Health inspection·December 31, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete for the resident not to wear depends while in bed and to cleanse the bilateral buttocks with soap and water, pat dry, and apply Triad paste every shift and as needed (prn) for incontinence. Review of an interdisciplinary team (IDT) note dated 11/10/25 at 1:26 P.M. by LPN #229 (facility's wound nurse) revealed the IDT met in regard to Resident #135 having moisture associated skin dermatitis (MASD) to the left buttock and a pressure ulcer to the right buttock. The resident was not able to state what happened due to cognitive decline. They agreed with assisting the resident with turning and repositioning as needed and the care plan was updated. Review of Resident #135's care plans that were initiated during her stay and remained in place until her discharge from the facility on 11/18/25 revealed she had two separate care plans that both addressed her skin impairment. One care plan for the resident having an actual area of skin impairment related to her being bedbound revealed she had a Stage II (a partial thickness skin loss where the outer layer and part of the later beneath were damaged appearing as a shallow open sore with a red or pink wound bed) and MASD to her left buttock. She had another care plan for an impaired skin integrity as evidenced by MASD to the right buttock and a Stage II pressure ulcer to the left buttock. The two care plans were contradictory or one another changing the type and the location of the resident's skin impairment. Review of a skin grid pressure assessment dated [DATE] revealed Resident #135's Stage II pressure ulcer to the right buttock was indicated to be present upon admission, when it was not noted until 11/09/25. It also identified the original date of the pressure ulcer as being 11/02/25, instead of 11/09/25, when it was first noted. Review of a progress note from the wound nurse practitioner the facility consulted for wound management revealed she saw Resident #135 and examined her on 11/12/25. The wound nurse practitioner erroneously identified the Stage II pressure ulcer as being on the resident's left buttock and MASD was identified as being on the right buttocks. An addendum was obtained from the wound nurse practitioner on 12/30/25 at 11:11 A.M. by the facility's Director of Nursing (DON), after it was brought to her attention that the resident's medical record included conflicting information with the type and location of the resident's skin impairment between her left and right buttock. The addendum was for a service date of 11/13/25 and clarified the pressure ulcer was on the resident's right buttock and the MASD was to the left buttock. On 12/30/25 at 11:11 A.M., an interview with LPN #229 revealed she was the facility's wound nurse and was wound certified. She was familiar with Resident #135 when the resident was residing in the facility. She confirmed the resident developed a Stage II pressure ulcer to her right buttock and MASD to the left buttock that originated on 11/09/25. She confirmed the care plan and the wound nurse practitioner's note on 11/13/25 had the areas reversed indicated the pressure ulcer was on the left buttock and the MASD was to the right buttock. She further confirmed the resident's wound assessments were not accurate when it indicated the Stage II pressure ulcer to the right buttock was present on admission and another area of the assessment had the date it originated as 11/02/25, when it was not noted until 11/09/25. She reported they have been having issues with the floor nurses entering the proper information on the wound assessments when it was first entered into the computer. She acknowledged the resident's medical record should accurately reflect the status of the resident's wounds, it's location, and when they originated. This deficiency represents non-compliance investigated under Complaint Number 2684375. Event ID: Facility ID: 365344 If continuation sheet Page 2 of 4 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 365344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luxe Rehabilitation and Care Center 957 Becks Knob Road Lancaster, OH 43130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and policy review, the facility failed to ensure appropriate personal protective equipment (PPE) was worn during tracheostomy care of a resident in enhanced barrier precautions (EBP's) for a medically invasive device. They also failed to ensure staff performing tracheostomy care and treatment of a peg tube site performed proper hand hygiene, after removing disposable gloves, and before touching environmental surfaces in the resident's room. This affected one (#58) of one resident reviewed for tracheostomy care. Findings include: Review of Resident #58's medical record revealed he was admitted to the facility on [DATE]. He had diagnoses that included acute and chronic respiratory failure, tracheostomy (an artificial airway established by surgically placing a plastic tube through the front of the neck) status, and gastrostomy (surgical placement of a tube through the abdomen and into the stomach for the administration of a liquid nutritional supplement for feeding purposes) status. Review of Resident #58's physician's orders revealed the resident had an order in place for tracheostomy care to be provided every shift and as needed (prn). He also had an order to cleanse his peg tube site with normal saline, pat dry, and apply a split gauze every shift and was receiving treatment to venous ulcers of