Health inspection·August 28, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few unresponsive and was barely breathing. LPN #200 stated she had checked her report sheet that had indicated Resident #54 was a full code (all life saving measures to be done) as well as another nurse who had checked the computer system which also indicated Resident #54 was a full code. LPN #200 stated she had immediately began CPR until the paramedics arrived. LPN #200 stated she had been informed a few days after the incident Resident #54 was a DNR-CC and stated she was not sure why the computer and report sheet had indicated a full code status. Review of facility undated policy titled DNR Protocol revealed no resuscitative measures should be done to save or sustain life. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 2 of 21 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 08/28/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop care plans for a resident with pressure ulcers and included a resident's code status. This affected two residents (#17, #27) of 20 residents reviewed for care planning. The facility census was 51. Findings include: 1. Review of the medical record for Resident #17 revealed an admission date of 04/22/23 and diagnoses included chronic kidney disease, osteoarthritis, diabetes mellitus, and diabetic neuropathy. Review of physician's orders dated 08/15/23 revealed Resident #17 had sacral wound and left hip wound. Review of Weekly Wound Report dated 08/15/23 revealed Resident #17 re-admitted from hospital on [DATE] with Stage 3 pressure ulcer on sacrum and a suspected deep tissue injury on left hip. Review of the current care plan for 08/24/23 revealed no evidence of care planning for actual pressure injuries. Interview on 08/24/23 at 9:25 A.M. with Minimum Data Set (MDS) Coordinator #73 verified there was no care plan for actual pressure injuries for Resident #17. MDS Coordinator #73 indicated she would expect to see a care plan for a specific wound and would be reviewed/revised by the wound nurse. Interview on 08/24/23 at 10:09 A.M. with the Director of Nursing (DON) verified there was no care plan for actual pressure injuries for Resident #17. Review of the facility policy Skin-Wound Care Treatment dated 01/30/16 revealed a plan of care was to be initiated no later than eight hours after admission regarding altered skin integrity. 2. Record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including asthma, gastro-esophageal reflux disease, hypertension, dementia, osteoporosis, and fracture of unspecified part of next of right femur. Review of a MDS completed on 06/28/23 revealed Resident #27 had a BIMS score of 3 indicating severely impaired cognition, required extensive assistance of two for bed mobility, transfer, and toilet use, and required a limited assist of one staff for eating. Review of Resident #27's orders revealed an order in place for a do not resuscitate comfort care (DNRCC) in place. Review of Resident #27's care plan did not indicate her code status. Interview on 08/23/23 at 1:43 P.M. with LPN #105 confirmed Resident #27's care plan did not indicate a code status, but orders revealed a code status of DNRCC. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 3 of 21 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 08/28/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to ensure a resident was assisted to the bathroom timely. This affected one resident (#15) of three residents reviewed for activities of daily living (ADL) assistance. The facility census was 51. Residents Affected - Few Findings include: Review of Resident #15's medical record revealed an admission date of 10/18/21 and diagnoses included type two diabetes mellitus with diabetic neuropathy, morbid obesity, and schizoaffective disorder, depressive type. Review of Resident #15's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 was cognitively intact. Resident #15 required extensive assistance of two staff members for toilet use. Resident #15 was occasionally incontinent of urine and frequently incontinent of bowel. Review of Resident #15's care plan revised 07/10/23 included Resident #15 had an ADL (Activity of Daily Living) self care deficit including incontinence. Resident #15 would maintain functional abilities through next review. Interventions included to toilet in advance of need; toileting with extensive assistance of one staff member. Observation on 08/24/23 at 7:45 A.M. of Resident #15 revealed State Tested Nursing Assistant's (STNA)'s #46 and #703 were changing Resident #15's shirt, pants and sheets because they were saturated with urine. STNA #46 stated Resident #15 had an accident because STNA #46 could not get to her call light fast enough. STNA #46 stated she was helping another resident and by the time she got to Resident #15 she was incontinent and it saturated her clothes and bedding. STNA #46 indicated this happened sometimes because there were only three aides for 51 nursing home residents and a lot ot the residents required extensive care to meet their needs. Interview on 08/24/23 at 8:32 A.M. of Resident #15 revealed she put her call light on because she had to go to the bathroom, but the aide did not answer her call light fast enough and she had an accident. Resident #15 stated her incontinence brief, bed and shirt needed to be changed because they were wet with urine. Resident #15 stated often she would put her call light on and the aides could not answer it fast enough and she would have an accident. Resident #15 did not remember how long her call light was on before she had an accident. This deficiency represents non-compliance investigated under Complaint Number OH00136232. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 4 of 21 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 08/28/2023 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to thoroughly assess and provide timely medical treatment to a resident with multiple fractures. This affected one resident (#31) of four residents reviewed for accidents. Residents Affected - Few Actual harm occurred on 04/16/23 when Resident #31 fell, hitting her elbow on the shower chair and landing on her buttocks. At the time of the fall, Resident #31 complained of elbow pain and tailbone pain, however only the elbow pain was assessed, and physician notified resulting in the resident receiving an Xray of the shoulder and being diagnosed with a fractured humeral head on 04/17/23. The failure of the facility to appropriately assess and document the resident's sacral pain at the time of the fall resulted in a delay in the diagnosis and treatment of the resident's fractured sacrum until 04/20/23. Harm continued 04/29/23 when facility staff failed to notify the resident's physician of swelling and pitting edema in Resident #31's left arm until 05/06/23 when the resident's physician was notified of the change in condition (swelling and pitting edema) and the resident received diagnostic testing and was diagnosed with a superficial venous thrombosis (SVT). Actual harm continued 05/06/23 when the resident's physician ordered the resident to receive a blood thinning medication in the treatment of the SVT and the treatment was not initiated until two days later on 05/08/23. Findings included: Record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including hypertension, major depressive disorder, osteoarthritis, anxiety disorder, overactive bladder, irritable bowel syndrome, and dementia. Review of a minimum data set (MDS) assessment completed on 04/06/23 revealed Resident #31 had a brief interview for mental status (BIMS) score of six (6) indicating moderately impaired cognition, required an extensive assist of one person for bed mobility, transfers, walking in the room and corridor, and toilet use and required the use of a walker. The MDS also indicated Resident #31 was frequently incontinent of bladder and had not been trialed on a toileting program. Review of nursing notes dated 04/16/23 through 04/20/23 revealed the front hall nurse, Licensed Practical Nurse (LPN) #21, witnessed Resident #31 on 04/16/23 at 5:08 P.M. walking into the bathroom when she fell on her bottom and hit her left elbow on the shower chair. Resident #31 was assessed with no injuries noted, was changed due to an episode of incontinence, and given ibuprofen for elbow pain with no rating or description of pain noted. There was no documentation regarding the resident's complaints of tailbone/sacrum pain. The morning of 04/17/23 at 8:14 A.M. Resident #31 was complaining of left arm and shoulder pain and presented with bruising on inner left upper arm and shoulder blade. The Medical Director was contacted and gave a verbal order to send to the emergency department for evaluation. At the hospital, Resident #31 was diagnosed with a fracture of the left humeral head, widening of subacromial space, and soft tissue swelling. Resident #31 returned to the facility with new orders to follow up with an orthopedic physician. On 04/19/23 at 9:26 P.M. a nursing note by LPN #21 stated Resident #31 was complaining of pain to her tailbone, which was tender to touch and aching. Resident's daughter had requested for day shift nursing staff to be notified of pain and to possibly get an X-ray. The order for an X-ray was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 5 of 21 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 08/28/2023 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 received until 04/20/23 at 2:13 P.M. and results were received at 6:40 P.M. stating Resident #31 had a fracture in her distal sacrum. Level of Harm - Actual harm Residents Affected - Few Review of a nursing note from Registered Nurse (RN) #11 on 04/29/23 at 2:52 P.M. revealed Resident #31's left hand was swollen and hanging from the arm sling. The nurse readjusted the sling but did not notify the physician of the swelling. There were no further relevant nursing notes until a note on 05/05/23 at 2:09 P.M. from LPN #105 revealed Resident #31's daughter was made aware of a new order from the Medical Director for a doppler (ultra-sound) to the left upper extremity due to redness and edema. An additional nursing note on 05/05/23 at 3:13 P.M. revealed Resident #31 presented with +2 pitting edema with redness to her left hand. Review of a nursing note from RN #11 on Saturday, 05/06/23 at 11:51 A.M. revealed an ultrasound had been completed and preliminary results were positive for a deep vein thrombosis. The nurse did notify the on-call physician who stated no new orders were needed until Monday (05/08/23). Resident #31's daughter was notified and requested the Medical Director be contacted to address the thrombus, but the facility staff declined stating the on-call physician had already addressed her concerns. Resident #31's daughter continued to request the Medical Director to be contacted regarding the thrombus. On 05/06/23 at 4:17 P.M. the final results for the ultrasound showed an SVT to the left basilic vein. On 05/06/23 at 6:13 P.M. the Medical Director ordered the blood thinning medication, Eliquis 2.5 milligrams (mg) twice a day for SVT. Review of the medication administration record (MAR) from May 2023 revealed the code of 9 for the administration of Eliquis 2.5 mg on the evening on 05/06/23, both doses on 05/07/23, and the morning dose of 05/08/23. Review of the MAR code keys revealed 9 indicates to review nursing notes. Review of MAR nursing note from LPN #105 on 05/06/23 at 6:13 P.M. revealed the order for Eliquis was received at that time and requested from the pharmacy. The MAR nursing notes on 05/07/23 from LPN #80 at 2:06 P.M. and from LPN #19 at 9:24 P.M. revealed Eliquis continued to be unavailable and was on order from the pharmacy. A MAR nursing note from RN #11 on 05/08/23 at 7:03 A.M. revealed Eliquis was not available from the pharmacy yet. The Medical Director was not notified regarding late administration of Eliquis. Interview on 08/23/23 at 11:33 A.M. with LPN #105 revealed on 05/05/23 she was helping with meals in the dining room when she noticed Resident #31 had pitting edema to her left hand and it was red. LPN #105 stated she spoke with RN #11 who normally works that unit and RN #11 stated Resident #31's hand had been like that for a while. LPN #105 stated she then contacted the Medical Director to get a doppler ordered and she scheduled the doppler test once the order was received. Interview on 08/23/23 at 11:49 A.M. with RN #11 revealed after Resident #31 had broken her shoulder, her hand began to swell as well, so the doctor was contacted and an order for a doppler was received. RN #11 stated she did not recall contacting the physician on 04/29/23 when she had first noticed the swelling because she thought it was related to Resident #31 leaning to her right side and the gravity was shifting the swelling to the left hand. Interview on 08/23/23 at 12:53 P.M. with LPN #510 revealed on 04/16/23 Resident #31 got up and walked out of her room to the front hall bathroom and fell. LPN #510 stated Resident #31 had complained of pain to her tailbone, and she thought she administered Tylenol at the time of the fall. LPN #510 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 6 of 21 