Inspection·June 29, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Medical record review for Resident #72 revealed an admission date of 05/05/23 with diagnoses including, but not limited to, cerebral infarction, urinary tract infection, neurofunction of bladder, hypertension, hyperlipidemia, and hemiplegia and hemiparesis. Review of the comprehensive MDS assessment dated [DATE] for Resident #72, revealed the resident had severely impaired cognition. Resident #72 was dependent on staff for enteral feeding. Review of the plan of care for Resident #72, revealed the resident had a feeding tube related to dysphagia and was dependent on staff for tube feedings and flushes. Review of the physician's orders dated 06/06/23 for Resident #72, revealed an order for nothing by mouth (NPO) and enteral feeds every four to six hours for hydration and nutritional needs via the resident's g-tube. Observation of Resident #72's room on 06/28/23 at 5:39 P.M. with LPN #105, revealed the resident positioned in the bed with the room door open and LPN #113 was standing at the bedside administering a liquid nutrition supplement via the resident's g-tube. Observation also revealed the resident's abdominal region was uncovered allowing visualization of his g-tube insertion site. Interview on 06/28/23 at 05:42 P.M. with LPN #105 indicated all enteral feedings should occur in the resident's room and/or in a private area. LPN #105 verified the door to Resident #72's room was open as LPN #113 provided the enteral feeding via G-tube. LPN #105 indicated Resident #72's door should have been closed, or a curtain pulled to provide the resident with privacy. Interview on 06/28/23 at 05:49 P.M. with LPN #113 verified she was administered the nutritional supplement to Resident #72 via G-tube and did not provide the resident with privacy during the procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365265 If continuation sheet Page 2 of 7 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 365265 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piqua Manor 1840 West High Street Piqua, OH 45356 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 - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, observations and review of facility policy, the facility failed to ensure pharmaceutical medications were stored properly. This affected three residents (#17, #42 and #62) reviewed for medication storage. Facility census was 79. Findings include: 1. Medical record for Resident #17 revealed an admission date of 08/30/22 with diagnoses including, but not limited to, depression, low back pain, hypertension, right artificial hip joint and history of falling. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #17 revealed a mildly impaired cognition. Review of the active physician's orders dated 10/05/22 for Resident #17, revealed an order for Bengay greaseless external cream (over the counter topical pain cream) 15 percent apply to affected areas as needed and Norco (narcotic pain reliever) tablet 5-325 milligrams (mg) one tablet every six hours. Observation on 06/26/23 at 12:24 P.M. of Resident #17's bedside table revealed a tube of Bengay pain relieving cream at bedside. Interview with Resident #42 at the same time, revealed she asked the nurses to apply the medication when she could not reach it. Interview on 06/26/23 at 1:10 P.M. with Licensed Practical Nurse (LPN) #01 verified the tube of Bengay was in Resident #17's room and should not have been as the resident does not have an order for medication self-administration. Observation of Resident #17's room on 06/29/23 at 2:17 P.M with Corporate Registered Nurse (RN) #300 and Director of Nursing (DON) #117, revealed a white tablet in a clear medication administration cup on bedside table. Interview on 06/29/23 at 2:20 P.M. with Corporate RN #300 verified the observation of the white tablet in the medication cup and further verified medication should not have been left in the room unsupervised. Interview on 06/29/29 at 2:25 P.M. with LPN #18 verified she left a Norco 5-325 mg tablet in Resident #17's room without observation of the medication administration. 2. Medical record review for Resident #42 revealed an admission date of 02/14/22 with diagnoses including, but not limited to, cardiomyopathy, intervertebral disc degeneration, hypothyroidism stage three chronic kidney disease, and congestive heart failure. Review of the quarterly MDS assessment dated [DATE] for Resident #42 revealed an impaired cognition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365265 If continuation sheet Page 3 of 7 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 365265 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piqua Manor 1840 West High Street Piqua, OH 45356 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 - Few Observation on 06/26/23 at 11:53 A.M. of Resident #42's bathroom, revealed a partially empty bottle of chlorhexidine gluconate 0.12 percent mouthwash dated 11/05/22 with a prescription pharmacy label affixed. Interview on 06/26/23 at 11:59 A.M. with LPN #113 verified Resident #42 does not have a current order for the chlorhexidine mouthwash. LPN #113 verified the medication mouth should not be in the resident's bathroom. Review of June 2023 physician orders for Resident #42 revealed no active orders for chlorhexidine gluconate 0.12 percent mouthwash. 