Health inspection·July 26, 2021

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Weekly Wound Report dated 04/27/21 revealed the left ankle wound of Resident #28 measured 2.5 cm in length by 2.0 cm in width by 1.0 cm in depth, was a stage three, and had 25 percent slough in the wound bed. There was no documentation the physician was notified of the decline. Review of the nursing notes/wound notes dated 04/27/21 at 7:37 A.M. revealed Resident #28 had a stage three pressure ulcer on the left ankle due to rubbing the foot repeatedly on the bed and from the plastic AFO (ankle foot orthosis) brace. There was no documentation of the decline or the physician was notified of the decline. Interview on 07/22/21 at 2:50 P.M. with the Director of Nursing confirmed there was no documentation the physician was notified on 04/27/21 of the change in status of the left ankle pressure ulcer of Resident #28. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 2 of 28 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 366264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #33 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease and urinary tract infections. Residents Affected - Few Review of the quarterly MDS 3.0, dated 06/18/21, revealed Resident #33 was alert and oriented and able to make her needs known. The resident needed extensive assistance of one person for toileting. Review of the current constipation plan of care revealed Resident #33 was at risk for constipation due to decreased mobility. Interventions included to follow the bowel protocol, monitor, document and report any signs or symptoms related to constipation and record bowel movements (BM) each day. Review of the BM record for June 2021 revealed Resident #33 did not have a BM after 06/15/21 at 1:58 P.M. until 06/20/21 at 1:13 A.M. There was no evidence the as needed medication for constipation was given. Further review of the June 2021 BM into July 2021 revealed after 06/28/21 at 11:14 P.M. Resident #33 did not have a BM until the afternoon of 07/03/21 at 5:37 P.M. There was no evidence the as needed mediation for constipation was given. On 07/22/21 at 11:39 A.M., interview with the DON verified the as needed medication for constipation was not given as planned. If no BM after three days a resident should be given milk of magnesia which was the standard of practice and was not done. Further review of the current constipation protocol verified it was not consistent with the standard of practice and needed updated. Based on medical record review, policy review, and interview the facility failed to implement a bowel protocol for two (Residents #10 and #33) of five residents reviewed for medication use. Findings include: 1. Review of Resident #10's medical record revealed diagnoses including dementia, type 2 diabetes mellitus, and pain. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was moderately cognitively impaired. Resident #10 required extensive assistance for toilet use and was always incontinent of bowel. Resident #10 had physician orders for two tablets of senna 8.6 milligrams (mg) in the morning for constipation, a dulcolax suppository every 72 hours as needed for constipation, and 30 milliliters (ml) of milk of magnesia every 72 hours as needed for constipation per bowel protocol. Resident #10's plan of care was silent regarding constipation and/or bowel protocol to be implemented. Review of bowel movement (BM) records since 06/22/21 revealed no recorded bowel movement from 06/23/21 to 06/26/21, 07/08/21 to 07/11/21, or 07/15/21 to 07/18/21. There was no evidence of milk of magnesia or dulcolax suppositories being administered according to physician orders. Review of the facility's Constipation policy (dated 01/30/16) revealed the night shift charge nurse would monitor bowel movement records daily and a bowel movement list would be created every night on a communication board. If a resident had no bowel movement for two days the resident would receive a laxative from the day shift charge nurse. If the resident did not have an order for a laxative to be administered on an as necessary basis, standing orders could be utilized. If the resident had no bowel movement for three days the night shift charge nurse would administer a suppository. If the resident did not have an order for a suppository, standing orders could be utilized. If the resident had no bowel movement for four days the charge nurse would administer a fleets enema during day shift or the first two hours of afternoon shift. The enema could be administered in accordance with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 3 of 28 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 366264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few standing orders. When a resident refused the laxative or suppository and there was no bowel movement within 24 hours a primary care provide had to be notified. When a resident refused an enema the primary care provider needed notified the same day. On 07/22/21 at 11:47 A.M. Registered Nurse (RN) #53 verified Resident #10's care plan did not address constipation. On 07/22/21 at 9:30 A.M. the lack of documentation of bowel movements and lack of documentation of bowel medications being administered was addressed with the Director of Nursing (DON). No additional information was provided. Review of the facility's Bowel Training policy (effective 05/01/16) indicated daily bowel movement was not necessary but time between bowel movements should not exceed three days. Staff were to ascertain when the last bowel movement occurred. If there was no bowel movement within three days, a digital rectal exam was to be completed. If firm stool was felt on digital exam, give gentle soapsuds enema or enema of choice ordered by the physician. Staff were instructed to document the following in the resident's record: bowel program established and results, pertinent information, and instructions given to resident/caregiver. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 4 of 28 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 366264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613 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** Based on observation, review of the medical record, interviews with staff, and review of the facility policy the facility failed to prevent the development of a pressure ulcer for Resident #28. Actual harm occurred when Resident #28 developed an avoidable, in house acquired, stage three (full thickness wound with fat and tissue exposed) pressure ulcer to the left outer ankle. This affected one (Resident #28) of three residents reviewed for pressure ulcers. The facility census was 42. Residents Affected - Few Findings include: Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including infection in left knee, arthritis, severe protein calorie malnutrition, epilepsy, altered mental status, gastro-esophageal reflux disease, osteoarthritis, COVID-19, major depression, hypertension, hemiplegia, and hemiparesis to left side following a cerebrovascular disease, and psychosis. Further review of the medical record revealed Resident #28 was discharged to the hospital on [DATE] and the order for the Left Ankle Foot Orthosis (AFO) brace was discontinued on 11/24/20. Resident #28 was readmitted to the facility on [DATE] without an order for the left AFO, however, the staff continued to place the AFO on the resident. Review of the Braden scale dated 12/02/20 revealed Resident #28 was high risk for developing pressure ulcers. Review of the significant change in status Minimum Data set 3.0 assessment dated [DATE] revealed Resident #28 had intact cognition, required extensive assistance for all activities of daily living (ADLS), and was at risk for pressure ulcers. The resident did not have any unhealed pressure ulcers and had a surgical wound. Review of the plan of care dated 01/21/21 revealed Resident #28 was at risk or had altered skin integrity due to being admitted with surgical wounds and being at risk for skin breakdown due to immobility, disease process and weakness. Interventions included to follow the facility skin protocol, immediately report any skin redness or breakdown to the nurse, inspect the skin with showers and baths and provide information to the nurse to review, notify the physician of any changes in the skin as needed, and perform treatments as ordered. Review of the January 2021 and