Inspection·September 1, 2018

F 0558 Level of Harm - Minimal harm or potential for actual harm Telephone interview on 08/30/18 at 9:38 A.M. with Physical Therapist (PT) #607 explained it was normal progression for someone that can stand well, but not pivot to use the sit to stand to build up the tolerance (like Resident #31). He stated the resident can stand well from a static (sitting) position. He stated about two weeks PT #607 wanted to use the stand (for Resident #31) and the cord was missing, and it was not functional. He explained the resident could be picked back up for therapy if the lift was functional. Residents Affected - Few Interview on 08/30/18 at 9:46 A.M. with the Administrator stated she was not aware that a cord for the sit to stand lift had not been ordered, and a resident was waiting on that to re-attempt therapy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 2 of 22 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 365368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestown Place Health and Rehab 4960 US 35 East Jamestown, OH 45335 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 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident accounts, staff interviews and reviews of facility policy and procedures, the facility failed to disburse Resident #41's personal fund account balance to the probate jurisdiction administering Resident #41's estate within 30 days of her death. This affected one (#41) out of six resident accounts reviewed. Facilty census was 37. Residents Affected - Few Findings include: Review of the resident's personal funds account on [DATE] at 10:51 A.M. with the Business Office Manager #14 revealed Resident #41 expired on [DATE]. Resident #41's personal account balance was $9.07 and as per regulatory guidelines has not been sent to the resident's estate. The Business Office Manager #14 explained the administrator had not issued a check in the amount of $9.07 to release the funds to the funeral home and close the expired resident's account. On [DATE] at 10:58 A.M. interview with the Administrator confirmed a check in the amount of $9.07 has not been issued to close the personal funds account of Resident #41. Review of the Patient Trust Fund Estate Refund Notices policy and procedure revealed: If there is no Will to be probated, but an estate is to be opened with an Administrator appointed, the Business Office Manager will process and print a copy of the resident's Personal Trust Account within ten (10) days of the date of death . The copy of the ledger will be mailed to the Administrator of the deceased estate. The refund will be made payable to the Estate of the deceased c/o the Administrator within 30 days of the date of death . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 3 of 22 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 365368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestown Place Health and Rehab 4960 US 35 East Jamestown, OH 45335 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and resident, family, and staff interview, the facility failed to ensure a window that was boarded up was timely fixed. This affected one (#31) of all resident rooms observed during initial tour. Facility census was 37. Findings included: Review of the medical record revealed Resident #31 was admitted on [DATE] with diagnosis that included major depression, diabetes, chronic kidney disease, and unspecified psychosis. Review of Minimum Data Set (MDS) dated [DATE] included the resident was moderately cognitively impaired and required extensive assistant or was dependent for staff assistance for all activities of daily living (except eating). Interview and observation on 08/27/18 at 1:54 P.M. with Resident #31 and family member #1 explained when the air conditioner was installed, the facility did not replace plexi-glass above it. Family member #1 stated, I think it is an eye sore and makes it dark. Resident #31 stated, I would like to be able to see out the Window. Observations on 08/28/18 at 10:52 A.M. and at 1:57 P.M. Res # 31's room remains with wood up in the window. Interview on 08/28/18 at 2:46 P.M. with Maintenance Director (MD) #130 confirmed there was wood in Resident #31's right window. MD #130 explained that the resident, still has one window (on the left). She explained the resident wanted an air conditioner, but no one makes air conditioners for roll out windows. There are no air conditioning units in the resident rooms, only the halls are air conditioned, she explained. The Air Conditioning unit with the wood piece to secure, and the boarded window would have been installed in May 2018. Observed directly after, with DM #130 revealed empty resident room [ROOM NUMBER] which had two windows, on the right window there was a piece of wood right above the air conditioner, and then a clear plexi-glass above it. DM #130 stated at this time there was no plan to replace the wood in Resident #31's boarded window, but the facility could discuss it. She confirmed other residents have the Air Conditioner units, but none of them have the second window boarded up above the unit (like Resident #31). MD #130 confirmed she would not leave a window at her house boarded up. Observation on 08/28/18 at 2:56 P.M. revealed unoccupied resident room [ROOM NUMBER] wood was measured at approximately four inches by 19 inches (above air conditioner to secure), and plexi-glass was three foot three inches by 19 inches (above the smaller wood piece). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 4 of 22 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 365368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestown Place Health and Rehab 4960 US 35 East Jamestown, OH 45335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and staff interviews, the facility failed to ensure a resident was free from a physically restraining device when the facility utilized a merry walker (enclosed rolling walker/ambulation device) without an assessment and adequate indication of use. This affected one (#30) out of one reviewed for restraints. The facility identified they had no residents who were physically restrained. The facility census was 37. Residents Affected - Few Findings include: Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include dementia without behavioral disturbances, heart failure, hypertension, peripheral vascular disease, muscle weakness, atrial fibrillation, anxiety, lack of coordination, cognitive communication deficit, hyperlipidemia, depression, atherosclerotic heart disease, gastroesophageal reflux disease, acute kidney failure, cardiac pacemaker, and difficult ambulation. Review of Resident #30's most recent Minimum Data Set, dated [DATE] revealed a brief interview for mental status (BIMS) was not able to be assessed as the resident is alert, but is rarely/never understood, indicating