Health inspection·August 17, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, staff interview, and review of facility policy, the facility failed to ensure a clean and sanitary environment when fecal matter was observed in a resident hallway. This had the potential to affect all 18 (#3, #4, #6, #12, #14, #17, #26, #27, #28, #32, #33, #39, #40, #42, #45, #48, #51, and #54) residents who resided on the hall. The facility census was 64. Findings include: Observation on 08/09/22 at 9:15 A.M. revealed a think pudding-like, brown substance, appearing as fecal matter, measuring approximately one inch by three inches in a hall. Observation on 08/09/22 at 9:17 A.M. revealed State Tested Nursing Assistance (STNA) #275 walked by the fecal looking matter in the hall without addressing it. Observation on 08/09/22 at 9:40 P.M. revealed Housekeeper #220 in the hall approximately four rooms away from the fecal matter. Observation on 08/09/22 at 9:41 A.M. revealed the fecal looking matter in the hall was still in the same location. Interview on 08/09/22 at 9:42 A.M. with Maintenance Assistant #245 verified the suspected fecal matter was in fact, fecal matter. Interview on 08/09/22 at 9:47 A.M. Housekeeper #220 reported she did not observe the fecal matter in the hall. Interview on 08/09/22 at 10:07 A.M. with STNA #275 denied observing the fecal matter in the hall. Review of facility policy titled, Quality of Life- Homelike Environment, revised May 2017, revealed the facility will offer a clean, sanitary, and orderly environment. The deficiency substantiates Complaint Number OH00134214. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365163 If continuation sheet Page 2 of 16 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 365163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northcrest Rehab and Nursing Center 240 Northcrest Drive Napoleon, OH 43545 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and review of the facility's abuse policy, the facility failed to report an allegation of resident to resident verbal abuse. This affected two (Residents #17 and #6) of three residents reviewed for abuse. The facility census was 64. Findings include: Review of the medical record for Resident #17 revealed a readmission date of 11/19/21 with medical diagnoses of unspecified dementia, anxiety disorder, and renal sclerosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had impaired cognition, required limited assistance of one person for transfers and supervision with setup only for walking. Further review revealed the resident had behavioral symptoms, not directed toward others, one to three days during the review period. Review of the medical record for Resident #6 revealed an admission date of 07/16/21 with medical diagnoses of cellulitis of the left lower limb and internal derangements of an unspecified knee. Review of the comprehensive MDS dated [DATE] revealed Resident #6 had impaired cognition. Review of Resident #6's progress notes revealed on 06/17/22, Resident #6 was verbally aggressive toward Resident #17 by swearing at the other resident, as witnessed by facility staff. Further review of a progress note dated 06/20/22 revealed Resident #6 was sitting at a different table than Resident #17, they were not near each other, and Resident #17 did not realize Resident #6 was yelling at him. Interview on 08/09/22 at 4:41 P.M. with the Director of Nursing (DON) #261 revealed she was aware of the incident and confirmed the incident was not documented on the facility's incident log. Review of the facility's investigation into the incident included witness statements and an overview of the incident, further indicating Resident #17 was unaware Resident #6's anger was directed at him. Interview on 08/11/22 at 10:20 A.M. with the DON #261 revealed she and the Administrator determined abuse did not occur to Resident #6 after their investigation was completed. However, the DON #261 was unable to provide a timeframe to outline the time lapse between the occurrence of the incident and the conclusion of the investigation. The incident was not reported to the state agency. Review of the facility's self-reported incidents on 08/11/22 revealed the facility did not report the incident between Resident #17 and Resident #6. Review of the facility's abuse policy titled, Abuse and Neglect Protocol, revised 06/13/21 revealed the, facility shall report immediately, but not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury to designated state agency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365163 If continuation sheet Page 3 of 16 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 365163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northcrest Rehab and Nursing Center 240 Northcrest Drive Napoleon, OH 43545 