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 08/28/2023 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 verified she did not assess the resident's complaints of tailbone pain, failed to document the resident's tailbone pain, and failed to notify the physician of the tailbone pain. Level of Harm - Actual harm Residents Affected - Few Interview on 08/24/23 at 9:18 A.M. with Director of Nursing (DON) revealed Eliquis was ordered on 05/06/23 which was a Saturday which would cause the medication to be delayed in arriving for administration. Interview on 08/24/23 at 2:12 P.M. with RN #222 revealed the pharmacy is on-call during the weekends so if she doesn't hear back after the first request for medication, she follows up. RN #222 stated the pharmacy works really quick, and that if she ordered a medication, that is not a controlled substance, on the weekend at about 8:00 A.M. it would typically arrive the same day between 11:00 A.M. and 2:00 P.M. The surveyor requested a facility policy for change in condition and notifying physician of change in condition, but none were received. This deficiency represents non-compliance investigated under Complaint Number OH00136232. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 7 of 21 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 08/28/2023 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, orthopedic consult review, therapy note review, and interview, the facility failed to manage Resident #31's pain adequately and within a timely manner. This affected one resident (#31) of one resident reviewed for pain management. The facility census was 51. Residents Affected - Few Actual harm occurred on 04/16/23 to Resident #31, who had sustained a fall with fractured left humeral head and sacrum, when staff failed to adequately address the resident's pain resulting in Resident #31 having a decline in her activities of daily living. The facility also failed to administer pain medications timely when staff were notified Resident #31 was crying out in pain during therapy sessions and was declining to participate in therapy services. Findings included: Record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including hypertension, major depressive disorder, osteoarthritis, anxiety disorder, overactive bladder, irritable bowel syndrome, and dementia. Review of a minimum data set (MDS) assessment completed on 04/06/23 revealed Resident #31 had a brief interview for mental status (BIMS) score of six (6) indicating moderately impaired cognition, required an extensive assist of one person for bed mobility, transfers, walking in the room and corridor, and toilet use and required the use of a walker. The MDS also indicated Resident #31 was frequently incontinent of bladder and had not been trialed on a toileting program. Review of MDS completed on 05/18/23 revealed Resident #31 required extensive assist of two staff for bed mobility and transfers and required extensive assist of one staff for toileting. Review of Resident #31's plan of care from 01/20/23 revealed interventions for pain included to monitor and report resident complaints of pain to the nurse and to notify physician if pain interventions are unsuccessful. Review of physician orders revealed Resident #31 had an order that started on 12/22/22 for Tramadol 50 milligram (mg) tablet to give 0.5 tablet every 8 hours as needed for pain, and an order that started on 12/22/22 for ibuprofen tablet 200 mg to give two tablets every 8 hours as needed for pain. The resident's current physician orders for pain management included the following: Tylenol, 650 mg, every eight (8) hours, as needed (started 05/06/23); Ibuprofen, 400 mg, every eight (8) hours, as needed (started 06/10/23). Review of nursing notes dated 04/16/23 revealed the front hall nurse witnessed Resident #31 on 04/16/23 at 5:08 P.M. walking into the bathroom when she fell on her bottom and hit her left elbow on the shower chair. Resident #31 was assessed with no injuries noted, was changed due to an episode of incontinence, and given ibuprofen for elbow pain. The facility documentation did not include a description of the pain to include rate or pain level. Review of a nursing note on 04/17/23 at 8:14 A.M. revealed Resident #31 was complaining of left arm (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 8 of 21 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 08/28/2023 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 0697 Level of Harm - Actual harm Residents Affected - Few and shoulder pain and presented with bruising on inner left upper arm and shoulder blade. Resident #31 was sent to the hospital where she was diagnosed with a fracture of the left humeral head, widening of subacromial space, and soft tissue swelling. Review of hospital discharge orders dated 04/17/23 revealed orders for Tramadol 50 mg give 0.5 tablet every 8 hours as needed for pain and ibuprofen tablet give 200mg, two tablets every 8 hours as needed for pain, remained unchanged. Review of a nursing note on 04/17/23 at 5:27 P.M. revealed Resident #31's family was concerned with the pain medication that was ordered, and requested staff to ask if the Medical Director could review the resident's orders for a stronger pain medication for the humeral fracture. The Medical Director declined to order more medication unless Resident #31 had additional complaints of pain. There was no documentation that Resident #31 was assessed for pain at this time. Review of a nursing note dated 04/19/23 at 9:26 P.M. revealed Resident #31 was complaining of pain to her left arm and tailbone, which was tender to touch. Nursing note stated Resident #31 said her tailbone was aching and painful. Further assessment was not completed due to Resident #31 being in pain and not able to reposition without causing additional discomfort. Resident #31's daughter had requested for day shift nursing staff to be notified of pain and to possibly get an X-ray. Review of a pain assessment completed on 04/19/23 revealed Resident #31 stated she had pain in the last five days frequently and it had made it hard for her to sleep at night as well as limited her day-to-day activities. Resident #31 rated her pain at an eight out of ten. Interventions listed on assessment included as needed (PRN) pain medication and ice. Review of an orthopedic consult dated 04/19/23 revealed Resident #31's orthopedic physician increased the order for Tramadol to 50 mg every 6 hours, scheduled, and to discontinue ibuprofen. Review of Resident #31's medication administration record (MAR) for April 2023 revealed multiple orders for Tramadol including: • Tramadol 50 mg, 0.5 