severe cognitive impairment. Further review of the MDS revealed the resident requires extensive assistance of one staff member for transfers and limited assistance of one staff member for walking in room and corridor. The MDS identified no restraints were being used. Review of Resident #30's care plan revealed a care plan dated 06/20/18 regarding the resident being at risk for falls and accidents. The care plan included measurable goals and included an intervention that instructed staff that the resident utilized a merry walker and the resident is to be in a common area at all times. Further record review revealed the care plan regarding the use of the merry walker; however, there was no assessments in the medical record regarding the use of a merry walker. Review of the physician orders revealed an order was obtained on 07/10/18 to use of the merry walker for ambulation. Review of Fall Risk assessment dated [DATE] revealed Resident #30 scored an eight on the assessment, indicating the resident is at risk for falls. On 08/28/18 at 1:18 P.M., observation of Resident #30 revealed that she ambulates throughout the facility with the use of a merry walker. The resident observed attempting to open several closed doors on this observation with no success. Resident observed to have staff oversight at the time of this observation and no falls were noted. This resident is unable to release the latch to open this walker on observation. On 08/30/18 at 12:18 P.M., an interview with the Director of Nursing (DON) verified Resident #30 had not been assessed for the use of restraints, and that this device was considered an enabler. The DON stated that the resident can sometimes open the latch for the walker, but not all the time. On 08/30/18 at 3:13 PM an interview with the DON verified Resident #30 does not have a completed assessment for the use of the merry walker. The DON also verified that the facility does not have an active policy on the use of a merry walker. The DON stated that she placed a call to the Corporate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 5 of 22 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 365368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestown Place Health and Rehab 4960 US 35 East Jamestown, OH 45335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 Level of Harm - Minimal harm or potential for actual harm Nurse and they do not have a policy on the use of a merry walker, as it is being used as an enabler and not a restraint. The DON stated that the resident has been in the merry walker for a long time now, and when asked if the resident can open it on her own, the DON stated that sometimes she can. The DON stated that she cannot remember when the resident was placed in the merry walker originally. The DON verified that the resident had been using the merry walker prior to the physician order on 07/10/18. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 6 of 22 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 365368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestown Place Health and Rehab 4960 US 35 East Jamestown, OH 45335 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the maintenance log, observations, resident, staff, and family interview, and review of the care planning policy, the facility failed to ensure a resident had a timely care planning meeting and the resident was included in decisions regarding the use/non-use of his side rails. This affected one (#31) of one reviewed for care planning. Facility census was 37. Findings included: 1. Review of the medical record revealed Resident #31 was admitted on [DATE] with diagnosis that included major depression, diabetes, chronic kidney disease, and unspecified psychosis. Review of Minimum Data Set (MDS) dated [DATE] included the resident was moderately cognitively impaired and required extensive assistant or was dependent for staff assistance for all activities of daily living (except eating). Interview on 08/27/18 at 2:04 P.M. with Resident #31 and family member #1 both indicated they had not been invited to nor participated in a care planning meeting for Resident #31. Interview on 08/29/18 at 3:34 P.M. Social Service Designee (SSD) #142 was unable to find care planning meeting information in the binder. SSD #142 stated she did not have any further documentation in the facility or in the resident's medical record that was indicate the resident had a meeting. SSD#142 could not recall a meeting for Resident #31. 2. Review of current falls care plan dated 04/12/17 for Resident #31 interventions included top ½ (half) side rails up to assist with bed mobility and involved resident and/or responsible party in treatment plan. Update as needed regarding changes in treatment/condition. Review of Maintenance log included on 04/16/18 included bed side rails were tied strapped bed railing down on all units. Review of Maintenance log on 06/04/18 included bed rails were removed in multiple resident rooms. Interview and observation on 08/27/18 at 1:54 P.M. with Resident #31 and family member #1, they explained the resident's side rails on the bed were tied down. They pointed to the ties and the area was observed. Resident #31 stated he would feel safer if he has the side rails up on his bed during patient care. Family member #1 indicated Resident #31 felt scared without them. Both explained there were no discussion regarding the removal of the use of the side rails. Interview with the Director of Nursing (DON) on 08/29/18 at 5:17 P.M. confirmed Resident #31 was alright with trialing the side rails removal. She stated Resident #31 did not like the trial though. She confirmed the facility rushed through the documentation and confirmed there was no indication the resident was involved with the decision or there was any follow up to determine if the resident should/should not have use of the side rail. She explained Resident #31 cannot physically move himself, but he can put his hand on the side rails if staff were turning him. The DON explained Resident #31 required two-person assist. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 7 of 22 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 365368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestown Place Health and Rehab 4960 US 35 East Jamestown, OH 45335 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 08/28/18 at 2:30 P.M. with State Tested Nursing Assistant (STNA) #136 confirmed the side rails were tied down on Resident #31's bed. STNA #136 stated Resident #31 would not be able to put the side rails up and down. She explained Resident #31 was completely dependent for care. She stated Resident #31 is able to put his hands on the rails (during care), but he is not able to help The staff have to push him with their full body weight. STNA #136 stated if Resident #31 had a fear of falling the staff were on both sides of him. When asked STNA #136 was if Resident #31 is fearful while they give care, she stated he gets jerky and the staff reassure him. She explained when the rails were up, it was more of a leverage to get him over. STNA #136 stated, I know Resident #31 does not like the rails being tied down. STNA #136 confirmed that the resident may feel reassured if there was a grab bar there. Review of Care Plan Review policy dated 02/2016 included all residents will receive a review of the Plan of Care by the Interdisciplinary team at least quarterly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 8 of 22 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 365368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestown Place Health and Rehab 4960 US 35 East Jamestown, OH 45335 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure proper supervision during meals. This affected one (#30) of five residents the facility identified as needing assistance during meals who also ate in the dining room. Facility census was 37. Residents Affected - Few Findings Included: Record Review of Resident #30 revealed that the resident was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbances, heart failure, muscle weakness, atrial fibrillation, anxiety, lack of coordination, cognitive communication deficit, depression, and gastroesophageal reflux disease. This resident was alert but was rarely/never understood on the most recent MDS assessment completed on 07/24/18, indicating severe cognitive impairments. It was also noted the resident required limited assistance for meals. Review of care plan dated 05/25/18 indicated the resident typically consumes less than the required amount. Impaired Neurological care plan dated 06/14/18 indicated it was due to Resident #30 diagnosis of dementia and subdural hematoma. Interventions included to monitor activities of daily living and render care as needed. Impaired cognitive care plan dated 06/14/18 included intervention to promote Resident #30's dignity. Impaired vision care plan dated 07/04/18 included the resident had a diagnosis of glaucoma. Dining observation began on 08/27/18 at 11:01 A.M. by 11:20 A.M. side items and/or meals were being served. At 11:21 A.M. Resident #30 was using her fingers to eat salad with a white dressing, and continues and she starts using appropriate silverware at 11:23 A.M. By 11:26 A.M. Resident #30 resumed eating her salad with her hands. At 11:29 A.M. Spaghetti was served, and Resident #30 used her fingers to eat spaghetti for a few pieces and then began using her silverware. At 11:30 A.M. Resident #30 was using her hand to eat salad with white dressing, then picks up butter knife and was licking it. The white dressing dripped down her face. At 11:31 A.M. Resident #30 was using her hands to eat spaghetti then wipes mouth. At 11:35 A.M. Resident #30 was using knife like it was a fork trying to eat the salad continues until 11:37 A.M. when Resident #30 was using the knife to scoop/eat salad then used knife to eat spaghetti. By 11:38 A.M. the resident was using her fingers to eat spaghetti. By 11:39 A.M. Activities Director (AD) #450 (who was the only staff member in the dining room providing assistance) asked Resident #30 if she was ok, and prompts the resident to eat and moves the plate of spaghetti closer and gives her fork. The resident continued to use the fork thereafter as he salad bowl and knife were pushed out of sight. Resident #30 was eating at a faster rate once she was given her fork. At 11:48 A.M. Resident #30 was offered a peanut butter and jelly sandwich and had no trouble eating. Additional observation on 08/30/18 at 11:25 A.M. Resident #30 had a slice of buttered bread (butter side up) lying directing on the table. She is using a spoon to cut the bread and eat it. At 11:29 A.M. AD #450 asks Resident #30 if she is ok and Resident #30 says no. At 11:30 A.M. Resident #30 was trying to drink cranberry sauce out of the dessert bowl two times. At 11:34 A.M. Resident #30 was trying to use her hands to pick up cranberry sauce and unsuccessful drops on clothing protector and she starts eating it off the clothing protector. At 11:38 Resident #30 was using her fingers to eat chunked pineapple. At 11:39 A.M. Resident #30 was eating cranberry sauce off of the table with her hands, and tried to eat more off of the clothing protector. At 11:40 A.M. continued to eat cranberry (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 9 of 22 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 365368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestown Place Health and Rehab 4960 US 35 East Jamestown, OH 45335 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sauce off of the table. At 11:46 A.M. Resident #30 attempts three times with her spoon to get chunked pineapple out of the dessert bowl. Each time putting the spoon in the bowl getting nothing and putting it to her mouth and taking a bite. Interview with observation at 11:50 A.M. with AD #450 confirmed Resident #30 was using her hands to eat. She explained she will be redirected and use silverware most of the time depending on the day. At 11:50 A.M. AD #450 asks Resident #30 if she wants some help and starts to feed Resident #30. By 11:55 A.M. Resident #30 had finished the entire bowl of pineapples with staff assistance. There were 14 residents, one family member, and one staff (AD #450). Interview on 08/30/18 at 12:57 P.M. with AD #450 explained she was the only person in the dining room at lunch, and also for dinner, however sometimes the nurses come in. She explained it was hard to effectively help and assist all of the residents. She confirmed at least four residents needed prompted and/or assisted. AD #450 confirmed Resident #30 will use a knife inappropriately and eats inappropriate items using her fingers. AD #450 explained typically there are fourteen up to sixteen residents eating in the dining room depending on which residents come to the dining room. Interview on 08/30/18 at 2:16 P.M. with the Director of Nursing (DON) confirmed Resident #22, #8, #30, #26, and #11, all need prompting and the last four need to be fed at times. The DON stated she was not aware that Resident #30 needed the additional assistance with eating. When asked if the DON thought one staff was enough to care for all of the residents who need assistance, the DON stated she did not think they all needed assistance at one time. The DON confirmed Resident #30 should be prompted to use silverware appropriately while eating to promote dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 10 of 22 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 365368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestown Place Health and Rehab 4960 US 35 East Jamestown, OH 45335 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, and