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of facility policy the facility failed to ensure a comprehensive care plan was developed to address safe smoking for one (Resident #53) of three residents reviewed for smoking. The facility census was 64. Findings include: Review of the medical record revealed Resident #53 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease, dependence on supplemental oxygen, essential (primary) hypertension, type two diabetes mellitus without complications, and anemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #53's care plan revealed goals or interventions in place for safe smoking. Review of the smoking assessments dated 07/03/22 and 07/10/22 revealed Resident #53 was safe to smoke with supervision and no apron was required. Observation on 08/09/22 at 12:30 P.M. revealed Resident #53 smoking outside in the designated smoking area with supervision. Interview on 08/09/22 at 4:34 P.M. with the Director of Nursing (DON) verified Resident #53's care plan did not address a plan for safe smoking. Review of the facility policy titled, Smoking, updated 04/14/22 revealed smoking privileges will be addressed in a care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365163 If continuation sheet Page 4 of 16 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 365163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northcrest Rehab and Nursing Center 240 Northcrest Drive Napoleon, OH 43545 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure nail care and grooming services was provided to a dependent resident. This affected one (Resident #43) of three residents reviewed for receiving assistance with Activities of Daily Living (ADLs). The facility census was 64. Residents Affected - Few Findings include: Review of the medical record revealed Resident #43 admitted to the facility on [DATE] with diagnoses including, type 2 diabetes mellitus, coronavirus 2019, neuromuscular urinary bladder, hypertension, major depression, multiple sclerosis, polyneuropathy, legal blindness, coronary artery disease, disorder of arteries and arterioles, atrial fibrillation, congestive heart failure, transient ischemic attack, ulcerative colitis, chronic obstructive pulmonary disease, and benign prostatic hyperplasia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had mild cognitive impairment and was dependent on two staff for the completion of ADLs, including dressing and hygiene. The resident utilized an indwelling urinary catheter and was incontinent of bowel. Review of the care plan dated 04/20/22 revealed Resident #43 had a self-performance deficit related to impaired cognition, weakness, pain, obesity, multiple sclerosis, and at times shortness of breath. The resident often refused care and instructed staff to leave him the alone. Interventions included the following, encourage to get up in chair daily and self propel, utilize mechanical lift and two staff assistance for transfers using green sling, one staff assist to propel wheelchair (w/c) for locomotion, call light within accessible reach, praise all efforts at self care, requires two staff to use toilet, requires one to two staff to reposition and turn in bed, encourage resident to participate to the fullest extent possible with each interaction, monitor/document/report to physician as needed, any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function, requires one staff with bathing, requires one assist with personal hygiene/oral care, and requires one staff participation to dress. Further review of the care plan revealed no specific interventions in place to encourage Resident #43 to participate in ADL care. There were also no specific interventions in place to address Resident #43's refusal of care. Observation on 08/08/22 at 9:47 A.M. revealed Resident #43 in bed wearing a hospital gown, with heavy beard growth, unkept hair, and black/brown substance underneath fingernails of both hands. Observation on 08/09/22 at 9:15 A.M. noted Resident #43 in bed wearing a hospital gown, with heavy beard growth, unkept hair, and black/brown substance underneath fingernails of both hands. Continued observations on at 10:46 A.M., and 11:53 A.M. revealed Resident #43 still in bed wearing a hospital gown, with heavy beard growth, unkept hair, and black/brown substance underneath fingernails of both hands. Interview on 08/09/22 at 12:19 P.M. with State Tested Nurse Aide (STNA) #275 revealed she cared for Resident #43 frequently. Resident #43 was asked to get cleaned up this morning and refused. STNA #275 indicated this behavior occurs often. STNA #275 was unaware if a care plan or interventions had been developed to assist with Resident #43 complying with ADL care. STNA #275 verified the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365163 If