February 2021 Medication Administration Record and Treatment Administration Record revealed no documentation of skin checks of the left ankle and/or under the AFO brace of Resident #28. During review of the medical record there was no evidence found of skin checks or shower sheets with skin checks for Resident #28. Review of physician orders for January and February 2021 revealed Resident #28 did not have an order for an AFO brace to the left foot. Review of the wound/skin progress note dated 02/16/21 revealed Resident #28 had a stage three pressure ulcer on the left outer ankle due to him rubbing his foot repeatedly on the bed and from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 5 of 28 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 366264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613 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 plastic AFO brace. Level of Harm - Actual harm Review of the Weekly Wound Report dated 02/16/21 revealed Resident #28 was found to have a stage three pressure ulcer to his left outer ankle which measured 4.0 centimeters (cm) in length by 1.0 cm in width by less than 1.0 cm in depth. Residents Affected - Few Review of the physician's orders dated 02/16/21 revealed Resident #28 had an order to hold the use of the AFO brace due to a pressure area on the left ankle. Interview on 07/21/21 1:20 P.M. the Director of Nursing (DON) indicated the State Tested Nursing Assistants (STNA) did not document under tasks for skin observations. During a telephone interview on 07/21/21 at 1:40 P.M. Registered Nurse (RN) #51, who was the facility's wound nurse, indicated she was told by the wound company to stage Resident #28's wound at a stage three for proper treatment. She indicated his AFO brace was rubbing his ankle and caused a pressure ulcer. During interview on 07/21/21 at 2:00 P.M. the DON verified there was no documentation of skin observation prior to the facility finding the stage three pressure ulcer to the left outer ankle of Resident #28 and there were no shower sheets to indicate the staff had been performing skin assessments on Resident #28 per his plan of care. During interview on 07/21/21 at 4:10 P.M. STNA #74 indicated they were to check a resident's skin during their bath or shower. They would then fill out a shower sheet and give it to the nurse, the nurse would sign it and they would put it in the shower book. She stated Resident #28 did get up and get a shower every week before he went on hospice but now hospice does his shower. She indicated they put the resident's AFO brace on when he got up out of bed and took it off while he was in bed. Review of the medical record revealed Resident #28 did not go under hospice care until 02/28/21. During interview on 07/21/21 at 4:15 P.M. Licensed Practical Nurse ((LPN) #73 indicated the STNA would fill out the shower sheet, give the sheets to the nurses, the nurses would sign the shower sheet and the STNA would put the sheet into the shower book on the unit. She indicated she had been checking the skin under Resident #28's AFO brace, however, she had not documented anywhere in his chart she had done it. During interview on 07/22/21 at 8:37 A.M. LPN #62 indicated Resident #28 had been in and out of the hospital so many times the order for his AFO brace must have dropped off and was never picked back up. She verified Resident #28 did not have an order for the AFO brace at the time he acquired the stage three pressure ulcer to his left outer ankle. During interview on 07/22/21 at 8:45 A.M. Resident #28 indicated he was unable to move his left leg and didn't feel much, however, he had told the staff his ankle was bothering him and that was when they found the sore. He indicated the staff did take the brace off at night, but they did not take his socks off. Observation on 07/22/21 at 11:09 A.M. revealed LPN #63 provided wound care to the left outer ankle pressure wound of Resident #28 with no concerns. The wound was approximately 1.0 cm in width by 1.0 cm in length with an undetermined depth due to the nurse did not measure the wound. The wound bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 6 of 28 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 366264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613 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 and peri wound was pink with granulation. There was a small amount of yellow drainage on the old dressing. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy, Nursing-Skin, dated 05/01/16 revealed the policy was to identify resident at risk for the development of pressure ulcers and define early interventions. Early interventions refer to treatment prescribed for those residents determined to be a risk for developing pressure ulcers. Event ID: Facility ID: 366264 If continuation sheet Page 7 of 28 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 366264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Resident #33 had planned interventions in place and was properly assessed to ensure new interventions were implemented after falls and failed to ensure staff utilized a gait belt for ambulation with Resident #195 as planned. This affected one of two residents reviewed for falls and one additional resident observed during ambulation. Findings include: 1. Resident #33 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease and a history of falls. Review of the quarterly Minimum Data Set (MDS) 3.0, dated 06/18/21, revealed Resident #33 was alert and oriented and able to make her needs known. The resident needed extensive assistance for activities of daily living including one person assist with a walker for ambulation and needed glasses for corrective vision. Review of the current fall plan of care revealed Resident #33 had a history of falls due to gait/balance problems. Interventions included to ensure appropriate footwear, follow the fall protocol, provide a safe environment and ambulate with a walker. Review of the 02/11/21 nurses notes revealed when the State Tested Nurse Aide (STNA) was assisting with toileting Resident #33 fell onto the floor. The STNA was not using a gait belt. The intervention was to in-service staff on proper use of a gait belt. Further review revealed there was no evidence of the gait belt in-service. Review of the 06/06/21 nurses notes revealed an STNA was transferring Resident #33 out of the recliner when the back of the recliner fell off causing the resident to fall and hit her head resulting in a hematoma to the right side of her head. Further review of the investigation revealed there was no evidence the resident was wearing glasses nor if the walker was in use. The investigation stated the STNA was transferring the resident into the recliner when the back fell off which contradicted the nurses notes. The resident was sent to the emergency room for evaluation. There were no new interventions or education completed to prevent further falls. Review of the 06/27/21 nurses notes revealed the STNA was walking with Resident #33 when she started walking too fast with the walker and fell. There was no evidence a gait belt was in use nor if the resident had on her glasses or if proper footwear was in place. Further review of the investigation revealed the same and again no evidence of proper footwear or glasses in place or use of a gait belt. Review of the 07/17/21 nurses notes revealed after showering Resident #33, the STNA assisted the resident out of the tub and was pulling up her pants when the resident fell backwards. There was no evidence of glasses in place or a gait belt being used at the time of the fall. Further review of the investigation revealed the resident did not have on proper footwear and there was no evidence of glasses nor a gait belt being used. The new intervention was to wear proper footwear which was already an intervention. There was no evidence of education of staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 8 of 28 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 366264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm On 07/21/21 at 11:17 A.M., STNA #66 was observed walking Resident #33 back to her room and into her bathroom. The resident was using her walker, had on glasses and proper shoes. STNA #66 had her hand touching the resident's back but was not using a gait belt. At 11:21 A.M., Resident #33 activated her bathroom call light and an unidentified STNA