Inspection·January 2, 2020

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Further review of the medical record revealed resident was sent to the hospital on [DATE] for a significant change in condition, and no verification was found in the medical record that the facility provided the resident with the bed hold policy and reserve bed payment when transferred. Interview conducted on 01/02/20 at 1:33 P.M. with Clinical Quality Coordinator #300 verified Resident #8 was transferred out of the facility on 12/30/19 to the hospital and the resident was not provided the required bed hold policy with reserve bed payment when transferred. Event ID: Facility ID: 365241 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 365241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE London Health & Rehab Center 218 Elm St London, OH 43140 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 medical record review, staff interview and policy review, the facility failed to ensure fall interventions were in place prior to a resident's fall and failed to thoroughly investigate a resident's fall. This affected one (#15) of one residents reviewed for falls. The census was 58. Findings include: Review of the medical record for Resident #15 revealed an admission date of 07/01/15 with diagnoses including anxiety, muscle wasting and atrophy, and unspecified lack of coordination. Review of the Resident #15's fall care plan revealed interventions to prevent falls which included Resident #15's bed being in lowest position while he was in the bed. Review of Resident #15's quarterly minimum data set (MDS) dated [DATE] revealed the resident was cognitively impaired and scored a zero out of 15 on the brief interview for mental status. Resident #15 requires extensive assistance of two or more staff for bed mobility and transfers and did not walk in his room or corridor. Resident #15's balance was unsteady with moving on/off the toilet and they facility did not assess as the activity did not occur for assessing the resident balance with moving from a seated to standing position, walking, turning around and facility the opposite direction while walking. Review of Resident #15's nursing progress notes revealed on 11/03/19 at 6:20 A.M. the nurse documented while performing medication pass, the resident was observed on the mat to the floor beside his bed yelling help. Resident #15 was assessed, the physician and family were notified. X-rays were ordered and obtained which showed no fractures of dislocations. Further review of the fall investigation dated 11/03/19 revealed Resident #15 had an unwitnessed fall out of bed on 11/03/19 and was found on the floor mat next to his bed with a resulting abrasion to his right upper extremity. Review of the fall investigation dated 11/03/19 further revealed Resident #15's bed was not in the lowest position at the time of the fall and Resident #15's depends were saturated at the time of the fall. The fall investigation further revealed State Tested Nurse Aide (STNA) #400 was interviewed regarding the fall and stated she checked on Resident #15 at 6:00 A.M. due to the resident yelling and between 6:04 A.M. and 6:30 A.M. Resident #15 was found on the floor by the nurse. The statement obtained by STNA #400 contained no information as to whether or not the residents depends were saturated and the bed was in the lowest position. Interview with Director of Nursing on 12/31/19 at 3:29 P.M. verified Resident #15's bed was not in the lowest position at the time of the fall and this was a care planned fall intervention. The interview further revealed STNA #400 should have been asked whether or not the bed was in lowest position at 6:00 A.M. and Resident #15's depends were saturated on 11/03/19 at 6:00 A.M. prior to the fall. Review of the facility policy titled Fall Prevention and Management Policy, last revised 12/09/19, revealed residents will be assessed for fall risk on admission, quarterly, after any fall, and as needed. If risks are identified, preventative measures will be put in place and care planned. All falls will be reviewed and investigated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365241 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 365241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE London Health & Rehab Center 218 Elm St London, OH 43140 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to ensure pharmacist recommendations were acted upon in a timely manner. This affected two (#15 and #23) of five residents reviewed for unnecessary medications. The census was 58. Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 07/01/15 with diagnoses including anxiety, depression, and hypertension. Review of the physician orders for Resident #15 revealed an order dated 07/30/18 for Duloxetine HCL capsule delayed release particles 60 milligrams by mouth one time a day for depression. Review of the Pharmacy Consultation Report dated 02/04/19 revealed the pharmacist recommended to please attempt a gradual dose reduction to Duloxetine 20 milligrams once per day while concurrently monitoring for reemergence of depressive and/or withdrawal symptoms. Review of the medical record for Resident #15 revealed the pharmacy recommendation dated 02/04/19 was not addressed by the physician until 05/24/19 when the order was discontinued. Interview with Regional Director of Clinical Services (RDCS) #302 on 01/02/20 at 9:24 A.M. verified Resident #15's pharmacy recommendation dated 02/04/19 was not addressed by the physician until 05/24/19. The interview further verified the pharmacy recommendation was not addressed in a timely manner. 2. Review of medical record for Resident #23 revealed an admission date of 02/08/19. Diagnoses include severe sepsis with septic shock, anemia, intraductal carcinoma in SITU of Unspecified breast, age-related osteoporosis, paroxysmal A-fib, anxiety disorder, and depressive disorder. Review of the minimum data set (MDS) assessment dated [DATE] revealed Resident #23 requires extensive two persons assist with activities of daily living. A care plan relative to her psychotropic medications revealed individualized interventions with measurable goals. Review of the Medication Administration Record from 02/08/19 to 12/31/19 revealed Resident #23 was prescribed: Amiodarone 200 milligrams twice a day for blood pressure and Aripiprazole 10 milligrams one tablet a day for major depression Review of the Pharmacy Consultation Report revealed on 03/04/19 the pharmacist stated Resident #23 was taking the two medications that are associated with a risk for Torsade's de Pointes (TdP) or prolonged OT interval and recommended the physician discontinue Aripiprazole, tapering the dose as necessary. The physician did not respond to the pharmacist's recommendation. Review of the Pharmacy Consultation Report dated 05/20/19 revealed the pharmacist repeated the recommendation from 03/04/19; that is to discontinue Aripiprazole, tapering the dose as necessary. The pharmacist requested the physician respond promptly to assure facility compliance with Federal regulations. The physician responded to the recommendation on 06/19/19 and ordered the medication Aripiprazole to be discontinued. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365241 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 365241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE London Health & Rehab Center 218 Elm St London, OH 43140 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 0756 Level of Harm - Minimal harm or potential for actual harm Review of the Pharmacy Consultation Report dated 11/11/2019 revealed the pharmacist recommended the physician decrease Resident #23's Amiodarone 200 milligrams twice a day for blood pressure. The pharmacist recommendation was because Resident #23 has been receiving the higher than the recommended maintenance dose since 02/08/19. As of 12/31/19, the physician had not responded to the pharmacist's recommendation. Residents Affected - Few On 01/02/20 at 09:16 A.M. interview with the Regional Clinical Director #302 confirmed the physician did not address the recommendation on 03/04/19 in a timely manner and did not respond to the recommendation made on 11/11/19 as of 01/02/20. Review of the Drug Regimen Review Policy and Procedure dated 11/28/17 revealed any irregularities noted by the pharmacist will be documented and sent to the attending physician, the facilities medical director, and the director of nursing. Irregularities will be addressed by the physician in a timely manner. The physician must document that the identified irregularity has been reviewed, and what if any action has been taken to address it. Should there be no change in the medication, the attending physician should document his rationale in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365241 If continuation sheet Page 5 of 5