continuation sheet Page 5 of 16 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 365163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northcrest Rehab and Nursing Center 240 Northcrest Drive Napoleon, OH 43545 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few fingernails were heavily soiled with a black/brown substance and the resident had heavy beard growth and unkept hair. Observations on 08/10/22 at 7:16 A.M. and 9:10 A.M. revealed Resident #43 remained in bed wearing a hospital gown with unkept hair, heavy beard growth, and black build-up underneath fingernails of both hands. Interview on 08/10/22 at 9:10 A.M. with STNA #256 revealed Resident #43 was going out to appointment at 10:00 A.M. STNA #256 confirmed the resident was dressed in a hospital gown, not shaven, with unkept hair, and had heavy build-up of black substance underneath his fingernails on both hands. STNA #256 stated the resident refused getting bathed and other ADL care. STNA #256 stated she would re-approach the resident at a later time. At 9:45 A.M. STNA #256 stated when she re-approached Resident #43 he indicated he was unaware his grooming was unkept and agreed to having ADL care completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365163 If continuation sheet Page 6 of 16 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 365163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northcrest Rehab and Nursing Center 240 Northcrest Drive Napoleon, OH 43545 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to monitor Resident #19's skin underneath a heel protector boot. This resulted in actual harm when Resident #19 developed two Deep Tissue Injuries (DTI) on the right foot, consistent with the strap of the heel protector boot being too tight. Additionally, the facility failed to complete accurate skin assessments and failed to ensure recommended interventions were in place for Resident #60. This resulted in actual harm when Resident #60 was discovered with an in-house acquired DTI to the foot. This affected two (Residents #19 and #60) of three residents reviewed for skin breakdown. The facility's census was 64. Residents Affected - Few Findings include: 1. Medical record review for Resident #19 revealed the resident admitted to the facility on [DATE]. Diagnoses included traumatic subarachnoid hemorrhage, pressure induced Deep Tissue Injury (DTI) deep tissue damage to right heel, Type II diabetes mellitus, hypertension, myocardial infarction, coronary artery disease, chronic embolism, thrombosis of right femoral vein, acute respiratory failure with hypoxia, Stage III pressure ulcer of sacral region, and coronary angioplasty implant and graft. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was severely cognitively impaired and was dependent upon staff for Activities of Daily Living (ADLs) including bed mobility and transfers. Resident #19 was incontinent of urine and admitted to the facility with a DTI. Review of the Pressure Sore Development Risk assessment dated [DATE] revealed the resident was at high risk for developing pressure ulcers. Review of Resident #19's care plan developed on 06/20/22 and revised on 07/13/22 revealed the resident was at risk for skin breakdown related to decreased mobility, occasional bowel incontinence, admitted with pressure ulcers, and often refuses to turn/reposition. Interventions included alternating air mattress to bed initiated on 06/20/22, assist/encourage resident to turn/reposition every two hours and as needed initiated on 06/20/22, bilateral heel boots as ordered initiated 07/22/22, monitor skin with daily care, report any new or worsening abnormalities added on 06/20/22, and monitor/document location, size and treatment of skin injuries, report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to physician initiated on 06/20/22. Review of Resident #19's physician orders dated 07/11/22 revealed an order was obtained for heel boots to be worn at all times. There was no documentation indicating the resident's skin integrity was assessed under the heel boots each shift. Continued review of Resident #19's physician orders revealed an order dated 07/21/22 for heel boots to be worn at all times. MAKE SURE STRAP IS EXTREMELY LOOSE TO R (right) FOOT!!! every shift for protection. Review of Resident #19's Treatment Administration Records from 07/11/22 to 08/04/22 revealed the heel boots were documented as applied on each shift. Further review of the medical record revealed no documentation the skin integrity to Resident #19's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365163 If continuation sheet Page 7 of 16 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 365163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northcrest Rehab and Nursing Center 240 Northcrest Drive Napoleon, OH 