Inspection·October 21, 2019

F 0580 Review of physician orders dated 10/10/19 and timed 9:17 A.M. revealed an order indicating Resident #18 could have no more than two alcoholic drinks when visiting with family. 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: 366270 If continuation sheet Page 2 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and interview the facility failed to maintain a homelike environment. This affected one (Resident #36) of 46 residents reviewed for environmental concerns. The facility also failed to maintain ambient temperatures within 71 and 81 degrees Fahrenheit (F) on the C wing on the South side hall. This affected two (Residents #14 and #43) of eight residents who resided on the C wing of the South side hall. Findings include: 1. Interviews on 10/06/19 at 10:39 A.M. and 10:51 A.M. with Residents #14 and #43 revealed the C wing of the South side hall was cold. Resident #43 stated it had felt cold since early September. Residents #14 and #43 stated they both reported the cold temperature to staff. Observation on 10/06/19 10:49 A.M. with Maintenance Director (MD) #214 of the thermostat located on C wing of the South side hall revealed the inside temperature was 69 degrees F. At this time MD #214 confirmed the temperature and stated he had not turned on the boiler and that this side of the building ran on the boiler. Interview on 10/08/19 at 8:34 A.M. and 10:20 A.M. with the administrator revealed the facility did not have a policy for temperatures, they followed the regulation. The administrator stated MD #214 monitored the temperatures by checking them but did not keep a temperature log. 2. Observation on 10/06/19 at 10:43 A.M. of Resident #36's bathroom revealed the toilet paper holder was missing the part that held the toilet paper roll. Interview on 10/08/19 at 11:02 A.M. with Resident #36 revealed the toilet paper roll holder had been that way since admission about one year ago. Observation at this time revealed the toilet paper holder was still missing the part that held the toilet paper. There were two rolls of toilet paper, one opened, sitting on the back of the toilet. Interview on 10/08/19 at 11:05 A.M. with Housekeeping Staff (HKS) #212 revealed part of her daily room cleaning was to replenish toilet paper and paper towels in the residents' rooms. HKS #212 stated the toilet paper holder in Resident #36's bathroom had been missing the spindle at least since June 2019. HKS #212 stated she always placed the toilet paper roll on the back of the toilet in Resident #36's bathroom. HKS #212 stated she had never reported it or asked about it due to thinking there was a reason for the toilet paper spindle not being there. Interview on 10/08/19 at 11:44 A.M. with MD #214 revealed he was not aware of Resident #36's toilet paper holder missing the part that held the toilet paper. MD #214 stated it was his fault because theoretically he should be checking the residents' rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 3 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, review of the medical record, review of a personnel file, and review of the abuse policy, the facility failed to protect a resident with impaired judgment and impulse control deficits from a sexual relationship with an employee. This affected one (Resident #47) of five residents reviewed for abuse. The facility census was 46. Findings include: Review of the closed record for Resident #47 revealed he was admitted on [DATE]. His diagnoses included traumatic brain injury, major depressive disorder, anxiety disorder, and bipolar disorder. Resident #47 was discharged to another nursing home on [DATE]. The resident's father was his legal guardian. Review of a progress note dated 01/06/19 at 8:47 A.M. revealed a female visitor was observed leaving Resident #47's room. Resident #47 stated female visitor spent the night in his room. A progress note dated 01/06/19 at 8:00 P.M. noted resident has a female visitor at this time in his room. Visitor noted wearing pajamas. Review of a psychiatric follow up assessment dated [DATE] indicated Resident #47 was being treated for bipolar disorder. The resident complained of mania, irritability, and restlessness. Resident #47 had limited judgement and insight. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #47 had no cognitive deficits. He displayed behaviors including physical behavioral symptoms directed towards others. The resident was independently ambulatory. Review of a progress note dated 04/24/19 revealed Resident #47's guardian was notified of the resident's sexual relationship with a staff member. The guardian voice no concern with the relationship. Review of the care plan for behaviors dated 03/19/18 indicated Resident #47 had the potential to demonstrate verbally abusive behaviors related to ineffective coping skills, mental/emotional illness, and poor impulse control. The resident tended to go into resident rooms on the north side of building and [NAME] the residents. He was currently not allowed past nurses station per his guardian. Resident #47 had walked to store to purchase alcohol for others. In April 2019, the resident had a verbal altercation with another resident. On 10/08/19 at 4:45 P.M., an interview with Activity Director #200 revealed Resident #47 had a thing for a staff who worked in the kitchen. She saw the female kitchen staff kissing Resident #47. They were in the parking lot in front of the building. Activity Director #200 was unable to identify the name of the staff. On 10/08/19 at 5:20 P.M., an interview with Dietary Director #206 indicated Dietary Aide #283 worked at the facility for over one year. Dietary Aide #283 would come into the building when she was off to visit Resident #47. A night shift nurse (6:00 P.M. to 6:30 A.M.) called Former Administrator #300 to report Dietary Aide #283's relationship with Resident #47. The next morning, the administrator called Dietary Director #206 into his office to see if she knew about the relationship. Former Administrator #300 called Dietary Aide #283 into the meeting and asked her about the relationship. Former Administrator #300 then called Resident #47's guardian. The guardian was okay with the relationship. Dietary Aide #283 was allowed to continue the relationship with rules. The rules included she was not allowed to take Resident #47 off grounds, and she was not allowed to visit while she was on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 4 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0600 clock. The dietary director could not recall when this occurred. Level of Harm - Minimal harm or potential for actual harm On 10/08/19 at 5:40 P.M., an interview with State Tested Nursing Assistant (STNA) #254 indicated Resident #47 had a relationship with a kitchen employee (Dietary Aide #283). The dietary aide would go into Resident #47's room and shut the door. When STNA #254 was asked if she notified the former administrator, she responded Former Administrator #300 was aware of the relationship. All the facility staff were talking about it. Residents Affected - Few On 10/08/19 at 6:00 P.M., an interview with Licensed Practical Nurse (LPN) #217 indicated Resident #47 dated a girl that worked in the kitchen, Dietary Aide #283. She was not allowed in his room when working. Dietary Aide #283 came at night. There were a lot of STNAs who felt it was awkward. The managers had a big meeting regarding the relationship. Resident #47 had brain damage and his father had to make the major decisions. LPN #217 was unable to state when this occurred. On 10/08/19 at 6:33 P.M., an interview with STNA #224 indicated Resident #47 was dating Dietary Aide #283 who worked in the kitchen. They were told it was okay because she did not provide his care but STNA #224 said it felt uncomfortable. Dietary Aide #283 would spend the night and leave before lunch. Dietary Aide #283 told STNA #224 she was having sex with Resident #47. On 10/08/19 at 7:05 P.M., an interview with Social Service Designee (SSD) #267 indicated Resident #47 had a relationship with a girl who worked in the kitchen. The dietary aide would stay overnight in resident's room. On 10/09/19 at 12:35 P.M., an interview with the administrator revealed she knew nothing about Dietary Aide #283 having a relationship with Resident #47. She indicated it must have been before she started working at the facility. The administrator indicated she started at the facility in April 2019. Review of the personnel file for Dietary Aide #283 revealed her date of hire was 12/07/17. She no longer was employed at the facility. Dietary Aide #283 put in two weeks notice on 06/22/19. Dietary Aide #283's last day worked was 07/04/19. Review of the personnel file revealed no evidence of corrective action or counseling for the relationship with Resident #47. Review of the facility policy titled Freedom from Abuse, Neglect, and Exploitation revised 10/10/19 revealed it is the facility's policy to provide for the safety and dignity of all its residents by implementing proper procedures for enforcing the residents' right to be free from abuse, neglect, misappropriation of resident property, and exploitation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 5 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, facility investigation, and associated investigation documents, the facility policy titled Freedom from Abuse, Neglect, and Exploitation, and The Elder Justice Act and Reporting Suspected Crimes Against Residents, and interview with staff, resident, and resident families the facility failed to implement the facility abuse policy following an allegation of resident to resident sexual abuse. This affected one (#38) of five residents reviewed relative to investigations of physical or sexual abuse. The facility identified 12 additional cognitively impaired residents the alleged perpetrator had access to (Residents #5, #11, #21, #24, #25, #26, #30, #33, #35, #40, #41, and #196). The facility census was 46. Residents Affected - Some Findings include: Review of the medical record revealed Resident #38 was admitted on [DATE] with diagnoses including vascular dementia with behavioral disturbance, depression with anxiety, arthritis, and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #38 had severe cognitive deficits with signs of delirium including inattention, disorganized thinking, and altered level of consciousness which fluctuated. The resident displayed no behaviors directed towards others or self. She required limited physical assistance of one staff for transfers and activities of daily living. Review of the care plan for communication dated 02/28/19 indicated Resident #38 was sometimes understood and sometimes understood others. She jumped from one topic to another and would become anxious. Interventions included communication techniques to enhance interactions. Staff were to allow adequate time to respond, repeat as necessary, not rush the resident, request feedback, and clarify with Resident #38 to ensure understanding. Review of the closed record for Resident #47 revealed the [AGE] year-old male resident was admitted on [DATE] with diagnoses including traumatic brain injury, major depressive disorder, anxiety disorder, and bipolar disorder. Resident #47 was discharged to a secured facility on 07/24/19. