Health inspection·September 11, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure pressure ulcer treatments were completed in accordance with physician orders. This affected one (#1) of three residents reviewed for wound care. The facility census was 61. Residents Affected - Few Findings include: Review of Resident #1's medical record revealed an admission date of 04/30/24. Diagnoses included chronic obstructive pulmonary disease, intellectual disabilities, stage III pressure ulcer to the upper right back, localized swelling mass and lump to trunk, cerebral infarction affecting right side with hemiplegia and hemiparesis, hypertension, scoliosis, chronic pain syndrome, neuromuscular dysfunction of the bladder, severe protein calorie malnutrition and muscle wasting and atrophy. Review of the Minimum Data Set (MDS) assessment, dated 08/04/24, revealed Resident #1 was moderately cognitively impaired, had bilateral range of motion impairment to the upper and lower extremities, was dependent on staff for the completion of activities of daily living (ADLs), required substantial to maximal assistance with bed mobility, utilized an indwelling urinary catheter, was incontinent of bowel, was at risk for pressure ulcer development and admitted with a stage IV pressure ulcer. Review of the plan of care, revised on 07/15/24, revealed Resident #1 had a pressure ulcer to the right flank area. Interventions included to administer treatments as ordered and monitor for effectiveness and to follow facility policies/protocols for the prevention/treatment of skin breakdown. Review of wound specialist certified nurse practitioner (WSCNP) wound assessment report, dated 08/26/24, revealed a right flank stage IV pressure ulcer wound was present upon admission on [DATE]. Wound descriptions included measurements with length 10.50 centimeters (cm) by (x) width 6.20 cm x depth 0.60 cm with a moderate amount of serosanguineous, tan/green drainage. Review of a physician order, dated 08/30/24, revealed an order to cleanse the right posterior chest wall and back pressure ulcer with normal saline (NS), pat dry, apply adaptic (non-adhering dressing) over the bone, pack wound with Calcium Alginate and cover with foam dressing every three days and as needed (PRN) if soiled or saturated. Review of a WSCNP wound assessment, dated 09/09/24, revealed Resident #1's right flank stage IV pressure ulcer wound as stable, measuring 10.50 cm long x 4.00 cm wide x 0.40 cm deep with a moderate amount of serosanguineous, tan/ green drainage. Observation on 09/10/24 at 12:35 P.M. revealed State Tested Nurse Aide (STNA) #600 in Resident #1's room, attempting to reposition the resident. Continued observation revealed Resident #1 had an undated abdominal (ABD)gauze dressing applied to the right back. The dressing was saturated with drainage, which was draining onto the bed linen. A large area of green and tan drainage was noted on the linen. Concurrent interview with STNA #600 verified the findings. Observation on 09/10/24 at 12:48 P.M. with Registered Nurse (RN) #400 and RN #401 revealed Resident #1 was positioned in bed to the left side. The resident's right back dressing was exposed and noted to be draining a copious amount of drainage through the ABD dressing. RN #400 proceeded to remove the dressing, cleanse the wound with NS and pat dry. RN #400 then applied adaptic over the bone, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365163 If continuation sheet Page 2 of 5 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 09/11/2024 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 - Minimal harm or potential for actual harm Residents Affected - Few packed wound with Calcium Alginate and covered with a foam dressing with initials and date applied on the dressing surface. Concurrent interview with RN #400 and RN #401 confirmed the dressing was saturated with a tan and green drainage, which drained onto the resident's bed linen. Further interview with RN #401 revealed Resident #1's wound was evaluated by the WSCNP on 09/09/24 and the dressing was applied at that time. RN #401 confirmed the dressing order was to change every three days and PRN and the resident's bed was heavily soiled with a tan/green drainage from the wound. RN #401 further verified the dressing removed from Resident #1's wound did not include a foam border dressing as indicated in physician orders and no attempts were made to change the saturated ABD dressing before the drainage penetrated the ABD and caused drainage to saturate the residents bed linen. Review of the facility policy titled Wound Care, revised October 2010, revealed to verify there is a physician order for the procedure, wound procedure/treatments shall be completed per physician order and, when applying dressing, place tape with initials, time and date onto the dressing. This deficiency represents non-compliance investigated under Master Complaint Number OH00157138. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365163 If continuation sheet Page 3 of 5 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 09/11/2024 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 Based on observation, medical record review and staff interview, the facility failed to ensure resident nutritional supplements were administered and monitored in accordance with physician orders. This affected one (#1) of three residents reviewed for nutritional support interventions. The facility census was 61. Residents Affected - Few Findings include: Review of Resident #1's medical record revealed an admission date of 04/30/24. Diagnoses included chronic obstructive pulmonary disease, intellectual disabilities, stage III pressure ulcer to the upper right back, localized swelling mass and lump to trunk, cerebral infarction affecting right side with hemiplegia and hemiparesis, hypertension, scoliosis, chronic pain syndrome, neuromuscular dysfunction of bladder, severe protein calorie malnutrition and muscle wasting and atrophy. Review of the Minimum Data Set (MDS) assessment, dated 08/04/24, revealed Resident #1 was moderately cognitively impaired, had bilateral range of motion impairment to upper and lower extremities, was dependent on staff for the completion of activities of daily living (ADLs), required substantial to maximal assistance with bed mobility, utilized an indwelling urinary catheter, was incontinent of bowel, had no identified weight loss, received a mechanically altered diet, was at risk for pressure ulcer development and admitted with a stage 4 pressure ulcer. Review of the dietitian nutrition/hydration status documentation, dated 08/01/24, revealed Resident #1 weighed 111.4 pounds (lbs), with no planned weight loss. Further review revealed current supplement orders included fortified pudding once daily, Thrive (nutritional supplement) with meals and Proheal (protein supplement) three times daily. Resident #1's supplement intake was between 75-100% and increased nutritional demands was evidenced by wounds and protein-calorie malnutrition. Additional comments included to honor resident food and beverage preferences. Review of current physician orders revealed on 08/05/24, a physician order was implemented for the nutritional supplement Boost Breeze to be given three times a day for oral intake/nutritional status. Instructions included to record the amount consumed. Review of the medication administration records (MAR) from August 2024 and September 2024 revealed the physician order dated 08/05/24 to administer Boost Breeze three times a day for oral intake/nutritional status and in all capital letters to RECORD AMOUNT CONSUMED. Further review of the MAR revealed staff initials for the administration of Boost Breeze; however, the MAR did not include documentation of the amount consumed. Observation on 09/10/24 at 12:01 P.M. of the lunch meal revealed Resident #1 was provided with his lunch meal and received assistance with eating from State Tested Nurse Aide (STNA) #600. No Boost Breeze supplement was observed with the resident's meal. A vanilla flavored Thrive was on the meal tray. Continued observation revealed Resident #1 finished the lunch meal. The Thrive container remained unopened and no Boost Breeze supplement was provided. Further observation on 09/11/24 at 8:20 A.M. of the breakfast meal revealed Resident #1 was served hot cereal (oatmeal) and a container of vanilla Thrive, which was opened but none consumed. No Boost Breeze was provided. Concurrent interview with Registered Nurse (RN) #400 verified Resident #1 did not receive the fortified beverage (Boost Breeze) during breakfast and she had not observed Boost (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365163 If continuation sheet Page 4 of 5 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 09/11/2024 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 Breeze provided to Resident #1 during the lunch meal on 09/10/24. RN #400 stated dietary provided supplements and Resident #1 preferred to consume the chocolate Boost Breeze. Interview on 09/11/24 at 8:24 A.M. with Dietary Manager (DM) #2 and [NAME] #500, during a review of Resident #1's diet/tray card, revealed Boost Breeze was not listed on the card. DM #2 verified Resident #1 was not being provided with a Boost supplement during meals. Interview on 09/11/24 at 8:30 A.M. with RN #401 verified Resident #1 had a physician order for Boost Breeze to be provided three times daily and to document the amount consumed. RN #401 confirmed there was no documentation of how much Resident #1 consumed of the the supplement. Interview on 09/11/24 at 8:45 A.M. with STNA #600 verified Resident #1 was not provided with the Boost Breeze supplement during the breakfast and lunch meal on 09/10/24 or during the breakfast meal on 09/11/24. STNA #600 stated Resident #1 preferred chocolate beverages and reported to the nurse the resident was not consuming the vanilla Thrive; however, no action was taken and no additional supplement was provided by the nurse. Interview on 09/11/24 at 10:35 A.M. with the Director of Nursing (DON) and Diet Technician (DT) #4 revealed Resident #1 was last evaluated by the dietitian on 08/01/24 due to weight loss. DT #4 confirmed staff were not documenting the percent of supplements taken as ordered for further monitoring and assessment of Resident #1's weights. This deficiency represents non-compliance investigated under Master Complaint Number OH00157138. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365163 If continuation sheet Page 5 of 5