November 6, 2012 By Certified Mail

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Midwest Division of Survey and Certification Chicago Regional Office 233 North Michigan Avenue, Suite 600 Chicago, IL 60601-5519 CMS Certification Number (CCN): 365795 Ms. Lori Ference, Administrator Pembrooke Place Nursing and Rehab Center 850 East Midlothian Blvd Youngstown, OH 44507 Dear Ms. Ference: November 6, 2012 By Certified Mail SUBJECT: SURVEY FINDINGS AND IMPOSITION OF REMEDIES Cycle Start Date: June 29, 2012 SURVEY RESULTS On June 27, 2012, a Life Safety Code survey was completed at Pembrooke Place Nursing and Rehab Center by the Ohio Department of Health (ODH) to determine if your facility was in compliance with the Federal requirements for nursing homes participating in the Medicare and Medicaid programs. This survey found that your facility was not in substantial compliance, with the most serious deficiency at scope and severity (S/S) level F, cited as follows: K50 -- S/S: F -- NFPA 101 -- Life Safety Code Standard On June 29, 2012, a complaint investigation and health survey were completed at Pembrooke Place Nursing and Rehab Center by the ODH to determine if your facility was in compliance with the Federal requirements for nursing homes participating in the Medicare and Medicaid programs. These surveys found that your facility was not in substantial compliance, with the most serious deficiencies at scope and severity (S/S) level G, cited as follows: F315 -- S/S: G -- 483.25(d) -- No Catheter, Prevent UTI, Restore Bladder F318 -- S/S: G -- 483.25(e)(2) -- Increase/Prevent Decrease In Range of Motion On August 2, 2012, a revisit was completed at Pembrooke Place Nursing and Rehab Center by the ODH to determine if your facility was in compliance with the Federal requirements for nursing homes participating in the Medicare and Medicaid programs. This survey found that your facility was not in substantial compliance, with the most serious deficiency at scope and severity (S/S) level E, cited as follows: F253 -- S/S: E -- 483.15(h)(2) -- Housekeeping & Maintenance Services

Page 2 On September 11, 2012, a complaint investigation was completed at Pembrooke Place Nursing and Rehab Center by the ODH to determine if your facility was in compliance with the Federal requirements for nursing homes participating in the Medicare and Medicaid programs. This survey found that your facility was not in substantial compliance, with the most serious deficiency at scope and severity (S/S) level D, cited as follows: F323 -- S/S: D -- 483.25(h) -- Free of Accident Hazards/Supervision/Devices The State agency advised you of the deficiencies that led to these determinations and provided you with a copy of the survey report (CMS-2567) for each survey. SUMMARY OF ENFORCEMENT REMEDIES As a result of the survey findings, and as authorized by the Centers for Medicare & Medicaid Services (CMS), the ODH notified you on July 18, 2012, of the imposition of the following remedy, as well as your appeal rights: Discretionary Denial of Payment for New Medicare and Medicaid Admissions effective August 13, 2012 Based on the survey findings, the ODH notified you they were recommending that the CMS impose additional remedies, as follows: Federal Civil Money Penalty of $650.00 per day beginning June 29, 2012, and continuing at a rate of $100.00 per day effective August 2, 2012 until your facility achieves substantial compliance Mandatory Termination of your Medicare and Medicaid provider agreements effective December 29, 2012 However, before the effective dates of these remedies, the ODH conducted revisits to your facility on October 3, 2012, and found that your facility was in substantial compliance as of September 16, 2012. As a result, the following remedy will not go into effect: Mandatory Termination of your Medicare and Medicaid provider agreements effective December 29, 2012 However, based on the period of time your facility was not in substantial compliance, the following remedies have gone into effect: Federal Civil Money Penalty of $650.00 per day for the thirty-four (34) days beginning June 29, 2012 and continuing through August 1, 2012 for a total of $22,100.00 Federal Civil Money Penalty of $100.00 per day for the forty-five (45) days beginning August 2, 2012 and continuing through September 15, 2012 for a total of $4,500.00 Discretionary Denial of Payment for New Medicare and Medicaid Admissions was effective August 13, 2012 and is being discontinued effective September 15, 2012. Thus, the remedy applies to any new Medicare and Medicaid admissions from August 13, 2012 through September 15, 2012 The authority for the imposition of remedies is contained in subsections 1819(h) and 1919(h) of

