Health inspection·March 20, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #72 was cognitively intact. Resident #72 did have feelings of being down, depressed, hopeless, and feeling bad about self. Review of the plan of care dated 02/19/25 revealed Resident #72 was at risk for falls. Interventions included to assess footwear for proper fit and non-skid soles, encourage the use of call lights, and instruct on safety measures. Interview on 03/17/25 at 2:13 P.M. with a family member of Resident #72 revealed they heard an incident occurred when Resident #72 fell in the front area of the building. The family member stated they were not sure if the DON yelled at Resident #72 but something did not feel right about the situation. Interview on 03/19/25 at 9:36 A.M. a staff member that requested to be anonymous revealed Resident #72 was crying after the fall in the lobby and stated the DON was screaming at him and said Resident #72 could not use his walker anymore. Resident #72 stated he was scared of the DON. The staff member believed several staff had reported the incident to the Licensed Nursing Home Administrator (LNHA). Interview on 03/20/25 at 10:32 A.M. with the LNHA verified a nurse notified him that another staff member had reported concerns of how the DON had spoken to Resident #72. The LNHA stated he got statements from the three witnesses that observed the fall and the DON going to Resident #72. The LNHA stated he was unable to interview Resident #72 because the resident was transferred to the hospital. The LNHA verified he did not report the allegation of possible verbal or emotional abuse to the state agency because he did not think abuse had occurred and was not sure if it should be reported. The LNHA stated the DON had reported yelling out Resident #72's name as the DON was trying to help Resident #72. On 03/20/25 at 12:17 P.M. a staff member that requested to be anonymous stated the DON was stern and the tone of voice was concerning when he went to Resident #72 after the fall. The staff member stated they reported their concern about the tone of voice the DON had used towards Resident #72. On 03/20/25 at 3:48 P.M. the DON verified Resident #72 had several falls. The DON stated Resident #72 fell in the lobby and the DON talked to Resident #72 but did not recall anything concerning about the incident. The DON verified he did tell Resident #72 he could no longer use a walker. Review of the Abuse Prohibition policy revised October 2022 revealed abuse is defined as willful infliction of intimidation or punishment resulting in mental anguish. Types of abuse include mental/emotional abuse. Mental abuse may occur through verbal or nonverbal conduct which causes or has the potential to cause the resident to experience intimidation, fear, shame, humiliation, agitation, or degradation. Ensure that all alleged violations involving abuse or mistreatment are reported immediately, but later than two hours after the allegation is made to the administrator and to other officials (including the State Survey Agency) in accordance with state law through established procedures. This deficiency represents non-compliance investigated under Complaint Number OH00162049. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 2 of 20 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 03/20/2025 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based of record review, Abuse Prohibition policy review, facility investigation, and interviews, the facility failed to thoroughly investigate an allegation of possible abuse by a staff member to Resident #72. This affected one (Resident #72) out of one residents reviewed for abuse. Facility census was 81. Residents Affected - Few Findings include: Review of the medical record revealed Resident #72 was admitted [DATE] and discharged [DATE] with diagnoses that included cerebral infarction, aphasia, convulsions, major depressive, anxiety, hemiplegia and hemiparesis. A nursing note dated 01/29/25 at 3:47 P.M. revealed the nurse practitioner was made aware Resident #72 had a fall and Resident #72 could be transferred to the hospital for evaluation. No further documentation of the fall was recorded in the medical record. Review of a written statement, dated 01/29/25 by Receptionist #501, revealed around 2:30 P.M. she witnessed Resident #72 starting to fall. Receptionist #501 went to get the Director of Nursing (DON)but the DON was already heading to Resident #72. The DON said you are done to Resident #72. Receptionist #501 wrote they believed the DON meant Resident #72 was done using the walker. Review of a typed statement, dated 01/29/25 by Human Resource #234, revealed Resident #72 was trying to walk without his walker. The DON asked Resident #72 where his walker was. Resident #72 pointed to it and the DON got the walker for Resident #72. The DON returned to his office. Resident #72 got up to walk and Resident #72 fell. The DON rushed out of his office and told Resident #72 we can't do this. Review of a typed statement, dated 01/29/25 by Receptionist #402, revealed while Resident #72 was waiting in the front lobby to go to an appointment, Resident #72 tried to stand up and fell to the side. The DON came out of his office and while going to Resident #72, the DON raised his voice and said you are done multiple times. Review of a written statement, dated 01/29/25 by Business Office Manager #214, revealed they did not witness the fall but were asked to assist with getting Resident #72 up (from the floor). Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #72 was cognitively intact. Resident #72 did have feelings of being down, depressed, hopeless, and feeling bad about self. Interview on 03/20/25 at 10:32 A.M. Licensed Nursing Home Administration (LNHA) verified a nurse notified him that another staff member had reported concerns of how the DON had spoken to Resident #72. The LNHA stated he got statements from the three witnesses that observed the fall and the DON going to Resident #72. The LNHA stated he was unable to interview Resident #72 because the resident was transferred to the hospital. The LNHA verified statements were not obtained from the nurse that reported the incident, staff that provided care to Resident #72 before being transferred to the hospital, or the DON. The LNHA stated he talked to the DON and the DON reported yelling out Resident #72's name as the DON was trying to help Resident #72. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 3 of 20 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 03/20/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 03/20/25 at 12:17 P.M. a staff member that requested to be anonymous stated the DON was stern and the tone of voice was concerning when he went to Resident #72 after the fall. The staff member stated they reported their concern about the tone of voice the DON had used towards Resident #72. On 03/20/25 at 3:48 P.M. the DON verified Resident #72 had several falls. The DON stated Resident #72 fell in the lobby and the DON talked to Resident #72 but did not recall anything concerning about the incident. The DON verified he did tell Resident #72 he could no longer use a walker and the DON verified he was not asked to write a statement about the incident. Review of the Abuse Prohibition policy revised October 2022 revealed abuse is defined as willful infliction of intimidation or punishment resulting in mental anguish. Types of abuse include mental/emotional abuse. Mental abuse may occur through verbal or nonverbal conduct which causes or has the potential to cause the resident to experience intimidation, fear, shame, humiliation, agitation, or degradation. Ensure that all alleged violations involving abuse or mistreatment are reported immediately, but later than two hours after the allegation is made to the administrator and to other officials (including the State Survey Agency) in accordance with state law through established procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 4 of 20 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 03/20/2025 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, interview and policy review the facility failed to ensure residents were provided their hearing aides/amplifiers to assist with their identified hearing loss. This affected one (Resident #16) three residents reviewed for activities of daily living. Residents Affected - Few Findings Include: Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia with psychotic and mood disturbance, heart disease, anxiety and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had severe impaired cognition, and moderate hearing impairment. Review of the Care Plan dated 03/01/25 revealed the resident was at risk for communication related to a hearing deficit and dementia. Interventions included be conscious of position when in groups, allow adequate time to respond, and repeat if necessary. The plan did not include information on hearing devices. Observation on 03/18/25 at 8:00 A.M. revealed the resident was sitting in the dining room. Resident #16 was not observed to be wearing a hearing device. Interview on 03/18/25 at 8:41 A.M. with Resident #16's daughter stated staff were not putting on her hearing amplifiers. Interview with Licensed Practical Nurse (LPN) #335 on 03/19/25 at 2:50 P.M. revealed Resident #16 loses personal items often due to her cognition. The resident had a habit of wrapping her dentures and hearing aids/amplifiers in paper towels and putting them in the garbage. LPN #335 stated Resident #16 had hearing amplifiers, however she did not know where they were. Observation on 03/20/25 at 8:25 A.M. of Resident #16 revealed she was not observed wearing a hearing device. Interview on 03/20/25 at 8:30 A.M. with Certified Nursing Assistant (CNA) #247 revealed the resident wore hearing amplifiers but the hearing amplifiers had been missing for about a week. CNA #247 verified Resident #16 was not wearing her hearing amplifiers. Interview on 03/20/25 at 9:00 A.M. with LPN #254 stated she found the hearing amplifiers in Resident 16's room. Interview on 03/20/25 at 9:30 A.M. with the MDS Nurse #410 verified Resident #16 did not have the hearing amplifiers applied this week. MDS #410 stated she put in a new order to apply hearing amplifiers in the A.M. and remove in the P.M. and to keep them in the medication cart. MDS #410 stated she updated the care plan to reflect the new information. Review of the facility policy titled Activities of daily living, revealed the facility will ensure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 5 of 20 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 03/20/2025 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 0676 a resident is given the appropriate treatment and service to maintain or improve his or her ability to conduct the activities of daily living. 