Inspection·December 14, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Review of the care plan dated 10/30/23 revealed Resident #46 was at risk for falls. Interventions included using call light and keep in easy reach at all times. Observation on 12/11/23 at 3:00 P.M. revealed Resident #46 was in bed with the call light hanging to the floor and out of reach. Residents Affected - Few Observation and interview on 12/11/23 at 3:05 P.M. with State Tested Nurse Assistant (STNA) #898 confirmed Resident #46's call light was out of reach and he was unable to retrieve it if he needed assistance. STNA #898 revealed Resident #46 had a history of stroke and required staff assistance. Observation and interview on 12/12/23 at 3:36 P.M. revealed Resident #46 in his room sitting in his wheelchair yelling out for assistance to use the bathroom. Resident #46 revealed he needed to go the bathroom and needed help. Resident #46's call light was not in reach. Observation and interview on 12/12/23 at 3:38 P.M. with State Tested Nurse Assistant (STNA) #872 confirmed Resident #46's call light was not in reach. Review of the facility document titled Answering the Call Light revised September 2022, revealed the policy provided guidance to ensure the call light was accessible to the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 2 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Based on interview and record review, the facility failed to ensure Resident #54 was able to attend a cardiology appointment. This affected one resident (#54) of one reviewed for appointments and transportation. The facility census was 75. Findings include: Review of the medical record for Resident #54 revealed an admission date of 04/13/22 and diagnoses including old myocardial infarction, tachycardia, chest pain, hypertension, congestive heart failure, and atherosclerosis. Review of the Resident Appointments and Transportation form dated 09/12/23 revealed Resident #54 had an appointment with cardiology on 01/10/24 at 2:15 P.M. and Resident #54 was to be transported via cot. Transportation had not yet been set up. Review of the Progress Note dated 11/02/23 revealed Resident #54's cardiology appointment on 01/10/24 had been rescheduled for 12/08/23 per his request. Review of Physician's Orders dated 12/08/23 revealed Resident #54 had an order for an appointment with a cardiologist on 12/08/23 at 11:00 A.M. Further review of Resident #54's medical record revealed no evidence of an appointment scheduled for 01/10/24. Interview on 12/11/23 at 10:15 A.M. with Resident #54 revealed he was supposed to have an appointment on 12/08/23 however the facility messed up transportation. Resident #54 indicated he got ready for the appointment, but no transport arrived to take him to the appointment. Interview on 12/13/23 at 11:20 A.M. with Transport Scheduler #880 revealed she was unaware of an appointment on 12/08/23 for Resident #54. Transport Scheduler #880 had not received an appointment scheduling form for Resident #54's appointment on 12/08/23. Transport Scheduler #880 thought Resident #54 had an appointment with cardiology in January 2024. Transport Scheduler #880 indicated Resident #54 had to be transported via cot. Interview on 12/13/23 at 11:53 A.M. with Licensed Practical Nurse (LPN) #826 revealed he had re-scheduled Resident #54's cardiology appointment for 12/08/23. They had gotten Resident #54 ready on 12/08/23 for his appointment however there was no transport arranged. LPN #826 indicated Resident #54 had a cardiology appointment scheduled for 01/10/24. Interview on 12/13/23 at 4:47 P.M. with a representative from Resident #54's cardiology office confirmed Resident #54 was supposed to have an appointment on 12/08/23 however he did not come to the appointment. The representative indicated there was no appointment scheduled for 01/10/24 as it had been canceled. Interview on 12/14/23 at 9:25 A.M. with Transport Scheduler #880 confirmed she did not set up transportation for Resident #54's cardiology appointment on 12/08/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 3 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 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 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. Based on medical record review, observation, interview, and review of facility policy, the facility failed to ensure a comprehensive care plan was in place that addressed the urological needs of Resident #19. This affected one (#19) of two residents reviewed for urinary catheters or urinary tract infection (UTI). The facility census was 75. Findings include: Review of the medical record for Resident #19 revealed an admission date of 11/12/23. Diagnoses included acute kidney failure, depression, hydronephrosis, stage