Health inspection·March 15, 2022

F 0580 change in condition and the resident is stable. Level of Harm - Minimal harm or potential for actual harm This deficiency substantiates Complaint Number OH00130403. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365228 If continuation sheet Page 2 of 14 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 03/15/2022 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 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, observations and staff interview, the facility failed to develop a plan of care for the use of psychotropic medications for Resident #3 and #309. This affected two (#3 and #309) of eight residents reviewed for unnecessary medications. Additionally, the facility failed to ensure Resident #41's care plan accurate reflected the resident hemodialysis access site. This affected one (#309) of one resident reviewed for dialysis. The facility census is 62. Findings included: 1. Medical record review for Resident #3 revealed that she was admitted to the facility on [DATE]. Diagnoses include dementia with behavior disturbance, anxiety disorder, cerebral infarction, diabetes mellitus, and major depression. Review of the physician orders for Resident #3 revealed she was prescribed Buspirone five milligrams (mg) by mouth three times daily for anxiety on 06/01/21. On 06/02/21, Resident #3 was prescribed citalopram 10 mg by mouth once daily. On 02/16/22, the Buspirone was decreased to five mg by mouth twice daily. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #3 had severe cognitive impairment was mildly depressed. Review of the current comprehensive care plan dated 06/01/22 revealed that it contained no documentation for a care plan addressing psychotropic medication use, diagnosis of anxiety, or for the diagnosis of depression. On 03/09/22 at 10:00 A.M., an interview with the MDS Nurse #132 confirmed that the was no plan of care developed for Resident #3 to address psychotropic medication use, diagnosis of anxiety, or for the diagnosis of depression. 2. Medical record review for Resident #309 revealed that he was admitted to the facility on [DATE]. Diagnoses include Parkinson's disease, anxiety disorder, pneumonia, and weakness. Review of the physician orders for Resident #309 revealed that he was prescribed Buspirone five mg by mouth three times daily for anxiety on 02/13/22. Review of the most recent quarterly MDS assessment dated [DATE] revealed that Resident #309 had severe cognitive impairment was moderately to severely depressed. Review of the current comprehensive care plan dated 02/11/22 revealed that it contained no documentation for a care plan addressing psychotropic medication use, diagnosis of anxiety, or for his depressed mood. On 03/10/22 at 10:12 A.M., an interview with the MDS Nurse #132 confirmed that the was no plan of care developed to address Resident #309's psychotropic medication use, diagnosis of anxiety, or for his depressed mood. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365228 If continuation sheet Page 3 of 14 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 03/15/2022 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. Review of Resident #41's medical record revealed an admission date of 09/10/18. Diagnoses included acute kidney failure, vascular dementia, diabetes, and hemiplegia and hemiparesis. Review of Resident #41's MDS assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) of 14 out of 15 which indicated the resident was cognitively intact. The MDS revealed the resident required extensive two-person assistance for bed mobility, and transfer. The resident required total two-person dependence for toileting and one-person total dependence for personal hygiene. The resident was independent for eating. Review of Resident #41's plan of care dated 10/14/21 revealed the resident received dialysis treatments at the Kidney Care on Monday, Wednesday and Friday. The plan of care identified the transportation time and the chair time. The plan of care revealed the resident's port was in the right upper chest. Interventions included to assess and monitor the dressing to the catheter site in the right upper chest. Observation and interview on 03/09/22 at 2:30 P.M. with Resident #41 revealed the resident had no port in his right chest. Resident #41 revealed his fistula was in his right forearm. Observation of the resident's right forearm revealed the fistula used for the resident's dialysis. Interview on 03/09/22 at 3:30 P.M. with the Director of Nursing (DON) confirmed the resident's plan of care was not accurate. The DON confirmed the resident did not have a port in his right chest. The DON confirmed the resident's fistula was in his right forearm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365228 