43545 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 right foot was assessed each shift. Level of Harm - Actual harm Review of the change in condition progress note dated 07/23/22 at 7:16 A.M. revealed Resident #19 was noted to have a purple area to the top and side of the right foot. The area to the top of the foot measured 10 centimeters (cm) long by (x) 3 cm wide x 0 cm deep and the area to the side of the foot measured 1 cm long x 1 cm wide x 0 cm deep. The resident had heel boots on, but the strap laid across the top of his foot. Recommendations included wrap foot with kerlix gauze wrap instead of ace bandage and keep the strap loose to the heel boot. Residents Affected - Few No further wound assessment was documented until 07/27/22 when the wound nurse, Registered Nurse (RN) #262, evaluated the wounds to the right foot. The wound located on the top of the right food was documented as in-house acquired and described as a suspected DTI measuring 8 cm long x 3 cm wide x 0 cm deep and purple in color. The right outer (lateral) foot wound was documented as in-house acquired and described as a suspected DTI measuring 2 cm long x 2 cm wide x 0 cm deep and purple in color. On 08/04/22 a physician order was initiated, DO NOT UTILIZE HEEL BOOTS! Float bilateral heels with pillows, AT ALL TIMES! Interview on 08/11/22 at 9:00 A.M., RN #262 verified Resident #19 developed two unstageable areas to the right food, resulting from the application of a heel protector. RN #262 confirmed there was no documentation contained in the resident's medical record indicating the skin under the heel protector was assessed or monitored daily as described in the plan of care. Observation on 08/11/22 at 10:55 A.M. of RN #262 providing wound care to Resident #19 revealed the wound to the right top foot was noted to be described as unstageable, measuring 8.0 cm long x 3.0 cm wide x 0.0 cm deep and lateral right foot was noted to be described as unstageable, measuring 2.0 cm long x 2.0 cm wide x 0.0 cm deep. 2. Medical record review for Resident #60 revealed an admission date of 05/12/22. Diagnoses included end stage renal disease, mixed incontinence, chronic atrial fibrillation, sciatica, Type II diabetes mellitus with diabetic polyneuropathy, peripheral vascular disease, and unspecified abnormalities of gait and mobility. Review of Resident #60's MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired. Resident #60 was at risk for pressure ulcers with a pressure reducing device for the bed. According to the assessment, Resident #60 had no pressure ulcers. Review of the Pressure Sore Development Risk Assessments dated 05/12/22 and 06/29/22 revealed Resident #60 was at moderate risk for developing pressure ulcers. Review of the Pressure Sore Development Risk Assessments dated 06/01/22, 07/30/22, and 08/06/22 revealed Resident #60 was at high risk for developing pressure ulcers. Review of the Skin Assessments dated 07/17/22 and 07/24/22 revealed Resident #60 had no new skin abnormalities noted. Review of the physician order dated 07/17/22 and updated 07/21/22 revealed an order to cleanse the left heel (originally ordered for right heel) with normal saline, pat dry, apply skin prep every day (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365163 If continuation sheet Page 8 of 16 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 365163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northcrest Rehab and Nursing Center 240 Northcrest Drive Napoleon, OH 43545 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 and night shift. Level of Harm - Actual harm Review of the physician order dated 07/26/22 revealed an order to elevate heels on a pillow when in bed every shift. Residents Affected - Few Review of Resident #60's Treatment Administration Record (TAR) for July 2022 revealed wound treatments were completed as ordered. Review of the Interdisciplinary Team (IDT) progress note revealed a late entry from 07/18/22 at 10:00 A.M. documented on 07/24/22 at 2:48 P.M. indicating Resident #60 was found with an area to the left heel. Interventions included heel boot protector and treatment to cleanse with normal saline, pat dry, and apply skin prep to area twice a day. Review of the Wound Evaluation Flowsheets dated 07/20/22, 07/27/22, and 08/03/22 revealed an in-house acquired suspected DTI was acquired on 07/17/22 measuring 1 cm x 1 cm. Treatment included skin prep twice a day with current treatment initiated 07/20/22. Prevention interventions included wearing a heel boot while in bed. The physician was notified on 07/18/22 at 12:00 A.M. Review of the change in condition progress note dated 07/21/22 revealed RN #262 and an unidentified nurse were providing care for Resident #60 and found a DTI on the left foot. The resident had a