Health inspection·June 28, 2022

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bedside table. The binder consisted of multiple pages which contained pictures and Russian words next to the pictures. Interview on 06/23/22 at 9:24 A.M. with STNA #396 revealed she was from a staffing agency and had not worked in the facility previously. STNA #396 stated STNA #324 gave her a walk through orientation regarding residents who required assistance with transfers, feeding, and the type of care needed. STNA #396 stated STNA #324 did not tell her about a communication book in Russian for Resident #48. Interview on 06/23/22 at 11:43 A.M. with STNA #324 revealed she communicated with Resident #48 using hand signals and an example would be holding up an incontinence brief to ask if she needed changed. STNA #324 stated she did not use a communication book to communicate with Resident #48, did not know where the communication book was and thought it was misplaced. STNA #324 stated she sometimes called FM #395 if she could not communicate with Resident #48 and did not know what she wanted. STNA #324 confirmed she did not know there was a communication book in Resident #48's room on her bedside table. Observation on 06/23/22 at 11:43 A.M. of Resident #48's room revealed a communication binder with pictures and Russian words next to the pictures was on the bedside tray table within plain site. Interview on 06/23/22 at 2:56 P.M. with STNA #325 revealed he took care of Resident #48 sometimes and a couple times he had trouble communicating with her. STNA #325 stated he felt bad because he did not know what she wanted. STNA #325 stated there was no communication book, he thought the facility tried to make a communication book at one time, but that was before he started working at the facility. Interview on 06/23/22 at 3:14 P.M. with Registered Nurse (RN) #376 stated she was often assigned to take care of Resident #48 and there were times she had trouble communicating with her. RN #376 stated she learned how to use non-verbal signs for different things both of them could understand. RN #376 stated there were times when there was miscommunication with Resident #48, she could not understand what she wanted, and Resident #48 got very frustrated. RN #376 stated Resident #48 did not have a communication board or book to communicate more effectively. RN #376 stated Resident #48's grandson was making a communication board but he was in pharmacy school and she did not know if the board was ever finished. RN #376 indicated she called FM #395 when she could not understand what Resident #48 wanted and Resident #48 was very upset. Interview on 06/27/22 at 12:33 P.M. with Occupational Therapy Assistant (OTA) #397 revealed Resident #48's last evaluation for Occupational Therapy was 05/2021. OTA #397 stated the therapy notes included Resident #48 was evaluated for hemiplegia, and abnormal posture and there were no notes regarding Resident #48's ability to use a communication book or board. OTA #397 stated there was an electronic program change a couple years ago she did not have access to and it was possible Resident #48 was evaluated for use of a communication book or board before the program change. Review of facility policy titled Resident Rights and Facility Responsibilities undated, included the resident had the right to be informed of, and participate in, his or her treatment, including information regarding health status. The right to be fully informed in language that he or she could understand of his or her total health status, including but not limited to, his or her medical condition. The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to the right to receive the services and or items included in the plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366385 If continuation sheet Page 2 of 18 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 366385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury of Twinsburg 9928 Vail Drive Twinsburg, OH 44087 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy the facility failed to ensure one resident's (Resident #22) physician order for a hematology physician appointment was completed. This affected one resident (Resident #22) out of three residents reviewed for physician orders. The census was 49. Residents Affected - Few Findings include: Review of Resident #22's medical record revealed an admission date of 03/19/20 and diagnoses included immune thrombocytopenic purpura (low levels of the blood cells that prevent bleeding, platelets), abnormal findings of blood chemistry, and acute kidney failure. Resident #22 was discharged from the facility on 06/21/22. Review of Resident #22's care plan dated 05/11/20 revealed Resident #22 had potential risk for abnormal bleeding secondary to anticoagulant therapy, and immune thrombocytopenic purpura. The goal indicated Resident #22 would not present with signs and symptoms of abnormal bleeding through next review date. Interventions included handle carefully when assisting resident with bed mobility and transfers due to risk for bleeding related to blood thinner; medications per physician orders, monitor for side effects or adverse reactions and report to physician; monitor for signs of abnormal bleeding such as bruising, black tarry stools, and hypotension; monitor labs as indicted and report abnormal results to physician; notify physician if changes in condition. Another goal indicated Resident #22 would experience no further decline in Hemoglobin and Hematacrit through next review. Interventions included to give medications per physician orders; monitor for signs and symptoms of acute anemia, paleness of skin, nails, or mucosa, weakness, shortness of breath, low grade temperature; monitor labs as indicated and as ordered per physician, report abnormal results to physician; notify physician with change in condition. Review of Resident #22's physician orders written by Medical Doctor (MD) #393 dated 11/03/21 revealed follow up with MD #392 (Hematology) on 01/19/22 at 1:40 P.M. Review of State Tested Nursing Assistant (STNA) #354's appointment calendar dated 01/19/22 at 1:40 P.M. revealed Resident #22 was transported to his appointment with MD #392, but the office location had moved and Resident #22 was not seen or evaluated by MD #392. Review of Resident #22's progress notes from 01/19/22 through 06/22/22 did not reveal documentation Resident #22 was seen and evaluated by MD #392 or that the appointment was rescheduled. There was no documentation related to Resident #22 being taken to the wrong address on 01/19/22 and not being seen or evaluated by MD #392. Review of Resident #22's physician orders and progress notes from 01/19/22 through 06/22/22 did not reveal documentation Resident #22 had a televisit with MD #392. Review of Resident #22's progress notes written by MD #393 on 01/27/22 at 7:54 P.M. revealed Resident #22 was advised to see hematologist for thrombocytopenia. Review of Resident #22's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 was cognitively intact and required extensive assistance of one staff member