Health inspection·December 27, 2022

F 0602 Ativan was transferred for Resident #190. Level of Harm - Minimal harm or potential for actual harm Review of Controlled Substance Accountability Sheet dated [DATE] revealed LPN #600 had written two Norco were transferred for Resident #188. Residents Affected - Some Review of the written witness statement dated [DATE] at 11:00 P.M. by LPN #602 revealed they were approached by another nurse (LPN #601) asking for assistance with obtaining a resident's as needed medication. The medication could not be dispensed due to the maximum doses had been dispensed in the last 24-hours. Review of the shift report revealed one nurse (LPN #600) had pulled all the allowed medication but none of the medication could be accounted for on the medication administration record (MAR) as being administered or in the narcotic count book as being pulled. New controlled substance accountability sheets had been made by the nurse that had dispensed the medication and the dispensed medication were not listed and the original controlled substance accountability sheets could not be located. Review of other resident's medications revealed the same concerns. Review of the written witness statement (no date) by LPN #601 revealed she attempted to pull Norco 5-325 for Resident #188. The medication was unable to be dispensed due to the maximum amount for the day had been dispensed. Pharmacy was called and told that the records revealed Resident #188 had only been dispensed three doses of Norco in the last 48 hours. Review of the narcotic book revealed a new controlled substance accountability sheet was started on [DATE] that showed LPN #600 had transferred three Norco. This nurse and another night shift nurse looked for the previous narcotic sheet. Dispense records revealed eight Norco tablets were pulled on [DATE] and [DATE] and only three were marked as administered. Resident #17 requested as needed Percocet. This medication also was not available to be dispensed due to LPN #600 had pulled the medication and Resident #17 was only allotted one Percocet 5-325 mg every 24 hours. The Percocet 5-325 mg was not signed off as administered or on the narcotic sign off sheet. The Director of Nursing (DON), Assistant Director of Nursing, and Corporate Nurse were notified. Review of the facility self-reported incident (SRI) tracking number 221707 dated [DATE] for misappropriation by facility staff affecting Residents #44, #188, and #190. The dispensed controlled medications were found without confirmation of administration of medication. A staff nurse notified administration when they discovered no available medication on a resident's prescription. An investigation was initiated, and the employee was suspended pending an investigation. Pharmacy was notified and dispense reports for the previous two weeks were pulled for the suspected nurse as well as other nurses for comparison. An employee was interviewed, a statement was taken, and a drug test was completed and was negative. The appropriate MARs and reports were reviewed. The Ohio Department of Health, police department, pharmacy, medical director, and Ohio Board of Nursing were notified. Review of the facility investigation dated [DATE] revealed night shift agency LPN #601 notified administration they were unable to pull narcotics for a resident due to all doses had already been dispensed. When the controlled substance accountability sheets were reviewed, it was discovered information had been transferred to a new sheets and LPN #600 had written transfer at the top of the sheets. The previous controlled substance accountability sheets were not located. Controlled dispenses for LPN #600 and all nurses were compared and it was determined LPN #600 dispensed a much higher amount. LPN #600's statement was taken, and LPN #600 stated she had shredded the original controlled substance accountability sheets for the medications and had left them in the drawer of the medication cart. The medications were unaccounted for, and LPN #600 failed to sign out the medications on the MAR. The diversion investigation revealed LPN #600 stated she forgot to sign the MAR for the as needed medications she had administered. LPN #600 also stated she pulled extra controlled as needed medications to be courteous for the following shift to administer if needed. LPN #600 stated she double (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 2 of 15 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 366463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Wooster 1700 East Smithville Western Road Wooster, OH 44691 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some locked the medications in the cart but did not complete a controlled substance accountability sheet. The total number of discrepancies identified was 95 with a discrepancy rate was 97.94%. LPN #600 denied taking the medications. No medication errors were identified, no negative findings involving residents, and all medications were to be credited per facility via pharmacy. On [DATE], LPN #600 was assigned to work 6:00 P.M. to 6:00 A.M. At approximately 11:00 P.M. on [DATE], LPN #601 attempted to