Inspection·March 4, 2024

F 0607 Level of Harm - Minimal harm or potential for actual harm Interview on 02/27/24 at 4:00 P.M. with the Administrator revealed employee files for the missing staff members on the BCI log were reviewed and BCI envelopes were not found. The Administrator had Human Resource Manager #500 call BCI and found BCI approval dates for all the missing employees other than Culinary Aide #423. Human Resource Manager #500 wrote the dates on the current staff list marked for the employees missing BCI checks. Residents Affected - Many Review of facility policy titled OHIO Abuse, Neglect & Misappropriation, dated 05/23/23, stated Furthermore, it is the intent of this facility to employ only properly screened persons as a part of the resident care team by the applicable requirements. The policy also stated Following the personal interview and upon recommendation of the interviewer, background checks will be performed. Lastly, the policy stated A pre-hire criminal background check will be performed for all potential OHIO staff . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 2 of 13 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 03/04/2024 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 0624 Prepare residents for a safe transfer or discharge from the nursing home. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff, resident, and family interviews, record review, policy review, and review of a local police report, the facility failed to ensure Resident #200 was not unnecessarily discharged from the facility and failed to ensure complete and accurate documentation related to Resident #200's discharge was recorded in the resident's medical record. This affected one (Resident #200) of three residents reviewed for discharge. The facility census was 104. Residents Affected - Few Findings include: Review of the medical record for Resident #200 revealed an admission date of 10/02/23 and a discharge date of 01/29/24. Medical diagnoses included Chronic Obstructive Pulmonary Disease (COPD), poly neuropathy, anemia, venous insufficiency, and lymphedema. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. He was recorded as having verbal and other behaviors not affecting others during one to three days in a seven-day lookback period of the assessment. He was not identified to have any hallucinations or delusions or to have rejected care. Resident #200 required supervision for completion of activities of daily living. Review of the interdisciplinary progress note dated 01/28/24 revealed a note timed 4:40 A.M. which stated Resident #200 was observed standing in the doorway to his room bleeding from his leg. He was short of breath and observed with an oxygen saturation level of 62% (normal level 95-100%). Staff applied supplemental oxygen and called emergency medical services to transport the resident to the hospital. A progress note dated 01/28/24 at 5:17 A.M. authored by the Director of Nursing (DON) revealed she was notified by Resident #200's nurse that he was in possession of medications he did not have an order for. The nurse stated the resident was exhibiting erratic behavior and the resident insisted on taking two bottles of medications with him during transport to the hospital. The DON recorded she had advised the floor nurse to contact the local hospital to inform of the medications the resident had. A subsequent progress note dated 01/28/24 at 5:52 A.M. revealed the local hospital had phoned the facility to inform them Resident #200 refused all treatment and was being returned to the facility. Review of the facility incident report dated 01/28/24 revealed Resident #200 was in possession of a medication he did not have an order for. The nurse stated the resident was exhibiting erratic behavior and the resident insisted on taking two medication bottles with him to the emergency room on [DATE]. The report indicated that Resident #200 was agitated and unpredictable in his behavior, and law enforcement was notified. Review of the interdisciplinary progress note dated 01/29/24 and timed 3:40 A.M. revealed Resident #200 was observed in his room stating help. Resident #200 was on the side of the bed and observed to have trouble breathing. The nurse instructed an aide to summon emergency medical services while the nurse assessed Resident #200. Resident #200 was transferred to a hospital of his choice. A subsequent progress note dated 01/29/24 and timed 9:00 A.M. revealed the resident returned to the facility after all testing performed at the hospital was within normal limits. A progress note dated 01/29/24 at 1:31 P.M. revealed Social Services Director (SSD) #460 held a phone conference with an outside agency to assist Resident #200 in getting an apartment in the community. The note identified another (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 3 of 13 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 03/04/2024 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 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few application was received by SSD #460 and would be completed. The final progress note dated 01/29/24 timed 4:37 P.M. authored by the DON revealed Resident #200 and his family were gathering the resident's belongings. The resident left the facility with family at this time on his own accord. Review of a local police report number 24-01507, dated 01/28/24, revealed the facility contacted emergency services as Resident #200 was getting aggressive and they requested the police to come assist. The police responded