Health inspection·June 8, 2023

F 0684 This deficiency represents non-compliance investigated under Complaint Number OH00143359. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365163 If continuation sheet Page 2 of 6 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 06/08/2023 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, staff interview, review of the medical record, review of the fall investigations, and review of the facility policy, the facility failed to ensure fall prevention interventions were in place for two (#12 and #61) of three residents reviewed for fall risk. Further, the facility failed to document and monitor residents' response to interventions intended to reduce falling and failed to identify and address trends in falls. This affected two (#12 and #61) of three residents reviewed for falls. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 03/14/23 with a diagnosis of repeated falls. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 03/20/23, revealed Resident #12 had impaired cognition and required extensive assistance of two people for bed mobility, transfers, and toileting. Further review revealed Resident #12 had one fall in the month prior to admission. Review of the progress notes for Resident #12 revealed she fell 13 times between 03/17/23 and 05/24/23. Review of the current care plan for Resident #12 revealed she was at risk for falls due to deconditioning. Interventions included non-skid strips in front of the toilet, low bed, fall mat, call light within reach, a defined perimeter mattress, and non-skid socks at all times. Observation on 06/07/23 at 9:03 A.M. of Resident #12's room revealed no non-skid strips in the bathroom. Concurrent interview with the Administrator confirmed there were no non-skid strips in Resident #12's bathroom. Review of the fall investigations with the Director of Nursing (DON) and MDS Coordinator #503 on 06/07/23 at 3:43 P.M. and on 06/08/23 at 9:35 A.M. with the staff reading the facility investigation to the surveyor, revealed the investigations into eight falls occurring on 03/23/23, 03/27/23, 04/01/23, 04/13/23, 04/19/23, 05/02/23, 05/06/23, and 05/08/23 did not identify if previously implemented fall interventions were in place at the time of the fall, including non-skid socks and a floor mat beside the bed. Further review revealed the root cause identified for nine falls occurring on 03/22/23, 03/23/23, 03/25/23, 03/27/23, 04/01/23, 04/19/23, 05/02/23, 05/06/23, and 05/08/23 were identified as either ambulating without assistance or self-transferring without assistance with no attempt to identify the reason the resident attempted self mobility. The interdisciplinary team (IDT) developed interventions in response to the nine falls included a low bed, a floor mat, non-skid socks, non-skid strips, resident education on call light use, and medication reviews. The investigations for the falls on 03/22/23 at 6:30 P.M., 03/23/23 at 7:00 A.M., 03/25/23 at 7:00 P.M., 03/27/23 at 7:30 A.M., 05/06/23 at 10:30 P.M., 05/08/23 at 8:20 P.M., and 05/24/23 at 5:10 A.M. identify the use of the bathroom, or desire to use the bathroom as a contributing factor to the fall. An intervention was developed after the fall on 03/23/23 to offer toileting prior to meals. An intervention was developed after the fifth bathroom related fall on 05/06/23 to assist Resident #12 to the bathroom upon rising, before bed, and after meals. Interviews with the DON and MDS Coordinator #503 at the time of the fall reviews confirmed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365163 If continuation sheet Page 3 of 6 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 06/08/2023 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 findings. Level of Harm - Minimal harm or potential for actual harm Continued interview on 06/07/23 at 3:43 P.M. and on 06/08/23 at 9:35 A.M., the DON confirmed non-skid strips in the bathroom were developed as an intervention after Resident #12's third fall in the bathroom on 03/25/23. Residents Affected - Few 2. Review of the medical record for Resident #61 revealed a readmission date of 03/21/21. Diagnoses included Parkinson's disease, urgency of urination, repeated falls, and dementia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #61 had impaired cognition and required extensive assistance of two people for bed mobility, transfers, and toileting. Further review revealed Resident #61 had two or more falls without injury and one fall without major injury since the previous assessment completed 01/03/23. Review of a physician order dated 08/31/22 revealed Resident #61 should have a pressure reducing perimeter mattress. Review of the current care plan revealed Resident #61 was at risk for falls related to impaired safety awareness and a desire to reach to the floor to look for something. Interventions included a call light within reach, a perimeter mattress, keeping Resident #61 in the lobby area during waking hours, encouraging Resident #61 to stay in the common area for supervision, encouraging Resident #61 to stay in the common area in line of sight of staff when awake, and encouraging Resident #61 to toilet every two hours as accepted/tolerated. Review of the Fall Risk Assessments completed on 03/06/23, 03/07/23, 04/05/23, 04/26/23, 04/29/23, 05/08/23, 05/24/23, 05/25/23, and 05/27/23 revealed Resident #61 was at high risk for falls. Observation on 06/07/23 at 8:52 A.M. revealed Resident #61 lying in bed in his room asleep. The call light was not within