Health inspection·January 8, 2024

F 0689 incident. Level of Harm - Immediate jeopardy to resident health or safety • On 10/19/23 at 7:45 P.M., Resident #100 was assessed, the physician was notified, and the resident was placed on increased supervision to ensure the safety of all residents. Residents Affected - Some • On 10/19/23 at 8:00 P.M., Resident #06 was assessed and sent to the hospital for evaluation with no adverse findings noted. Resident #06 returned to the facility on [DATE] at 11:00 P.M. • On 10/19/23 at 8:40 P.M., staff statements were obtained related to the incident. • On 10/19/23 at 10:09 P.M., the police were notified of the incident. • On 10/19/23, all residents residing on the secured unit were assessed with skin assessments completed. There were no negative findings noted. • On 10/20/23 at 9:20 A.M., Resident #06 had diagnostic images completed by an in-house provider out of an abundance of caution with no negative findings noted. • On 10/20/23 at 11:43 A.M., Social Service Designee (SSD) #850 assessed Resident #100 who had no recollection of the events of 10/19/23 and no psychosocial changes. • On 10/20/23 at 1:43 P.M., SSD #850 spoke with Resident #06 and the resident's niece who voiced concerns regarding Resident #100. • On 10/20/23 at 3:48 P.M., a room change was completed for Resident #06 who was moved off the secured unit away from Resident #100 per request. • On 10/20/23 at 6:00 P.M., Resident #100 was placed on one-to-one supervision. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 2 of 17 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 365284 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestwood Care Center 225 W Main Street Shelby, OH 44875 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 - Immediate jeopardy to resident health or safety On 10/20/23, Certified Nurse Practitioner (CNP) #850 was updated on the situation and gave orders for an in-patient stay, medication review, and psychiatric review for Resident #100. • Residents Affected - Some On 10/20/23, SSD #850 sent two referrals for Resident #100 to local psychiatric facilities and was denied by both. Resident #100 was to remain on one-to-one observation until a psychiatric evaluation was completed. • On 10/20/23, education was provided to all staff members regarding the facility's abuse policy and procedures by the DON. All staff were educated on 10/20/23. • On 10/24/23 at 2:00 P.M., Psychiatric Nurse Practitioner (PNP) #860 performed an assessment of Resident #100, including a medication review, with no concerns and no incidents of increased behavior. Resident #100's care plan was updated, and the resident was removed from one-to-one observation. Resident #100 remained free of incidents involving other residents. • On 10/25/23, ongoing audits to assess three residents for skin abnormalities weekly for six weeks to be completed by the DON/designee was initiated. The results of the audit observations were to be reviewed and trended for compliance through the facility's Quality Assurance Committee for a minimum of six months. No further skin abnormalities were identified. • On 12/28/23 at 10:35 P.M., nursing management was re-educated on resident supervision and the guidelines related to it by the DON. • On 12/28/23, all staff were re-educated by the DON on supervision and the guidelines related to it. • On 12/29/23 at 3:00 P.M., an initial audit of residents was completed by reassessing residents for the last 90 days who may have a history of resident-to-resident altercations, without provocation, and have interventions in place specific to those residents and monitor to ensure staff are implementing those interventions to prevent the same actions, situations, and/or practices from occurring in the future. This was completed by RDCO #150 with no negative findings. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 3 of 17 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 365284 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestwood Care Center 225 W Main Street Shelby, OH 44875 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 Beginning 12/29/23, ongoing audits will be performed to ensure supervision is adequate on locked dementia unit daily for six weeks completed by the DON/or designee. Level of Harm - Immediate jeopardy to resident health or safety • Residents Affected - Some Beginning the week of 01/01/24, the Administrator will hold specialized Quality Assurance and Performance Improvement (QAPI) meetings weekly for six weeks for the duration of the ongoing audits to review results and review effectiveness of education. This will continue weekly for six weeks. • Beginning 01/02/24, ongoing audits of staff knowledge regarding the abuse policy and procedure, and supervision and guidelines will be conducted three times per week with three different staff members by the DON/designee. • Beginning 01/02/24, ongoing audits of residents to be completed by assessing residents moving forward involved in any resident-to-resident altercations, without provocation, and have interventions in place specific to those residents and monitor to ensure staff are implementing those interventions to prevent the same actions, situations, and/or practices from occurring in the future to be completed by DON/designee. • On 01/02/24, the Administrator/designee held a QAPI meeting to review the results of all initial audits to be provided by the DON. • Interviews on 12/29/23 and 01/02/24 between 9:00 A.M. and 3:00 P.M. with State Tested Nurse Aide (STNA) #300, STNA #310, STNA #320, STNA #330, LPN #140, LPN #400, and Registered Nurse (RN) #120 all verified they were educated regarding the facility abuse policy and reporting procedure as well as guidelines for resident supervision. All staff members interviewed were knowledgeable regarding the content of the education. Although the Immediate Jeopardy was removed on 10/20/23, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of Resident #06's medical record revealed an admission date of 08/15/23. Diagnoses included cerebral infarction, delirium, Alzheimer's