for bed mobility, and limited assistance of one staff member for toilet use and transfers. Resident #22 had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366385 If continuation sheet Page 3 of 18 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 366385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury of Twinsburg 9928 Vail Drive Twinsburg, OH 44087 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 0684 medically complex conditions. Level of Harm - Minimal harm or potential for actual harm Observation on 06/21/22 at 9:42 A.M. of Resident #22 revealed he was sitting in a wheelchair in his room. Interview on 06/21/22 at 9:42 A.M. with Resident #22 revealed he was supposed to have an appointment to see MD #392, but the appointment to see the blood doctor never was made and that was six months ago. Residents Affected - Few Observation on 06/22/22 at 12:05 P.M. of Resident #22 revealed he was sitting in a wheelchair in his room. Interview on 06/22/22 at 12:05 P.M. with Registered Nurse (RN) #336 revealed RN #336 thought the location for Resident #22's appointment was closed down but the facility was not aware the location was not open. RN #336 stated there might have been a miscommunication about the location of MD #392's office, the appointment was canceled and Resident #22 returned to the facility. RN #336 stated she thought the appointment was rescheduled by STNA #354 but could not remember for sure. Interview on 06/22/22 at 2:25 P.M. with STNA #354 revealed she scheduled resident appointments and also transported residents to their appointments. STNA #354 stated she made Resident #22's appointment on 01/19/22 at 1:40 P.M. to visit MD #392 and drove him to MD #392's office address, but the office was closed, and a sign was on the door stating the office moved to a new address. STNA #354 stated Resident #22 never went to a physician visit with MD #392 because he had other appointments, and it slipped her mind. STNA #354 stated she recently made an appointment for Resident #22 to visit MD #392 in 09/2022 because Resident #22 told her he never went to the appointment. STNA #354 indicated she did not write a note in Resident #22's medical record about the missed appointment on 01/19/22 because she was an STNA and STNAs don't chart in the electronic record. Interview with the Director of Nursing (DON) on 06/22/22 at 3:35 P.M. confirmed Resident #22 was taken to an appointment with MD #392 on 01/19/22, the office moved to a new address and Resident #22 did not see MD #392 on 01/19/22. The DON stated someone at the facility should have followed up about the address and rescheduled Resident #22's appointment with MD #392. The DON stated both MD #392 and MD #394 were located at the main campus office and specialized in blood disorders. The order was written for Resident #22 to have an appointment with MD #392 because he would be closer to Resident #22, and MD #394 was moving to a further away location. The DON stated Resident #22 was discharged from the facility to home on [DATE]. The DON stated Resident #22 had a televisit with MD #394 in 03/2022 and would send the progress notes from the visit. The DON stated labs from 04/05/22 were faxed to MD #394. Interview on 06/27/22 at 1:00 P.M. with the DON revealed she was unable to provide the progress notes from Resident #22's televisit in 03/2022 with MD #394. The DON also confirmed there was no documentation in Resident #22's medical record about a televisit with MD #394. Review of the facility policy titled Transportation and Appointments revised 12/2008, include appointments would be scheduled through the transportation department. The facility would contact the providers. The facility would work with the provider offices to schedule all appointments as ordered, or as soon as available with the provider. Transportation would be arranged through the transportation department as needed based on resident's clinical status/family availability. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366385 If continuation sheet Page 4 of 18 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 366385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury of Twinsburg 9928 Vail Drive Twinsburg, OH 44087 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy the facility failed to ensure Resident #36 did not develop avoidable pressure injuries of the knees. Actual harm occurred when Resident #36 developed a right knee deep tissue injury (Persistent non-blanchable deep red, maroon or purple discoloration intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue.) and a left knee Stage 3 pressure ulcer (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and/or eschar may be visible but do not obscure the depth of tissue loss.). This affected one resident (Resident #36) of three residents reviewed for pressure injuries. The census was 49. Residents Affected - Few Findings include: Review of Resident #36's medical record revealed an admission date of 07/30/21 and diagnoses including senile degeneration of the brain, multiple fracture of ribs on the left side, acute respiratory failure with hypoxia, dementia, and generalized muscle weakness. Review of Resident #36's physician orders dated 07/30/21 revealed turn and reposition every two hours right, back, left every shift. Review of Resident #36's Braden Scale For Predicting Pressure Sore Risk dated 02/14/22 revealed Resident #36 was at risk for developing a pressure ulcer, injury. Review of Resident #36's progress notes dated 05/07/22 at 2:55 P.M. revealed Resident #36 was sitting in her Broda chair, tipped it over head first and fell on the floor. The fall was witnessed by Registered Nurse (RN) #376, but she could not reach Resident #36 quickly enough to stop the chair from tipping over. No injuries were noted, neuro checks were initiated, and the responsible party and physician were notified. Review of Resident #36's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not completed due to resident was rarely or never understood. Resident #36 required extensive assistance of one staff member for bed mobility and toilet use, was always incontinent of urine and bowel, and was totally dependent on two staff members for transfers. Resident #36 did not have a pressure ulcer or injury. Review of Resident #36's Braden Scale For Predicting Pressure Sore Risk dated 05/10/22 revealed Resident #36 was at risk for developing a pressure ulcer, injury. Review of Resident #36's Physical Therapy Plan of Treatment dated 05/10/22 revealed diagnoses of senile degeneration of the brain, abnormal posture, and unsteadiness on feet. The plan stated clinical impressions were Resident #36 was a high fall risk due to impulsive behaviors in Broda chair and getting a new chair with increased depth and seat belt would help mitigate the fall risk. The plan also included level of skilled services were not applicable at this time and this was an evaluation only for chair assessment. Review of Resident #36's physician orders dated 05/10/22 revealed Resident #36 would benefit from an improved Broda chair with increased seat depth and arm rest