review of the Activity Director job description, the facility failed to ensure a resident (#28) was thoroughly assessed for activities and was provided an increased amount of activities as recommended. This affected one resident (#28) of one reviewed for activities. Facility census was 37. Residents Affected - Few Findings Included: Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnosis that included intellectual disability, obsessive compulsive disorder, depression and dementia. Review of all care plans provided did not include a specific activity care plan. A care plan (not dated) indicated the resident had behaviors which include shouting, name calling, calling people on the phone repeatedly, insists on having meetings and ordering things, getting angry with staff, going in other resident rooms when they don't want him to. Intervention included attempt interventions before the behaviors begin. Encourage the resident to participate in activities he likes games, crafts, and drawing. Review of provider progress notes included 03/08/18 and 06/07/18 Psychiatric Certified Nurse Practitioner (CNP) progress note which included the resident appears to be stable. Pleasant and talkable. Intrusive at times. Plan included would benefit from more activities and structure. Review of Activity Participation from 06/2018 to 08/2018 included the resident went out of the facility on one occasion, there no indications of physical games played in the last three months, and no indication of when a game of cards (like Uno) was offered or played. Review of quarterly activity assessment dated 07/2018 included the resident's mood and behavior patterns, memory, and communication needs. It listed the resident likes BINGO, socials, newspaper, church, and cleaning. The resident is an active participant in activities. There was no further indication of a comprehensive list of items the resident was asked regarding his preferences. It was noted, frequently bothers others, shuts the facility's curtains every night, frequently makes plans for things that cannot happen. Interview on 08/30/18 at 8:17 A.M. with Social Service Designee (SSD) #142 explained a few years ago the facility tried to get Resident #28 enrolled in a workshop, however $41 a day would have to be released daily from the facility from the resident's patient liability. The facility declined the offer. Telephone interview on 08/30/18 at 8:26 A.M. with local county board of intellectual disability representative #1 stated for Resident #28 as long as he has Medicaid funding it would be duplication of services for the resident to received skilled services at the nursing home, and receive services at workshop. Our understanding is the resident is living at a facility who is supplying him with care and act that he is having his day fulfilled. We don't typically provide services for folks in the nursing home because they have an activity director and social services. Interview with the Resident #28 on 08/30/18 at 10:40 A.M. revealed he likes to go out of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 11 of 22 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 365368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestown Place Health and Rehab 4960 US 35 East Jamestown, OH 45335 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility to eat (specifically a privately-owned restaurant in a neighboring town), he likes to play Uno (cards), likes to play soccer and likes to play with balloons (resident was seen juggling three balloons on 08/29/18). On 08/30/18 at 11:13 A.M. Resident #28 came into the conference room and asked to go to the Flea Market. At 11:34 A.M. Resident #28 requested snacks from the surveyors. At 1:15 P.M. Resident #28 wanted a raise for one of the staff. At 2:40 P.M. the resident interrupts surveyor and Administrative staff completing paperwork. At 2:48 P.M. Resident #28 notified surveyors about concerns he has regarding an unknown person. Interview on 08/30/18 at 1:10 P.M. with Activity Director (AD) #450 confirmed Resident #28's activity schedule does not indicate refusals or when he is invited and does not attend. Confirmed the activity assessment was not comprehensive and does not have the original. AD #450 explained the resident likes to set up BINGO, shut curtains and the resident is always asking for jobs. AD #450 confirmed Resident #28 has not been out of the facility for the past few months, except in August a family member who came in from Texas and took him out. AD #450 confirmed Resident #28 likes to leave the facility. AD #450 explained the last time we went out was in April and he did go on that trip, we took him to Walmart shopping. AD #450 was aware Certified Nurse Practitioner noted for involvement in more activities. AD #450 explained more items Resident #28 liked to do and confirmed the assessment available was not a comprehensive list. She confirmed she is unable to indicate how she has attempted to increase activities since the recommendation was made. Review of Activity Director's job description dated 02/05/18 included the AD is responsible to develop organize and implement a program of activities to meet the social, emotional, physical and other therapeutic needs of residents as identified on the residents' plan of care. Initiate and promote activities both within the facility and outside the facility. Consistently maintain standards for activity scheduling and documentation established by polices and regulatory requirements. Solicit the involvement of the community. Maintain detailed records of activity programs and participation of individual residents. Participate in resident care planning by identifying the activity needs of residents in accordance with the medical assessment. Maintain all activity related records required by regulations and Medical records including activity assessments and progress notes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 12 of 22 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 365368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestown Place Health and Rehab 4960 US 35 East Jamestown, OH 45335 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff, resident and family interview, the facility failed to ensure a prescription for new eyeglasses was filled timely. This affected one resident (#31) of one reviewed for vision. Facility census was 37. Residents Affected - Few Findings included: Review of the medical record revealed Resident #31 was admitted on [DATE] with diagnosis that included major depression, diabetes, chronic kidney disease, and unspecified psychosis. Review of impaired vision care plan dated 07/03/18 included the resident has impaired vision related to degenerative changes. Inability to see small print. Interventions included vision exam as needed. Review of Minimum Data Set (MDS) dated [DATE] included