three chronic kidney disease, mild protein calorie malnutrition, congenital occlusion of ureteropelvic junction, hyperkalemia, infection or inflammatory reaction due to indwelling urethral catheter, sepsis, bladder neck obstruction, and bacteremia. Review of the admission Minimum Data Set (MDS) assessment, dated 11/19/23, revealed Resident #19 had intact cognition and had the ability to make himself understood and to understand others. The MDS assessment further revealed Resident #19 had an indwelling urinary catheter. Review of the admission assessment progress note dated 11/12/23 revealed Resident #19 was admitted to the facility with bilateral nephrostomy tubes (a tube that lets urine drain from the kidney through an opening in the skin on the back) to straight drain. Review of the comprehensive care plan dated 11/14/23 revealed Resident #19 had no interventions related to nephrostomy tube monitoring or care from 11/14/23 to 12/13/23. Observation on 12/13/23 at 2:40 P.M. revealed the drainage bag from the right nephrostomy was full and bulging. A closer look at the drainage bag revealed it held up to 600 milliliters (ml) of urine and dark amber urine was filled over the line marking the 600 ml volume. Further observation revealed the left nephrostomy drainage bag contained approximately 350 to 400 ml yellow urine. Interview on 12/13/23 at 2:40 P.M. with Resident #19 revealed the nephrostomy drainage tubes and bags had not been monitored and stated, nobody has been in here to look at this all day. Further interview revealed the state tested nurse aides (STNAs) would empty his nephrostomy bags in the evenings at change of shift and the nurses did not clean or provide care to the nephrostomy tube sites. Interview on 12/15/23 at 3:05 P.M. with Licensed Practical Nurse (LPN) #826 confirmed the medical record contained no written instructions on nephrostomy tube care but stated they kept them clean and provide resident education. LPN #826 was unable to elaborate on specific cleaning frequency or method. Interview on 12/14/23 at 9:59 A.M. with Registered Nurse (RN) #874 confirmed Resident #19 had bilateral nephrostomy tubes and there were no orders and no care plan interventions regarding the nephrostomy tubes prior to 12/13/23. She further confirmed there was no place for staff to document nephrostomy output separately from the indwelling urinary catheter urine output prior to 12/13/23 and verbalized uncertainty as to whether the total recorded urine outputs were accurate. Review of facility policy date October 2010, titled Nephrostomy Tube, Care of, revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 4 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 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 0656 resident's care plan should be reviewed to assess any specific nephrostomy care needs. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 5 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on medical record review, interview, and review of facility policy, the facility failed to revise resident care plans when interventions were changed. This affected two residents (#40 and #63) of 23 reviewed for care planning. The facility census was 75. Findings include: 1. Review of the medical record for Resident #40 revealed an admission date of 07/28/23. Diagnoses included generalized muscle weakness, malaise, polycythemia vera, fatigue, history of transient ischemic attack, chronic venous hypertension, diabetes mellitus, neuropathy, anxiety, and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/17/23, revealed Resident #19 had intact cognition and required moderate assistance for toileting, bathing, bed to chair and shower transfers. Review of the care plan dated 11/22/23 revealed Resident #40 was to be transferred with a one person assist. Interview with Resident #40 on 12/11/23 at 10:20 A.M. revealed he needed a Hoyer (mechanical) lift for transfers out of bed. Interview on 12/14/23 at 11:43 A.M. with State Tested Nurse Aide (STNA) #906 confirmed Resident #19 required a Hoyer lift and two staff for all transfers. Interview on 12/14/23 at 11:49 A.M. with Registered Nurse (RN) #874 confirmed the physician's order and comprehensive care plan indicated Resident #40 was to be transferred with one-assist. RN #874 further confirmed the written care card for STNAs indicated Resident #40 required a mechanical lift for transfers. RN #874 stated she wasn't sure where they got that information, since there was no order or care plan intervention for a mechanical lift. Interview on 12/14/23 at 12:27 P.M. with Therapy Director #940 and Corporate Nurse #944 confirmed Resident #40 required a Hoyer lift. Corporate Nurse #940 confirmed the care plan needed updated to indicate Resident #40's need for a Hoyer