disease, chronic obstructive pulmonary disease, and a transient alteration of awareness. Review of Resident #06's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate decline of cognitive function. The resident was assessed to require supervision with bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 4 of 17 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 365284 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestwood Care Center 225 W Main Street Shelby, OH 44875 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 - Immediate jeopardy to resident health or safety mobility, transfers, dressing, and personal hygiene, and required an extensive one person assist with toilet use. A walker, cane, or wheelchair were utilized as she was fully ambulatory. Review of the medical record for Resident #100 revealed an admission date of 11/28/22. The diagnoses included cerebral vascular accident, psychoactive substance abuse, dysphagia, and schizoaffective disorder. Residents Affected - Some Review of Resident #100's quarterly MDS assessment dated [DATE] revealed the resident had a severe cognitive decline and the only behavior charted was rejecting care. Review of Resident #100's most recent care plan revealed he had a behavior problem at times due to impulsive behavior related to a stroke. The resident was known to lay on the floor at times, and wander into other resident's rooms and take their belongings. The resident experienced increased agitation, threatened violence, refused care, and refused medications when experiencing increased agitation. The care plan updated on 10/24/23 revealed the resident received a medication review with psychiatry. Review of a physician's application for emergency admission dated 08/29/20 revealed Resident #100 was admitted to a psychiatric hospital due to bizarre and aggressive behavior toward staff and other residents. The resident was yelling and threatening and involved in a physical altercation with another female resident that resulted in a fall and mild head trauma. Review of a self-reported incident (SRI) dated 08/26/21 revealed a female resident (#150) was walking down the hall of the memory care unit knocking on resident's doors. When Resident #150 came to Resident #100's door he pushed the female resident causing her to fall and hit her head. Resident #150 was transferred to the hospital for evaluation and found no injuries. Review of a physician's application for emergency admission dated 08/27/21 revealed Resident #100 had an ongoing psychiatric disorder and was at risk of harm to others and in need of inpatient psychiatric care. The resident was noted to be at risk of harming others and had assaulted a co-resident without any reason. Resident #100 had also tried to elope and required 24-hour supervision due to his behaviors. Review of an SRI dated 08/18/22 revealed Resident #100 was sitting at a table eating dinner when a female resident (#105) approached him and attempted to take his meal tray. Resident #100 stood up, grabbed her arm, and pushed her. There were no injuries. Review of an SRI dated 11/18/22 revealed Resident #100 and a female resident (#103) were walking through the memory care unit when Resident #100 became agitated. Resident #100 began yelling at Resident #103 to leave him alone, then pushed her which resulted in Resident #103 falling to the floor. Resident #103 received a bruise to the elbow. Review of Resident #100's progress note dated 02/22/23 revealed the resident was having increased behaviors and elevated vital signs. The resident was verbally and physically aggressive, and a physician order was received to send Resident #100 to a local psychiatric hospital. Review of an interdisciplinary team note dated 04/03/23 revealed an unnamed staff member observed Resident #100 kick another resident in the ankle with no injuries noted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 5 of 17 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 365284 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestwood Care Center 225 W Main Street Shelby, OH 44875 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 - Immediate jeopardy to resident health or safety Residents Affected - Some Review of an SRI dated 10/19/23 revealed Resident #100 was ambulating independently in the memory care unit hallway when Resident #06 approached him and attempted to link arms. Resident #06 was formerly a nurse and had a history of assisting other residents in various ways. Per staff report, Resident #100 then moved away from Resident #06, pulling his arm away from her arm and grasp causing Resident #06 to lose balance and fall to the floor. Resident #06 had complaints of pain in her hip and was sent to a local hospital for evaluation and treatment. The niece of Resident #06 stated she witnessed the incident and Resident #100 pushed Resident #06 to the ground. Notifications were made to the Director of Nursing (DON) and Executive Director (ED) and an investigation was initiated. Statements were collected, and per staff report, Resident #100 was without any increased agitation, or recollection of events when interviewed. Immediately following the incident, Resident #100 was assessed, and the physician was notified and placed with increased supervision as an immediate intervention to ensure safety of all residents. Resident #06 returned to the facility on the same date from the emergency room (ER) without any injuries. On 10/20/23 the SSD #850 assessed Resident #100 who had no recollection of the event, and no adverse psychosocial effect. On that date the ED and SSD #850 interviewed Resident #06 and her niece, who were concerned regarding Resident #100. Resident #100 was known to wander in and out of rooms at times so a room change was requested. The facility nurse practitioner was updated on the investigation and orders were received to send a referral for inpatient medication and psychiatric review for Resident #100. Referrals were sent to two local facilities, and both were denied per SSD #850. In an abundance of caution, orders