arrived for work at 3:00 P.M., had been answering resident call lights, and had not provided incontinence care for Resident #335. RN #837 walked in Resident #335's room and stated she did not tell STNA #922 that Resident #335 needed his incontinence brief changed. RN #837 stated she told STNA #820 who left at 3:00 P.M. that Resident #335 needed his incontinence brief changed. RN #837 assisted STNA #922 to provide incontinence care for Resident #335. Observation revealed Resident #335's incontinence brief was soaked with urine and a very large diarrhea bowel movement. Further observation revealed Resident #335's buttocks and sacral area were dark red and purple areas were noted along with a large black area on the left buttock. Large open areas with red wound beds and reddish drainage approximately three inches in diameter were noted across bilateral buttocks. These observations were confirmed by RN #837. After surveyor intervention, RN #837 and STNA #922 cleaned additional diarrhea from the crease of Resident #335's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 14 of 20 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 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Falls Village Skilled Nursing & Rehabilitation 330 Broadway East Cuyahoga Falls, OH 44221 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 buttocks which was missed when incontinence care was completed. Additional observations revealed Resident #335's upper thigh was red in area of scrotum, scrotum was red and irritated looking. Additional observations were confirmed by RN #837. Interview on 03/13/23 at 5:13 P.M. with the DON revealed she did Resident #335's initial wound assessment. The DON indicated there was one spot that looked like it had MASD (moisture associated skin damage) surrounding it, and was not macerated, open, or bleeding. The DON stated there was some redness. The DON stated she noted Resident #335 had excoriation on the inside of his thighs and scrotum. The DON indicated Resident #335 was admitted from the hospital on [DATE]. Review of Resident #335's nurse aide charting dated 03/13/23 and 03/14/23 revealed Resident #335's incontinence brief was changed on 03/13/23 at 10:48 P.M. and on 03/14/23 at 1:06 A.M., 1:56 P.M. and 7:42 P.M. There was no further documented evidence in Resident #335's medical record that his incontinence brief was checked and changed. Observation on 03/14/23 at 10:50 A.M. of Resident #335 with WNP #925 and the DON revealed this was her first visit for Resident #335. Observation revealed Resident #335 was lying on his back in bed and his incontinence brief was soaked with urine and a very large liquid bowel movement which was brownish green in color. Resident #335's urine and bowel movement leaked out of the incontinence brief and was noted on the sheets and blanket. The DON stated she did the initial assessment when Resident #335 was admitted to the facility, but Resident #335 had a dressing on and she did not pull the dressing all the way down to do a full assessment. The DON stated when he was admitted she just pushed the dressing down a little bit but did not see the entire buttock area. The DON stated another nurse started the assessment and she finished it. Interview on 03/14/23 at 2:33 P.M. with LPN #884 revealed he admitted Resident #335. LPN #884 could not remember details but remembered the wounds were dark in spots, had some redness, purple areas and the wounds were not bleeding. LPN #884 stated he started, and the DON finished up the admission assessment. LPN #884 stated Resident #335 was weak and sore and needed a lot of help with bed mobility and could not do it on his own. Interview on 03/16/23 at 10:59 A.M. with STNA #960 revealed she had not provided incontinence care for Resident #335. STNA #960 stated she started at the back of her nursing unit and worked her way forward and was going in Resident #335's room in the next few minutes. STNA #960 stated another aide told her Resident #335 was changed around 8:00 A.M. Review of Resident #335's aide charting on 03/16/23 did not reveal evidence Resident #335's incontinence brief was changed at 8:00 A.M. Review of the facility policy titled Perineal Care, dated 04/18/11, included the purpose of this procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. This deficiency represents non-compliance investigated under Complaint Number OH00140816 and Complaint Number OH00140473. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 15 of 20 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 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Falls Village Skilled Nursing & Rehabilitation 330 Broadway East Cuyahoga Falls, OH 44221 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, interview, record review, and review of manufacturer's instructions, the facility failed to ensure Resident #335's ICD (implantable cardioverter defibrillator) discharge instructions were documented in the medical record and failed to ensure ICD bedside monitoring device education was provided to the nursing staff. This affected one resident (#335) out of three residents reviewed for quality of care. The facility census was 80. Findings include: Review of Resident #335's cardiology daily progress note dated 03/07/23 included Resident #335 had an ICD placement on 03/06/23. Review of Resident #335's medical record revealed an admission date of 03/08/23 with diagnoses including ventricular tachycardia, acute respiratory failure with hypoxia, and type two diabetes mellitus. Review of Resident #335's hospital discharge Gold Form Provider Orders dated 03/08/23 included to keep appointment in the device clinic (ICD) and keep incision clean and dry for five days after the procedure, do not submerge incision in tub, pool, hot tub, or lake for four weeks; if the incision was bleeding or draining please call the office; if redness, swelling, drainage, have more pain at the site or a fever greater than 100 degrees Fahrenheit (F) call the office immediately. Activity restrictions included do not raise elbow higher than shoulder on the