Health inspection·February 24, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement an individualized care plan related to the hygiene and application of a palm guard for Resident #12 regarding bilateral hand contractures. This affected one of three residents reviewed for activities of daily living (#12, #16, #40 and #398) and one resident (#12) reviewed for position and mobility. Findings include: Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including COVID 19, muscle weakness, cognitive communication deficit, hereditary motor and sensory neuropathy, dementia without behavioral disturbance, diabetes, chronic pain syndrome, obesity, anxiety, pain, spinal stenosis cervical region and strain of muscle fascia. Review of the physician's order dated 07/04/19 revealed to cleanse palms daily with soap and water, allow to dry; apply and use palm guard at all times as tolerated. May remove for hygiene. Night shift to cleanse palms nightly with soap and water. Review of the comprehensive assessment (MDS 3.0) dated 12/17/21 indicated Resident #12 had severe cognitive impairment. She displayed other behavioral symptoms not directed toward others and rejected evaluation or care on one to three days of the assessment period. Resident #12 required the extensive assistance of two staff for bed mobility and personal hygiene. Review of the Activities of Daily Living (ADL) care plan indicated the interventions included Resident #12 will follow rehabilitation recommendations, receive pain medication prior to participation, utilize adaptive equipment as ordered and assist with completion with ADLs as necessary. There was no care plan found that specifically addressed use of a palm guard or hand hygiene related to contractures. Interview with and observation of Resident #12 on 02/22/22 at 11:45 A.M. indicated she was not able to open her left hand at all and the right hand opened slightly but her fingers did not extend. Her left hand was tightly fisted and bent in at the wrist. Her nails were chipped and jagged on both hands and her nails on her right hand were full of debris. She reported doing her own nail care by picking away at them. There was a sign posted in the bathroom indicating to cleanse and place a rolled-up wash cloth in her left hand. Resident #12 reported they used to something put in her left hand but was unable to say the last time that was done. She said she did her own exercises but both hands were painful. On 02/23/22 at 10:15 A.M. Resident #12's left hand remained closed tightly with no washcloth in her palm and the nails remained the same. She reported her hands had not been washed and there was no washcloth in her left hand. On 02/24/22 at 10:00 A.M. State Tested Nurse Aide (STNA) #566 was observed completing hand hygiene on Resident #12. STNA #566 had never worked with Resident #12 previously. She prepared by running the water until it was warm, soaked a washcloth with the water and added a small amount of soap on the washcloth. STNA #566 began by wiping the outside of the left hand with the washcloth. Resident #12 winced a few times and when STNA #566 attempted to wipe the inside of the left hand the resident said she was hurting her wrist. With the first wipe, there was a yellow/brown thick plaque and debris on the washcloth. STNA #566 referred to the debris as gunk and said there was a lot in there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366289 If continuation sheet Page 2 of 10 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 366289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia at Sumner 970 Sumner Parkway Copley, OH 44321 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 verifying her hand not been cleansed in some time. STNA #566 kept turning the washcloth after each attempt at cleaning the left palm and between the fingers. An excessive amount of debris was removed after each wipe. Resident #12 said ouch, don't do it anymore and moved her hand away from the STNA, wincing in pain. STNA #566 stopped and got a new washcloth to clean the right hand. Resident #12 continued to complain while her right hand was cleansed. The fingernails were long and jagged and filled with old food and other brown debris. STNA #566 confirmed the resident's hands and nails had not been cleansed in a while. Resident #12 also confirmed her hands were not cleansed routinely. On 02/24/22 at 10:10 A.M. the Director of Nursing (DON) was informed of the observation. On 02/24/22 at 11:28 A.M. the DON verified a care plan had not been developed to address application of a palm guard or hand hygiene related to contractures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366289 If continuation sheet Page 3 of 10 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 366289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia at Sumner 970 Sumner Parkway Copley, OH 44321 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide adequate hand hygiene and apply a palm guard as ordered for Resident #12 who was dependent for activities of daily living care. This affected one (Resident #12) of four residents (#12, #16, #40 and #398) reviewed for activities of daily living. Residents Affected - Few Findings include: Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including COVID 19, muscle weakness, cognitive communication deficit, hereditary motor and sensory neuropathy, dementia without behavioral disturbance, diabetes, chronic pain syndrome, obesity, anxiety, pain, spinal stenosis cervical region and strain of muscle fascia. Review of the physician's order dated 07/04/19 revealed to cleanse palms daily with