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #47 had no cognitive deficits. He displayed behaviors including physical behavioral symptoms directed towards others. Resident #47 was independently ambulatory. Review of the care plan for behaviors dated 03/19/18 indicated Resident #47 had the potential to demonstrate verbally abusive behaviors related to ineffective coping skills, mental/emotional illness, and poor impulse control. The resident tended to go into resident rooms on the north side of building and [NAME] the residents. He was currently not allowed past the nurses' station per the guardian. Resident #47 had walked to the store to purchase alcohol for others. In April 2019, the resident had a verbal altercation with another resident. Review of the facility's summary of the investigation initiated 07/17/19 at 3:15 P.M., revealed SSD #267 reported to the administrator Resident #47 may have attempted sexual advances towards Resident #38. Resident #47 was placed on 15-minute visual checks. Resident #38 had a head to toe assessment with no negative findings. The administrator accompanied by SSD #267 interviewed Resident #38. It was difficult at times to understand what the resident was attempting to communicate. During the interview, Resident #38 stated hoochie koochie which she stated often and pointed to her perineal area. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 6 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The administrator interviewed Resident #47 who denied the allegation. Resident #47 expressed understanding that he needed permission prior to entering another resident's room. Staff statements were obtained. All cognitively intact residents were interviewed and voiced no concern. According to the administrator, SSD #267 stated later that same day that she no longer felt physical contact occurred between Resident #47 and Resident #38. The administrator contacted both residents' responsible parties and the primary care physician (the medical director). Resident interviews were completed with all residents with intact cognition. Review of the facility's investigation revealed no statement from SSD #267 who initially alleged sexual abuse on 07/17/19. The investigation included two statements: One dated 07/17/19 by LPN #270 who observed Resident #47 in Resident 38's room on 07/15/19 and one dated 07/17/19 by the administrator. Review of LPN #270's statement revealed on 07/15/19 at approximately 6:00 P.M. she observed Resident #47 seated on Resident #38's bed and Resident #38 seated in her recliner. No inappropriate touching or interaction was observed. The residents were separated with no further contact observed on that date. There was no evidence the local authorities or State Agency were notified. There was no evidence Residents #5, #11, #21, #24, #25, #26, #30, #35, #40, #41, and #196 who were identified as cognitively impaired and residing in the facility on 07/17/19 were assessed for signs of sexual abuse or physical injury. Review of 15-minute check sheets revealed visual checks were completed 07/17/19 from 3:30 P.M. through 07/19/19 at 11:45 P.M., at which time Resident #47 was taken off monitoring. Observation on 10/06/19 at 11:35 A.M. revealed Resident #38 was awake and alert sitting in a chair in her room. An attempt to interview Resident #38 was unsuccessful. Resident #38 was confused to time and place and unable to answer questions. On 10/08/19 at 4:30 P.M., an interview with State Tested Nurse Assistant (STNA) #218 indicated it was rumored Resident #47 got into bed with a female resident, Resident #38. The two residents' rooms were right next to each other on the South Hall. On 10/08/19 at 4:45 P.M., an interview with Activity Director #200 revealed she never trusted Resident #47. He made her feel uncomfortable, safety-wise. Before being discharged in July 2019, Activity Director #200 stated Resident #47 would have guys in his room watching pornography. On 10/08/19 at 5:10 P.M., an interview with the administrator indicated she started at the facility on 04/15/19. She reported there had been no SRIs involving sexual abuse. On 10/08/19 at 5:20 P.M., an interview with Dietary Director #206 revealed Resident #47 had sexually inappropriate behavior, mostly verbal. He said things to both staff and other residents. Dietary Director #206 indicated she never observed him display inappropriate touching. Resident #47 used to go into North Hall resident rooms. Dietary Director #206 stated she heard Resident #47 went into another female resident's room, Resident #38, sometime during the summer of 2019 just before he was discharged from facility. On 10/08/19 at 6:00 P.M., an interview with LPN #217 indicated the facility moved Resident #47 from the North Hall to the South Hall because he was inappropriate and arguing with other residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 7 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 10/08/19 at 6:20 P.M., an interview with STNA #253 revealed Resident #47 was stalking her on Facebook, copying images of her and her child onto his Facebook page. He messaged the STNA that she was hot. STNA #253 stated Resident #47 would make weird noises when she passed him. When the resident was acting inappropriate towards her, she went to her supervisor. STNA #253 stated Resident #47 was inappropriate verbally to everyone, staff and residents, sometimes sexually. Staff and administration knew the resident was inappropriate and that was why he was not allowed on the North Hall. STNA #253 indicated she heard stories of Resident #47 being inappropriate with another resident, Resident #38. STNA # 253 stated Resident #38 reported he touched her. On 10/08/19 at 6:33 P.M., an interview with STNA #224 indicated Resident #47 tried getting flirty with her. STNA #224 indicated she heard a rumor that Resident #47 went into Resident #38's room. Resident #38 later pointed at her private area and then at Resident #47. STNA #224 stated she could not remember when that occurred. She referred the surveyor to Resident #38's niece, SSD #267, who knew more about the incident. On 10/08/19 at 7:05 P.M., an interview with SSD #267 revealed Resident #47 had a traumatic brain injury. When he was admitted he did not want to be in the facility. At first, Resident #47 was acclimating without problems. However, he started to change, picking on the elderly residents. Administration then moved him to a private room on the South Hall and he was no longer allowed on the North Hall. SSD #267 indicated Resident #47 knew right from wrong sexually. The last straw was her aunt, Resident #38. Her aunt repeated something to her several times then said That boy referring to Resident #47. SSD #267 stated she immediately notified the administrator. She and the administrator interviewed Resident #38. During the interview Resident #38 kept pushing her hands in her pants. The administrator then stated, So he did do it. The administrator reported the allegation to the corporate director of nursing. The administrator and the corporate director of nursing asked SSD #267 what she wanted. She instructed them to call Resident #38's son. The son said he did not want Resident #38 sent out for a rape test. SSD #267 indicated to her knowledge, Resident #38 was not assessed nor were any other confused residents, and no one was immediately interviewed. SSD #267 never indicated she changed her mind regarding whether the physical contact between Resident #47 and Resident #38 occurred. On 10/09/19 at 10:06 A.M., a phone interview with Resident #47's guardian revealed Resident #47 had off the wall behaviors. The behaviors scared some residents. The resident's guardian stated at times, Resident #47 was sexually inappropriate. Resident #47 was asked to leave the facility in mid July 2019. The guardian indicated the last straw was Resident #47 gave an alert and oriented female resident a sex toy which she had not asked for or wanted. The facility helped find placement for him after asking the resident to leave. On 10/09/19 at 10:20 A.M., a phone interview with the POA for Resident #38 revealed he was made aware a male resident entered his mother's room and that he did something with her. The POA was asked if he wanted his mother sent to the hospital to get a rape test which he did not. The POA stated he spoke to Resident #38 and felt the incident did not go that far. An interview on 10/09/19 at 3:50 P.M., with the administrator revealed immediately following SSD #267 alleging something occurred she and SSD #267 interviewed Resident #38. At 3:58 P.M., SSD #267 joined the interview with the administrator. They agreed Resident #38 kept pushing on the front of her pants in the area of her privates (groin area) then said, No. SSD #267 asked the resident who? and Resident #38 responded, He did. At this point, the administrator indicated she did not feel Resident #38 was alleging sexual abuse. The administrator indicated she notified the resident's POA on 07/17/19 at 3:54 P.M. The POA did not want her sent to the hospital for a rape test. The administrator did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 8 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0607 not notify the local authorities or State Agency because she did not feel it was an allegation sexual abuse. Level of Harm - Minimal harm or potential for actual harm An interview on 10/10/19 at 8:35 A.M., with the administrator and Regional Director of Clinical Services #295 revealed SSD #267 reported the allegation of sexual abuse at 3:15 P.M. on 07/17/19. The administrator notified Resident #38's son (POA) then initiated an investigation. They confirmed there was no evidence of cognitively impaired residents being assessed for signs of sexual abuse or injury. Residents Affected - Some On 10/10/19 at 2:15 P.M., an interview with Primary Care Physician-Medical Director #290 revealed she was made aware of the sexual abuse allegation at the time of the allegation July and again on 10/09/19. Review of the facility policy titled Freedom from Abuse, Neglect, and Exploitation revised 10/10/19 revealed it was the facility's policy to provide for the safety and dignity of all its residents by implementing proper procedures for enforcing the residents' right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy indicated the facility must ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, thoroughly investigated, and must prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress. If the facility reasonably suspected that a crime had occurred against a resident or person receiving care, the facility must report that suspicion to the police, state survey agency, and Adult Protective Services. Review of the facility policy titled The Elder Justice Act and Reporting Suspected Crimes Against Residents dated 2017 indicated all associates had a duty to report any reasonable suspicion of a crime. The facility had a duty to report all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property. This deficiency substantiates Complaint Number OH00107652. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 9 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0608 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, facility investigation, and associated investigation documents, the facility policy titled Freedom from Abuse, Neglect, and Exploitation, and The Elder Justice Act and Reporting Suspected Crimes Against Residents, and interview with staff the facility failed to implement the facility abuse policy following an allegation of resident to resident sexual abuse. This resulted in Immediate Jeopardy and the likelihood of serious physical and emotional harm for one cognitively impaired resident (Resident #38) when the administrator became aware of an allegation of sexual abuse by a resident with known sexual behaviors (Resident #47) and failed to report the allegation to local authorities. This affected one of five residents reviewed relative to investigations of physical or sexual abuse. The facility identified 12 additional cognitively impaired residents the alleged perpetrator had access to (Residents #5, #11, #21, #24, #25, #26, #30, #33, #35, #40, #41, and #196). The facility census was 46. On 10/09/19 at 4:58 P.M., the Administrator and Regional Director of Clinical Services #27 were informed that Immediate Jeopardy began on 07/17/19 at 3:15 P.M. when Social Service Designee (SSD) #267 reported an allegation of sexual abuse on behalf of Resident #38 and the administrator failed to report the suspicion of sexual abuse to the local authorities. The resident perpetrator (Resident #47) remained in the facility on 15-minute checks from 07/17/19 at 3:30 P.M. through 07/19/19 at 11:45 P.M., at which time he was removed from monitoring. Resident #47 remained in the facility until discharge on [DATE] at 10:30 A.M. The Immediate Jeopardy was removed on 10/10/19 at 10:00 A.M. when the facility implemented the following corrective actions: • On 07/17/19 at 3:54 P.M., Resident #38's power of attorney (POA) was notified of the sexual abuse allegation and that the facility had completed a head to toe assessment with no negative findings. The POA declined to have Resident #38 transferred to the hospital for a rape test. • On 07/24/19 at 10:30 A.M., Resident #47 was discharged to a secured nursing home with a large population of residents with behavioral health needs. • On 10/09/19 at 6:00 P.M., Licensed Practical Nurse (LPN) #228 and LPN #264 initiated body audits of all cognitively impaired residents. On 10/10/19 by 10:00 A.M., the body audits of all cognitively impaired residents (Residents #5, #11, #21, #24, #25, #26, #30, #35, #38, #40, and #41) were completed. • On 10/09/19 at 6:00 P.M., the administrator began interviewing staff regarding their knowledge of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 10 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0608 inappropriate sexual contact between Resident #47 and Resident #38. Level of Harm - Immediate jeopardy to resident health or safety • On 10/09/19 at 6:18 P.M., the administrator submitted a self-report incident (SRI) for an allegation of sexual abuse to the State Agency. Residents Affected - Some • On 10/09/19 at 7:29 P.M., the administrator contacted the local police department. • On 10/09/19 at 7:45 P.M., the local police officer arrived at the facility to initiate an investigation. • On 10/10/19 at 6:30 A.M., Registered Nurse (RN) #276, SSD #267, and LPN #268 initiated staff education on the facility's policies titled Freedom from Abuse, Neglect, and Exploitation and The Elder Justice Act and Reporting Suspected Crimes Against Residents. By 4:00 P.M. the Minimum Data Set 3.0 Coordinator #256, four of six Registered Nurses (#226, #249, #257, and #261), 11 of 14 LPNs (#217, #228, #229, #231, #232, #236, #247, #260, #262, #264, and #282), 18 of 28 State Tested Nursing Assistants (#218, #219, #22, #224, #227, #230, #231, #234, #235, #248, #250, #251, #252, #253, #259, #263, and #265) , Activity Director #200, three of three Housekeepers (#211, #212, #213), Laundry Aide #215, Dietitian #204, Dietary Director #206, six of seven Dietary Aides (#205, #207, #209, #210, #280, and #281), Maintenance Staff #214, Certified Occupation Therapy Assistant #266, and Physical Therapy Assistant #269 had received the training. • On 10/10/19 from 8:00 A.M. to 4:00 P.M., LPN #245 conducted resident interviews. Twenty eight of 45 residents residing in the facility were interviewed (Residents #3, #4, #7, #8, #9, #10, #12, #13, #14, #15, #16, #17, #18, #19, #20, #22, #23, #29, #31, #32, #34, #36, #37, #39, #42, #43, #45, and #146). The residents indicated they had not been abused, had not witnessed any other resident being abused, and had no concerns with any other resident. • On 10/10/19 at 10:00 A.M., [NAME] President of Operations #275 provided education to the administrator and the director of nursing on abuse reporting and the facility policies titled Freedom from Abuse, Neglect, and Exploitation and The Elder Justice Act and Reporting Suspected Crimes Against Residents. • On 10/10/19 at 2:15 P.M., an interview with Medical Director #290 revealed she was made aware of the sexual abuse allegation and was involved in the facility's corrective action plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 11 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0608 • Level of Harm - Immediate jeopardy to resident health or safety On 10/10/19 at 5:00 P.M., Interview with [NAME] President of Operations #275 revealed any staff that had not yet received the education on abuse reporting and the facility policy for abuse would receive the training prior to working their next scheduled shift. The training would be provided by RN #276, SSD #267, and LPN #268. Residents Affected - Some • The administrator/designee will perform random weekly audits by interviewing five residents with Brief Interview of Mental Status (BIMS) scores of ten or higher four times a week for four weeks and perform random weekly audits by completing skin assessments for five residents with BIMS of nine or less four times a week for four weeks. The administrator/designee will perform random weekly audits by interviewing five random staff members to ensure staff understands the abuse, neglect and misappropriation policy four weeks. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Review of the medical record revealed Resident #38 was admitted on [DATE]. Her diagnoses included vascular dementia with behavioral disturbance, depression with anxiety, arthritis, and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #38 had severe cognitive deficits with signs of delirium including inattention, disorganized thinking, and altered level of consciousness which fluctuated. The resident had no behaviors directed towards others or self. She needed limited physical assistance of one staff for transfers and activities of daily living. Review of the care plan for communication dated 02/28/19 indicated Resident #38 was sometimes understood and sometimes understood others. She jumped from one topic to another and would become anxious. Interventions included communication techniques to enhance interactions. Staff were to allow adequate time to respond, repeat as necessary, do not rush the resident, request feedback, and clarify with Resident #38 to ensure understanding. Review of the closed record for Resident #47 revealed the [AGE] year-old male was admitted on [DATE] with diagnoses including traumatic brain injury, major depressive disorder, anxiety disorder, and bipolar disorder. Resident #47 was discharged to a secured facility on 07/24/19. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #47 had no cognitive deficits. He displayed behaviors including physical behavioral symptoms directed towards others. Resident #47 was independently ambulatory. Review of the care plan for behaviors dated 03/19/18 indicated Resident #47 had the potential to demonstrate verbally abusive behaviors related to ineffective coping skills, mental/emotional illness, and poor impulse control. The resident tended to go into resident rooms on the north side of building and [NAME] the residents. He was currently not allowed past the nurses' station per the guardian. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 12 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0608 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Resident #47 had walked to the store to purchase alcohol for others. In April 2019, the resident had a verbal altercation with another resident. Review of the facility's summary of the investigation initiated 07/17/19 at 3:15 P.M., revealed SSD #267 reported to the administrator Resident #47 may have attempted sexual advances towards Resident #38. Resident #47 was placed on 15-minute visual checks. Resident #38 had a head to toe assessment with no negative findings. The administrator accompanied by SSD #267 interviewed Resident #38. It was difficult at times to understand what the resident was attempting to communicate. During the interview, Resident #38 stated hoochie koochie which she stated often and pointed to her perineal area. The administrator interviewed Resident #47 who denied the allegation. Resident #47 expressed understanding that he needed permission prior to entering another resident's room. Staff statements were obtained. All cognitively intact residents were interviewed and voiced no concern. According to the administrator, SSD #267 stated later that same day that she no longer felt physical contact occurred between Resident #47 and Resident #38. The administrator contacted both residents' responsible parties and the primary care physician (the medical director). Resident interviews were completed with all residents with intact cognition. Review of the facility's investigation revealed no statement from SSD #267 who initially alleged sexual abuse on 07/17/19. The investigation included two statements: One dated 07/17/19 by LPN #270 who observed Resident #47 in Resident 38's room on 07/15/19 and one dated 07/17/19 by the administrator. There was no evidence the local authorities or State Agency were notified. There was no evidence Residents #5, #11, #21, #24, #25, #26, #30, #35, #40, #41, and #196 who were identified as cognitively impaired and residing in the facility on 07/17/19 were assessed for signs of sexual abuse or physical injury. Review of 15-minute check sheets revealed visual checks were completed 07/17/19 from 3:30 P.M. through 07/19/19 at 11:45 P.M., at which time Resident #47 was taken off monitoring. On 10/08/19 at 5:10 P.M., an interview with the administrator indicated she started at the facility on 04/15/19. She reported there have been no self-report incidents (SRIs) involving sexual abuse. On 10/08/19 at 7:05 P.M., an interview with SSD #267 revealed Resident #47 had a traumatic brain injury. When he was admitted he did not want to be in the facility. At first, Resident #47 was acclimating without problems. However, he started to change, picking on the elderly residents. Administration then moved him to a private room on the South Hall and he was no longer allowed on the North Hall. SSD #267 indicated Resident #47 knew right from wrong sexually. The last straw was her aunt, Resident #38. Her aunt repeated something to her several times then said That boy referring to Resident #47. SSD #267 stated she immediately notified the administrator. She and the administrator interviewed Resident #38. During the interview Resident #38 kept pushing her hands in her pants. The administrator then stated, So he did do it. The administrator reported the allegation to the corporate director of nursing. The administrator and the corporate director of nursing asked SSD #267 what she wanted. She instructed them to call Resident #38's son. The son said he did not want Resident #38 sent out for a rape test. SSD #267 indicated to her knowledge, Resident #38 was not assessed nor were any other confused residents, and no one was immediately interviewed. SSD #267 never indicated she changed her mind regarding whether the physical contact between Resident #47 and Resident #38 occurred. An interview on 10/09/19 at 3:50 P.M., with the administrator revealed immediately following SSD #267 alleging something occurred she and SSD #267 interviewed Resident #38. At 3:58 P.M., SSD #267 joined the interview with the administrator. They agreed Resident #38 kept pushing on the front of her pants in the area of her privates (groin area) then said, No. SSD #267 asked the resident who? and Resident #38 responded, He did. At this point, the administrator indicated she did not feel Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 13 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0608 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some #38 was alleging sexual abuse. The administrator indicated she notified the resident's POA on 07/17/19 at 3:54 P.M. The POA did not want her sent to the hospital for a rape test. The administrator did not notify the local authorities or State Agency because she did not feel it was an allegation sexual abuse. Review of the facility policy titled Freedom from Abuse, Neglect, and Exploitation revised 10/10/19 revealed it was the facility's policy to provide for the safety and dignity of all its residents by implementing proper procedures for enforcing the residents' right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility must ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, thoroughly investigated, and must prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. If the facility reasonably suspected that a crime had occurred against a resident or person receiving care, the facility must report that suspicion to the police, State survey agency, and Adult Protective Services. Review of the facility policy titled The Elder Justice Act and Reporting Suspected Crimes Against Residents dated 2017 indicated all associates have a duty to report any reasonable suspicion of a crime. The facility has a duty to report all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown sources and misappropriation as resident property. This deficiency substantiates Complaint Number OH00107652. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 14 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, facility investigation, and associated investigation documents, the facility policy titled Freedom from Abuse, Neglect, and Exploitation, and The Elder Justice Act and Reporting Suspected Crimes Against Residents, and interview with staff the facility failed to implement the facility abuse policy following an allegation of resident to resident sexual abuse. This resulted in Immediate Jeopardy and the likelihood of serious physical and emotional harm for one cognitively impaired resident (Resident #38) when the administrator became aware of an allegation of sexual abuse by a resident with known sexual behaviors (Resident #47) and failed to report the allegation to the State Agency as required. This affected one of five residents reviewed relative to investigations of physical or sexual abuse. The facility identified 12 additional cognitively impaired residents the alleged perpetrator had access to (Residents #5, #11, #21, #24, #25, #26, #30, #33, #35, #40, #41, and #196). The facility census was 46. On 10/09/19 at 4:58 P.M., the Administrator and Regional Director of Clinical Services #27 were informed that Immediate Jeopardy began on 07/17/19 at 3:15 P.M. when Social Service Designee (SSD) #267 reported an allegation of sexual abuse on behalf of Resident #38 and the administrator failed to report the allegation to the State agency. The resident perpetrator (Resident #47) remained in the facility on 15-minute checks from 07/17/19 at 3:30 P.M. through 07/19/19 at 11:45 P.M., at which time he was removed from monitoring. Resident #47 remained in the facility until discharge on [DATE] at 10:30 A.M. The Immediate Jeopardy was removed on 10/10/19 at 10:00 A.M. when the facility implemented the following corrective actions: • On 07/17/19 at 3:54 P.M., Resident #38's power of attorney (POA) was notified of the sexual abuse allegation and that the facility had completed a head to toe assessment with no negative findings. The POA declined to have Resident #38 transferred to the hospital for a rape test. • On 07/24/19 at 10:30 A.M., Resident #47 was discharged to a secured nursing home with a large population of residents with behavioral health needs. • On 10/09/19 at 6:00 P.M., Licensed Practical Nurse (LPN) #228 and LPN #264 initiated body audits of all cognitively impaired residents. On 10/10/19 by 10:00 A.M., the body audits of all cognitively impaired residents (Residents #5, #11, #21, #24, #25, #26, #30, #35, #38, #40, and #41) were completed. • On 10/09/19 at 6:00 P.M., the administrator began interviewing staff regarding their knowledge of inappropriate sexual contact between Resident #47 and Resident #38. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 15 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0609 • Level of Harm - Immediate jeopardy to resident health or safety On 10/09/19 at 6:18 P.M., the administrator submitted a self-report incident (SRI) for an allegation of sexual abuse to the State Agency. • Residents Affected - Some On 10/09/19 at 7:29 P.M., the administrator contacted the local police department • On 10/09/19 at 7:45 P.M., the local police officer arrived at the facility to initiate an investigation. • On 10/10/19 at 6:30 A.M., Registered Nurse (RN) #276, SSD #267, and LPN #268 initiated staff education on the facility's policies titled Freedom from Abuse, Neglect, and Exploitation and The Elder Justice Act and Reporting Suspected Crimes Against Residents. By 4:00 P.M. the Minimum Data Set 3.0 Coordinator #256, four of six Registered Nurses (#226, #249, #257, and #261), 11 of 14 LPNs (#217, #228, #229, #231, #232, #236, #247, #260, #262, #264, and #282), 18 of 28 State Tested Nursing Assistants (#218, #219, #22, #224, #227, #230, #231, #234, #235, #248, #250, #251, #252, #253, #259, #263, and #265) , Activity Director #200, three of three Housekeepers (#211, #212, #213), Laundry Aide #215, Dietitian #204, Dietary Director #206, six of seven Dietary Aides (#205, #207, #209, #210, #280, and #281), Maintenance Staff #214, Certified Occupation Therapy Assistant #266, and Physical Therapy Assistant #269 had received the training. • On 10/10/19 from 8:00 A.M. to 4:00 P.M., LPN #245 conducted resident interviews. Twenty eight of 45 residents residing in the facility were interviewed (Residents #3, #4, #7, #8, #9, #10, #12, #13, #14, #15, #16, #17, #18, #19, #20, #22, #23, #29, #31, #32, #34, #36, #37, #39, #42, #43, #45, and #146). The residents indicated they had not been abused, had not witnessed any other resident being abused, and had no concerns with any other resident. • On 10/10/19 at 10:00 A.M., [NAME] President of Operations #275 provided education to the administrator and the director of nursing on abuse reporting and the facility policies titled Freedom from Abuse, Neglect, and Exploitation and The Elder Justice Act and Reporting Suspected Crimes Against Residents. • On 10/10/19 at 2:15 P.M., an interview with Medical Director #290 revealed she was made aware of the sexual abuse allegation and was involved in the facility's corrective action plan. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 16 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0609 Level of Harm - Immediate jeopardy to resident health or safety On 10/10/19 at 5:00 P.M., Interview with [NAME] President of Operations #275 revealed any staff that had not yet received the education on abuse reporting and the facility policy for abuse would receive the training prior to working their next scheduled shift. The training would be provided by RN #276, SSD #267, and LPN #268. • Residents Affected - Some The administrator/designee will perform random weekly audits by interviewing five residents with Brief Interview of Mental Status (BIMS) scores of ten or higher four times a week for four weeks and perform random weekly audits by completing skin assessments for five residents with BIMS of nine or less four times a week for four weeks. The administrator/designee will perform random weekly audits by interviewing five random staff members to ensure staff understands the abuse, neglect and misappropriation policy four weeks. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Review of the medical record revealed Resident #38 was admitted on [DATE]. Her diagnoses included vascular dementia with behavioral disturbance, depression with anxiety, arthritis, and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #38 had severe cognitive deficits with signs of delirium including inattention, disorganized thinking, and altered level of consciousness which fluctuated. The resident had no behaviors directed towards others or self. She needed limited physical assistance of one staff for transfers and activities of daily living. Review of the care plan for communication dated 02/28/19 indicated Resident #38 was sometimes understood and sometimes understood others. She jumped from one topic to another and would become anxious. Interventions included communication techniques to enhance interactions. Staff were to allow adequate time to respond, repeat as necessary, do not rush the resident, request feedback, and clarify with Resident #38 to ensure understanding. Review of the closed record for Resident #47 revealed the [AGE] year-old male was admitted on [DATE] with diagnoses including traumatic brain injury, major depressive disorder, anxiety disorder, and bipolar disorder. Resident #47 was discharged to a secured facility on 07/24/19. Review of the quarterly MDS 3.0 assessment dated [DATE] Resident #47 had no cognitive deficits. He displayed behaviors including physical behavioral symptoms directed towards others. Resident #47 was independently ambulatory. Review of the care plan for behaviors dated 03/19/18 indicated Resident #47 had the potential to demonstrate verbally abusive behaviors related to ineffective coping skills, mental/emotional illness, and poor impulse control. The resident tended to go into resident rooms on the north side of building and [NAME] the residents. He was currently not allowed past the nurses' station per the guardian. Resident #47 had walked to the store to purchase alcohol for others. In April 2019, the resident had a verbal altercation with another resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 17 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of the facility's summary of the investigation initiated 07/17/19 at 3:15 P.M., revealed SSD #267 reported to the administrator Resident #47 may have attempted sexual advances towards Resident #38. Resident #47 was placed on 15-minute visual checks. Resident #38 had a head to toe assessment with no negative findings. The administrator accompanied by SSD #267 interviewed Resident #38. It was difficult at times to understand what the resident was attempting to communicate. During the interview, Resident #38 stated hoochie koochie which she stated often and pointed to her perineal area. The administrator interviewed Resident #47 who denied the allegation. Resident #47 expressed understanding that he needed permission prior to entering another resident's room. Staff statements were obtained. All cognitively intact residents were interviewed and voiced no concern. According to the administrator, SSD #267 stated later that same day that she no longer felt physical contact occurred between Resident #47 and Resident #38. The administrator contacted both residents' responsible parties and the primary care physician (the medical director). Resident interviews were completed with all residents with intact cognition. Review of the facility's investigation revealed no statement from SSD #267 who initially alleged sexual abuse on 07/17/19. The investigation included two statements: One dated 07/17/19 by LPN #270 who observed Resident #47 in Resident 38's room on 07/15/19 and one dated 07/17/19 by the administrator. There was no evidence the local authorities or State Agency were notified. There was no evidence Residents #5, #11, #21, #24, #25, #26, #30, #35, #40, #41, and #196 who were identified as cognitively impaired and residing in the facility on 07/17/19 were assessed for signs of sexual abuse or physical injury. Review of 15-minute