Health inspection·May 16, 2024

F 0604 facility. Level of Harm - Minimal harm or potential for actual harm Interview with LPN #315 on 05/16/24 at approximately 2:00 P.M., revealed she was in the doorway to the courtyard area during the entire incident between LPN #500 and Resident #56. LPN #500 had asked her to go with him to the courtyard as a witness to telling Resident #56 she could not be smoking after 10:00 P.M. They both went to the courtyard and LPN #500 went to the area where Resident #56 was located and she stayed in the doorway. She heard Resident #56 and LPN #500 arguing about having to go inside and not being allowed to smoke. There was no physical altercations until LPN #500 grabbed Resident #56's wrist. After LPN #500 grabbed her wrist, Resident #56 attempted to swat his hand to let her go and LPN #500 continued to hold her wrist. After a couple minutes of continuing to try to get Resident #56 inside, LPN #500 pulled Resident #56's wrist close to her body and it appeared LPN #500 was holding her wrist to restrain her. At that point, LPN #500 moved in front of Resident #56, pushed his backside against Resident #56's body, and appeared to sit on her while they were both on the bench outside. While this occurred, two other aides went outside to see if they could help the situation. LPN #500 got off Resident #56 after a couple minutes, and one of the aides was able to calm her down to walk her back inside the building. When asked if she felt the physical contact by LPN #500 was necessary due to Resident #56 hitting LPN #500, LPN #315 stated it was not because Resident #56 did not physically engage with LPN #500 until he grabbed her wrist. LPN #315 confirmed LPN #500 initiated the physical contact and was restraining Resident #56. Residents Affected - Few Review of facility Abuse Prevention Policy, dated 10/02/19, revealed the facility will prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation of all residents. This includes, but not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. The definition of abuse was defined as the willful infliction, unreasonable confinement, intimidation, or corporate punishment with resulting physical harm, pain, or mental anguish. Review of the facility's corrective action plan revealed the following actions were implemented and the deficiency corrected as of 05/03/24: • On 04/28/24, a head to toe assessment was completed on Resident #56 and Resident #56 was found to have a slight bruise noted to her right shoulder. • On 04/28/24, LPN #500 was suspended pending the outcome of the investigation. • On 04/28/24, the Administrator/designee interviewed all current residents who were able to effectively communicate, and re-evaluated all current residents who were not able to effectively communicate to determine if there were any injuries of unknown origin or suspicion of abuse. No concerns were noted. • On 04/28/24, the Administrator/designee educated all current staff on the facility abuse policy, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365250 If continuation sheet Page 2 of 8 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 365250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buckeye Care and Rehabilitation 1900 East Main Street Lancaster, OH 43130 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few which included the use of physical restraints. Also, all current staff were educated on proper customer service and de-escalation techniques. • On 04/30/24, the Administrator/designee completed a weekly audit of five residents which included interviews with the residents. No concerns were reported. • On 05/02/24, the Administrator/designee reviewed the smoking policy and added a provision for situations where a resident may be agitated or trying to decompress while smoking outside of designated times. This update grants the nurse the authority to deviate from the standard policy to prioritize the safety of both the resident and the staff. • On 05/02/24, the Administrator/designee re-educated current staff and current resident smokers on the updated smoking policy. • On 05/03/24, the Administrator/designee terminated LPN #500's employment due to issues with poor customer service. • On 05/06/24, the Administrator/designee completed a weekly audit of four residents which included interviews with the residents regarding any care concerns. No concerns were reported. • On 05/09/24, the Administrator/designee completed a weekly audit of four residents which included interviews with the residents regarding any care concerns. No concerns were reported. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365250 If continuation sheet Page 3 of 8 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 365250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buckeye Care and Rehabilitation 1900 East Main Street Lancaster, OH 43130 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, staff interview and facility policy review, the facility failed to ensure multi use vials of tuberculin purified protein derivative (PPD) were dated when they were opened. This had the potential to affect all 93 residents in the facility. The census was 93. Findings include: Observation on 05/14/24 at 10:49 A.M. of the medication room refrigerator located on Maple Street and Main Street revealed an opened box with a used vial of tuberculin PPD five unit/0.1 milliliter(ml) one ml/vial with no date as to when it was