history of decreased bed mobility. The physician was aware, and a recommendation was received to turn and reposition the resident and for the resident to wear the heel boot while in bed. Review of the physician order dated 07/26/22 revealed an order to elevate the resident's heels with a pillow when in bed, every shift. Review of the care plan initiated on 05/29/22 revealed Resident #60 was at increased risk for pressure ulcer development due to decreased bed mobility, bladder incontinence, diabetes mellitus, and pain. The care plan was updated on 07/27/22 to include off-loading of heels while in bed. Observation on 08/09/22 at 12:40 P.M. revealed Resident #60 was lying in bed and moved the blankets slightly to show heel boots were applied. No pillow was observed to be in place to off load the heels as ordered. Interview on 08/09/22 at 12:45 P.M. with Licensed Practical Nurse (LPN) #276 verified there was no pillow under Resident #60's heels as ordered. Observation and interview on 08/10/22 at 1:15 P.M. revealed Resident #60 was in bed and reported the heel was causing less pain than the previous day. Resident #60 was observed to be wearing heel boots with a pillow under the knees rather than under the heels as ordered. RN #262 verified the pillow was not placed correctly and was not offloading the heels. RN #262 evaluated Resident #60's left heel wound and reported the wound appeared to be a DTI and measured approximately 1 cm by 0.9 cm. Interview on 08/11/22 at 8:57 A.M. with the Director of Nursing (DON) verified Resident #60's DTI was discovered on 07/17/22 and verified the skin assessment dated [DATE] at 11:45 P.M. and 07/24/22 documented no new skin abnormalities. The DON reported the interdisciplinary team progress note dated 07/18/22 was a late entry documented on 07/24/22. The DON further verified Resident #60's wound was not evaluated until 07/20/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365163 If continuation sheet Page 9 of 16 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 365163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northcrest Rehab and Nursing Center 240 Northcrest Drive Napoleon, OH 43545 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 Level of Harm - Actual harm Review of the facility policy titled, Pressure Ulcers/Skin Breakdown, revised March 2014, revealed the physician will help identify medical interventions related to wound management and will assist with staff review and modify the care plan as appropriate. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365163 If continuation sheet Page 10 of 16 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 365163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northcrest Rehab and Nursing Center 240 Northcrest Drive Napoleon, OH 43545 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to provide restorative care as ordered. This affected one (#35) resident reviewed for range of motion. The facility census was 64. Findings include: Review of the medical record revealed Resident #35 was admitted on [DATE]. Diagnosis included quadriplegia, other retention of urine, muscle weakness, abnormal posture, chronic pain due to trauma, overactive bladder, cervicalgia, cramp and spasm, anxiety disorder, major depressive disorder, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of the physician order dated 12/05/21 revealed an order for passive range of motion (PROM) to Bilateral lower extremities (BLE) to bilateral hips, knees, and ankles for 10 to 15 reps during A.M. and P.M. care up to seven days per week as tolerated/accepted. Review of the care plan revised on 05/19/22 revealed a focus area for activities of daily living self-performance deficit due to quadriplegia. An intervention included passive PROM to BLE to bilateral hips, knees, and ankles for 10 to 15 reps during A.M. and P.M. care up to seven days per week as tolerated/accepted. Review of the passive range of motion (PROM) documentation dated 07/12/22 through 08/10/22 revealed Resident #35 received restorative care 24 out of a possible 60 times as ordered and care planned. There was only one event marked as refused. Interview on 08/09/22 at 3:55 P.M. with Resident #35 revealed range of motion services were not being offered regularly. Resident #35 stated range of motion services were not offered most days and he did not refuse the service. Interview on 08/10/22 at 8:06 A.M. with State Tested Nursing Assistant (STNA) #258 verified providing care for Resident #35 on 08/09/22. STNA #258 stated she was not aware Resident #35 had a restorative care program and did not provide range of motion services on 08/09/22. Interview on 08/10/22 at 5:50 P.M. with the Director of Nursing (DON) verified range of motion documentation was not completed as ordered. Review of the