Health inspection·March 23, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 record review, review of the facility self-reported incidents, staff interview, and review of the facility policy on abuse, the facility failed to ensure the results of all abuse allegation investigations were reported in a timely manner. This affected three (#3, #15, and #25) of seven residents reviewed for abuse. The census was 53. Findings include: 1. Review of the open medical record for Resident #25 revealed an admission date of 10/27/20. Diagnoses included cerebrovascular disease, anxiety disorder, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had severely impaired cognition. Review of the progress note dated 02/11/22 at 6:34 A.M. revealed Resident #25 was brought to the nurse's station with a report that she had left the building. Review of the facility self-reported incident (SRI) #217752 revealed it was created on 02/10/22 and completed on 03/31/22. On 03/23/23 at 10:25 A.M., interview with the Director of Nursing (DON) verified the investigation for SRI #217752 was not completed within five days of the incident. Review of the facility policy titled Abuse Prohibition, not dated, revealed allegations of abuse would be reported to the Ohio Department of Health no later than two hours after the allegation and the results of the thorough investigation would be reported within five working days of the incident. 2. Review of the open medical record for Resident #3 revealed an admission date of 11/13/20. Diagnoses included vascular dementia with agitation, anxiety disorder, history of falling, history of transient ischemic attack, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 01/18/23, revealed Resident #3 had no cognitive impairment and required extensive assistance of one staff for activities of daily living (ADL). Review of the facility self-reported incident (SRI) #203299 revealed it was created on 03/09/21, there was no completion date, and there was no conclusion indicated. On 03/20/23 at 4:38 P.M., interview with the Director of Nursing (DON) verified SRI #203299 did not have a completion date or a conclusion. She stated she could not locate anything in their records regarding the incident and did not have any documentation of the investigation for the incident. Review of the facility policy titled Abuse Prohibition, not dated, revealed allegations of abuse would be reported to the Ohio Department of Health no later than two hours after the allegation and the results of the thorough investigation would be reported within five working days of the incident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366300 If continuation sheet Page 2 of 27 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 366300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709 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 - Minimal harm or potential for actual harm 3. Review of the open medical record for Resident #15 revealed an admission date of 10/10/19. Diagnoses included anxiety disorder, dementia, and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had severe cognitive impairment. Residents Affected - Few Review of the facility self-reported incident (SRI) #232901 revealed it was created on 03/11/23 and completed on 03/22/22. On 03/23/23 at 10:25 A.M., interview with the Director of Nursing (DON) verified the investigation for SRI #232901 was not completed within five days of the incident. On 03/23/23 at 10:53 A.M., interview with Facility Advisor #414 stated the investigation conclusion was not reported timely and the completion date of 03/22/23 reflected the date that the conclusion of the investigation was reported. Review of the facility policy titled Abuse Prohibition, not dated, revealed allegations of abuse would be reported to the Ohio Department of Health no later than two hours after the allegation and the results of the thorough investigation would be reported within five working days of the incident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366300 If continuation sheet Page 3 of 27 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 366300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility self-reported incidents, staff interview, and review of the facility policy on abuse, the facility failed to conduct a thorough investigation for an allegation of abuse. This affected two (#3 and #13) of seven residents reviewed for abuse. The census was 53. Residents Affected - Few Findings include: 1. Review of the open medical record for Resident #3 revealed an admission date of 11/13/20. Diagnoses included vascular dementia with agitation, anxiety disorder, history of falling, history of transient ischemic attack, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 01/18/23, revealed Resident #3 had no cognitive impairment and required extensive assistance of one staff for activities of daily living (ADL). Review of the facility self-reported incident (SRI) #203299, dated 03/09/21, revealed Resident #3 stated she was thrown into bed and this resulted in a skin tear to her left forearm. There were no named witnesses, no named alleged perpetrators, and no supporting documentation. The incident report had no completion date and no conclusion indicated. Review of the progress note dated 03/10/21 at 1:58 P.M. revealed Resident #3 had a skin tear to her left forearm and small bruises to her lower legs. On 03/20/23 at 4:38 P.M., interview with the Director of Nursing (DON) verified SRI #203299 was not completed. She stated she could not locate anything in their records regarding the incident and did not have any documentation of the investigation for the incident. Review of the facility policy titled Abuse Prohibition, not dated, revealed a thorough investigation of all allegations of abuse would be completed and kept in an investigation file. Investigations would include assessing the resident for injury, notify the physician, notify the family or responsible party, interview the resident, implement an interdisciplinary plan of care, and use all information gathered during the investigation to determine whether the allegation was substantiated or not. 2. Review of the open medical record for Resident #13 revealed an admission date of 04/11/18. Diagnoses included bipolar disorder, major depressive disorder, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had no cognitive impairment and required total dependence or extensive assistance for activities of daily living (ADLs). Review of the facility self-reported incident (SRI) #215818, dated 12/21/21, revealed Resident #13 stated a staff member placed a urine soaked gown on her face. The investigation file only included witness statements from staff. There was no other investigation information included in the investigation file. On 03/23/23 at 8:37 A.M., interview with the Director of Nursing (DON) verified the investigation for SRI #215818 was not a complete and thorough investigation into the incident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366300 If continuation sheet Page 4 of 27 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 366300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709 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 - Minimal harm or potential for actual harm Review of the facility policy titled Abuse Prohibition, not dated, revealed a thorough investigation of all allegations of abuse would be completed and kept in an investigation file. Investigations would include assessing the resident for injury, notify the physician, notify the family or responsible party, interview the resident, implement an interdisciplinary plan of care, and use all information gathered during the investigation to determine whether the allegation was substantiated or not. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366300 If continuation sheet Page 5 of 27 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 366300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure all required information was sent to the receiving provider upon Resident #50's transfer to the hospital. This affected one resident (Resident #50) out of one resident reviewed for hospitalization. Findings Include: Resident #50 admitted to facility on 02/03/23 with diagnoses of cerebral vascular accident, anxiety disorder, pneumonia, history of fall with right hip fracture, and cognitive deficits. Review of the Base Line Care Plan dated 02/04/23, revealed Resident #50 required assist of one staff member for activities of daily living (ADL). Resident #50 Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of eleven, indicating moderate cognitive impairment. Review of progress note dated 02/15/23 at 5:50 PM, revealed Resident #50 slid out of the recliner on to the floor. Progress note dated 02/15/23 at 6:17 PM revealed Licensed Practical Nurse (LPN) #334 assessed Resident #50 for injury; noted a purple raised area to left side of forehead, a purple raised area to left shoulder with complaint of left shoulder and left hip pain. LPN #334 notified certified nurse practitioner (CNP), and received orders to send Resident #50 to the hospital for evaluation and treatment as indicated. Emergency Medical Services (EMS) arrived at facility and transported Resident #50 to a local hospital. Resident #50's information sent to the hospital included Resident Demographic sheet, Physician Orders and Advanced Directive status form. Review of progress note dated 02/17/23 at 11:28 AM, revealed Resident #50 was discharged and return to the facility was not anticipated. Review of Resident #50's Transfer or Discharge information revealed the information provided to the receiving hospital did not include Resident #50 special risk factors, comprehensive care plan goals, baseline and current mental, behavioral, and functional status, reason for transfer, and recent vital signs. The information also did not include the required discharge summary reflecting Resident #50 stay while at the facility. Interview with Director of Nursing, on 03/21/23 at 2:04 PM, confirmed Resident #50 discharge information sent to the local hospital included Resident Demographic Sheet, Physician orders and Advanced Directives form. Resident #50's discharge information did not include the above required information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366300 If continuation sheet Page 6 of 27 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 366300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709 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 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** Based on record review and interview, the facility failed to notify Resident #50's resident representative in writing of the resident's transfer and discharge. This affected one resident (Resident #50) out of one resident reviewed for hospitalization. Findings Include: Resident #50 admitted to facility on 02/03/23 with diagnoses of cerebral vascular accident, anxiety disorder, pneumonia, history of fall with right hip fracture, and cognitive deficits. Review of the Base Line Care Plan dated 02/04/23, revealed Resident #50 required assist of one staff member for activities of daily living (ADL). Resident #50 Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of eleven, indicating moderate cognitive impairment. Review of progress note dated 02/15/23 at 5:50 PM, revealed Resident #50 slid out of the recliner on to the floor. Progress note dated 02/15/23 at 6:17 PM revealed Licensed Practical Nurse (LPN) #334 assessed Resident #50 for injury; noted a purple raised area to left side of forehead, a purple raised area to left shoulder with complaint of left shoulder and left hip pain. LPN #334 notified certified nurse practitioner (CNP), and received orders to send Resident #50 to the hospital for evaluation and treatment as indicated. Emergency Medical Services (EMS) arrived at facility and transported Resident #50 to a local hospital. Review of progress note dated 02/16/23 at 1:40 AM, revealed Resident #50 was admitted to the local hospital intensive care unit for multiple fractures. Review of progress note dated 02/16/23 at 1:51 PM, revealed Resident #50 family members removed personal items from Resident #50 current room in the facility. Review of progress note dated 02/17/23 at 11:28 AM, revealed Resident #50 was discharged and return to the facility was not anticipated. Record review revealed Resident #50 representative was not sent a written transfer or discharge notice of Resident #50's transfer to hospital. Interview on 03/22/23 at 12:54 PM with Licensed Social Worker #412 confirmed there was no written transfer or discharge notice sent to Resident #50 representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366300 If continuation sheet Page 7 of 27 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 366300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709 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 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, review of hospital records, and interviews the facility failed to ensure a newly admitted resident had routine care and dietary orders to provide immediate care. This affected one (Resident #203) of three closed records reviewed. Residents Affected - Few Findings included: Closed medical record for Resident #203 revealed the resident was admitted on [DATE] with diagnoses including syncope and collapse, chronic kidney disease, nonrheumatic mitral valve, absence of kidney, Barrett's esophagus, chest pain, atrial fibrillation, depression, pain, and hypotension. Review of Resident #203's nursing note dated 09/09/22 at 6:43 P.M., revealed the resident was admitted to the facility from the a local hospital and left against medical advice (AMA) on 09/10/22 at 11:22 A.M. Review of Resident #203's physician orders dated 09/09/23 to 09/10/23 revealed there was only orders for medication and code status. There was no evidence of orders for diet or routine care. Review of Resident #203's nursing note dated 09/10/22 created at 2:56 P.M., by Licensed Practical Nurse (LPN) #300 revealed the LPN entered the resident's room at 9:47 A.M. and observed there was no breakfast tray on the tray table. The LPN inquired if she had breakfast this morning. The resident stated she didn't have breakfast yet. The LPN proceeded to let the resident know she had her medication and after she took her medication a staff member would be in to get her breakfast order. The staff offered the resident everything on the breakfast menu and the resident requested yogurt and cranberry juice. Review of Resident #203's nursing note created on 09/10/22 at 3:48 P.M., revealed at 10:43 A.M. staff reported the resident's daughter wanted to speak to the Administrator and Director of Nursing (DON) regarding the resident not being admitted into the facility due to the hospital packet still in the resident room and the care her mother was currently receiving. The resident had been admitted to the facility under skilled nursing services. Review of Resident #203's nursing note dated 09/10/22 created at 4:02 P.M., by LPN #300 revealed at 11:10 A.M. the resident's daughter came up to the nurse