lift. 2. Review of the medical record for Resident #63 revealed an admission date of 07/07/23. Diagnoses included pneumonia, COVID-19 (added 11/17/23), neuromuscular dysfunction of the bladder, urinary tract infection, urogenital candidiasis, nontraumatic intracranial brain hemorrhage, gastrostomy status, and other bacterial infections of unspecified site. Review of Resident #63's orders revealed a physician order dated 09/20/23 to maintain contact precautions. The indication for contact precautions was not listed within the order. Review of the care plan dated 11/22/23 revealed Resident #63 required contact isolation precautions due to colonization of candida auris and droplet isolation precautions related to COVID-19. Interventions included contact isolation, droplet precautions and use of the appropriate personal protective equipment (PPE) as indicated by the isolation type listed in the care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 6 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview on 12/12/23 from 3:10 P.M. to 3:20 P.M. with Licensed Practical Nurse (LPN) #816 confirmed Resident #63 was to be under contact precautions and that the care plan stated both contact and droplet precautions. LPN #816 further confirmed she was unaware of the source of infection that triggered contact precautions but was certain Resident #63 was no longer in droplet isolation for COVID-19. Throughout this interview, LPN #816 searched Resident #63's electronic medical record and hard chart at the nurses station to find the reason Resident #63 was in contact isolation. After ten minutes of searching, LPN #816 confirmed she could not determine the source of infection and stated, it looks like they never downgraded him from droplet precautions to just contact precautions. Interview on 12/13/23 at 2:00 P.M. with Registered Nurse (RN) #945 confirmed Resident #63 was on contact precautions for colonization of Carbapenem-resistant Enterobacterale (CRE) in his sputum. RN #945 further confirmed Resident #63 was no longer in droplet isolation. Review of the policy titled Isolation - Categories of Transmission-Based Precautions dated 09/15/22 revealed the facility was to ensure the resident's care plan and specialist communication system indicated the appropriate type of isolation precautions implemented for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 7 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 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. Based on medical record review, observation, interview, and review of facility policy, the facility failed to ensure sufficient treatment and services were provided that appropriately addressed the urological needs of a resident. This affected one (Resident #19) of two residents reviewed for urinary catheters or urinary tract infection (UTI). The facility census was 75. Findings include: Review of the medical record for Resident #19 revealed an admission date of 11/12/23. Diagnoses included acute kidney failure, depression, hydronephrosis, stage three chronic kidney disease, mild protein calorie malnutrition, congenital occlusion of ureteropelvic junction, hyperkalemia, infection or inflammatory reaction due to indwelling urethral catheter, sepsis, bladder neck obstruction, and bacteremia. Review of the admission Minimum Data Set (MDS) assessment, dated 11/19/23, revealed Resident #19 had intact cognition and had the ability to make himself understood and to understand others. The MDS assessment further revealed Resident #19 had an indwelling urinary catheter. Review of the admission assessment progress note dated 11/12/23 revealed Resident #19 was admitted to the facility with bilateral nephrostomy tubes (a tube that lets urine drain from the kidney through an opening in the skin on the back) to straight drain. Review of physician orders revealed Resident #19 had no orders in place that addressed his nephrostomy tubes. Random observation on 12/12/23 at 3:27 P.M. revealed Resident #19's catheter drainage bag laying on the floor next to the resident's bed. Interview on 12/12/23 at 3:27 P.M. with Licensed Practical Nurse (LPN) #816 confirmed the catheter bag was on the floor. After picking up the bag and tubing and hooking the drainage bag to the side of Resident #19's bed, she stated at least it had the right bag; he has a blue bag to maintain privacy. Observation on 12/13/23 at 2:40 P.M. revealed the drainage bag from the right nephrostomy full and bulging. A closer look at the drainage bag revealed it held up to 600 milliliters (ml) of urine and dark amber urine was filled over the line marking the 600 ml volume. Further observation revealed the left nephrostomy drainage bag contained approximately 350 to 400 ml yellow urine. Interview on 12/13/23 at 