soap and water, allow to dry; apply and use palm guard at all times, as tolerated. May remove for hygiene. Night shift to cleanse palms nightly with soap and water. Review of the comprehensive assessment (MDS 3.0) dated 12/17/21 indicated she had severe cognitive impairment. She displayed other behavioral symptoms not directed toward others and rejected evaluation or care on one to three days of the assessment period. Resident #12 required the extensive assistance of two staff in bed mobility and personal hygiene. Review of the Activities of Daily Living (ADL) care plan indicated the interventions included Resident #12 will follow rehabilitation recommendations, receive pain medication prior to participation, utilize adaptive equipment as ordered and assist with ADLs as necessary. There was no care plan found that specifically addressed application of a palm guard or hand hygiene related to contractures. Review of the February 2022 Treatment Administration Record (TAR) revealed the nurses had signed indicating her left hand was cleansed with soap and water, allowed to dry, and a palm guard was applied twice daily and night shift cleansed her palms nightly with soap and water. Interview with and observation of Resident #12 on 02/22/22 at 11:45 A.M. indicated she was not able to open her left hand at all and the right hand opened slightly but her fingers did not extend. Her left hand was tightly fisted and bent in at the wrist. Her nails were chipped and jagged on both hands and her nails on her right hand were full of debris. She reported doing her own nail care by picking away at them. There was a sign posted in the bathroom indicating to cleanse and place a rolled-up wash cloth in her left hand. Resident #12 reported they used to something put in her left hand but was unable to say the last time that was done. She said she did her own exercises but both hands were painful. On 02/23/22 at 10:15 A.M. Resident #12's left hand remained closed tightly with no washcloth in her palm and the nails remained the same. She reported her hands had not been washed and there was no washcloth in her left hand. Interview with Licensed Practical Nurse (LPN) #522 on 02/23/22 at 10:28 A.M. reported Resident #12 complained of pain in her hands but would allow a washcloth to be put into it for periods of time per her request. She indicated Resident #12 refused to have her nails filed or cut by staff. On 02/24/22 at 10:00 A.M. State Tested Nurse Aide (STNA) #566 was observed completing hand hygiene on Resident #12. STNA #566 had never worked with Resident #12 previously. She prepared by running (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366289 If continuation sheet Page 4 of 10 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 366289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia at Sumner 970 Sumner Parkway Copley, OH 44321 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the water until it was warm, soaked a washcloth with the water and added a small amount of soap on the washcloth. STNA #566 began by wiping the outside of the left hand with the washcloth. Resident #12 winced a few times and when STNA #566 attempted to wipe the inside of the left hand the resident said she was hurting her wrist. With the first wipe, there was a yellow/brown thick plaque and debris on the washcloth. STNA #566 referred to the debris as gunk and said there was a lot in there verifying her hand not been cleansed in some time. STNA #566 kept turning the washcloth after each attempt at cleaning the left palm and between the fingers. An excessive amount of debris was removed after each wipe. Resident #12 said ouch, don't do it anymore and moved her hand away from the STNA, wincing in pain. STNA #566 stopped and got a new washcloth to clean the right hand. Resident #12 continued to complain while her right hand was cleansed. The fingernails were long and jagged and filled with old food and other brown debris. STNA #566 confirmed the resident's hands and nails had not been cleansed in a while. Resident #12 also confirmed her hands were not cleansed routinely. On 02/24/22 at 10:10 A.M. the Director of Nursing (DON) was informed of the observation. On 02/24/22 at 11:28 A.M. the DON confirmed the nurses had been signing the TAR to indicate Resident #12's hands were cleansed and the palm guard was applied twice a day and her hands were cleansed nightly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366289 If continuation sheet Page 5 of 10 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 366289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia at Sumner 970 Sumner Parkway Copley, OH 44321 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of facility policy the facility failed to ensure kitchen staff wore appropriate hair coverings. This had the potential to affect 39 residents who received food from the kitchen. The facility census was 39. Findings include: Observation on 02/22/22 at 8:30 A.M. during tour of the kitchen, revealed Food Service Manager (FSM) #538 was not wearing a hairnet. Interview on 02/22/22 at 8:30 A.M. with FSM #538 confirmed he was not wearing a hairnet. Observation on 02/22/22 at 11:02 A.M. of the kitchen located on the [NAME] unit revealed [NAME] #580 was not wearing a hairnet. Interview on 02/22/22 at 11:02 A.M. with [NAME] #580 revealed she did not wear a hairnet because she wore her hair in braids and the hairnets did not fit. [NAME] #580 confirmed she was not wearing a hairnet. Observation on 02/22/22 at 12:14 P.M. revealed [NAME] #546 enter the kitchen located on the [NAME] unit without a hairnet. Interview