Inspection·May 5, 2022

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, resident interview, staff interview and facility policy review, the facility failed to provide a resident the opportunity to participate in a plan of care meeting. This affected one Resident (#4) of one resident reviewed for care planning. The facility census was 85. Findings Include: On 05/02/22 at 1:12 P.M., an interview with Resident #4 was conducted. Resident #4 stated she was concerned about a wound that was bothering her on her head and a loose tooth causing discomfort in her mouth. Resident #4 further stated she did not remember talking to the staff about her concerns. She also stated she had not been asked to participate in a plan of care meeting to discuss those concerns. A review of the medical record for Resident #4 revealed an admission date of 08/17/21 and diagnoses that included diabetes mellitus, hypertension, renal insufficiency, chronic pain, fibromyalgia. Review of the Minimum Data Set (MDS) dated [DATE] indicated Resident #4 was alert and oriented, able to make decisions, and required extensive to total assist with mobility. The most recent Interdisciplinary Team (IDT) plan of care meeting was documented on 08/27/21. The record was silent for any plan of care meeting notes after 08/27/21. A review of the social service progress notes dated 11/23/21, 02/04/22, and 04/25/22 revealed that all notes on those dates stated a care conference invitation letter was to be sent. All three of the notes also stated a meeting would be scheduled after response received. A further review of the medical record for Resident #4 revealed it was silent for evidence that a care plan invitation had been sent, a response was received, and that any other meeting took place. On 05/05/22 at 10:57 A.M. an interview with Social Worker #525 confirmed that Resident #4 had not had a plan of care meeting since 08/27/21. Social Worker #525 was not able to provide evidence that Resident #4 was invited to a care plan meeting and had not offered to have the meeting in her room. A review of the facility policy titled Care Plan Meetings, with a revised date of April, 2022, revealed care conferences shall be offered upon admission, quarterly, and after a significant change in status. The meeting was to be scheduled at the convenience of the resident or their representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365077 If continuation sheet Page 2 of 9 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 365077 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monterey Care Center 3929 Hoover Road Grove City, OH 43123 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and facility staff interview the facility failed to ensure a resident who had discontinuation of hospice services had timely monitoring and evaluation of anti-seizure medication. This affected one resident (#38) of one resident reviewed for change of condition. The total facility census was 85. Residents Affected - Few Findings Include: Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that include but are not limited to unspecified dementia adult failure to thrive, seizures, unstable angina, repeated falls. hypertension and trans ischemic attack. Review of a significant change Minimum Data Set, dated [DATE] revealed the resident is not able to complete the brief interview of mental status score, resident had no behaviors, delusions, hallucinations, rejection of care but had one instance of wandering during the review period. Resident #38 required extensive assist with bed mobility, dressing, toileting, and hygiene, and limited assist with transfers, walk in the room and eating. The resident is coded as requiring supervision with walking in the corridor, location off and on the unit. Resident #38 is not coded as having hospice services and as having seizures disorder. Review of April 2022 physician monthly orders revealed the resident had an order to admit to hospice services for cerebral atherosclerosis dated 02/18/21. The order had no end date or discontinuation date. Monthly orders revealed the resident had orders for Keppra solution 100mg/ml, 2.5 ml (250 mg) by mouth twice a day for seizures (dated 11/08/21). The resident's physician orders were silent to any monitoring of the Keppra levels, or any blood laboratory orders. Review of hospice documentation revealed on 03/02/22 hospice services were discontinued due to revocation. The order was signed by the hospice physician and not the facility physician. The medical record was silent to the facility physician notification of the discontinuation of hospice services. Review of progress note dated 03/16/22 at 11:38 A.M. revealed Resident #38 was no longer under the care of hospice. Review of Resident #38's care plan revealed the resident is at risk for potential seizure activity related to diagnosis disorder and for side effects of toxicity of medication dated 03/17/22. The goal is to have the resident be free of seizure activity and toxicity and or side effects of medications dated 03/17/22 through 06/30/22. Interventions include: monitor labs as ordered 03/17/22. Review of the medical record revealed the physician