Health inspection·March 11, 2024

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Notice of Medicare Non-Coverage letters and staff interview, the facility failed to inform the residents of the appeal agency and their phone number. This affected five (Resident #22, Resident #28, Resident #29, Resident #49, and Resident #62) of five residents reviewed for liability notices. The census was 61. Residents Affected - Some Findings include: 1. Review of Resident #22's medical record revealed they were admitted to the facility on [DATE]. Review of a Notice of Medicare Non-Coverage letter revealed services were ended on 11/10/23. The letter did not contain the name and phone number of the agency to send an appeal. 2. Review of Resident #28's medical record revealed they were admitted to the facility on [DATE]. Review of a Notice of Medicare Non-Coverage letter revealed services were ended on 02/21/24. The letter did not contain the name and phone number of the agency to send an appeal. 3. Review of Resident #29's medical record revealed they were admitted to the facility on [DATE]. Review of a Notice of Medicare Non-Coverage letter revealed services were ended on 02/27/23. The letter did not contain the name and phone number of the agency to send an appeal. 4. Review of Resident #49's medical record revealed they were admitted to the facility on [DATE]. Review of a Notice of Medicare Non-Coverage letter revealed services were ended on 02/11/24. The letter did not contain the name and phone number of the agency to send an appeal. 5. Review of Resident #62's medical record revealed they were admitted to the facility on [DATE]. Review of a Notice of Medicare Non-Coverage letter revealed services were ended on 01/09/24. The letter did not contain the name and phone number of the agency to send an appeal. Interview on 03/05/24 at 12:45 P.M. with Social Service Director #882 verified the letters to the residents did not name the appeal agency's name or phone number. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366391 If continuation sheet Page 2 of 13 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 366391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Skilled Nursing and Rehabilitation 3537 12th Street, NW Canton, OH 44708 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** 2. Review of the medical record for Resident #41 revealed an admission date of 06/29/23 with diagnoses including chronic pulmonary obstructive disease, diabetes mellitus, and hypertension. Review of the 30-day discharge notice, dated 02/09/24, revealed Resident #41 was issued the discharge notice due to non-payment. Review of the progress note, dated 02/16/24 timed 3:00 P.M., revealed Resident #41 was issued a 30-day discharge notice due to non-payment. The note did not include information regarding notification to the Ombudsman. On 03/05/24 at 2:35 P.M., interview with Social Services Designee (SSD) #882 revealed the administrator or Business Office Manager (BOM) #807 completed the 30-day discharge notifications. On 03/06/24 at 2:42 P.M., interview with BOM #807 revealed she mailed the 30-day discharge notifications to the Ombudsman's office on 02/09/24. On 03/06/24 at 3:27 P.M., interview with Ombudsman #918 revealed she did not receive notification of the 30-day discharge notice issued in February 2024 for Resident #41. Ombudsman #918 stated the facility frequently failed to notify her of discharges in a timely manner. On 03/06/24 at 3:40 P.M., interview with BOM #807 verified she had no evidence of sending Resident #41's discharge notice to the Ombudsman's office. Review of facility policy titled Transfer or Discharge Notice, dated December 2016, revealed a copy of the discharge notice would be sent to the Ombudsman. Based on interview and record review the facility failed to provide timely notification to the state ombudsman of 30 day discharges for Resident #33 and Resident #41. This affected two residents of four reviewed for discharge notices. The facility census was 61. Findings include: 1. Review of Resident #33's medical records revealed the Resident was admitted on [DATE] with diagnoses including diabetes mellitus, fracture of the vertebrae (spine), lack of coordination, chronic obstructive pulmonary disease, and moderate cognitive impairment. Review of the Resident #33's Notice of 30-day Discharge for non-payment dated 02/09/24 indicated the Ohio Department of Health and Ombudsman were notified via postal mail. The proposed discharge date was 03/10/24. An interview on 03/06/23 at 2:42 P.M. with Business Office Manager #807 revealed the Notice of 30-day Discharge for Resident #33 was mailed via postal carrier on 02/09/24, however verified there was no evidence the notice was mailed on that date. An interview with Ombudsman #918 on 03/06/24 at 3:27 P.M. indicated receipt of Resident #33's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366391 If continuation sheet Page 3 of 13 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 366391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Skilled Nursing and Rehabilitation 3537 12th Street, NW Canton, OH 44708 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 Notice of 30-day Discharge for non- payment on 03/04/24. 