dispense a controlled substance for a resident and noted no further dispenses were available as the number of pills on the prescription had been exhausted. LPN #601 checked with a coworker, notified pharmacy, management, and the doctor on-call that a resident's medication could not be dispensed. A new order was obtained so the resident could receive the requested medication. The nurses also noted the controlled substance accountability sheets had been transferred to a new sheet (page two) and page one was unavailable. The MAR for each of the residents had not been initialed to identify medication was administered. Further review of the facility investigation revealed, when questioned, LPN #600 denied diverting the medication for herself or anyone else. LPN #600 admitted she dispensed the medications, and she administered the medications but forgot to document in the MAR. In addition, LPN #600 stated the medications she did not administer were locked in the medication cart as a courtesy to the following shift in case they would need to administer as needed medication. LPN #600 admitted she did not print out the Controlled Substances Accountability Sheet for the medication she dispensed and place it in the cart for shift-to-shift count. The other staff nurses denied medications being left in the cart. LPN #600 verified she shredded page one of the Controlled Substances Accountability Sheets for several residents. A drug test was completed on [DATE] and the results were negative. A limited accountability audit was conducted which included all controlled as needed medications from the AlixaRX (on-site medication dispensing machine) dispensed by LPN #600. The pharmacy report identified 97 as needed controlled medications dispensed to LPN #600 with a total of two out of the 97 controlled medications initialed on MAR as administered. Results of the audit included but may not be limited to: a. controlled substances were dispensed without further documentation on the MAR to substantiate administration of the drug to the resident. b. Controlled Substances Accountability Sheets (page one) were disposed of and transferred to page two. c. Controlled substances were signed out without accountability for waste. d. Controlled Substances Accountability Sheets were rewritten as transferred and the original page one with signatures was unavailable. Review of the Control PRN (as needed) Dispenses by Shift from [DATE] to [DATE] revealed LPN #600 dispensed 79 Oxycodone 10 mg for Resident #44. One other nurse dispensed two Oxycodone on [DATE]. Review of the MAR revealed LPN #600 administered two of the 79 Oxycodone to Resident #44. Review of the Control PRN Dispenses by Shift from [DATE] to [DATE] revealed LPN #600 dispensed 24 Ativan 0.5 mg for Resident #190. No other nurses dispensed Ativan for Resident #190. Review of the MAR revealed no documentation LPN #600 administered any of the 24 Ativan to Resident #190. Review of the Control PRN Dispenses by Shift from [DATE] to [DATE] revealed LPN #600 dispensed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 3 of 15 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 366463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Wooster 1700 East Smithville Western Road Wooster, OH 44691 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some eight Norco 5-325 mg for Resident #188. No other nurses dispensed Norco for Resident #188. Review of the MAR revealed LPN #600 administered one of the eight Norco to Resident #188. Review of the Control PRN Dispenses by shift from [DATE] to [DATE] revealed LPN #600 dispensed one Percocet 5-325 mg for Resident #17. No other nurses dispensed Percocet for Resident #17. Review of the MAR revealed no documentation LPN #600 administered the Percocet to Resident #17. A typed statement by LPN #600 dated [DATE] revealed she received a call from Corporate Registered Nurse (RN) #604 on [DATE] to come to the facility as soon as possible to discuss the narcotic count sheets. LPN #600 got someone to watch her child and went to the facility as quickly as possible. LPN #600 wrote she had never taken any medication from the facility. LPN #600 stated she was trained to pull as needed medications for her shift and the next shift. LPN #600 wrote she did not understand the severity of pulling these medications. A note handwritten at the bottom of the statement revealed the nurse was shaking, nervous, repeated questions, and seemed confused. Review of complaint form dated [DATE] revealed the Ohio Board of Nursing was notified of the allegation of misappropriation by LPN #600. Review of Employee Discipline Form dated [DATE] revealed LPN #600 had a serious/critical violation due to the facility's Controlled Substances and Controlled Substance Storage policy and procedure was not followed and the destruction of reconciliation sheets and improper storage of controlled substances. LPN #600 was terminated on [DATE]. On [DATE], the Ohio Board of Nursing subpoenaed a certified copy of the entire personnel file of LPN #600 as well as a certified copy of LPN #600 timesheets for May, a certified copy of any and all investigative records related to LPN #600. A certified copy of any and all drug screen records, including chain of custody paperwork, screen results, and any confirmation report or Medical Review Officer report. Interview on [DATE] at 11:35 A.M. Corporate RN #604 revealed an investigation was completed but the facility was unable to prove that LPN #600 took the missing medications. Corporate RN #604 verified medications were missing for Residents #17, #44, #188, and #190. Corporate RN #604 verified the facility had identified 95 controlled medications were missing but was unable to verify the exact amount due to LPN #600 shredded multiple Controlled Substance Accountability Sheets. The Abuse Prohibition policy (no date) revealed misappropriation of resident property meant the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings without the residents consent. Review of Medication Administration-Preparation and General Guidelines Controlled Substances Policy and Procedure dated 12/17 revealed accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the date and time of administration, amount administered, remaining quantity, and initials of the nurse administering the medication on the accountability record and MAR. Current controlled substance accountability records were kept in a designated book. Completed accountability records are submitted to the Director of Nursing and kept on file for five years at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 4 of 15 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 366463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Wooster 1700 East Smithville Western Road Wooster, OH 44691 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, self-reported incident review, facility investigation review, policy and procedure review, and interview the facility failed to follow their policy for the prevention of misappropriation of resident medication for Residents #17, #44, #188, and #190. This affected four (Residents #17, #44, #188, and #190) out of six residents reviewed for misappropriation. The facility census was 77. Residents Affected - Some Findings include: Review of the employee file revealed Licensed Practical Nurse (LPN) #600 was hired on [DATE] for the 6:00 P.M. to 6:00 A.M. shift. LPN #600's nursing license was in good standing and was issued on [DATE] and expired [DATE]. Review of the medical record revealed Resident #17 was admitted on [DATE] with diagnoses including chronic pain, rotator cuff tear, hammer toes, and mononeuropathy of bilateral lower limbs. Resident #17 was ordered Percocet (opioid) 5-325 milligram (mg) by mouth every 24 hours as needed for pain. Review of the medical record revealed Resident #44 was admitted on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia, chronic pain syndrome, anxiety, and pain in right knee. Resident #44 was ordered Oxycodone (opioid) 10 mg by mouth every three hours as needed for pain. Review of the medical record revealed Resident #188 was admitted on [DATE] and discharged on [DATE] with diagnoses including Parkinson's disease, fracture of vertebra, and a Stage III (full-thickness loss of skin that extends to the subcutaneous tissue) pressure ulcer. Resident #188 was ordered Norco (opioid) 5-325 mg by mouth as needed every six hours. Review of the medical record revealed Resident #190 was admitted on [DATE] and discharged on [DATE] with diagnoses including metabolic encephalopathy, kidney failure, malignant neoplasm of colon, sciatica, and dementia. Resident #190 was ordered Ativan (antianxiety) 0.5 mg every four hours as needed for anxiety. Review of self-reported incident (SRI) tracking number 221707 dated [DATE] for misappropriation by facility staff affecting Residents #44, #188, and #190. The dispensed controlled medications were found without confirmation of administration of medication. A staff nurse notified administration when they discovered no available medication on a resident's prescription. An investigation was initiated, and the employee was suspended pending an investigation. Pharmacy was notified and dispense reports for the previous two weeks were pulled for the suspected nurse as well as other nurses for comparison. An employee was interviewed, a statement was taken, and a drug test was completed and was negative. The appropriate Medication Administration Records (MARs) and reports were reviewed. The Ohio Department of Health, police department, pharmacy, medical director, and Ohio Board of Nursing were notified. A limited accountability audit was conducted which included all controlled as needed medications from the AlixaRX (on-site medication dispensing machine) dispensed by LPN #600. The pharmacy report identified 97 as needed controlled medications dispensed to LPN #600 with a total of two out of the 97 controlled medications initialed on MARs as administered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 5 of 15 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 366463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Wooster 1700 East Smithville Western Road Wooster, OH 44691 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 0607 Results of the audit included but may not be limited