3. Medical record review for Resident #62 revealed an admission date of 03/28/22 with diagnoses including, but not limited to, irritable bowel syndrome, unspecified psychosis, and Alzheimer's disease. Review of the quarterly MDS assessment dated [DATE] for Resident #62, revealed an intact cognition. Observation of Resident #62's room on 06/26/23 at 2:25 P.M. revealed a bottle of nystatin powder on the resident bathroom sink a prescription pharmacy label affixed. Interview on 06/26/23 at 2:31 P.M. with LPN #113 stated the medication should not be left in the resident's room. Review of the June 2023 physician's order for Resident #62 revealed an order to cleanse under bilateral breasts with soap and water and pat dry and apply antifungal powder (nystatin) two times a day and as needed. Review of 03/30/22 facility policy titled Medication Storage in the Facility revealed medications and biologicals will be stored safely, securely, and properly and medications are accessible only to licensed nursing personnel or staff member lawfully authorized to administer medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365265 If continuation sheet Page 4 of 7 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 365265 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piqua Manor 1840 West High Street Piqua, OH 45356 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy review, the facility failed to ensure staff followed Enhanced Barrier Precautions (EBPs) during personal care. This affected three residents (#69, #71, and #72) of the five residents reviewed for infection control. Facility identified 39 residents who were on EBPs. The facility census was 79. Residents Affected - Few Findings include: 1. Medical record review for Resident #71 revealed an admission date on 05/19/23 with diagnoses that included, but not limited to, acute respiratory failure, anxiety, overactive bladder, epilepsy, hypertension, and lupus. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] for Resident #71, revealed the resident had severely impaired cognition. Resident #71 required extensive assistance from two staff members for bed mobility, transfers, and toileting. Resident #71 required total dependence for eating. Resident #71 received all nutritional intake via feeding tube. Review of the plan of care dated 05/23/23 for Resident #71, revealed the resident had a gastrostomy tube (g-tube) and was in EBPs. Interventions include educate family/resident and staff on EBPs, monitor for psychosocial effects, encourage participating in activities, and go to the dining room for meals and report any concerns. Review of the physician's orders dated 06/18/23 or Resident #71, revealed an order for Diabetisource AC (enteral liquid nutrition administered through an artificial opening in the abdomen) per g-tube at 55 milliliter/hour (mL/hr.) from 6:00 A.M. to 10:00 P.M. Orders revealed to flush the g-tube every six hours with 200 mL of water. Observation on 06/26/23 at 10:20 A.M. of Resident #71's room entrance, revealed a posted sign which indicated providers and staff must wear gloves and a gown for high contact care activities including central line, urinary catheter, feeding tube, and tracheostomy. Observation of Resident #71 on 06/28/23 at 05:30 P.M., revealed the resident was positioned in a Geri-chair in the hallway in front of the nursing station with Licensed Practical Nurse (LPN) #113 administering a water flush via the resident's g-tube. Observation revealed LPN #113 did not have a gown on per EBPs. Interview on 06/28/23 at 05:42 P.M. with LPN #105, verified all staff should be wearing a protective gown when completing any g-tube procedures on Resident #71 due to the resident being on EBPs. Interview on 06/28/23 at 05:49 P.M. with LPN #113, verified she administered a water flush through Resident #71's g-tube who was on EBPs and she was not wearing a protective gown during the procedure and should have been. 2. Medical record review for Resident #72 revealed an admission date of 05/05/23 with diagnoses including, but not limited to, cerebral infarction, urinary tract infection, neurofunction of bladder, hypertension, hyperlipidemia, and