check sheets revealed visual checks were completed 07/17/19 from 3:30 P.M. through 07/19/19 at 11:45 P.M., at which time Resident #47 was taken off monitoring. On 10/08/19 at 5:10 P.M., an interview with the administrator indicated she started at the facility on 04/15/19. She reported there have been no self-report incidents (SRIs) involving sexual abuse. On 10/08/19 at 7:05 P.M., an interview with SSD #267 revealed Resident #47 had a traumatic brain injury. When he was admitted he did not want to be in the facility. At first, Resident #47 was acclimating without problems. However, he started to change, picking on the elderly residents. Administration then moved him to a private room on the South Hall and he was no longer allowed on the North Hall. SSD #267 indicated Resident #47 knew right from wrong sexually. The last straw was her aunt, Resident #38. Her aunt repeated something to her several times then said That boy referring to Resident #47. SSD #267 stated she immediately notified the administrator. She and the administrator interviewed Resident #38. During the interview Resident #38 kept pushing her hands in her pants. The administrator then stated, So he did do it. The administrator reported the allegation to the corporate director of nursing. The administrator and the corporate director of nursing asked SSD #267 what she wanted. She instructed them to call Resident #38's son. The son said he did not want Resident #38 sent out for a rape test. SSD #267 indicated to her knowledge, Resident #38 was not assessed nor were any other confused residents, and no one was immediately interviewed. SSD #267 never indicated she changed her mind regarding whether the physical contact between Resident #47 and Resident #38 occurred. An interview on 10/09/19 at 3:50 P.M., with the administrator revealed immediately following SSD #267 alleging something occurred she and SSD #267 interviewed Resident #38. At 3:58 P.M., SSD #267 joined the interview with the administrator. They agreed Resident #38 kept pushing on the front of her pants in the area of her privates (groin area) then said, No. SSD #267 asked the resident who? and Resident #38 responded, He did. At this point, the administrator indicated she did not feel Resident #38 was alleging sexual abuse. The administrator indicated she notified the resident's POA on 07/17/19 at 3:54 P.M. The POA did not want her sent to the hospital for a rape test. The administrator did not notify the local authorities or State Agency because she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 18 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0609 did not feel it was an allegation sexual abuse. Level of Harm - Immediate jeopardy to resident health or safety Review of the facility policy titled Freedom from Abuse, Neglect, and Exploitation revised 10/10/19 revealed it was the facility's policy to provide for the safety and dignity of all its residents by implementing proper procedures for enforcing the residents' right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility must ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, thoroughly investigated, and must prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. If the facility reasonably suspected that a crime had occurred against a resident or person receiving care, the facility must report that suspicion to the police, state survey agency, and Adult Protective Services. Residents Affected - Some Review of the facility policy titled The Elder Justice Act and Reporting Suspected Crimes Against Residents dated 2017 indicated all associates have a duty to report any reasonable suspicion of a crime. The facility has a duty to report all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property. This deficiency substantiates Complaint Number OH00107652. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 19 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0610 Respond appropriately to all alleged violations. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, facility investigation, and associated investigation documents, the facility policy titled Freedom from Abuse, Neglect, and Exploitation, and The Elder Justice Act and Reporting Suspected Crimes Against Residents, and interview with staff, resident, and resident families the facility failed to implement their abuse policy following an allegation of resident to resident sexual abuse. This resulted in Immediate Jeopardy and the likelihood of serious physical and emotional harm for one cognitively impaired resident (Resident #38) when the administrator became aware of an allegation of sexual abuse by a resident with known sexual behaviors (Resident #47) and failed to ensure adequate monitoring of the alleged resident perpetrator, thoroughly investigate the allegation and report the allegation to law enforcement and the State Agency. This affected one of five residents reviewed relative to investigations of physical or sexual abuse. The facility identified 12 additional cognitively impaired residents the alleged perpetrator had access to (Residents #5, #11, #21, #24, #25, #26, #30, #33, #35, #40, #41, and #196). The facility census was 46. Residents Affected - Some On 10/09/19 at 4:58 P.M., the administrator and Regional Director of Clinical Services #27 were informed Immediate Jeopardy began on 07/17/19 at 3:15 P.M. when Social Service Designee (SSD) #267 reported an allegation of sexual abuse on behalf of Resident #38 and the administrator failed to follow their policy and procedure for investigation of the allegation and providing safety for the residents from the alleged perpetrator (Resident #47). Resident #47 remained in the facility on 15-minute checks from 07/17/19 at 3:30 P.M. through 07/19/19 at 11:45 P.M., at which time he was removed from monitoring without the facility completing a thorough investigation of the sexual abuse allegation. Resident #47 remained in the facility until discharge on [DATE] at 10:30 A.M. The Immediate Jeopardy was removed on 10/10/19 at 4:00 P.M. when the facility implemented the following corrective actions: • On 07/17/19 at 3:54 P.M., Resident #38's power of attorney (POA) was notified of the sexual abuse allegation and that the facility had completed a head to toe assessment with no negative findings. The POA declined to have Resident #38 transferred to the hospital for a rape test. • On 07/24/19 at 10:30 A.M., Resident #47 was discharged to a secured nursing home with a large population of residents with behavioral health needs. • On 10/09/19 at 6:00 P.M., Licensed Practical Nurse (LPN) #228 and LPN #264 initiated body audits of all cognitively impaired residents. On 10/10/19 by 10:00 A.M., the body audits of all cognitively impaired residents (Residents #5, #11, #21, #24, #25, #26, #30, #35, #38, #40, and #41) were completed. • On 10/09/19 at 6:00 P.M., the administrator began interviewing staff regarding their knowledge of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 20 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0610 inappropriate sexual contact between Resident #47 and Resident #38. Level of Harm - Immediate jeopardy to resident health or safety • On 10/09/19 at 6:18 P.M., the administrator submitted a self-report incident (SRI) for an allegation of sexual abuse to the State Agency. Residents Affected - Some • On 10/09/19 at 7:29 P.M., the administrator contacted the local police department. • On 10/09/19 at 7:45 P.M., the local police officer arrived at the facility to initiate an investigation. • On 10/10/19 at 6:30 A.M., Registered Nurse (RN) #276, SSD #267, and LPN #268 initiated staff education on the facility's policies titled Freedom from Abuse, Neglect, and Exploitation and The Elder Justice Act and Reporting Suspected Crimes Against Residents. By 4:00 P.M. the Minimum Data Set 3.0 Coordinator #256, four of six RNs (#226, #249, #257, and #261), 11 of 14 LPNs (#217, #228, #229, #231, #232, #236, #247, #260, #262, #264, and #282), 18 of 28 State Tested Nursing Assistants (#218, #219, #22, #224, #227, #230, #231, #234, #235, #248, #250, #251, #252, #253, #259, #263, and #265) , Activity Director #200, Social Service Designee #267, three of three Housekeepers (#211, #212, #213), Laundry Aide #215, Dietitian #204, Dietary Director #206, 6 of 7 Dietary Aides (#205, #207, #209, #210, #280, and #281), Maintenance Staff #214, Certified Occupation Therapy Assistant #266, and Physical Therapy Assistant #269 had received the training. • On 10/10/19 from 8:00 A.M. to 4:00 P.M., LPN #245 conducted resident interviews. Twenty eight of 45 residents residing in the facility were interviewed (Residents #3, #4, #7, #8, #9, #10, #12, #13, #14, #15, #16, #17, #18, #19, #20, #22, #23, #29, #31, #32, #34, #36, #37, #39, #42, #43, #45, and #146). The residents indicated they had not been abused, had not witnessed any other resident being abused, and had no concerns with any other resident. • On 10/10/19 at 10:00 A.M., [NAME] President of Operations #275 provided education to the administrator and the director of nursing on abuse reporting and the facility policies titled Freedom from Abuse, Neglect, and Exploitation and The Elder Justice Act and Reporting Suspected Crimes Against Residents. • On 10/10/19 at 2:15 P.M., an interview with Medical Director #290 revealed she was made aware of the sexual abuse allegation and was involved in the facility's corrective action plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 21 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0610 • Level of Harm - Immediate jeopardy to resident health or safety On 10/10/19 at 5:00 P.M., interview with [NAME] President of Operations #275 revealed any staff that had not yet received the education on abuse reporting and the facility policy for abuse would receive the training prior to working their next scheduled shift. The training would be provided by RN #276, SSD #267, and LPN #268. Residents Affected - Some • The administrator/designee will perform random weekly audits by interviewing five residents with Brief Interview of Mental Status (BIMS) scores of ten or higher four times a week for four weeks and perform random weekly audits by completing skin assessments for five residents with BIMS of nine or less four times a week for four weeks. The administrator/designee will perform random weekly audits by interviewing five random staff members to ensure staff understands the abuse, neglect and misappropriation policy four weeks. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Review of the medical record revealed Resident #38 was admitted on [DATE] with diagnoses including vascular dementia with behavioral disturbance, depression with anxiety, arthritis, and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #38 had severe cognitive deficits with signs of delirium including inattention, disorganized thinking, and altered level of consciousness which fluctuated. The resident displayed no behaviors directed towards others or self. She required limited physical assistance of one staff for transfers and activities of daily living. Review of the care plan for communication dated 02/28/19 indicated Resident #38 was sometimes understood and sometimes understood others. She jumped from one topic to another and would become anxious. Interventions included communication techniques to enhance interactions. Staff were to allow adequate time to respond, repeat as necessary, not rush the resident, request feedback, and clarify with Resident #38 to ensure understanding. Review of the closed record for Resident #47 revealed the [AGE] year-old male resident was admitted on [DATE] with diagnoses including traumatic brain injury, major depressive disorder, anxiety disorder, and bipolar disorder. Resident #47 was discharged to a secured facility on 07/24/19. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #47 had no cognitive deficits. He displayed behaviors including physical behavioral symptoms directed towards others. Resident #47 was independently ambulatory. Review of the care plan for behaviors dated 03/19/18 indicated Resident #47 had the potential to demonstrate verbally abusive behaviors related to ineffective coping skills, mental/emotional illness, and poor impulse control. The resident tended to go into resident rooms on the north side of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 22 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some building and [NAME] the residents. He was currently not allowed past the nurses' station per the guardian. Resident #47 had walked to the store to purchase alcohol for others. In April 2019, the resident had a verbal altercation with another resident. Review of the facility's summary of the investigation initiated 07/17/19 at 3:15 P.M., revealed SSD #267 reported to the administrator Resident #47 may have attempted sexual advances towards Resident #38. Resident #47 was placed on 15-minute visual checks. Resident #38 had a head to toe assessment with no negative findings. The administrator accompanied by SSD #267 interviewed Resident #38. It was difficult at times to understand what the resident was attempting to communicate. During the interview, Resident #38 stated hoochie koochie which she stated often and pointed to her perineal area. The administrator interviewed Resident #47 who denied the allegation. Resident #47 expressed understanding that he needed permission prior to entering another resident's room. Staff statements were obtained. All cognitively intact residents were interviewed and voiced no concern. According to the administrator, SSD #267 stated later that same day that she no longer felt physical contact occurred between Resident #47 and Resident #38. The administrator contacted both residents' responsible parties and the primary care physician (the medical director). Resident interviews were completed with all residents with intact cognition. Review of the facility's investigation revealed no statement from SSD #267 who initially alleged sexual abuse on 07/17/19. The investigation included two statements: One dated 07/17/19 by LPN #270 who observed Resident #47 in Resident 38's room on 07/15/19 and one dated 07/17/19 by the administrator. Review of LPN #270's statement revealed on 07/15/19 at approximately 6:00 P.M. she observed Resident #47 seated on Resident #38's bed and Resident #38 seated in her recliner. No inappropriate touching or interaction was observed. The residents were separated with no further contact observed on that date. There was no evidence the local authorities or State Agency were notified. There was no evidence Residents #5, #11, #21, #24, #25, #26, #30, #35, #40, #41, and #196 who were identified as cognitively impaired and residing in the facility on 07/17/19 were assessed for signs of sexual abuse or physical injury. Review of 15-minute check sheets revealed visual checks were completed 07/17/19 from 3:30 P.M. through 07/19/19 at 11:45 P.M., at which time Resident #47 was taken off monitoring. Observation on 10/06/19 at 11:35 A.M. revealed Resident #38 was awake and alert sitting in a chair in her room. An attempt to interview Resident #38 was unsuccessful. Resident #38 was confused to time and place and unable to answer questions. On 10/08/19 at 4:30 P.M., an interview with State Tested Nurse Assistant (STNA) #218 indicated it was rumored Resident #47 got into bed with a female resident, Resident #38. The two residents' rooms were right next to each other on the South Hall. On 10/08/19 at 4:45 P.M., an interview with Activity Director #200 revealed she never trusted Resident #47. He made her feel uncomfortable, safety-wise. Before being discharged in July 2019, Activity Director #200 stated Resident #47 would have guys in his room watching pornography. On 10/08/19 at 5:10 P.M., an interview with the administrator indicated she started at the facility on 04/15/19. She reported there had been no SRIs involving sexual abuse. On 10/08/19 at 5:20 P.M., an interview with Dietary Director #206 revealed Resident #47 had sexually inappropriate behavior, mostly verbal. He said things to both staff and other residents. Dietary Director #206 indicated she never observed him display inappropriate touching. Resident #47 used to go into North Hall resident rooms. Dietary Director #206 stated she heard Resident #47 went into (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 23 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some another female resident's room, Resident #38, sometime during the summer of 2019 just before he was discharged from facility. On 10/08/19 at 6:00 P.M., an interview with LPN #217 indicated the facility moved Resident #47 from the North Hall to the South Hall because he was inappropriate and arguing with other residents. On 10/08/19 at 6:20 P.M., an interview with STNA #253 revealed Resident #47 was stalking her on Facebook, copying images of her and her child onto his Facebook page. He messaged the STNA that she was hot. STNA #253 stated Resident #47 would make weird noises when she passed him. When the resident was acting inappropriate towards her, she went to her supervisor. STNA #253 stated Resident #47 was inappropriate verbally to everyone, staff and residents, sometimes sexually. Staff and administration knew the resident was inappropriate and that was why he was not allowed on the North Hall. STNA #253 indicated she heard stories of Resident #47 being inappropriate with another resident, Resident #38. STNA # 253 stated Resident #38 reported he touched her. On 10/08/19 at 6:33 P.M., an interview with STNA #224 indicated Resident #47 tried getting flirty with her. STNA #224 indicated she heard a rumor that Resident #47 went into Resident #38's room. Resident #38 later pointed at her private area and then at Resident #47. STNA #224 stated she could not remember when that occurred. She referred the surveyor to Resident #38's niece, SSD #267, who knew more about the incident. On 10/08/19 at 7:05 P.M., an interview with SSD #267 revealed Resident #47 had a traumatic brain injury. When he was admitted he did not want to be in the facility. At first, Resident #47 was acclimating without problems. However, he started to change, picking on the elderly residents. Administration then moved him to a private room on the South Hall and he was no longer allowed on the North Hall. SSD #267 indicated Resident #47 knew right from wrong sexually. The last straw was her aunt, Resident #38. Her aunt repeated something to her several times then said That boy referring to Resident #47. SSD #267 stated she immediately notified the administrator. She and the administrator interviewed Resident #38. During the interview Resident #38 kept pushing her hands in her pants. The administrator then stated, So he did do it. The administrator reported the allegation to the corporate director of nursing. The administrator and the corporate director of nursing asked SSD #267 what she wanted. She instructed them to call Resident #38's son. The son said he did not want Resident #38 sent out for a rape test. SSD #267 indicated to her knowledge, Resident #38 was not assessed nor were any other confused residents, and no one was immediately interviewed. SSD #267 never indicated she changed her mind regarding whether the physical contact between Resident #47 and Resident #38 occurred. On 10/09/19 at 10:06 A.M., a phone interview with Resident #47's guardian revealed Resident #47 had off the wall behaviors. The behaviors scared some residents. The resident's guardian stated at times, Resident #47 was sexually inappropriate. Resident #47 was asked to leave the facility in mid July 2019. The guardian indicated the last straw was Resident #47 gave an alert and oriented female resident a sex toy which she had not asked for or wanted. The facility helped find placement for him after asking the resident to leave. On 10/09/19 at 10:20 A.M., a phone interview with the POA for Resident #38 revealed he was made aware a male resident entered his mother's room and that he did something with her. The POA was asked if he wanted his mother sent to the hospital to get a rape test which he did not. The POA stated he spoke to Resident #38 and felt the incident did not go that far. An interview on 10/09/19 at 3:50 P.M., with the administrator revealed immediately following SSD (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 24 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some #267 alleging something occurred she and SSD #267 interviewed Resident #38. At 3:58 P.M., SSD #267 joined the interview with the administrator. They agreed Resident #38 kept pushing on the front of her pants in the area of her privates (groin area) then said, No. SSD #267 asked the resident who? and Resident #38 responded, He did. At this point, the administrator indicated she did not feel Resident #38 was alleging sexual abuse. The administrator indicated she notified the resident's POA on 07/17/19 at 3:54 P.M. The POA did not want her sent to the hospital for a rape test. The administrator did not notify the local authorities or State Agency because she did not feel it was an allegation sexual abuse. An interview on 10/10/19 at 8:35 A.M., with the administrator and Regional Director of Clinical Services #295 revealed SSD #267 reported the allegation of sexual abuse at 3:15 P.M. on 07/17/19. The administrator notified Resident #38's son (POA) then initiated an investigation. They confirmed there was no evidence of cognitively impaired residents being assessed for signs of sexual abuse or injury. On 10/10/19 at 2:15 P.M., an interview with Primary Care Physician-Medical Director #290 revealed she was made aware of the sexual abuse allegation at the time of the allegation July and again on 10/09/19. Review of the facility policy titled Freedom from Abuse, Neglect, and Exploitation revised 10/10/19 revealed it was the facility's policy to provide for the safety and dignity of all its residents by implementing proper procedures for enforcing the residents' right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy indicated the facility must ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, thoroughly investigated, and must prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress. If the facility reasonably suspected that a crime had occurred against a resident or person receiving care, the facility must report that suspicion to the police, state survey agency, and Adult Protective Services. Review of the facility policy titled The Elder Justice Act and Reporting Suspected Crimes Against Residents dated 2017 indicated all associates had a duty to report any reasonable suspicion of a crime. The facility had a duty to report all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property. This deficiency substantiates Complaint Number OH00107652. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 25 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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** 2. Review of the medical record for Resident #18 revealed the resident was admitted on [DATE] with diagnoses including but not limited to alcohol dependence, unspecified convulsions, Parkinson's disease, acute respiratory failure with hypoxia, diabetes , anxiety disorder, manic episode with psychotic symptoms and hemiplegia. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact with no behaviors, required extensive assist of two for transfers and toileting and had one fall with injury. Review of a care plan dated 08/22/19 revealed care areas for impaired thought process related to traumatic brain injury, behavior problem as evidence by making sexually inappropriate comments to staff, diabetes, nutrition, antidepressant use, socially inappropriate with disruptive behaviors and hemiplegia. Under the care area for socially inappropriate with disruptive behaviors there was an intervention dated 01/03/13 per doctor orders no alcoholic beverages. Under the care area for resident very set in his ways, impaired thought and socialization skills there was an intervention dated 07/14/15 stating resident may participate in social hour with mild alcoholic beverages at discretion of staff. Under the nutrition care area there was an intervention dated 09/02/15 for no alcohol related to history of alcohol abuse. Review of a progress note dated 06/23/19 revealed Resident #18 received a visit from his sister in his room. When the nurse took Resident #18 his medication, he had Black Velvet whiskey. The nurse told the resident he was not allowed to drink and confiscated the alcohol. Review of a progress note dated 09/29/19 revealed Resident #18 received a visit form his sister who brought him alcohol. Interview on 10/10/19 at 9:06 A.M. with MDS Coordinator #245 verified the care plan contained conflicting information regarding Resident #18's alcohol use. The MDS Coordinator reported she was not aware of Resident #18 having alcohol in the facility as documented in the progress notes. The MDS Coordinator verified Resident #18 did not have his having alcohol in the facility, despite a diagnosis of history of alcohol abuse in his care plan. Based on record review, observation, and interview the facility failed to develop a smoking care plan for Resident #3 and revise Resident #18 's care plan regarding alcohol use. This affected two (Residents #3 and #18) of 16 residents reviewed for care plans. Findings include: 1. Record review of Resident #3's medical record revealed an admission date of 06/19/19. Diagnoses included unspecified lack of coordination, muscle weakness, nicotine dependence unspecified uncomplicated, and chronic obstructive pulmonary disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition, required extensive assistance of two staff for bed mobility, transfers, and toilet use, and used tobacco. Review of the smoking assessments dated 06/28/19 and 09/26/19 revealed Resident #3 required one on one supervision and was determined to be supervised smoker. Review of Resident #3's current care plan on 10/07/19 revealed no information related to supervised smoking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 26 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 Observation on 10/08/19 at 8:12 A.M. revealed Resident #3 with staff outside in the designated smoking area smoking a cigarette. There were no noted concerns observed. Interview on 10/08/19 at 11:55 A.M. with MDS Coordinator #245 verified Resident #3 did not have a care plan for smoking and that she initiated Resident #3's care plan for supervised smoking today. Residents Affected - Few Review of the facility policy titled Resident Smoking Policy and Procedure dated 05/20/19 revealed the determination of supervision level should be noted in the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 27 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure restorative programing to maintain residents' abilities for activities of daily living (ADL) and/or ambulation following therapy. This affected two (Residents #17 and #38) of two residents reviewed for ADLS. The facility census was 46 residents. Residents Affected - Few Findings include: 1. Review of the record revealed Resident #38 was admitted on [DATE] with diagnoses including dementia with behavioral disturbance, diabetes, and anxiety disorder. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had severe cognitive impairment and needed limited physical assistance for transfers, dressing, personal hygiene, and toilet use. The quarterly MDS 3.0 assessment dated [DATE] revealed Resident #38 had a decline in activities of daily living. She needed extensive physical assistance with dressing, personal hygiene and toilet use. Resident #38 received occupational therapy (OT) for the decline in activities of daily living from 08/21/19 to 09/19/19. Review of the plan of care for OT indicated therapy worked with the resident on standing tolerance, standing balance, general strength, dressing, and transfers. Review of the functioning level at the time of discharge from OT on 09/19/19 revealed Resident #38 was able to retrieve clothing using wheeled walker independently, dress upper body independently, dress lower body with set up assistance, and complete all functional transfers safely with modified independence (with assistive device or extra time needed). There was no evidence Resident #38 received restorative services following discontinuation from therapy to maintain her ability to perform activities of daily living. Review of the electronic charting by the state tested nursing assistants from 09/27/19 to 10/09/19 revealed Resident #38 needed limited to extensive physical assistance with dressing and limited physical assistance to total dependence for toilet use and personal hygiene. On 10/07/19 at 3:06 P.M., an interview with Physical Therapy Assistant (PTA) #269 revealed Resident #38 worked with therapy six times between 08/21/19 and 09/19/19. The resident improved with dressing, putting on her shoes, clothing retrieval from the closet, and doing her hair. On 10/07/19 at 3:17 P.M., an interview with Certified Occupation Therapy Assistant (COTA) #266 revealed she worked with Resident #38 for retrieving her clothing, getting dressed, cleaning her mouth and brushing her dentures, toileting, changing her brief with verbal cuing, and combing her hair. Resident #38 improved during therapy. On 10/08/19 at 9:00 A.M., an interview with State Tested Nursing Assistant (STNA) #218 revealed night shift usually got Resident #38 washed up and dressed in the morning. First shift just had to take her to the bathroom. Resident #38 needed extensive assistance with toileting and extensive physical assistance when she changed her pants, which she did several times a day. Resident #38 needed extensive physical assistance with pulling up her pants. During an interview on 10/10/19 at 9:10 A.M., PTA #269 indicated when physical and occupational therapies were discontinued she completed the restorative referral form with any recommendations. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 28 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and COTA #266 spoke and together they decided what restorative nursing programs to recommend. The programs available included ambulation, range of motion, strengthening, balance activities, and activities of daily living. PTA #269 indicated she forgot to recommend any restorative nursing programs for Resident #38. 2. Review of the record revealed Resident #17 was admitted on [DATE] with diagnoses including dementia, bipolar disorder, and depressive disorder. Review of the quarterly MDS 3.0 assessment dated [DATE] indicated the resident was cognitively intact. She was independent for transfers and ambulation in her room and needed supervision with locomotion. Resident #17 received physical therapy from 07/11/19 to 08/09/19 for bed mobility, gait distance and assistive device, gait level surfaces, transfers, and weight bearing status right and left lower extremities. Review of the Restorative Referral Form dated 08/09/19 revealed recommendations included exercise, balance and ambulation, active range of motion to lower extremities with three pound weights, active range of motion to upper extremities with two pound weights, and walking with wheeled walker 200 plus feet. Review of the Physical Therapy - Progress and Discharge summary dated [DATE] indicated discontinued with restorative nursing program. Review of restorative programing documentation revealed Resident #17 had not received restorative nursing programing since July 2019. During an observation and interview on 10/08/19 at 3:38 P.M., Resident #17 was seated in the hallway outside her room door. She asked the surveyor to tell the facility not to pull the restorative aide to the floor to work as an aide. She indicated when they pulled the restorative aide, she could not do the restorative programs. During an interview on 10/09/19 at 3:00 P.M., Licensed Practical Nurse-Care Plan Nurse (LPN-CP Nurse) #268 revealed Resident #17's restorative programing was discontinued in July 2019 because she was picked up by therapy. When a resident was discontinued from therapy, LPN-CP Nurse #268 usually received a recommendation for a restorative nursing program. Resident #17 did not have a current restorative program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 29 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to ensure bread stored in the kitchen was not expired and free from mold. This had the potential to affect all residents except Resident #25 who received nothing by mouth. The facility census was 46. Findings include: Tour of the kitchen on 10/06/19 at 8:30 A.M. revealed on the bread rack, four bags of buns that had expired on 09/28/19 and one of the bag of buns had a moderate amount of mold on the bottom. At this time Dietary Aide (DA) #207 verified the findings. Review of the facility policy titled Food Receiving and Storage revised July 2014 revealed food shall be received and stored in a manner that complies with safe food handling practices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 30 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, review of facility policies and procedures, and facility Self-Reported Incident (SRI) history, the facility administration failed to ensure facility abuse prevention policies were implemented and appropriate measures were taken in response to an allegation of sexual abuse involving Resident #38. Residents Affected - Many The administrative failure resulted in incidents of Immediate Jeopardy at Data Tags F607, F608, F609, and