were received for one-to-one monitoring for Resident #100 until a psychiatric evaluation could be completed. On 10/24/23 a psychiatric consultation occurred, and Resident #100 was removed from one-to-one observation. A medication review was completed. Resident #100 remained without increased agitation or anxiety at that time and without any psychosocial impact. Resident #06 was assessed for further psychosocial adversities from baseline daily for 72 hours post-incident after a room change, and no further adverse effects were observed. Further review of the SRI dated 10/19/23 revealed after completing a full comprehensive investigation into this incident, Resident #100 was placed on increased supervision, a psychiatric evaluation was completed, and psychiatric referrals were made to two locations and were denied. A medication review was also completed for Resident #100 with no changes noted, the care plan was updated, and like residents had skin assessments completed by the nurse with no concerns. Review of Resident #06's ER report dated 10/19/23 revealed she was examined due to a fall. A computed tomography (CT) scan of her cervical spine, head, and brain revealed no concerns. An x-radiation (x-ray) of the left elbow and left femur also were negative. Diagnoses included a fall with a contusion of the left lower extremity and contusion of the left elbow. Review of Resident #06's social service note dated 10/20/23 revealed she did not feel safe residing near Resident #100. SSD #850 requested staff to keep Resident #100 away from Resident #06 and allow her to keep her door closed. Resident #06 was moved to a room outside of the memory care unit. Review of Resident #06's nursing notes dated 10/20/23 revealed due to continued pain, the physician ordered further testing for the resident. Review of Resident #06's x-ray results dated 10/20/23 revealed x-rays of the left shoulder, left arm, left leg, and left hip were negative for fractures. Review of Resident #06's medication administration record (MAR) dated 10/21/23 through 10/25/23 revealed the pain medication Tramadol 25 milligrams (mg) was prescribed for the resident due to pain. The medication was to be administered every six hours as needed for moderate to severe pain for five days. Documentation revealed on 10/21/23 the resident's pain level was rated a six on a ten-point (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 6 of 17 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 365284 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestwood Care Center 225 W Main Street Shelby, OH 44875 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 - Immediate jeopardy to resident health or safety Residents Affected - Some scale with ten being the highest level of pain. On 10/23/23, Resident #06's pain was rated a seven, on 10/24/23 the resident's pain level was rated an eight, and on 10/25/23 the resident received three doses of pain medication for pain levels of 10, eight, and nine on a ten-point pain scale. Review of Resident #06's hospital notes dated 10/25/23 revealed the resident presented to the hospital for evaluation of left hip pain, and stated she sustained a fall last week and sought out care for this at a local hospital. Resident #06's niece stated the fall occurred in the nursing home due to her being pushed by another resident one week ago. Resident #06 denied any falls since that time. Resident #06 had continued pain in her lower back, left ribs, left hip, and the pain was worsening. The pain was present without walking or ambulation and when coughing and deep breathing. Review of a CT image of the left hip without contrast revealed fractures of the left sacrum (a bony structure located between the left and right hip bones forming the back of the pelvis) and left superior pubic ramus (pubic bone) and left inferior pubic ramus. These conditions have prevented the resident from walking since her fall on 10/19/23. Review of a CT image of the chest and abdomen revealed Resident #06 had a possible sternal fracture, however, this could be an artifact (a deviation of the visual integrity of an anatomic structure) of motion. Further documentation revealed Resident #06 had no tenderness over the sternum, so the physician believed the finding from the chest CT image to be an artifact for the possible sternal fracture. Resident #06 was in stable condition in the ER, although the resident was mildly hypoxic (low oxygen saturation) and was diagnosed with pneumonia of the right middle lobe. The resident was to be admitted to the hospitalist service for intravenous antibiotics for pneumonia as well as pain control and physical therapy for the fractures. Interview on 12/21/23 at 12:55 P.M. with the previous Administrator revealed Resident #100 did have issues in the past with aggression toward others, but he had not had any negative behaviors recently. The former Administrator stated Resident #06's family accused Resident #100 of pushing Resident #06 to the ground on 10/19/23, but due to a staff witness (STNA #330) having a statement of an accidental fall no ongoing precautions were put into place. The previous Administrator stated after the incident on 10/19/23 Resident #100 was placed on one-to-one observation and was seen by the facility psychiatric nurse practitioner who released him from close observation status. Observation on 12/27/23 at 9:10 A.M. and on 12/28/23 at 8:49 A.M. revealed Resident #100 was walking freely up and down the hallway in the memory care unit. The resident was walking alone. Staff were observed down the hallway caring for other residents. Interview with LPN #400 on 12/27/23 at 9:18 A.M. revealed Resident #100 did refuse care and would become verbally aggressive with staff. LPN #400 was aware of Resident #100's prior behaviors of aggression but denied any recent issues. There were no plans in place regarding Resident #100's aggression toward others. Interview with STNA #320 on 12/27/23 at 9:51 A.M. revealed Resident #100 walked freely about the memory care unit daily. STNA #320 denied seeing Resident #100 be