entered the room and assisted the resident back to her recliner without the use of a gait belt. Residents Affected - Few On 07/21/21 at 11:22 A.M., interview with STNA #66 verified she did not use a gait belt when ambulating with Resident #33. On 07/21/21 at 9:30 A.M., interview with Director of Nursing (DON) verified she was not able to provide any documentation of gait belt education to staff including for the 02/11/21 fall for Resident #33. When informed of the above observations of staff assisting residents without the use of a gait belt, the DON verified gait belts are part of the uniform (meaning all STNAs were to wear a gait belt around their waist at all times) and a gait belt should always be used when transferring and ambulating residents who needed assistance. On 07/22/21 at 9:45 A.M., interview was completed with the DON for review of the above falls. • For the fall on 02/11/21 the DON verified there was no education provided as planning for any of the staff for not using the gait belt. • For the fall on 06/06/21 (in the exercise/activity room) the DON verified the nurses notes and the witness statements (as part of the investigation) contradicted each other and no one attempted to determine the actual event other than the back of the recliner broke. Further review of the narrative in the investigation revealed the resident did not sustain any injuries but the DON verified the resident was sent to the emergency room with a hematoma caused by hitting her head during the fall. The DON also verified there was no documentation of use of a gait belt when transferring the resident. • For the fall on 06/27/21 there was no documentation a gait belt in use when the STNA was ambulating with the resident, nor was there evidence the resident was wearing glasses or proper footwear. • For the 07/17/21 fall the DON verified the STNA did not have proper footwear on the resident after bathing. There was no evidence a gait belt was in use and no education was provided. The DON verified a gait belt should have been used in all the above falls. On 07/22/21 at 10:50 A.M., interview with Resident #33 verified some staff utilized the gait belt while other staff did not when transferring and/or ambulating her. Review of the gait belt policy, dated 05/01/16, revealed a gait belt would be used at all times when transferring, moving, and/or ambulating a resident unless clinically contraindicated. A gait belt was an assistive device used to lift a resident from a sitting position, to transfer a resident from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 9 of 28 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 366264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm one seat to another and to provide support when helping a resident to walk. Instructions included to immobilize the bed, chair and/or wheelchair then assist the resident to a sitting position with the feet resting on the floor. Ensure appropriate, non skid footwear were in place and the resident was balanced before changing positions. Grip the gait belt with one hand placed at the resident's back and the other hand placed on the belt portion (weaker side if indicated). Residents Affected - Few Review of the fall policy, dated 12/01/17, revealed the facility would identify residents at risk for falls and initiate measures that would help reduce falls. Education was to be provided yearly to staff and all new admissions would be considered a fall risk for the first five days. Residents were to wear proper footwear, glasses and hearing aids as deemed appropriate. Assessments were to be completed on admission, after each fall, quarterly and with annual review. The fall risk log, which was to be completed by the DON, would be discussed at morning stand up meetings. Staff would offer toileting to residents every two hours or as required depending on the functional ability of the resident. A plan of care would be initiated on admission and adjusted as necessary. A fall investigation would be completed and logged on a tracking log. For every fall at least one intervention was required immediately and other long term interventions as needed. The medical director would review the monthly quality assurance report for input. 2. On 07/22/21 at 10:20 A.M., observation of Physical Therapy Assistant (PTA) #40 and Activities Director (AD) #17 assisting Resident #195 who was utilizing a walker revealed there was no use of a gait belt. On 07/22/21 at 10:23 A.M., interview with PTA #40 verified a gait belt should have been used for any residents requiring contact guard or assistance of staff with ambulation including Resident #195 but no gait belt was used. On 07/22/21 at 10:25 A.M., interview with AD #17 verified Resident #195 needed assistance with ambulation and no gait belt was used for the ambulation from the resident's room into the exercise room. On 07/22/21 at 2:40 P.M., interview with the DON verified the above concern. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 10 of 28 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 366264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613 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, review of the medical record and interviews with staff the facility failed to ensure Resident #12 had her oxygen on as ordered. This affected one (Resident #12) of two residents reviewed for respiratory therapy. Residents Affected - Few Findings include: Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses of pulmonary embolism, hypertension, spondylosis, chronic kidney disease, hernia, myocardial infarction, and chronic sinusitis. Review of the admission Minimum Data Set 3.0 assessment revealed Resident #12 had moderately impaired cognition and did not require oxygen. Review of the July 2021 physician's orders revealed Resident #12 had an order dated 05/12/21 for oxygen at two liters via nasal cannula, continuously, for shortness of breath. Observation on 07/21/21 at 3:45 P.M. revealed Resident #12 was in bed without her oxygen on. The nasal cannula was hanging on the oxygen concentrator across the room. Interview on 07/21/21 at 3:45 P.M. with Resident #12 indicated she had not had it on for awhile because they never put it on her when she came back from her appointment. Observation on 07/21/21 at 3:47 P.M. revealed Licensed Practical Nurse (LPN) #73 checked Resident #12's oxygen saturation and she was at 83 percent. LPN #73 had put the resident's oxygen back on her and her oxygen saturation immediately came up to 88 percent. An interview at this time with LPN #12 verified Resident #12's oxygen should have been on her continuously per physician's orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 11 of 28 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 366264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure State Tested Nurse Aides (STNA) received at least 12 hours of training annually including dementia care training. This had the potential to affect all 42 residents currently residing in the facility. Residents Affected - Many Findings include: Review of the most recent dementia care training for staff revealed it was completed December of 2019. Review of STNA #49's personnel file revealed she was hired on 06/11/20 and had only received nine hours of training which included her orientation training and no evidence of annual dementia care training. Review of STNA #76's personal file revealed she was hired on 01/12/21 and had not received the dementia care training. Review of STNA #83's personnel file revealed she was hired on 07/12/21 and had not received the dementia care training. On 07/22/21 at 10:00 A.M., interview with the Director of Nursing (DON) verified there was no evidence of staff dementia care training since December 2019. The DON verified STNA #49 did not receive the required 12 hours annually of training. On 07/23/21 at 4:12 P.M., interview with Nursing Secretary (NS) #46 verified the human resource director had been out and there was no tracking system in place to ensure the STNAs received their required 12 hours of annual training. NS #46 was able to find STNA #49 had nine hours of training since being hired on 06/11/20 and did not meet the required 12 hours of training annually including dementia care training. Review of the Facility Assessment, not dated, revealed the facility provided Alzheimer's and/or dementia care for all levels of cognitive