tablet, every eight hours PRN ordered on 12/22/22 and discontinued on 04/19/23. • Tramadol 50 mg, four times a day ordered on 04/19/23 and discontinued on 04/20/23 which was administered four times. • Tramadol 50 mg, every six hours for pain, ordered on 04/20/23 and discontinued on 04/21/23 which was administered twice. • Tramadol 50 mg, four times a day for 14 days, ordered on 04/21/23 and discontinued on 04/21/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 9 of 21 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 08/28/2023 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 0697 which was administered twice. Level of Harm - Actual harm • Residents Affected - Few Ibuprofen 200 mg, two tablets every eight hours PRN, ordered on 12/22/22 and discontinued on 04/19/23. • Tramadol 50 mg, every eight hours PRN, for 14 days ordered on 04/21/23. • Tramadol, 50 mg, was discontinued on 06/09/23. There were no nursing notes regarding why the orthopedic physician orders for pain management on 04/19/23 were not followed. Review of physician orders revealed: An order dated 04/19/23 for a donut cushion to sit on to help alleviate tailbone pain. An order dated 04/24/23 for physical therapy (PT) to evaluate and treat the resident. An order dated 04/27/23 for occupational therapy (OT) to evaluate and treat the resident. Review of a nursing note on 04/29/23 revealed Resident #31 continued with complaints of pain to lower back and left arm. Further pain descriptors were not provided. Review of PT note from 05/04/23 at 3:21 P.M. revealed Resident #31 had complaints of left shoulder pain during treatment. Review of the May 2023 MAR revealed on 05/04/23 pain medication, Tramadol 50 mg, was given at 7:37 A.M. but was not given again after complaints of pain in therapy. Review of OT note from 05/05/23 at 12:16 P.M. revealed Resident #31 would wince with pain during range of motion (ROM). Review of MAR for 05/05/23 revealed pain medication was administered at 7:28 A.M. but was not given after complaints of pain in therapy. Review of PT note from 05/08/23 at 3:54 P.M. revealed Resident #31 complained of pain in her left arm. Review of MAR for 05/08/23 revealed Tylenol was administered at 5:30 P.M. and Tramadol was administered at 10:35 P.M. Both medications were administered after therapy. There was no evidence the resident was administered pain medication prior to her therapy. Review of PT note on 05/13/23 at 11:18 A.M. revealed Resident #31 had pain in her left shoulder. Review of 05/13/23 MAR revealed pain medication was not administered until 4:41 P.M. Review of OT on 05/16/23 at 1:00 P.M. revealed Resident #31 had complained of pain and nursing was made aware. Review of the 05/16/23 MAR revealed Resident #31 received Tramadol at 4:21 A.M. and at 3:32 P.M. Medication was ordered for administration every eight hours and could have been administered at 12:00 P.M. prior to her therapy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 10 of 21 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 08/28/2023 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 0697 Level of Harm - Actual harm Residents Affected - Few Review of PT note from 05/17/23 at 3:48 P.M. revealed Resident #31 had pain and excessive swelling in LUE. There was no documented evidence the resident's complaints of pain and swelling were reported to the nursing staff. Review of 05/17/23 MAR revealed Resident #31 received Tramadol 25 mg at 7:40 P.M. There was no evidence the resident was medicated for pain prior to her therapy appointment and was not provided pain medication until four hours after her she complained of pain during therapy. Review of PT note from 05/19/23 revealed at 11:07 A.M. Resident #31 had pain in her LUE. Review of OT note for 05/19/23 revealed Resident #31 yelled out and screamed with any movement to shoulder, 40-45 degrees of flexion was completed, and resident was visibly in pain even with pain medication prior to treatment. Occupational Therapy continued even with Resident #31 screaming out in pain. Review of the 05/19/23 MAR revealed Resident #31 had received 50 mg of Tramadol at 8:05 A.M. and Tylenol at 2:01 P.M. Review of OT note from 05/25/23 at 1:29 P.M. revealed Resident #31 had complained of pain to LUE with behaviors of screaming at therapist. Review of 05/25/23 MAR revealed Resident #31 received Tramadol 50 mg at 8 A.M., 2 P.M., and 8 P.M. Review of OT note from 05/30/23 at 7:47 A.M. revealed Resident #31 screamed out and moaned that ROM was painful with eight out of ten pain scale after medication was administered. Review of 05/30/23 MAR revealed Resident #31 received Tramadol 50 mg at 8 A.M., 2 P.M., and 8 P.M. The resident did not receive pain medication prior to ROM being performed. Interview on 08/23/23 at 8:37 A.M. with Physical Therapy Assistant (PTA) #501 revealed when Resident #31 received therapy, she had a seven out of ten pain at rest, and eight out of ten pain with movement. PTA #501 stated Resident #31 would yell out in pain during therapy at the slightest touch, but PTA #501 felt it was behavioral more than actual pain. Interview and observation on 08/24/23 at 9:00 A.M. with Resident #31 revealed she was unable to recall the incident (the fall on 04/16/23). Resident #31 was holding her upper left arm and complaining of pain stating, it hurts, hurts, hurts, at the time of the interview. Interview and observation on 08/24/23 at 9:03 A.M. with State Tested Nursing Assistant (STNA) #37 revealed Resident #31 does still complain of pain often in her LUE. STNA #37 explained Resident #31's ROM in left arm has decreased and Resident #31 no longer walks around the facility like she did before but uses the wheelchair to get around. Wheelchair was in room at this time and observed to be without the donut cushion. When asked about the donut cushion missing from Resident #31's wheelchair, STNA #37 stated resident did not like the donut cushion because it hurt her. There was no documentation of Resident #31 refusing the donut cushion. During interview STNA #37 was helping Resident #31 go to the bathroom and resident complained of pain. Interview on 08/24/23 at 10:44 A.M. with RN #780 revealed Resident #31 does still complain of pain and guards her left arm. When asked if pain medication had been administered on this date (08/24/23), RN #780 stated no one had reported the resident complained of pain. Review of a policy titled General Pain Management revealed the nurse should assess a resident's pain and evaluate the effectiveness of the interventions, reassess pain, and document findings in the medical record. It stated dosage conversations should be held with the interdisciplinary team. This deficiency represents non-compliance investigated under Complaint Number OH00136232. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 11 of 21 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 08/28/2023 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to monitor a dialysis fistula site for a resident receiving dialysis. This affected one resident (#48) of one reviewed for dialysis treatments. The facility identified one resident as receiving dialysis treatments. The facility census was 51. Residents Affected - Few Findings include: Review of the medical record for Resident #48 revealed an admission date of 06/28/22 and diagnoses included end stage renal disease, dependence on renal dialysis, diabetes mellitus, heart failure, and lymphedema. Review of the physician order dated 01/18/23 revealed Resident #48 received dialysis treatments on Monday, Wednesday, and Friday. Review of progress note dated 06/26/23 revealed Resident #48 had dialysis fistula (hemodialysis access connection made by joining a vein onto an artery) replaced. Review of care plan dated 07/10/23 revealed Resident #48 had tunneled hemodialysis catheter (hemodialysis access by placement of catheter under skin and into major vein) to right internal jugular and fistula to left arm. Care plan indicated to monitor for signs and symptoms of infection to dialysis access sites. Review of the Treatment Administration Record (TAR) for July 2023 and August 2023 revealed no evidence of monitoring dialysis access site for infection and patency. Review of Dialysis and Nursing Home Handoff Communication Tools for July 2023 and August 2023 revealed access site monitoring on 08/21/23, 08/14/23, 08/11/23, 08/07/23, 08/04/23, 08/02/23, 07/31/23, 07/29/23, and 07/28/23. There was no additional evidence of monitoring access site. Interview on 08/23/23 at 2:29 P.M. with Registered Nurse (RN) #222 revealed there was no order for monitoring dialysis access site. RN #222 indicated she only documents on the TAR when Resident #48 goes to dialysis and checks vitals and weight prior to treatment. Interview on 08/24/23 at 10:07 A.M. with Director of Nursing (DON) confirmed there was no order for monitoring dialysis access site for infection or patency. This deficiency represents non-compliance investigated under Complaint Number OH00136232. Review of facility policy Hemodialysis Therapy dated 01/01/17 revealed dialysis shunt patency will be monitored daily by palpation of thrill and auscultation of bruit. The policy indicated staff will monitor resident for signs of infection (fever, chills, warmth around site) and report to physician and dialysis center of any findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 12 of 21 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 08/28/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, record review, review of facility policy, and manufacturer's recommendations the facility failed to ensure open bottles of insulin for Resident's #17, #47, and #256 were dated. This had the potential to affect nine resident's (Resident's #3, #15, #17, #18, #24, #43, #48, #156, #256) requiring insulin who resided in the facility. The facility census was 51. Findings include: 1. Review of Resident #256's medical record revealed an admission date of 04/15/19 and diagnoses included type two diabetes mellitus without complications. Review of Resident #256's physician orders dated 08/09/23 revealed Lantus (insulin glargine) subcutaneous solution 100 units per milliliter (ml), inject 10 units subcutaneously at bedtime for type two diabetes mellitus. Further review revealed Humalog (insulin lispro) injection solution 100 units per ml, inject per sliding scale: if blood sugar was 151 to 200 administer 4 units, for blood sugar 201 to 250 administer 6 units, for blood sugar 251 to 300 administer 8 units, for blood sugar 301 to 350 administer 10 units, and for a blood sugar of 351 to 400 administer 12 units subcutaneously before meals and at bedtime for blood glucose. 2. Review of Resident #47's medical record revealed an admission date of 03/08/22 and diagnoses included type two diabetes mellitus with diabetic neuropathy. Review of Resident #47's physician orders dated 05/30/23 revealed Humalog (insulin lispro) injection solution 100 units per ml, inject per sliding scale if blood sugar was 151 to 200 administer 4 units, for blood sugar 201 to 250 administer 6 units, for blood sugar 251 to 300 administer 8 units, for blood sugar 301 to 350 administer 10 units, for blood sugar 351 to 400 administer 12 units, call physician if blood sugar greater than 400, subcutaneously four times a day for blood sugar control. 3. Review of Resident #17's medical record revealed an admission date of 11/23/21 and diagnoses included type two diabetes mellitus with diabetic neuropathy. Review of Resident #17's physician orders dated 08/10/23 revealed Toujeo SoloStar (insulin glargine) subcutaneous solution Pen-Injector 300 units per ml, inject 8 units subcutaneously at bedtime for type two diabetes mellitus. Observation on 08/22/23 at 9:01 A.M. of a facility medication cart with Registered Nurse (RN) #780 revealed: a. Resident #256 had an opened, undated bottle of insulin lispro (Humalog) in the medication cart. Further observation revealed the box the insulin lispro was stored in was labeled with Resident #256's name and dated 07/05/23. RN #780 confirmed Resident #256's bottle of insulin lispro was opened and undated. RN #780 indicated insulin was only good for a month after it was opened and first used. RN #780 stated Resident #256 was currently receiving insulin lispro. Further observation of the medication cart with RN #780 revealed Resident #256 had an opened, undated bottle of Lantus insulin (insulin glargine) stored in a box labeled with Resident #256's name and dated 06/25/23. RN #780 confirmed the box was dated 06/25/23, the bottle of Lantus insulin was opened and not dated, the box was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 13 of 21 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 08/28/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dated almost two months ago and insulin was only good for 30 days once it was opened. RN #780 stated Resident #256 was currently receiving Lantus insulin. b. Resident #47 had an opened, undated bottle of insulin lispro 100 units per ml in the medication cart. Resident #47's insulin was stored in a box labeled with her name and a date of 06/27/23 written on the box. RN #780 confirmed Resident #47's insulin lispro was opened, undated, and stored in a box with the date 