If continuation sheet Page 4 of 14 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 03/15/2022 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of Medscape medication guidance, the facility failed to ensure a resident was free of unnecessary psychotropic medications when the facility failed to have adequate indication of use for a resident's psychotropic medications, failed to provide monitoring for the use of psychotropic medications and failed to monitor for side effects of psychotropic medications. This affected one resident (#47) of seven resident's reviewed for unnecessary medications. The facility census was 62. Findings included: Review of Resident #47's medical record revealed an admission date of 12/27/21. Diagnoses included chronic obstructive pulmonary disease with acute exacerbation, chronic bronchitis, protein-calorie malnutrition, diabetes, asthma, hypertension, developmental disorder of speech and language, atherosclerotic heart disease, paranoid schizophrenia, unspecified psychosis, and dysphagia. Review of Resident #47's Minimum Data Set (MDS) dated [DATE] revealed the Brief Interview Mental Status (BIMS) of fifteen. Review of the MDS revealed the resident required extensive one-person assistance for bed mobility, toileting, dressing and personal hygiene. The resident required extensive two-person assistance for transfers. The resident was independent with set-up help for eating. Further review of Resident #47's MDS revealed the resident had no hallucinations, no delusions, and no aberrant behaviors, Review of Resident #47's plan of care dated 12/28/21 revealed the resident had a psychiatric disorder. The goal was to have no behavioral manifestations. The plan of care also identified the resident received antianxiety, antidepressant and antipsychotic medications. Interventions included to monitor extra pyramidal side-effects, and to monitor and report target behavior symptoms. Review of the progress notes from 12/27/22 to 03/08/22 revealed no documentation of the resident having had any hallucinations, delusions, or aberrant behaviors. The progress notes were silent for any notes related to anxiety, depression, or psychosis. The progress notes consistently revealed the resident was pleasant and cooperative. Review of the physician orders dated 01/12/22 revealed risperidone three milligrams (mg) one time a day for unspecified psychosis not due to a substance or known physiological condition. Review of the Resident #47's medical record from 12/27/21 through 03/08/22 revealed no evidence or documentation of monitoring for side-effects of the antipsychotic (risperidone) medication. The progress notes were silent for report of any aberrant behaviors, hallucinations or delusions or side effects of the medication. Review of the Abnormal Involuntary Movement Scale (AIMS) revealed the diagnosis triggering the review was paranoid schizophrenia. The AIMS identified the medication Prozac was the medication triggering the review. Review of Medscape medication guidance, the medication Prozac is not a medication used to treat paranoid schizophrenia and does not require an AIMS assessment. Risperidone does require an AIMS assessment and was not included as a medication for the AIMS. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365228 If continuation sheet Page 5 of 14 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 03/15/2022 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 0758 Level of Harm - Minimal harm or potential for actual harm Review of the physician orders dated 01/11/22 revealed Trazadone 50 mg at bedtime related to unspecified psychosis not due to a substance or know physiological condition. Review of Medscape medication guidance revealed the facility's diagnosis for Trazadone was not included in the accepted diagnoses and indications for the medication. Residents Affected - Few Review of the physician order dated 01/11/22 revealed clonazepam 0.5 mg. give one tablet two times a day related to unspecified psychosis not due to a substance or know physiological condition. Review of Medscape medication guidance revealed the facility's diagnosis for clonazepam was not included in the accepted diagnoses and indications for the medication. Interview on 03/09/22 12:32 P.M. with Licensed Practical Nurse (LPN) #126 revealed the facility typically monitored for psychotropic behaviors and side-effects on the resident's Medication Administration Record (MAR). Further review of Resident #47's electronic MAR with LPN #126 confirmed the resident had no documentation or monitoring on the electronic charting to monitor or document side-effects or behaviors. Interview on 03/09/22 at 1:02 P.M. with the Director of Nursing (DON) confirmed there was no monitoring of psychotropic side-effects or target behaviors available for review for Resident #47. The DON also confirmed the Resident #47's clonazepam and Trazadone had incorrect diagnoses. The DON also confirmed an AIMS was not completed for the antipsychotic medication risperidone. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365228 If continuation sheet Page 6 of 14 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 03/15/2022 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. 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, staff interview and policy review, the facility failed to obtain laboratory services as ordered by a physician. This affected two (#54, #215) out of two residents reviewed for laboratory services. The facility census was 62. Residents Affected - Few Findings include: 1. Record review for Resident #54 revealed an admission date of 02/01/21. Diagnosis included paraplegia, schizoaffective disorder, abscess of epididymis, cutaneous abscess of the perineum, major depressive disorder, mood disorder, anemia, gastro esophageal reflux disease, insomnia, and diabetes mellitus 2. Review of the minimum data set (MDS) annual assessment, dated 02/08/22, revealed Resident #54 has intact cognition as evidenced by his brief interview for mental status (BIMS) score of 14. Further review of the MDS assessment revealed Resident #54 required extensive assistance from staff with bed mobility, dressing, and personal hygiene. Resident #54 was totally dependent on staff for toilet use. However, Resident #54 was independent and required no help from staff with eating. Review of Resident #54 orders revealed a urinary analysis (UA) was ordered on 03/01/22. Review of the UA lab result letter for Resident #54, dated 03/06/22 revealed a specimen was taken and tested on [DATE], however, no results due to possible contamination. No further UA was obtained. Interview with the director of nursing (DON) on 03/10/22 at 10:53 A.M. confirmed the facility has not followed up with the physician regarding the results of Resident #54's UA ordered on 03/01/22. 2. Review of the medical record for the Resident #215 revealed an admission date of 11/16/21 and he was discharged to the hospital on [DATE]. Diagnoses included obesity, disorder of kidney and ureter, anemia, disease of the spinal cord, diabetes mellitus 2, essential primary hypertension, osteoarthritis, and spinal stenosis. Review of Resident #215's medical record revealed an dated 11/19/21 to obtain a hemoglobin A1C, complete blood count (CBC), basic metabolic panel (BMP) and B-type natriuretic peptide (BNP). Further review of Resident #215's medical record revealed there was no evidence of a hemoglobin A1C, CBC, BMP or BNP being obtained. Review of the admission MDS assessment, dated 11/23/21, revealed Resident #215 had intact cognition as evidenced by a score of 14 on his brief interview for mental status BIMS exam. Resident #215 required extensive assistance from staff with bed mobility and eating. Further review of the MDS assessment revealed Resident #215 was totally dependent on staff with transfers, toilet use, personal hygiene, and bathing. Review of the nursing progress notes for Resident #215 dated, 11/23/21, revealed the resident had difficulty swallowing including a gurgle at the back of his throat. The nursing staff notified speech therapy for further evaluation and the Resident #215's surgeon, however, no documentation was identified notifying the facility physician. Further review of Resident #215's nursing progress notes revealed on 11/24/21 resident had a productive cough, and the nurse practitioner (NP) ordered a chest (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365228 If continuation sheet Page 7 of 14 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 03/15/2022 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 0770 x-ray. Level of Harm - Minimal harm or potential for actual harm Review of Resident #215's speech therapy evaluation dated, 11/23/21, revealed Resident #215 was unable to complete consecutive swallows. During the evaluation Resident #215 reported having a significant globus sensation compared to previous assessment. Further review of the speech therapy evaluation on 11/23/21 revealed an order was placed for a modified barium swallow (MBS). Residents Affected - Few Review of Resident #215's physician orders for November 2021 revealed an order dated, 11/23/22, a MBS for dysphagia. Further medical record review revealed there was no documentation regarding attempts to schedule or obtain a MBS for Resident #215. Review of the Medical Director #500 visit notes dated 11/26/21 revealed the physician's plan of care for Resident #215 was listed as review the plan of care with staff, implement supportive care, monitor closely, and