undated facility policy titled, Restorative/Functional Maintenance Nursing Services, verified residents will receive restorative/functional nursing care as needed to help promote optimal safety and independence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365163 If continuation sheet Page 11 of 16 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 365163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northcrest Rehab and Nursing Center 240 Northcrest Drive Napoleon, OH 43545 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 observation, medical record review, staff interview, and review of facility smoking policy, the facility failed to ensure supervision was provided to a resident assessed as requiring supervision during smoking. This affected one (Resident #20) of two residents reviewed for smoking. The facility census was 64. Findings include: Review of the medical record revealed Resident #20 admitted to the facility on [DATE] with the diagnosis including, atrial fibrillation, major depression, insomnia, cognitive communication deficit, muscle weakness, nicotine dependence, hypertension, mitral/aortic valve stenosis, congestive heart failure, occlusion and stenosis of carotid artery, peripheral vascular disease, chronic obstructive pulmonary disease, benign prostatic hyperplasia, and tremor. On 06/04/22 a smoking assessment was completed and determined Resident #20 required supervision when smoking. Review of the late entry physician progress note dated 06/07/22 revealed Resident #20 was only able to smoke with supervision in a wheelchair. Review of the care plan dated 06/22/22 revealed Resident #20 smoked with interventions including the resident will not smoke without supervision, instruct resident about smoking risks and hazards and about smoking cessation aids that are available, instruct resident about the facility policy on smoking: locations, times, safety concerns, notify charge nurse immediately if it is suspected resident has violated facility smoking policy, observe clothing and skin for signs of cigarette burns, smoking assessment per protocol, resident requires a smoking apron while smoking, resident requires supervision while smoking, and resident's smoking supplies are stored at the nurses station. Observation on 08/08/22 at 12:35 P.M. noted Resident #20 outside smoking with five additional residents. Resident #20 lit his own cigarette and was wearing a smoking apron. There were no staff members present outside to supervise the smoking residents, including Resident #20 (who required supervision when smoking). The closest staff member was Recreation Therapy Director (RTD) #243, who was located inside the building conducting an activity with additional residents. Interview on 08/09/22 at 3:29 P.M. with RTD #243 revealed RTD #243 was assigned to monitor residents while smoking on 08/08/22 at 12:30 P.M. RTD #243 verified residents were not supervised by staff when smoking on 08/08/22 at 12:30 P.M. Interview on 08/10/22 at 7:30 A.M. Unit Manager Registered Nurse (RN) #262 verified Resident #20 required supervision of staff when smoking. Review of the facility smoking policy updated 04/14/22 revealed smoking restrictions will be noted in the residents record, smoking privileges will be addressed in a care plan, and a smoking assessment will determine level of supervision needed for resident to be allowed to smoke. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365163 If continuation sheet Page 12 of 16 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 365163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northcrest Rehab and Nursing Center 240 Northcrest Drive Napoleon, OH 43545 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 0692 Provide enough food/fluids to maintain a resident's health. 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, and staff interview, the facility failed to implement specific dietary interventions to potentially prevent weight loss. This affected one (Resident #20) of four residents reviewed for nutritional management. The facility's census was 64. Residents Affected - Few Findings include: Review of the medical record revealed Resident #20 admitted to the facility on [DATE] with the diagnosis including atrial fibrillation, major depression, insomnia, cognitive communication deficit, muscle weakness, nicotine dependence, hypertension, mitral/aortic valve stenosis, congestive heart failure, occlusion and stenosis of carotid artery, peripheral vascular disease, chronic obstructive pulmonary disease, benign prostatic hyperplasia, and tremor. Review of the care plan dated 06/08/22 revealed Resident #20 had goals and interventions in place to address the resident's nutrition. Goals included the resident will maintain weight without significant weight