the resident was moderately cognitively impaired and required extensive assistant or was dependent for staff assistance for all activities of daily living (except eating). Review of nursing note dated 10/27/17 01:20 P.M. included Resident #31 was out to eye doctor by stretcher via transportation services escorted by spouse. Review of nursing note dated 04/17/18 at 10:01 A.M. included Social Services Designee (SSD) #142 was trying to get Resident #31 new glasses, the resident was seen by the eye doctor, but his insurance would not cover and that was resolved. He was to be fitted recently and the physician had a car accident & that has been postponed, will get that rescheduled soon. Review of nursing note dated 07/03/18 at 2:07 P.M. included SSD #142 has been working on getting his new glasses. Optical was to be here to fit him for new glasses but had a car accident on the way here and had to reschedule. SSD #142 to follow up on when they will be here again. On 08/27/18 at 2:06 P.M. an interview with Resident #31 and family member #1 was conducted. Family member #1 stated, They sent him to get his eyes tested. When I went to get his prescription filled they did not take his insurance. Family member #1 explained this was a year ago in November/December (2017). He has to be retested for his glasses now and I am not happy. Resident #31 stated, I would wear glasses if I got them. I am about blind, and I have glasses that are not effective. Interview on 08/29/18 at 3:28 P.M. with SSD #142 revealed our contracted eye physician saw Resident #31 and there was a problem with the script and insurance was not covering the glasses. Now they want to get another eye exam and Resident #31 was not eligible to be seen again until August 2018, they think the prescription was too old. SSD #142 was trying to find an optical place to take his insurance. He would have to go by stretcher and SSD #142 could not find anyone to take him and the family would not. The contracted physician promised they would fill his prescription, but it was too old. SSD #142 stated it was last seen in August of last year (2017), and contracted eye physician won't come see any residents until they have several to see. SSD #142 was not able to indicate when the eye physician would be in to visit Resident #31 and/or the new prescription could be filled. Review of Ophthalmic Services care plan dated 02/2016 included ophthalmic services will be provided (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 13 of 22 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 365368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestown Place Health and Rehab 4960 US 35 East Jamestown, OH 45335 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 0685 Level of Harm - Minimal harm or potential for actual harm to all residents as needed and it is the charge nurse and social services responsibility. After the resident returns from the appointment review the recommendations and communicate as needed with the attending physician. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 14 of 22 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 365368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestown Place Health and Rehab 4960 US 35 East Jamestown, OH 45335 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and staff interview, the facility failed to ensure a resident was supervised according to a fall risk care plan while utilizing a merry walker (enclosed rolling walker/ambulation device). This resulted in Actual Harm when Resident #30 was utilizing a merry walker in an unsupervised area, the resident experienced an avoidable fall and was subsequently hospitalized for the treatment of a traumatic subdural hematoma. This affected one (#30) out of two residents reviewed for falls. Facility census was 37. Findings include: Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include dementia without behavioral disturbances, heart failure, hypertension, peripheral vascular disease, muscle weakness, atrial fibrillation, anxiety, lack of coordination, cognitive communication deficit, hyperlipidemia, depression, atherosclerotic heart disease, gastroesophageal reflux disease, acute kidney failure, cardiac pacemaker, and difficult ambulation. Review of Resident #30's most recent Minimum Data Set, dated [DATE] revealed a brief interview for mental status (BIMS) was not able to be assessed as the resident is alert, but is rarely/never understood, indicating severe cognitive impairment. Further review of the MDS revealed the resident requires extensive assistance of one staff member for transfers and limited assistance of one staff member for walking in room and corridor. Review of Resident #30's care plan revealed a care plan dated 06/20/18 regarding the resident being at risk for falls and accidents. The care plan included measurable goals and included an intervention that instructed staff that the resident utilized a merry walker and the resident is to be in a common area at all times. Further record review revealed the care plan regarding the use of the merry walker; however, there was no assessments in the medical record regarding the use of a merry walker. Review of the physician orders revealed an order was obtained on 07/10/18 to use of the merry walker for ambulation. Review of Fall Risk assessment dated [DATE] revealed Resident #30 scored an eight on the assessment, indicating the resident is at risk for falls. Further review of fall investigation dated 06/22/18, revealed Resident #30 was ambulating per self with a merry walker to the dining room. As the resident was ambulating herself, the wheels to her walker became stuck on a raised floor strip at the entrance of the dining room. This caused the walker to tip over, as the resident continued pushing the walker. The resident sustained a laceration to her left eyebrow area, and she was transported to the hospital for evaluation and treatment. Review of hospital medical records dated 06/22/18 revealed this resident was admitted to the hospital on [DATE]. The resident was diagnosed with a subdural hematoma and was then transported to a higher level trauma hospital. The resident was discharged and returned to the facility on [DATE]. No further falls were noted on her record. On 08/28/18 at 1:18 P.M., observation of Resident #30 revealed that she ambulates throughout the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 15 of 22 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 365368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestown Place Health and Rehab 4960 US 35 East Jamestown, OH 45335 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 - Actual harm Residents Affected - Few facility with the use of a merry walker. The resident was observed attempting to open several closed doors on this observation with no success. Resident #30 was