in the hallway and started verbally attacking the nurse over the resident not receiving breakfast. The nurse attempted to tell the daughter she did get breakfast and what she had asked for and received. The daughter stated in a loud angry voice my mom did not get a breakfast and this lady was nice enough to get my mom oatmeal. I don't care what you have to say. The nurse proceeded to explain the resident had asked for yogurt and cranberry juice. The daughter interrupted again and was yelling at the nurse that her mom was forgetful and that her mom's hospital packet was still in her mom's room which meant she wasn't even admitted into the facility. The nurse tried to explain that nurses was looking at her mom's chart and that she was admitted , and that medication were ordered. The daughter proceeded to tell the nurse she wanted to talk with the Administrator or DON and that she wanted a wheelchair she was taking her mother out of the facility and proceeded walking down hallway to elders room. Review of Resident #203's discharged minimum data set (MDS) for not anticipating to return dated 09/10/22 revealed the assessments were not completed for function, cognition, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366300 If continuation sheet Page 8 of 27 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 366300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709 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 0635 Level of Harm - Minimal harm or potential for actual harm swallowing/nutritional status. The bowel and bladder section indicated the resident was always continent of urine and bowel was unknown. Review of Resident #203's baseline plan of care revealed the resident was discharged with power of attorney (POA) prior to the completion of the baseline plan. Residents Affected - Few Review of Resident #203's recapitulation of resident stay dated 09/12/22 and locked 12/01/22 revealed the resident was admitted from the hospital after stay for syncope, collapse and orthostatic hypotension. She came in on 09/09/22 skilled through insurance services for physical and occupational therapy services and nursing monitoring due to recent medication changes and hypotension episodes. Further review of Resident #203's electronic medical record revealed the only hospital records scanned into the medical record was the resident medication reconciliation list. There was no evidence of resident's status and care needs (activities of daily living, diet, therapy orders, etc.) Interview on 03/20/23 at 10:12 A.M., with Resident #203's daughter revealed her mom called her confused. When she arrived to the facility on [DATE] her mom was weak and lethargic. No one had helped her to the bathroom, and she had been incontinent and had feces on her. She had tried to toilet herself and had urinated on the floor. Her mom was not provided a dinner on 09/09/22 or a breakfast on 09/10/22 until almost lunch time. Her mom was a fall risk due to she had fallen at home and when she arrived her moms call light was not in reach, nor did she have any bedrails. Interview on 03/21/23 at 4:00 P.M., with LPN #300 revealed the admission nurse was from agency and did not enter all the residents' orders nor did the staff complete a nursing assessment. The daughter was upset and was not able to be reason with. The daughter wanted her mom to have a full coarse breakfast and she was trying to explain the diet orders were entered and she had identified the resident did not receive a breakfast [NAME] this morning and she had the kitchen provide the resident with cranberry juice and yogurt as she requested. Interview on 03/21/23 at 5:06 P.M., with the DON revealed Resident #11 did not have a nursing assessment or diet orders. Interview on 03/22/23 1:23 P.M., with Registered Nurse (RN) #305 revealed she was the DON during that time of the incident with Resident #203. The resident arrived between shift change around 6:30 P.M. on 09/09/22. The ongoing and coming on nurses were agency nurses and they were aware of the admission. The admission nursing assessment was not competed nor was all the orders including the diet orders. Around 10:30 A.M., the next day (09/10/22) she had received a call from LPN #300 regarding that Resident #203's daughter was upset that her mom was not fed and the admission paper work from the hospital was still in the residents room. RN #305 reported she had completed an investigation but the facility cannot find it the investigation including the staff interviews. This deficiency represents non-compliance investigated under Complaint Number OH00135930. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366300 If continuation sheet Page 9 of 27 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 366300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, review of hospital records, and interviews, the facility failed to ensure a newly admitted resident received quality standard care. This affected one (Resident #203) of three closed records reviewed. Residents Affected - Few Findings included: Closed medical record for Resident #203 revealed the resident was admitted on [DATE] with diagnoses including syncope and collapse, chronic kidney disease, nonrheumatic mitral valve, absence of kidney, Barrett's esophagus, chest pain, atrial fibrillation, depression, pain, and hypotension. Review of Resident #203's nursing note dated 09/09/22 at 6:43 P.M., revealed the resident was admitted to the facility from the a local hospital and left against medical advice (AMA) on 09/10/22 at 11:22 A.M. Review of Resident #203's physician orders dated 09/09/23 to 09/10/23 revealed there was only orders for medication and code status. There was no evidence of orders for diet or routine care. Review of Resident #203's nursing note dated 09/10/22 created at 2:56 P.M., by Licensed Practical Nurse (LPN) #300 revealed the LPN entered the resident's room at 9:47 A.M. and observed there was no breakfast tray on the tray table. The resident was on telephone; and asked person which she was talking on phone with if she could call them back. The resident hung up the phone and the LPN inquired if she had breakfast this morning. The resident stated she didn't have breakfast yet. The LPN proceeded to let the resident know she had her medication and after she took her medication a staff member would be in to get her breakfast order. The resident was sitting on side of bed with call light in reach. Staff offered resident everything on the breakfast menu and the resident refused everything except yogurt and cranberry juice. Review of Resident #203's nursing note created on 09/20/22 at 3:48 P.M., revealed at 10:43 A.M. staff reported the resident's daughter wanted to speak to the Administrator and Director of Nursing (DON) regarding the resident not being admitted into the facility due to the hospital packet still in the resident room and the care her mother was currently receiving. The creator of the note asked the staff member to let the daughter know she was with another resident and would be down shortly. The resident had been admitted to the facility under skilled nursing services. Review of Resident #203's nursing note dated 09/10/22 created at 4:02 P.M., by LPN #300 revealed at 11:10 A.M. she had just left a resident's room when the dietary cook came to her cart to let her know the resident's daughter was upset and wanted to talk with the nurse, Administrator, or DON. The nurse asked the dietary cook to let the daughter know she would be right there. The daughter came up to the nurse in the hallway and started verbally