his left inner and outer ankle. On 12/30/25 at 2:16 P.M., a treatment observation was completed for Resident #58's tracheostomy care and the treatment of his peg tube site. The treatment was provided by Licensed Practical Nurse (LPN) #170 and she was assisted by Registered Nurse (RN) #194. LPN #170 was the unit manager and RN #194 was the nurse assigned to work the floor on that date. Resident #58's door to his room was noted to have a sign that identified him as being on EBP's. There was PPE hanging on the outside of the door for the staff to use when providing care to the resident. Neither of the two nurses donned any PPE before entering the room or when performing tracheostomy care/ treatment of the peg tube site. Both nurses were next to the resident's bed as they performed tracheostomy care and the resident was noted to be coughing during the procedure to include suctioning of the resident during three separate attempts. The resident was also observed coughing with the removal of his inner cannula. After removing the resident's inner cannula, LPN #170 realized that she did not have the proper size of the inner cannula she had to re-insert into his tracheostomy. She was observed to remove her gloves, without performing hand hygiene, and was noted to rummage through a box in the room that contained the resident's extra respiratory supplies to locate the inner cannula of the proper size. She was not able to locate the proper size inner cannula in the resident's room. RN #194 was noted to remove the old split gauze dressing from around the resident's peg tune site to allow the surveyor to observe the stoma and skin around the peg tube's insertion site. She disposed of the old split gauze dressing and was asked by LPN #170 to leave the resident's room to retrieve the proper sized inner cannula needed to complete the tracheostomy care. RN #194 was observed to remove her disposable gloves she had on when removing the old split gauze dressing, without performing hand hygiene, and before leaving the resident's room. It was not until RN #194 returned to the resident's room, that both nurses performed hand hygiene by washing hands with soap and water before donning gloves to resume insertion of the inner cannula. On 12/30/25 at 2:29 P.M., an interview with LPN #170 confirmed that she and RN #194 did not don any additional PPE when they entered the room of Resident #58 to perform tracheostomy care to the resident, despite it being known that the resident was in EBP's. She confirmed the resident had a sign on the outside of his door identifying him as being on EBP's and he also had PPE hanging on the outside of his door. She stated they should have donned a gown, gloves, mask, and face shield when performing tracheostomy care to the resident since they were up against the side of his bed and was performing a procedure that promoted him to Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365344 If continuation sheet Page 3 of 4 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 365344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luxe Rehabilitation and Care Center 957 Becks Knob Road Lancaster, OH 43130 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete cough while they were in close proximity. She also confirmed that she did not perform hand hygiene, after she removed her gloves, and when searching his room for the proper size of the inner cannula she needed to complete his tracheostomy care. She acknowledged removing gloves did not negate the need to perform hand hygiene before touching other environmental surfaces or supplies in the resident's room. On 12/30/25 at 2:37 P.M., an interview with RN #194 confirmed she did not perform hand hygiene, after she removed her disposable gloves, following her handling Resident #58's split gauze dressing, and before she left the room to obtain the proper size of the inner cannula LPN #170 needed to complete his tracheostomy care. She acknowledged the removal of disposable gloves did not negate the need to perform hand hygiene before coming in contact with environmental surfaces with her potentially contaminated hands. She further acknowledged the nurses should have donned additional PPE, other than just gloves, when providing care to the resident, since he was on EBP's. Review of the facility's policy on EBP's dated July 2024 revealed the facility would implement EBP's for eligible residents to reduce multi-drug resistant organisms (MDRO's) spread. EBP required gown and gloves for specified high- contact care activities and hand hygiene at all times. Residents that required EBP's included those with indwelling medical devices and/ or chronic wounds. The staff were instructed to don gown and gloves before high-contact care. Review of the facility's hand hygiene policy dated October 2024 revealed the facility considered hand hygiene the primary means to prevent the spread of infections. All personnel should be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel should follow the handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use of an alcohol-based hand rub or soap and water should occur before and after handling an invasive device. It should also occur after removing gloves. The use of gloves does not replace hand washing/ hand hygiene. Integration of glove use along with routine hand hygiene was recognized as the best practice for preventing healthcare-associated infections. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 2684375. Event ID: Facility ID: 365344 If continuation sheet Page 4 of 4