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: 366463 If continuation sheet Page 6 of 20 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 03/20/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and staff interviews the facility failed to ensure pressure reducing devices were in place for residents at risk for developing pressure injuries. This affected one resident (Resident #1) of two residents reviewed for pressure injuries. The facility census was 81. Residents Affected - Few Findings include: Review of the medical record for Resident #1 revealed an admission date of 08/12/21 with diagnoses including but not limited to stroke with right side hemiplegia, type two diabetes, and vascular dementia. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of three out of 15 and required assistance from staff to complete bed mobility, transfers, and personal hygiene tasks. Further review revealed the resident was at risk for the development of pressure injuries with interventions in place including pressure reducing mattress, pressure reducing device in the wheelchair, and turning/repositioning program. Review of the physician orders revealed an order dated 08/21/21 to encourage the resident to float the bilateral heels on pillows while in bed every shift, an order dated 11/18/24 for treatment to bilateral heels apply skin prep and leave open to air every day shift every Monday, Wednesday, and Friday for skin care and prevention, an order dated 11/18/24 for treatment to bilateral lower extremities for pressure relieving boots while in bed every shift for skin care and prevention, and an order dated 12/17/24 for device use for bilateral heel lift suspension boots every shift every day for skin prevention. Review of Resident #1's Treatment Administration Record (TAR) dated 03/01/25 to 03/19/25 revealed the order dated 12/17/24 for device use of bilateral heel lift suspension boots every shift every day for skin prevention was marked as being completed for every shift. Review of Resident #1's care plan dated 04/10/23 revealed Resident #1 had the potential for impaired skin integrity and pressure injury development with interventions including the use of heel boots as tolerated. Review of Resident #1's progress notes dated 03/01/25 to 03/19/25 revealed no documentation revealing Resident #1 refused to wear the pressure reducing boots to the bilateral lower extremities. Observation on 03/17/25 at 11:30 A.M. revealed Resident #1 was resting in bed, watching television. There was a pair of pressure reducing green boots laying on the window seat in the room. Resident #1 did not have any pressure reducing devices on her bilateral lower extremities. Observation on 03/18/25 at 8:20 A.M. revealed Resident #1 was resting in bed eating the breakfast meal. The pressure reducing green boots were lying on the window seat in the same position as the day before. Observation on 03/18/25 at 2:40 P.M. revealed Resident #1 returned to her room with staff assisting in positioning Resident #1 in bed. The pressure reducing green boots continued be located on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 7 of 20 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 03/20/2025 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 0686 window seat in the room. Level of Harm - Minimal harm or potential for actual harm Observation on 03/19/25 at 7:10 A.M. revealed Resident #1 sleeping in bed with out any pressure reducing devices on the bilateral lower extremities. The pressure reducing green boots were lying on the seat of the high back chair located in her room. Residents Affected - Few Interview on 03/18/25 at 2:42 P.M. with Certified Nursing Assistant (CNA) #375 revealed Resident #1 would refuse to wear the pressure reducing boots. The CNA's will report the refusal to the nurse who will document the refusal in the progress notes. Interview on 03/19/25 at 11:18 A.M. with Licensed Practical Nurse (LPN) #254 confirmed Resident #1 did not have the pressure reducing boots in place and the TAR dated 03/19/25 was marked as having the pressure reducing boots in place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 8 of 20 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 03/20/2025 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 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 closed record review, facility investigation review, and interview, the facility failed to implement appropriate fall prevention interventions for Resident #9 after a fall. This affected one (Resident #9) of four residents reviewed for accidents. The facility census was 81. Findings include: Review of the closed medical record revealed Resident #9 was admitted on [DATE] with diagnoses that included acute and chronic respiratory failure, peripheral vascular disease, chronic kidney disease, major depressive disorder, anxiety, osteophyte left hip, and osteoporosis. A nursing note dated 02/23/25 at 10:08 P.M. revealed the nurse was called to Resident #9's room. Resident #9 had fallen out of the (shower) chair while being transferred into the shower. Resident #9 stated the Certified Nursing Assistant (CNA) hit the lip going into the shower. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #9 was cognitively intact. Resident #9 required substantial to maximum assistance with bathing. Review of the plan of care dated 03/04/25 revealed Resident #9 was at risk for an actual fall with major injury. The only intervention in place was to send Resident #9 to the emergency department. Interview on 03/18/25 at 3:41 P.M. with CNA #383 revealed Resident #9 fell out of the shower chair. CNA #383 was attempting to pull the shower chair over the lip into the shower stall. Interview on 03/18/25 at 3:57 P.M. with the Director of Nursing (DON) revealed staff were educated on using the seatbelt when moving residents in a shower chair. The DON stated Resident #9 refused to use the seatbelt. The DON verified no other interventions were put in place. Interview on 03/19/25 at 4:12 P.M. with Resident #9 revealed she was afraid to have the seatbelt in place when being transferred because of the shower chair tipping and Resident #9 being strapped to the shower chair. Resident #9 stated she preferred a shower to a bed bath and she had not received a shower since she had returned to the facility. Resident #9 stated she would feel safe if there were two staff members present while the shower chair was being put into the shower. An additional interview on 03/19/25 at 5:14 P.M. the DON revealed Resident #9 had not wanted to get in the shower. The DON verified no training or education had been provided to staff about Resident #9's individualized safety measures for Resident #9's specific needs and abilities. The DON verified he was not aware Resident #9 would feel safer with two staff providing care. The DON stated he would educate the staff and update the care plan for two staff members to assist Resident #9 with showers. On 03/19/25 at 5:28 P.M. a new order was written for Resident #9 to have two staff assistance with all showers. A new intervention was added to Resident #9's plan of care on 03/19/25 for two staff to assist with all showers. Interview on 03/20/25 at 7:46 A.M. Resident #9's daughter revealed she had suggested that two staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 9 of 20 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 03/20/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm members be present when putting Resident #9 in the shower. The daughter also stated the facility staff did not provide any information on how they would provide Resident #9 a shower and keep Resident #9 safe. This deficiency represents non-compliance investigated under Complaint Number OH00162049. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 10 of 20 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 03/20/2025 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to ensure there was consistent communication between the facility and the dialysis center regarding Resident #15's hemodialysis treatments. This affected one (Resident #15) of one residents reviewed for dialysis. The facility census was 81. Residents Affected - Few Findings include: Review of the medical record revealed Resident #15 was admitted on [DATE] with diagnoses that included hemiplegia, aphasia, convulsions, and dependence on renal dialysis. Review of physician orders revealed Resident #15 received hemodialysis three times a week on Tuesday, Thursday, and Saturday. Review of Resident #15's medical record from 01/02/25 to 03/15/25 revealed there were missing dialysis visit notes for the last 30 dialysis treatments. Out of the 30 times Resident #15 was sent out of the facility for a dialysis treatment, 14 of those visits did not have a dialysis visit notes to indicate what Resident #15's pre-weight and dry weight (weight after dialysis) were, what the resident's vital signs were, what medications were administered, and how Resident #15 tolerated the dialysis treatment during each visit. Interview on 03/20/25 at 3:38 P.M. with Unit Manager (UM) #353 verified there were dialysis communication sheets missing and adequate communication was not occurring between the facility and Resident #15's dialysis center. UM #353 acknowledged the dialysis center was not sending a dialysis visit note for Resident #15 that let the facility nurse know what Resident #15's pre-weight and dry weight was when Resident #15 received hemodialysis. There was also no communication of any medications that may have been administered to Resident #15 or how Resident #15 tolerated the dialysis treatment. The Dialysis Monitoring policy revised 12/2022 revealed the facility will maintain ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 11 of 20 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 03/20/2025 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, Psychotropic Drug Use policy review, Medication Regimen review, and interview the facility failed to ensure pharmacy recommendations were addressed appropriately by the physician for Resident #9, #16, and #41. The facility also failed to ensure an abnormal involuntary movement scale (AIMS) assessment was completed for Resident #70. This affected four (Resident #9, #16, #41, and #70) out of five residents reviewed for unnecessary medications. The facility census was 81. Findings include: 1. Review of the medical record revealed Resident #9 was admitted on [DATE] with diagnoses that included acute and chronic respiratory failure, major depressive disorder, and anxiety. Review of the pharmacy recommendation dated 02/07/25 revealed Resident #9 received Buspirone (anxiolytic) five milligram (mg) three times a day without a gradual dose reduction (GDR). The pharmacy recommended a reduction to five mg twice a day. If the physician did not agree documentation needed added to the medical record indicating why the GDR would be detrimental to Resident #9's mental or physical health. The recommendation was marked disagreed by Psychiatric Nurse Practitioner #201 on 02/19/25 with a rational of patient refused. The significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #9 was cognitively intact. Resident #9 received antianxiety, antidepressant, and anticonvulsant medications. Interview on 03/20/25 at 3:26 P.M. Psychiatric Nurse Practitioner #605 verified the only reason documented for disagreeing with the GDR was Resident #9 refused. Psychiatric Nurse Practitioner #201 also verified there was no documentation of Resident #9 being educated about the benefits of a GDR or why Resident #9 refused to have Buspirone decreased. 2. Review of the medication record revealed Resident #41 was admitted on [DATE] with diagnoses that included respiratory failure, psychosis, mild cognitive impairment, major depressive disorder, anorexia, and obsessive compulsive disorder. The quarterly MDS dated [DATE] revealed Resident #41 had cognitive impairment. The MDS revealed Resident #41 received antianxiety and antidepressant medications. Review of the pharmacy recommendation dated 02/07/25 revealed Resident #41 received Fluvoxamine (antidepressant) 75 mg once a day without a GDR. The pharmacy recommended a reduction to 50 mg a day. If the physician did not agree documentation needed added to the medical record indicating why the GDR would be detrimental to Resident #41's mental or physical health. The recommendation was marked disagreed by Psychiatric Nurse Practitioner #201 on 02/19/25 with a rational of patient refused. Interview on 03/20/25 at 3:26 P.M. Psychiatric Nurse Practitioner #605 verified the only reason documented for disagreeing with the GDR was Resident #41refused. Psychiatric Nurse Practitioner #201 also verified there was no documentation of Resident #41 being educated about the benefits of a GDR or why Resident #41 refused to have Fluvoxamine decreased. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 12 of 20 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 03/20/2025 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. Review of Resident #16's medical record revealed the Resident was admitted to the facility on [DATE]. Diagnoses included dementia with psychotic and mood disturbance, heart disease, anxiety and depression. Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had severe impaired cognition and no behaviors. The assessment identified that the resident receives an antipsychotic, antianxiety, antidepressant, and anticonvulsant. Review of the Pharmacist Recommendation dated 01/12/25 revealed gradual dose reduction (GDR) for Depakote 125 milligram (mg). The practitioner marked disagree with the recommendation there was no reason noted. Recommendation dated 02/07/25 revealed gradual dose reduction (GDR) for Risperidone 0.5 mg. The practitioner marked disagree with the recommendation with a note that stated family refused. Review of the Nurse Practitioner (NP) #605 progress note dated 02/19/25 revealed a generic note stating the resident symptoms continue to be well managed with current medication. Modifying the medication has a potential risk for destalinization. The note was not specific to the medications recommended for a GDR. Interview on 03/20/25 at 3:21 P.M. with NP #605 stated she reviews medications for GDRs monthly and documents them in her progress notes. Interview on 03/20/25 at 3:45 P.M. with the Director of Nursing (DON) revealed he reviews GDR with practitioners monthly. The DON was unaware the practitioners were not documenting specific justifications and contraindications of GDRs. Review of the Medication Regimen Review policy dated 12/17 revealed recommendations are acted upon and documented by the facility staff and/or the prescriber. The prescriber accepts and acts upon recommendation or rejects and provides an explanation for disagreeing. Review of the Psychotropic Drug Use policy (no date) revealed an unnecessary drug is any medication that is used in excessive doses, for excessive duration. A GDR must be completed annually unless clinically contraindicated and adequate written justification is provided by the physician as to the reason that a reduction is not justified. 