on 02/22/22 at 12:14 P.M. with [NAME] #546 confirmed he was not wearing a hairnet. Observation on 02/22/22 at 12:30 P.M. of the door used to enter the kitchen located on the [NAME] unit, revealed a sign that informed staff that hair restraints and masks must be worn in the kitchen area. Review of the facility documents titled Dietary Services undated, revealed the facility had a policy in place to prevent contamination of food products and therefore prevent foodborne illness that included wearing hair nets. Review of the document revealed the facility did not implement the policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366289 If continuation sheet Page 6 of 10 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 366289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia at Sumner 970 Sumner Parkway Copley, OH 44321 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to properly prevent the potential spread of infections such as COVID-19 as evidenced by failing to ensure all staff and visitors were consistently screened for COVID-19 when entering the facility. This had the potential to affect all 39 residents currently residing in the facility. Residents Affected - Many Findings include: Review with the Administrator of Staffing Schedules and the staff COVID-19 screening log form dated 02/15/22 revealed State Tested Nursing Assistant (STNA) #502, STNA #504, Licensed Practical Nurse (LPN) #506, STNA #508, Housekeeping (HSK) #519 (tested positive for COVID-19 on 02/17/22), [NAME] #525, HSK #529, STNA #541, Activity Director (AD) #550, STNA #551, Activity Aide (AA) #553, LPN #558, STNA #559, STNA #567, STNA #572 [NAME] #580, AA #582, STNA #905, Kitchen #912 and Kitchen #913 were not screened for COVID-19 prior to their work shift. Review with the Administrator of the Staffing Schedules and the staff COVID-19 screening log form dated 02/16/22 revealed STNA #500, STNA #502, STNA #504, HSK #519, [NAME] #525, LPN #527, HSK #529, AD #550, Food Service #538, [NAME] #546, STNA #551, STNA #556, STNA #565, STNA #566, STNA #567, Medical Records #572, AA #573, AA #582, Kitchen #912 and Kitchen #913 were not screened for COVID-19 prior to their work shift. Review with the Administrator of the Staffing Schedules and the staff COVID-19 screening log form dated 02/17/22 revealed STNA #504, STNA #523, [NAME] #525, LPN #527, HSK #529, STNA #530, Food Service #538, [NAME] #546, STNA #555, STNA #556, STNA #560, STNA #564, STNA #565, STNA #566, STNA #570, STNA #572, [NAME] #580 and Kitchen #911 were not screened for COVID-19 prior to their work shift. Review with the Administrator of the Staffing Schedules and the staff COVID-19 screening log form dated 02/18/22 revealed STNA #500, STNA #508, STNA #509, [NAME] #525, LPN #526, HSK #529, STNA #530, HSK #537, Food Service #538, [NAME] #546, AD #550, AA #553, STNA #555, STNA #560, STNA #567, Medical Records #572, [NAME] #580, AA #582, STNA #906 and Kitchen #911 were not screened for COVID-19 prior to their work shift. Interview on 02/23/22 at 9:55 A.M. with STNA #567 indicated she was screened for COVID-19 on the [NAME] Unit upon entrance into the facility. Review of the staff COVID-19 screening log form dated 02/23/22 revealed STNA #567 did not sign the form indicating she was screened for COVID-19. Interview on 02/23/22 at 9:56 A.M. with LPN #521 confirmed STNA #567 did not screen for COVID-19 on the COVID-19 screening form as required. Interview on 02/23/22 at 9:57 A.M. with STNA #559 indicated she was screened for COVID-19 on the [NAME] Unit upon entry into the facility. Review of the Staff COVID-19 screening log form dated 02/23/22 revealed STNA #559 did not sign the form confirming she was screened for COVID-19. Interview on 02/23/22 at 10:03 A.M. with STNA #566 indicated she had been employed in the facility two weeks and she forgot to screen for COVID-19 upon entry into the facility and prior to her work shift. Review of the Staff COVID-19 screening log form dated 02/23/22 revealed STNA #566 did not sign the form confirming she was screened for COVID-19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366289 If continuation sheet Page 7 of 10 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 366289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia at Sumner 970 Sumner Parkway Copley, OH 44321 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 02/23/22 at 10:06 A.M. with [NAME] #580 indicated she was screened for COVID-19 upon entry into the building. Review of the Staff COVID-19 screening log form dated 02/23/22 revealed [NAME] #580 did not sign the form confirming she was screened for COVID-19. Interview on 02/23/22 at 10:07 A.M. with [NAME] #546 indicated he was rushed and did not self-screen for COVID-19 upon entry into the building. Interview on 02/23/22 at 10:20 A.M. with [NAME] #580 confirmed she did not self-screen for COVID-19 prior to entrance into the building. Observation on 02/23/22 at 12:35 P.M. with Visitor #900 indicated he was in the facility to visit the nurse. Visitor #900 did not screen for COVID-19 prior to entering the nursing station. Interview on 02/23/22 at 12:36 P.M. with Visitor #900 confirmed he came into the facility to visit the nurse and did not self-screen for COVID-19 upon entry into the building. Observation on 02/23/22 at 2:09 P.M. with Resident #920's husband revealed the visitor did not self-screen for COVID-19 and sign the visitor COVID-19 screening log form upon entry into the building. Interview on 02/23/22 at 2:20 P.M. with Physical Therapist (PT) #901 confirmed Resident #920's husband did not appropriately screen for COVID-19 