Health inspection·June 8, 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, interview and policy review, the facility failed to timely report allegations of abuse as required to the State Agency. This affected one resident (Resident #3) of one resident reviewed for abuse. The facility census was 81 residents. Findings include: Review of Resident #3's medical record revealed an admission date of 07/01/21 and diagnoses including unspecified dementia without behaviors, hypertension, chronic obstructive pulmonary disease, Alzheimer's disease, anxiety and constipation. Review of a quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 was cognitively impaired, had no limitations to range of motion and did not display behaviors. Review of a nurses' note for Resident #3 on 06/01/23 at 4:22 P.M. written by Executive Director of Quality (EDQ)/Registered Nurse (RN) #614 revealed a skin assessment was completed to back and upper arms. Resident #3 was calm and no complaints were noted. Resident #3's daughter and provider were updated. Review of a late entry nurses' note on 06/02/23 revealed Resident #3 was getting up on her own twice while sitting in the caring corner. Resident #3 did sit back down after being asked to sit down for safety. Able to redirect and offered activities which was effective. Resident alert to self. Physician on call and Resident #3's power of attorney (POA) were notified. Review of a concern form dated 06/01/23 revealed an incident involving Resident #3. A timeline was attached as follows: • At 3:15 P.M. State Tested Nursing Assistant (STNA) #605 came into the Administrator #511's office to say she saw STNA #556 provide inappropriate care to Resident #3 and saw STNA #556 slap Resident #3's arm. • At 3:20 P.M. STNA #556 was removed from the floor and explained to administrative staff that Resident #3 was getting up and she guided Resident #3 back to her seat. STNA #556 provided a statement at this time. • At 3:25 P.M. Administrator #511 and Facility Manager (FM) #508 staff talked to Resident Assistant (RA) #681 who was the aide in caring corner and saw nothing. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366334 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366334 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethany Nursing Home, Inc 626 34th Street, 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 Residents Affected - Few At 3:30 P.M. FM #508, Administrator #511 and EDQ/RN #614 met with Licensed Practical Nurse (LPN) #551 who demonstrated the manner in which STNA #556 assisted Resident #3 back to her seat and denied observing STNA #556 slap Resident #3. LPN #680 was interviewed as well but he did not have eyesight on the caring corner at that time. The concern form included a typed sheet dated 06/01/23 with statements for LPN #551 and RA #681 which did not allege abuse or indicate that Resident #3 was slapped. Review of a typed statement dated 06/01/23 at 3:20 P.M. for STNA #556 revealed Resident #3 was trying to get up quickly. STNA #556 got up from her chair and got Resident #3 back into her chair. Resident #3 was startled when she got back into her chair. STNA #605 confronted her about the interaction and she told STNA #605 that Resident #3 was getting up quickly and she tried to get her safely back into her seat. Review of a typed statement dated 06/02/23 written by STNA #605 revealed on 06/01/23 at 3:16 P.M. she had clocked out and noticed Resident #3 was trying to get up out of her chair in the caring corner. STNA #556 was on her phone and told Resident #3 to not stand up in an aggressive manner. STNA #556 then placed her hands on the bridge of Resident #3's pants and with significant force thrust Resident #3 back into her chair. STNA #605 asked STNA #556 if everything was okay and STNA #556 proceeded to slap Resident #3's left arm and placed her finger five centimeters from Resident #3's face and pointed her index finger, saying Don't move again in a harsh manner. STNA #605 asked STNA #556 what she was doing and told her her actions were inappropriate. STNA #605 then reported the concern to Administrative Assistant (AA) #541 and Administrator #511. The concern form included six skin sweeps from residents on the unit with no negative findings. Interviews on 06/06/23 at 12:25 P.M. and 4:57 P.M. with Administrator #511 verified the facility did not report the incident between STNA #556 and Resident #3 to the State Agency (SA). Administrator #511 stated STNA #556 was removed from the floor and they proceeded to talk to LPN #551 who demonstrated how STNA #556 moved Resident #3 back into the recliner. Administrator #511 stated they were comfortable not reporting this incident as a self-reported incident (SRI) to the SA due to the information they got from the two eyewitnesses and the speed they were able to investigate the incident. Administrator #511 was made aware during the interviews that slapping constituted physical abuse and should have been reported to the SA as a SRI. Interview on 06/06/23 at 2:20 P.M. with STNA #605 verified her written statement and reiterated that she saw STNA #556 slap Resident #3's left forearm and then she reported this as abuse to AA #541 and then Administrator #511. Interview on 06/06/23 at 2:37 P.M. with STNA #556 verified her written statement. STNA #556 stated Resident #3 hit her and she had sat Resident #3 back down to prevent her from falling. STNA #556 stated STNA #605 told FM #508 and Administrator #511 she had slapped Resident #3. STNA #556 stated LPN #551 was looking at her during the entire interaction and reiterated she did not slap Resident #3. Interview on 06/07/23 at 12:24 P.M. with RA #681 verified her written statement and stated she had heard STNA #556 had placed her hands on Resident #3 inappropriately but did not see the interaction. Interview on 06/07/23 at 12:45 P.M. with LPN #551 verified her written statement and shared she was working at the medication cart when Resident #3 stood up and STNA #556 sat her back down and was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366334 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366334 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethany Nursing Home, Inc 626 34th Street, 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 not forceful during the interaction. LPN #551 denied hearing or seeing any resident being slapped. Level of Harm - Minimal harm or potential for actual harm Interview on 06/07/23 at 4:34 P.M. with Assistant Director of Nursing (ADON)/LPN #510 and the Director of Nursing (DON) revealed there were discrepancies as part of the incident investigation as STNA #556 stated Resident #3 slapped her and STNA #605 stated STNA #556 slapped Resident #3 on her arm. The facility was unable to determine if abuse actually occurred. The DON indicated Administrator #511 would be responsible for reporting any SRIs to the SA. Residents Affected - Few Interview on 06/08/23 at 11:07 A.M. with Administrative Assistant (AA) #541 revealed she did not witness the incident involving Resident #3 on 06/01/23 but had went to get STNA #556 to assist another resident on the patio. STNA #605 told her she needed to speak to her and stated she saw STNA #556 abuse Resident #3 and wanted to make a report so they went down to the DON's office but she was gone for the day so they then went down to Administrator #511's office. When asked to clarify what STNA #605 told her, AA #541 stated STNA #605 reported STNA #556 sat Resident #3 down in a rough manner but did not mention any slapping. Review of the policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, reviewed August 2022 revealed the facility would promptly identify and investigate all possible incidents of abuse. The facility would investigate and report any allegations within timeframes required by federal requirements. This deficiency represents non-compliance investigated under Complaint Number OH00143450. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366334 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366334 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethany Nursing Home, Inc 626 34th Street, 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure assessments were accurately completed. This affected two (Residents #44 and #75) of 21 residents reviewed for Minimum Data Set (MDS) 3.0 assessments. The facility census was 81. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #44 was admitted on [DATE] with diagnoses including Alzheimer's Disease, congestive heart failure and chronic kidney disease. Review of the significant change MDS 3.0 assessment dated [DATE] for Section G for Resident #44 revealed he needed extensive assistance of two staff members for bed mobility, transfers and toileting. Resident #44 needed extensive assistance of one staff member for dressing, personal hygiene and eating. There was no daily documentation from staff to show the resident's functional status. Interview on 06/07/23 10:31 A.M. with Registered Nurse (RN) #614 verified she had documented and completed Resident #44's MDS dated for 04/10/23. She verified she was unable to provide the documentation she utilized to determine the resident's functional status. 2. Review of the medical record for Resident #75 revealed an admission date of 02/08/23 with diagnoses including metabolic encephalopathy, difficulty in walking, muscle weakness and pressure ulcer of sacral region, unspecified stage. Review of the weekly skin grids dated from 02/08/23 through 05/31/23 for the unstageable pressure areas to the left heel, left malleolus and coccyx/sacrum/bilateral upper buttocks, revealed all three pressure ulcers were still classified as unstageable pressure ulcers from 02/08/23 through 05/16/23. The coccyx/sacrum/bilateral upper buttocks area was changed from an unstageable pressure ulcer to a stage three pressure ulcer on 05/16/23. Review of the quarterly MDS 3.0 assessment dated [DATE] for Resident #75 under Section M revealed she had a stage three pressure ulcer and two unstageable pressure ulcers that were present on admission. Interview on 06/07/23 at 11:23 A.M. with RN #614 verified the MDS dated [DATE] for Resident #75 was incorrect as it should have stated three unstageable pressure ulcers instead of one stage three pressure ulcer and two unstageable pressure ulcers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366334 If continuation sheet Page 5 of 5