changes, the resident will maintain adequate nutritional status as evidenced by maintaining weight within five percent (%) of 158 pounds (lbs.), the resident will have no signs or symptoms of malnutrition, and consume at least 76% of at least two meals daily through review date. Interventions included honor/update dietary preferences as necessary, provide and serve Regular Thin Liquid Diet as ordered, monitor intake and record each meal. On 06/14/22 a dietary assessment was completed, which revealed Resident #22's ideal body weight was 160 lbs. give or take ten pounds. The resident was noted with good meal intakes and consumed a regular diet. Recommendations included to monitor weekly weight and meal intakes. Review of Resident #20's weight record revealed upon admission on [DATE], the resident weighed 152.3 lbs. On 06/17/22, the resident weighed 162.4 lbs. and on 08/10/22, the resident weight 146.6 lbs., indicating a 8.99% weight loss. Review of Resident #20's meal intakes between 07/12/22 and 08/09/22 revealed meal intakes were not being monitored daily and/or for each meal. On 08/01/22 and 08/07/22 no meals intakes were documented. One meal intake was recorded on 07/17/22 at 9:14 P.M. with 51-75 % intake. One meal intake was recorded on 07/20/22 at 6:00 P.M. with 75-100 % intake. One meal intake was recorded on 07/28/22 at 6:00 P.M. with 51-75% intake. One meal intake was recorded on 08/02/22 at 8:24 P.M. with 51-75% intake. One meal intake was recorded on 08/09/22 at 9:39 P.M. with 26-50% intake. Two meals were recorded on 07/12/22, 07/16/22, 07/18/22, 07/21/22, 07/22/22, 07/24/22, 07/27/22, 07/29/22, 07/31/22, 08/04/22, 08/05/22, 08/06/22. Review of laboratory (lab) blood test results dated 08/05/22 revealed the following: a total protein of 5.0 grams (g) per (/) deciliter (dl) (normal 6.3-8.2 g/dl) and albumin 2.4 g/dl (normal 3.5-5.0 g/dl). On 08/10/22 it was noted the resident had a low albumin level of 2.5 g/dl (normal 3.5-5.0 g/dl), hemoglobin (hgb) low at 9.1 (normal 13.8-17.8) and hematocrit (hct) 31.1 % (normal 42.9-52.0 %). Observation on 08/08/22 at 9:16 A.M. noted Resident #20 in his room seated in a wheelchair at bedside. The resident was sleeping with a meal tray untouched, and fork on the floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365163 If continuation sheet Page 13 of 16 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 365163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northcrest Rehab and Nursing Center 240 Northcrest Drive Napoleon, OH 43545 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 08/08/22 at 11:13 A.M. Resident #20's family member stated the resident had lost weight and no interventions to promote weight gain had been implemented. Observation on 08/09/22 at 9:19 A.M. revealed Resident #22 was in his room with a breakfast tray on the bed, untouched. The beverages remained unopened, a banana was unopened, the dry cereal was covered with plastic wrap. Observation on 08/10/22 at 8:40 A.M. revealed Resident #22 was in his room with a breakfast tray. The resident consumed less than 25% of the meal. Interview on 08/10/22 at 11:45 A.M. with Diet Technician (DT) #1 verified Resident #20 was at risk for weight loss with no specific interventions to support his nutritional intake. DT #1 was unaware if the resident was taking in a sufficient amount of food during meals. DT #1 verified Resident #20's meal intakes were not documented three times per day, every day. DT #1 further reported it was difficult to determine the amount a resident eats at each meal. Interview on 08/10/22 at 8:50 A.M. with State Tested Nurse Aide (STNA) #258 revealed she attempted to assist Resident #20 with eating more food and the resident refused. STNA #258 verified no additional nutritional supplements were provided to Resident #20. Interview on 08/10/22 at 11:58 A.M. with Unit Manager Registered Nurse (RN) #262 verified Resident #20's albumin level was below normal ranged on 08/10/22. RN #262 verified no additional interventions were put in place to address the resident's nutrition. Additionally, RN #262 verified Resident #20's meal intakes were not being documented consistently, day to day or meal to meal. RN #262 reported the resident frequently refused to eat, however no interventions had been initiated to promote Resident #20's specific food interests nor were nutritional supplements added to assist with maintaining an adequate nutritional status for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365163 If continuation sheet Page 14 of 16 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 365163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northcrest Rehab and Nursing Center 240 Northcrest Drive Napoleon, OH 43545 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 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. 