observed to have staff oversight at the time of this observation and no falls were noted. Care plan interventions were in place. On 08/29/18 at 1:44 P.M., observation of Resident #30 revealed that this resident is ambulating with the use of her merry walker at this time. No obstacles were observed. No observations of the resident attempting to open closed doors. Resident is ambulating in the hallways of the facility, and is not currently in the commons area of the building. On 08/30/18 12:18 P.M., interview with the Director of Nursing (DON) revealed that the doors to the dining room were closed on the evening of 06/22/18 at 7:00 P.M. She stated Resident #30 was pushing her merry walker while trying to push the doors to the dining room open. A floor strip was pulled up in one place at that time, and the resident got caught on that strip and fell forward. She stated that no one was with the resident at the time of the fall, and the nurse was at the nursing station when she heard the fall happen. The nurse responded to the resident fall, and assessed the resident for injuries, at which time the resident was found with a laceration to her left eyebrow. The DON stated the resident was send to the hospital and diagnosed with a traumatic subdural hematoma. The resident returned to the facility on [DATE]. The DON stated the resident has not had any falls prior to, or after this incident. The DON stated that the resident was unattended at the time of the fall. The DON verified that this resident is care planned to be in the commons area of the building at all times while in her merry walker. On 08/30/18 at 12:20 P.M., observation of Resident #30 revealed this resident is currently ambulating with the use of her merry walker in the hallway leading to her room. Facility staff were present for oversight. On 08/30/18 at 12:28 P.M. interview with Maintenance Director #130 revealed that all flooring and threshold strips are inspected daily for any problem areas including raised areas of the strips. Maintenance Director #130 stated that the Resident #30 was attempting to open the doors to the dining room, as she had pulled the door open towards her as this door is a one-way door. She stated that the resident had gotten the door open and was attempting to move through the doorway when the wheels on her merry walker got stuck on the floor strip. She stated that as far as she knew, the resident was by herself at the time of this fall. On 08/30/18 at 1:31 P.M. an interview with Licensed Practical Nurse (LPN) #526 confirmed Resident #30 required increased supervision while using the merry walker. She stated she would go through doors while in the merry walker. She stated the resident was up around the nurses station the last time she saw her. The resident is constantly bumping into things such as medication carts and other items. She said usually the dining room door remains open unless there is an activity. She verified that she did not witness the fall. The resident had a history of walking in the direction of the dining room. LPN #526 confirmed the strip did not lift up but stated it was thicker than the one that is there now. LPN #526 described it as a silver strip and they replaced it with gold. She explained the resident would not be aware due to her cognition that her pushing through and over the strip was an unsafe act, she would not know to turn around. LPN #526 stated she feels the wheel on the merry walker separated the the device when she fell. She broke the merry walker going over the strip and lost her balance and fell. On 08/30/18 at 2:41 P.M., an interview with Maintenance Director #130 revealed the metal strip was replaced on 06/22/18, and it was the same type as was previously installed there. She also verified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 16 of 22 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 365368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestown Place Health and Rehab 4960 US 35 East Jamestown, OH 45335 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 the merry walker was broken at the time of the fall, and was repaired with a screw to hold the piping together. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 08/30/18 at 3:13 P.M. an interview with the DON verified Resident #30 does not have a completed assessment for the use of the merry walker. The DON also verified that the facility does not have an active policy on the use of a merry walker. The DON stated that she placed a call to the Corporate Nurse and they do not have a policy on the use of a merry walker, as it is being used as an enabler and not a restraint. The DON stated Resident #30 has utilized a merry walker for a long time now, and when asked if the resident can open it on her own, the DON stated that sometimes she can. The DON stated that she cannot remember when the resident started utilizing a merry walker originally. The DON confirmed they should be assessing the resident for the use of the merry walker. The DON further verified Resident #30 was not supervised by facility staff on 06/22/18, which contributed to her fall and subsequent injury. Event ID: Facility ID: 365368 If continuation sheet Page 17 of 22 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 365368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestown Place Health and Rehab 4960 US 35 East Jamestown, OH 45335 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure an order to apply oxygen as needed was monitored and/or implemented as needed. This affected one (#22) of one resident reviewed for respiratory care. Facility census was 37. Residents Affected - Few Findings Included: Review of the medical record revealed Resident #22 was admitted on [DATE] with diagnosis that included persistent atrial fibrillation, and hydrocephalus. Review of physician order dated 04/18/17 included to apply oxygen as needed for oxygen saturation levels less than 90%. Also noted on monthly orders dated 08/2018. Review of care plan dated 04/03/18 included the resident was at risk for altered cardiac output and has the potential for impaired gas exchanged related to high blood pressure, shortness of breath and persistent atrial fibrillation. Interventions included to monitor vital signs as ordered. Review of Minimum Data Set, dated [DATE] included the resident was severely cognitively impaired and requested extensive assistance or was dependent for all activities of daily living. Review of Medication Administration Record for August 2018 revealed the order as written, however there was no indication that the resident's oxygen saturation level was checked to determine if administration was needed. Interview on 08/28/18 at 11:58 A.M. with Registered Nurse (RN) #238 and review of the MAR revealed RN #238 confirmed the facility does not take the resident's oxygen saturation level on a routine