height as well as self-releasing seat (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366385 If continuation sheet Page 5 of 18 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 366385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury of Twinsburg 9928 Vail Drive Twinsburg, OH 44087 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 belt to help reduce fall risk and improve safety in the facility. Level of Harm - Actual harm Review of Resident #36's progress notes dated 05/10/22 revealed the Director of Nursing (DON) contacted Hospice Representative (HR) #382 regarding recommendations for seating to see if hospice was able to accommodate the recommendations. The DON would follow up with the Director of Rehab (DOR) after speaking with hospice for confirmation. Residents Affected - Few Review of Resident #36's progress notes dated 05/11/22 revealed therapy evaluated Resident #36 and made recommendation for a Broda chair with a seat depth of 20 inches and adjustable arm rests. The noted indicated currently awaiting a return call from hospice to confirm. Review of Resident #36's care plan dated 05/23/22 revealed Resident #36 had a potential for alteration in skin integrity related to decreased physical mobility, and bowel and bladder incontinence. Resident #36's skin was fragile and bruised and tore easily. The goal indicated Resident #36 would have decreased risk of alteration in skin integrity through next review date. Interventions included to monitor for new bruising when present every shift and report changes promptly to nurse in charge; turn and reposition per schedule; monitor for changes in skin and notify physician as needed; skin care protocol per state tested nursing assistants (STNA). Review of Resident #36's progress notes dated 05/26/22 at 12:32 P.M. revealed the DON spoke with HR #383 regarding a new chair for Resident #36. HR #383 stated chair would not be provided through hospice due to resident being discharged from hospice in two weeks. Review of hospice notes from 05/10/22 through 06/10/22 did not reveal a reason Resident #36 was discharged from hospice services. The notes did not reveal documentation hospice evaluated Resident #36's position in the rental Broda chair with tray. Review of Resident #36's progress notes dated 05/27/22 at 8:25 A.M. revealed the DON and DOR spoke to determine new seating for resident. A new Broda chair was ordered for Resident #36 with a 20 inch seat depth and a tray table to facilitate easy access to her snacks and personal items due to inability to place Resident #36 at table related to injuries from Resident #36 kicking tables. While awaiting new Broda chair a Broda chair with an 18 inch seat and tray table were being rented from the facility supply company. Review of Resident #36's progress notes from 05/27/22 through 06/16/22 did not reveal documentation Resident #36 had redness or sores on her right or left knee. Review of a delivery order revealed an 18 inch Broda Midline Chair and an 18 inch Broda Tray were delivered to the facility on [DATE] for Resident #36. Review of Resident #36's progress notes dated 06/17/22 at 12:58 P.M. written by Registered Nurse (RN)/Wound Nurse (WN) #365 revealed an unidentified State Tested Nursing Assistant (STNA) reported Resident #36 had new areas of skin impairment to her knees. Observation revealed Resident #36 had a new deep tissue injury (DTI) to right knee, and a new Stage 3 pressure ulcer to the left knee. The areas were caused by Resident #36's tray table being too low and causing continuous pressure to areas. Application of skin prep and foam dressing to right knee. Cleansed area to the left knee with normal saline solution, applied calcium alginate, and covered with foam dressing. Therapy was consulted to evaluate chair to see if tray table could be raised or seat could be lowered to relieve pressure from knees. The physician and power of attorney (POA) were notified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366385 If continuation sheet Page 6 of 18 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 366385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury of Twinsburg 9928 Vail Drive Twinsburg, OH 44087 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 Level of Harm - Actual harm Residents Affected - Few Review of Resident #36's Skin and Wound Evaluation dated 06/17/22 at 12:17 P.M. revealed Resident #36 had a right knee DTI and the injury was a medical device related pressure injury. The DTI was new, in-house acquired and measured a length of 1.7 centimeters (cm), width of 1.5 cm, and depth was unable to be determined. The edges were attached, the skin was intact with unbroken skin, and no swelling noted. Resident #36 experienced pain when the area was touched and pulled her knees up to her chest. The Evaluation further indicated Resident #36 had a new DTI due to pressure from tray on the chair. Skin prep was applied and the area was covered with a foam dressing. Therapy to evaluate chair to see if tray can be raised or seat lowered to relieve pressure from the area. Review of Resident #36's Skin and Wound Evaluation dated 06/17/22 at 12:18 P.M. revealed Resident #36 had a Stage 3 medical device related pressure injury to the left knee. The left knee Stage 3 pressure injury was new, in-house acquired and measured a length of 2.0 cm, width of 1.9 cm and depth was unable to be determined. The wound bed was 70 percent epithelial tissue, 30 percent granulation tissue, was red in color, and had a light amount of serosanguinous (pink colored) drainage. The surrounding tissue had redness of the skin. Resident #36 experienced pain when the area was touched or cleansed and pulled knees up to her chest. The Evaluation indicated Resident #36's new Stage 3 pressure ulcer to the left knee was due to pressure from the tray on the chair. The wound was cleansed with normal saline solution, calcium alginate applied, and covered with a foam dressing. Therapy to evaluate the chair to see if tray can be raised or seat lowered to relieve pressure from the area. Observation on 06/22/22 at 12:00 P.M. revealed Resident #36 was sitting in a Broda chair in her room and there was no tray attached to the chair. RN/WN #365 and RN/Infection Control Prevention Officer (ICPO) #390 were preparing to change Resident #36's dressings. During observation of the dressing change on 06/22/22 at 12:00 P.M., RN/WN #365 stated Resident #36's Broda chair tray was too tight on her knees and caused the wounds. RN/WN #365 stated the dressings were changed daily by the nurses assigned to take care of Resident #36, and RN/WN #365 changed them once a week when she made rounds with the wound physician. RN/WN #365 stated the left knee pressure ulcer wound bed had 80 percent eschar (dead) tissue, and 20 percent epithelial tissue with redness around edges, and the peri-wound had reddened, dry flaky skin. RN/WN #365 stated the measurements were length 3.0 cm, width 1.6 cm, and depth was unable to be determined. RN/WN #365 cleaned the wound with normal saline soaked gauze, applied calcium alginate and a border dressing. RN/WN #365 stated Resident #36's right knee pressure ulcer wound bed had 80 percent very dark colored eschar, redness around the edges with dry flaky skin, 10 percent granulation tissue and 10 percent slough (dead tissue). The measurements were length 1.4 cm, width 1.5 cm, and depth unable to be determined. RN/WN #365 cleaned the right knee pressure ulcer with normal saline, applied skin prep and a border dressing. RN/WN #365 revealed Resident #36 was not evaluated by the wound physician today because RN/WN #365 did not get approval from Resident #36's POA. RN/WN #365 did not request the approval because she wanted to wait a week after finding the pressure ulcers to see if the wounds improved. RN/WN #365 stated Resident #36's knee pressure ulcers had not improved and she would get approval from the POA to have the wounds evaluated by the wound physician. Review of Resident #36's Skin and Wound Evaluation dated 06/22/22 revealed Resident #36's left knee Stage 3 pressure ulcer acquired in-house on 06/17/22 measured a length of 1.9 cm, width of 1.9 cm and depth unable to be determined. The wound bed was 20 percent epithelial tissue, 80 percent slough with light amount serosanguinous drainage. The wound was red around the edges and had dry flaky skin. The Evaluation stated the wound had little to no improvement from the previous week. The wound physician was to be consulted, and an attempt to contact the POA was made with no answer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366385 If continuation sheet Page 7 of 18 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 366385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury of Twinsburg 9928 Vail Drive Twinsburg, OH 44087 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 Level of Harm - Actual harm Residents Affected - Few Review of Resident #36's Skin and Wound Evaluation dated 06/22/22 revealed Resident #36's right knee deep tissue pressure injury acquired in-house on 06/17/22 measured a length of 1.1 cm, width of 1.2 cm and depth was unable to be determined. The wound bed had 10 percent granulation tissue, 10 percent slough, and 80 percent eschar. The wound had light serous drainage, and the edges were red with dry flaky skin. The Evaluation indicated the wound had little to no improvement from the previous week and the wound physician was to be consulted. An attempt to contact the POA was made with no answer. A message was sent to Resident #36's physician to change the treatment to cleanse with normal saline solution, apply calcium alginate and cover with foam dressing. Interview on 06/22/22 at 4:30 P.M. with DOR #391 revealed she was not allowed to work with Resident #36 while she was receiving hospice services, and these were hospice rules. Resident #36 came off hospice on 06/10/22 but DOR #391 was not notified until 06/17/22. DOR #391 had no input fitting Resident #36 in her rented Broda chair; hospice fitted Resident #36 to the Broda chair. DOR #391 indicated the DON told her Resident #36 was off hospice and she evaluated Resident #36 around 06/21/22. The DON told DOR #391 there were problems feeding Resident #36 because her legs bent so much and the tray was causing pressure. DOR #391 stated Resident #36 was not positioned great in the Broda chair, and she observed bruises the tray table made. The therapy department tried to make recommendations for a deeper Broda to help elongate Resident #36 but that did not happen. The therapy department wanted a deeper Broda chair. DOR #391 did not know why hospice did not follow the recommendations. The Broda chair was lowered to give Resident #36's legs more length and flexion. DOR #391 stated a different chair specific to the resident needed ordered, and the chair she had was a standard Broda chair and not fit to Resident #36. Interview on 06/23/22 at 2:46 P.M. with STNA #325 revealed he found the Broda chair tray on Resident #36's knees. STNA #325 had not worked for a few days and noticed the tray attached to Resident #36's Broda chair. STNA #325 stated Resident #36 looked like she was uncomfortable with the tray on the chair and the tray should not have been on the chair. STNA #325 immediately repositioned Resident #36 in her chair. STNA #325 indicated Resident #36 was wearing capri pants (longer than shorts but not as long as trousers), and when he readjusted the pants he noticed spots on her knees, reddened circular areas with skin breakdown which looked like rug burn. STNA #325 stated he had not taken care of Resident #36 for awhile and she probably slid in her chair and her knees pressed up against the tray. STNA #325 stated he made the observation around the time of the lunch meal and he told RN/WN #365 right away; RN/WN #365 was walking past and he called her over to look at the wounds. STNA #325 stated the tray was removed from the chair and had not been on it since. STNA #325 stated Resident #36's legs were contracted and he asked the nurse why Resident #36 had a tray table on her chair but could not remember which nurse he talked to or what she said. Interview on 06/23/22 at 3:59 P.M. with the DON and RN/ICPO #390 revealed Resident #36 was using a standard Broda chair ordered on 08/03/21, and had numerous falls. The DON and RN/ICPO #390 felt the standard chair did not fit Resident #36 appropriately and they wanted to find a way to keep her from getting severely injured from falling and requested recommendations from the therapy department. The DON stated therapy gave recommendations on 05/10/22 for Resident #36 to have a custom Broda chair with a lower seat and a seat belt. The DON indicated Resident #36 received hospice services and she reached out to hospice to facilitate obtaining the custom Broda chair recommended by therapy. The hospice representative told her hospice was planning to have an interdisciplinary team meeting and would get back to her regarding the Broda chair. The hospice representative did not call back, and the DON followed up with hospice on 05/26/22. The hospice representative told the DON they were not going to buy the Broda chair and Resident #36 was going to be dropped from hospice services in two weeks. The DON stated after she found (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366385 If continuation sheet Page 8 of 18 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 366385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury of Twinsburg 9928 Vail Drive Twinsburg, OH 44087 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 Level of Harm - Actual harm Residents Affected - Few out Resident #36 was going to be dropped from hospice she placed an order on 05/27/22 for a custom Broda chair from the facility supply company. After the DON ordered the custom Broda chair she contacted the supply company to order a rental chair with a tray that was similar to the Broda chair ordered to use until the custom Broda chair arrived. The DON stated the supply company did not have a rental chair similar to the chair ordered but sent a rental chair with a tray around 06/16/22. The DON stated she wanted therapy to re-evaluate Resident #36 but therapy stated