Page 3 the Social Security Act ("Act") and Federal regulations at 42 CFR Subpart F, Enforcement of Compliance for Long-Term Care Facilities with Deficiencies. DENIAL OF PAYMENT FOR NEW ADMISSIONS The ODH notified you that the remedy of mandatory denial of payment for all new Medicare admissions is imposed effective August 13, 2012 and was discontinued effective September 15, 2012 due to your facility's failure to achieve compliance within the required three months. This action is mandated by the Social Security Act at Sections 1819(h)(2)(D) and 1919 (h)(2)(c) and Federal regulations at 42 CFR Section 488.417(b). We are notifying CGS J-15 MAC that the denial of payment for all new Medicare admissions was effective on August 13, 2012 and was discontinued effective September 15, 2012. We are further notifying the State Medicaid agency that the denial of payment for all new Medicaid admissions was effective August 13, 2012 and was discontinued effective September 15, 2012. You should notify all Medicare and Medicaid residents who were admitted on or after this date of the restriction. The remedy has remained in effect until your facility was determined to be in substantial compliance effective September 16, 2012. Please note that the denial of payment for new Medicare admissions includes Medicare beneficiaries enrolled in managed care plans. It is your obligation to inform Medicare managed care plans contracting with your facility of this denial of payment for new admissions. CIVIL MONEY PENALTY In determining the amount of the Civil Money Penalty (CMP) that we are imposing, we have considered your facility's history, including any repeated deficiencies; its financial condition; and the factors specified in the Federal requirement at 42 CFR 488.404. We are imposing the following CMP: Federal Civil Money Penalty of $650.00 per day for the thirty-four (34) days beginning June 29, 2012 and continuing through August 1, 2012 for a total of $22,100.00 Federal Civil Money Penalty of $100.00 per day for the forty-five (45) days beginning August 2, 2012 and continuing through September 15, 2012 for a total of $4,500.00 The total CMP amount imposed is $26,600.00. If you believe that you have documented evidence that should be considered in establishing the amount of the CMP, the following documents should be submitted to this office within fifteen (15) days from the receipt of this notice: Written, dated request specifying the reason financial hardship is alleged List of the supporting documents submitted Current balance sheet Current income statements Current cash flow statements Most recent full year audited financial statements prepared by an independent accounting firm, including footnotes Most recent full year audited financial statements of the home office and/or related entities, prepared by an independent accounting firm, including footnotes Disclosure of expenses and amounts paid/accrued to the home office and/or related entities

Page 4 Schedule showing amounts due to/from related companies or individuals included in the balance sheets. The schedule should list the names of related organizations or persons and indicate where the amounts appear on the balance sheet (e.g., Accounts Receivable, Notes Receivable, etc.) If the nursing home requests an extended payment schedule of more than twelve (12) months duration, the provider must submit a letter from a financial institution denying the provider s loan request for the amount of the CMP The CMP is due and payable and may be placed in an escrow account fifteen days after one of the following, whichever occurs first: The date on which an Independent IDR process is completed, if applicable or The date which is 90 calendar days after the date of the notice of imposition of the CMP CMP CASE NUMBER A CMP case number will be assigned to your case only when the final CMP is due and payable. At that time you will receive a notice from this office with the CMP case number and payment instructions. Prior to the assignment of a CMP case number, you must ensure that your facility s name, CMS Certification Number (CCN), and the enforcement cycle start date appear on any correspondence pertaining to this CMP. Your CMS Certification Number (CCN) is 365795. The start date for this cycle is June 29, 2012. CMP PAYMENT When due, the CMP is payable by check to CMS at the following address: Centers for Medicare & Medicaid Services Division of Accounting Operations Mail Stop C3-11-03 Post Office Box 7520 Baltimore, MD 21207 If you use a delivery service, such as Federal Express, use the following address only: Centers for Medicare & Medicaid Services Division of Accounting Operations Mail Stop C3-11-03 7500 Security Boulevard Baltimore, MD 21244 Note that your check must be sent to one of the above addresses--not to the Chicago Regional Office. However, a copy of your check and, if applicable, your waiver of your right to a hearing must be sent to the attention of Jan Suzuki at the Chicago Regional Office. Failure to do so could result in our office proceeding with collection of the full amount of the CMP.

Page 5 If the total amount of the CMP is not received by the due date, interest will be assessed in accordance with the regulations at 42 CFR Section 488.442 on the unpaid balance of the penalty beginning on the due date. The Federal rate of interest is 10.375%. The CMP, and any interest accrued after the due date, will be deducted from sums owing to you without any further notification from this office. CMP REDUCED IF HEARING WAIVED If you waive your right to a hearing, in writing, within 60 calendar days from receipt of this notice, the amount of your CMP will be reduced by thirty-five percent (35%). To receive this reduction, the written waiver should be sent to the Centers for Medicare & Medicaid Services, Division of Survey and Certification, 233 North Michigan Avenue, Suite 600, Chicago, Illinois 60601-5519. The failure to request a hearing within 60 calendar days from your receipt of this notice does not constitute a waiver of your right to a hearing for purposes of the 35% reduction. APPEAL RIGHTS This formal notice imposed: Federal Civil Money Penalty effective beginning June 29, 2012 If you disagree with the finding of noncompliance which resulted in this imposition, you or your legal representative may request a hearing before an administrative law judge of the Department of Health and Human Services, Departmental Appeals Board (DAB). Procedures governing this process are set out in Federal regulations at 42 CFR Section 498.40, et. seq. A written request for a hearing must be filed no later than 60 days from the date of receipt of this notice. Such a request should be made to: Department of Health and Human Services Departmental Appeals Board, MS 6132 Civil Remedies Division Attention: Karen R. Robinson, Director 330 Independence Avenue, SW Cohen Building, Room G-644 Washington, D.C. 20201 It is important that you send a copy of your request to our Chicago office to the attention of Jan Suzuki. Failure to do so could result in our office proceeding with collection of the CMP. A request for a hearing should identify the specific issues and the findings of fact and conclusions of law with which you disagree, including a finding of substandard quality of care, if applicable. It should also specify the basis for contending that the findings and conclusions are incorrect. You do not need to submit records or other documents with your hearing request. The DAB will issue instructions regarding the proper submittal of documents for the hearing. The DAB will also set the location for the hearing. Counsel may represent you at a hearing at your own expense. INDEPENDENT INFORMAL DISPUTE RESOLUTION (INDEPENDENT IDR) In accordance with 488.431, when a civil money penalty subject to being collected and placed