impairment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 12 of 28 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 366264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #25's medical record revealed diagnoses including chronic obstructive pulmonary disease, gastro-esophageal reflux disease, anemia, and chronic congestive heart failure. Review of the July 2021 Medication Administration Record (MAR) revealed medication scheduled for administration at 9:00 A.M. included abilify (antipsychotic), calcium carbonate with vitamin D, vitamin D, ferrous sulfate (iron), levothyroxine (thyroid medication), omeprazole (medication used to treat gastro-esophageal reflux disease), potassium, symbicort inhaler (used to treat chronic obstructive pulmonary disease), venlafaxine (used to treat depression), cholestyramine (used to treat high cholesterol), furosemide (diuretic), acetaminophen, midodrine (vasopressor used to treat low blood pressure), and lorazepam (used to treat anxiety). Review of Medscape information regarding administration of levothyroxine indicated it should be administered with a full glass of water preferably 30 minutes to one hour before breakfast on an empty stomach. Medscape indicated levothyroxine should be administered greater than four hours apart from drugs known to interfere with absorption. Medication which was identified as affecting absorption of levothyroxine included ferrous sulfate and omeprazole. It indicated furosemide increased risk of toxicity of levothyroxine. Review of meal times revealed breakfast was scheduled at 7:00 A.M. Review of the June 2021 pharmacy recommendation revealed no recommendations for change in the administration time of levothyroxine. On 07/21/21 at 1:53 P.M., Pharmacist #80 verified levothyroxine should not be given with other medications and was usually given around 6:00 A.M. to avoid other medications and foods. On 07/22/21 at 10:32 A.M., RN #53 indicated there was no medical reason or other rationale for Resident #25 receiving levothyroxine at the same time as other medications. On 07/22/21 at 11:04 A.M., Pharmacist #80 indicated due to COVID 19 his medication regimen reviews were completed off-site. Pharmacist #80 stated he did not have access to medication administration times so he did not address co-administration of levothyroxine with other medications or in relation to meal times. Based on observation, review of the medical record, interview with staff, and review of Medscape website the facility failed to ensure Synthroid was given at least four hours before any other medications per manufacturer's recommendations. This affected three (Resident #9, #25, and #28) of six residents reviewed for unnecessary medications. Findings include: 1. Resident #28 was admitted to the facility on [DATE] with diagnoses of infection in left knee, arthritis, severe protein calorie malnutrition, epilepsy, altered mental status, gastro-esophageal reflux disease, osteoarthritis, COVID-19, major depression, hypertension, hemiplegia, and hemiparesis to left side following a cerebrovascular disease, and psychosis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 13 of 28 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 366264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #28 had intact cognition, required extensive assistance for all activities of daily living, and had one stage two and one stage three pressure ulcer. Review of the July 2021 physician's orders revealed Resident #28 had an order for Synthroid (for hypothyroidism) 50 micrograms (mcg) in the morning. Review of the July 2021 Medication Administration Record (MAR) revealed Resident #28 was scheduled to receive Synthroid 50 mcg in the morning, Lasix (a diuretic) 20 milligrams (mg) at 9:00 A.M. and omeprazole (for gastric reflux) 20 mg in the morning. Observation on 07/21/21 at 7:54 A.M. revealed Licensed Practical Nurse (LPN) #73 administered; Synthroid 50 mcg, Lasix 20 mg, divalproex sodium (for seizure disorders) 500 mg, Risperdal (an antipsychotic) 0.5 mg, Paxil (an antidepressant) 20 mg, omeprazole 20 mg, and MS Contin (a narcotic) 15 mg to Resident #28. Interview on 07/21/21 at 1:53 P.M. revealed Pharmacist #80 indicated Synthroid should not be given with other medications and was usually given around 5:00 or 6:00 A.M. to avoid administration with other medications and foods. Interview on 07/22/21 at 8:50 A.M. with the Director of Nursing (DON) verified they gave the Synthroid with other medication if the resident did not want to be wakened early. She indicated it was the resident's choice what time they took their medications. She verified there was no documentation in the medical record or plan of care indicating Resident #28 did not want to be wakened early to take the Synthroid at 5:00 A.M. Interview on 07/22/21 at 10:35 A.M. with Registered Nurse (RN) #53 indicated they did not give Resident #9 Synthroid at 5:00 A.M. because she did not like to be wakened. She verified there was no reason why Resident #28 could not receive his Synthroid at a different time. Interview on 7/22/21 at 11:04 A.M. with Pharmacist #80 indicated when doing the medication regimen reviews off-site he did not have access to medication administration times so he did not address co-administration of Synthroid with other medications. Review of the Consultant Pharmacist's Medication Regimen Review for February, March, April, May and June 2021 revealed no recommendations for addressing co-administration of Synthroid with other medications for Residents #9 and #28. Review of the Medscape administration guidelines revealed Synthroid was to be taken with a full glass of water preferably 30 minutes to one hours before breakfast on an empty stomach and to administer oral Synthroid at least four hours apart from drugs known to interfere with absorption. Review of the Medscape drug interactions checker revealed omeprazole decreased levels of levothyroxine by increasing gastric potential hydrogen (pH) in the oral form of the medication. Review of the Medscape Drug Interactions checker revealed a minor interaction between Lasix and Synthroid. The Lasix increased toxicity of Synthroid and higher doses of Lasix may inhibit binding of thyroid hormones to carrier protein and result in transient increase in free thyroid hormones, followed by overall decrease in total thyroid hormone levels. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 14 of 28 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 366264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of hypertension, anxiety disorder, hypothyroidism, osteoporosis, COVID-19, insomnia, and dementia with behaviors. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #9 had severely impaired cognition. Review of the July 2021 physician's orders revealed Resident #9 had an order for Synthroid 112 mcg every morning. Review of the July 2021 MAR revealed Resident #9 received her Synthroid in the morning with her other medications. Observation on 07/21/21 at 8:15 A.M. revealed RN #53 administered; Bursar (antidepressant) 15 mg, diltiazem (for high blood pressure) 30 mg, divalproex sodium 125 mg, Namenda (for dementia) 14 mg, Synthroid 112 mcg, Protonix (for gastric reflux) 40 mg, and aldactone (diuretic) 25 mg to Resident #9. Interview on 07/21/21 at 1:53 P.M. with Pharmacist #80 indicated Synthroid should not be given with other medications and was usually given around 5:00 or 6:00 A.M. to avoid administration with other medications and foods. Interview on 07/22/21 at 8:50 A.M. with the DON verified they gave the Synthroid with other medications if the resident did not want to be wakened. She indicated it was their choice what time they took their medications. She verified there was no documentation in the medical record or plan of care indicating Resident #9 did not want to be wakened to take the Synthroid at 5:00 A.M. Interview on 07/22/21 at 10:35 A.M. with RN #53 indicated they did not give Resident #9 Synthroid at 5:00 A.M. because she did not like to be wakened. Interview on 7/22/21 at 11:04 A.M. with Pharmacist #80 indicated when doing the medication regimen reviews off-site he did not have access to medication administration times so he did not address co-administration of Synthroid with other medications. Review of the Consultant Pharmacist's Medication Regimen Review for February, March, April, May and June 2021 revealed no recommendations for addressing co-administration of Synthroid with other medications for Resident #9. Review of the Medscape Drug Interactions checker revealed a minor interaction between Protonix and Synthroid. The Protonix decreases the levels of Synthroid by increasing gastric potential hydrogen. This applies only to oral form of both agents. Review of the Medscape administration guidelines revealed Synthroid was to be taken with a full glass of water preferably 30 minutes to one hours before breakfast on an empty stomach and administer oral Synthroid at least four hours apart from drugs known to interfere with absorption. Review of the Medscape Drug Interactions checker revealed a minor interaction between Lasix and Synthroid. The Lasix increased toxicity of Synthroid and higher doses of Lasix may inhibit binding of thyroid hormones to carrier protein and result in transient increase in free thyroid hormones, followed by overall decrease in total thyroid hormone levels. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 15 of 28 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 366264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on medical record review, policy review, and interview the facility failed to ensure a resident receiving psychotropic medications had time limits for the use of anti-anxiety medication ordered on an as necessary basis and failed to ensure a physician provided rationale for refusal of gradual dose reductions of psychotropic medication. This affected one (Resident #10) of five residents reviewed for medication use. Findings include: Review of Resident #10's medical record revealed diagnoses including depression, dementia, Alzheimer's disease, and psychotic disorder with delusions. An April 2021 pharmacy recommendation indicated Resident #10 had been receiving risperidone (an antipsychotic) 0.25 milligrams (mg) in the morning and 0.5 mg in the evening starting 09/30/20. The pharmacist inquired if a gradual dose reduction would be appropriate. A response dated 05/11/21 indicated no with documentation hospice patient. A May 2021 pharmacy recommendation indicated Resident #10 was receiving duloxetine (medication used to treat depression and anxiety) 60 mg twice a day. The pharmacist asked if a gradual dose reduction would be advisable. The word no was written on the form but with no rationale. A June 2021 pharmacy recommendation indicated Resident #10 was receiving duloxetine 60 mg twice a day and again inquired if a gradual dose reduction was advisable. The response indicated the duloxetine was discontinued on 12/24/19. However, the duloxetine order remained on the July 2021 orders. Resident #10 also had a physician's order for ativan (anti-anxiety) 0.5 mg every six hours as needed which was dated 07/22/20 with no end date or time frame for re-evaluation. No pharmacy reviews addressed the order for ativan on an as necessary basis or a need for time limits of a psychotropic medication ordered as necessary. On 07/21/21 at 12:00 P.M., the Director of Nursing (DON) verified although Resident #10 was a recipient of hospice services, the ativan ordered on an as necessary basis should be time limited with a time frame for re-evaluation of its needed use. The DON verified the order for ativan on an as necessary basis had not been addressed by the pharmacist during monthly medication regimen reviews. The DON indicated the physician would usually not order gradual dose reductions of medication ordered by hospice or the psychiatrist. On 07/21/21 at 2:30 P.M., the DON indicated no on the May recommendation for a gradual dose reduction of duloxetine was written because the duloxetine had been discontinued. The DON indicated she had written the note on the June pharmacy recommendation indicating duloxetine had been discontinued after reviewing Resident #10's medication list. Neither of the recommendations contained documentation by the physician. Orders for duloxetine remained current on July medication orders. The DON reported the facility had no policy regarding pharmacy recommendations. On 07/06/21 at 2:40 P.M., Pharmacist #80 verified he had not addressed a needed time limit for the order of ativan on an as necessary basis because the medical director had indicated the hospice orders for ativan generally were not used until end stage. Review of the facility's Psychotropic Medications policy (effective 05/01/16) indicated frequent reassessment for reduction or elimination of psychotropic medication would be completed by the interdisciplinary team. The DON or designee would monitor reduction and need of psychotropic medications and encourage the attending physician to titrate medications to find the lowest dose necessary and/or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 16 of 28 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 366264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613 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 0758 actual need for medication. 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: 366264 If continuation sheet Page 17 of 28 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 366264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613 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 record review, observation and staff interviews the facility failed to ensure a medication error rate below five percent. Observation of 37 medications administered with two medication errors resulted in a medication error rate of 5.4 percent. This affected two (Residents #9 and #28) of six residents observed for medication administration. Residents Affected - Some Findings include: 1. Resident #28 was admitted to the facility on [DATE] with the diagnoses of infection in left knee, arthritis, severe protein calorie malnutrition, epilepsy, altered mental status, gastro-esophageal reflux disease, osteoarthritis, COVID-19, major depression, hypertension, hemiplegia, and hemiparesis to left side following a cerebrovascular disease, and psychosis. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #28 had intact cognition. Review of the July 2021 physician's orders revealed Resident #28 had an order for Synthroid 50 micrograms (mcg) in the morning. Review of the July 2021 Medication Administration Record (MAR) revealed Resident #28 was scheduled to receive Synthroid 50 mcg in the morning, Lasix 20 (diuretic) milligrams (mg) at 9:00 A.M. and omeprazole (for gastric reflux) 20 mg in the morning. Observation on 07/21/21 at 7:54 A.M. revealed Licensed Practical Nurse (LPN) #73 administered; Synthroid 50 mcg, Lasix 20 mg, divalproex (anti seizure) sodium 500 mg, Risperdal (antipsychotic) 0.5 mg, Paxil (anti depressant) 20 mg, omeprazole 20 mg, and MS Contin (narcotic) 15 mg to Resident #28. Interview on 07/21/21 at 1:53 P.M. revealed Pharmacist #80 indicated Synthroid should not be given with other medications and was usually given around 5:00 or 6:00 A.M. to avoid other medications and foods. On 07/22/21 at 8:50 A.M. the Director of Nursing (DON) verified they gave the Synthroid with other medication if the resident did not want to be woken up. She indicated it was the resident's choice what time they took their medications. She verified there was no documentation in the medical record or plan of care indicating Resident #28 did not want to be woken up to take the Synthroid at 5:00 A.M. Interview on 07/22/21 at 10:35 A.M. Registered Nurse (RN) #53 indicated they did not give Resident #9 Synthroid at 5:00 A.M. because she did not like to be woke up. She verified there was no reason why Resident #28 could not receive his Synthroid at a different time. Interview on 7/22/21 at 11:04 A.M. revealed Pharmacist #80 indicated when doing the medication regimen reviews off-site he did not have access to medication administration times so he did not address co-administration of Synthroid with other medications. Review of the Consultant Pharmacist's Medication Regimen Review for February, March, April, May and June 2021 revealed no recommendations for addressing co-administration of Synthroid with other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 18 of 28 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 366264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613 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 medications for Resident #28. Level of Harm - Minimal harm or potential for actual harm Review of the Medscape administration guidelines revealed Synthroid was to be taken with a full glass of water preferably 30 minutes to one hours before breakfast on an empty stomach and administer oral Synthroid at least four hours apart from drugs known to interfere with absorption. Residents Affected - Some Review of the Medscape drug interactions checker revealed omeprazole decreases levels of levothyroxine by increasing gastric potential hydrogen (pH) in the oral form of the medication. Review of the Medscape Drug Interactions checker revealed a minor interaction between Lasix and Synthroid. The Lasix increased toxicity of Synthroid and higher doses of Lasix may inhibit binding of thyroid hormones to carrier protein and result in transient increase in free thyroid hormones, followed by overall decrease in total thyroid hormone levels. 2. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of hypertension, anxiety disorder, hypothyroidism, osteoporosis, COVID-19, insomnia, and dementia with behaviors. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #9 had severely impaired cognation. Review of the July 2021 physician's orders revealed Resident #9 had an order for Synthroid 112 mcg every morning. Review of the July 2021 MAR revealed Resident #9 received her Synthroid in the morning with her other medications. Observation on 07/21/21 at 8:15 A.M. revealed RN #53 administered; Bursar (anti depressant) 15 mg, diltiazem (for high blood pressure) 30 mg, divalproex sodium 125 mg, Namenda (for dementia) 14 mg, Synthroid 112 mcg, Protonix (gastric reflux) 40 mg, and aldactone (diuretic) 25 mg to Resident #9. Interview on 07/21/21 at 1:53 P.M. with Pharmacist #80 indicated Synthroid should not be given with other medications and was usually given around 5:00 or 6:00 A.M. to avoid other medications and foods. Interview on 07/22/21 at 8:50 A.M. revealed the DON verified they gave Synthroid with other medication if the resident did not want to be woken up. She indicated it was their choice what time they took their medications. She verified there was no documentation in the medical record or plan of care indicating Resident #9 did not want to be woken up to take the Synthroid at 5:00 A.M. Interview on 07/22/21 at 10:35 A.M. RN #53 indicated they did not give Resident #9's Synthroid at 5:00 A.M. because she did not like to be woke up. Interview on 07/22/21 at 11:04 A.M. revealed Pharmacist #80 indicated when doing the medication regimen reviews off-site he did not have access to medication administration times so he did not address co-administration of Synthroid with other medications. Review of the Consultant Pharmacist's Medication Regimen Review for February, March, April, May and June 2021 revealed no recommendations for addressing co-administration of Synthroid with other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 19 of 28 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 366264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613 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 medications for Resident #9. Level of Harm - Minimal harm or potential for actual harm Review of the Medscape Drug Interactions checker revealed a minor interaction between Protonix and Synthroid. The Protonix decreases the levels of Synthroid by increasing gastric potential hydrogen. This applies only to oral form of both agents. Residents Affected - Some Review of the Medscape administration guidelines revealed Synthroid was to be taken with a full glass of water preferably 30 minutes to one hours before breakfast on an empty stomach and administer oral Synthroid at least four hours apart from drugs known to interfere with absorption. Review of the Medscape Drug Interactions checker revealed a minor interaction between Lasix and Synthroid. The Lasix increased toxicity of Synthroid and higher doses of Lasix may inhibit binding of thyroid hormones to carrier protein and result in transient increase in free thyroid hormones, followed by overall decrease in total thyroid hormone levels. Observation from 07/20/21 at 10:30 A.M. to 07/22/21 at 8:15 A.M. of the medication administration revealed 37 medications were observed, for six of residents, administered by four nurses, with two medications errors made for a medication error rate of 5.4 percent. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 20 of 28 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 366264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on record review and interview the facility failed to ensure the Facility Assessment (FA) was comprehensive and reviewed annually as required. This had the potential to affect all 42 residents currently residing in the facility. Findings include: Review of the FA revealed it was not dated, updated nor did it contain any signatures, and was not comprehensive. The FA did not mention a Legionella bacteria plan, the capacity of the facility, the care required by the resident population and overall acuity level nor a comprehensive review of staff competencies necessary to provide the level and types of care needed for the resident population. On 07/22/21 at 10:00 A.M., interview with the Director of Nursing (DON) verified the FA was not dated and there were no signatures available to show the assessment was reviewed annually as required. On 07/22/21 at 4:40 P.M., interview with Administrator #82 verified the FA was not dated and did not have any signatures to show it was reviewed annually. The Administrator also verified the Legionella policy indicated the FA would identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system but there was no evidence or mentioning of a Legionella plan in the FA. Additionally, the FA did not contain the census, or adequate amount needed based on the acuity level (no acuity level) and no comprehensive review of staff competencies necessary to provide the level and types of care needed for the resident population was found. Review of the water management program to reduce/eliminate Legionella bacteria policy, dated 09/21/17, revealed the facility would actively identify and manage hazardous conditions that support the growth and spread of Legionella, the facility would implement a water management program to reduce Legionella growth and spread by following the Center for Disease Control (CDC) guidelines. This included conducting a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. The program would include control measures including physical controls, temperature management, disinfectant level control, visual inspections and environmental testing of pathogens. The facility would identify testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken as needed. In addition to testing areas of the building where pipes are continually wet, equipment such as breathing machines and hydrotherapy equipment may be tested. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 21 of 28 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 366264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613 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 Based on record review and interview the facility failed to ensure a comprehensive program to reduce and/or eliminate Legionella bacteria. This had the potential to affect all 42 residents currently residing in the facility. Residents Affected - Many Findings include: Review of the most recent potable water samples report, completed by an outside company, was dated 01/11/2018. There was no further evidence of monitoring, testing, tracking, measuring or preventing Legionella bacteria. On 07/22/21 at 4:40 P.M., interview with Administrator #82 verified the facility put the program in place in 2017 and the most recent monitoring, testing, tracking and/or prevention was 01/11/18. Administrator #82 verified the facility had a policy (which was not provided) that stated further monitoring, testing, tracking, and/or prevention measured would be implemented with an outbreak of Legionella bacteria. Review of the water management program to reduce/eliminate Legionella bacteria policy, dated 09/21/17, revealed the facility would actively identify and manage hazardous conditions that support the growth and spread of Legionella, the facility would implement a water management program to reduce Legionella growth and spread by following the Center for Disease Control (CDC) guidelines. This included conducting a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. The program would include control measures including physical controls, temperature management, disinfectant level control, visual inspections and environmental testing of pathogens. The facility would identify testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken as needed. In addition to testing areas of the building where pipes are continually wet, equipment such as breathing machines and hydrotherapy equipment may be tested. Review of the undated Facility Assessment revealed it did not address Legionella bacteria. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 22 of 28 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 366264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #31 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, urinary retention and chronic obstructive pulmonary disease. Residents Affected - Many Review of the current plan of care related to bladder incontinence and urinary tract infections (UTI) revealed to monitor Resident #31 for signs and symptoms (s/s) including pain, burning, blood tinged urine, cloudiness, no urine output, deepening of urine color, increased temperature, urinary frequency, foul smelling urine, chills, altered mental status, change in behaviors and/or eating patterns. Check and change every two hours and as needed for incontinence. Wash, rinse and dry perineum after each incontinence episode, encourage adequate fluids and give antibiotic therapy as ordered. Notify the physician with any signs or symptoms (s/s) of a UTI. Review of the physician progress note dated 05/18/21 revealed there were no concerns with Resident #31 continue to encourage fluids. Review of the nurse notes dated 05/17/21, 05/18/21 and 05/19/21 revealed there was no evidence Resident #31 had any s/s of a UTI. Review of the 05/19/21 urinalysis/culture and sensitivity (UA/C&S) test was submitted to the laboratory for testing. Further review of the physician order revealed an antibiotic (ATB) was started for 10 days. Review of the nurses notes dated 05/19/21 revealed the physician was notified Resident #31 did not meet the criteria for the ATB stewardship program. Review of the suspected UTI SBAR revealed Resident #31 did not meet the criteria to initiate ATB. The assessment was not signed or dated by any staff including the physician but did indicate an ATB was initiated. Review of the UA/C&S results dated 05/21/21 revealed the results were received from the facility to show Resident #31 had escherichia coli in her urine. Review of the medication administration record (MAR) revealed Resident #31 received the ATB as ordered from 05/19/21 through 05/29/21. Review of the nurses notes dated 06/01/21 revealed Resident #31 had foul smelling urine but no other s/s and a UA/C&S was collected on 06/02/21. Review of the nurses notes was dated 06/04/21 revealed to start Resident #31 on an intramuscular ATB due to the UA/C&S reported 06/04/21 stated Resident #31 had proteus mirabilis and providencia stuartii in her urine. Review of the suspected UTI SBAR, dated 06/04/21, revealed Resident #31 did not meet the criteria to start an ATB therapy. There were no signatures on the assessment. Review of the physician progress note dated 06/08/21 revealed there was no evidence Resident #31 had any recent UTIs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 23 of 28 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 366264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Further review of the MAR revealed Resident #31 continued the course of ATB until it was finished on 06/14/21. Review of the bladder assessment, dated 06/16/21, revealed Resident #31 was incontinent of urine. Review of the nurses notes 06/14/21 through 06/25/21 revealed Resident #31 had no s/s of a UTI but on 06/20/21 a follow up UA/C&S was collected. Review of the results of the UA/C&S reported 06/23/21 revealed Resident #31 had enercoccoccus faecalis in her urine and was started on an ATB. Review of the suspected UTI SBAR, dated 06/24/21, revealed Resident #31 did not meet the criteria for starting ATB therapy. The assessment was not signed. Further review of the nurses notes dated 06/26/21 revealed Resident #31 had a change in mental status and no other s/s. Review of the MAR revealed Resident #31 started a course of ATB in the evening of 06/24/21 and continued to course until 07/01/21. The nurses notes dated 06/27/21, 06/28/21 and 07/01/21 indicated Resident #31 had foul smelling urine but no other s/s. Review of the annual minimum data set (MDS) 3.0 dated 07/01/12 revealed Resident #31 was cognitively intact but needed assistance of staff for toileting. Review of the physician progress note dated 07/06/21 revealed there was no evidence Resident #31 had recent UTIs. Review of the nurses notes dated 07/07/21 revealed a follow up UA/C&S was obtained. Further review of the results reported on 07/09/21 revealed Resident #31 had pseudomonas airuginosa in her urine and the physician ordered an ATB despite not having any s/s. Review of the suspected UTI SBAR, dated 07/09/21, revealed Resident #31 did not meet the criteria for initiating ATB therapy. The assessment was not signed. Further review of the MAR revealed the ATB therapy was given as ordered from 07/09/21 through 07/19/21. On 07/19/21 at 12:20 P.M., interview with Resident #31 denied any concerns with incontinence or UTIs. On 07/20/21 at 8:17 A.M., 10:32 A.M., 11:23 A.M. and 12:35 P.M., Resident #31 was observed in bed. At 1:17 P.M., the resident was receiving incontinence care by State Tested Nurse Aide (STNA) #56 and #66. On 07/20/21 at 1:36 P.M., interview with STNA #56 verified Resident #31 frequently refused to be taken to the toilet and frequently refused incontinence care. This was the first time all day she would allow them to do incontinence care. When the resident was taken to the toilet she performed her own pericare but when incontinent the staff provided pericare. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 24 of 28 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 366264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613 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 0881 Level of Harm - Minimal harm or potential for actual harm On 07/20/21 at 1:45 P.M., interview with STNA #66 verified Resident #31 had been refusing to be toileted and changed all day because she liked to stay in bed and not be bothered. When the resident was taken to the toilet she performed her own pericare but when incontinent the staff provided pericare. On 07/21/21 at 9:40 A.M., Resident #31 was observed sleeping in bed. Residents Affected - Many On 07/21/21 at 10:58 A.M., interview with the Director of Nursing (DON) and LPN #62, who was assisting in the infection prevention role, verified the medical director (MD) #80 was the physician at the facility and he saw all the residents. The DON stated MD #80 thought Resident #31 may have a dropped bladder but the resident refused to go see a urologist. LPN #62 verified she initiated all above suspected UTI SBAR assessments and they may not have been completed timely and verified there were no signatures by any staff nor the physician. LPN #62 also verified the SBARs showed Resident #31 did not meet the criteria for initiated ATB therapy and when she informed the physician he would still continue the ATB therapy. The DON stated the nurse who received the results of the UA/C&S should inform the physician of the results with the results of the suspected UTI SBAR but there was no evidence this was being done. The DON stated it was the physician's decision when to use the ATB and had not done any education and/or training with the physician related to the ATB stewardship program. The DON verified the ATB stewardship policy and procedures were not being followed in an attempt to reduce the use of ATBs. On 07/21/21 at 11:27 A.M. and 2:00 P.M., Resident #31 was observed sleeping in bed. On 07/21/21 at 3:08 P.M., interview with Pharmacist (RPH) #80 revealed he was not included in the ATB stewardship program nor did he receive any of the UA/C&S results. RPH #80 stated the facility had a high rate of ATB usage and was informed of this but there had not been any discussions in an attempt to try and reduce the amount of ATB use. On 07/21/21 at 4:10 P.M., Resident #31 was receiving incontinence care. On 07/22/21 at 3:12 P.M., phone interview with MD #80 verified he attended the quality assurance meetings as well as addressed any concerns the day they arise and does