to the facility on [DATE] at 6:49 A.M. and upon arrival met with nursing staff who stated they were attempting to remove a male from the facility for bringing in an outside prescription drug. Resident #200 was stated to have brought suboxone into the facility that was not prescribed by said staff. Officers then spoke with Resident #200 who stated he was not leaving, as he was a resident of the facility. Resident #200 was informed by staff and officers that he was violating the facility rules and that he was being asked to leave the premises. Due to Resident #200 being a long-term resident of the facility and having medical issues he was not immediately removed by the police. The police officer advised the facility staff that the local Law Director would be contacted to review charges of criminal trespass for Resident #200. An entry on the police report dated 01/29/24 stated the officer met with the local Law Director and the resident did not have the right to refuse leaving the property. The local Law Director stated if the subject refused after being given a warning, he could be charged with criminal trespass. The police contacted the facility's administrative staff and advised them of the ruling. They relayed the information to the subject (Resident #200) who continued to refuse to leave the property. The officer then stated he traveled to the facility, contacted the subject and advised him if he did not leave within a reasonable amount of time, he would be arrested for criminal trespass. The subject (Resident #200) agreed to leave the facility at 6:00 P.M. Review of the video recording in Resident #200's room dated 01/29/24 beginning at 2:44 P.M. revealed a police officer in the doorway of Resident #200's room, and Resident #200 seated in a wheelchair facing the officer in the doorway. SSD #460 and the DON were visible in the doorway of Resident #200's room behind the police officer. The officer stated he had a meeting with the local Law Director to hear the resident's side and the facility's side, and the resident was being asked to leave the building. The officer stated to the resident if the facility says you have to leave the premises today then you have to. The officer further stated to the resident you realize if you don't voluntarily leave, what happens next, you will be arrested for criminal trespassing. The officer stated Resident #200 had to prepare to leave within a reasonable time frame and stated he would give the resident until 6:00 P.M. the same day to leave the facility. The resident can be heard on the video asking if he had rights, and stated he was not signing an AMA (against medical advice discharge form). The officer stated directly to the resident that if he did not leave the facility by 6:00 P.M. the officer would come back and arrest him for criminal trespass. Resident #200 stated he wanted to adhere to the law. The video ended on 01/29/24 at 2:48 P.M. An interview on 02/20/24 at 10:35 A.M. with Family Member (FM) #325 revealed a relation to Resident #200. FM #325 stated Resident #200 was a long-term resident of the facility and was kicked out of the facility by the police on 01/29/24. FM #325 stated the facility had phoned the police, who were present at the facility twice, once on 01/28/24 and the second time on the day of discharge 01/29/24. FM #325 stated Resident #200 did have a car and was able to drive, but he had no home to go to and Resident #200 had no other choice but to go to the home of FM #325. An interview on 02/20/24 at 11:52 A.M. by phone with Resident #200 revealed he was currently at another facility. He recalled the incident from 01/28/24 and 01/29/24 and stated the facility had called the police, who responded and threatened to arrest him if he did not leave. Resident #200 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 4 of 13 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 03/04/2024 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 0624 Level of Harm - Minimal harm or potential for actual harm he did not want to leave the facility, and had not planned, or thought about, leaving the facility against medical advice. Resident #200 stated he had no home to go to, but feared being arrested by the police. Resident #200 stated he could only walk short distances and was dependent on a wheelchair for mobility due to chronic leg issues. He stated when he left the facility, he drove himself to the home of FM #325 as he had nowhere else to go. Residents Affected - Few An interview on 02/20/24 at 4:49 P.M. with the DON revealed Resident #200 was a former resident of the facility. On 01/28/24, a Sunday, there was a situation where an aide saw what she believed to be a bottle of suboxone (medication used to treat dependence on opioid drugs) on or around Resident #200's coat when she was assisting with preparing him for an emergency department transfer. After Resident #200 left with the squad for the emergency department, the aide communicated to Licensed Practical Nurse (LPN) #409 what she saw, and LPN #409 phoned the DON to inform her of the situation. The DON stated she was not in the building on Sunday, but the information was relayed to her by the nurse on duty that upon the resident's return from the emergency department, Resident #200 exhibited erratic behavior and the police were called who responded to the building. The DON was unsure exactly what behaviors were exhibited but staff described belligerent behaviors. On 01/29/24, the police made a return visit to the facility, and after consulting the