Page 6 in an escrow account is imposed, you have one opportunity to question cited deficiencies through an Independent IDR process. You may also contest scope and severity assessments for deficiencies which resulted in a finding of actual harm or immediate jeopardy to resident health or safety (i.e., at a scope and severity level of G or above). To be given such an opportunity, you are required to send your written request, along with the specific deficiencies being disputed, and an explanation of why you are disputing those deficiencies (or why you are disputing the scope and severity assessments of deficiencies which have been found to constitute actual harm or immediate jeopardy) to: Kathryn Kimmet, Chief Bureau of Regulatory Compliance 246 N. High Street, Third Floor Columbus, OH 43215 Email: BRC@odh.ohio.gov This request must be sent within 10 calendar days of receipt of this offer. An incomplete Independent IDR process will not delay the effective date of any enforcement action. INFORMAL DISPUTE RESOLUTION You were previously advised by the State agency of the results of the informal dispute resolution (IDR) process. We have considered the IDR results in determining appropriate enforcement actions. NURSE AIDE TRAINING PROHIBITION Please note that Federal law, as specified in the Act at Sections 1819(f)(2)(B) and 1919(f)(2)(B), prohibits approval of nurse aide training and competency evaluation programs and nurse aide competency evaluation programs offered by, or in, a facility which, within the previous two years, has operated under a 1819(b)(4)(C)(ii)(II) or 1919(b)(4)(C)(ii) waiver (i.e., waiver of full-time registered professional nurse); has been subject to an extended or partial extended survey as a result of a finding of substandard quality of care; has been assessed a total civil money penalty of not less than $5,000.00; has been subject to a denial of payment, the appointment of a temporary manager or termination; or, in the case of an emergency, has been closed and/or had its residents transferred to other facilities. Because a denial of payment remedy went into effect, this provision is applicable to your facility. Therefore, Pembrooke Place Nursing and Rehab Center is prohibited from offering or conducting a Nurse Aide Training and/or Competency Evaluation Program (NATCEP) for two years from August 13, 2012. You will receive further information regarding this from the State agency. This prohibition remains in effect for the specified period even though other actions relating to remedies are being taken, as indicated above. However, under Public Law 105-15, you may contact the State agency and request a waiver of this prohibition if certain criteria are met. REQUIRED SPRINKLER STATUS BY AUGUST 13, 2013 On August 13, 2008, CMS published a final rule that requires all long-term care facilities to be equipped with a complete supervised automatic sprinkler system by no later than August 13, 2013. Facilities with no or partial sprinkler systems installed and/or that use waivers or the Fire Safety Evaluation System (FSES) to comply with the current sprinkler requirements have until August 13, 2013 to install or upgrade the sprinkler system. Please review your facility s

Page 7 sprinkler system to ensure it fully complies with the National Fire Protection Association s (NFPA) Standard for the Installation of Sprinkler Systems (1999 Edition, NFPA 13). The Federal survey process requires review of the sprinkler system to determine if the system is providing complete coverage or only partial coverage. Complete coverage means that the entire facility, including all closets, storage areas and walk-in coolers and freezers are sprinkler protected. There are specific requirements for overhangs attached to the outside of the building (1999 Edition, NFPA 13, Section 5-13.8), electrical equipment rooms (1999 Edition, NFPA 13, Section 5-13.11) and Elevator Hoistways and Machine Rooms (1999 Edition, NFPA 13, Section 5-13.6) that are the responsibility of the facility to understand and comply with, that may result in costly upgrades that will require time to complete. Since there is no waiver and/or FSES provision after August 13, 2013, it is imperative that you ensure that your facility is fully sprinkled in accordance with the regulation on August 13, 2013. Failure to do so is likely to result in enforcement remedies, including but not limited to termination. If you have any questions regarding the sprinkler status requirements, please contact Daniel Kristola, LSC Principal Program Representative in the Chicago regional office at 312-886-5210. CONTACT INFORMATION If you have any questions regarding this matter, please contact me at (312) 886-5209 or Maria Vergel de Dios, Certification Specialist, at (312) 353-3647. Information may also be faxed to (443) 380-6602. All correspondence should be directed to me in our Chicago office. Sincerely, Jan Suzuki Acting Branch Manager Long Term Care Certification & Enforcement Branch cc: Ohio Department of Health Ohio Department of Job and Family Services CGS - J15 MAC Ohio Department of Aging - Beverly Laubert Ohio KePRO