they could not be involved because Resident #36 was on hospice. The DON indicated the rental Broda chair with the tray arrived around 06/16/22 and the Broda chair should have stayed in the front of the facility until therapy could fit Resident #36 in the chair. The DON stated if the Broda chair was used before therapy fit Resident #36 to the chair the tray should not have been used until they had physician orders to use the tray. The DON and RN/ICPO #390 stated they did not know which staff member took the chair and tray from the front of the facility and placed Resident #36 in the chair for the first time. The DON was not aware the rental Broda chair and tray were being used until RN/WN #365 was called to check Resident #36's knees and the tray was taken off the chair immediately. The DON stated STNA #363 who worked night shift, told RN/WN #365 on 06/17/22 Resident #36's knees were red and sores were noted. The DON stated RN/WN #365 did not evaluate Resident #36's knees immediately because she was busy doing something else. The DON and RN/ICPO #390 indicated they wanted to have a tray on the Broda chair to keep Resident #36 away from the tables in the common area because she kicked at the tables when she got close to them. Interview on 06/23/22 at 4:15 P.M. with RN/WN #365 confirmed STNA #363 told her Resident #36 had sores on her knees in the morning and she did not evaluate the sores until later in the day because she was taking care of issues for other residents. Interview on 06/24/22 at 5:56 P.M. with STNA #363 revealed she worked night shift, took care of Resident #36 on 06/17/22 and noticed she had nickel size sores on both knees. The sores had scabs on them and did not have drainage. STNA #363 had taken care of Resident #36 before 06/17/22 and Resident #36 did not have sores on her knees. STNA #363 indicated Resident #36 was lying in bed when she noticed the sores on her knees, and immediately told RN/WN #365 about the sores. STNA #363 stated she assisted Resident #36 from her bed into the Broda chair which had the tray attached. STNA #363 stated she was not in the facility when the Broda chair with the tray arrived and did not put Resident #36 in it for the first time. STNA #363 stated Resident #36 was using the Broda chair with the tray at least a couple weeks and maybe longer. STNA #363 thought the Broda chair with the tray caused the sores on Resident #36's knees because Resident #36's legs were contracted and her knees pushed and bumped against the tray table. Interview on 06/27/22 at 8:50 A.M. with RN/WN #365 confirmed the measurements on the Skin and Wound Evaluations dated 06/22/22 were different from the measurements taken manually during the dressing changes on 06/22/22. RN/WN #365 stated the facility used an electronic wound application and the wound application did not measure the same as the manual measurements. RN/WN #365 stated the wound nurse practitioner called the company recently about the wound application inaccuracy. RN/WN #365 stated the wound physician and nurse practitioner wanted manual measurements, but she was instructed by the facility to use the electronic wound application for the Skin and Wound Evaluations. Review of the facility policy titled Wound Care Management Protocol dated, 04/14/16 included it was the facility policy to screen, assess, and monitor the residents for pressure ulcers as follows. The wound care nurse designee was to be notified as soon as possible. The wound care nurse designee would obtain a consult for the wound nurse practitioner as soon as possible for all in-house pressure areas and other wounds deemed appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366385 If continuation sheet Page 9 of 18 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 366385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury of Twinsburg 9928 Vail Drive Twinsburg, OH 44087 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** 2. Medical record review revealed Resident #31 was admitted on [DATE] with diagnoses including acute kidney failure, major depressive disorder, unspecified dementia, without behavior, protein calorie malnutrition and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment of 5/03/22 revealed the resident was severely cognitively impaired and required total dependence of two for activities of daily living (ADLs). Review of the care plan of 05/26/22 revealed a care area for needs related to Alzheimer's disease with interventions including assist with majority of ADLs, arrange physical/occupational therapies as indicated and as ordered per physician (05/27/21) and completion of restorative nursing screens quarterly. Review of the physical therapy (PT) discharge of 06/29/21 revealed Resident #31 was referred for restorative range of motion (ROM) for functional maintenance. Review of the occupational therapy (OT) discharge of 06/18/21 revealed Resident #31 was referred for restorative ROM for bilateral upper extremities. Interview with the Director of Nursing (DON) on 06/23/22 12:18 P.M. revealed there was a problem with the former Director of Rehab and nursing did not receive the referrals for restorative services. Interview with the DON on 06/23/22 at 12:58 P.M. verified quarterly restorative assessments should have been completed upon her admission and quarterly and Resident #31 should have received restorative services per the discharges from PT and OT. Review of Restorative program polices dated of 10/10/18 revealed all residents were screened and referred for restorative for appropriate treatment, upon admission and quarterly. Based on interview and record review the facility failed to initiate restorative nursing programs per therapy recommendations affecting two residents (Resident #28 and #31) out of two residents (Residents #28 and #31) reviewed for decline in activities of daily living. This had the potential to affect 17 residents (Residents #2, #4, #6, #7, #10, #14, #15, #16, #19, #20, #23, #25, #26, #28, #31, #33, #47) that were recommended to be on a restorative nursing program. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 11/25/19 and diagnoses included chronic respiratory failure with hypoxia, morbid obesity, dependence on a ventilator, hypertension, and anxiety. Review of care plan dated 02/15/21 revealed Resident #28 required assistance with most of her activities of daily living. Interventions included assist with one to two people with bed mobility and dressing, transfer bed to chair with a mechanical lift with a two person staff assist, restorative nursing screening to be completed quarterly and programs as indicated. Review of the Therapy Discharge summary dated [DATE] completed by Physical Therapist #901 revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366385 If continuation sheet Page 10 of 18 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 366385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury of Twinsburg 9928 Vail Drive Twinsburg, OH 44087 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 Resident #28 achieved her highest practical level and was discontinued from physical therapy. The summary revealed she was to maintain her functional abilities and her prognosis was excellent with consistent staff support. She was discharged on a restorative nursing program. Review of Occupational Therapy Discharge summary dated [DATE] completed by Occupational Therapist #902 revealed Resident #28 achieved her highest practical level and was discontinued from occupational therapy. The summary revealed she was to maintain her functional abilities and her prognosis was excellent with consistent staff support. She was discharged on a restorative nursing program. Review of undated facility form labeled, Staff Education completed per Physical Therapy Assistant (PTA) #903 revealed Resident #28 had the following restorative nursing program recommendations that included staff were to follow the Marching, Ankles, Reaching and Kicks (M.A.R.K.) program five times a week once a day. The instructions revealed Resident #28 was to be seated in a locked wheelchair and instructed to complete 20 times each exercise that was listed on the handout. The handout revealed Resident #28 was to march 20 times with each leg while sitting in her wheelchair, bend her ankles up and down 20 times, reach over her head as high as possible 20 times with each arm complete kicks to the side 20 times on each leg. Review of quarterly Minimum Data Set (MDS) 3.0 dated 04/29/22 revealed Resident #28 had intact cognition and no behaviors. She required extensive assist of two people with bed mobility, personal hygiene, and she required total dependence of two people with transfers and toileting. She required extensive assist of one person with dressing. She was unable to ambulate. The MDS indicated she had not received any restorative nursing during the assessment period. Review of task bar per electronic medical record from 06/01/22 to 06/21/22 revealed Resident #28 did not have any restorative programs ordered or completed. Review of physician orders for June 2022 revealed Resident #28 did not have an order for a restorative nursing program. Interview on 06/21/22 at 9:56 A.M. with Resident #28 revealed when she completed therapy, the therapist had stated she would continue to receive exercises by the staff on her arms and legs to maintain her functional ability, but she had not received any exercises since her therapy had ended. She revealed she felt she was declining since she did not have therapy or exercises provided. Interview on 06/23/22 at 8:35 A.M. with Rehabilitation Director #387 revealed Resident #28 was discharged from physical therapy on 03/17/22 and Occupation Therapy on 03/22/22 and therapy had recommended to continue a M.A.R.K. restorative nursing program to maintain her functional ability five times a week once a day. She revealed Resident #28 should have been receiving this program since discharge from therapy and should still be receiving the program. She revealed anytime a resident was discontinued from therapy and referred to restorative, a program was given to nursing to input an order into the medical record and complete the program. Interview on 06/23/22 at 10:35 A.M. with State Tested Nursing Assistant (STNA) #325 revealed to his knowledge Resident #28 did not have a restorative nursing program. STNA #325 said any resident on a restorative program showed up on the task bar on the computer system including the type and frequency of the program he was to complete when he was on the floor. He revealed Resident #28 did not have any restorative program under the tasks he was assigned. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366385 If continuation sheet Page 11 of 18 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 366385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury of Twinsburg 9928 Vail Drive Twinsburg, OH 44087 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 Interview on 06/23/22 at 12:18 P.M. with the Director of Nursing (DON) revealed she had no documentation from 03/17/22 to current (06/23/22) that Resident #28 was to be on a restorative nursing program as the staff had not completed any restorative program for Resident #28. The DON said the facility had an issue with the Previous Rehabilitation Director #900 forwarding the programs to nursing. The rehabilitation director was to forward any restorative recommendations to Registered Nurse (RN)/ Unit Manager #327 who would then input the restorative program into the task bar on the computer so the floor STNAs would know and complete the program. She revealed there was a breakdown in the facility system as Resident #28 should have been receiving restorative nursing based on the therapy recommendation, but that nursing had never received the referral for the program. Review of facility policy labeled, Restorative Programs Policy dated 10/ 10/18 revealed the purpose of the policy was to promote optimal wellness and prevent a decline in functional status of a resident. The policy revealed all residents would be screened quarterly, the program would be written up per the nursing unit manager and performed by the STNA. The policy revealed the nurse would place the program that was to be initiated into the medical record and the unit manager would monitor the program. The policy revealed physician orders would be written to reflect the restorative nursing program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366385 If continuation sheet Page 12 of 18 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 366385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury of Twinsburg 9928 Vail Drive Twinsburg, OH 44087 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 interview, observation and record review the facility failed to ensure medications were maintained in a safe and secure manner. This affected two residents (Residents #12 and #43) out of four residents (Residents #3, #12, #18, and #43) reviewed for unsecured medications and had the potential to affect all 49 residents residing at the facility. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 06/24/20 and diagnoses included chronic obstructive pulmonary disease (COPD) with acute exacerbation, chronic respiratory failure with hypoxia, solitary pulmonary nodule, adult failure to thrive, dependence of oxygen, and Alzheimer's disease. There was no medication self-administration assessment in her medical record. Review of care plan dated 07/13/20 revealed Resident #12 had Alzheimer's disease and a decline in cognition, mobility and activities of daily living was expected due to disease process. Interventions included explain all procedures prior to implementation, anticipate and meet needs to avoid frustration, medication per physician orders, and monitor for changes in mental status and cognition. Review of care plan dated 11/23/20 revealed Resident #12 had impaired air exchange due to COPD and chronic respiratory failure. Interventions included oxygen as ordered, keep head of bed elevated, monitor for increased shortness of breath, and respiratory distress. The care plan did not include anything regarding maintaining inhalers at bedside. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 had intact cognition. Review of June 2022 physician orders revealed Resident #12 had a physician order for Breo Ellipta Aerosol powder breath activated 100-25 microgram per inhalation to administer one inhalation orally in the morning for COPD and to rinse her mouth after inhalation with four to eight ounces of water or juice. There were no physician orders regarding keeping her inhaler at bedside or that Resident #12 was able to self-administer her medications including her inhaler. Observation on 06/ 27/22 at 9:59 A.M. revealed Resident #12 was laying in her bed and there was one Breo Ellipta 100- 25 mcg inhaler laying on her bedside table. Interview on 06/27/22 at 10 :00 A.M. with Resident #12 revealed the nurse had left the inhaler on her bedside table so that she would administer later after she got up. Upon interview Resident #12 stated she was not sure of the name of the medication, dose of the medication, how many inhalations she was to take, when she was to take the inhaler, the frequency of when she was to take her inhaler and if there were any special instructions such as rinsing her mouth out after use of the inhaler. She revealed she usually took one or two inhalations when she was having trouble breathing. Interview on 06/27/22 at 10:05 A.M. with the Administrator and Director of Nursing verified there was one Breo Ellipta 100- 25 mcg inhaler laying on Resident #12's bedside table. The Director of Nursing verified Resident #12 was not able to self-administer medications as she had intermittent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366385 If continuation sheet Page 13 of 18 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 366385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury of Twinsburg 9928 Vail Drive Twinsburg, OH 44087 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 confusion and was unable to know medication, dose of inhalation, frequency, time of when to take her inhaler, and any special instructions such as rinsing out her mouth after use. The Director of Nursing verified the nurse was to administer the inhaler per physician order and not leave the inhaler on her bedside table. The Director of Nursing verified there was no self-administration assessments per Resident #12's medical record. Residents Affected - Few 2. Review of the medical record for Resident #43 revealed an admission date of 12/22/20 and diagnoses including major depressive disorder, essential hypertension, hyperlipidemia, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 was cognitively intact. Review of Resident #43's physician orders for June 2022 revealed an order for Fluticasone Propionate Suspension 50 micrograms (improves breathing and controls symptoms of asthma) two sprays in both nostrils in the morning for nasal congestion. There was no order to leave medications at bedside. Observation on 06/21/22 at 10:25 A.M. of Resident #43 revealed Fluticasone Propionate Suspension sitting on the bedside table and the nurse was not in the room. Interview at the time of the observation with Resident #43 revealed she did not administer her own medications and stated the nurse must have forgotten to take the medication with them before leaving her room. Interview on 06/21/22 at 10:38 A.M. with Registered Nurse (RN) #386 verified the Fluticasone Propionate Suspension was sitting on the bedside table in Resident #43's room. RN #386 verified Resident #43 did not have orders to self-administer medications, or that any medications could be left at the bedside. Review of facility policy labeled, Administering Medications dated December 2012 revealed medications shall be administered in a safe, timely and as prescribed manner. The policy revealed only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. The policy revealed residents may self-administer their own medications only if the attending physician and interdisciplinary care team had determined that the resident had the decision-making capacity to do so safely. This deficiency substantiates Complaint Number OH00133681. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366385 If continuation sheet Page 14 of 18 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 366385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury of Twinsburg 9928 Vail Drive Twinsburg, OH 44087 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medical records were complete and accurate for Residents #31 and #43. This affected two residents of six residents (Residents #5, #12, #28, #31, #43 and #250) reviewed for nutrition and Activities of Daily Living (ADL). Findings include: 1. Review of the medical record revealed Resident #31 was admitted on [DATE] with diagnoses including acute kidney failure, major depressive disorder, unspecified dementia without behavior, protein calorie malnutrition and Alzheimer's disease. Review of the quarterly Minimum Data (MDS) 3.0 assessment of 05/03/22 revealed the resident was severely cognitively impaired and required total dependence of two for ADLs. Review of the care plan of 05/26/22 revealed a care area for hospice services (added 08/09/21) for a terminal diagnosis of Alzheimer's disease. Review of the electronic and paper charts for Resident #31 revealed no documentation from hospice beyond their contact information. Interview on 06/23/22 at 12:00 P.M. with the Director of Nursing (DON) verified the facility had no documentation from hospice for Resident #31 despite the resident receiving hospice services since 08/09/21. 2. Review of the medical record revealed Resident #43 was admitted on [DATE] with diagnoses including major depressive disorder, essential hypertension, hyperlipidemia, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #43's medical record revealed a weight of 168.6 pounds on 05/04/22 and 144.8 pounds on 06/14/22 for a weight loss of 14.12 percent. Review of Resident #43's medical record revealed no documentation of the facility's attempt to reweigh Resident #43 and review of the nursing progress notes from 06/14/22 through 06/22/22 revealed no documentation regarding the weight loss or attempt to reweigh. Interview on 06/23/22 at 9:48 A.M. with Corporate Dietician #385 revealed the facility's policy was to place the resident on weekly weights and reweigh when there was a new weight loss trigger to determine the weight loss was true. Interview on 06/23/22 at 10:45 A.M. with Corporate Dietician #385 revealed Resident #43 refused to be reweighed on 06/20/22. Interview on 06/23/22 at 3:16 P.M. with Corporate Dietician #385 and the Director of Nursing verified the facility had no documentation in Resident #43's medical record regarding Resident #43's refusal to be reweighed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366385 If continuation sheet Page 15 of 18 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 366385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury of Twinsburg 9928 Vail Drive Twinsburg, OH 44087 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 0842 Review of the facility's policy, Resident Weights, dated 11/11/19 stated, all resident refusals to be weighed shall be documented in the resident's medical record. 