Inspection·March 20, 2025

F 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to provide culturally competent, trauma-informed care in accordance with professional standards of practice or account for experience and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of Resident #52's post-traumatic stress disorder (PTSD). This affected one resident (#52) of two residents reviewed for trauma informed care. The facility census was 50. Residents Affected - Few Findings include: Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] with diagnoses of PTSD, morbid (severe) obesity due to excess calories, and anxiety disorder. Review of the undated comprehensive care plan revealed the absence of a care plan addressing PTSD or associated triggers and the absence of a psychosocial assessment for Resident #52. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #52 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Interview with Resident #52 on 03/17/25 at 8:35 A.M. revealed a history of PTSD from sexual abuse as a minor and a sexual assault that occurred in the shower room of the nursing facility (NF) where he previously lived. He stated his triggers were the shower room in the NF and having to receive personal care from male staff members. Resident #52 stated he had requested to not have male caregivers and stated the facility had honored that request. He further stated he frequently refused showers and preferred bed baths because of his triggers. Interview with Resident #52 on 03/18/25 at 8:26 A.M. revealed he was receiving supportive services from contracted Psychological Services and enjoyed talking with his counselor. He also stated he felt very safe in this facility. Interview with Social Service Designee (SSD) #743 on 03/18/25 at 3:37 P.M. revealed psychosocial assessments were not completed for all residents. She stated she didn't complete psychosocial assessments unless the MDS nurse instructed her to do so. SSD #743 also stated the MDS nurse completed all care plans for all residents' psychosocial issues. Interview with the MDS/Licensed Practical Nurse (LPN) #727 on 03/18/25 at 3:45 P.M. revealed her understanding was contracted Psychological Services would complete psychosocial assessments on all residents. MDS/LPN #727 stated she was unsure who provided staff in-services and education about PTSD. She verified the absence of a care plan for PTSD and the absence of a psychosocial assessment. Interview with LPN #736 on 03/19/25 at 12:33 P.M. revealed she was aware of Resident #52's request for no male caregivers but was unaware of other PTSD triggers. LPN #736 further stated the facility had a male aide on night shift, but all staff knew not to allow him to provide care to Resident #52. LPN #736 stated those instructions were not written down anywhere but were passed along in report. Interview with Certified Nursing Assistant (CNA) #750 on 03/19/25 at 12:35 P.M. revealed she was unaware of any of Resident #52's PTSD triggers, was never told about triggers and had never been educated about the resident's history of PTSD or triggers associated with his diagnosis of PTSD. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 2 of 5 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 03/20/2025 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 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy titled Trauma Informed Care and Culturally Competent Care, dated 2001, revealed the facility would perform universal screening of residents for exposure to traumatic events, utilize screening tools and methods that were facility-approved, competently delivered, culturally relevant and sensitive, and utilize initial screening to identify the need for further assessment and care. The policy further stated the facility would complete an assessment that would evaluate the presence of PTSD symptoms, their relationship to trauma and the identification of triggers. The policy also stated the facility would develop an individualized care plan that addressed past trauma to identify and decrease exposure to triggers that may re-traumatize the resident. Event ID: Facility ID: 366270 If continuation sheet Page 3 of 5 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 03/20/2025 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #43 had adaptive equipment as ordered when eating. This affected one resident (#43) out of one resident reviewed for adaptive equipment when eating. This had the potential to affect seven residents (#5, #10, #11, #17, #30, #32, and #43) that had orders for adaptive equipment while eating. The facility census was 50. Residents Affected - Few Findings included: Review of the medical record for Resident #43 revealed an admission date of 11/02/23 with diagnoses including multiple sclerosis, muscle weakness, and schizoaffective disorder. Review of the March 2025 physician's orders revealed Resident #43 had an order dated 11/03/23 to have built-up utensils and a two handled mug for all meals. Review of the care plan dated 03/11/25 revealed Resident #43 had a nutritional problem related to excessive energy intake and self-feeding deficit which required adaptive equipment with meals. Interventions included occupational therapy screening and providing adaptive equipment for feeding including non-spill cups and built-up utensils. Observation on 03/17/25 at 8:06 A.M. revealed there was no adaptive equipment on Resident #43's meal tray including built-up utensils and a two handled mug. Resident #43 refused her breakfast tray. Review of the Meal Ticket on Resident #43's meal tray dated 03/18/25 revealed there was no indication she was to have adaptive equipment while eating including built- up utensils and/or a two handled mug. Interview on 03/18/25 at 11:48 A.M. with Certified Nursing Assistant (CNA) #737 revealed Resident #43 did not have any adaptive equipment for meals. She had never seen adaptive equipment on her tray including built-up utensils and a two handled mug. Observation on 03/18/25 at 12:15 P.M. revealed Resident #43 was in her room eating. She had regular silverware and a plastic cup without two handles. Interview on 03/18/25 at 12:15 P.M. with Resident #43 revealed she never received built-up utensils and/or a two handled mug. She revealed she did not feel they were necessary as she felt she ate and drank without any difficulty. Interview on 03/18/25 at 12:19 P.M. with Licensed Practical Nurse (LPN) #733 verified Resident #43 had a physician's order to receive built-up utensils and a two handled mug. She verified the adaptive equipment was not on her tray, and the kitchen was responsible for ensuring anyone with adaptive equipment had it on their meal tray. Interview on 03/18/25 at 12:27 P.M. with Dietary Manager #746 revealed she started in November 2024 and stated I will be honest, when started it was a cluster mess because the adaptive equipment that she had in the kitchen did not match what nursing had as orders. She revealed she had been meaning to complete an audit to ensure they matched but had not had a chance. She verified Resident #43's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 4 of 5 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 03/20/2025 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 0810 Level of Harm - Minimal harm or potential for actual harm meal ticket did not have that Resident #43 was to receive adaptive equipment including built-up utensils and a two handled mug. Interview on 03/18/25 at 1:12 P.M. with Dietician #747 revealed she was not aware Resident #43 had a physician's order to receive built-up utensils and/or a two handled mug. Residents Affected - Few Review of the facility policy labeled, Assistive Devices and Equipment, dated 2001, revealed the facility maintains and supervises the use of assistive devices and equipment for residents. Certain devices and equipment that assisted with resident mobility, safety, and independence were provided for residents that may include specialized eating utensils and equipment. The policy recommended the use of devices and equipment was based on comprehensive assessment and documented in the resident care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366270 If continuation sheet Page 5 of 5