Health inspection·March 13, 2025

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) and Advanced Beneficiary Notice (ABN) at least two days in advance for Residents #28, #91, and #92. This affected three residents (#28, #91, and #92) of five residents reviewed for beneficiary notices. The facility census was 32. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 02/10/25 with diagnoses including schizoaffective disorder bipolar type, night terrors, atrial fibrillation, anxiety, and post-traumatic stress disorder. Resident #28 was discharged on 03/03/25. Review of the NOMNC for Resident #28 revealed the last covered day of 03/03/25. The NOMNC and ABN were signed by Resident #28 on 03/03/25. 2. Review of the medical record for Resident #91 revealed an admission date of 12/18/24 with diagnoses including spinal stenosis, prostate cancer, hyperlipidemia, dementia, schizoaffective disorder, and hypertension. Resident #91 was discharged on 01/31/25. Review of the NOMNC for Resident #91 revealed the last covered day of 01/06/25. The NOMNC and ABN were signed by Resident #91 on 01/07/25. 3. Review of the medical record for Resident #92 revealed an admission date of 11/15/24 with diagnoses including cerebral infarction, chronic kidney disease stage four, hyperlipidemia, and hypertension. Resident #92 was discharged on 11/15/24. Review of the NOMNC for Resident #92 revealed the last covered day of 11/13/24. The NOMNC and ABN were signed by Resident #92 on 11/13/24. On 03/10/25 at 5:32 P.M., interview with Social Services Designee (SSD) verified the NOMNC and ABN forms were not provided at least two days in advance for Residents #28, #91, and #92. SSD said she had only been in her position for one week and she did not know NOMNC and ABN forms had to be provided two days in advance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366277 If continuation sheet Page 2 of 8 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 03/13/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, staff interview, and review of facility correspondence, and facility policy review, the facility failed to maintain the upper level shower in proper working order which resulted in Residents #5 and #6 not being able to receive showers per their preferences and had the potential to affect all 13 residents (#1, #5, #6, #8, #11, #13, #18, #20, #21, #24, #27, #35, and #140) residing on the upper level. Additionally, the facility failed to maintain comfortable temperatures in the bathrooms of Residents #2 and #14. The facility census was 32. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 09/02/21 with diagnoses including age-related osteoporosis, fibromyalgia, and multiple sclerosis. Review of the Minimum Data Set (MDS) annual assessment, dated 08/15/24, revealed Resident #5 reported it was very important to her to be able to choose between a tub bath, shower, bed bath, and sponge bath. Review of the quarterly MDS assessment, dated 01/23/25, revealed Resident #5 was cognitively intact, was dependent for tub and shower transfers, and required substantial or maximal assistance for showering or bathing self. Review of the activities of daily living (ADLs) care plan, revised 02/09/25, revealed Resident #5 had a self-care deficit related to weakness, decreased mobility, balance/gait problems, decreased safety awareness, right sided rigidity, and incontinence. Interventions included provide bathing/hygiene with substantial assistance of one staff, maintain resident privacy during care, and Resident #5 had a preference for showers twice per week on day shift. Review of the nurse aide documentation for bathing revealed Resident #5 received a shower on one day (02/11/25 at 9:59 P.M.) out of the previous 30 days. No other showers were documented. Interview on 03/10/25 at 10:10 A.M., interview with Resident #5 stated the upper level shower had been broken for two months and the facility was not fixing it. Resident #5 said it had been brought up in Resident Council and the facility's solution was to use the shower on the lower level. She stated that was too much because staff would undress her in her room, then transport her down the elevator to the lower level, give her a shower, and then transport her back up the elevator to the upper level while she was soaking wet. Resident #5 said the facility needed to fix the upstairs shower instead of putting residents through all that. 2. Review of the medical record for Resident #6 revealed an admission date of 03/04/21 with diagnoses including cerebral infarction, transient cerebral ischemic attack, dementia, and hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side. Review of the annual MDS assessment, dated 01/02/25, revealed Resident #6 reported it was very important to her to be able to choose between a tub bath, shower, bed bath, and sponge bath. Review of the quarterly MDS assessment, dated 01/24/25, revealed Resident #6 had moderate cognitive impairment and required substantial or maximal assist for transfers to the tub or shower and for showering or bathing self. