Health inspection·October 20, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few adverse outcomes, was absent of any distress, and they were monitoring him. On [DATE] at 8:15 A.M., RN #111 spoke with Resident #12's Responsible Party (RP) and notified the RP of Resident #12 leaving the facility and being taken to hospital by law enforcement.On [DATE] at 9:30 A.M., Resident #12 returned to the facility accompanied by paramedics. RN #111 obtained vital signs and assessed Resident #12. Resident #12's Responsible Party was notified of the resident's return to the facility and present at bedside at the time of assessment. Resident #12 was non-verbal, had non-sensical speech, and was unable to provide any pertinent information due to cognitive impairment.On [DATE] at 9:30 A.M., Resident #12's wander guard was placed back on by RN #111 and Resident #12 was placed on one-on-one (1:1) supervision.On [DATE] from 9:00 A.M. to 1:57 P.M., RN Manager #109, Administrator, and Assistant Director of Nursing (ADON) #103, Therapy Director #112, and Housekeeping Supervisor #113 educated facility staff on the Wandering/unsafe resident policy, Behavioral Assessment, Intervention, and Monitoring policy, ensuring interventions were in place for residents with exit seeking behaviors which may include but was not limited to 15 min checks, 1:1, and wander guards, ensuring interventions were put back in place when residents returned from the hospital, and not giving residents or families the door code.On [DATE] from 9:30 A.M. to 10:17 A.M., RN #101 audited resident orders and care plans for wander guards. Any variances were corrected immediately upon audit.On [DATE] from 10:00 A.M. to 11:30 A.M., Receptionist #114 and Maintenance Director #115 audited all residents with wander guards for functioning, placement, and to ensure all were within expiration date. All were placed properly, functioning appropriately, and not expired. No variances were noted.On [DATE] from 10:00 A.M. to 11:30 A.M., Maintenance Director #115 audited all exit doors and the wander guard system at all doors to ensure proper function. On [DATE] from 10:30 A.M. to 12:00 P.M., RN #101 audited 30 days of current resident progress notes to ensure if behaviors consistent with exit seeking were noted, then residents had appropriate interventions in place. On [DATE] at 12:00 P.M., Resident #12's Nurse Practitioner (NP) #116 was notified of Resident #12 leaving the facility and being taken to hospital by law enforcement with return to facility. On [DATE] from 12:00 P.M. to 12:15 P.M., the Administrator audited the facility records of exit door function checks for the last 30 days. On [DATE] from 12:00 P.M. to 2:00 P.M., ADON #103 completed elopement and wandering risk assessments on all in-house residents. On [DATE] from 12:45 P.M. to 12:54 P.M., an elopement drill was completed by Maintenance Director #115. On [DATE] from 2:00 P.M. to 2:10 P.M., an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the facility correction plan including ongoing compliance.On [DATE] from 3:45 P.M. to 4:15 P.M., ADON #103 educated all current resident responsible parties via phone that they were to ensure staff let them in and out the doors when the front door was locked and should not enter the code themselves or let anyone else out without staff assistance.On [DATE] from 3:45 P.M. to 4:00 P.M., SecureCare was called and the front door code was changed by Maintenance Staff #117.On [DATE], the Care Conference form was updated by the Administrator to include education for new families and a reminder for others to request staff assistance with doors when locked, not put in code themselves or assist anyone else out of facility.On [DATE], Resident #12's care plan was updated by RN #101 to include wandering and elopement risk with interventions including 1:1 as needed, monitor and report changes in behaviors, orient to new surroundings, provide diversional activities of interest as needed (based on the activities assessment completed on [DATE] at the time of admission), redirect as needed, and wander guard with placement and function checks as ordered. Beginning on [DATE], nursing staff would monitor the effectiveness of interventions for Resident #12 by reviewing point of care (POC) documentation five days weekly Monday through Friday and conducting a 72-hour review on Monday for weekend POC. CNAs would report behaviors to the charge nurse if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366391 If continuation sheet Page 2 of 6 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 10/20/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few behaviors were not resolved with interventions. In addition, 1:1 (staff) supervision would continue for Resident #12 until discharge.Beginning on [DATE], if a call off occurred for a person doing 1:1 supervision, the Administrator would be immediately notified and re-assign floor staff, management staff, or other department staff to cover 1:1 as appropriate. The Administrator would oversee 1:1 coverage scheduling.Beginning on [DATE], all new hires and agency staff would be educated regarding the facility's Wandering/unsafe resident policy, Behavioral