aggressive toward other residents, but the resident would be aggressive toward staff and called staff inappropriate names. STNA #320 denied Resident #100 requiring any restrictions or plans regarding his previous behaviors. Interview with Resident #06's niece on 12/29/23 at 12:20 P.M. revealed she witnessed the incident on 10/19/23 between Resident #06 and Resident #100. Resident #06's niece stated she and Resident #06 returned to the facility from an outing. The niece and STNA #330 were in the hallway standing together when they witnessed Resident #100 shuffling down the hall. Resident #06's niece stated Resident #06 (a retired nurse and care giver) then informed Resident #100 that he should hold onto the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 7 of 17 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 365284 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestwood Care Center 225 W Main Street Shelby, OH 44875 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 - Immediate jeopardy to resident health or safety Residents Affected - Some handrail so he would not fall. Resident #100 grabbed Resident #06's shirt, lifted her off the ground, and threw her across the hallway. As Resident #06 fell, she hit her head on the handrail, and her buttocks bounced off the floor once and back down again. Resident #06's niece stated she screamed, and the nurse came running. Both Resident #06 and Resident #100 were assessed, and emergency medical services (EMS) was called for Resident #06. Resident #06's niece stated the resident was found to have no injuries with the testing that was done in the hospital, and five days after the fall the family felt Resident #06 was in too much pain, so with staff assistance the family transported Resident #06 to a different hospital. Resident #06's niece confirmed Resident #06 was then diagnosed with several sacral fractures, a breastbone fracture, and pneumonia due to not being able to ambulate or take deep breaths due to the pain and injuries. At the time of the interview Resident #06 continued to be non-ambulatory due to the injuries suffered in the fall on 10/19/23. Telephone interview with STNA #330 on 01/02/24 at 2:28 P.M. stated on 10/19/23, Resident #06 and her niece returned from an outing and the niece asked STNA #330 to get a sheet for the resident's bed. As STNA #330 and Resident #06's niece were walking down the hall, Resident #06 walked up to Resident #100, and she weaved her arm into his and was holding onto him. STNA #330 stated he then saw Resident #06 fall to the floor, and stated he did not see Resident #100 push Resident #06. STNA #330 stated he did witness Resident #100 push another resident previously for taking his comb which agitated Resident #100. Review of the undated facility policy titled, Unit Supervision, revealed it was the policy of the facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety is a primary concern for our residents, staff, and visitors. 2. Review of Resident #79's medical record revealed an admission date of 10/07/21. Diagnoses included hemiplegia and hemiparesis following a cerebral infarction, chronic obstructive pulmonary disease, atrial fibrillation, contractures of the left wrist and right hand, and epilepsy. Review of Resident #79's MDS assessment dated [DATE] revealed the resident had an intact cognitive function. He had an upper body impairment on both sides. Review of Resident #79's most recent care plan revealed he utilized nicotine products. The resident was educated on the smoking policy. The care plan revealed he was independent and was in need of updating since his cerebral vascular accident and return from the hospital. Observation of Resident #79 on 12/21/23 at 8:59 A.M. revealed the resident was laying in his bed. On the floor to the left side of his bed was a lighter and also noted was a pack of cigarettes on top of his dresser which was situated at the foot of the bed. Interview with Resident #79 on 12/21/23 at approximately 9:00 A.M. revealed he was allowed to have his cigarettes and lighter on his person. Interview with STNA #300 on 12/21/23 at 9:01 A.M. verified that Resident #79 had a lighter and cigarettes in his room and that was not allowed per facility policy. Review of the undated facility policy titled, Resident Smoking Guidelines, revealed the facility staff will secure smoking material in a locked area when not in use by the resident/patient for both independent and supervised smokers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 8 of 17 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 365284 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestwood Care Center 225 W Main Street Shelby, OH 44875 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 This deficiency represents non-compliance investigated under Complaint Number OH00149010. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 9 of 17 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 365284 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestwood Care Center 225 W Main Street Shelby, OH 44875 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Immediate jeopardy to resident health or safety Based on observation, record review, job description review, staff interviews and policy review, the facility failed ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by effectively implementing their plan of correction. This resulted in Immediate Jeopardy when on-going non-compliance was identified during an on-site complaint and post-survey revisit, with previous deficiencies centering around appropriate supervision to prevent and address resident-to-resident physical and verbal abuse by Resident #100 to five residents (97, #98, #80, #83, and #101) who resided on the Memory Care Unit (MCU). Additionally, the facility failed to ensure Resident #100, and Resident #91 were free from significant medication errors, failed to accurately maintain resident records to accurately record resident-to-resident altercations, and failed to correct the frequency of physician visits. The facility failed to effectively