F610 for not implementing the facility abuse policy, reporting the allegation to local authorities, notifying the State Agency, ensuring adequate monitoring of the alleged resident perpetrator (Resident #47), and thoroughly investigating the allegation. This affected one (Resident #38) of five residents reviewed relative to investigations of physical or sexual abuse and had the potential to affect all 46 residents residing in the facility. Findings include: Review of the medical record revealed Resident #38 was admitted on [DATE] with diagnoses including vascular dementia with behavioral disturbance, depression with anxiety, arthritis, and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #38 had severe cognitive deficits with signs of delirium including inattention, disorganized thinking, and altered level of consciousness which fluctuated. The resident displayed no behaviors directed towards others or self. She required limited physical assistance of one staff for transfers and activities of daily living. Review of the closed record for Resident #47 revealed the [AGE] year-old male resident was admitted on [DATE] with diagnoses including traumatic brain injury, major depressive disorder, anxiety disorder, and bipolar disorder. Resident #47 was discharged to a secured facility on 07/24/19. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #47 had no cognitive deficits. He displayed behaviors including physical behavioral symptoms directed towards others. Resident #47 was independently ambulatory. Review of the care plan for behaviors dated 03/19/18 indicated Resident #47 had the potential to demonstrate verbally abusive behaviors related to ineffective coping skills, mental/emotional illness, and poor impulse control. The resident tended to go into resident rooms on the north side of building and [NAME] the residents. He was currently not allowed past the nurses' station per the guardian. Resident #47 had walked to the store to purchase alcohol for others. In April 2019, the resident had a verbal altercation with another resident. Review of the facility's summary of the investigation initiated 07/17/19 at 3:15 P.M., revealed Social Service Designee (SSD) #267 reported to the administrator Resident #47 may have attempted sexual advances towards Resident #38. Resident #47 was placed on 15-minute visual checks. Resident #38 had a head to toe assessment with no negative findings. The administrator accompanied by SSD #267 interviewed Resident #38. It was difficult at times to understand what the resident was attempting to communicate. During the interview, Resident #38 stated hoochie koochie which she stated often and pointed to her perineal area. The administrator interviewed Resident #47 who denied the allegation. Resident #47 expressed understanding that he needed permission prior to entering another resident's room. Staff statements were obtained. All cognitively intact residents were interviewed and voiced no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 31 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many concern. According to the administrator, SSD #267 stated later that same day that she no longer felt physical contact occurred between Resident #47 and Resident #38. The administrator contacted both residents' responsible parties and the primary care physician (the medical director). Resident interviews were completed with all residents with intact cognition. Review of the facility's investigation revealed no statement from SSD #267 who initially alleged sexual abuse on 07/17/19. The investigation included two statements: One dated 07/17/19 by Licensed Practical Nurse (LPN) #270 who observed Resident #47 in Resident 38's room on 07/15/19 and one dated 07/17/19 by the administrator. There was no evidence the local authorities or State Agency were notified. There was no evidence Residents #5, #11, #21, #24, #25, #26, #30, #35, #40, #41, and #196 who were identified as cognitively impaired and residing in the facility on 07/17/19 were assessed for signs of sexual abuse or physical injury. Review of 15-minute check sheets revealed visual checks were completed 07/17/19 from 3:30 P.M. through 07/19/19 at 11:45 P.M., at which time Resident #47 was taken off monitoring. Observation on 10/06/19 at 11:35 A.M. revealed Resident #38 was awake and alert sitting in a chair in her room. An attempt to interview Resident #38 was unsuccessful. Resident #38 was confused to time and place and unable to answer questions. On 10/08/19 at 4:30 P.M., an interview with State Tested Nurse Assistant (STNA) #218 indicated it was rumored Resident #47 got into bed with a female resident, Resident #38. The two residents' rooms were right next to each other on the South Hall. On 10/08/19 at 4:45 P.M., an interview with Activity Director #200 revealed she never trusted Resident #47. He made her feel uncomfortable, safety-wise. Before being discharged in July 2019, Activity Director #200 stated Resident #47 would have guys in his room watching pornography. On 10/08/19 at 5:10 P.M., an interview with the administrator indicated she started at the facility on 04/15/19. She reported there had been no SRIs involving sexual abuse. On 10/08/19 at 5:20 P.M., an interview with Dietary Director #206 revealed Resident #47 had sexually inappropriate behavior, mostly verbal. He said things to both staff and other residents. Dietary Director #206 indicated she never observed him display inappropriate touching. Resident #47 used to go into North Hall resident rooms. Dietary Director #206 stated she heard Resident #47 went into another female resident's room, Resident #38, sometime during the summer of 2019 just before he was discharged from facility. On 10/08/19 at 6:00 P.M., an interview with LPN #217 indicated the facility moved Resident #47 from the North Hall to the South Hall because he was inappropriate and arguing with other residents. On 10/08/19 at 6:20 P.M., an interview with STNA #253 revealed Resident #47 was stalking her on Facebook, copying images of her and her child onto his Facebook page. He messaged the STNA that she was hot. STNA #253 stated Resident #47 would make weird noises when she passed him. When the resident was acting inappropriate towards her, she went to her supervisor. STNA #253 stated Resident #47 was inappropriate verbally to everyone, staff and residents, sometimes sexually. Staff and administration knew the resident was inappropriate and that was why he was not allowed on the North Hall. STNA #253 indicated she heard stories of Resident #47 being inappropriate with another resident, Resident #38. STNA # 253 stated Resident #38 reported he touched her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 32 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0835 Level of Harm - Minimal harm or potential for actual harm On 10/08/19 at 6:33 P.M., an interview with STNA #224 indicated Resident #47 tried getting flirty with her. STNA #224 indicated she heard a rumor that Resident #47 went into Resident #38's room. Resident #38 later pointed at her private area and then at Resident #47. STNA #224 stated she could not remember when that occurred. She referred the surveyor to Resident #38's niece, SSD #267, who knew more about the incident. Residents Affected - Many On 10/08/19 at 7:05 P.M., an interview with SSD #267 revealed Resident #47 had a traumatic brain injury. When he was admitted he did not want to be in the facility. At first, Resident #47 was acclimating without problems. However, he started to change, picking on the elderly residents. Administration then moved him to a private room on the South Hall and he was no longer allowed on the North Hall. SSD #267 indicated Resident #47 knew right from wrong sexually. The last straw was her aunt, Resident #38. Her aunt repeated something to her several times then said That boy referring to Resident #47. SSD #267 stated she immediately notified the administrator. She and the administrator interviewed Resident #38. During the interview Resident #38 kept pushing her hands in her pants. The administrator then stated, So he did do it. The administrator reported the allegation to the corporate director of nursing. The administrator and the corporate director of nursing asked SSD #267 what she wanted. She instructed them to call Resident #38's son. The son said he did not want Resident #38 sent out for a rape test. SSD #267 indicated to her knowledge, Resident #38 was not assessed nor were any other confused residents, and no one was immediately interviewed. SSD #267 never indicated she changed her mind regarding whether the physical contact between Resident #47 and Resident #38 occurred. On 10/09/19 at 10:06 A.M., a phone interview with Resident #47's guardian revealed Resident #47 had off the wall behaviors. The behaviors scared some residents. The resident's guardian stated at times, Resident #47 was sexually inappropriate. Resident #47 was asked to leave the facility in mid July 2019. The guardian indicated the last straw was Resident #47 gave an alert and oriented female resident a sex toy which she had not asked for or wanted. The facility helped find placement for him after asking the resident to leave. On 10/09/19 at 10:20 A.M., a phone interview with the Power of Attorney (POA) for Resident #38 revealed he was made aware a male resident entered his mother's room and that he did something with her. The POA was asked if he wanted his mother sent to the hospital to get a rape test which he did not. The POA stated he spoke to Resident #38 and felt the incident did not go that far. An interview on 10/09/19 at 3:50 P.M., with the administrator revealed immediately following SSD #267 alleging something occurred she and SSD #267 interviewed Resident #38. At 3:58 P.M., SSD #267 joined the interview with the administrator. They agreed Resident #38 kept pushing on the front of her pants in the area of her privates (groin area) then said, No. SSD #267 asked the resident who? and Resident #38 responded, He did. At this point, the administrator indicated she did not feel Resident #38 was alleging sexual abuse. The administrator indicated she notified the resident's POA on 07/17/19 at 3:54 P.M. The POA did not want her sent to the hospital for a rape test. The administrator did not notify the local authorities or State Agency because she did not feel it was an allegation sexual abuse. An interview on 10/10/19 at 8:35 A.M., with the administrator and Regional Director of Clinical Services #295 revealed SSD #267 reported the allegation of sexual abuse at 3:15 P.M. on 07/17/19. The administrator notified Resident #38's son (POA) then initiated an investigation. They confirmed there was no evidence of cognitively impaired residents being assessed for signs of sexual abuse or injury. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 33 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the facility policy titled Freedom from Abuse, Neglect, and Exploitation revised 10/10/19 revealed it was the facility's policy to provide for the safety and dignity of all its residents by implementing proper procedures for enforcing the residents' right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy indicated the facility must ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, thoroughly investigated, and must prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress. If the facility reasonably suspected that a crime had occurred against a resident or person receiving care, the facility must report that suspicion to the police, state survey agency, and Adult Protective Services. Review of the facility policy titled The Elder Justice Act and Reporting Suspected Crimes Against Residents dated 2017 indicated all associates had a duty to report any reasonable suspicion of a crime. The facility had a duty to report all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 34 of 35 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 366270 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eagle Pointe Skilled Nursing & Rehab 87 Staley Road Orwell, OH 44076 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure Quality Assessment and Assurance (QAA) meetings occurred quarterly. This had to the potential to affect all residents. The facility census was 46. Residents Affected - Many Findings include: Interview on 10/10/19 at 3:33 P.M. with the Administrator revealed QAA prior to her appointment as administrator had occurred quarterly. The Administrator stated the meetings were now held monthly and included herself, the management team, Director of Nursing, and the Medical Director. The Administrator stated quarterly the ancillary representatives such as pharmacy would attend and the next quarterly meeting would be sometime in October 2019. Review of the QAA meeting sign in sheets revealed for the fourth quarter dated February 2019 key staff had attended. The first quarter sign in sheet dated May 2019 revealed key staff had attended. There was no sign in sheet or evidence for the second quarter meeting for July 2019. Interview on 10/10/19 at 4:05 P.M. with the Administrator revealed she was unable to produce any evidence of a meeting for July 2019. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 35 of 35