Assessment, Intervention, and Monitoring policy, ensuring interventions are in place for residents with exit seeking behaviors which may include but was not limited to 15 min checks, 1:1, and wander guards, ensuring interventions are put back in place when residents return from the hospital, and not giving residents or families the door code.Beginning on [DATE], the Administrator or designee would review all door checks five times a week for four weeks to ensure all doors were checked and functioning appropriately. All variances would be corrected upon discovery and education/follow-up would be provided as deemed necessary.Beginning on [DATE], Maintenance Director #115 or designee would conduct elopement drills weekly for four weeks to ensure staff respond accordingly. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.Beginning on [DATE], the DON or designee would assess all residents with wander guards to ensure proper placement, function and expiration three times a week for a period of four weeks. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.Beginning on [DATE], the Administrator or designee would audit the wander guard system and resident accessible exit doors to ensure they were functioning properly three times a week for a period of four weeks to ensure all doors were intact and functioning properly, including alarm. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.Beginning on [DATE], the DON or designee would complete elopement and wandering risk assessments for facility residents weekly for period of four weeks to ensure no changes in behavior patterns or acute changes in condition affecting mental status were present placing residents at risk for elopement and ensuring that appropriate and effective interventions were in place. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.Beginning on [DATE], the DON or designee would audit progress notes five times weekly for a period of four weeks to ensure any residents with behaviors that increase risk for elopement or exit seeking have appropriate interventions in place.Beginning on [DATE], the Administrator or Designee would interview two visitors three times weekly for four weeks to ensure visitors were aware they were not to enter door codes when the door was locked and should wait for staff assistance to exit facility, as well as not let anyone else out without staff assistanceBeginning on [DATE], the facility Quality Assurance (QA) committee would review audits weekly to ensure compliance. Variances would be corrected Immediately upon discovery and education provided. Results of these audits would be reported to the facility quality assurance committee. Ongoing compliance would be maintained by recommendations of the facility quality assurance committee. Findings include: Review of the medical record for Resident #12 revealed an admission date of [DATE] with diagnoses including senile degeneration of brain, anxiety disorder, encephalopathy, and type two diabetes mellitus. Review of the admission Nursing Observation, dated [DATE] at 5:58 P.M., revealed Resident #12 was alert and oriented to person only. Resident #12 required limited assistance for walking in his room and in the corridor. Review of the wandering risk assessment, dated [DATE] at 6:13 P.M., revealed Resident #12 was at high risk for wandering with a score of 12. The assessment indicated Resident #12 was disoriented, did not understand surroundings, admitted within the last month, ambulated with one assist, had a diagnosis of Alzheimer's disease, and had a history (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366391 If continuation sheet Page 3 of 6 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 10/20/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few of wandering. Review of the Brief Interview for Mental Status (BIMS) assessment, dated [DATE] at 6:14 P.M., revealed Resident #12 had severe cognitive impairment with a score of 0 out of 15. Review of the elopement risk assessment, dated [DATE] at 6:15 P.M., revealed Resident #12 was physically capable of leaving the building, was confused to time and place, and displayed wandering behaviors. Interventions included a wander guard (a device intended to alarm/alert staff when they approach or exit secured areas) Review of the progress note dated [DATE] at 4:06 A.M. revealed on [DATE] at approximately 11:57 P.M., Resident #12 experienced a seizure, paramedics were called, and paramedics transported Resident #12 to the emergency room for evaluation on [DATE] at 12:30 A.M.Review of LPN #107's witness statement (obtained [DATE]) indicated when paramedics were attempting to transport Resident #12 to the hospital on [DATE] around 12:30 A.M., the door alarms were sounding due to the resident's wander guard, and the paramedics cut the wander guard off Resident #12 at that time. Review of the progress note dated [DATE] at 6:30 A.M. revealed Resident #12 returned from the hospital at that time and vitals were obtained, skin was assessed, morning medication was provided, and the physician and family were notified of the resident's return. The note did not include any information regarding a wander guard