saw the resident on 04/14/22 and documented no labs, resident is on hospice. Review of April 2022 medication administration record (MAR) revealed staff documented NA for the Keppra 250 mg twice daily medication on 04/09/22 at 8:00 A.M., 04/14/22 at 8:00 A.M., 04/15/22 at 8:00 A.M., 04/16/22 at 8:00 P.M., 04/21/22 at 8:00 A.M., and 04/23/22 at 8:00 P.M. During an interview with Licensed Practical Nurse (LPN) #510 on 05/04/22 at 9:07 A.M. it was revealed the code NA on Resident #38's medication administration record (MAR) means the medication was not administered. The LPN confirmed the April 2022 MAR had six doses that were coded as NA and there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365077 If continuation sheet Page 3 of 9 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 365077 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monterey Care Center 3929 Hoover Road Grove City, OH 43123 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 0684 Level of Harm - Minimal harm or potential for actual harm was no documented physician notification of the medication not being administered. The LPN #510 stated if a resident does not take a medication the expectation is the staff will re-approach the resident later and offer the medication again and if that is unsuccessful the staff will call the doctor and let them know of the missed medication dose. The staff will follow any direction from the physician and document in the progress notes the physician notification and any changes made to the plan of care from the physician notification. Residents Affected - Few Review of Resident #38's progress notes revealed on 04/23/22 the nurse heard a resident scream, the nurse documented they ran down the hall and found Resident #38 laying on the ground having seizure like activity which lasted approximately 3 minutes. The nurse documented the family was called and requested the resident be sent to the hospital. The nurse documented 911 was called and the resident was transported to an acute care hospital for further evaluation. Hematoma noted to right side of forehead, will start neuro checks when the resident returns from the hospital, all aware. Review of hospital documentation for Resident #38 revealed the resident arrived to the emergency room on [DATE] at 6:18 P.M. Resident had a Keppra level obtained at 6:41 P.M. There was a CT of the cervical spine performed on 04/23/22 at 7:59 P.M. with indications for the test documented as seizure and fall. Keppra level from emergency room visit on 04/23/22 the level was <1.0 with a reference range of 3.0-60.0 ug/ml. emergency room documentation from 04/23/22 revealed final diagnosis: breakthrough seizure and cystitis. Medications administered in the emergency department were documented as Ativan 0.5 mg intravenously at 7:45 P.M., Keppra 1320 mg intravenously at 9:29 P. M. and Rocephin 1 gm intravenously at 9:30 P.M. Review of Resident #38's medical record revealed the last Keppra level in the record was on 02/11/21 with a level of 4.9 with a reference range of 10.0-40.0 mcg/ml. On 05/03/22 the facility provided a Keppra level of 28.9 for the resident which was obtained by the facility on 04/29/22 after a the resident was found on the floor with seizure activity and went to the acute emergency department for treatment. No other Keppra levels were obtained at the facility from 02/11/21 to 04/29/22 and the resident stopped hospice services on 03/02/22. During an interview with Licensed Practical Nurse (LPN) #510 on 05/04/22 at 9:10 A.M. it was verified the Keppra level in the medical record for Resident #38 on 04/29/22 and was 28.9 ug/ml which was within the reference range of 10-40 ug/ml. The LPN #510 agreed the laboratory test was completed after the resident had been to the hospital for seizure activity. The LPN verified the prior Keppra level for Resident #38 was obtained on 02/11/21 and was 4.9 ug/ml (below the 10-40 ug/ml reference range). The LPN #510 stated often when a resident is on hospice services laboratory testing will be discontinued. LPN #510 was asked even for high risk medications and medications where there is a therapeutic level; and the LPN stated the resident does not do well with laboratory blood draws and that could be part of the reason the testing was discontinued. Observation of the front of the medical record on 05/04/22 at 9:10 A.M. revealed there was a sticker on the front of the medical record that said Resident #38 was under the care of Hospice. LPN #510 during this observation verified the hospice sticker was still on the front of Resident #38's medical chart indicating the resident was receiving hospice services, when those services had been discontinued the month before. During an observation and interview with the Director of Nursing (DON) on 05/05/22 at 8:30 A.M. it was confirmed there was no order to discontinue hospice services in the medical record and there was no order in the medical record to obtain a Keppra level for the laboratory test completed on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365077 If continuation sheet Page 4 of 9 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 365077 