local Law Director, determined the police could legally remove Resident #200 from the building and charge him with criminal trespassing. She discussed with Resident #200, and so did the police, if the resident left on his own accord, the matter would be dropped, and no arrest or charges would occur. The DON stated this was a police directive that she did not believe the facility could influence or go against the police. The police gave Resident #200 until 6:00 P.M. that day to leave the building. The staff assisted Resident #200 in packing up his belongings, and a family member arrived at the facility to get him. The DON stated she was unsure where he went upon discharge and verified the circumstances leading up to Resident #200's discharge from the facility were not recorded in his medical record. An interview on 02/21/24 at 5:51 A.M. with Licensed Practical Nurse (LPN) #409 revealed she was on duty Saturday night 01/27/24 into the morning of Sunday 01/28/24 and had to send Resident #200 out to the hospital for shortness of breath and a low oxygen level. He had a car at the facility and would periodically sign out of the facility on a leave of absence and return on his own accord. On the morning of 01/28/24, Resident #200 had requested his coat prior to leaving with the squad. LPN #409 had been attending to the resident and STNA #399 retrieved Resident #200's coat. She noticed two pill bottles in or near Resident #200's coat, neither of which were from the facility's pharmacy. LPN #409 stated she was told by STNA #399 one of the bottles was suboxone. LPN #409 stated she phoned the DON and was told to communicate what the aide saw to the local emergency department. Resident #200 returned to the facility after declining treatment at the local emergency department. Upon the resident's return, she, and Central Supply Coordinator (CSC) #407, talked with Resident #200 and asked him for the pill bottles. Resident #200 produced two bottles of antibiotics, one being Bactrim (generic name Sulfamethoxazole-trimethoprim, an antibiotic used to treat bacterial infections), and she could not remember the other medication. An interview on 02/21/24 at 6:40 A.M. with Central Supply Coordinator (CSC) #407 revealed she was the weekend manager on duty and assisted LPN #409 in talking to Resident #200 about the prescription medications that were allegedly in his room. LPN #409 and CSC #407 asked Resident #200 for his prescription medications he did not have an order for, and he provided two pill bottles. CSC #407 stated she was told by staff the two bottles were antibiotics, but she was not a clinician to say for certain. CSC #407 stated the police were called as Resident #200 refused to provide the suboxone. When the police arrived, he refused to allow the staff or police to search his room. The police left the building and indicated they would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 5 of 13 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 03/04/2024 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 0624 return the next day after discussing the situation with the local law director. Level of Harm - Minimal harm or potential for actual harm An interview on 02/21/24 at 8:19 A.M. with Ombudsman #610 revealed she was not informed by the facility of Resident #200's planned discharge. Ombudsman #610 stated she received an urgent phone call on 01/29/24 around 4:00 P.M. from FM #325 who stated Resident #200 was told by the police he had to leave the facility by 6:00 P.M. that day. Ombudsman #610 phoned the Social Services Director (SSD) #460 and attempted to intervene. Ombudsman #610 spoke with SSD #460, the DON, and Administrator #625; facility staff indicated on the phone conversation that the situation with Resident #200's discharge was solely a police matter and out of the hands of the facility. Residents Affected - Few An interview on 02/21/24 at 9:52 A.M. with SSD #460 revealed she started at the facility mid-January and did not know Resident #200 well. She recalled the instance surrounding Resident #200's discharge, and identified the situation started over the weekend, and continued into Monday 01/29/24. The police came to the facility after contacting the local Law Director and stated the resident had to leave against medical advice or the police would arrest Resident #200 for criminal trespass. SSD #260 stated Administrator #625 indicated the facility would treat this situation as Resident #200 leaving against medical advice and instructed her not to attempt to set up any discharge arrangements or services for Resident #200. SSD #460 verified Resident #200 stated he did not want to leave against medical advice and had no plans for immediate discharge prior to police involvement. SSD #460 stated she recently assisted Resident #200 in filling out an application for a home choice program but there was a process and a long waiting list, and no arrangements were in place as of 01/29/24. SSD #460 stated she believed the discharge was unsafe and stated she had no clue who Resident #200 left with or what location he discharged to. SSD #460 indicated Resident #200 had a car at the facility but had no security of knowing he went to a safe environment, and again verified she had not set up or attempted to set up any services, nor had there been an evaluation to identify and/or meet Resident #200's care needs. An interview on 02/21/24 at 11:52 A.M. with Administrator #625 revealed knowledge of the police interaction with Resident #200. Administrator #625 stated he was