06/27/23 written on it. RN #780 confirmed insulin was only good for a month once it was opened. RN #780 indicated Resident #47 was currently receiving insulin lispro. c. Resident #17 had an opened Toujeo SoloStar (insulin glargine) subcutaneous solution Pen-Injector 300 units per ml, and the date on the pen was 05/06/23. RN #780 confirmed the pen was dated 05/06/23 which was three and a half months ago. RN #780 confirmed Resident #17 was currently receiving Toujeo SoloStar (insulin glargine) Pen-Injector 300 units per ml. Interview on 08/22/23 at 9:30 A.M. of the Director of Nursing (DON) confirmed insulin bottles were opened and undated for Resident #256 and #47. The DON confirmed Resident #17's Toujeo SoloStar Pen-Injector was dated 05/06/23. The DON confirmed the insulin bottles should have been dated when they were opened, and insulin glargine and lispro were only good for a month once they were opened. Review of the manufacturer's instructions for Insulin Lispro Injection 100 units per ml included do not use Insulin Lispro Injection past the expiration date printed on the label or 28 days after you first use it. Review of the manufacturer's instructions for Lantus Insulin (insulin glargine injection) 100 units per ml included do not use Lantus after the expiration date stamped on the label or 28 days after you first use it. Review of the manufacturer's instructions for Toujeo SoloStar Pen-Injector 300 units per ml included to only use your pen for up to 56 days after its's first use. Review of the facility policy titled General Guidelines-Medication Administration dated 05/01/16 included remember to date and initial the vial (bottle) and the box of multi-dose medications the first time you use a medication. Once opened and dated, the medication can be used for 30 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 14 of 21 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 08/28/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure clean and sanitary kitchen area and ensure appropriate glove use by kitchen staff. This had the potential to affect all residents receiving meals from the facility kitchen. The facility identified one resident (#38) as not receiving meals from kitchen for Nothing by Mouth (NPO) status. The facility census was 51. Findings include: Observations on 08/21/23 from 9:06 A.M. to 9:23 A.M. revealed under dry storage room storage racks was darkened, sticky flooring and there was various food debris and plasticwares. The main food preparation area contained food preparation tables, racks for storing cookware, and equipment including steamtable, deep fryer, oven with range and flat grill top. There was a microwave on a storage rack. Inside the microwave was splattered with red food substance. Under preparation tables revealed darkened flooring with grease build up with significant food debris. Observation of deep fryer revealed significant dark brown grease build up on splash guards and yellow colored build up on basket hanger. There was splatter of grease/ food debris down front of deep fryer. Observation of oven with range revealed splattering of grease/food debris down front of oven range. Observation of flat top grill revealed significant dark brown grease build up and food debris. There was splatter of grease/food debris down front and sides of flat top grill. Observation of kitchen hood revealed significant grease build up with dust sticking to grease on the fire suppression system within kitchen hood and grates. Findings were confirmed with Dietary Director #900 at time of observation. Observation on 08/23/23 from 10:51 A.M. to 11:08 A.M. of [NAME] #520 preparing pureed lunch items revealed [NAME] #520 wearing disposable gloves. Dietary Director #900 was present during time of puree preparations. [NAME] #520 was observed to use gloved hand to scoop vegetable blend into food processor. [NAME] #520 did not dispose gloves after scooping vegetables. [NAME] #520 continued to prepare purees while wearing same disposable gloves. [NAME] #520 continued on to prepare pureed veal patties while wearing same gloves. [NAME] #520 grabbed tongs from a drawer on prep table while wearing same disposable gloves. [NAME] #520 was noted to pull down surgical mask to taste test vegetable blend puree and veal puree while wearing same disposable gloves. [NAME] #520 continued on to puree garlic bread. [NAME] #520 grabbed garlic bread out of oven with same gloved hands and did not use utensil. Observation also revealed tray of garlic bread on metal storage rack placed on top of clean cookware. The tray of garlic bread was uncovered. Interview on 08/23/23 at 11:08 A.M. with [NAME] #520 and Dietary Director #900 confirmed findings of inappropriate glove usage and uncovered garlic bread left on the shelf. Review of facility policy General Sanitation of Kitchen dated 2017 revealed staff would maintain the sanitation of the kitchen through a written comprehensive cleaning schedule. Review of Weekly Cleaning Schedule undated revealed cleaning schedules for kitchen hood and filters, stove and oven, tables including bottom, floors including corner, fryer, and cook room. Review of kitchen education on personal hygiene and hand washing dated 03/28/23 revealed glove are used to protect food and not keep hands of employee clean, gloves should be changed between each activity, and gloves were not a substitute for washing hands. The education revealed when handling food use tongs or other appropriate utensils. The education was completed by [NAME] #520 on 07/14/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 15 of 21 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 08/28/2023 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 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, facility failed to send a referral to speech therapy after Resident #27 experienced a choking episode which required a downgrade in diet texture. This affected one resident (#27) of two residents reviewed for nutrition. The facility census was 51. Residents Affected - Few Findings included: Record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including asthma, gastro-esophageal reflux disease, hypertension, dementia, osteoporosis, and fracture of unspecified part of next of right femur. Review of a minimum data set (MDS) completed on 06/28/23 revealed Resident #27 had a brief interview for mental status score of 3 indicating severely impaired cognition, required extensive assistance of two for bed mobility, transfer, and toilet use, and required a limited assist of one staff for eating. The MDS also revealed Resident #27 did not have