reach and his bed was a standard mattress. Interview and observation on 06/07/23 at 8:54 A.M. with Administrator in Training (AIT) #505 confirmed Resident #61's call light was on the floor beyond the foot of the bed and not within reach of Resident #61. Interview and observation on 06/07/23 at 8:59 A.M. with the Director of Nursing (DON) confirmed Resident #61 did not have a perimeter mattress as ordered and care planned. Observation on 06/07/23 at 9:30 A.M. revealed Maintenance Director (MD) #501 carrying a perimeter mattress through the facility toward Resident #61's room. Interview at the time with MD #501 confirmed the mattress was for Resident #61. Review of the fall investigations with the DON and MDS Coordinator #503 on 06/07/23 at 3:43 P.M. and on 06/08/23 at 9:35 A.M. with the staff reading the facility investigation to the surveyor, revealed Resident #61 had 14 falls between 03/04/23 and 05/26/23. Of the 14 falls, 13 occurred between 4:52 P.M. and 10:16 P.M. Five falls occurred in the lounge and six falls occurred in or near the bathroom. Further interview revealed the root cause for 11 of the falls occurring on 03/05/23, 03/07/23, 03/25/23, 04/25/23, 05/07/23, 05/08/23, 05/22/23, 05/24/23, twice on 05/25/23, and 05/26/23 was Resident #61's attempts to self-transfer. Interventions developed by the interdisciplinary team included keeping resident in common areas when he was awake, reminders to call for assistance, evaluation by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365163 If continuation sheet Page 4 of 6 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 06/08/2023 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 therapy, medication reviews, non-skid strips in bathroom, keeping the television on the sports channel, offering to sit in recliner, and increased staffing assistance in the bathroom. The fall investigations did not always include an assessment of the effectiveness of prior interventions, did not include the presence or absence of staff with Resident #61 for falls occurring in the bathroom, and did not always address the actions of staff during witnessed falls. Resident #61 did not remain in the common area or within the line of sight of staff while he was awake as evidenced by six falls in or near the bathroom and three unwitnessed falls in the common area. The facility did not identify or develop interventions to address the repeated falls from approximately 5:00 P.M. until approximately 10:00 P.M. Interviews with the DON and MDS Coordinator #503 at the time of the fall reviews confirmed the findings. Review of the facility policy titled Falls - Clinical Protocol, revised September 2012, revealed the staff and physician would monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. If an individual continues to fall, the staff and physician would re-evaluate the situation and consider other possible reasons for the resident's falling and would re-evaluate the continued relevance of current interventions. This deficiency represents non-compliance investigated under Complaint Number OH00143359. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365163 If continuation sheet Page 5 of 6 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 06/08/2023 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, staff interview, review of the medical record, and review of the facility policy, the facility failed to ensure residents received thickened water as ordered by the physician. This affected one (Resident #30) of three residents reviewed for thickened beverages. The facility census was 57. Findings include: Review of the medical record for Resident #30 revealed an admission date of 05/16/23 with a readmission date of 06/02/23 and a medical diagnosis of dysphagia. Review of the physician order dated 06/02/23 revealed Resident #30 was on a regular diet with regular textured foods and nectar thickened liquids. Observation on 06/06/23 at 7:17 A.M. revealed Resident #30 lying in bed with her call light on waiting for assistance. Resident #30 had a thermos mug on her overbed table. Interview with Resident #30 at that time revealed she was able to reach the water in the thermos mug. Observation on 06/06/23 at 7:23 A.M. with Registered Nurse (RN) #206 revealed the thermos mug within reach of Resident #30 was filled almost full with un-thickened water. Interview at that time with RN #206 confirmed Resident #30 had thin liquids in the thermos mug at bedside. Interview on 06/06/23 at 8:06 A.M. in the dining room with Speech Language Pathologist (SLP) #500, who was providing therapy treatment to Resident #30 during the meal, confirmed she recommended Resident #30 receive thickened liquids and consume liquids while sitting up. SLP #500 further stated she determined Resident #30's likelihood for aspiration with fluids was positional (such as reclining or slouching), rather than a mechanical (muscle-based) swallowing difficulty. Interview on 06/06/23 at approximately 9:41 A.M. with SLP #500 revealed the facility did not use the Frazier Water Protocol (a protocol that allows residents on thickened beverages to consume un-thickened water). Review of the facility policy titled Therapeutic Diets, revised November 2015, revealed a therapeutic diet must be prescribed by the resident's Attending Physician and staff will ensure each resident receives his or her diet as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00143359. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365163 If continuation sheet Page 6 of 6