4. Review of Resident #70's medical record revealed initial admission date 09/27/24 and readmission date 01/03/25 with diagnoses including but not limited to right femur fracture, multiple sclerosis (MS), anxiety, depression, and psychosis. Resident #70 had moderately impaired cognition with a Brief Interview of Mental Status (BIMS) score of 12 out of a possible 15 dated 01/04/25. Review of Resident #70's signed physician orders revealed an order dated 01/03/25 for antipsychotic medication Seroquel oral tablet 50 milligrams (mg) give 50 mg by mouth three times a day for delirium and psychosis. The antipsychotic medication Seroquel had initially been implemented on 11/19/24. Review of Resident #70's admission Mimium Data Set (MDS) dated [DATE] revealed Section N Medications was marked as Resident #70 receiving antipsychotic medication. Review of Resident #70's psychotropic medication use care plan dated 12/04/24 revealed Resident #70 received antipsychotic medication related to psychosis and delirium. There were no target behaviors for the use of antipsychotic medication use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 13 of 20 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 03/20/2025 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #70's assessments revealed a completed Abnormal Involuntary Movement Scale (AIMS) dated 12/27/24 for the antipsychotic medication Seroquel. There was no completed AIMS assessment dated when the antipsychotic medication Seroquel was implemented on 11/19/24. An interview on 03/25/25 at 1:26 P.M. with MDS Licensed Practical Nurse (LPN) #410 confirmed Resident #70 did not have an AIMS assessment completed upon implementation of the antipsychotic medication Seroquel on 11/19/24. MDS LPN #410 stated there should have been an AIMS completed when the antipsychotic medication was initiated. Review of the facility policy titled, Psychotropic Drug Use undated revealed, Qualified staff will monitor the resident for potential undesirable adverse effects that are associated with the use of psychotropic drugs upon initiation of the psychotropic medication and at minimum every six months utilizing the Abnormal Involuntary Movement Scales as well as monitor for other adverse effects in accordance with CMS and State specific rules and regulations routinely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 14 of 20 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 03/20/2025 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interview, and facility policy review the facility failed to ensure dietary dining equipment was made available for residents requiring adaptive dining equipment to maintain independence with eating. This deficient practice affected one Resident (Resident #14) out of one resident reviewed for use of dining adaptive equipment. The facility census was 81. Residents Affected - Few Findings Include: Review of Resident #17's medical record revealed admission date 02/29/22 with diagnoses including but not limited to stroke with right side hemiplegia, squamous cell carcinoma of the scalp, and type two Diabetes. Resident #14 had moderate cognitive impairment with a Brief Interview of Mental Status (BIMS) score of nine out of a possible 15 dated 01/28/25. Resident #17 required assistance from staff to complete Activities of Daily Living (ADL) tasks and was independent with eating. Review of Resident #17's signed physician orders revealed an order dated 08/23/24 for no added salt, low concentrated sweets, regular texture with thin liquids diet and an order dated 12/13/24 for Device Use: Adaptive Dining Equipment: Plate guard at meals every shift. Review of Resident #17's Treatment Administration Record (TAR) dated 03/01/25 to 03/19/25 revealed the order for Device Use: Adaptive Dining Equipment: Plate guard at meals every shift was marked as being completed. Review of Resident #17's assessments revealed a Dietary assessment dated [DATE] with a plate guard marked as being used during meals. Review of Resident #17's Dietary care plan dated 01/30/25 revealed interventions included to provide adaptive equipment as ordered to improve self-feeding. Review of Resident #17's weight listing dated 10/01/24 to 03/05/25 revealed Resident #17's weights were stable with no weight loss noted. Observation on 03/17/25 at 10:37 A.M. revealed Resident #17 sitting at a table in the unit lounge finishing the breakfast meal, there was no plate guard attached to the plate or lying on the tray. Resident #17's dietary slip had adaptive equipment marked as a plate guard. Observation on 03/18/25 at 9:08 A.M. revealed Resident #17 sitting at a table in the unit lounge eating the breakfast meal, there was no plate guard attached to the plate or lying on the tray. Observation on 03/18/25 at 11:40 A.M. revealed Certified Nursing Assistant (CNA) #385 serving Resident #17's lunch tray in the unit lounge. There was no plate lying on the tray and CNA #385 did attach a plate guard to Resident #17's plate. Interview on 03/18/25 at 11:55 A.M. with CNA #385 confirmed Resident #17 did not have a plate guard available on the meal trays. CNA #385 stated the adaptive equipment used for eating and drinking is provided by the kitchen and comes on the meal trays for use by either the Resident or the staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 15 of 20 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 03/20/2025 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 0810 Level of Harm - Minimal harm or potential for actual harm Interview on 03/18/25 at 1:41 P.M. with Dietary Supervisor #325 revealed therapy or nursing will give dietary a list of who needs adaptive equipment for dietary purposes and then we will put that on their ticket and then when the food is served the equipment will be placed on the tray. For a plate guard, it makes the lid stick up, so we place it on the tray and then the floor staff will attach it to the plate when