implement their previous plans of corrections to achieve compliance with the regulations which had the potential to affect all residents residing in the facility. The facility census was 107. Residents Affected - Many On 05/10/24 at 9:43 A.M., the Administrator, Director of Nursing (DON), Regional Director of Clinical Operations (RDCO) #250 and Divisional Director of Clinical Operations (DDCO) #310 were notified that Immediate Jeopardy began on 02/12/24 when Resident #100, who was known to have an extensive history of aggressive behavior, had his antipsychotic medication erroneously omitted by a facility nurse while transcribing a consultant provider ' s new medication orders. On 04/24/24, Resident #100 began having increased aggressive behaviors towards residents and staff, with numerous incidents being reported by staff and few documented in the residents ' medical records. These behaviors included punching other residents, pulling hair in an upward motion lifting a resident up out of the chair, forceful grabbing of arms resulting in skin issues, and verbal threats of physical harm. The facility failed to implement their approved plan of corrections regarding enhanced supervision to prevent resident-to-resident altercations, failed to appropriately audit medical records for resident-to-resident altercations and significant medication errors, and failed to achieve compliance with the frequency of physician visits. The Immediate Jeopardy was removed on 05/16/24 when the facility implemented the following corrective actions: • On 05/07/24, laboratory testing and urinalysis was obtained for Resident #100 to rule out medical reasoning for increased agitation. • On 05/07/24, all self-reported incidents were completed and submitted to the Ohio Department of Health (ODH) by the Administrator. • On 05/07/24, an investigation of all incidents was conducted and completed by RDCO #250. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 10 of 17 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 365284 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestwood Care Center 225 W Main Street Shelby, OH 44875 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 0835 At the time of the incidents, Residents #97, #98, #80, #83, and #101 were interviewed and assessed by SSD #300 with no apparent adverse effect. Level of Harm - Immediate jeopardy to resident health or safety • Residents Affected - Many On 05/07/24, notification to the physician and families of the involved residents were completed by the DON. • On 05/07/24, the police department was notified of the resident-to-resident incidents by the Administrator. • On 05/07/24, Corporate Nurse #330 obtained staff statements regarding the resident-to-resident incidents, and anyone involved in the state reportable incidents. • On 05/08/24, Resident #100 was sent for an inpatient psychiatric evaluation. • On 05/08/24 (no time provided), Resident #100 ' s plan of care was updated with all interventions provided by RDCO #250. • On 05/10/24, a timeline of events was completed by the DON or designee. • On 05/10/24, an initial audit of all psychiatric progress notes received since 02/12/24, and all other physician notes since 04/10/24, was completed by Corporate Nurse #330. • On 05/10/24, an initial audit of all progress notes for the last 30 days for all residents was completed to identify any potential incidents that should be reported to ODH as a self-identified, state reportable, with proper investigation and notifications made and documented. This was completed by Corporate Nurse #330. • On 05/10/24, an audit of all resident-to-resident incidents was conducted to identify trends with residents and address increased behaviors, or risk for increased behaviors, and completion of interventions. This was completed by Corporate Nurse #330. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 11 of 17 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 365284 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestwood Care Center 225 W Main Street Shelby, OH 44875 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 0835 • Level of Harm - Immediate jeopardy to resident health or safety On 05/10/24, any residents found to be with trends of aggression or increased agitation will be referred for inpatient psychiatric evaluation and treatment by the Administrator. • Residents Affected - Many On 05/10/24, education was provided to facility leadership on the abuse policy, risk management, investigation, supervision, behavior management policy, implementation of interventions, order transcription, and the risk escalation process. This education was completed by DDCO #310 and RDCO #250. • On 05/10/24, education was provided to all staff on the abuse policy, risk management and investigation, supervision, behavior management policy, order transcription. This was completed by RDCO #250. • On 05/10/24, education was provided to Psychiatric Nurse Practitioner #604, who will write all orders as telephone orders and communicate to nursing leadership in person prior to leaving the facility upon completion of rounds. This training was provided by RDCO #250. • On 05/10/24, an audit was conducted to ensure all residents had been evaluated by a physician. This was completed by Corporate Nurse #330. • On 05/10/24, Education was provided to the Administrator and DON on ensuring plans of correction are completed as written to achieve ongoing compliance. This was completed by DDCO #310. • An ongoing audit will be conducted weekly for psychiatric and physician progress notes received, observing for any noted orders that were not properly transcribed. This will be completed weekly by RDCO #250 beginning on 05/11/24. • An ongoing audit of resident ' s progress notes will be completed to identify any potential incidents that should be reported to ODH as a state reportable, with proper investigations and notifications made and documented will be completed by RDCO #250 or designee three times weekly for four weeks starting on 05/11/24. • An ongoing audit of all resident-to-resident