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: 366391 If continuation sheet Page 4 of 13 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 366391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Skilled Nursing and Rehabilitation 3537 12th Street, NW Canton, OH 44708 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 ensure Resident #56 was provided adequate supervision to prevent an attempted elopement, and failed to investigate a fall and re-assess the resident to determine if current fall interventions remained appropriate to prevent future falls. This affected one (Resident #56) of five residents reviewed for accidents and hazards. Findings include: 1. Review of Resident #56's medical record revealed the resident was admitted on [DATE] with diagnoses including major depressive disorder, aphasia, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. Review of Resident #56's Wandering Risk assessment dated [DATE] revealed the resident was low risk for wandering. Review of Resident #56's Elopement Risk Assessment form dated 01/26/24 revealed the resident was a low risk for elopement. Review of Resident #56's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of a progress note dated 02/03/24 timed 8:30 P.M. authored by Registered Nurse (RN) #828 revealed RN #828 assessed Resident #56 due to a change in behavior. Resident #56 was observed pulling his brief out of his pants and trying to wrap the brief around the arm rest of his wheelchair. Resident #56 was also observed yelling in the hallway three feet from his room. RN #828 called the physician to report Resident #56 had deviated from his baseline behavior. The physician gave orders for bloodwork. The note further indicated at 7:20 P.M., RN #828 went to check on Resident #56 and the resident's room was dark and his wheelchair was on the left side of the bed near the window. A search was immediately conducted inside and outside the facility. Each unit was alerted to the missing resident. The administrator was called for guidance. The administrator provided instruction to call the family and find out if the resident went on a leave of absence (LOA). The family denied taking the resident on a LOA. The administrator arrived and searched outside. After an unknown time, the resident was found. He was dressed in pants, long-sleeved shirt, orange baseball cap and winter jacket. He was very agitated and a WanderGuard (a bracelet that triggers alarms and can lock monitored doors) was initiated and the resident's room was changed. Resident #56 was alert to self only. The physician was alerted to the incident and Resident #56 was sent to the emergency room (ER) for evaluation . Review of Resident #56's progress note dated 02/04/24 timed 5:20 A.M. authored by Assistant Director of Nursing (ADON) #808 revealed Resident #56 returned from the hospital and all assessments, labs and diagnostic results were negative and all medications were unchanged. Review of Resident #56's Wandering Risk assessment dated [DATE] revealed the resident was a moderate risk for wandering. Review of Resident #56's Elopement Risk assessment dated [DATE] revealed the resident was placed on one to one supervision for safety, a WanderGuard was placed, the resident's room was changed, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366391 If continuation sheet Page 5 of 13 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 366391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Skilled Nursing and Rehabilitation 3537 12th Street, NW Canton, OH 44708 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 the resident had family support. Level of Harm - Minimal harm or potential for actual harm Interview on 03/04/24 at 4:56 P.M. with the administrator revealed he came to the facility within five minutes of being called by the staff. Resident #56 was outside by the assisted living (AL) located on the same property when found by State Tested Nursing Assistant (STNA) #863. The administrator indicated staff brought Resident #56 back into the facility and assessed him. Resident #56 was on the property in back of the skilled nursing facility, by the AL. The administrator indicated he spent approximately forty-five minutes communicating with Resident #56 and found out the niece was in the building earlier in the day which aggravated Resident #56 and caused him to become upset and want to go home. The administrator stated Resident #56 was not in a wheelchair when the staff found him. Resident #56 walked out of the building although he was normally wheelchair bound due to right sided weakness. The staff had never observed Resident #56 walking independently prior to the incident. Residents Affected - Few Telephone interview on 03/04/24 at 5:09 P.M. with RN #828 revealed she was approached by STNA #849 who asked her to assess Resident #56. Resident #56 was sitting outside of his room door pulling his brief out of his pants and attempting to wrap it around the arm of his wheelchair. RN #828 stated Resident #56 appeared off his baseline and she called the physician. Physician #916 ordered bloodwork and a urinalysis. Upon checking in on Resident #56, approximately 30 minutes later, his room was dark, the lights were off, and his wheelchair was next to the window. RN #828 started looking for Resident #56 in the hallways and had an STNA look outside. RN #828 got the other staff involved, everyone was searching, and the administrator was called. The STNA (STNA #856) came back inside the building and reported she could not find Resident #56. Another STNA, STNA #863 eventually found Resident #56 outside on the property. RN #828 was not sure how Resident #56 got out of the building. RN #828 indicated the entire incident took place between 7:00 P.M. and 8:00 P.M.; she was aware Resident #56 was missing at approximately 7:20 P.M. When Resident #56 was located, brought back inside the facility, and returned to his room at approximately 8:00 P.M. she completed an assessment. Interview on 03/04/24 at 5:34 P.M. with STNA #856 revealed she was Resident #56's caregiver on 02/03/24. STNA #856 indicated she asked Resident #56 if he wanted something to drink, went to obtain the drink and came back to deliver the drink to find the resident was missing. STNA #856 stated she alerted the nurse immediately. She stated the staff looked in every closet and every room. She looked in the front part of the building and then her co-worker, STNA #863, found Resident #56 on the curb in front of the assisted living facility located on the same property. STNA #856 stated there was not a sidewalk and he apparently was tired from the walk and sat down on the curb. STNA #856 was not sure how long he was gone but she did observe him in his room maybe ten to fifteen minutes prior. STNA #856 said STNA #863 used her personal car to look for Resident #56 and observed the resident sitting on the curb. STNA #863 parked her car at the adjacent daycare and walked over to Resident #56 so she would not startle him. STNA #863 convinced Resident #56 to return to her car and drove him back to the facility. A follow up interview on 03/05/24 at 8:43 A.M. with the administrator revealed he thought Resident #56 may have left the building by the ambulance sliding door entrance off of the 300 hall because that door was never locked and the resident's room was located on the 300 hall near the sliding doors. Observation with the administrator of the path Resident #56 would have most likely traveled revealed upon exiting the ambulance sliding doors and turning to the right there was a driveway near the assisted living center. Resident #56 had been found at the end of that driveway sitting on the curb. The distance from the sliding glass ambulance door to the curb was approximately 422 feet. Interview on 03/06/24 at 9:13 A.M. with Therapy Director #888 indicated Resident #56 had the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366391 If continuation sheet Page 6 of 13 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 366391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Skilled Nursing and Rehabilitation 3537 12th Street, NW Canton, OH 44708 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 ability to walk with assistance. He was able to walk 20 feet and was fatigued easily. Therapy Director #888 indicated Resident #56 was impulsive and unsteady on his feet. Review of the Wandering and Elopement policy revised March 2019 revealed the facility would identify residents who were at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 2. Review of Resident #56's medical record revealed the resident was admitted on [DATE] and discharged on 02/25/24 with diagnoses including essential hypertension, hyperlipidemia and polyarthritis. Review of Resident #56's Fall Risk Assessment form dated 01/26/24 revealed the resident was a moderate risk for falls. Review of Resident #56's Falls Care Plan revealed interventions which included a parameter mattress, commode/urinal at bedside, commonly used articles within reach, maintain a clear pathway, bed stabilizers, lock bed, provide rest periods and rehab referral. Review of Resident #56's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #56's progress note dated 02/17/24 timed 11:46 A.M. revealed