being applied upon the resident's return to the facility. Review of RN #119's witness statement (obtained [DATE]) indicated she was the nurse who re-admitted Resident #12 upon returning from the hospital on [DATE] at 6:30 A.M. and she was unaware that Resident #12 required a wander guard. RN #119 did not verify whether Resident #12 had a wander guard or not and did not assess the resident's need for a wander guard. Review of the progress note dated [DATE] at 11:19 A.M. revealed Resident #12 appeared very tired and the resident's nurse practitioner was notified. There were no progress notes written between [DATE] at 11:19 A.M. and [DATE] at 4:35 A.M. Review of the facility's incident log revealed an elopement incident for Resident #12 on [DATE] at 4:35 A.M. Review of CNA #122's witness statement (obtained [DATE]) indicated Resident #12 was wandering the building, he was re-directed to watch television, CNA #122 went to complete rounds, and at some point a door alarm was going off but other staff responded so she continued to do her work. Review of CNA #123's witness statement (obtained [DATE]) indicated Resident #12 was wandering throughout the building during the night and staff were attempting to keep the resident occupied with television, snacks, and conversation. The statement included at 2:30 A.M., CNA #123 observed another staff member escort Resident #12 back to his room. Review of RN #108's witness statement (obtained [DATE]) indicated Resident #12 was wandering during the night throughout the building and staff attempted to redirect with snacks, television, and conversation. Around 2:30 A.M., Resident #12 appeared to be very tired and was escorted back to his room. Review of LPN #107's witness statement (obtained [DATE]) indicated Resident #12 set off the door alarm on the 200-hall around 3:00 A.M. and was redirected at that time, however, the resident continued to walk up and down the hallway. Review of CNA #121's witness statement (obtained [DATE]) indicated Resident #12 would not stay in his room and was walking throughout the building, setting off the door alarm on the 200-hall during her shift. The statement included CNA #121 last saw Resident #12 walking in the hall around 3:30 A.M. Review of CNA #106's witness statement (obtained [DATE]) indicated they last saw Resident #12 walking back and forth in the hallway on [DATE] at 3:50 A.M. and redirection attempts were unsuccessful. Review of LPN #107's witness statement (obtained [DATE]) indicated she worked night shift on [DATE] and Resident #12 went to the hallway doors, which caused the alarms to sound, and she assumed the (resident's) wander guard had been re-applied. LPN #107 did not assess Resident #12 to verify that the wander guard had been re-applied. LPN #107 indicated Resident #12's responsible party had informed staff upon admission that wandering and pacing were normal behaviors for Resident #12, so they allowed the resident to do so and redirected as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366391 If continuation sheet Page 4 of 6 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 10/20/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few needed. LPN #107 received a phone call from local law enforcement on [DATE] at 4:35 A.M. informing her that Resident #12 had been found while walking and they were taking the resident to the emergency room for evaluation. LPN #107's statement also indicated the front doors were locked, however, the family members of another resident were letting themselves in and out of the building throughout the night without staff assistance and LPN #107 believed Resident #12 followed someone out the door as they left. Review of CNA #120's witness statement (obtained [DATE]) indicated Resident #12 was observed walking up and down the hallway on [DATE] at 3:45 A.M. and that CNA #106 attempted to get Resident #12 to lay down at 3:50 A.M., which the resident refused. CNA #120's statement further revealed other residents had family members in the facility throughout the night who knew the code to the doors and were going in and out without staff assistance. CNA #120 indicated Resident #12 must have followed someone out the door. Review of the historical weather information, obtained from https://www.timeanddate.com/weather/usa/[NAME]/historic?month=10&year=2025, revealed on [DATE] around 3:51 A.M. the outside temperature was 46 degrees Fahrenheit, and the skies were clear. Review of police report #2510545 revealed law enforcement received a call on [DATE] at 4:16 A.M. from a concerned citizen (Good Samaritan) regarding a man walking in the road wearing a t-shirt, pajama pants, and no shoes. Law enforcement arrived on scene on [DATE] at 4:29 A.M. and identified the man as Resident #12. Law enforcement officers called the facility to notify them that they had located Resident #12, facility staff confirmed Resident #12 was supposed to be in their care, and facility staff were unable to provide a response as to how this happened. Review of the progress note dated [DATE] at 4:35 A.M. revealed the facility received a phone call from local law enforcement, who found Resident #12 walking outside the facility