any concerns with coughing or choking and was not receiving a mechanically altered diet. Review of orders revealed Resident #27 had an order in place for a regular diet with mechanical soft texture and thin liquid consistency starting on 07/19/23. Review of a note dated 07/19/23 revealed Resident #27 had difficultly swallowing and choked on her food leading to downgrading her diet to mechanical soft texture with no indication of the physician being notified. Review of a note from 07/20/23 revealed the dietician was aware of the choking incident. Interview on 08/23/23 at 8:35 A.M. with Occupational Therapy Assistant (OTA) #67 revealed Resident #27 did not receive speech therapy services after having an episode of choking. Interview on 08/23/23 at 9:36 A.M. with Therapy Manager (TM) #30 confirmed the therapy department was not made aware of Resident #27's choking episode and they did not receive a referral for speech therapy. Interview on 08/23/23 at 1:48 P.M. with the Director of Nursing (DON) #60 confirmed the physician was not notified Resident #27 had a choking episode. The DON #60 stated a referral to speech therapy would only be sent if a diet needed upgraded, if they admitted with orders for speech therapy or if the physician requested a referral be sent. Interview on 08/24/23 at 10:19 A.M. with Dietician #701 revealed nursing staff should send a referral to speech therapy when choking or a change in diet texture occurs. Review of a policy titled Texture and Consistency Modified Diets, undated, revealed individuals with indicators of dysphagia, including choking and delayed swallowing, will be referred to the speech language pathologist for evaluation of dysphagia. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 16 of 21 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 08/28/2023 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 0851 Level of Harm - Minimal harm or potential for actual harm Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview, record review, and review of PBJ (Payroll Based Journal) data report the facility failed to ensure accuracy of PBJ information. This had the potential to affect all 51 residents residing in the facility. Residents Affected - Many Findings include: Review of the facility PBJ Staffing Data Report dated 01/01/23 through 03/31/23 revealed submitted weekend staffing data was excessively low. Review of the facility nursing schedules from 01/03/23 through 02/28/23 did not reveal documentation when nurses assigned to the Nursing Home area of the facility were also required to cover the Assisted Living area on night shift. Further review did not reveal nurses signed out from the Nursing Home when they needed to go to the Assisted Living area, and did not sign back in when they returned. Interview on 08/21/23 at 11:30 A.M. of Registered Nurse (RN) #445 revealed she worked in the Nursing Home part of the facility, but sometimes when she worked night shift from 6:00 P.M. through 6:00 A.M. she was required to cover the Nursing Home and the Assisted Living (AL) because the AL did not have a nurse who worked night shift. RN #445 stated she could not remember the dates she covered the Assisted Living as part of her assignment. RN #445 indicated she had not been required to cover the Assisted Living for at least a couple months now. RN #445 stated she did not know what changed or why she was not required to cover the AL now. RN #445 stated she did not know if the AL staffing was better now, and if that was the reason she was not required to cover the AL now. RN #445 stated when she did cover the AL it was pretty much every other night that she worked. RN #445 indicated she could not think of any negative effect residents in the Nursing Home experienced when she covered the AL. RN #445 revealed night shift was the only time the nurses were required to take the keys for the AL and cover the AL if a nurse was needed. RN #445 stated two nurses usually worked night shift in the Nursing Home, and depending on the needs of the residents in the AL she would usually be gone about a half hour, but had been gone for two hours due to a resident fall. Interview on 08/21/23 at 3:59 P.M. of the Director of Nursing (DON) confirmed nurse's from the Nursing Home covered the Assisted Living during some night shifts. The DON stated nurses from the Nursing Home had not been required to cover the AL for a few months now. The DON indicated it only happened for a few months because the AL did not have enough staff, but now they had enough staff. The DON stated she could not provide information for which nights the nurses covered the Assisted Living and the time they spent in the AL meeting the residents needs. The DON stated the nursing schedule did not reflect the days the nurses were required to cover the AL. The DON stated the nurses did not sign in and out when they went to the AL and there was no way to tell how long they were in the AL. The DON stated the nurse who took the AL keys for the medication cart completed a narcotic count with the nurse who was leaving the AL, then came back to the Nursing Home. Interview on 08/22/23 at 5:46 A.M. of RN #445 revealed she did not document how long she was gone when she left the Nursing Home and went to the AL to meet a resident's needs. RN #445 stated on the nights she was required to cover the AL, she would go to the AL when she arrived for work, complete a narcotic count with the nurse who was leaving, then return to the Nursing Home. RN #445 stated when the AL attendants called her because a resident needed her for a reason like medication administration or a fall she did not document when she left the Nursing Home or when she returned. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 17 of 21 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 08/28/2023 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 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 08/24/23 at 1:10 P.M. of the DON revealed she was not the Director of Nursing during the months when the Nursing Home nurses covered the Assisted Living. The DON stated she could not answer any questions related to the accuracy of the PBJ data since she was not in the DON role at that time. The DON stated the facility did not have a shared staffing policy because the AL and the NH were all one entity. This deficiency represents non-compliance investigated under Complaint Number OH00140656 and OH00137403 Event ID: Facility ID: 366264 If continuation sheet Page 18 of 21 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 08/28/2023 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 observation, interview, record review, and review of facility policy the facility failed to identify a pattern of urinary tract infections (UTIs) did not occur for ten residents (#13, #18, #23, #34, #38, #41, #50, #156, #158 and #256) residing in the same nursing unit, the facility failed to ensure appropriate use of personal protective equipment (PPE) for resident (#308) on droplet precautions, and failed to ensure documentation of education for hand hygiene, gloves and cleansing of perineal area. This affected ten residents (#13, #18, #23, #34, #38, #41, #50, #156, #158 and #256) of 16 residents reviewed for UTIs, one (#308) out of four residents reviewed for transmission based precautions. The facility census was 51. Residents Affected - Many Findings include: 1.Review of the infection control log dated July 2023 revealed ten residents (that resided on the same nursing unit and required staff assistance with personal/incontinence care) had UTIs in July 2023; however the log did not provide the contact organism for all of them. a. Resident #13 developed a UTI on 07/05/23. The resident was identified as incontinent by Registered Nurse (RN) #500 on 08/24/23 at 3:30 P.M. b. Resident #18 developed a UTI on 07/20/23. The resident was identified as incontinent by RN #500 on 08/24/23 at 3:30 P. M c. Resident #23 developed a UTI on 07/12/23. The resident was identified as incontinent by RN #500 on 08/24/23 at 3:30 P.M. d. Resident #34 developed a UTI on 07/12/23. The resident was identified as occasionally incontinent by RN #500 on 08/24/23 at 3:30 P.M. e. Resident #38 developed a UTI on 07/20/23. The resident was identified as incontinent by RN #500 on 08/24/23 at 3:30 P.M. f. Resident #41 developed a UTI on 07/08/23. The resident was identified as occasionally incontinent by RN #500 on 08/24/23 at 3:30 P.M. g. Resident #50 developed a UTI on 07/13/23. The resident was identified as occasionally incontinent by RN #500 on 08/24/23 at 3:30 P.M. h. Resident #156 developed a UTI on 07/06/23. The resident was identified as incontinent by RN #500 on 08/24/23. i. Resident #158 developed a UTI on 06/12/23. The resident was identified as incontinent by RN #500 on 08/24/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 19 of 21 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 08/28/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many j. Resident #256 developed a UTI on 07/12/23. The resident was identified as occasionally incontinent by RN #500 on 08/24/23 at 3:30 P.M. 2. Observation and interview on 08/24/23 at 12:01 P.M. revealed a gown hanging on outside of door of Resident #308 (under isolation precautions). The gown was for staff reuse. This was verified verified by Licensed Practical Nurse (LPN) #19 at the time of the observation. Interview on 08/24/23 at 2:23 P.M. with RN #500 revealed gowns should not be hung outside an isolation room for reuse. She stated they are disposable for a reason. RN #500 verified the trend for UTIs in July 2023 in the same nursing unit for residents (#13, #18, #23, #34, #38, #41, #50, #156, #158 and #256) who were incontinent and required staff assistance with perineal/incontinence care. RN #500 stated she completed audits for handwashing in July 2023 but only did verbal training on perineal care in July 2023. The last documented evidence of training for perineal care was in April 2023. Review of the Hand Hygiene Contact Precautions Monitoring Tool, dated July 2023, revealed instances of hand hygiene not being completed upon entry or exit from resident room and gloves were not always worn as expected. Review of the facility policy titled Infection Control Policies and Procedures, dated 01/01/17 revealed the facility should provide on-going employee education counseling based on results of investigation in a timely manner. Education should include proper use of personal protective equipment and sterile technique. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 20 of 21 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 08/28/2023 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure an effective pest control program in the kitchen area. This had the potential to affect all residents receiving meals from the facility kitchen. The facility identified one Resident (#38) as not receiving meals from kitchen for Nothing by Mouth (NPO) status. The facility census was 51. Residents Affected - Many Findings include: Observations on 08/21/23 from 9:06 A.M. to 9:23 A.M. revealed significant fly and gnat activity in kitchen preparation areas. Observations revealed door through dry storage room in kitchen leading directly outside to dumpster area. There were noted kitchen cleanliness concerns in the kitchen preparation areas. Observations on 08/23/23 from 10:51 A.M. to 11:08 A.M. revealed continued significant fly and gnat activity in kitchen preparation areas. Interview on 08/23/23 at 11:08 A.M. with Dietary Director #900 confirmed fly and gnat activity. Dietary Director #900 indicated maintenance was responsible for pest control. Dietary Director #900 indicated staff try to mitigate activity by killing flies and gnats. Interview on 08/23/23 at 3:08 P.M. with Maintenance Director #450 revealed the facility used a pest control service on a monthly basis. Maintenance Director #450 indicated there was a high concentration of flies in general due to weather. Maintenance Director #450 indicated it was recommended by pest control service that the dumpster outside of the dietary department be closed. Maintenance Director #450 indicated he had a meeting scheduled for next week with trash company to discuss moving the dumpster further from the building. Maintenance Director #450 stated he had planned to educate the dietary staff on using the further of the two dumpsters for food items and the closer of the two for boxes and non-perishable items. Maintenance Director #450 also stated he planned to tell dietary to keep the kitchen door closed to the outside. Interview on 08/24/23 at 12:13 P.M. with Pest Control Representative (PCR) #702 revealed he inspects and treats the facility monthly. PCR #702 stated it was recommended the dumpster lids be closed last month. PCR #702 stated the facility had not requested additional services. Review of Orkin Service Information reports dated 05/26/23, 06/05/23, and 07/28/23 revealed no treatments for gnats or flies. Review of Orkin Service Information report dated 06/30/23 revealed kitchen was treated for flies. There was no evidence of additional services requested to address flies or gnats. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366264 If continuation sheet Page 21 of 21