they serve the food. Residents Affected - Few Review of the facility's policy tilted, Assistive Devices Policy undated revealed, Assistive devices shall be provided to residents who need them for all meals to maintain or improve their ability to eat independently. Adaptive equipment is made available at mealtime by Dining Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 16 of 20 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 03/20/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility policy and procedures, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and failed to ensure food was stored properly. This had the potential to affect all residents living at the facility. The facility census 81. Findings include: Observations on 03/17/25 from 8:25 A.M. to 8:35 A.M. during the tour of the kitchen with [NAME] #218 revealed the top of oven and steamer were covered with crumbs and debris. The grill had a missing panel that covered the front right side of the front grill. The panel was stored behind the grill. The [NAME] had large clumps of crumbs floating in the grease. The floor and lower back wall of the stove, oven, steamer and grill were covered with dirt, debris and grease. The freezer had two open bags of onion rings with no label or date. There was an opened brown bag with hashbrown with no label or date and an unopened bag of chicken tender and fish filets with label or date Interview on 03/17/25 between 8:25 A.M. and 8:40 A.M. with [NAME] #218 verified the identified findings and stated they will be taken care of right away. [NAME] #218 stated the staff from prior day did not clean and strain the [NAME]. Follow-up visit on 03/18/25 at 3:03 P.M. with Dietary Manager #325 Revealed the freezer had an open bag of waffles undated and an open bag of onion rings unlabeled and dated. There was a carton of ice cream with no open date. The refrigerator had an open container of humus with an open date of 02/27/25. Interview with the Dietary Manager #325 verified the findings and stated on 03/17/25 he noticed floor and the back wall of grill, steamer and oven were dirty and it was cleaned. Reviewed policy General sanitation of the kitchen, undated revealed food and nutrition services staff will maintain the sanitation of the kitchen. Leftovers are used within 7 days or discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 17 of 20 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 03/20/2025 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, Antibiotic Stewardship policy review, and interviews, the facility failed to ensure the appropriate antibiotics were administered for Resident #9 and #23. The facility also failed to ensure Resident #46 did not receive duplicate antibiotic therapy. This affected three (Resident #9, #23, and #46) out of five residents reviewed for unnecessary medications. Facility census was 81. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #9 was admitted on [DATE] with diagnoses that included acute and chronic respiratory failure, chronic kidney disease, and history of urinary tract infections. A nursing note dated 10/10/24 at 12:04 A.M. revealed Resident #9 was straight cathed to obtain a urine sample. A nursing note dated 10/10/24 at 6:34 P.M. revealed a new order was obtained for Resident #9 to start Macrobid (antibiotic) 100 milligram (mg) twice a day for urinary tract infection (UTI). A nursing note dated 10/11/24 at 3:18 A.M. revealed Resident #9 started Macrobid for possible UTI. A nursing note dated 10/13/24 at 2:08 A.M. revealed the on call provider was informed of Resident #9's allergies, current antibiotic order, and what antibiotic came back as susceptible. The on call provider asked for Resident #9's renal function. Resident #9 did not have any recent labs results in the chart. The on call provider stated it was not an emergency to change Resident #9's antibiotic and to call back in the morning. A nursing note dated 10/13/24 at 8:16 A.M. revealed the nurse practitioner reviewed the urine culture and discontinued the Macrobid and started Resident #9 on Levaquin (antibiotic) 250 mg daily for three days to culture and sensitivity results. A nursing note dated 12/02/24 at 9:49 P.M. revealed Resident #9 was straight cathed to obtain a urine sample. A nursing note dated 12/04/24 at 9:25 P.M. revealed Resident #9's urine sample leaked and a new sample was needed. Resident #9 could not be straight cathed at that time due to vaginal cream had already been inserted. A nursing note dated 12/06/24 at 5:25 P.M. revealed a new order was received to start Resident #9 on Keflex 500 mg twice a day for seven days while waiting for the urinalysis and culture and sensitivity results. A nursing note dated 12/08/24 at 3:22 P.M. revealed Resident #9 was positive for pseudomonia aeruginosa. The current antibiotic could be discontinued. A nursing note dated 12/09/24 at 2:17 P.M. revealed Resident #9 was ordered Cefdinir (antibiotic) 300 mg every 12 hours for 10 days due to elevated white blood count and to help manage UTI symptoms. The significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #9 was cognitively intact. Interview on 03/19/25 at 9:46 A.M. Licensed Practical Nurse (LPN) #335 verified doctors start antibiotics before urine results come back if there was a positive urine dip. Interview on 03/19/25 at 