opened. Interview on 05/14/24 at 10:50 A.M. with Licensed Practical Nurse (LPN) #299 verified there was no date as to when the tuberculin PPD vial was opened and stated, I know it was just opened yesterday as this is our last vial in the facility as there was a new admission and we do that for all new admission residents. Review of the facility policy titled Administering Medications, dated April 2019, revealed the policy stated when opening a multi-dose container, the date opened is recorded on the container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365250 If continuation sheet Page 4 of 8 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 365250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buckeye Care and Rehabilitation 1900 East Main Street Lancaster, OH 43130 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on review of the menu, review of the dietary spreadsheet, observations, staff interview, and review of facility policy, the facility failed to ensure the menu was followed. This affected 23 residents (Residents #1, #3, #6, #10, #13, #18, #22, #32, #36, #40, #41, #43, #45, #50, #59, #63, #69, #77, #81, #85, #153, #247, and #299) who were ordered a dysphagia advanced, mechanical soft, or pureed diet. The facility census was 93. Findings include: Review of the menu for the lunch meal on 05/15/24 revealed the meal consisted of a cheeseburger on a bun, lettuce and tomato, French fries, creamy coleslaw, and a cookie. Review of the dietary spreadsheet for the lunch meal on 05/15/24 revealed residents who received a dysphagia advanced diet should have received a sandwich with ground cheeseburger and a cup of shredded lettuce. Residents who received a mechanical soft diet should have received a number 10 scoop of ground pureed cheeseburger. Residents who received a pureed diet should have received a number 10 scoop of pureed cheeseburger. Interview on 05/15/24 at 10:35 A.M. with [NAME] #211 revealed there were no changes to the menu made for the lunch meal on 05/15/24. Observation on 05/15/24 at 10:35 A.M. of [NAME] #211 preparing pureed food items revealed the cook used a number 10 scoop to place eight scoops of ground meat with a red sauce into the blender. There were no buns or bread added to the blender. Interview on 05/15/24 at 10:37 A.M. with [NAME] #211 revealed he used a homemade recipe to make sloppy joes and was not making cheeseburgers for the residents. [NAME] #211 stated the sauce keeps it more moist for the residents. Observation on 05/15/24 at 10:39 A.M., revealed [NAME] #211 stopped the blender, emptied the pureed sloppy joes into a metal serving container, covered it with plastic wrap, and placed it in the steamer to keep it warm until it was time to be served. Observations on 05/15/24 from 11:35 A.M. to 12:15 P.M. of the lunch meal tray line with [NAME] #211 revealed the cook served ground sloppy joes on a bun to residents on a dysphagia advanced diet or mechanical soft diet. [NAME] #211 used gloved hands to scoop a handful of shredded lettuce on to the plates and did not use a portion controlled utensil to ensure the residents received one cup of shredded lettuce as indicated on the dietary spreadsheet. [NAME] #211 served pureed sloppy joes (without any bun) to residents who received a pureed diet. Interview on 05/15/24 at 2:24 P.M. with the Dietary Manager (DM) #200, [NAME] #211, and the Administrator confirmed [NAME] #211 did not follow the dietary spreadsheet for the lunch meal. [NAME] #211 confirmed he served sloppy joes instead of cheeseburgers. [NAME] #211 confirmed he did not add any buns to the pureed sloppy joes and did not have pureed bread on the tray line. [NAME] #211 stated, usually I puree it all together but I just forgot today. [NAME] #211 confirmed he used gloved hands to scoop and plate shredded lettuce instead of using a portion control utensil to ensure the appropriate amount was plated for the residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365250 If continuation sheet Page 5 of 8 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 365250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buckeye Care and Rehabilitation 1900 East Main Street Lancaster, OH 43130 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 0803 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Food Preparation and Service, revised 11/2022, revealed the policy stated, the facility will have spreadsheets for all meals coordinated with the weekly menus. These will indicate portion sizes for each menu item as well as any necessary modifications or substitutions to specific menu items for modified textures and therapeutic diets, making it clear to the staff just how to handle special situations without confusion. The Registered Dietician will review all spreadsheets and menus. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365250 If continuation sheet Page 6 of 8 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 365250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buckeye Care and Rehabilitation 1900 East Main Street Lancaster, OH 43130 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and facility policy review, the facility failed to ensure food was not expired and was stored appropriately. Additionally, the facility failed to ensure staff practiced proper hand hygiene when handling food. This had the potential to affect all 93 residents who resided in the facility. The facility identified all 93 residents received meals from the kitchen. The census was 93. Findings include: 1. During an initial tour of the kitchen on 05/13/24 from 11:40 A.M. to 11:50 A.M. with Dietary Manager (DM) #200, the following food items were observed in the refrigerator: one large half used container of salsa with a use by date of 05/03/24, one large unopened bag of brown, soggy shredded lettuce with a use by date of 05/09/24, one bag of fresh grapes which were opened, exposed to the air and undated, one unopened bag of pre-sliced potatoes with a use by date of 05/09/24, and one small partially used bottle of Red Hot hot sauce which was undated. Interview on 05/13/24 at 11:45 A.M. with DM #200 confirmed the above findings and DM #200 discarded the items from the refrigerator. Observation of the freezer on 05/13/24 at 11:47 A.M. revealed there was one large bag of premade peanut butter cookie dough cookies, opened, exposed to the air, and undated. Interview on 05/13/24 at 11:50 A.M. with DM #200 confirmed there was one large bag of premade peanut butter cookie dough cookies, opened, exposed to the air, and undated in the freezer. DM #200 discarded it from the freezer. Review of the facility policy titled Food Receiving and Storage, revised 11/2022, revealed the policy stated foods shall be received and stored in a manner that complies with safe food handling practices. 2. Observations on 05/15/24 at 11:25 A.M. of [NAME] #211 checking food temperatures revealed [NAME] #211 donned one clean glove on his right hand without completing any hand hygiene prior to putting the clean glove on. [NAME] #211 used his gloved hand to handle French fries in order to obtain a temperature. [NAME] #211 removed the glove after obtaining the temperature and discarded it in the trashcan. [NAME] #211 did not complete any hand hygiene after removing the glove and continued checking food temperatures. At 11:28 A.M., [NAME] #211 donned one clean glove on his right hand without completing any hand hygiene prior to putting the glove on. [NAME] #211 used his gloved hand to handle slices of cheese in order to obtain a temperature. After obtaining a temperature, [NAME] #211 removed the glove and discarded it in the trashcan. [NAME] #211 did not complete any hand hygiene after removing the glove. [NAME] #211 then started tray line. Observation on 05/15/24 at 11:35 A.M., revealed [NAME] #211 placed two large plastic bags of hamburger buns on a cart with his bare hands then donned clean gloves to both hands. [NAME] #211 did not complete any hand hygiene prior to putting on the clean gloves. [NAME] #211 used his gloved hands to scoop a handful of shredded lettuce, a tomato slice, and two onion slices onto a plate to serve to a resident. With the same gloves on, [NAME] #211 then grabbed a hamburger bun from the plastic bag and placed it on the plate. The cook used tongs to place a hamburger patty onto the bun and then used (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365250 If continuation sheet Page 7 of 8 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 365250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Buckeye Care and Rehabilitation 1900 East Main Street Lancaster, OH 43130 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the same gloved hands to place a slice of cheese on top of the hamburger patty and then placed the top of the bun on top of the cheeseburger. [NAME] #211 did not complete any hand hygiene or change his gloves and continued to use the same process for several more plates. At 11:46 A.M., [NAME] #211 placed a #10 scoop of pureed sloppy joe meat, mashed potatoes with gravy, and pureed carrots into three separate bowls and placed plastic lids on each bowl with the same gloves on. At 11:55 A.M., [NAME] #211 removed his gloves, discarded them in the trashcan, and washed his hands at the sink. [NAME] #211 donned two more clean gloves. At 12:00 P.M., [NAME] #211 used his gloved hands to move the cart that had the hamburger buns on it. The cook then ripped open one of the plastic bags of buns. [NAME] #211 did not change gloves or complete any hand hygiene and continued using his gloved hands to handle plates, shredded lettuce, tomato slices, onion slices, slices of cheese, and hamburger buns with the same gloves on. At 12:02 P.M., another male kitchen staff handed [NAME] #211 two large bags of frozen French fries from the freezer. [NAME] #211 used his gloved hands to open both bags of fries and dump them into the fryer. [NAME] #211 did not remove his gloves or complete any hand hygiene and again continued to handle plates, shredded lettuce, tomato slices, onion slices, slices of cheese, and hamburger buns while wearing the same gloves. Interview on 05/15/24 at 2:24 P.M. with the Administrator, Dietary Manager (DM) #200, and [NAME] #211 confirmed [NAME] #211 should have washed his hands before donning clean gloves and/or after removing gloves. [NAME] #211 confirmed the above observations of not following appropriate hand hygiene procedures during the lunch meal service. Review of the facility policy titled Food Preparation and Service, revised 11/2022, revealed the policy stated, cross-contamination can occur when harmful substances are transferred to food by hands (including gloved hands). Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodbourne illness. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365250 If continuation sheet Page 8 of 8