interactions will be conducted to identify trends with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 12 of 17 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 365284 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestwood Care Center 225 W Main Street Shelby, OH 44875 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 0835 Level of Harm - Immediate jeopardy to resident health or safety residents, and address increased behaviors or risk, to assist in accurately maintaining the resident ' s record or record instances of resident-to-resident altercations. This will be completed by RDCO #250 or designee weekly for four weeks starting on 05/11/24 with oversight from [NAME] President of Risk Management #680. • Residents Affected - Many Beginning 05/11/24, staff interviews will be conducted by RDCO #250 five days per week, one staff per unit, and three staff members per day on random shifts, to determine if any resident behaviors were identified. • An ongoing audit of the daily clinical meeting and its operations, with attention to the implementation, effectiveness of interventions, and to ensure all incidents are recorded accurately in the resident record will be conducted by RDCO #250 and Regional Director of Operations (RDO) #530 five times weekly for four weeks beginning on 05/13/24. • An ongoing audit of the frequency of physician visits, to ensure regulatory compliance, will be completed by RDCO #250 weekly. • The results of the audit observations will be reported, reviewed, and trended for compliance through the facility Quality Assurance Committee for a minimum of six months, then randomly thereafter for further recommendations. • Ad hoc Quality Assurance and Performance Improvement meetings were conducted on 05/13/24, 05/14/24, and 05/15/24 by the facility ' s interdisciplinary team. • On 05/16/24, behavior training specific to dementia and memory care, provided by an outside licensed behavioral specialist, was completed for all staff who work on the memory care unit. Although the Immediate Jeopardy was removed on 05/16/24, the deficiency remained at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: During an interview on 05/08/24 at 9:01 A.M., the Administrator stated he had only been employed at the facility for approximately one month. The Administrator recognized the facility was out of compliance and his highest priority was getting the facility back into compliance. The Administrator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 13 of 17 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 365284 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestwood Care Center 225 W Main Street Shelby, OH 44875 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many stated the concerns were getting the facility back into compliance and achieving staff stability. The Administrator was unable to state how the facility was achieving compliance with previously cited deficiencies. He stated he would have to check the survey binders to familiarize himself to what areas the facility was out of compliance. During the on-site complaint and post-survey revisit, continued non-compliance was identified by the survey team. The facility ' s failure to effectively audit, monitor, and correct previously cited deficiencies resulted in the potential for serious harm or injury to all residents. 1. Review of the Facility Assessment, revised on 04/04/24 and reviewed with the Quality Assurance and Performance Improvement (QAPI) committee on 04/25/24, revealed the facility provided mental health and behavior management. Specific care provided to this population of residents included managing the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identifying, and implementing interventions to help support individuals with issues such as dealing with anxiety, cognitive impairment, residents with depression, trauma/post-traumatic stress disorder (PTSD), other psychiatric diagnoses, and intellectual or developmental disabilities. The facility identified it was able to provide medication administration by various routes. The section of the facility assessment which discussed working with medical providers in describing the facility ' s plan to recruit and retain enough medical practitioners and how the facility collaborates with the providers to meet the medical needs of the population was blank. 2. The facility failed to ensure Resident #100, who had a history of physical aggression towards other residents and staff, had appropriate supervision, monitoring, and services rendered to manage his behaviors, supervise his actions, and protect other residents of the facility. Resident #100 was assessed to have severely impaired cognition, an extensive history of aggressive behaviors, and resided on a secured MCU. On 02/12/24, Resident #100 was seen by the psychiatrist for a medication adjustment/follow-up and the resident was ordered Seroquel to be stopped and Risperdal started. The Seroquel was discontinued; however, the Risperdal was never started. Review of Resident #100's Medication Administration Record (MAR) indicated he received no antipsychotic medication from 02/12/24 until Resident #100 was seen by a visiting physician on 05/07/24 due to multiple instances of aggression and behaviors and his Seroquel was restarted. As a result, Resident #100 was off his antipsychotic medications for 85 days. In this time frame, Resident #100 began having increased physical behaviors as well as verbal threats of physical harm towards other residents in the Memory Care Unit (MCU). On or about 04/24/24, Resident #100 started having increased aggressive behaviors towards the residents and staff. The resident has numerous incidences of aggressive behaviors involving other residents, with few being documented in the residents ' medical record. The resident's behaviors included punching other residents in the stomach, pulling residents hair and pulling them upwards out of a chair, forcefully grabbing others ' arms causing skin issues and verbally threatening residents with harm. Resident #100's care plan has not