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monterey Care Center 3929 Hoover Road Grove City, OH 43123 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 04/29/22. The DON additionally looked on the physician clip board of orders to sign and in the documents ready to be filed in resident charts and could not find orders to discontinue hospice or obtain a Keppra level for Resident #38. The DON stated she did not know where the order to obtain the laboratory test completed on 04/29/22 was obtained from. The DON was asked how the physician would know when hospice services were discontinued if there was no order on the medical record and she stated the hospice company would notify the physician. Event ID: Facility ID: 365077 If continuation sheet Page 5 of 9 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 365077 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monterey Care Center 3929 Hoover Road Grove City, OH 43123 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 0710 Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and facility staff interview the facility failed to ensure a physician was directing the care of a resident. This affected one resident (#38) of one reviewed for change of condition. The total facility census was 85. Residents Affected - Few Findings Include: Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that include but are not limited to unspecified dementia adult failure to thrive, seizures, unstable angina, repeated falls, hypertension, and trans ischemic attack. Review of significant change Minimum Data Set, dated [DATE] revealed the resident is not able to complete the brief interview of mental status score, resident had no behaviors, delusions, hallucinations, rejection of care but had one instance of wandering during the review period. Resident #38 required extensive assist with bed mobility, dressing, toileting, and hygiene, and limited assist with transfers, walk in the room and eating. The resident is coded as requiring supervision with walking in the corridor, location off and on the unit. Resident #38 is not coded as not having hospice services and as having seizures disorder. Review of April 2022 physician monthly orders revealed the resident has an order to admit to hospice services for cerebral atherosclerosis dated 02/18/21. The order has no end date or discontinuation date. Monthly orders revealed the resident had orders for Keppra solution 100 mg/ml, 2.5 ml (250 mg) by mouth twice a day for seizures dated 11/08/21. The resident physician orders were silent to any monitoring of the Keppra levels, or any blood laboratory orders. Review of hospice documentation revealed on 03/02/22 hospice services were discontinued due to revocation. The order was signed by the hospice physician and not the facility physician. The medical record was silent to the facility physician notification of the discontinuation of hospice services. Review of Resident #38's progress notes dated 03/16/22 at 11:38 A.M. revealed Resident #38 was no longer under the care of hospice. Review of the medical record revealed the facility physician saw the resident on 04/14/22 and documented no labs, resident is on hospice. Review of April 2022 medication administration record (MAR) revealed staff documented NA for the Keppra 250 mg twice daily medication on 04/09/22 at 8:00 A.M., 04/14/22 at 8:00 A.M., 04/15/22 at 8:00 A.M., 04/16/22 at 8:00 P.M., 04/21/22 at 8:00 A.M., and 04/23/22 at 8:00 P.M. During an interview with Licensed Practical Nurse (LPN) # 510 on 05/04/22 at 9:07 A.M. it was revealed the code NA on Resident #38's medication administration record (MAR) means the medication was not administered. The LPN confirmed the April 2022 MAR had six doses that were coded as NA and there was no documented physician notification of the medication not being administered. The LPN #510 stated if a resident does not take a medication, the expectation is the staff will re-approach the resident later and offer the medication again and if that is unsuccessful the staff will call the doctor and let them know of the missed medication dose. The staff will follow any direction from the physician and document in the progress notes the physician notification and any changes made to the plan of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365077 If continuation sheet Page 6 of 9 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 365077 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monterey Care Center 3929 Hoover Road Grove City, OH 43123 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 0710 care from the physician notification. Level of Harm - Minimal harm or potential for actual harm Review of Resident #38's medical record revealed the last Keppra level in the record was on 02/11/21 with a level of 4.9 with a reference range of 10.0-40.0 mcg/ml. On 05/03/22, the facility provided a Keppra level of 28.9 for the resident which was obtained by the facility on 04/29/22 after a the resident was found on the floor with seizure activity and went to the acute emergency department for treatment. No other Keppra levels were obtained at the facility from 02/11/21, to 04/29/22 and the resident