affected side for the first four weeks; however, it was important to move the shoulder joint gently each day to prevent the shoulder from becoming stiff; avoid any activity, exercise which involved rough contact with device site or might cause a heavy blow to the skin over the device; follow up with the physician prior to any activity that might be considered as rough. Review of Resident #335's care plan, physician orders, and progress notes did not reveal documentation of above information. Review of Resident #335's admission Assessment and Baseline Care Plan dated 03/08/23 revealed Resident #335 arrived via a cot and was alert to self, person, place, and time. Resident #335 required partial or moderate assistance for bed mobility. Resident #335 required assistance of two staff and used a mechanical lift for transfers. Resident #335 was occasionally incontinent of bowel and bladder. Resident #335 had an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough [yellow, tan, gray, green or brown] and/or eschar [tan, brown or black] in the wound bed) to the sacrum and measurements were length 4.0 centimeters (cm) and width of 3.0 cm, with slough and MASD (moisture associated skin damage) surrounding. Review of Resident #335's care plan dated 03/08/23 included Resident #335 required the use of an antibiotic. Resident #335 took an antibiotic prophylactically for an ICD placement. Resident #335 would exhibit no signs or symptoms of side effects relating to antibiotics. Interventions included administering antibiotics as ordered and monitor and report signs and symptoms of antibiotic side effects. Further review of the care plan revealed no education or instruction for Resident #335's ICD and monitoring system. Observation on 03/13/23 at 3:09 P.M. of Resident #335's room revealed a white device with a button in the center of the device showing the color green. The device was placed on Resident #335's bedside table. When asked what the device was, Resident #335 stated he did not know what it was. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 16 of 20 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 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Falls Village Skilled Nursing & Rehabilitation 330 Broadway East Cuyahoga Falls, OH 44221 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 03/13/23 at 3:09 P.M. of Registered Nurse (RN) #837 revealed she did not know what the white monitor was for that had a green button in the center of it which was placed on Resident #335's bedside table. Interview on 03/13/23 at 3:15 P.M. of the Director of Nursing (DON) revealed she did not know what the white device with the green button was for that was in Resident #335's room on the bedside table. The DON stated she would check in Resident #335 medical record to determine what it was. Interview on 03/13/23 at 3:30 P.M. of the DON revealed Resident #335 had an ICD placed, and the device came with the ICD. The DON stated the facility waited for the physician's office to call and give instructions on what the facility needed to do for the ICD. The DON stated she was not sure what the white device placed at Resident #335's bedside was for and was pretty sure the facility did not need to do anything with it. Interview on 03/16/23 at 11:49 A.M. of Manufacturer Representative (MR) #961 revealed Resident #335's ICD was placed ten days ago. MR #961 stated the white device with the green button was a monitoring device which sent information automatically about how the heart was working to the physician. MR #961 stated Resident #335 did not have to do anything with the monitoring device until instructions were given by the physician for manual transmission of the information. MR #961 stated the monitoring device needed to be within ten feet of Resident #335 when he was sleeping and to always ensure the button in the center of the device showed a green light. The green light was confirmation the device was working properly. MR #961 stated if the button showed a different color, Resident #335 would be contacted to let him know the device was not working correctly. MR #961 stated if a facility staff member or Resident #335 noticed the button light was not green, the manufacturer needed to be contacted immediately. MR #961 stated a smart phone could be used instead of the monitoring device, but it was easier to use the bedside monitoring device. Interview on 03/16/23 at 12:28 P.M. of Interim RN/Interim Minimum Data Set (MDS) Nurse (IRN/IMDS) #962 revealed Resident #335's white bedside monitoring device was a patient optional monitoring device that took information from Resident #335's implanted device and put it in the cloud. IRN/IMDS #962 stated the facility did not need to know anything about the device and it was tied to an app on a personal phone. Review of manufacturer's instructions included the white bedside monitoring device was a MyCareLink Relay Home Communicator and was an alternative monitoring option for patients who prefer not to use a smartphone. The instructions stated the MyCareLinkRelay must be plugged in, and patients must be within communication range for successful transmissions and the monitoring device required a Wi-Fi or cellular connection. Further review revealed increased patient adherence and save lives. Cardiac device patients who were not adherent with remote monitor transmissions would miss out on the following benefits: 50 percent potential increase in survival rate of patients, 35 percent potential reduction in emergency room visits, and 18 percent potential reduction in length of hospital stay. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 17 of 20 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 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Falls Village Skilled Nursing & Rehabilitation 330 Broadway East Cuyahoga Falls, OH 44221 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 observation, record review, interview, and policy review the facility failed to ensure a medication error rate of 5% (percent) or less. A total of 27 medications were administered with two errors for a medication error rate of 7.41%. This finding affected two residents (#52 and #53) of five residents observed for medication administration. Residents Affected - Few Findings include: 1. Review of Resident #53's medical record revealed he was admitted on [DATE] with diagnoses including type two diabetes, adjustment disorder with anxiety, and unspecified dementia. Review of Resident #53's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited moderate cognitive impairment. Review of Resident #53's physician orders revealed an order dated 02/27/22 for Humalog (fast acting insulin) inject five units subcutaneously before meals for diabetes mellitus. Observation on 03/13/23 at 9:53 A.M. with Licensed Practical Nurse (LPN) #864 of Resident #53's morning medication administration revealed his medications including five units Humalog insulin was administered at this time. Interview on 03/13/23 at 9:56 A.M. with LPN #864 confirmed Resident #53's fast acting insulin was supposed to be administered prior to his breakfast meal and he had already received and consumed his meal. She stated she did not normally work on that unit and determined he required insulin after the breakfast meal, and she had administered the insulin late. 2. Review of Resident #52's medical record revealed he was admitted on [DATE] with diagnoses including hemiplegia, acute respiratory failure, and cerebral infarction. Review of Resident #52's MDS 3.0 assessment dated [DATE] revealed he exhibited a memory problem. Review of Resident #52's physician orders revealed an order dated 08/17/22 for Keppra 100 mg (milligrams)/ml (milliliters) give 10 ml via PEG (percutaneous gastrostomy tube used for feedings and medications through the stomach wall) two times a day for seizures due at 12:00 P.M. and 12:00 A.M. Observation on 03/13/23 at 11:15 A.M. with LPN #879 of Resident #52's morning medication administration revealed the nurse unhooked the tube feeding solution from the PEG tube, placed a tube syringe in place and then immediately poured the Keppra solution into the syringe. She did not flush prior to administering the Keppra anti-seizure medication per the facility policy and best practice guidelines. Interview on 03/13/23 at 11:20 A.M. with LPN #879 confirmed she did not flush Resident #52's tube feeding syringe prior to administering the Keppra anti-seizure medication and she was not aware that she was required to. Review of the Medication Administration policy, dated 06/21/17, indicated to check the medication administration record for the order, identify the resident, explain the procedure, provide privacy, prepare the medications, place resident in a proper position, wash hands, verify tube placement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 18 of 20 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 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Falls Village Skilled Nursing & Rehabilitation 330 Broadway East Cuyahoga Falls, OH 44221 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 Level of Harm - Minimal harm or potential for actual harm according to facility policy, flush tube with at least 30 ml of water prior to administering medication, administer each medication separately and flush the tube after the medication pass with at least 30 ml of water. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 19 of 20 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 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Falls Village Skilled Nursing & Rehabilitation 330 Broadway East Cuyahoga Falls, OH 44221 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, interview, record review, and policy review the facility failed to ensure proper cleansing of a multi-resident use glucometer after obtaining blood sugar for Resident #53 and returning it to the medication cart on the Birchwood unit. This affected one resident (#53) of five residents reviewed for medication administration and had the potential to affect nine residents (#5, #16, #21, #25, #27, #37, #39, #46 and #53) who required blood sugar testing on the Birchwood unit. The facility census was 80. Residents Affected - Some Findings include: Review of Resident #53's medical record revealed he was admitted on [DATE] with diagnoses including type two diabetes, adjustment disorder with anxiety, and muscle weakness. Review of Resident #53's MDS 3.0 assessment dated [DATE] revealed he exhibited moderate cognitive impairment. The resident resided on the Birchwood unit. Review of Resident #53's physician orders revealed an order dated 03/03/23 for blood sugar checks every 6:00 A.M. and at bedtime and report results of less than 70 or greater than 300. Observation on 03/13/23 at 9:50 A.M. with LPN #864 of Resident #53's morning medication administration revealed she obtained a blood sugar level of 97 and exited the room and walked to the medication administration cart. She placed the contaminated glucometer on top of the medication administration cart and proceeded to remove Resident #53's medications including insulin to be administered. She left the contaminated glucometer on top of the medication cart and walked down the hall to the resident's room to administer his medications. Upon administration, she left the room and walked back to the medication administration cart, opened the top drawer with the stock medications and placed the contaminated glucometer in the drawer. Interview on 03/13/23 at 10:00 A.M. with LPN #864 indicated she was aware she needed to clean the glucometer to prevent cross-contamination of blood borne pathogens, but she wanted to get her medications done so she put the contaminated glucometer in the drawer with the stock medications. Interview on 03/16/23 at 10:41 A.M. with the Administrator confirmed Residents #5, #16, #21, #25, #27, #37, #39, #46 and #53 required blood sugar testing on the Birchwood unit. Review of the glucometer cleaning policy, revised 02/02/19, indicated the glucometer would be decontaminated after each use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 20 of 20