not aware of the situation until 01/29/24, at which time he was informed there was a police directive for Resident #200 to leave. Administrator #625 indicated he did not initiate a 30-day or an immediate discharge notice, as there was no need to give a discharge notice. Administrator #625 stated he believed the police's verbal directive trumped the facility's discharge process. Administrator #625 indicated Resident #200 was safe when he left the building but stated he did not know Resident #200's discharge location, nor did he know any staff member of the building who was aware of where Resident #200 discharged to. Administrator #625 stated the facility treated Resident #200's discharge as against medical advice but verified Resident #200 never signed a discharge against medical advice form and stated he did not wish to leave against medical advice. Administrator #625 stated he absolutely believed Resident #200's choice to discharge and leave the facility on 01/29/24 was directly related to the police threatening to arrest him for criminal trespassing. A follow up interview on 02/22/24 at 5:20 P.M. with Administrator #625 verified the facility did not give any discharge notice, did not document notifications to the physician or responsible party, nor did facility staff initiate or document conversations with the ombudsman in Resident #200's medical record. Administrator #625 stated he never looked up the Ohio Revised Codes as referenced by the police officer on 01/29/24 and in the local police report, nor ever questioned the police's directions or decisions. Administrator #625 stated more could have been done to ensure Resident #200 was safe upon discharge on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 6 of 13 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 03/04/2024 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 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A follow up interview on 02/27/24 at 10:24 A.M. with SSD #460 verified prior to the police involvement Resident #200 had not mentioned leaving against medical advice. She stated she had had a discharge planning meeting earlier that day with an outside agency and Resident #200, but there was a long wait list for senior housing, and there were no solid plans for the resident's discharge on [DATE]. SSD #460 stated she was uncomfortable with the decision to discharge the resident but was following the directive of Administrator #625. An interview conducted on 02/27/24 at 3:49 P.M. with Nurse Practitioner (NP) #475 verified she was not aware Resident #200 left against medical advice until the next day, after the fact. NP #475 verified she placed a note in Resident #200's record indicating he had left against medical advice, as that is what the staff had relayed to her. NP #475 stated she was not notified of the against medical advice situation when it was occurring. Review of the undated policy Resident Rights identified residents have the right to discharge planning and protection against unfair transfer or discharge. The resident additionally may not be made to leave the nursing home unless any of the following are met: transfer is necessary for the welfare, health, or safety of resident or others, resident no longer requires the care due to health improvement to the point nursing home care is no longer necessary, failure to pay for services or the facility closes. Residents have a right to appeal a transfer or discharge to the state. Except in emergencies, the facility must provide a 30-day written notice of the plan and reason to discharge or transfer the resident and the facility will provide a safe and order transfer or discharge and provide proper notice of bed-hold and/or readmission requirements. Review of the undated policy, Transfer and Discharge Policy, revealed it is the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents, including a smooth transition of care for discharge or transfer. The discharge plan will identify the needs of each resident and will include the interdisciplinary team, will involve the resident and the resident's caregiver/support person, and will address the resident's goals of care and treatment preferences. Documentation in the resident's medical record must include the basis for the transfer or discharge. If the basis is because it is necessary for the resident's welfare and the resident's needs cannot be met in the facility, the facility must document the specific resident need that cannot be met and the facility's attempts to meet the resident's needs. This deficiency represents non-compliance investigated under Complaint Numbers OH00150661, OH00150658, OH00150640, and OH00149809. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 7 of 13 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 03/04/2024 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 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interviews, record review, and policy review, the facility failed to ensure physician visits were completed as required. This affected four (Residents #01, #40, #43, and #200) of six residents reviewed for physician visits. The facility census was 104. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #01 revealed an admission date of 12/05/23. Medical diagnoses included dementia, cellulitis, malnutrition, and venous insufficiency. Review of the admission Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] revealed Resident #01 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Review of the medical record revealed Resident #01 was seen by the previous medical director, Medical Doctor (MD) #700 on 12/06/23. The record revealed Resident #01 had multiple visits by Nurse Practitioner (NP) #475 but did not contain evidence that Resident #01 had been seen by the new medical director, MD #750, or any other physician, since the visit dated 12/06/23. An interview conducted on 02/27/24 at 3:58 P.M. with Resident #01 revealed she was alert, awake, and aware of the current day of the week, current year, and where she was at. Resident #01 stated she had no knowledge of whom her physician was at the facility and denied any recent physician visits since arriving to the facility. 2. Review of the medical record for Resident #40 revealed an admission date of 07/19/17. Medical diagnoses included type II diabetes mellitus, pancytopenia, morbid obesity, and hypertensive heart disease. Review of the annual MDS assessment dated [DATE] revealed Resident #40 had a BIMS score of 15, indicating intact cognition. Review of the medical record revealed Resident #40 was seen by the former medical director, MD #700 on 02/24/23. The medical record revealed frequent visits by NP #475, but no additional physician visit until MD #750 saw Resident #40 on 02/08/24. An interview conducted on 02/27/24 at 2:23 P.M. revealed Resident #40 did not recall seeing a physician, only recognizing NP #475 as his primary provider. Resident #40 denied being notified that his in-house physician had changed. 3. Review of the medical record for Resident #43 revealed an admission date of 10/25/22. Medical diagnoses included chronic obstructive pulmonary disease (COPD), anemia, arthritis, and chronic kidney disease. Review of the quarterly MDS assessment dated [DATE] revealed Resident #43 had a BIMS score of 12, indicating moderately impaired cognition. Review of the medical record revealed Resident #43 was seen by MD #700 on 04/29/23 and 09/06/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 8 of 13 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 03/04/2024 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 0712 Level of Harm - Minimal harm or potential for actual harm She had frequent visits recorded by NP #475 but no additional physician visit until MD #750 saw Resident #43 on 02/05/24. An interview conducted on 02/21/24 at 1:10 P.M. with Resident #43 revealed she had been asking to see a physician as she rarely sees one. Residents Affected - Some 4. Review of the medical record for Resident #200 revealed an admission date of 10/02/23 and a discharge date of 01/29/24. Medical diagnoses included chronic obstructive pulmonary disease (COPD), poly neuropathy, anemia, venous insufficiency, and lymphedema. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 had a BIMS score of 15, indicating intact cognition. Review of the medical record revealed Resident #200 was seen by MD #700 on 10/21/23. The resident had multiple visits by NP #475 but had no additional physician visit after the visit dated 10/21/23. An interview on 02/20/24 at 11:52 A.M. with Resident #200 by phone revealed he could not recall the last time he saw an actual doctor while a resident of the facility. An interview on 02/27/24 at 1:15 P.M. with the Director of Nursing (DON) verified there had been a change in the facility's medical director in December 2023 and physician visits were not completed timely for Residents #01, #40, #43, and #200. An interview on 02/29/24 at 1:35 P.M. with MD #750 verified he took over after the prior medical director was already gone. MD #750 stated he is still getting caught up in seeing long term residents and thought he had a few months to see everyone. MD #750 stated he prioritized seeing the post-acute patients over long-term residents as he began to see residents at the facility. Review of the undated policy, General Physician Services, revealed residents will be evaluated by a physician at least once every thirty days for the first ninety days after admission or three evaluations. After this period, each resident will be evaluated every sixty days, but the physician must see the resident no less than every 120 days. This deficiency represents non-compliance investigated under Complaint Numbers OH00150658, OH00150640, and OH00149983. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 9 of 13 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 03/04/2024 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on interview, observation, and policy review, the facility failed to serve foods at the appropriate temperatures. The had the potential to affect all residents that resided in the facility as the facility identified all residents received food from the kitchen. The facility census was 104. Residents Affected - Many Findings include: Interview on 02/21/24 at 12:40 P.M. with Resident #57 revealed the food is fair but usually cold. Interview on 02/21/24 at 12:55 P.M. with Resident #40 revealed the food delivered to his hall was usually last and the food was cold. Interview on 02/21/24 at 1:20 P.M. with Resident #43 revealed the food was not always hot. Interview on 02/21/24 at 3:17 P.M. with Resident #48 revealed sometimes the food was served cold. Observation of the lunch tray line on 02/22/24 at 11:56 A.M. with Culinary Director #490 and District Manager #111 revealed the lunch menu consisted of Italian sausage, Penne pasta, and spinach. Interview on 02/22/24 at 1:07 P.M. with Culinary Director #490 revealed they ran out of spinach for the lunch service. Culinary Director #490 stated broccoli was the substitute vegetable