2:59 P.M. Unit Manager (UM) #353 verified Resident #9 was ordered antibiotics for a possible UTI prior to the urinalysis or culture and sensitivity results being received. UM #353 verified Resident #9 was started on antibiotics on 10/10/24 and 12/06/24 that had to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 18 of 20 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 03/20/2025 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 0881 changed after the culture and sensitivity results were received. Level of Harm - Minimal harm or potential for actual harm Interview on 03/20/25 at 11:54 A.M. Certified Nurse Practitioner (CNP) #600 verified antibiotics were ordered sometimes without waiting for urinalysis or culture and sensitivity results. Residents Affected - Few Review of the antibiotic stewardship policy revised 12/2016 revealed when a culture and sensitivity was ordered, lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified or discontinued. 2. Review of the medical record revealed Resident #23 was admitted on [DATE] with diagnoses that included type 2 diabetes and chronic kidney disease. The quarterly MDS dated [DATE] revealed Resident #23 was cognitively intact. Review of nursing note dated 02/27/25 at 2:44 P.M. revealed a new order was received for a urinalysis with culture and sensitivity due to Resident #23 had complaints of lower right back pain. A nursing note dated 02/28/25 at 3:22 P.M. revealed a urine sample was collected. A nursing note dated 02/28/25 at 5:33 PM. revealed Resident #23 was started on Cefuroxime (antibiotic) 500 mg twice a day for 14 days. A nursing note dated 03/06/25 at 8:53 A.M. revealed the urinalysis results were reviewed and no new orders were received. On 03/07/25 at 11:16 A.M. Resident #23's urine results were reviewed and new orders were received to hold Cefuroxime and start Cefdinir (antibiotic) 300 mg twice a day for seven days. Interview on 03/19/25 at 9:46 A.M. LPN #335 verified doctors start antibiotics before urine results come back if there was a positive urine dip. Interview on 03/19/25 at 3:02 P.M. UM #353 verified Resident #23 was ordered antibiotics for a possible UTI prior to the urinalysis or culture and sensitivity results being received. UM #353 verified Resident #23 was started on antibiotics on 02/28/25 that had to be changed after the culture and sensitivity results were received. Interview on 03/20/25 at 11:54 A.M. Certified Nurse Practitioner (CNP) #600 verified antibiotics were ordered sometimes without waiting for urinalysis or culture and sensitivity results. Review of the antibiotic stewardship policy revised 12/2016 revealed when a culture and sensitivity was ordered, lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified or discontinued. 3. Review of Residnet #46's medical record revealed admission date 05/09/24 with diagnoses including but not limited to systemic sclerosis, asthma, Chronic Obstructive Pulmonary Disease (COPD), kidney atrophy, and heart failure. Resident #46 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 out of 15 dated 02/25/25. Resident #46 was frequently incontinent of urine and required moderate assistance from staff for toileting. Review of Resident #46's laboratory results dated [DATE] for Urinalysis Culture and Sensitivity (UACS) revealed abnormal results indicating a urinary tract infection (UTI) . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 19 of 20 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 03/20/2025 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #46's signed physician orders revealed an order dated 01/24/25 for antibiotic Macrobid oral capsule 50 milligram (MG) give 50 MG by mouth at bedtime (HS) for urinary tract infection (UTI) prevention and an order dated 02/27/25 for antibiotic Ciprofloxacin 500 MG to give 500 MG two times a day for five days for UTI. Review of Resident #46's Medication Administration Record (MAR) dated 02/27/25 to 03/04/25 revealed the order for antibiotic Macrobid 50 MG was marked has being administered every HS with no documentation of the antibiotic not being administered or held. Further review of Residnet #46's MAR dated 02/27/25 to 03/04/25 revealed the order for antibiotic Ciprofloxacin 500 MG was marked as being administered two times a day for five days. An interview on 03/20/25 at 11:40 A.M. with Certified Nurse Practitioner (CNP) #600 revealed when a resident is currently receiving an antibiotic for UTI and their laboratory results are received with indications of a UTI, another antibiotic will be ordered and the current antibiotic will be placed on hold for the duration of the new antibiotic therapy. Once the new antibiotic therapy has been completed, the exisisting antibiotic therapy will be reinstated. Review of the facility policy titled, Medication Management dated 08/14 revealed, The interdisciplinary team reviews the resident's medication regimen for efficancy and actual or potential medication - related problems. An interview on 03/20/25 at 11:57 A.M. with Licensed Practical Nurse (LPN) Unit Manager (UM) #353 confirmed Resident #46 had received both antibiotics Macrobid 50 MG daily and Ciprofloxacin 500mg twice daily for a total of five days between 02/27/25 to 03/04/25. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366463 If continuation sheet Page 20 of 20