attacking the nurse over the resident not receiving breakfast. The nurse attempted to tell the daughter she did get breakfast and what she had asked for and received. The daughter stated in a loud angry voice my mom did not get a breakfast and this lady was nice enough to get my mom oatmeal. I don't care what you have to say. The nurse proceeded to explain the resident had asked for yogurt and cranberry juice. The daughter interrupted again and was yelling at the nurse that her mom was forgetful and that her mom's hospital packet was still in her mom's room which meant she wasn't even admitted into the facility. The nurse tried to explain that nurses was looking at her mom's chart and that she was admitted , and that medication were ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366300 If continuation sheet Page 10 of 27 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 366300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The daughter proceeded to tell the nurse she wanted to talk with the Administrator or DON and that she wanted a wheelchair she was taking her mother out of the facility and proceeded walking down hallway to elders room. Review of Resident #203's discharged minimum data set (MDS) for not anticipating to return dated 09/10/22 revealed the assessments were not completed for function, cognition, and swallowing/nutritional status. The bowel and bladder section indicated the resident was always continent of urine and bowel was unknown. Review of Resident #203's baseline plan of care revealed the resident was discharged with POA prior to the completion of the baseline plan. Review of Resident #203's recapitulation of resident stay dated 09/12/22 and locked 12/01/22 revealed the resident was admitted from the hospital after stay for syncope, collapse and orthostatic hypotension. She came in on 09/09/22 skilled through insurance services for physical and occupational therapy services and nursing monitoring due to recent medication changes and hypotension episodes and discharged out on 09/10/22 when family took her from the facility prior to admission paperwork being completed as an unplanned discharge. No home care paperwork was set up and family would not wait to take her mother home until this could be arranged. Further review of Resident #203's electronic medical record revealed the only hospital records scanned into the medical record was the resident medication reconciliation list. There was no evidence of resident's status and care needs (activities of daily living, diet, therapy orders, etc.) Interview on 03/20/23 at 10:12 A.M., with Resident #203's daughter revealed her mom called her confused. When she arrived, her mom was weak and lethargic. No one had helped her to the bathroom, and she had been incontinent and feces on her. She was not provided a dinner on 09/09/22 or a breakfast on 09/10/22. Her mom was a fall risk because she had fallen at home and her call light was not in reach, nor did she have any bedrails. Interview on 03/21/23 at 4:00 P.M., with LPN #300 revealed the admission nurse was from agency and did not enter all the residents' orders nor completed a nursing assessment. The daughter was upset and was not able to be reason with. The daughter wanted her mom to have a full coarse breakfast and she was trying to explain the diet orders were not entered in the computer and did not receive a breakfast tray and she had the kitchen provide the resident with cranberry juice and yogurt as she requested. Interview on 03/21/23 at 5:06 P.M., with the DON revealed Resident #11 did not have a nursing assessment or diet orders. Interview on 03/22/23 1:23 P.M., with Registered Nurse (RN) #305 revealed she was the DON during that time of the incident with Resident #203. The resident arrived between shift change around 6:30 P.M. on 09/09/22. The ongoing and coming on nurses were agency nurses and they were aware of the admission. The admission nursing assessment was not competed and orders including diet orders were not entered. Around 10:30 A.M., the next day (09/10/22) she received a call from LPN #300 regarding that Resident #203's daughter was upset that her mom was not fed and the admission paper work form the hospital was still in the room. RN #305 reported she had completed an investigation but the facility cannot find the investigation, including staff interviews. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366300 If continuation sheet Page 11 of 27 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 366300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709 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 0658 This deficiency represents non-compliance investigated under Complaint Number OH00135930. 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: 366300 If continuation sheet Page 12 of 27 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 366300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 and staff interview, the facility failed to ensure residents with pressure ulcer wounds had wound assessments completed at least every seven days. This affected one (Resident #204) of two residents reviewed for wounds. Residents Affected - Few Findings include: Review of Resident #204's medical record revealed an admission date of [DATE] with a readmission date of [DATE]. admission diagnoses included pressure ulcer to the heel, Alzheimer's disease with dementia and chronic obstructive pulmonary disease. Further review of the medical record revealed upon readmission to the facility on [DATE], Resident #204 was identified with a pressure ulcer wound to the right heel. Initial pressure ulcer wound assessment was completed on [DATE] which identified the wound as a stage two pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) measuring 4.0 centimeters (cm) by 5.0 cm and a depth of less than 0.1 cm. Further review of the wound assessments revealed no additional wound assessment completed. Resident #204 remained in the facility until [DATE] when she expired under hospice services. Review of hospice visitation notes revealed on [DATE] Resident #204's pressure ulcer to the right heel remained a stage two. Interview with Registered Nurse (RN) #307 on [DATE] at 11:10 A.M. verified no comprehensive wound assessments completed after the initial assessment on [DATE] for Resident #204's stage two pressure ulcer to the right heel. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366300 If continuation sheet Page 13 of 27 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 366300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents received restorative therapy per plan of care. This affected one (Resident #12) of one reviewed for limited range of motion. Findings included: Record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including need for assistance with personal care, senile ectropion of eyelid, ganglion, pain left and right leg, anorexia, dysphagia, constipation, hyponatremia, abdominal pain, neuropathy, abnormal weight loss, neoplasm of skin of scalp and neck, pain in toes, edema, gout, restless leg syndrome, polyneuropathy, heart failure, rheumatoid arthritis, osteoarthritis of left wrist, presbyopia, pain, dementia, chronic kidney disease, Alzheimer's, gastro-esophageal reflux disease, hyperlipidemia, joint pain unspecified, vitiligo, urge incontinence, and effusion of ankle and foot. Review of Resident #12's range of motion plan of care revealed the resident was at risk for impaired mobility due to activity of daily living decline, decrease in strength, and weakness. The resident's interventions were