not wait until a meeting. When asked about ATB stewardship program he stated there was still some debate on that but verified he was not involved in the program. The physician stated he tried not to use an ATB unless they were needed. He verified Resident #31 was on four different ATBs that did not meet the criteria for use since May 2021 but his progress notes did not reflect the resident had any UTIs. Review of the ATB stewardship program policy, dated 11/11/17, revealed the program would improve resident safety and potentially impact rates of antimicrobial resistance. The act of using ATBs appropriately by using ATBs only when truly needed and by using the correct ATB for each infection. Stewardship or protecting the effectiveness of ATB, which is the most important tool available to treat life threatening bacterial infections. ATB resistance occurs when the bacteria adapt so drugs used to treat infections are less effective or do not work at all. The facility would work closely with the Center for Disease Control (CDC) recommendations and implement their core elements consisting of the infection preventionist (IP) having resources, the Medical Director being responsible for the program outcomes and the pharmacist working with staff to improve (reduce) ATB use. The facility would work together to identify recommended actions as an ATB time out 48-72 hours after the initial ATB had been started. This would include working closely with the physician and the pharmacist after the culture results become available to see if the ATB is the right choice, dose and route. And if an ATB (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 25 of 28 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 366264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many should be given and if so for how long the ATB should be given. The facility would monitor at a minimum: if started in the facility, was the suspected UTI SBAR form used, which ATB was prescribed, cultures that were performed including results, was ATB appropriate or were there resistance patterns. The IP would report at a minimum quarterly, at the quality assurance meeting, to the physician, nurses and relevant staff the findings on ATB use and resistance and the on-going process. Education would be completed and performed to staff on an on-going and case-by-case bases on audits of the suspected UTI SBAR use, ATB initiation and result findings. The facility would educate staff on the Stop-and-Watch program to help identify changes in the resident conditions. Staff would fill out the Stop-and-Watch form, located at both nurses stations, when a change in condition or something out of the normal was recognized. The facility would follow the policy titled minimum criteria for common infections. Review of the minimum criteria for common infections, dated 11/22/17, revealed it was aimed at reducing the unnecessary prescribing for the three infections where ATB were most frequently prescribed including UTIs. The resident suspected of having an infection would be assessed and a suspected UTI SBAR form would be completed. For UTIs without an indwelling catheter, the resident should meet criteria of one of the three situations: acute dysuria alone OR fever of 100 degrees Fahrenheit AND at least one of the following new or worsening conditions: urgency, frequency, suprapubic pain, gross hematuria, costovertebral angle tenderness, urinary incontinence OR no fever, then two or more of the following: urgency, frequency, suprapubic pain, gross hematuria or urinary incontinence. Also, urine cultures should not be used to identify UTIs in the absence of symptoms. Smelly or cloudy urine is not a symptom of a UTI. Urine cultures should be used to identify the most appropriate ATB use if needed. Based on medical record review, policy review, review of infection control tracking logs, and interview, the facility failed to ensure residents who received antibiotic orders were reviewed for appropriateness of use in a timely manner to permit communication with the physician regarding those residents who did not meet criteria of infections. The facility also failed to involve the pharmacist in the antibiotic stewardship program after multiple residents were treated with antibiotics without criteria for infections being met. This affected one (Resident #31) of two residents reviewed for urinary tract infections and had the potential to affect all 41 other residents currently residing in the facility. The facility census was 42. Findings include: 1. Review of the facility's Antibiotic Stewardship Program policy (effective 11/11/17) revealed the pharmacist was to work with staff to improve antibiotic use. The facility would monitor antibiotics started in the facility if the SBAR (SBAR is an acronym for Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication.) was form was used and if the antibiotic use was appropriate. The policy indicated the facility was to follow a policy titled Minimum Criteria for Common Infections. Review of the facility's policy, Minimum Criteria for Common Infections (effective 11/22/17), indicated the purpose of the policy was to reduce unnecessary use of antibiotics. If a resident did not meet criteria the nurse could ask the physician for supporting treatment. The SBAR form was to be used on an as needed basis any time an infection was suspected regardless of the type of infection. The policy indicated minimum criteria were necessary for initiating an antibiotic. Review of the May 2021 Infection control tracking log revealed the following residents were treated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 26 of 28 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 366264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613 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 0881 for infections but evaluation on the SBAR revealed the residents did not meet the criteria for infections: Level of Harm - Minimal harm or potential for actual harm Resident #200 for a urinary tract infection (UTI) Resident #205 for pneumonia Residents Affected - Many Resident #210 for UTI Resident #215 for pneumonia Resident #31 for UTI Resident #43 for UTI Review of the June 2021 Infection control tracking log revealed the following residents were treated for infections but evaluation on the SBAR revealed the residents did not meet the criteria for infections: Resident #31 for UTI with onset dates of 06/05/21 and 06/24/21 Review of the July 2021 Infection control tracking log revealed the following residents were treated for infections but only one resident (Resident #31) had an evaluation on the SBAR and criteria for infection was not met: Resident #43 for UTI Resident #36 for wound infection Resident #31 for UTI Resident #44 for skin infection Resident #6 for UTI Resident #1 for pneumonia Resident #12 for pneumonia On 07/21/21 at 3:13 P.M., Pharmacist #80 stated he had not been involved in the antibiotic stewardship program, indicating he had not been asked to discuss the use of antibiotics for residents who did not meet criteria for infections with the physician. On 07/22/21 at 1:45 P.M., Licensed Practical Nurse (LPN) #62 stated she was responsible for notifying the physician if residents with antibiotic orders did not meet criteria for infections. The physician did not provide rationale for continuing antibiotics without the criteria being met. On 07/22/21 at 2:30 P.M., Administrator #43 stated he was aware of the physician prescribing antibiotics without criteria being met. Administrator #43 stated the facility discussed antibiotic use and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 27 of 28 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 366264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brewster Convalescent Center 264 Mohican Street NE Brewster, OH 44613 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete infections every month during Quality Assurance meetings but refused to provide a topic list of areas discussed. On 07/22/21 at 4:40 P.M., LPN #62 stated the facility had not evaluated antibiotics ordered in July 2021 to determine if criteria for infections was met. LPN #62 agreed the facility would not be able to address if an ordered antibiotic did not meet criteria for an infection if staff did not evaluate if criteria was met in timely manner. Event ID: Facility ID: 366264 If continuation sheet Page 28 of 28