Health inspection·July 7, 2022

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #9's medical record revealed diagnoses including neuromuscular dysfunction of the bladder, chronic kidney disease, and multiple sclerosis. An annual MDS 3.0 assessment dated [DATE] indicated Resident #9 was cognitively intact and required extensive assistance for toilet use and personal hygiene. A nursing note dated 12/03/21 at 1:30 P.M. indicated the nurse spoke to someone from a clinic who reported Resident #9 was transferred to the emergency room for evaluation and treatment. Resident #9 was lethargic (abnormally drowsy) and his blood pressure was low (82/54). A nursing note dated 12/03/21 at 6:47 P.M. indicated the hospital reported Resident #9 was being admitted with a urinary tract infection sepsis. No transfer notice information was able to be located. Resident #9 returned to the facility 12/17/21. On 07/06/22 at 9:55 A.M., SSD #536 revealed she was unaware the facility was required to provide transfer notices when residents were sent to the hospital. SSD #536 verified Resident #9 was at the hospital from [DATE] to 12/17/22. Based on medical record review and staff interview, the facility failed to provide written notification of transfer to the hospital to the resident and/or the resident's representative. This affected two (Resident's #9 and #37) of two residents reviewed for hospitalization. The facility census was 38. Findings include: 1. Review of the medical record for Resident #37 revealed an admission date of 07/07/22. Diagnoses included type two diabetes, hyperlipidemia, major depressive disorder, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognitive impairment. Resident #37 required extensive assistance of one staff member for bed mobility, dressing, toilet use, and person hygiene. She was frequently incontinent of bowel and bladder. Review of the nursing progress note dated 04/17/22 revealed Resident #37 was transferred to the hospital via ambulance. Upon request, the facility did not provide evidence of written notification of transfer to the hospital to Resident #37's representative. On 07/06/22 at 9:52 A.M., interview with the Social Service Designee #536 verified no written notification of transfer to the hospital was given to Resident #37's representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366277 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 366277 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bel Air Care Center 2350 South Cherry Street Alliance, OH 44601 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure an accurate Pre-admission Screening and Record Review (PASRR) was completed prior to admission. This affected one (Resident #23) of four residents reviewed for PASRR. The facility census was 38. Residents Affected - Few Findings include: Review of Resident #23's medical record revealed an admission date of 06/19/18. Diagnoses on admission included schizoaffective disorder, major depressive disorder (recurrent), vascular dementia without behavioral disturbance, mood disorder, and delusional disorders. Review of a PASRR record dated 12/09/14 revealed dementia nor any of the mental illness diagnoses were listed. On 07/06/22 at 9:10 A.M., Registered Nurse (RN) #505 stated when Resident #23 was admitted he had a PASRR from the previous facility which came with him. When it was discussed the PASRR from 2014 did not reflect mental illness diagnoses, no explanation was provided as to why Resident #23 was not reassessed to determine if he could benefit from specialized services. On 07/06/22 at 12:03 P.M., the Administrator stated Resident #23 had been in a different facility between the one who provided the PASRR and this facility. The Administrator stated Resident #23 had been a long-term resident at the first facility and had no psychiatric diagnoses. The Administrator indicated he was not sure why Resident #23 had multiple psychiatric diagnoses added at the facility he resided in prior to being admitted to this facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366277 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 366277 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bel Air Care Center 2350 South Cherry Street Alliance, OH 44601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to ensure foods and chemicals were stored separately in the kitchen. This had the potential to affect all 38 residents receiving food from the facility kitchen. The facility census was 38. Findings include: On 07/06/22 at 4:22 P.M., observation of the kitchen revealed two carts with ready to eat foods and beverages were stored in the same area as chemical products. At the time of observation, interview with Dietary Manager #570 confirmed the snack carts were stored alongside chemical products. On 07/07/22 at 8:23 A.M., observation of the kitchen revealed one cart with ready to eat foods and beverages was stored in the same area as chemical products. At the time of observation, interview with [NAME] #556 verified the snack cart was stored alongside chemical products. [NAME] #556 stated the kitchen staff usually pushed the snack carts to the chemical storage area when they needed to move the carts out of the way. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366277 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 366277 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bel Air Care Center 2350 South Cherry Street Alliance, OH 44601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure all staff wore appropriate personal protective equipment (PPE) during a COVID-19 outbreak. This had the potential to affect all 38 residents residing in the facility. Residents Affected - Many Findings include: Review of the facility COVID-19 testing logs revealed a dietary staff member tested positive for COVID-19 on 06/27/22 and the facility went into outbreak status at that time. On 07/06/22 at 4:13 P.M., observation of the kitchen revealed Dietary Aid #519, [NAME] #543, Dietary Aid #554, and Dietary Manager #570 were not wearing face masks while working in the kitchen. On 07/06/22 at 4:58 P.M., interview with Dietary Manager #570 verified face masks were not worn by dietary staff. She stated they were not required to wear masks while working in the kitchen. Review of an email, dated 11/24/20, sent to the facility from the Stark County Health Department indicated dietary staff working in the kitchen were not required to wear N95 masks while working in the kitchen. The email did not indicate staff could work with no face covering. On 07/07/22 at 12:03 P.M., interview with the Stark County Health Department revealed the facility was to follow the guidance of the Alliance City Health Department regarding wearing face masks during the COVID-19 pandemic. On 07/07/22 at 12:55 P.M., interview with the Alliance City Health Department revealed the facility was to follow the Centers for Disease Control and Prevention (CDC) guidance for wearing face masks during the COVID-19 pandemic. Review of the CDC's Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, updated 01/21/22, revealed the following: Healthcare personnel with prolonged close contact with any patient, visitor, or healthcare personnel with confirmed SARS-CoV-2 infection while not wearing a facemask should follow all recommended infection prevention and control practices including wearing well-fitting source control. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366277 If continuation sheet Page 5 of 5