to receive restorative active range of motion to bilateral upper and lower extremities time 10 reps, wheelchair mobility in halls using legs for propulsion for 25-30 feet for fifteen minutes six to seven times a week. Review of the aides task documentation dated 02/20/23 to 03/21/23 revealed the resident was to receive restorative active range of motion to bilateral upper and lower extremities time 10 reps, wheelchair mobility in halls using legs for propulsion for 25-30 feet for fifteen minutes six to seven times a week. The week of 02/20/23 to 02/25/23 the resident only received restorative four times. The week of the 02/26/23 to 03/04/23 the resident had received restorative four time that week. The week of 03/05/23 to 03/11/23 the resident received restorative five times. The week of 03/12/23 to 03/18/23 the resident had received restorative three times and was not available one day of the seven days. Review of Resident #12's quarterly minimum date set (MDS) dated [DATE] revealed the resident had limited range of motion on upper and lower extremities on both sides and required extensive assistance with the majority of her activities of daily living. Interview on 03/21/23 at 2:09 PM with Registered Nurse (RN)/Restorative Nurse #309 confirmed Resident #12 did not receive restorative services per her plan of care (5-6 times a week) from 02/20/23 to 03/21/23. RN #309 reported the resident was ordered therapy for leg strengthening on 03/07/23 to 04/06/23, however the restorative program would continue due to the resident was not receiving upper ROM exercises from therapy. RN #309 reported restorative services had over 40 programs with 37 residents and only have two restorative aides. The restorative aides attempt to do as many programs during the week the can but they don't have the manpower to complete all the programs as care planned. The goal was to do as many programs as possible. Interview on 03/22/23 at 7:45 A.M., with restorative aide (RA)/State Tested Nurse's Aide (STNA) #322 revealed on Tuesday, Wednesday, and Thursday there was two restorative aides and only one on the other days. The floor staff did not have time to perform restorative therapy and occasionally the restorative aides get pulled to the floor to help. They had two substitute restorative aides but with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366300 If continuation sheet Page 14 of 27 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 366300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the staffing shortage the two substitute aides have not been able to help. The RA reported there was over 40 programs and with each program 15 minutes there was not enough time in one day for one person to complete all the programs. RA #322 verified resident in restorative were not receiving restorative therapy 6-7 days a week because there was not enough time or staff to complete all the programs. She tried to alterative floors to ensure the resident are at least receiving restorative 3-4 times a week. RA #332 confirmed Resident #12 should still be receiving restorative for upper extremities even though therapy was providing strength training for her lower extremities. RA #332 verified when she was short of time she would skip the residents that were receiving therapy services even though therapy may not be treating the area the resident was ordered for restorative services. Interview on 03/22/23 at 2:06 P.M., with Therapy Manger (TM) #410 revealed Resident #12 was receiving therapy for leg strengthening and restorative should continue to provided services to the upper extremities. TM #410 reported if a resident was in a restorative program and was picked up by therapy, restorative would still continue to provided services for areas not treated by therapy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366300 If continuation sheet Page 15 of 27 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 366300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to complete a comprehensive fall investigation to include root cause and ensure the safety of the resident after a fall with injury. This affected one resident (Resident #50) out of two residents reviewed for falls. Findings Include: Record review on 03/20/23 revealed Resident #50 admitted to facility on 02/03/23 with diagnoses of cerebral vascular accident, anxiety disorder, pneumonia, history of fall with right hip fracture, COVID 19 and cognitive deficits. Resident #50 Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of eleven, indicating moderate cognitive impairment. Review of the Base Line Care Plan dated 02/04/23, revealed Resident #50 required assist of one staff member for Activities of Daily Living (ADL) including transfers and toileting. Review of Resident #50's Fall Care Plan dated 02/06/23 revealed interventions to prevent falls included call light with in reach, appropriate footwear, and red dot on doorframe to indicate high fall risk. Review of progress note dated 02/15/23 at 5:50 PM, revealed Resident #50 slid out of the recliner on to the floor. Progress note dated 02/15/23 at 6:17 PM revealed Licensed Practical Nurse (LPN) #334 assessed Resident #50 for injury; noted a purple raised area to left side of forehead, a purple raised area to left shoulder with complaint of left shoulder and left hip pain. LPN #334 notified certified nurse practitioner (CNP), and received orders to send Resident #50 to the hospital for evaluation and treatment as indicated. Emergency Medical Services (EMS) arrived at facility and transported Resident #50 to a local hospital. Review of progress note dated 02/16/23 at 1:40 AM, revealed Resident #50 was admitted to the local hospital intensive care unit for multiple fractures. Resident #50 did not return to the facility. Review of a fall witness statement in reference to Resident #50's fall 02/15/23, by LPN #334 dated 02/16/23, revealed Resident #50 was eating dinner in room due to being in droplet isolation following new diagnoses of COVID 19. At 5:50 P.M. Resident #50 was observed on the floor by recliner by State Tested Nursing Assistant (STNA) #412; LPN #334 was notified and assessed Resident #50 for injury; LPN #334 observed a purple raised area on left forehead, a purple raised area on left shoulder and complaint of pain to left shoulder and left hip. LPN #334 and STNA #412 assisted Resident #50 up from the floor and placed her in bed for further assessment, rather than assessing the resident prior to moving her. LPN #334 left Resident #50's room to notify the resident's representative of the fall. STNA #412 also left the room. Resident #50's daughter called facility to report she was observing Resident #50 after the fall, via video camera located in room, standing beside her bed. LPN #334 stated STNA #412 took Resident #50 to the restroom following notification by daughter of Resident #50 standing up from bed. Review of Resident #50's 02/15/23 fall investigation completed by Director of Nursing (DON) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366300 If continuation sheet Page 16 of 27 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 366300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709 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 0689 Level of Harm - Minimal harm or potential for actual harm revealed Resident #50 had increased anxiety due to being in droplet isolation precautions. Resident #50 typically ate meals in the dining room. DON indicated LPN #334 did not complete a thorough fall event assessment on Resident #50 when she fell on [DATE]. On 02/20/23, individual education on safety procedures was given to LPN #334 and staff education for safety procedures was performed by DON. The fall investigation did not identify a root cause for Resident #50 fall on 02/15/23. Residents Affected - Few Interview with DON on 03/22/23 at 12:42 P.M. confirmed Resident #50 had been moved following LPN #334 initial assessment of Resident #50 with complaint of pain and possible injuries. DON revealed the resident should not have been moved off the floor without a thorough assessment. DON also confirmed there was no root cause identified for Resident #50 fall on 02/15/23. This deficiency represents non-compliance investigated under Master Complaint Number OH00135930. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366300 If continuation sheet Page 17 of 27 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 366300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and policy review, the facility failed to ensure Resident #11's pharmacy review was acted upon timely, as needed psychotropic medication had stop dates, and resident received appropriate dose of anti-anxiety medication. This affected one (Resident #11) of five reviewed for medications. Findings included: Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including dementia with mood disorder, anxiety, depression, restlessness, insomnia, impulsiveness, and Alzheimer's. 1. Review of Resident #11's pharmacy recommendation dated 03/08/23 recommended to discontinue Remeron 7.5 milligrams (mg). The physician agreed to discontinue the Remeron on 03/15/23. Review of Resident #11's physiatrist note dated 03/15/23 revealed to discontinue Remeron. Review of Resident #11's orders and Medication Administration Records dated 03/2023 revealed no evidence the Remeron 7.5 mg had been discontinued. Interview on 03/22/23 at 1:23 P.M., with the Director of Nursing (DON) verified the Remeron should have discontinued on 03/15/23, however it was not discontinued. 2. Review of Resident #11 physician orders dated 03/2023 revealed the resident had been ordered Ativan (anti-anxiety) 0.5 mg, Benadryl (antihistamine) 25 mg and Haldol (antipsychotic) 1 mg (ABH) GEL, apply as need three times daily (every eight hours as needed) for agitation/restlessness since 08/15/22. There was no evidence of a stop date. Interview on 03/22/23 at 1:23 P.M., with the DON verified the there was no stop date the ABH gel. The DON reported she had spoken to hospice to remind them to indicate stop dates as needed medication. 3. Review of Resident #11's orders dated 03/20/23 revealed the resident was ordered Ativan (anti-anxiety) 0.5 mg, Benadryl (antihistamine) 25 mg and Haldol (antipsychotic) 1 mg (ABH) GEL, apply as needed three times daily (every eight hours as needed) for agitation/restlessness since 08/15/22, ABH gel apply once in the morning for agitation/restlessness. Apply to back of neck or lower back in the morning for agitation/restlessness since 09/20/22, Remeron 7.5 mg po daily, Ativan 0.5 mg four times daily for agitation/anxiety, Zoloft 50 mg at bedtime for depression, and Melatonin 3 mg at night for insomnia. Review of hospice recert dated 02/12/23 and medication list dated 03/15/23 revealed the resident was ordered Ativan 0.25 mg every six hours. There was a discrepancy noted from the facilities orders of Ativan 0.5 mg compared to Hospice orders of 0.25 mg. Review of Resident #11's psychiatrist noted dated 03/15/23 indicated the resident was only (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366300 If continuation sheet Page 18 of 27 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 366300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few receiving the ABH gel three times daily as needed and Ativan 0.5 mg four times daily. The plan indicated the resident used the ABH gel and Ativan as needed for behaviors. A second note indicated the Ativan was used for comfort measures. There was no reference to the resident receiving scheduled ABH gel per the orders. Review of Resident #11's Nurse Practitioner (NP) dated 03/16/23 revealed the resident was only receiving the ABH gel as needed and Ativan 0.5 mg four times a day. The plan indicated the resident was only receiving as needed medication from hospice. There was no reference to the resident receiving scheduled ABH gel per the orders. Observation on 03/20/23 at 10:32 A.M., of Resident #11 revealed the resident would not respond when attempting to talk with him. Observation on 03/21/23 at 8:24 A.M. of Resident #11 revealed the resident was sitting in the dining room asleep. His breakfast tray was setting on the table untouched and uncovered. Observation on 03/21/23 at 9:11 A.M., Resident #11 was still in the dining room asleep as an activity was in progress. Observation on 03/22/23 at 7:35 A.M., Resident #11 was asleep in the hallway. Observation and interview with Resident #11 on 03/23/23 at 9:10 A.M., with Registered Nurse (RN) #307 revealed the resident answered two question and stopped responding. The resident could not keep eyes open. RN #307 reported the resident was more active in the evening. Interview on 03/22/23 at 1:23 P.M., with the DON verified psychiatrist notes and NP notes were not accurate to reflect the resident current medications. The DON reported she would have to reach out to hospice to verify the Ativan order. Interview on 03/23/23 at 9:46 A.M., with Hospice RN #416 and Hospice Clinical Director #417 revealed they understood the concerns with the Ativan order due to the physician had signed scripts for Ativan 0.5 mg, however on the hospice recertification forms and the hospice medication list indicated the resident was only on Ativan 0.25 mg. The Hospice Clinical Director reported they would talk to the physician and get the Ativan discrepancy clarified and assess the resident. Review of the facilities policy titled, Psychotropic Drug Use undated revealed the use of psychotropic drug therapy would be used when appropriate to enhance the resident's quality of life, while maximizing functional potential and well-being of the residents. As needed anti-psychotic medication are limited to 14 days and will not be renewed unless the attending physician or prescribing practitioner evaluates the resident in person, for the appropriateness of that medication. A psychotropic drug is considered a chemical restraint when it was used as the first intervention to control behaviors, mood, or mental status. The consulting pharmacist would perform a chart review of each resident each month to assess for unnecessary drug therapies and potential reduction. This deficiency represents non-compliance investigated under Complaint Number OH00131654. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366300 If continuation sheet Page 19 of 27 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 366300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident received laboratory testing per orders. This affected one (Resident #45) of five reviewed for medication review. Findings included: Record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including Parkinson's with orthostatic hypotension, edema, hypertension, atrial fibrillation, aortic aneurysm, and anemia. Review of Resident #45's orders dated 02/2023 revealed to check a Complete Blood Count (CBC) and Complete Metabolic Panel (CMP) every six months for hypertension and anemia. Review of Resident #45's laboratory results revealed on 02/21/23 no evidence a CMP was completed, however there was basic metabolic panel collected (BMP) along with a CBC. Interview on 03/22/23 at 3:42 P.M., and 02/23/23 at 9:12 A.M., with the Director of Nursing (DON) confirmed on 02/21/23 a CMP should have been collected not a BMP. There was no order to collect a BMP. The DON reported she had spoken to the attending physician, and she wanted a CMP to be drawn in the morning and she would complete a medication error form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366300 If continuation sheet Page 20 of 27 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 366300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709 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 0791 Provide or obtain dental services for each resident. 