been revised to reflect his behaviors and/or any interventions to monitor and address his pattern of behavior. There is limited documentation about his behaviors, despite the staff interviews reporting the behaviors, and no evidence of preventative measures or increased supervision to ensure the safety of other residents on the unit. The resident was noted to have potential to experience increased agitation and/or threatens violence, refuses care, and refuses medications at times of increased agitation. This resulted in Resident #100 being physically aggressive with numerous other residents because of not having proper interventions and adequate supervision in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 14 of 17 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 365284 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestwood Care Center 225 W Main Street Shelby, OH 44875 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Review of facility SRIs, medical records, and staff interviews regarding Resident #100 revealed the resident had five resident-to-resident altercations with five different residents between 04/24/24 and 05/06/24 in the MCU: On 04/24/24, Resident #100 was observed by facility staff attempting to strike Resident #97 in the face. Staff was unsure if Resident #100 struck Resident #97 ' s face with his hand, but Resident #100 was observed throwing juice in Resident #97 ' s face. On or about 04/25/24, Resident #100 was observed by facility staff using his forearm in a backwards, reflexive type motion and pushed Resident #98 in the abdomen. Interviews conducted on 05/06/24 with a family member of Resident #98 revealed she was told the resident was punched in the stomach by Resident #100. Interviews conducted on 05/07/24 with State Tested Nursing Assistant (STNA) #252 and STNA #262 revealed both witnessed the event in the MCU dining room and reported Resident #100 punched Resident #98 in the stomach. On 04/28/24, Resident #100 was observed by facility staff yelling, cursing, and making verbal threats of harm and attempted to physically lunge towards Resident #80. LPN #406 intervened and as a result was physically struck by Resident #100. On 05/03/24, Resident #100 was involved in a verbal and physical altercation in the dining room with Resident #83. Resident #83 had stated Resident #100 hit him, and following the event was observed with bruising and a skin tear to his left arm. On 05/06/24, Resident #100 was observed by facility staff to grasp a handful of Resident #101 ' s hair and forcefully lift her up off the seat of a chair. Resident #100 then dropped the resident back down before staff responded to separate the two residents. 3. Review of the facility ' s plan of correction for the survey dated 01/08/24 revealed the facility implemented an ongoing audit of residents involved in resident-to-resident altercations without provocation, to ensure interventions were in place for the involved residents. The audit tool noted the need for monitoring to ensure staff are implementing the interventions to prevent the same actions, situations, and/or practices from occurring in the future. This audit tool was to be completed by the DON or designee. Resident #100 was not listed on the audit tool upon initiation of the audit on 01/02/24 through the most recent entry on the log dated 04/29/24. For the week of 04/22/24 to 04/29/24, RDCO #250 recorded there had been no resident-to-resident altercations. During an interview on 05/08/24 at 7:56 A.M., Corporate Nurse #330 verified the resident-to-resident altercation audit was incorrect, as there were three resident-to-resident interactions, all involving Resident #100 during that time frame. Corporate Nurse #330 verified Resident #100 ' s altercations should have been noted on the audit and that the audit tool had not yet been completed for the week of 04/29/24 to 05/06/24. Review of the facility ' s plan of correction to the survey dated 03/04/24 revealed RDCO #250 provided education to the DON, the Administrator, Medical Director (MD) #750, and the former Nurse Practitioner (NP) #475 on 02/28/24. An initial audit was completed of the last physician visit for all residents by the DON or designee by 03/20/24. The facility alleged compliance by 03/26/24. Review of the running list of residents with their most recent physician visit dates revealed approximately 90 residents with no evidence of a current physician visit on the audit log. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 15 of 17 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 365284 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestwood Care Center 225 W Main Street Shelby, OH 44875 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Review of a statement dated 04/25/24 authored by Corporate Nurse #330 stated she spoke with MD #750 and educated him on the status of resident physician visits and established a plan for compliance. The statement stated MD #750 will see all residents who have not had a visit documented in the electronic medical record on record. MD #750 was provided an excel spreadsheet with the last physician visit documented and will see residents in reverse chronological order from the oldest date last seen to current to establish compliance. The statement indicated MD #750 had seen several individuals but had not documented the visit in a physician ' s progress note but will try to get the notes in the proper format. During an interview on 05/07/24 at 8:13 A.M., Licensed Practical Nurse (LPN) #325 stated she rarely sees MD #750 at the facility. The facility previously had a full-time Nurse Practitioner, but she was removed from the building two months ago. When MD #750 is at the facility, the nurses are not told he is here, rather if something medically is needed for a patient, the facility nursing staff must use the after-hours telehealth provider who are unfamiliar with the residents. During an observation on 05/07/24 at 10:20 A.M., the DON was performing rounds with visiting Physician #800. The DON stated Physician #800 was the