2:40 P.M. with Resident #19 confirmed the nephrostomy drainage tubes and bags had not been monitored and stated, nobody has been in here to look at this all day. Further interview revealed the state tested nurse aides (STNAs) would empty his nephrostomy bags in the evenings at change of shift, but no facility staff routinely checked or cleaned his tube insertion sites. He added that the nurses never did anything with his nephrostomies. Resident #19 further stated the nephrostomy tube sites only got cleaned when he rinsed them off in the shower. Observation on 12/13/23 at 2:55 P.M. revealed STNA #912 draining the urinary catheter bag and both nephrostomy drainage bags. No glove changes or cleaning of the exit ports of the tubing was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 8 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 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 performed during the process. STNA #912 stated out loud to Resident #19 at the time she was draining urine from his catheter bag that there were no alcohol swabs in his room for her to swab the end of the tubing from his drainage bag. At the time of the observation, STNA #912 confirmed 600 ml was emptied from the right nephrostomy, 300 ml was emptied from the left nephrostomy, and 600 ml was emptied from the indwelling urinary catheter. Residents Affected - Few Interview on 12/13/23 at 3:01 P.M. with STNA #912 revealed she was taught she was supposed to clean the tubing after she drained the urine, before securing it back on the bag, but did not clean the tubing at any time during the process of draining Resident #19's urinary drainage bags. STNA #912 further stated Resident #19's room never had any alcohol swabs available for her to clean the way she was taught. An interview on 12/13/23 at 3:05 P.M. with Licensed Practical Nurse (LPN) #826 confirmed Resident #19's medical record contained no orders or written instructions on nephrostomy tube care. Interview on 12/13/23 at 4:00 P.M. with STNA #912 revealed Resident #19's urinary output was documented in the chart under the bladder task. STNA #912 confirmed that she combined all the urine output from the catheter and nephrostomy tubes and documented it, then confirmed the amount entered for that date was 600 ml. Interview on 12/14/23 at 9:59 A.M. with Registered Nurse (RN) #874 confirmed Resident #19 had bilateral nephrostomy tubes since admission and there were no orders or care plan interventions regarding the nephrostomy tubes prior to 12/13/23. During the interview, RN #874 confirmed nephrostomy tubes should be cleaned and a dry dressing should be applied daily by the assigned floor nurse. RN #874 further indicated it was her expectation the drainage bags be checked by nurses when they were passing medications and by the STNAs when they responded to call lights or at least approximately every two hours. RN #874 stated nephrostomy output should be recorded by the nurse after the STNA reported the total to the nurse and then the STNA should document the output from the urinary catheter. RN #874 confirmed there was no place for staff to document nephrostomy output separately from the indwelling urinary catheter urine output prior to 12/13/23 and verbalized uncertainty as to whether the total recorded urine outputs were accurate. Review of facility policy dated October 2010, titled Nephrostomy Tube, Care of, revealed physician orders should be verified for residents with nephrostomy tubes. The policy listed the following guidelines: assess the resident for indications of bleeding in the flank area every eight hours, verify tube placement and integrity during assessments, empty bag every shift and as needed, change drainage bag monthly or and as needed, measure output every eight hours, measure output from the right and left kidneys separately and record the output from the kidneys separately from the urine output, change the dressing every one to three days, and use sterile technique during dressing changes. Review of the policy titled Catheter Care, Urinary (last revised August 2022) revealed aseptic technique must be used when handling the drainage system and the catheter tubing and drainage bag were to be kept off the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 9 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and policy review, the facility failed to ensure oxygen tubing was up-to-date per physician orders and sterile water containers were changed and dated for use with oxygen concentrator. This affected two residents (#7 and #174) of two residents reviewed for oxygen. The facility census was 75. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 12/18/19 with diagnoses that included dementia, epilepsy, and acute respiratory failure with hypoxia. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated he was alert and oriented to person, place, and time. Further review of the MDS assessment revealed Resident #7 required oxygen therapy. Review of the care plan dated 11/01/23 revealed Resident #7 was at risk for respiratory distress and had a history of chronic obstructive pulmonary disease (COPD). Interventions included administer oxygen as ordered, monitor, and report change in condition to physician. Review of the physician orders dated 10/31/23 revealed an order for oxygen via nasal cannula at two liters per minute continuously every shift. Review of the physician orders dated 11/05/23 revealed an order to change and date oxygen mask, tubing and humidifier bottle, every night shift every Sunday. Observation and interview on 12/12/23 at 8:57 A.M. with Resident #7 revealed a blue oxygen concentrator with a plastic bottle with a minimal amount of sterile water located adjacent to the foot of the bed. The bottle of sterile water was dated 11/25/23 in blue writing . There was no date located on the oxygen tubing or oxygen mask. Resident #7 revealed he utilized his oxygen every day, but staff did not change his tubing and mask regularly. Resident #7 revealed he used oxygen via nasal cannula. Observation and interview on 12/12/23 at 9:03 A.M. with State Tested Nursing Assistant (STNA) #918 confirmed Resident #7's oxygen mask and tubing was not dated and the bottle of sterile water was dated 11/25/23. STNA #918 verified the current date of 12/12/23, approximately three weeks after the water bottle was dated. Interview on 12/12/23 at 3:47 P.M. with Licensed Practical Nurse (LPN) #852 revealed Resident #7 utilized oxygen on a continuous basis. LPN #852 revealed Resident #7 received two liters of oxygen per minute to keep oxygen saturation levels up. LPN #852 said she changed his oxygen tubing, mask, and sterile water as needed. Observation and interview on 12/13/23 at 1:56 P.M. with Registered Nurse (RN) #851 confirmed Resident #7's oxygen tubing and mask was undated and the sterile water container was dated 11/25/23. RN #851 revealed the sterile water usually became empty after a week of use and the oxygen tubing, mask, and sterile water would be changed at the same time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 10 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of the medical record for Resident #174 revealed an admission date of 12/06/23 with diagnoses that included pneumonia, muscle weakness, and chronic respiratory failure with hypoxia. Review of the care plan dated 12/06/23 revealed Resident #174 was at risk for respiratory distress and chronic obstructive pulmonary disease (COPD). Interventions included administering oxygen as ordered, monitoring, and reporting changes in condition to physician. Review of the physician orders dated 12/10/23 revealed an order to change and date oxygen mask, tubing and humidifier bottle, every night shift every Sunday. Review of the physician orders dated 12/11/23 revealed an order for oxygen via nasal cannula at one liter per minute continuously every shift to maintain oxygen saturation levels above 90 percent. Observation on 12/12/23 at 9:00 A.M. of Resident #174's room, revealed a blue oxygen concentrator with a plastic bottle with a minimal amount of sterile water located adjacent to the left side of the bed. The bottle of sterile water and oxygen tubing was undated. Observation and interview on 12/12/23 at 9:03 A.M. with State Tested Nurse Aide (STNA) #918 confirmed Resident #174's oxygen tubing and sterile water was undated. Observation on 12/13/23 at 1:00 P.M. revealed Resident #174's bottle of sterile water was empty and undated. Observation and interview on 12/13/23 at 2:20 P.M. with Registered Nurse (RN) #851 confirmed Resident #174's oxygen tubing was undated and the sterile water was undated and empty. RN #851 revealed the sterile water usually became empty after a week of use and the oxygen tubing, mask, and sterile water would be changed at the same time. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed it was in progress. Review of the facility document titled Oxygen Administration revised October 2010, revealed guidance to verify physician orders, assemble equipment and supplies as needed and document the date and time of oxygen setup or adjustment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 11 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 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 2. Observation of medication administration for Resident #33 on 12/12/23 at 8:12 A.M. revealed Registered Nurse (RN) #851 preparing the morning medications. RN #851 opened a bottle of ferrous sulfate, shook out one ferrous sulfate tablet onto the inside of the lid of the ferrous