hemiplegia and hemiparesis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365265 If continuation sheet Page 5 of 7 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 365265 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piqua Manor 1840 West High Street Piqua, OH 45356 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 - Few Review of the comprehensive MDS assessment dated [DATE] for Resident #72, revealed a severe cognitive impairment. Resident #72 required extensive assistance from two staff for bed mobility, and total dependence for toileting, and transfers from two staff members. Resident #72 received abdominal tube feeding. Review of the plan of care for Resident #72 revised on 06/28/23, revealed the resident had g-tube and was on EBPs. Interventions include educate family/resident and staff on EBPs, monitor for psychosocial effects, encourage the resident to participate in activities, and go to the dining room for meals and report any concerns. Review of the physician's orders dated 06/06/23 for Resident #72, revealed an order for nothing by mouth (NPO), 225 milliliters (ml) water flush every four hours via g-tube for hydration, and an enteral feed of 360 milliliter liquid bolus every six hours via g-tube. Observation on 06/26/23 at 11.31 A.M. of Resident #72's room entrance revealed a posted sign which indicated providers and staff must wear gloves and a gown for high contact care activities including central line, urinary catheter, feeding tube, and tracheostomy. Observation of Resident #72's room on 06/28/23 at 5:39 P.M. with LPN #105, revealed the resident was resting in bed with the door to the room open and LPN #113 was standing at the bedside administering a liquid nutritional supplement to the resident via the resident's g-tube and without wearing a protective gown. Interview on 06/28/23 at 05:42 P.M. with LPN #105 verified Resident #72 was on EBPs and LPN #113 should have been wearing a protective gown during the g-tube feeding. Interview on 06/28/23 at 05:49 P.M. with LPN #113 verified that she was administering nutritional supplement to Resident #72 via a g-tube and did not have a protective gown on and should have according to the EBPs. 3. Review of medical record for Resident #69 revealed admission date of 05/19/23. The resident was admitted with diagnoses including non-traumatic subarachnoid hemorrhage, anxiety, and chronic obstructive pulmonary disease. The admission MDS assessment dated [DATE] for Resident #69 revealed the resident had a Brief Interview Mental Status (BIMS) score of 06 indicating impaired cognition. She required extensive two-person assistance for bed mobility, transfers, toileting, and total dependence for eating. Observation of the medication administration on 06/28/23 at 8:19 A.M., revealed LPN #115 entered Resident #69's room with gloves on and no other Personal Protective Equipment (PPE) to administer the resident's morning medication. Observation revealed a posted sign on the exterior of the resident's door frame, which indicated the resident was on EBP. The sign indicated providers and staff must wear gloves and a gown for high contact care activities including central line, urinary catheter, feeding tube, and tracheostomy. Continued observation revealed Resident #69 was positioned in the bed and LPN #115 pulled up the resident's gown to expose a jejunostomy tube (j-tube). LPN #115 was observed to administer the resident's medications through the residents j-tube with no protective gown in place. Interview on 06/28/23 at 8:29 A.M., with LPN #115, verified he did not wear a protective gown as he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365265 If continuation sheet Page 6 of 7 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 365265 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piqua Manor 1840 West High Street Piqua, OH 45356 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 administered medications to Resident #69 via his j-tube. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy titled Enhance Barrier Precautions dated August 2022 revealed it is the intent of the facility to use EBP in addition to standard precautions for residents to prevent transmission of multi-drug resistant organisms (MDROs) in their care community. All personnel must wear gloves when high-contact resident care activities are being performed. Shared resident care equipment should be clean and disinfected. High contact resident care activities listed were dressing, bathing/showering, transferring, providing hygiene, changing linens, changing attends, or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care: any skin opening requiring a dressing. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365265 If continuation sheet Page 7 of 7