assistant Medical Director for the corporation and had been called in to get physician visits current. During an interview on 05/08/24 at 7:56 A.M., Corporate Nurse #330 stated she had previously had a discussion with MD #750 and documented the conversation. MD #750 had submitted his resignation, citing he had not been aware of the time commitment required, but stated he would stay on until a new Medical Director was found. Corporate Nurse #330 reviewed the facility audit tool and verified the significant number of residents who remained out of compliance for physician visits. Review of the Medical Director Agreement form between the facility and MD #750, dated 12/11/23, revealed the agreement contained the Medical Director ' s duties and responsibilities which included: developing policies and procedures in concert with the facility, the facility ' s administration, and the medical staff to assure quality patient care, active treatment, appropriate level of professional and technical staff and personnel and will review professional standards of practice within the facility. Additionally, duties included to provide medical supervision for treatment modalities within the facility, ensuring compliance with the medical staff bylaws of the facility, providing the facility with timely information and reports, and providing all other services required to ensure the facility is run in an efficient, prudent manner to provide the facility ' s patients with the best possible care. 4. Review of the facility ' s plan of correction for the survey dated 04/11/24 revealed the facility did an audit of all residents ' Medication Administration Records (MAR) to observe for potential issues related to documentation of medications, with no issues or concerns found. Facility nursing staff were re-educated on medication administration and the documentation of medication administration. Review of a facility audit, completed between 04/23/24 and 05/01/24, revealed the DON audited all residents ' MAR to ensure all medications were administered as ordered. Resident #91 was included in this audit. Review of Resident #91 ' s physician ' s orders revealed an order dated 03/25/24 for dextromethorphan-quinidine (Neudexta, a central nervous system agent used to treat pseudobulbar affect) 20-10 milligram (mg) one capsule by mouth twice daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 16 of 17 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 365284 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestwood Care Center 225 W Main Street Shelby, OH 44875 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Review of Resident #91 ' s April 2024 and May 2024 MAR records revealed the resident missed a total of 30 doses of her ordered Neudexta between 04/18/24 and 05/10/24. Review of Resident #91 ' s interdisciplinary progress notes, dated 04/01/24 to 05/10/24, revealed frequent entries noting the resident ' s Neudexta medication was on order, still not available, or there was none on hand. A note dated 05/10/24 at 12:55 P.M. revealed a conversation with a pharmacy representative indicating that Resident #91 ' s ordered Neudexta would be delivered that night. The note indicated the resident ' s physician was notified and provided an order to hold the medication. During an interview on 05/13/24 at 5:24 P.M., the DON stated there had been an issue with getting Resident #91 ' s Neudexta medication covered through insurance, as it required a prior authorization prior to the pharmacy being able to dispense and deliver the medication. The DON verified Resident #91 ' s missing doses and confirmed there was no evidence of the provider being aware of the missing doses until she contacted the provider on 05/10/24. The DON stated the process had been started to obtain the prior authorization, but there was an assumption amongst the nurses that someone else had ordered the medication and notified the provider. During an interview on 05/15/24 at 3:10 P.M., RDCO #250 verified the DON audited each resident ' s MAR records. RDCO #250 verified the facility should have identified Resident #91 ' s missed Nuedexta doses during that audit. RDCO #250 confirmed the previous audit performed was ineffective. Review of the Executive Director ' s (Administrator) job description, dated 05/28/18, revealed the position of Executive Director provides leadership to all staff to assure that care standards are met, and the highest degree of quality resident care is provided at all times. The Executive Director has the authority, responsibility, and accountability for the overall operation and financial success of the center. Job duties included to efficiently manage facility resources and operations to ensure that the needed resources will be available to provide quality care and a safe, homelike environment for all residents, maintain and work within established policies, procedures, objectives, and quality improvement programs, and to provide leadership to the staff. Review of the Director of Nursing job description, dated May 2022, revealed the DON position provides leadership to the nursing staff to assure that care standards are met and the highest degree of quality resident care is provided at all times. Job duties included to assist in developing, implementing, and coordinating department policies and procedures, resident care plans, and nursing procedure manuals, executing resident care policies, assuming authority, responsibility, and accountability of directing the nursing service department, and making daily rounds to assure that department personnel are performing required duties and to assure that appropriate resident care is being rendered. Additional job duties listed included supervising and maintain resident documentation, records, and charts to ensure an accurate, up to date record of the resident ' s medical records. This included reviewing care plans as needed for any changes, using monitoring tools consistently and correctly, and recording all resident information as required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 17 of 17