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, resident interview, and staff interviews, the facility failed to ensure a resident was seen by a physician as required. This affected one (Resident #35) of one resident reviewed for physician visits. The facility census was 64. Residents Affected - Few Findings include: Review of the medical record revealed Resident #35 was admitted on [DATE]. Diagnoses included quadriplegia, other retention of urine, muscle weakness, abnormal posture, chronic pain due to trauma, overactive bladder, cervicalgia, cramp and spasm, major depressive disorder, anxiety disorder, major depressive disorder, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Interview on 08/08/22 at 3:27 P.M. with Resident #35 revealed he believes only meeting with the physician three times since admission. Review of the physician visits revealed Resident #35 met with a physician on the following dates: 06/15/21, 08/10/21, 11/02/21, 11/16/21, 12/21/21, 02/08/22, 04/05/22, 06/07/22, and 06/21/22. There were no physician visits documented for July or September 2021. Interview on 08/09/22 at approximately 5:00 P.M. with the Director of Nursing (DON) verified Resident #35's physician notes did not show evidence of physician visits as required, specifically once every thirty days for the first 90 days of admission. Interview on 08/11/22 at 12:10 P.M. the DON reported Physician #500 verified all physician visits with Resident #35 were documented correctly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365163 If continuation sheet Page 15 of 16 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 365163 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northcrest Rehab and Nursing Center 240 Northcrest Drive Napoleon, OH 43545 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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, observation, staff interview, and resident interview, the facility failed to ensure call lights functioned properly in resident rooms. This affected two residents (#14 and #40) of 64 residents reviewed for call light functioning. The facility census was 64. Residents Affected - Few Findings include: Review of the medical record for Resident #14 revealed an admission date of 11/30/21 with medical diagnoses of congestive heart failure, peripheral vascular disease, and gastroesophageal reflux disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had impaired cognition and required supervision with setup help only for transfers, walking, and toileting. Review of the medical record for Resident #40 revealed an admission date of 01/07/21 with medical diagnoses of Parkinson's disease, long term use of anticoagulants, and cognitive communication deficit. Review of the quarterly MDS assessment dated [DATE] revealed Resident #40 had intact cognition and required extensive assistance of one person for transfers, dressing and hygiene, and extensive assistance of two people for toileting. Observation on 08/08/22 at approximately 10:10 A.M. revealed Resident #14 and Resident #40 shared a room. During the observation, Resident #40 requested the surveyor to, push in his call light because it was not working. The surveyor pressed his call light button, and his roommate's (Resident #14) call light button and determined they did not function. Resident #40 indicated the box needed to be pushed into the wall. At the surveyor's request, Housekeeping Aide #220 entered the residents' room and adjusted the call light box on the wall. At that time, the call light buttons for Resident #14 and Resident #40 became functional. Observation and interview on 08/08/22 at approximately 3:30 P.M. revealed Resident #14 walking into his room. Resident #14 reported his call light was not functioning again and he had to walk to the nurse's station to get his pain medication. Interview and observation on 08/09/22 at 3:44 P.M. with Maintenance Director (MD) #201 confirmed Resident #14 and Resident #40's shared call light system was not functioning. MD #201 repositioned the call light box on the wall and the call light system resumed normal function. MD #201 stated he had not been told about the non-functioning call light. Further interview revealed staff could report maintenance needs through the TELS system (the facility's electronic maintenance tracking software) and all staff had access to the TELS system. Interview on 08/10/22 at 11:18 A.M. with Housekeeping Aide #220 revealed she had access to the TELS system and knew how to report broken items to the maintenance department. Further interview revealed she had not reported the broken call light in Resident #14 and Resident #40's room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365163 If continuation sheet Page 16 of 16