the nurse was called to the resident's room by the state tested nurse aide (STNA). The resident was in the bathroom and had been incontinent of stool and urine and was on the floor. Resident #56 was sitting with his back against the wall and had an open area to the right head with moderate bleeding and a laceration to the right elbow. The area to the right head was cleansed and dressed. The physician, assistant director of nursing and power-of-attorney were notified. Review of hospital documentation dated 02/17/24 revealed Resident #56 presented with an unwitnessed fall in his bathroom with head trauma. Resident #56 was admitted for observation with physical therapy and occupational therapy to see if his falls and abnormal neurologic exam could be limiting capabilities to coordinate and ambulate safely as well as performing activities of daily living (ADLs). The documentation indicated Resident #56 had a history of recent cerebrovascular accident (stroke) and right sided deficits. Review of Resident #56's progress note dated 02/20/24 timed 8:30 P.M. indicated the resident returned from the acute hospital via a stretcher. Review of Resident #56's progress note dated 02/20/24 timed 9:00 P.M. indicated the resident returned to the facility after a fall which resulted in a head laceration to the right upper scalp. Staples and glue were noted to the laceration. The incision was clean and dry with no drainage, redness, pain or swelling noted. His aphasia appeared to be far more scrabbled and word salad at best. Right sided weakness continued per the resident's baseline. Review of Resident #56's Fall Risk Assessment form dated 02/20/24 revealed the resident was a high risk for falls. Review of Resident #56's progress note dated 02/21/24 timed 8:27 P.M. (late entry) authored by Registered Nurse (RN) #828 revealed Resident #56 was observed in the restroom and conveyed by pointing and garbled noises that he wanted to use the toilet. The resident was assisted to transfer from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366391 If continuation sheet Page 7 of 13 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 366391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Skilled Nursing and Rehabilitation 3537 12th Street, NW Canton, OH 44708 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 wheelchair to the toilet. Resident #56 tried to self-transfer and pulled aggressively while lunging towards the toilet. Resident #56 was upset and assertively put his head on the wall four times. Bruising was noted and the stitches on his head remained intact. Interview on 03/06/24 at 9:13 A.M. with Therapy Director #888 indicated Resident #56 had the ability to walk with assistance. He was able to walk 20 feet and was fatigued easily. Therapy Director #888 indicated Resident #56 was impulsive and unsteady on his feet. Interview on 03/06/24 at 4:13 P.M. with STNA #856 revealed on 02/21/24, Resident #56 was found in the bathroom on the floor. He was sitting Indian style on the floor in the bathroom between the wheelchair and the toilet. STNA #856 leaned down to assist the resident up and he jumped up with her assistance and got in the wheelchair. He then immediately jumped out of the wheelchair and got on the toilet which caused him to bump his head against the wall with no injuries. STNA #856 said she reported she found the resident on the floor to RN #828 who then assessed the resident. Interview on 03/06/24 at 5:08 P.M. with RN #828 indicated she documented exactly what she observed on 02/21/24 and she was not aware Resident #56 was found on the floor at the time she completed the assessment. RN #828 said a fall investigation was not completed for Resident #56's fall as she was unaware the resident was found on the bathroom floor. Interview on 03/11/24 at 10:59 A.M. with the Director of Nursing (DON) indicated she had spoken to RN #828 who denied she was informed Resident #856 sustained a fall on 02/21/24. Review of the Fall policy revised March 2018 indicated staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. This deficiency represents non-compliance investigated under Complaint Numbers OH00151670 and OH00151384. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366391 If continuation sheet Page 8 of 13 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 366391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Skilled Nursing and Rehabilitation 3537 12th Street, NW Canton, OH 44708 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on record review and interview, the facility failed to ensure there was a full-time dietary manager to oversee daily kitchen operations. This had the potential to affect all 58 residents (except Residents #9, #54 and #212) who received food from the kitchen. The facility census was 61. Findings include: Review of the dietary staff schedules and punch detail for February 2024 through March 2024 revealed [NAME] #811 worked part-time, less than 35 hours per week. On 03/04/24 at 7:30 A.M., interview with [NAME] #810 revealed there was no dietary manager and that [NAME] #811 was overseeing kitchen operations. On 03/05/24 at 3:04 P.M., interview with Registered Dietitian (RD) #819 revealed she was part time at the facility and was only in the building for eight to ten hours per week, spending most of her time on clinical work. On 03/05/24 at 3:33 P.M., interview with Regional Quality Assurance Nurse #920 revealed [NAME] #811 was a Certified Dietary Manager and that [NAME] #811 had no interest in being a manager. On 03/06/24 at 2:57 P.M., interview with Regional Director of Operations #917 revealed the former dietary manager's last day was on 02/21/24. On 03/06/24 at 5:00 P.M., interview with Regional Director of Operations #917 verified the dietary staff schedules and confirmed that [NAME] #811 only worked part-time in the kitchen. Review of a list provided by the facility revealed Residents #9, #54 and #212 did not receive food prepared in the kitchen. This deficiency represents non-compliance investigated under Complaint Number OH00151691. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366391 If continuation sheet Page 9 of 13 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 366391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Skilled Nursing and Rehabilitation 3537 12th Street, NW Canton, OH 44708 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and review of the dietary schedules, the facility failed to ensure there was sufficient competent staff to work in the kitchen. This had the potential to affect all 58 residents (except Residents #9, #54, and #212) who received food from the kitchen. The facility census was 61. Findings include: Review of the dietary staff punch detail revealed there was no morning dietary aide and no evening cook on 02/22/24; no dietary aide all day and no evening cook on 02/23/24; no morning dietary aide on 02/24/24; no morning dietary aide and no evening cook on 02/26/24; no morning dietary aide on 02/27/24; no morning dietary aide on 02/28/24; no evening cook on 03/01/24; no morning dietary aide on 03/02/24, and no morning dietary aide on 03/04/24. On 03/04/24 at 7:30 A.M., interview with [NAME] #810 revealed there was not enough dietary staff and staff from other departments had to help in the kitchen. On 03/05/24 at 10:48 A.M., observation of the resident activity occurring in the dining room revealed Activities Director #802 ended the activity early to assist in the kitchen. On 03/06/24 at 9:25 A.M., interview with Bus Driver #915 revealed he was working in the kitchen due to a shortage of dietary staff. On 03/06/24 at 9:49 A.M., interview with Activities Director #802 verified she ended the activity on 03/05/24 to help with lunch. Activities Director #802 stated she had helped in the kitchen a couple times over the past couple weeks due to not having enough staff in the kitchen. On 03/06/24 at 5:00 P.M., interview with Regional Director of Operations #917 verified the dietary schedules and punch detail. She stated that shifts without dietary staff were covered by administrative staff. Regional Director of Operations #917 stated on the shifts without a cook, Business Office Manager (BOM) #807 and Social Services Designee (SSD) #882 cooked the meals for the residents. In regard to training, Regional Director of Operations #917 stated BOM #807 and SSD #882 had received their annual trainings on facility policies. On 03/07/24 at 12:20 P.M., interview with BOM #807 revealed her kitchen training consisted of shadowing [NAME] #810 a couple times while he showed BOM #807 how to prepare the foods for specialized diets and mechanical alterations. On 03/07/24 at 12:24 P.M., observation of the kitchen revealed the following staff were working in the kitchen for lunch tray line: BOM #807, [NAME] #810, Personal Care Assistant (PCA) #879, and Respiratory Therapist (RT) #886. Interview at the time of observation with PCA #879 and RT #886 revealed they helped in the kitchen as dietary aides whenever needed. The facility was unable to provide evidence that all non-dietary staff working in the kitchen had received training in food safety and food preparation for specialized diets or mechanical alterations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366391 If continuation sheet Page 10 of 13 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 366391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Skilled Nursing and Rehabilitation 3537 12th Street, NW Canton, OH 44708 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 0802 Level of Harm - Minimal harm or potential for actual harm Review of a list provided by the facility revealed Residents #9, #54 and #212 did not receive food prepared in the kitchen. This deficiency represents non-compliance investigated under Complaint Number OH00151691. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366391 If continuation sheet Page 11 of 13 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 366391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Skilled Nursing and Rehabilitation 3537 12th Street, NW Canton, OH 44708 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on record review, observation, interview, and review of facility policy, the facility failed to store foods in a manner to prevent contamination, monitor sanitizer solution concentration, monitor dishwasher temperatures, and ensure staff working in the kitchen had their hair secured and covered. This had the potential to affect all 58 residents (except Residents #9, #54, and #212) who received food from the kitchen. The facility census was 61. Findings include: On 03/04/24 at 7:30 A.M., tour of the kitchen revealed there were 10 boxes of food stored on the floor in the walk in freezer, which was verified by [NAME] #810 at the time of observation. In the walk-in refrigerator, there was one bag of shredded cheese that was open to air and not sealed, one bag of shredded carrots that was open to air and not sealed, and one container of pasta salad that was open to air and not sealed, all of which were verified by [NAME] #810 at the time of observation. During the tour, Business Office Manager (BOM) #807 entered the kitchen with her hair unsecured. BOM #807 proceeded to walk through the kitchen, stopped by the food preparation table in the middle of the kitchen and combed her fingers through her hair, after which she secured part of her hair with a hair tie and then twisted her hair into a bun and secured it. After securing her hair in the food preparation area, BOM #807 then obtained a hair net and put it over her hair. BOM #807 verified this at the time of observation. On 03/06/24 at 9:30 A.M., observation of the kitchen revealed four boxes of food stored on the floor in the walk-in freezer, which was verified by [NAME] #811 at the time of observation. There were two prepared food items in the walk-in refrigerator with preparation dates of 03/07/24 and [NAME] #811 verified that the preparation date was marked incorrectly on those two items. On 03/07/24 at 1:05 P.M., observation of the logs posted in the kitchen titled Sanitizing Sink and Bucket Log and Dishwashing/Warewashing Machine Temperature Log for February 2024 revealed several blanks on the logs. There were no logs posted for March 2024. Review of the sanitizing sink and bucket log revealed there was no documentation of the sanitizing solution on 02/03/24 at dinner, 02/05/24 at breakfast and lunch, 02/07/24 at breakfast, 02/08/24 at dinner, 02/09/24 at dinner, 02/12/24 at dinner, 02/13/24 at dinner, 02/14/24 at lunch and dinner, 02/16/24 at lunch, 02/18/24 at dinner, 02/19/24 at breakfast and lunch, 02/22/24 at all three meals, 02/23/24 at lunch and dinner, 02/24/24 at lunch and dinner, 02/25/24 at lunch, 02/26/24 at dinner, 02/27/24 at dinner, 02/28/24 at breakfast and lunch, and 02/29/24 at lunch. Review of the dishwasher temperature log revealed there was no temperature recorded on 02/03/24, 02/06/24, 02/09/24, 02/10/24, 02/11/24, 02/12/24, 02/13/24, 02/14/24, 02/15/24, 02/16/24, 02/17/24, 02/19/24, 02/20/24, 02/22/24, 02/23/24, 02/24/24, 02/25/24, 02/26/24, 02/27/24, and 02/28/24. In addition, the temperature for 02/21/24 was logged after the temperature for 02/29/24 on the log. On 03/07/24 at 1:50 P.M., interview with the administrator verified the missing documentation on the sanitizing and dishwashing logs from the kitchen and that the dishwasher temperature log had dates out of order. He also verified there were no sanitizer or dishwasher temperature logs for March 2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366391 If continuation sheet Page 12 of 13 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 366391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Skilled Nursing and Rehabilitation 3537 12th Street, NW Canton, OH 44708 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of facility policy titled Food Preparation and Service, dated April 2019, revealed food and nutrition services employees would prepare and serve food in a manner that complied with safe food handling practices and food and nutrition services staff would wear hair restraints. Review of facility policy titled Food Receiving and Storage, dated October 2017, revealed foods would be stored in a manner that complied. Review of a list provided by the facility revealed Residents #9, #54 and #212 did not receive food prepared in the kitchen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366391 If continuation sheet Page 13 of 13