sulfate bottle then dropped the ferrous sulfate in a medication cup along with the other medications. RN #851 screwed the lid back on the ferrous sulfate bottle and when placing the bottle back in the cart the lid came loose and fell to the floor. RN #851 picked up the lid and screwed it back on the bottle and placed it back in the cart without cleaning the lid. Residents Affected - Few Interview on 12/12/23 at 8:50 A.M. with RN #851 confirmed she placed the ferrous sulfate bottle back in the cart without sanitizing/cleaning the lid which had fallen to the floor. RN #851 stated she was unsure of what to do with the lid after it was dropped. Based on medical record review, observation, interview, and review of facility policy, the facility failed to ensure proper infection control practices were maintained for Resident #63 related to transmission-based precautions and tube feeding procedures. The facility also failed to ensure infection control procedures were maintained during medication administration. This affected Individual #33, one of five residents observed during medication administration. The facility census was 75. Findings include: 1. Review of the medical record for Resident #63 revealed an admission date of 07/07/23. Diagnoses included pneumonia, COVID-19 (added 11/17/23), neuromuscular dysfunction of the bladder, urinary tract infection, urogenital candidiasis, nontraumatic intracranial brain hemorrhage, gastrostomy status, and other bacterial infections of unspecified site. Review of Resident #63's orders revealed a physician order dated 09/20/23 to maintain contact precautions. Further review of physician orders revealed a tube feeding order dated 12/11/23 for Isosource 1.5 milligrams (mg), 360 milliliters (ml) bolus feed, five times a day, followed by a 210 ml water flush after each bolus through the gastrostomy tube (GT). Review of the admission Minimum Data Set (MDS) assessment, dated 11/17/23, revealed Resident #63 had moderately impaired cognition. Further review of the MDS revealed Resident #63 had an indwelling urinary catheter and received tube feeding. Observation on 12/12/23 at 2:50 P.M. of Resident #63's room revealed an unsealed 1000 ml bag of Isosource 1.5 sitting on the windowsill. The upper corner side of the bag was diagonally cut open. The window blind was pulled down over the top of the open bag. The sun was shining in the room. Further observation on 12/12/23 at 3:24 P.M. of Resident #63's room with Licensed Practical Nurse (LPN) #816 revealed the opened unsealed bag of Isosource was lying flat on the windowsill. Interview at this time with LPN #816 revealed she cut open the 1000 ml bag because there were no small cartons of Isosource 1.5 available for the 8:00 A.M. tube feeding. LPN #816 used the same bag for the 8:00 A.M. and 12:00 P.M. feeding and the bag was left unsealed between the two feedings. During this interview, LPN #816 leaned into the resident's room, grabbed the plastic graduated cylinder sitting at Resident #63's bedside with ungloved hands, and brought the graduated cylinder outside of the room, pushing it in the air toward the surveyors to show the lines she drew with marker indicating how much tube feed and flush she used for Resident #63's bolus feeds. At this time, LPN #816 confirmed she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 12 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few knew she should not have removed the unclean item from the resident's room or touched the container with ungloved hands, acknowledging Resident #63 was in contact isolation. Observation on 12/14/23 at 1:40 P.M. revealed State Tested Nurse Aide (STNA) #915 pulled a pile of gloves out of her pocket and laid them on the bed of Resident #63 who was in contact isolation during a dressing change. Once the dressing change was completed, she picked the pile of gloves up from the bed, placed them in her pocket, and exited the room. Interview on 12/14/23 at 1:50 P.M. with STNA #915 confirmed she put some gloves on the Resident #63's bed, then placed them in her pocket. She further confirmed they were still in her pocket. Review of the policy titled Isolation - Categories of Transmission-Based Precautions dated 09/15/22, revealed staff were supposed to wear gloves when entering a room of a resident in contact precautions and when handling potentially infective equipment. Review of the manufacturer's instructions for Isosource 1.5 revealed SpikeRight bags were to shaken before use, and kept out of excessive heat. Staff were to ensure proper technique was followed, which included accessing the formula by inserting a SpikeRight Plus connector into the port and securing tightly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366222 If continuation sheet Page 13 of 13