stopped hospice services on 03/02/22. Residents Affected - Few During an observation and interview with the Director of Nursing (DON) on 05/05/22 at 8:30 A.M. it was confirmed there was no order to discontinue hospice services in the medical record and there was no order in the medical record to obtain a Keppra level for the laboratory test completed on 04/29/22. The DON additionally looked on the physician clip board of orders to sign and in the documents ready to be filed in resident charts and could not find orders to discontinue hospice or obtain a Keppra level for Resident #38. The DON stated she did not know where the order to obtain the laboratory test completed on 04/29/22 was obtained from. The DON was asked how the physician would know when hospice services were discontinued if there was no order on the medical record and she stated the hospice company would notify the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365077 If continuation sheet Page 7 of 9 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 365077 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monterey Care Center 3929 Hoover Road Grove City, OH 43123 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interview, and facility policy review, the facility failed to properly store/date food in the main kitchen. This had the potential to affect 82 of 85 residents who receive food from the facility kitchen (Residents #8, #16, and #19 receive no food by mouth). The census was 85. Findings Include: Observations on 05/02/22 from 8:38 A.M. to 8:47 A.M. revealed the following items were found in the walk in freezer as opened and undated/improperly dated: opened bag of country friend steak that had a delivery date of 01/05/22 on the opened box, but no date on the bag of steak that was opened, and bags of chicken patties, breadsticks, green peas, and chicken tenders were opened and undated as to when they were opened or should be used by. Observations on 05/02/22 from 8:50 A.M. to 8:55 A.M. revealed the following items were found in the walk in refrigerator as opened and undated/improperly dated: bag of hot dogs, cole slaw, and two bags of lettuce were all opened and had no dates indicated as to when they were opened or when to use by. Also, there was a pan of cheese sauce with plastic wrap on it. On the plastic wrap was written, 04/20/22 to 04/26/22. Interview with Dietary Manager #204 on 05/02/22 at 8:45 A.M. and 8:54 A.M. confirmed the food items that were opened, should have had an open date or a use by date indicated on them. Also, she confirmed the cheese sauce should have been discarded. Review of facility Labeling and Dating Food policy, dated 01/01/12, revealed the facility will ensure all food items are properly labeled and dated. Freezing food stops the date marking clock, but does not reset it. If a food item is stored at 41 degrees for two days and then frozen, it can still be stored at 41 degrees for five more days when it begins to thaw. The freezing date and thawing date need to be put on the container along with the prep date, or an indication of how many of the original seven days have been used. If a food is not marked with these dates, it must be used or discarded within 24 hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365077 If continuation sheet Page 8 of 9 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 365077 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monterey Care Center 3929 Hoover Road Grove City, OH 43123 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on facility document review and staff interview, the facility failed to fully participate in Quality Assurance and Assessment (QAA) committee activities. This had the potential to affect 85 of 85 residents in the facility. Residents Affected - Many Findings Include: Review of facility QAA meeting sign in sheets, dated March 2021 to March 2022, revealed the only meeting that the facility medical director attended was in April 2021. Review of facility Medical Director Monthly Reports, dated January 2022, October 2021, and July 2021, revealed hand written notes that indicated the QAA meeting minutes were reviewed with the medical director. There was no documentation to support which QAA meeting minutes and information was reviewed at that time, so there was no documentation to support the information reviewed with the medical director was current/relevant to what was discussed in each monthly/quarterly QAA meeting. Also, there was no documentation/evidence to support the medical director was provided, or offered meaningful participation in the QAA program. Interview with Director of Nursing (DON) on 05/05/22 at 12:32 P.M. confirmed there was no evidence that the medical director attended any QAA meetings with the QAA committee since April 2021. She confirmed she would meet with the medical director on a monthly basis to discuss what the QAA committee had reviewed in their full meeting. But she also confirmed the medical director did not attend (in person or on the phone) the QAA meetings with the entire committee, since April 2021. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365077 If continuation sheet Page 9 of 9