to: Level of Harm - Minimal harm or potential for actual harm a. controlled substances were dispensed without further documentation on the MAR to substantiate administration of the drug to the resident. Residents Affected - Some b. Controlled Substances Accountability Sheets (page one) were disposed of and transferred to page two. c. Controlled substances were signed out without accountability for waste. d. Controlled Substances Accountability Sheets were rewritten as transferred and the original page one with signatures was unavailable. Review of the Control PRN (as needed) Dispenses by Shift from [DATE] to [DATE] revealed LPN #600 dispensed 79 Oxycodone 10 mg for Resident #44. One other nurse dispensed two Oxycodone on [DATE]. Review of the MAR revealed LPN #600 administered two of the 79 Oxycodone to Resident #44. Review of the Control PRN Dispenses by Shift from [DATE] to [DATE] revealed LPN #600 dispensed 24 Ativan 0.5 mg for Resident #190. No other nurses dispensed Ativan for Resident #190. Review of the MAR revealed no documentation LPN #600 administered any of the 24 Ativan to Resident #190. Review of the Control PRN Dispenses by Shift from [DATE] to [DATE] revealed LPN #600 dispensed eight Norco 5-325 mg for Resident #188. No other nurses dispensed Norco for Resident #188. Review of the MAR revealed LPN #600 administered one of the eight Norco to Resident #188. Review of the Control PRN Dispenses by shift from [DATE] to [DATE] revealed LPN #600 dispensed one Percocet 5-325 mg for Resident #17. No other nurses dispensed Percocet for Resident #17. Review of the MAR revealed no documentation LPN #600 administered the Percocet to Resident #17. A typed statement by LPN #600 dated [DATE] revealed she received a call from Corporate Registered Nurse (RN) #604 on [DATE] to come to the facility as soon as possible to discuss the narcotic count sheets. LPN #600 got someone to watch her child and went to the facility as quickly as possible. LPN #600 wrote she had never taken any medication from the facility. LPN #600 stated she was trained to pull as needed medications for her shift and the next shift. LPN #600 wrote she did not understand the severity of pulling these medications. A note handwritten at the bottom of the statement revealed the nurse was shaking, nervous, repeated questions, and seemed confused. Review of Employee Discipline Form dated [DATE] revealed LPN #600 had a serious/critical violation due to the facility's Controlled Substances and Controlled Substance Storage policy and procedure was not followed and the destruction of reconciliation sheets and improper storage of controlled substances. LPN #600 was terminated on [DATE]. Interview on [DATE] at 11:35 A.M. Corporate RN #604 revealed an investigation was completed but the facility was unable to prove that LPN #600 took the missing medications. Corporate RN #604 verified medications were missing for Resident #17, #44, #188, and #190. Corporate RN #604 verified the facility had identified 95 controlled medications were missing but was unable to verify the exact amount due to LPN #600 shredded multiple Controlled Substance Accountability Sheets. The Abuse Prohibition policy (no date) revealed misappropriation of resident property meant the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 6 of 15 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 366463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Wooster 1700 East Smithville Western Road Wooster, OH 44691 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings without the residents consent. Review of Medication Administration-Preparation and General Guidelines Controlled Substances Policy and Procedure dated 12/17 revealed accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the date and time of administration, amount administered, remaining quantity, and initials of the nurse administering the medication on the accountability record and MAR. Current controlled substance accountability records were kept in a designated book. Completed accountability records are submitted to the director of nursing and kept on file for five years at the facility. Event ID: Facility ID: 366463 If continuation sheet Page 7 of 15 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 366463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Wooster 1700 East Smithville Western Road Wooster, OH 44691 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure residents were assisted with meals timely. This finding affected of one (Resident #185) of ten residents (Residents #13, #26, #31, #35, #57, #62, #73, #185, #227 and #277) who required direct assistance with meals. The facility census was 77 and all residents receive meals from the kitchen. Residents Affected - Few Findings include: Review of Resident #185's medical records revealed an admission date of 11/29/22. Diagnosis included muscle weakness, stroke with left sided weakness, dysphagia, alerted mental status, and difficulty walking. Review of the care plan dated 12/04/22 revealed Resident #185 required assistance of one staff for eating. Resident #185 had a potential for weight loss related to diagnosis of a stroke. The resident was a total assist at meals (revised on 12/07/22). Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #185 had no recorded cognition score due to the resident was rarely understood. Resident #185 required extensive assistance with eating. Review of the progress note dated 12/09/22 revealed Resident #185 cannot feed herself at times and required extensive to total assist. Observation on 12/19/22 at 1:05 P.M. revealed the meal trays were delivered to the unit. Observation on 12/19/22 at 1:20 P.M. revealed Resident #185's husband had approached State Tested Nursing Assistant (STNA) #829 and was upset because the resident's food was cold and she had not been assisted with her meal. Interview with the resident's husband revealed on 12/16/22 he had asked an aide to heat up the residents dinner and the aide had told him I have 23 other trays to pass out and when I'm done I can feed her. Interview on 12/19/22 at 1:30 P.M. revealed STNA #829 was in Resident #57's room assisting the resident with her lunch. STNA #829 stated she had three to four residents who required feeding assistance. At the time of the interview STNA #855 had entered the room and asked STNA #829 if she needed assistance. STNA #829 asked STNA #855 to assist Resident #185 who was in the dining area with her lunch. This deficiency substantiates Master Complaint Number OH00132227 and Complaint Number OH00131921. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 8 of 15 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 366463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Wooster 1700 East Smithville Western Road Wooster, OH 44691 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure expired medications were discarded as appropriate. This finding affected four Residents (#20, #24, #36 and #182) during review of four medication administration carts. Findings include: 1. Review of Resident #36's medical record revealed she was admitted on [DATE] with diagnoses including age-related osteoporosis without a current pathological fracture and neuromuscular dysfunction of the bladder. Review of Resident #36's physician orders revealed an order dated 11/15/22 for calcium citrate give 600 mg (milligrams) by mouth one time a day for a supplement. Observation on 12/19/22 at 9:01 A.M. with Licensed Practical Nurse (LPN) #863 of Resident #36's medication administration revealed eighteen medications were administered including three calcium citrate 200 mg tablets. Interview on 12/19/22 at 9:07 A.M. with LPN #863 confirmed Resident #36's calcium citrate medication had expired on 10/22. 2. Review of Resident #20's medical record revealed she was admitted to the facility on [DATE] with diagnoses including dependence on renal dialysis, end stage renal disease, and type two diabetes mellitus. Review of Resident #20's physician orders revealed an order dated 12/16/21 to inject seven units of Novolog (Humalog insulin) subcutaneously with meals for diabetes mellitus. Observation on 12/19/22 at 9:10 A.M. of the C hall medication administration cart revealed Resident #20's fast acting Humalog Kwik pen (insulin injector) was dated 11/12/22 and expired 12/10/22. Interview on 12/19/22 at 9:11 A.M. with LPN #863 confirmed Resident #20's Humalog insulin Kwik pen was opened on 11/12/22 and expired on 12/10/22. She confirmed Resident #20 received her insulin prior to dialysis earlier in the day. Review of the undated Humalog Insulin Manufacturer's Directions form indicated Humalog Kwik pens expired 28 days after opening and do not refrigerate. 3. Review of Resident #24's medical records revealed an admission date of 02/09/22 with diagnosis that included diabetes. Review of current physician orders for December 2022 revealed Resident #24 was ordered Lantus (long-acting insulin) 15 units in the morning for diabetes. 4. Review of Resident #182's medical records revealed an admission date of 12/06/22 with diagnosis (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 9 of 15 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 366463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Wooster 1700 East Smithville Western Road Wooster, OH 44691 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 0761 including chronic kidney disease. Level of Harm - Minimal harm or potential for actual harm Review of the current physician orders for December 2022 revealed Resident #182 was ordered Lispro (short-acting insulin) to be injected per sliding scale four times a day. Residents Affected - Some Observation of medication cart on 12/19/22 at 8:50 A.M. with LPN #867 revealed a Lantus pen for Resident #24 that was opened and was undated. Further observation revealed a Lispro pen for Resident #182 that was open and undated. Interview with LPN #867 revealed insulin pens were to be dated after opening and were to be discarded 30 days after opening. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 10 of 15 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 366463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Wooster 1700 East Smithville Western Road Wooster, OH 44691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation and interview, the facility failed to ensure residents who received pureed diets were served the correct portion sizes. This finding affected seven Residents (#6, #13, #22, #31, #35, #57 and #73) of seven residents who required a pureed consistency diet. The facility census was 77. Findings include: Observation on 12/19/22 at 11:33 A.M. of [NAME] #885 with Kitchen Manager #883 during plating of the lunch meal revealed she placed four ounces of pureed chicken, four ounces of pureed green beans, and three ounces of pureed pasta onto each plate of those residents who were ordered pureed diets including Residents #6, #13, #22, #31, #35, #57 and #73. Interview on 12/19/22 at 11:50 A.M. with Kitchen Manager #883 revealed [NAME] #885 accidentally mixed up the scoops for the chicken and the pasta and the residents on a pureed diet did not receive the correct portion sizes during the lunch meal. She stated the #10 scoop was a three-ounce scoop and the #8 scoop was a four ounce scoop, and Residents #6, #13, #22, #31, #35, #57 and #73 received four ounces of chicken but only three ounces of pasta. She confirmed the menu required each resident to be served four ounces of pasta using a #8 scoop. Review of the Menu Extension form dated 12/19/22 confirmed pureed chicken paprika required a #10 scoop, pasta required a #8 scoop, and green beans required a #8 scoop. Review of the Portion Control Chart indicated a #8 scoop was four ounces and a #10 scoop was three ounces. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 11 of 15 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 366463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Wooster 1700 East Smithville Western Road Wooster, OH 44691 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure meals were palatable and served at an appetizing temperature. This finding had the potential to affect 77 residents who received meals from the kitchen. The facility census was 77. Residents Affected - Many Findings include: 1. Interviews on 12/19/22 at 9:19 A.M. with Resident #26; 12/19/22 at 9:35 A.M. with Resident #39; 12/19/22 at 9:47 A.M. with Resident #43; 12/19/22 at 10:12 A.M. with Resident #46; 12/19/22 at 10:25 A.M. with Resident #32; 12/19/22 at 11:35 A.M. with Resident #27; 12/19/22 at 2:16 P.M. with Resident #36; 12/20/22 at 8:58 A.M. with Resident #5; and on 12/20/22 at 9:15 A.M. with Resident #8 voiced concerns with cold food or the palpability of the meals. A test tray was conducted on 12/19/22 at 11:56 A.M. with Kitchen Manager #883 and Registered Dietitian (RD) #999 which consisted of baked paprika chicken, green beans, noodles with red sauce, banana pudding, bread and butter. The chicken's temperature was 126.2 degrees Fahrenheit, the green beans temperature was 113.6 degrees Fahrenheit, the noodles with red sauce's temperature was 108.9 degrees Fahrenheit. The chicken was slightly warm and not hot, the noodles and the green beans were cold. Interview on 12/19/22 at 11:58 A.M. with RD #99 confirmed the chicken was required to have a holding temperature of 135 degrees and the chicken did not meet the required temperature to prevent bacteria growth. She also confirmed the green beans and the noodles with red sauce were cold to the taste. Interview on 12/19/22 at 1:25 P.M. with Diet Tech #899 indicated she handled some of the food council meetings which had a lot of cold food complaints. She confirmed the food council met on a monthly basis. Interview on 12/20/22 at 8:57 A.M. with the Administrator indicated the plate warmer had been broken for approximately six months and needed repaired. 2. Review of scheduled mealtimes revealed the B hall was to be served a 11:45 A.M. Observation on 12/19/22 at 1:10 P.M. revealed trays had arrived on the B Hall. Observation made during meal pass beginning at 1:10 P.M. and ending at 1:20 P.M. revealed Residents #10, #34, and #64 had approached STNA #829 and had complained their meals were cold and asked for them to be heated up. STNA #829 had stated that residents complained about cold food frequently and she had to heat up their meals. Observation on 12/19/22 at 1:20 P.M. revealed Resident #185's husband had approached STNA #829 and was upset that the resident's food was cold. Interview with the residents' husband at the time of the observation revealed on several occasions the resident's food was cold. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 12 of 15 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 366463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Wooster 1700 East Smithville Western Road Wooster, OH 44691 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and facility policy review the facility failed to deliver meal trays in a timely manner. This finding affected two Residents (#10 and #227) of 77 residents who receive meals from the kitchen. Findings include: 1. Review of Resident #227 revealed an admission date of 12/08/22 with diagnoses including falls and pelvic fracture. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #227 had intact cognition. Review of the current physician orders for December 2022 revealed Resident #227 was ordered a no salt added mechanical soft diet. 2. Review of Resident #10's medical records revealed an admission date of 11/22/22 with diagnosis including respiratory failure. Review of the MDS 3.0 dated 11/18/22 revealed Resident #10 had intact cognition. Review of the current physician orders for December 2022 revealed Resident #10 was ordered a regular diet. Interview on 12/19/22 at 9:24 A.M. revealed Resident #227 had not received a breakfast tray. Interview at the time of the observation with State Tested Nursing Assistant (STNA) #829 stated she was not aware Resident #227 had not received a tray. Observation of the meal cart with STNA #829 revealed Resident #227's tray remained on the cart and had not been delivered. STNA #829 was unable to provide an explanation as to why the tray was not delivered and stated she would contact the kitchen and have a new tray delivered. Interview on 12/19/22 at 9:40 A.M. with Resident #10 revealed he had not received a breakfast tray. Resident #10 further stated he had informed the aide (unable to provide a name or time) and stated he still had not received a tray. At the time of the interview, STNA #844 entered the resident's room, and she denied being aware the resident had requested a tray or that he had not received one. STNA #844 stated she would contact the kitchen and have a tray delivered. Review of the undated facility policy titled Room Service revealed nursing staff to deliver trays to rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 13 of 15 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 366463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Wooster 1700 East Smithville Western Road Wooster, OH 44691 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and facility policy review the facility failed to ensure staff donned the appropriate personal protective equipment (PPE) when testing residents and staff for COVID-19 and failed to ensure staff completed appropriate hand-hygiene when exiting resident rooms who were placed on contact isolation precautions. This finding affected Resident #66 and had the potential to affect all other residents and staff who entered the facility. The facility census was 77. Residents Affected - Many Findings include: 1. Review of Resident #184's medical records revealed an admission date of 12/12/22. Diagnosis included clostridium difficile (c-diff) bacterial infection. Review of the care plan dated 12/12/22 revealed no care plan related to infection control. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed an incomplete assessment. Review of current physician orders for December 2022 revealed Resident #184 was to be on contact precautions until 01/12/23. Observation on 12/19/22 at 8:23 A.M. revealed State Tested Nursing Assistant (STNA) #829 has exited Resident #184's room that was identified as being on isolation precautions and had used hand sanitizer upon exiting. She then walked down the hall to Resident #66's room and provided care to that resident. She used hand sanitizer when exiting Resident #66's room. Interview on 12/19/22 at 8:28 A.M. with STNA #829 revealed Resident #184 was on contact precautions for c-diff. STNA #829 stated she did not wash her hands prior to exiting the room because she forgot. Observation on 12/20/22 at 9:04 A.M. revealed STNA #835 exited Resident #184's room and had used hand sanitizer. Interview with STNA #835 revealed she had not washed her hands prior to exiting the resident's room and she was not aware if she was required to do so. Interview on 12/21/22 at 3:11 P.M. with Director of Nursing (DON) revealed staff were to wash their hands with soap and water prior to leaving a room with a c-diff infection. 2. Observation on 12/21/22 at 11:20 A.M. revealed Receptionist #816 exited the facility and approached a car outside of the facility. Receptionist #816 was observed to have collected a nasal swab from the vehicle and had re-entered the building Receptionist #816 was observed to have not been wearing any PPE at the time of the observation. Interview with Receptionist #816 after entering the building and walking behind the receptionist desk confirmed she had collected a COVID-19 test from an employee and she was not wearing PPE. Receptionist #816 stated she was aware she should have worn gloves during the collection of the nasal swab; however, she was not able to state if she was required to wear any additional PPE. Review of the facility policy titled Categories of Transmission-Based Precautions, dated 10/18, indicated staff and visitors will wear gloves when entering the room and the gloves would be removed and hand hygiene performed before leaving the room. The staff would wear a disposable gown upon (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 14 of 15 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 366463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avenue at Wooster 1700 East Smithville Western Road Wooster, OH 44691 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 entering the room and remove before leaving the room to avoid touching potentially contaminated surfaces with clothing after the gown is removed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 15 of 15