and there were 16 residents left to feed. Observation of the test tray being plated on 02/22/24 at 1:20 P.M. with Culinary Director #490. The Italian sausage was 170 degrees Fahrenheit, the Penne pasta was 150 degrees Fahrenheit, and the spinach was not on the test tray because it was not available. Broccoli was still in the steamer and not up to temperature at the time of the test tray being plated. The test tray left the kitchen at 1:28 P.M. Observation of the test tray and after all residents were served on 02/22/24 at 1:34 P.M. revealed Culinary Director #490, temperature checked and confirmed the following food temperatures: The Italian sausage was 130 degrees Fahrenheit, and the Penne pasta was 109 degrees Fahrenheit. Interview with Culinary Director #490 at the same time, revealed the hot food should leave the kitchen at 140 degrees Fahrenheit and be at least 130 degrees Fahrenheit when it gets to the residents. Culinary Director #490 verified the food temperatures were out the appropriate range. Interview on 02/22/24 at 3:45 P.M. with Nurse Aide #413 revealed residents reported the food and/or coffee was served cold. Interview on 02/27/24 at 2:45 P.M. with District Manager #111, revealed they try and keep the hot food at 135 degrees Fahrenheit and above as an appropriate temperature for food transportation. District Manager #111 verified there were no residents nothing by mouth (NPO) and all residents received food from the kitchen. Review of the Food Preparation Policy dated 09/2017 stated All foods will be held at appropriate temperatures, greater than 135 degrees Fahrenheit for hot holding and less than 41 degrees for cold holding. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 10 of 13 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 03/04/2024 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 0804 Level of Harm - Minimal harm or potential for actual harm Review of the Meal Distribution Policy dated 09/2017 stated All food items will be transported promptly for appropriate temperature maintenance. This deficiency represents non-compliance investigated under Complaint Numbers OH00149983 and OH00149809. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 11 of 13 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 03/04/2024 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 0942 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Based on record review, review of personnel records, and staff interview the facility failed to provide training on the rights of the residents to the staff. This affected three (Licensed Practical Nurses [LPNs] #435 and #443, and State Tested Nursing Assistant [STNA] #520) of the five personnel records reviewed. This had the potential to affect all 104 residents who resided in the facility. Findings include: Review of STNA #520 employee personnel file revealed a hire date of 12/11/23. The employee file contained no documented evidence of the rights of the residents training being provided to the employee prior to working in the facility. Review of LPN #435's employee personnel file revealed a hire date of 06/02/23. The employee file contained no documented evidence of the rights of the residents training being provided to the employee prior to working in the facility. Review of LPN #443's employee personnel file revealed a hire date of 07/07/23. The employee file contained no documented evidence of the rights of the residents training being provided to the employee prior to working in the facility. Interview on 02/27/24 at 4:47 P.M. with Human Resource Manager #500 confirmed LPNs #435 and #443, and STNA #520 personnel files had no documented evidence of the rights of the residents training being provided to the employees upon hire. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 12 of 13 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 03/04/2024 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 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on record review, review of personnel records, and staff interviews, the facility failed to provide abuse, neglect, exploitation and misappropriation of resident property training for staff. This affected three (Licensed Practical Nurses [LPNs] #435 and #443, and State Tested Nursing Assistant [STNA] #520) of the five personnel records reviewed. This had the potential to affect all 104 residents who resided in the facility. Findings include: Review of STNA #520's personnel file revealed a hire date of 12/11/23. The employee file contained no documented evidence of abuse, neglect, exploitation, and misappropriation of resident property training being completed prior to working in the facility. Review of LPN #435's personnel file revealed a hire date of 06/02/23. The employee file contained no documented evidence of abuse, neglect, exploitation, and misappropriation of resident property training being completed prior to working in the facility. Review of LPN #443's personnel file revealed a hire date of 07/07/23. The employee file contained no documented evidence of abuse, neglect, exploitation, and misappropriation of resident property training being completed prior to working in the facility. Interview on 02/27/24 at 4:47 P.M. with Human Resources Manager #500 confirmed LPNs #435 and #443, and STNA #520 personnel files had no documented evidence of abuse, neglect, exploitation, and misappropriation of resident property training being completed upon hire. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365284 If continuation sheet Page 13 of 13