upon entry into the building. Interview on 02/24/22 from 9:54 A.M. with the Administrator confirmed staff (activity, dietary, nursing, housekeeping) and visitors were not consistently screening for COVID-19 upon entry into the building. Interview on 02/24/22 at 11:04 A.M. with Housekeeping Supervisor #540 confirmed her housekeeping staff did not screen for COVID-19 symptoms from 02/15/22 to 02/18/22. She indicated she self-screened on 02/24/22 in the assisted living portion of the facility. She also confirmed when staff entered the facility through the back entrance designated for employees, her staff were required to travel in the hall past two resident rooms to the nurses' station to screen for COVID-19 symptoms (on the [NAME] Unit). Housekeeping Supervisor #540 confirmed there was not a screening station at the back employee entrance. When asked, Housekeeping Supervisor #540 stated when staff were not screened consistently, COVID-19 infection may enter the building and the facility would have an outbreak. Interview on 02/24/22 at 11:26 A.M. with the Director of Nursing (DON) revealed she was not aware she had to screen for COVID-19 upon entry into the building to prevent potential transmission of COVID-19 to other staff and residents. She confirmed she signed the screening log form that she screened for COVID-19 on 02/24/22 which was the only entry on the form. The DON confirmed staff and visitors were required to self-screen for COVID-19 upon entry into the building. The DON was unable to provide the staff self-screening policy for COVID-19. When asked, the DON stated that when staff were not screened consistently, there was a risk of a COVID-19 outbreak. Review of the facility Visitation Policy dated 11/18/21 indicated visitors who have a positive viral test for COVID-19, symptoms of COVID-19, or currently meet the criteria for quarantine, should not enter the facility and facilities should screen all who enter for these exclusions. Review of the Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 02/02/22 revealed options could include (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366289 If continuation sheet Page 8 of 10 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 366289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia at Sumner 970 Sumner Parkway Copley, OH 44321 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm (but are not limited to) individual screening on arrival at the facility or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility (https://www.cdc.gov/Coronavirus/2019-ncov/hcp/infection-control-recommendations.html). This deficiency substantiates Complaint Number OH00115581. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366289 If continuation sheet Page 9 of 10 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 366289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia at Sumner 970 Sumner Parkway Copley, OH 44321 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 0888 Ensure staff are vaccinated for COVID-19 Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to implement their vaccination policy and monitor staff members, contract employees and visitors to ensure that 100% (percent) of staff have received at least one dose of a COVID-19 vaccine, have a pending request for exemption, or have been identified as appropriate for a temporary delay per Centers for Disease Control (CDC) guidance. The vaccination rate for the facility was calculated at 97.3%. This had the potential to affect all 39 residents currently residing in the facility. Residents Affected - Many Findings include: Observation on 02/22/22 at 10:10 A.M. revealed Volunteer #666 and Volunteer #667 were providing communion services to various residents. Both volunteers visit the facility approximately every three weeks to provide communion services. Observation on 02/22/22 at 10:13 A.M. revealed hospice State Tested Nursing Assistant (STNA) #668 was in the nursing station on the [NAME] Unit. Interview on 02/22/22 at 10:14 A.M. with hospice STNA #668 confirmed she was in the facility to provide care for Resident #30 and she usually provided the resident's care on Tuesdays and Thursdays. Interview on 02/22/22 at 3:11 P.M. with the Director of Nursing (DON) confirmed the hospice companies did not provide the vaccination or exemption status of the employees and were not tracked by the facility according to the policy. The DON also revealed she thought Volunteers #666 and #667 were visitors and thus exempt from tracking for COVID-19 vaccination or exemption status. Interview on 02/23/22 at 10:50 A.M. with Volunteer #667's husband indicated he was called this morning for the COVID-19 vaccination card and he sent it in to the facility. Review of the undated COVID-19 Staff Vaccination Status for Providers form did not reveal evidence Volunteer #666, Volunteer #667 or STNA #668 were placed on the form to track for the vaccination status, exemption or temporary delay. Calculation of vaccination status including all three revealed the vaccination rate was 97.3% versus 100%when calculated without them. Review of the facility Vaccination Policy revised 02/08/22 confirmed within 30 days, the facility would have policies and procedures developed and implemented for ensuring all facility staff were vaccinated against COVID-19 and ensure that 100% of staff have received at least one dose of a COVID-19 vaccine, having a pending request for exemption, or have been identified as appropriate for a temporary delay per the CDC. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366289 If continuation sheet Page 10 of 10