with no apparent injuries. The police officers took Resident #12 to the hospital for an assessment. Immediate interventions upon return would be a wander guard and one-on-one (1:1) staff supervision. Review of the progress note dated [DATE] at 9:30 A.M. revealed Resident #12 returned from the hospital at that time, vitals were obtained, Resident #12 was placed on 1:1 supervision, and a wander guard was placed on the resident's right ankle. Review of the functional abilities and goals assessment, dated [DATE] at 1:18 P.M., revealed Resident #12 required (staff) supervision or touching assistance for putting on/taking off footwear, lying to sitting on edge of bed, sit to stand, transfers, walking 10 feet, walking 50 feet, walking 150 feet, going up and down a one-step curb, going up and down up to 12 steps, and did not utilize a wheelchair or scooter. Review of the elopement care plan, initiated [DATE], revealed Resident #12 was at risk for elopement or wandering due to impaired cognition. Interventions included one-on-one staff as needed ([DATE]), monitor and report changes in behavior ([DATE]), orient resident to new surroundings ([DATE]), provide diversional activities of interest ([DATE]), redirect as needed ([DATE]), and wander guard with placement and function checks as ordered ([DATE]). Review of the physician's orders for Resident #12 revealed an order for a wander guard to be placed to right ankle and check placement and function every shift dated [DATE]. On [DATE] at 1:01 P.M., an interview with RN Manager #109 revealed on the day of the incident, she got a call that Resident #12 was taken to the hospital by the police. RN Manager #109 said she notified the Administrator and ADON #103. RN Manager #109 stated Resident #12 had been wandering quite a bit that night and staff tried to re-direct with activities and snacks but were unsuccessful. RN Manager #109 revealed staff reported to her Resident #12 was last seen about 30-45 minutes prior to the call from the police. RN Manager #109 confirmed on the previous night, Resident #12 had to be transported to the hospital and the paramedics cut the wander guard off Resident #12 at that time. On [DATE] at 1:40 P.M., an interview with CNA #106 revealed following admission Resident #12 had been wandering around the halls and it was impossible to chase someone around for 12 hours and get (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366391 If continuation sheet Page 5 of 6 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 10/20/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete all other assigned duties completed at the same time. CNA #106 said Resident #12 would not sit for long periods of time and was going door to door all night long. CNA #106 said Resident #12 was supposed to have a wander guard, but it had been cut off when he went to the hospital the night before. CNA #106 said the wander guard must not have been put back on because it would have alarmed when the resident left the facility if it had been in place. CNA #106 revealed Resident #12 had set off the alarm on the egress door on the hallway, but he thought Resident #12 followed someone out the front sliding doors because those doors stay open for several seconds once they are unlocked. On [DATE] at 2:12 P.M., an interview with Resident #12's Responsible Party revealed Resident #12 went to the hospital in the middle of the night Friday ([DATE]) and the resident's wander guard had been removed at the time he left the facility. The Responsible Party indicated she believed facility staff neglected to replace the wander guard upon his return to the facility on Saturday ([DATE]). She further revealed when Resident #12 admitted , she informed the facility of his wandering behaviors and the need for a wander guard at all times. On [DATE] at 4:19 P.M., an interview with the Administrator verified the witness statements obtained from staff reflected the on-duty nurse was unaware of Resident #12's need for a wander guard upon his return to the facility on [DATE] at 6:30 A.M. The Administrator also verified on [DATE] Resident #12 was located approximately one-half mile away from the facility. Attempts to contact LPN #107 and RN #108, who were on duty at the time of the incident, were unsuccessful during the investigation. Review of the facility policy titled Wandering and Elopements, revised [DATE], revealed the facility would identify residents at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment. If at risk for wandering or elopement, resident care plans would include strategies and interventions to maintain the resident's safety. If a resident goes missing, the elopement/missing resident emergency procedure would be initiated to: a) determine if the resident was out on authorized leave; b) if not on authorized leave, initiate a search of the building and premises; and c) if unable to locate the resident, notify the Administrator, the DON, the resident's legal representative, the attending physician, and law enforcement officials. This deficiency represents non-compliance investigated under Complaint Number 2642643. Event ID: Facility ID: 366391 If continuation sheet Page 6 of 6