get chest x-ray with further recommendations pending the results. Further review of Resident #215's medical record revealed an order dated 11/26/21 to obtain a UA but there was no written order for a chest x-ray. Further review of the medical record revealed there was no evidence of a chest x-ray or UA being obtained on 11/26/21. Interview on 03/15/22 at 9:11 A.M. with the Director of Nursing (DON) confirmed the facility obtained orders for Resident #215 to receive a hemoglobin A1C, CBC, BMP and BNP on 11/29/21; however, these were never obtained. The DON confirmed the speech therapy recommended a MBS on 11/23/21 and the orders were obtained for the MBS but it was never scheduled or obtained. The DON confirmed the chest x-ray and UA which were recommended/ordered on 11/26/21 by the physician were never completed. Review of the facility policy titled, Physician Orders, dated 01/27/11, revealed the facility failed to obtain and follow a physician's order for care. The policy stated, the charge nurse [NAME] transcribes and review all physician/provider orders. This deficiency substantiates Complaint Number OH00130403. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365228 If continuation sheet Page 8 of 14 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 03/15/2022 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 0776 Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. 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, staff interview and policy review, the facility failed to obtain radiology and other diagnostic services as physician ordered. This affected one (#215) out of two residents reviewed for radiology and diagnostic services. The facility census was 62. Residents Affected - Few Findings include: Review of the medical record for the Resident #215 revealed an admission date of 11/16/21 and he was discharged to the hospital on [DATE]. Diagnoses included obesity, disorder of kidney and ureter, anemia, disease of the spinal cord, diabetes mellitus 2, essential primary hypertension, osteoarthritis, and spinal stenosis. Review of Resident #215's medical record revealed an dated 11/19/21 to obtain a hemoglobin A1C, complete blood count (CBC), basic metabolic panel (BMP) and B-type natriuretic peptide (BNP). Further review of Resident #215's medical record revealed there was no evidence of a hemoglobin A1C, CBC, BMP or BNP being obtained. Review of the admission Minimum Data Set (MDS) assessment, dated 11/23/21, revealed Resident #215 had intact cognition as evidenced by a score of 14 on his brief interview for mental status (BIMS) exam. Resident #215 required extensive assistance from staff with bed mobility and eating. Further review of the MDS assessment revealed Resident #215 was totally dependent on staff with transfers, toilet use, personal hygiene, and bathing. Review of the nursing progress notes for Resident #215 dated, 11/23/21, revealed the resident had difficulty swallowing including a gurgle at the back of his throat. The nursing staff notified speech therapy for further evaluation and the Resident #215's surgeon, however, no documentation was identified notifying the facility physician. Further review of Resident #215's nursing progress notes revealed on 11/24/21 resident had a productive cough, and the nurse practitioner (NP) ordered a chest x-ray. Review of Resident #215's speech therapy evaluation dated, 11/23/21, revealed Resident #215 was unable to complete consecutive swallows. During the evaluation Resident #215 reported having a significant globus sensation compared to previous assessment. Further review of the speech therapy evaluation on 11/23/21 revealed an order was placed for a modified barium swallow (MBS). Review of Resident #215's physician orders for November 2021 revealed an order dated, 11/23/22, a MBS for dysphagia. Further medical record review revealed there was no documentation regarding attempts to schedule or obtain a MBS for Resident #215. Review of the Medical Director #500 visit notes dated 11/26/21 revealed the physician's plan of care for Resident #215 was listed as review the plan of care with staff, implement supportive care, monitor closely, and get chest x-ray with further recommendations pending the results. Further review of Resident #215's medical record revealed an order dated 11/26/21 to obtain a urine analysis (UA) but there was no written order for a chest x-ray. Further review of the medical record revealed there was no evidence of a chest x-ray or UA being obtained on 11/26/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365228 If continuation sheet Page 9 of 14 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 03/15/2022 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 0776 Level of Harm - Minimal harm or potential