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366277 If continuation sheet Page 3 of 8 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 03/13/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Review of the activities of daily living (ADLs) care plan, revised 02/06/25, revealed Resident #6 had a self-care deficit related to weakness, decreased mobility, balance/gait problems, decreased safety awareness, confusion, and decreased autonomy with ADLs. Interventions included provide bathing/hygiene with partial assistance of one staff, maintain resident privacy during care, and Resident #6 had a preference for showers three times weekly in the mornings. Residents Affected - Some Review of the nurse aide documentation for bathing revealed Resident #6 received showers on five days (02/14/25 at 9:44 P.M., 02/17/25 at 7:50 P.M., 02/21/25 at 3:13 P.M., 02/24/25 at 3:42 P.M., and 03/03/25 at 9:59 P.M.) out of the previous 30 days. No other showers were documented. Review of the text message quote from a contractor, dated 01/03/25 at 12:26 P.M., revealed the facility was quoted $7,500 to $8,500 to replace the upper level shower with an estimated completion time of two days. Interview on 03/10/25 at 11:24 A.M. with Resident #6 said the upper level shower had not worked in months. On 03/10/25 at 11:40 A.M., interview with Maintenance Director #200 confirmed the facility had to shut off the upper level shower because it was leaking into the lower level bathroom. He further stated he had a contractor come and give an estimate for replacement, the quote was too expensive, and he was working with the Administrator to figure out a plan for fixing it. On 03/10/25 at 12:05 P.M., interview with Maintenance Director #200 verified they got the quote for the shower replacement via text message on 01/03/25 at 12:26 P.M., the estimate was not approved by the Administrator because it was too expensive. Maintenance Director #200 said the facility's solution was for upper level residents to use the lower level shower. On 03/11/25 at 8:42 A.M., observation of upper level shower room with Maintenance Director #200 revealed the shower had a gray rubber flexible raised border along bottom edge. Maintenance Director #200 said they don't use the shower because the bottom edge of the shower doesn't seal properly and he pointed along edge where gray rubber border was. He said none of the sealant products they had tried worked to correct the issue and the shower was not used due to continued leaking. Maintenance Director #200 said the Administrator wanted to get a seamless shower installed and that's what they got the quote for, but it was too expensive. Review of the Resident Council meeting minutes, dated 01/27/25, revealed Residents expressed concerns about the upstairs shower being broken and they did not want to go downstairs to shower. The facility's response was that the quote for replacing the shower was too high and Maintenance Director #200 and the Administrator agreed to have residents use the downstairs shower until a resolution was found for the upstairs shower (despite residents voicing they did not want to use the downstairs shower). Review of the facility's policy titled Resident Bathing or Showering, dated 01/01/17, revealed the facility would provide an individualized and resident-centered approach to bathing, residents could request a bed bath or shower per their choice, and efforts would be made to schedule bed baths or showers at a time of the resident's choosing. 3. Record review revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses include spinal stenosis of lumbar region (spine disease of the lower back), congestive heart failure, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366277 If continuation sheet Page 4 of 8 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 03/13/2025 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 0584 atherosclerotic heart disease (plaque build up in heart arteries), chronic pain syndrome, and chest pain. Level of Harm - Minimal harm or potential for actual harm Interview on 03/10/25 at 12:42 P.M. with Resident #2 revealed they felt the room temperature was continuously too cold. The resident stated they had mentioned to facility staff the room temperature being uncomfortable. The resident stated the bathroom was even colder. Residents Affected - Some 4. Record review revealed Resident #14 was admitted to the facility on [DATE]. Diagnoses include malignant neoplasm of tongue (tongue cancer), major depressive disorder, malignant neoplasm of floor of mouth (mouth cancer), heart failure, alcoholic cirrhosis of liver without ascites (liver disease), Type II diabetes, anxiety disorder, chronic kidney disease stage 3, and chronic obstructive pulmonary disease (lung and airway disease that restricts breathing). Interview on 03/10/25 at 12:50 P.M. with Resident #14 revealed they felt the room was too cold. The resident stated they had mentioned to facility staff the room temperature being uncomfortable. The resident stated the bathroom was even colder. On 03/13/25 at 10:00 A.M. observation with Maintenance Assistant #150 for room temperature checks revealed the shared bathroom for Resident #2 and Resident #14 read 69.9 degrees Fahrenheit. Maintenance Assistant #150 confirmed the bathroom felt cold. On 03/13/25 at 10:08 A.M. interview with Maintenance Assistant #150 confirmed the temperature read outs and verified the thermometer was the one used for room temperature spot checks. Review of the resident handbook, undated, included in the resident admission packet revealed the following statement: Our Maintenance personnel ensure that resident rooms and the entire facility are in good repair at all times. Their goal is to provide an environment that is safe and functional for our residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366277 If continuation sheet Page 5 of 8 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 03/13/2025 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, resident interview, staff interview, and review of the activity participation logs, the facility failed to provide activities on all days, including evenings and weekends, to meet the needs and preferences of residents. This affected five residents (#2, #5, #6, #30, and #36) of six residents reviewed for activities. The facility census was 32. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 07/28/22 with diagnoses including congestive heart failure, chronic pain syndrome, major depressive disorder, and hypertension. 