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: 366385 If continuation sheet Page 16 of 18 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 366385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury of Twinsburg 9928 Vail Drive Twinsburg, OH 44087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and review of facility policy the facility failed to ensure appropriate hand hygiene was implemented during the medication pass for three residents (Residents #13, #14, #47), during meal time for six residents (Residents #13, #24, #26, #36, #42, #44) and failed to ensure the glucometer for Resident #33 was disinfected after it was used to check a blood sugar. This affected nine out of nine residents reviewed for infection control and had the potential to affect all 28 residents residing on the 300 nursing unit. The facility census was 49. Residents Affected - Some Findings include: Observation on 06/21/22 at 12:06 P.M. revealed State Tested Nursing Assistant (STNA) #344 was passing out meal trays and assisting residents with their meals in the dining area. STNA #344 gave Resident #24 her meal tray and assisted her with the tray set up prior to her eating. After STNA #344 assisted Resident #24 he walked to the meal cart and picked up Resident #42's meal tray. STNA #344 walked over to Resident #42, set her tray on the table and assisted her with her tray set up prior to her eating. STNA #344 did not use hand sanitizer or wash his hands before or after assisting Resident's #24 and #42 with their meal trays. STNA #344 did not use hand sanitizer or wash his hands, walked to the meal cart and picked up Resident #44's meal tray, carried it over to him, and set the tray down on the table in front of Resident #44. STNA #344 walked to the meal tray without using hand sanitizer or washing his hands, picked up Resident #13's meal tray walked over and set the meal tray on the table in front of Resident #13. STNA #344 sat down in a chair placed between Resident #13 and Resident #44 and began to feed Resident #13. STNA #344 fed Resident #13 a spoonful of his food, turned to Resident #44 and fed him a spoonful of food, turned back to Resident #13 and fed him a couple spoonfuls of food and adjusted Resident #13's clothing protector, turned back to Resident #44 and fed him some food. STNA #344 continued to feed Resident #13 and Resident #44 in this manner until they were finished with their meal. At no time during the meal did STNA #344 use hand sanitizer or wash his hands. STNA #344 stood up and did not use hand sanitizer or wash his hands, walked past Resident #26, patted Resident #26 reassuringly on his arm, walked to the meal cart and pushed the cart into the dining area. STNA #344 proceeded to pick up the residents' used meal trays and placed them in the meal cart. STNA #344 walked to Resident #13, took his clothing protector off of him, went in the dirty utility room to place the used bib in a linen hamper and walked out of the dirty utility room over to Resident #26 and #36. STNA #344 did not use hand sanitizer or wash his hands before removing Resident #26's and #36's protective bibs from them and walk to the dirty utility room to place them in the linen hamper. Interview on 06/21/22 at 12:30 P.M. with STNA #344 confirmed he did not use hand sanitizer or wash his hands at any time during the observation. Observation on 06/22/22 at 7:46 A.M. revealed Licensed Practical Nurse (LPN) #384 standing at the medication cart preparing medications for administration to Resident #47. LPN #384 walked into Resident #47's room, administered the medications and walked back to the medication cart without using hand sanitizer or washing her hands. Observation on 06/22/22 at 7:52 A.M. revealed LPN #384 preparing medications for administration to Resident #14 without using hand sanitizer or washing her hands. LPN #384 walked into Resident #14's room, administered the medications and returned to the medication without using hand sanitizer or washing her hands. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366385 If continuation sheet Page 17 of 18 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 366385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury of Twinsburg 9928 Vail Drive Twinsburg, OH 44087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 06/22/22 at 8:05 A.M. revealed LPN #384 preparing medications for administration to Resident #13 without using hand sanitizer or washing her hands. LPN #384 walked into Resident #13's room, administered the medications and walked back to the medication cart without using hand sanitizer or washing her hands. Observation on 06/22/22 at 8:25 A.M. revealed LPN #384 taking a glucometer from the medication cart and walking into Resident #33's room to check her blood sugar. LPN #384 did not use hand sanitizer or wash her hands before checking Resident #33's blood sugar. After she checked the blood sugar LPN #384 returned to the medication cart and placed the glucometer on the top of the cart. There was no observation of LPN #384 disinfecting the glucometer or using hand sanitizer or washing her hands. Interview on 06/22/22 at 8:25 A.M. with LPN #384 confirmed she did not used hand sanitizer or wash her hands during the observation of medication administration. LPN #384 confirmed she did not disinfect the glucometer used to check Resident #33's blood sugar before or after placing the glucometer on top of the medication cart. Interview on 06/22/22 at 8:45 A.M. with Registered Nurse (RN) #336 revealed RN #336 opened the bottom drawer of the medication cart for bleach wipes to disinfect the glucometer after surveyor informing her LPN #384 did not disinfect the glucometer used for Resident #33's blood sugar. RN #336 stated there were no bleach wipes in the medication cart and she would need to get some. Observation on 06/22/22 at 8:45 A.M. confirmed there were no bleach wipes in the medication cart used by RN #336. Review of the policy titled Handwashing/Hand Hygiene undated, revealed the facility considered hand hygiene the primary means to prevent the spread of infection. All personnel should follow the handwashing, hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62 percent alcohol, or soap and water for the following situations including before and after direct contact with residents, before preparing or handling medications, after contact with a resident's intact skin, before and after assisting a resident with meals. The use of gloves did not replace hand washing, hand hygiene. Integration of glove use along with routine hand hygiene was recognized as the best practice for preventing healthcare-associated infections. Review of the policy titled Administering Medications revised, 12/2012 revealed staff would follow established infection control procedures (for example, handwashing, antiseptic technique, gloves, isolation precautions et cetera) for administration of medications, as applicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366385 If continuation sheet Page 18 of 18