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, email review, interviews, and policy review, the facility failed to ensure a resident with Medicaid received timely dental services per therapy/physician orders. This affected one (Resident #12) of one reviewed for dental services. Residents Affected - Few Findings included: Resident #12 was admitted to the facility on [DATE] with diagnoses including need for assistance with personal care, senile ectropion of eyelid, ganglion, pain left and right leg, anorexia, dysphagia, constipation, hyponatremia, abdominal pain, neuropathy, abnormal weight loss, neoplasm of skin of scalp and neck, pain in toes, edema, gout, restless leg syndrome, polyneuropathy, heart failure, rheumatoid arthritis, osteoarthritis of left wrist, presbyopia, pain, dementia, chronic kidney disease, Alzheimer's, gastro-esophageal reflux disease, hyperlipidemia, joint pain unspecified, vitiligo, urge incontinence, effusion of ankle and foot. Resident #12 received Medicaid. Review of Resident #12's undated dental consent revealed the resident agreed to dental services. Review of Resident #12's quarterly minimum data set (MDS) dated [DATE] revealed the resident had broken or loosely fitting or partial dentures (chipped, cracked, uncleanable, or loose). Review of Resident #12's orders dated 01/23/23 revealed speech evaluation only, no skilled therapy was needed. Speech recommended to follow up with dentist due to ill-fitting dentures. Further review of Resident #12's medical record revealed no evidence the resident had been seen by the dentist since 09/09/22. Review of Resident #12's dietary note dated 03/16/23 revealed the resident had voiced concerns with chewing difficulties with top dentures which were not worn often per resident. Resident stated she strongly disliked ground meats and stated she would continue to select bite-sized meats. Review of Resident #12's dental plan of care revealed the resident had full upper and was not wearing upper dentures. The facility would coordinate arrangements for dental care, transportation as needed/as ordered. Review of the facilities email to the dentist dated 03/21/23 revealed the facility had requested to have contacted regarding setting up the facilities next dental visit. Interview on 03/20/23 at 10:49 A.M., with Resident #12 revealed she don't wear her dentures because staff don't help her put them in. The resident reported the dentures were in the bathroom in a green cup and she couldn't reach them. The resident reported the top dentures were ill fitting as well and she had not seen a dentist for a good while. Interview on 03/21/23 at 11:30 A.M. and 3:05 PM with the Director of Nursing (DON)revealed she did not feel the dental concerns was an emergency and the dentist only comes every six months. The DON reported the facility had sent the dental office an email to have the resident added to the list to have her dentures evaluated. The DON reported she was not aware staff were not assisting the resident with her dentures and she would start staff education. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366300 If continuation sheet Page 21 of 27 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 366300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709 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 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 03/21/23 at 4:00 P.M., with Licensed Practical Nurse (LPN) #300 confirmed the residents' dentures were ill fitting. Interview on 03/23/23 11:06 A.M. with the DON revealed the dentist would not come to the facility to see the resident. The facility was looking into contracting with another company. The DON reported she was currently calling local dentist office trying to find a dentist who would accept the residents insurance (Medicaid). Review of the facilities policy titled Dental Services dated 03/21/23 revealed it was the facilities policy to ensure that residents obtain needed dental services, including routine dental services. The facility will, if necessary or if requested, assist the resident in making an appt. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366300 If continuation sheet Page 22 of 27 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 366300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review and interviews, the facility failed to ensure a newly admitted resident had diet orders and received their breakfast tray timely. This affected one (Resident #203) of three closed records reviewed. Findings included: Closed medical record for Resident #203 revealed the resident was admitted on [DATE] with diagnoses including syncope and collapse, chronic kidney disease, nonrheumatic mitral valve, absence of kidney, Barrett's esophagus, chest pain, atrial fibrillation, depression, pain, and hypotension. Review of Resident #203's physician orders dated 09/09/23 to 09/10/23 revealed no evidence of diet orders. Review of Resident #203's nursing note dated 09/10/22 created at 2:56 P.M., by Licensed Practical Nurse (LPN) #300 revealed the LPN entered the resident's room at 9:47 A.M. and observed there was no breakfast tray on the tray table. The LPN inquired if she had breakfast this morning. The resident stated she didn't have breakfast yet. The LPN proceeded to let the resident know she had her medication and after she took her medication a staff member would be in to get her breakfast order. The staff offered the resident everything on the breakfast menu and the resident requested yogurt and cranberry juice. Review of Resident #203's nursing note dated 09/10/22 created at 4:02 P.M., by LPN #300 revealed at 11:10 A.M. the resident's daughter came up to the nurse in the hallway and started verbally attacking the nurse over the resident not receiving breakfast. The daughter stated in a loud angry voice my mom did not get a breakfast and this lady was nice enough to get my mom oatmeal. I don't care what you have to say. The nurse proceeded to explain the resident had asked for yogurt and cranberry juice. Interview on 03/20/23 at 10:12 A.M., with Resident #203's daughter revealed her mom called her confused. When she arrived to the facility on [DATE] her mom was weak and lethargic. Her mom was not provided a dinner on 09/09/22 or a breakfast on 09/10/22 until almost lunch time. Interview on 03/21/23 at 4:00 P.M., with LPN #300 revealed the admission nurse was from agency and did not enter all the residents' orders nor did the staff complete a nursing assessment. The daughter was upset and was not able to be reason with. The daughter wanted her mom to have a full course breakfast and she was trying to explain the diet orders were entered and she had identified the resident did not receive a breakfast tray this morning and she had the kitchen provide the resident with cranberry juice and yogurt as she requested. Interview on 03/21/23 at 5:06 P.M., with the DON revealed Resident #11 did not have a nursing assessment or diet orders. Interview on 03/22/23 1:23 P.M., with Registered Nurse (RN) #305 revealed she was the DON during that time of the incident with Resident #203. The resident arrived between shift change around 6:30 P.M. on 09/09/22. The ongoing and coming on nurses were agency nurses and they were aware of the admission. The admission nursing assessment was not competed nor was all the orders including the diet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366300 If continuation sheet Page 23 of 27 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 366300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709 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 0800 Level of Harm - Minimal harm or potential for actual harm orders. Around 10:30 A.M., the next day (09/10/22) she had received a call from LPN #300 regarding that Resident #203's daughter was upset that her mom was not fed and the admission paper work from the hospital was still in the residents room. RN #305 reported she had completed an investigation but the facility cannot find it the investigation including the staff interviews. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00135930. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366300 If continuation sheet Page 24 of 27 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 366300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, facility policy review and staff interview, the facility failed to ensure antibiotic assessments were completed to determine appropriate use and indication for antibiotic medications. The affected three (Residents #8, #16 and #23) of eight residents reviewed for antibiotic use. The facility census was 53. Residents Affected - Few Findings include: 1. Review of Resident #8's medical record revealed an admission date of 09/13/19 with diagnoses that included diabetes mellitus, dementia, chronic kidney disease and peripheral vascular disease. Further review of Resident #8's medical record including physician's medication orders revealed on 01/25/22 Resident #8 was prescribed the use of Levaquin (antibiotic) 500 milligrams (mg) daily for seven days for pneumonia. Further review of Resident #8's medical record found no evidence of an antibiotic assessment completed prior to antibiotic initiation to determine if antibiotic use was appropriate and indicated. Review of the facility policy titled Infection Control: Antibiotic Stewardship Policy with a revision date of 08/01/18 indicated monitoring tool criteria - McGeer's criteria will be used to identify appropriate antibiotic use. Interview with Licensed Practical Nurse (LPN) #310 on 03/21/23 at 2:05 P.M. verified no antibiotic assessment completed prior to antibiotic initiation for Resident #8. 2. Review of Resident #16's medical record revealed an admission date of 05/04/22 with diagnoses that included severe vascular dementia, chronic obstructive pulmonary disease and atrial fibrillation. Further review of Resident #16's medical record including physician's medication orders revealed on 03/17/23 Resident #16 was prescribed the use of Macrobid (antibiotic) 100 mg twice daily for ten days for a urinary tract infection. Further review of Resident #16's medical record found no evidence of an antibiotic assessment completed prior to antibiotic initiation to determine if antibiotic use was appropriate and indicated. Review of the facility policy titled Infection Control: Antibiotic Stewardship Policy with a revision date of 08/01/18 indicated monitoring tool criteria - McGeer's criteria will be used to identify appropriate antibiotic use. Interview with LPN #310 on 03/21/23 at 2:05 P.M. verified no antibiotic assessment completed prior to antibiotic initiation for Resident #16 3. Review of Resident #23's medical record revealed an admission date of 10/28/20 with diagnoses that included pneumonia, Parkinson's disease with dementia and cerebrovascular accident. Further review of Resident #23's medical record including physician's medication orders revealed on 02/01/23 Resident was prescribed the use of Doxycycline (antibiotic) 100 mg twice daily for seven days for pneumonia. On 02/09/23 the Doxycycline use was extended for an additional three days for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366300 If continuation sheet Page 25 of 27 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 366300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709 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 0881 pneumonia. Level of Harm - Minimal harm or potential for actual harm Further review of Resident #23's medical record found no evidence of an antibiotic assessment completed prior to antibiotic initiation to determine if antibiotic use was appropriate and indicated. Residents Affected - Few Review of the facility policy titled Infection Control: Antibiotic Stewardship Policy with a revision date of 08/01/18 indicated monitoring tool criteria - McGeer's criteria will be used to identify appropriate antibiotic use. Interview with LPN #310 on 03/21/23 at 2:05 P.M. verified no antibiotic assessment completed prior to antibiotic initiation for Resident #23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366300 If continuation sheet Page 26 of 27 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 366300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canton Christian Home 2550 Cleveland Avenue NW Canton, OH 44709 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 0885 Report COVID19 data to residents and families. Level of Harm - Minimal harm or potential for actual harm Based on review of list of COVID positive staff, review of robo call report, interview, and policy review, the facility failed to ensure residents, their representatives, and families were notified timely after confirmation of staff testing positive for COVID-19. This had the potential to affect all 53 residents in the facility. Residents Affected - Many Findings included: Review of list of COVID positive staff undated revealed State Tested Nurse Aide (STNA) #319 tested positive for COVID-19 on 03/13/23 and STNA #337 on 03/16/23. Review of robo call report dated 03/20/23 revealed residents, their representatives, and families were not notified until 03/20/23 at 10:36 A.M., of the positive staff member from 03/15/23 and 03/16/23. The message reported the facility had two staff member test positive for COVID in the last week. Review on facilities policy titled Confirmed COVID-19 cases Notification revised 09/2022 revealed all families, residents, and staff would be notified by utilizing the robo-calling, skype, 1:11 phone calls, letters, memos, and direct communication within 72 hours of the known infections. There was no evidence family, residents, or staff would be notified by 5:00 P.M., the following day after one single case of COVID was identified. Interview on 03/23/23 at 10:58 A.M, with Licensed Practical Nurse (LPN)/Infection Preventionist (IP) #310 confirmed families, residents, and staff were not notified timely of the two positive COVID cases on 03/15/23 or 03/16/23. The LPN verified the policy did not include the notification would be by 5:00 P.M. the following day after confirmation of a positive COVID resident/staff. The LPN reported the facility had misinterpreted the guidelines and thought they had 72 hours, however the notification was still not within 72 hours of the positive confirmation on 03/15/23. The LPN reported families, residents, and staff were all notified by the robo system. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366300 If continuation sheet Page 27 of 27