for actual harm Interview on 03/15/22 at 9:11 A.M. with the Director of Nursing (DON) confirmed the facility obtained orders for Resident #215 to receive a hemoglobin A1C, CBC, BMP and BNP on 11/29/21; however, these were never obtained. The DON confirmed the speech therapy recommended a MBS on 11/23/21 and the orders were obtained for the MBS but it was never scheduled or obtained. The DON confirmed the chest x-ray and UA which were recommended/ordered on 11/26/21 by the physician were never completed. Residents Affected - Few Review of the facility policy titled, Physician Orders, dated 01/27/11, revealed the facility failed to obtain and follow a physician's order for care. The policy stated, the charge nurse [NAME] transcribes and review all physician/provider orders. This deficiency substantiates Complaint Number OH00130403. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365228 If continuation sheet Page 10 of 14 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 03/15/2022 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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, observations, staff and family interview and policy review, the facility to ensure ice cream was served at the appropriate temperature when the staff served ice cream that was foamy and melted. This affected one (#42) out of three residents reviewed for food temperature. The facility census was 62. Residents Affected - Few Findings include: Record review for Resident #42 revealed an admission date of 12/27/17. Diagnosis included dementia with behavioral disturbance, asthma, major depressive disorder, [NAME] failure, anemia, anxiety disorder, essential primary hypertension, anemia, gastro-esophageal reflux disease, insomnia, dysphagia, chronic obstructive pulmonary disease. Review of the Resident #42's annual minimum data set (MDS) assessment dated , 01/24/22, revealed she had impaired cognition. Further review of the MDS assessment revealed Resident #42 required extensive assistance from staff with bed mobility, transfers, dressing, eating, and personal hygiene. Resident #42 was totally dependent on staff with toilet use and bathing. Interview and observation on 03/07/22 at 12:05 P.M. with Resident #42's family revealed the family assists Resident #42 with her meals. Resident #42's family stated the resident enjoys her ice-cream, however, they had a concern with the way the ice cream was being served. Resident #42's family held the spoon over the foam cup which contained melted ice cream as the ice cream poured off the spoon into the ice cream cup. Resident #42's family stated the ice is served foamy and melted daily. Interview and observation on 03/09/22 at 12:42 P.M. with social worker (SW) #104 revealed SW #104 was assisting with passing resident lunch trays. SW #104 confirmed the ice cream was foamy and melted. Interview on 03/09/22 at 12:50 P.M. dietician #156 confirmed the facility has had issues with the ice cream being served foamy and melted. Dietician #156 stated she believes the issues is related to the dietary staff placing ice cream in the fridge instead of the freezer. Follow up interview on 03/10/22 at 09:50 A.M. with dietician #156 stated the facility is utilizing a black frozen bucket to keep the ice cream frozen, however, the dietary staff are sitting the bucket outside of the freezer prior to tray line being completed which is allowing it to melt. Review of the facility policy titled, Food Temperature Policy, dated 08/28/19 stated frozen items such as ice cream and sherbet do not need a temperature check. However, the policy stated the ice cream and sherbet's temperature should not rise to the point of melting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365228 If continuation sheet Page 11 of 14 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 03/15/2022 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 observations, staff interview, policy review, review of information from the Centers for Disease Control and Prevention (CDC) and review of information from the Centers for Medicare and Medicaid Services (CMS), the facility failed to properly don (put on) personal protective equipment (PPE) and/or wash their hands to potentially prevent the spread of Coronavirus Disease 2019 (COVID-2019). This had the potential to affect all 62 residents residing in the facility. The facility census was 62. Residents Affected - Many Finding include: 1. Observation on 03/08/22 at 2:44 P.M. of the facilities laundry room revealed housekeeper manager (HM) #114 and housekeeper (HK) #116 folding laundry with no mask or eye protection. Interview with HM #114 on 03/08/22 at 2:44 P.M. revealed she decided not to wear a mask or eye protection because she is in laundry today and the room is hot. HM #114 confirmed she has never receiving training to work in laundry and does not know how she would handle potentially infectious laundry. HM #114 stated she is guessing she would put on gloves. Interview with HK #116 on 03/08/22 at 2:45 P.M. stated she does not wear eye protection or mask in the laundry room due to the heat. HK #116 confirmed she does not working in laundry and has not received training on how to handle potentially contaminated laundry or linen. 