2. Review of the medical record for Resident #5 revealed an admission date of 09/02/21 with diagnoses including age-related osteoporosis, fibromyalgia, and multiple sclerosis. 3. Review of the medical record for Resident #6 revealed an admission date of 03/04/21 with diagnoses including cerebral infarction, transient cerebral ischemic attack, dementia, and hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side. 4. Review of the medical record for Resident #30 revealed an admission date of 07/12/21 with diagnoses including occlusion and stenosis of bilateral carotid arteries, anxiety disorder, dementia, major depressive disorder, and schizoaffective disorder. 5. Review of the medical record for Resident #36 revealed an admission date of 08/30/24 with diagnoses including major depressive disorder, anxiety, dementia, and hypertension. Review of the facility's activity participation records for November 2024 through March 2025 revealed there was no documentation for any group activities on Saturday 11/02/24, Sunday 11/03/24, Saturday 11/09/24, Sunday 11/10/24, Saturday 11/16/24, Sunday 11/17/24, Sunday 11/24/24, Thursday 11/28/24 (Thanksgiving Day), Friday 11/29/24, Saturday 11/30/24, Sunday 12/01/24, Saturday 12/07/24, Sunday 12/08/24, Saturday 12/14/24, Sunday 12/15/24, Saturday 12/21/24, Sunday 12/22/24, Tuesday 12/24/24 (Christmas Eve), Wednesday 12/25/24 (Christmas Day), Saturday 12/28/24, Sunday 12/29/24, Wednesday 01/01/25 (New Year's Day), Saturday 01/04/25, Sunday 01/05/25, Saturday 01/11/25, Sunday 01/12/25, Saturday 01/18/25, Sunday 01/19/25, Saturday 01/25/25, Sunday 01/26/25, Saturday 02/01/25, Sunday 02/02/25, Saturday 02/08/25, Sunday 02/09/25, Saturday 02/15/25, Sunday 02/16/25, Saturday 02/22/25, Sunday 02/23/25, Saturday 03/01/25, Sunday 03/02/25, Saturday 03/08/25, and Sunday 03/09/25. Review of the posted activities calendars for November 2024 through March 2025 revealed there were no activities scheduled after 4:00 P.M. daily, there were no activities scheduled on Sundays, there were only one to two activities scheduled between 1:00 P.M. and 2:30 P.M. on Saturdays in November 2024 and December 2024, and there were no weekend activities scheduled in January 2025, February 2025, and March 2025. Review of the schedules for activities staff revealed all activities staff were scheduled to work Monday through Friday from 8:00 A.M. to 4:00 P.M. There was no activities staff scheduled to work after 4:00 P.M. or on Saturdays and Sundays. On 03/10/25 at 10:05 A.M., interview with Activities Assistant confirmed activities staff left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366277 If continuation sheet Page 6 of 8 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 03/13/2025 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 0679 Level of Harm - Minimal harm or potential for actual harm daily at 4:00 P.M. and there were no activities scheduled for the evenings. She also confirmed the scheduled activity for 03/10/25 at 4:00 P.M. was take a nap. On 03/10/25 at 10:13 A.M., interview with Resident #5 stated there were no activities on the weekends because the activities staff did not work on the weekends. Residents Affected - Some On 03/10/25 at 10:39 A.M., interview with Resident #36 stated there were no activities on the weekends. On 03/10/25 at 10:41 A.M., interview with Resident #30 stated there were no weekend activities and said the facility did not offer alternate activities when she was unable to participate due to the function in her hands. On 03/10/25 at 11:22 A.M., interview with Resident #6 stated there were no activities in the evenings or on the weekends. On 03/10/25 at 12:32 P.M., interview with Resident #2 stated activities could be better because they only have bingo once per week and sometimes had no activities at all. On 03/11/25 at 2:08 P.M., interview with Activities Director confirmed there was a lack of activities, and stated she had recently taken over the role of Activities Director. On 03/11/25 at 2:26 P.M., interview with Activities Director confirmed activities staff worked daily until 4:00 P.M. and there were no activities planned for after 4:00 P.M. The facility was unable to provide a policy for the activities program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366277 If continuation sheet Page 7 of 8 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 03/13/2025 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 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Potential for minimal harm Based on personnel file review and staff interview, the facility failed to ensure the Activities Director was qualified for the position. This had the potential to affect all 32 residents residing in the facility. Residents Affected - Many Findings include: Review of the personnel file for Activities Director revealed no evidence of training or certification to be an Activities Director. Review of the receipt for Modular Education Program for Activities Professionals revealed registration for an upcoming training course was completed on 03/12/25. On 03/11/25 at 2:26 P.M., interview with Activities Director confirmed she was new to her position as Activities Director and was still learning the role. On 03/12/25 at 11:17 A.M., interview with Human Resources (HR) Director confirmed Activities Director did not have any formal training or education to be an Activities Director. HR Director further stated it was planned for Activities Director to complete the training but it had not been completed yet. On 03/12/25 at 3:21 P.M., interview with the Director of Nursing (DON) verified Activities Director enrolled in the training course on 03/12/25. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366277 If continuation sheet Page 8 of 8