Health inspection·June 6, 2019

F 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the resident fund management service (RFMS) the facility failed to timely convey personal funds after death. This affected one Resident (#61) of five reviewed for personal funds. The facility census was 63. Residents Affected - Few Findings include: Closed record review revealed Resident #61 was admitted to the facility on [DATE] with diagnoses to include hypertension, diabetes, and dementia. Review of the nurse notes dated [DATE] revealed Resident #61 expired at the facility. Review of the RFMS statement dated from [DATE] to [DATE] revealed the account had debit and credit transactions after her death until the account was closed on [DATE]. On [DATE] there was a wire transfer amount of $902.00 back into the residents personal funds account. On [DATE] a check was sent to the funeral home for burial in the amount of $618.48 (The bill from the funeral home was dated [DATE]). The account was closed on [DATE] with a balance of $64.92 which needed to be sent back to the state recovery. Interview on [DATE] at 10:30 A.M., when funds were reviewed with the Business Office Manager (BOM) #24 stated somehow her money was moved over to the operational account on error. She confirmed the funds needed to be conveyed within 30 days and the check had not been sent to the state. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365228 If continuation sheet Page 2 of 4 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 365228 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wilmington Nursing & Rehab 75 Hale Street Wilmington, OH 45177 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 record review, observation and interview, the facility failed to provide supervision for residents who required assistance to community doctor appointments. This affected one (Resident #42) of 18 residents reviewed. The facility census was 63. Findings included: Record review revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included macular degeneration, dementia and muscle spasms. Review of the minimum data set (MDS) assessment dated [DATE] documented no cognitive impairment. The resident required extensive assistance of one staff for locomotion on and off the unit and she had impaired vision. During interview on 06/05/19 at 8:39 A.M., Resident #42 stated she was sent out to an appointment sometime last week, which she was not supposed to go to, and she went by herself. During interview on 06/05/19 at 8:56 A.M., State Tested Nursing Assistant (STNA) #5 stated Resident #42 was going to the ear, nose and throat (ENT) doctor on 05/30/19. STNA #5 said she was off that day and did not know why the resident was not seen at the appointment. She checked the schedule book which stated the appointment had been rescheduled for 06/10/19. Written on the paper with an asterisk which stated make sure family was present. During interview on 06/05/19 at 9:14 A.M., ENT Office Staff #300 stated Resident #42 had an appointment on 05/30/19, however she was unable to be seen as she was sent with another resident's paperwork. The resident was sent by taxi cab and the office was located on the third floor of the building. The resident has very limited vision and was unable to see to fill out the paperwork. Her family was not present nor was anyone from the facility. She said graciously the cab driver helped her up to their office since she could not see. She finally was able to get a hold of someone who did not even know the resident had an appointment. The facility was called and told the resident could not be seen, so they sent a taxi cab back to pick the resident up. During interview on 06/05/19 at 9:34 A.M., the Director of Nursing (DON) and Registered Nurse (RN) #37 stated they had spoke to STNA #5 and she had set up transport with the local transportation company, because her family was unable to take her. During interview on 06/05/19 at 9:42 A.M., RN #48 stated the resident's son normally would go with her to appointments. She said the cab came to pick her up and she thought this was strange, but she allowed her to leave for the appointment. She said later the doctor's office called, upset, and asked them not to send the resident alone in a cab. She did not have the correct paperwork, and she just sent her by herself in the cab. She further reported she did not call the cab, this was already set up. During interview on 06/06/19 at 8:36 A.M., the DON stated she was unaware the resident was sent out in a cab. She further said she would look into who set up transportation of the cab service because she should not have went alone in the cab. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365228 If continuation sheet Page 3 of 4 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 365228 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wilmington Nursing & Rehab 75 Hale Street Wilmington, OH 45177 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and policy review, the facility failed to ensure biohazard materials were stored properly. This had the potential to affect all residents in the facility. The facility census was 76. Residents Affected - Many During observation of the biohazard room behind the nursing station for the A and D halls on 06/05/19 at 8:40 A.M., three red three red bags containing biohazard materials were lying on the floor and not in the designated containers in the biohazard room. During interview at the time of the observation, Housekeeper #39 confirmed the findings. During interview on 06/05/19 at 3:12 P.M., the Administrator revealed all staff placing red biohazard bags in the biohazard room are to place the bags in the red plastic containers, the bags should not be left on the floor of the biohazard room. Review of the facility policy titled Hazardous Waste Access/Disposal Policy, dated September 2009, revealed housekeeping will monitor the hazardous waste receptacle in the waste rooms each day. Once the receptacle is full it will be removed from the floor and stored until the scheduled pick up by the contracted waste management company. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365228 If continuation sheet Page 4 of 4