2. Observation on 03/09/22 at 11:57 A.M. revealed HM #114 mopping the hallway floor on the resident hallway with her mask sitting below her nose. Interview on 03/09/22 at 11:57 A.M. with HM #114 confirmed her mask was sitting below her nose as she. 3. Observation on 03/07/22 from 8:04 A.M. until 8:30 A.M. of the breakfast tray line revealed the Dietary Aide (DA) #109 wore her surgical mask below her nose during observation of the tray line. Further observations revealed during the tray line, [NAME] #112 removed her gloves and donned another pair of gloves without washing her hands. Interview on 03/07/22 at 8:38 A.M. with [NAME] #112 confirmed she had not washed her hands after doffing gloves and donning new gloves during the tray line. Interview on 03/07/22 at 8:39 A.M. with the DA #109 confirmed she was wearing her surgical mask below her nose during the tray line. Interview on 03/07/22 at 10:40 A.M. with the Dietary Manager #156 confirmed dietary staff are required to wear surgical masks appropriately, covering their mouth and nose. Dietary Manager #156 also confirmed staff are to wash their hands after removing gloves and prior to donning new gloves. Review of the facility policy titled, Clinical: Infection Control, dated 09/15/21, revealed under the Employee Section, on page 3, supports resident safety by adhering to all policies and procedures related to infection prevention. Review of an online resource from CMS titled COVID-19 Nursing Home data at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365228 If continuation sheet Page 12 of 14 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 03/15/2022 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete https://data.cms.gov/covid-19/covid-19-nursing-home-data revealed the county in which the facility was situated was experiencing a moderate spread (yellow) of COVID 19 with a positivity rate of 7.6% for the week ending in 03/01/22. Review of an online resource per the CDC titled Infection Control Guidance for Healthcare Professionals about Coronavirus (COVID-19) at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html revealed the use of eye protection in healthcare facilities is recommended in areas with moderate to substantial community transmission and staff should don eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area. Event ID: Facility ID: 365228 If continuation sheet Page 13 of 14 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 03/15/2022 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 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff and resident interview, and review of facility policy, the facility failed to implement their policy regarding assessing a resident for smoking safety. This affected one (#10) of two reviewed for smoking. The census was 62. Residents Affected - Few Findings include: Review of Resident #18's medical record revealed an admission dated of 01/07/21. Diagnoses included cervical stenosis, insomnia, psychoactive substance abuse, cerebrovascular disease, and obstructive sleep apnea. Resident #18 was assessed as being cognitively intact and being independent with activities of daily living (ADL's). Review of Resident #18's careplan date 01/22/21 revealed Resident #18 was a supervised smoker. Staff were to complete a smoking assessment. Further review of Resident #18's medical record revealed a smoking assessment was last completed on 07/07/21. During an interview on 03/07/22 at 12:50 P.M. Resident #18 confirmed she smoked at the facility. Resident #18 stated she was a supervised smoker and thought that she should be an independent smoker. During an interview on 03/10/22 at 9:10 A.M. Registered Nurse (RN) #170 stated that resident smoking assessments are completed quarterly. In a follow-up interview on 03/10/22 at 11:45 A.M. RN #170 confirmed that Resident #18 last smoking assessment prior to 03/10/22 was completed on 07/07/21. A smoking assessment was just completed for Resident #18 on 03/10/22. Review of a facility policy titled Resident Smoking Policy dated as revised 01/20/22 revealed that all residents will have a safe smoking evaluation completed with readmission, quarterly, and with any significant change in the resident's condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365228 If continuation sheet Page 14 of 14