basis. RN # 238 explained that they would take it if she is symptomatic. RN #238 confirmed that it was not always possible to tell a person's oxygen saturation level by looking at them. She was unable to explain how they were implementing the order as written. She confirmed they should be taking Resident #22's oxygen saturation level on a routine basis. Interview on 08/28/18 at 12:05 P.M. with the Director of Nursing (DON) confirmed the order to check Resident #22's oxygen level and apply oxygen as needed should be implemented. The DON explained when the last company took over, they had the ancillary orders removed to clean up the MAR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 18 of 22 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 365368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestown Place Health and Rehab 4960 US 35 East Jamestown, OH 45335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on review of the facility menu, observation and staff and confidential resident interview, the facility failed to ensure staff followed a prepared menu. This had the potential to affect all 37 residents residing in the facility. Facility census was 37. Findings included: Review of the menu for the week included Spaghetti and meat sauce for 08/29/18 with broccoli. Confidential interviews on 08/27/18 with two residents indicated they had concerns regarding the quality of the food. Observation on 08/29/18 at 9:57 A.M. revealed the Goulash appeared dry and the temperature was taken, and it was above the appropriate temperature. An interview with conducted right after with [NAME] #241. [NAME] #241 was asked if she used a recipe for the goulash and she stated, DM (Dietary Manager) #340 just tells us what to put in. At 10:36 A.M. DM #240 explained she had no recipe for the goulash, as the vegetable lasagna had not come in. She explained on 08/27/18 she served spaghetti with meat sauce because the lasagna was not in, but she was going to serve it on 08/29/18 . However, the lasagna never came in. [NAME] #241 began plating meals for staff, then residents thereafter. At 11:25 A.M. [NAME] #241 put the first pan of goulash (previously being used to serve the dining room and some resident rooms) and switched it for another pan that had been in the oven. At 11:43 A.M. DM #340 was interviewed about residents having concerns with the meals. She explained it was hard to please everyone. She stated they had a lot of trouble with the a certain resident. She stated the resident demanded to use specific items (specific store) honey peanut butter for example. She stated the resident had strawberry bread but the facility could never toast it quite right. At 11:45 A.M. the test tray was plated and by 11:48 A.M. had left the kitchen. By 11:57 A.M. the cart was delivered to the last hallway and at 12:25 P.M. the test tray was delivered. The temperature of the items was appropriate. However, the goulash was mushy and bland, and the breadstick was doughy confirmed with DM #340. Dietician #706 joined the observation/interview. She stated she was not aware of the goulash recipe and her and DM #340 had not discussed it prior to meal service. DM #340 explained she made the meal like spaghetti but substituted V8 juice for the sauce. Two confidential Resident interviews directly after included one resident stated he could tell the goulash was made without sauce as it had not much flavor and another resident explained the goulash was bland without taste. Observation with interview on 08/29/18 at 4:05 P.M. with Dietary Manager (DM) #340 confirmed she had no recipe available for Goulash, she had just pulled (prior to the interview) two off of internet American she said that was like Spaghetti, and Cincinnati Goulash which calls for Catsup. She stated DM #340 and the Dietician are going to come up with a recipe. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 19 of 22 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 365368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestown Place Health and Rehab 4960 US 35 East Jamestown, OH 45335 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 review of the facility menu, observation and staff and confidential resident interview, the the facility failed to ensure food served was palatable. This had the potential to affect all 37 residents residing in the facility. Facility census was 37. Residents Affected - Many Findings included: Review of the menu for the week included Spaghetti and meat sauce for 08/29/18 with broccoli. Confidential interviews on 08/27/18 with two residents indicated they had concerns regarding the quality of the food. Observation on 08/29/18 at 9:57 A.M. revealed the Goulash appeared dry and the temperature was taken, and it was above the appropriate temperature. An interview with conducted right after with [NAME] #241. [NAME] #241 was asked if she used a recipe for the goulash and she stated, DM (Dietary Manager) #340 just tells us what to put in. At 10:36 A.M. DM #240 explained she had no recipe for the goulash, as the vegetable lasagna had not come in. She explained on 08/27/18 she served spaghetti with meat sauce because the lasagna was not in, but she was going to serve it on 08/29/18 . However, the lasagna never came in. [NAME] #241 began plating meals for staff, then residents thereafter. At 11:25 A.M. [NAME] #241 put the first pan of goulash (previously being used to serve the dining room and some resident rooms) and switched it for another pan that had been in the oven. At 11:43 A.M. DM #340 was interviewed about residents having concerns with the meals. She explained it was hard to please everyone. She stated they had a lot of trouble with the a certain resident. She stated the resident demanded to use specific items (specific store) honey peanut butter for example. She stated the resident had strawberry bread but the facility could never toast it quite right. At 11:45 A.M. the test tray was plated and by 11:48 A.M. had left the kitchen. By 11:57 A.M. the cart was delivered to the last hallway and at 12:25 P.M. the test tray was delivered. The temperature of the items was appropriate. However, the goulash was mushy and bland, and the breadstick was doughy confirmed with DM #340. Dietician #706 joined the observation/interview. She stated she was not aware of the goulash recipe and her and DM #340 had not discussed it prior to meal service. DM #340 explained she made the meal like spaghetti but substituted V8 juice for the sauce. Two confidential Resident interviews directly after included one resident stated he could tell the goulash was made without sauce as it had not much flavor and another resident explained the goulash was bland without taste. Observation with interview on 08/29/18 at 4:05 P.M. with Dietary Manager (DM) #340 confirmed she had no recipe available for Goulash, she had just pulled (prior to the interview) two off of internet American she said that was like Spaghetti, and Cincinnati Goulash which calls for Catsup. She stated DM #340 and the Dietician are going to come up with a recipe. This deficiency substantiates Complaint Number OH00099554. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 20 of 22 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 365368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestown Place Health and Rehab 4960 US 35 East Jamestown, OH 45335 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 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, resident, and family interviews, the facility failed to ensure therapy was continued as indicated when a lift needed was non-functional. This affected one (#31) of two residents reviewed for limited range of motion. Facility census was 37. Residents Affected - Few Findings included: Review of the medical record revealed Resident #31 was admitted on [DATE] with diagnosis that included major depression, diabetes, chronic kidney disease, and unspecified psychosis. Review of Minimum Data Set (MDS) dated [DATE] included the resident was moderately cognitively impaired and required extensive assistant or was dependent for staff assistance for all activities of daily living (except eating). Review of Physical Therapy discharge summary noted start of care 06/19/18 and ended 08/13/18 included the resident required maximum assistance with standing tolerance of 1:15-1:30 at this time. Client does not transition to enable a pivot transfer and as such remains on a lift and has reached a plateau. Under Impact on Burden of Care/Daily life included possible re-attempt of Physical Therapy once sit to stand lift is functioning. Interview with Resident #31 and family member #1 on 08/27/18 at 2:09 P.M. explained the facility does not provide restorative, and they were not sure what was going on with Resident #31's therapy. They also expressed concerns they had heard regarding the mechanical lifts used to get Resident #31 in/out of bed. Interview on 08/30/18 at 8:50 A.M. with Occupational Therapist Assistant (OTA) #602 (acting therapy manager) explained Resident #31 was on caseload and he was able to tolerate standing for about a minute. She thought towards the end of therapy for Resident #31 they figured out the cord was missing to the sit to stand, because they wanted him to work on tolerating it more. OTA #602 thought the cord has been ordered the previous week by Maintenance Director (MD) #130. OTA #602 thought MD #130 was working on permission to get the battery. Interview on 08/30/18 at 8:57 A.M. with MD #130 stated she was notified the cord was missing on 08/27/18 for the sit to stand lift. She stated her corporate office had asked her what was needed and to create an inventory list. When she talked with therapy they explained they needed a cord. No one had previously notified MD #130 that the cord was needed it for a resident and that the therapy could possibly be resumed when the sit to stand was functional. Telephone Interview on 08/30/18 at 9:38 A.M. with Physical Therapist (PT) #607 explained it was normal progression for someone that can stand well, but not pivot to use the sit to stand to build up the tolerance (like Resident #31). He stated the resident can stand well from a static (sitting) position. He stated about two weeks PT #607 wanted to use the stand (for Resident #31) and the cord was missing, and it was not functional. He explained the resident could be picked back up for therapy if the lift was functional. Interview on 08/30/18 at 9:46 A.M. with the Administrator stated she was not aware that a cord for the sit to stand lift had not been ordered, and a resident was waiting on that to re-attempt therapy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 21 of 22 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 365368 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestown Place Health and Rehab 4960 US 35 East Jamestown, OH 45335 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a Sit to Stand lift was in proper working order. This affected one (#31) of two reviewed for limited range of motion. Facility census was 37. Residents Affected - Few Findings included: Review of the medical record revealed Resident #31 was admitted on [DATE] with diagnosis that included major depression, diabetes, chronic kidney disease, and unspecified psychosis. Review of Minimum Data Set (MDS) dated [DATE] included the resident was moderately cognitively impaired and required extensive assistant or was dependent for staff assistance for all activities of daily living (except eating). Review of Physical Therapy discharge summary noted start of care 06/19/18 and ended 08/13/18 included the resident required maximum assistance with standing tolerance of 1:15-1:30 at this time. Client does not transition to enable a pivot transfer and as such remains on a lift and has reached a plateau. Under Impact on Burden of Care/Daily life included possible re-attempt of Physical Therapy once sit to stand lift is functioning. Interview with Resident #31 and family member #1 on 08/27/18 at 2:09 P.M. explained the facility does not provide restorative, and they were not sure what was going on with Resident #31's therapy. They also expressed concerns they had heard regarding the mechanical lifts used to get Resident #31 in/out of bed. Interview on 08/30/18 at 8:50 A.M. with Occupational Therapist Assistant (OTA) #602 (acting therapy manager) explained Resident #31 was on caseload and he was able to tolerate standing for about a minute. She thought towards the end of therapy for Resident #31 they figured out the cord was missing to the sit to stand, because they wanted him to work on tolerating it more. OTA #602 thought the cord has been ordered the previous week by Maintenance Director (MD) #130. OTA #602 thought MD #130 was working on permission to get the battery. Interview on 08/30/18 at 8:57 A.M. with MD #130 stated she was notified the cord was missing on 08/27/18 for the sit to stand lift. She stated her corporate office had asked her what was needed and to create an inventory list. When she talked with therapy they explained they needed a cord. No one had previously notified MD #130 that the cord was needed it for a resident and that the therapy could possibly be resumed when the sit to stand was functional. Telephone Interview on 08/30/18 at 9:38 A.M. with Physical Therapist (PT) #607 explained it was normal progression for someone that can stand well, but not pivot to use the sit to stand to build up the tolerance (like Resident #31). He stated the resident can stand well from a static (sitting) position. He stated about two weeks PT #607 wanted to use the stand (for Resident #31) and the cord was missing, and it was not functional. He explained the resident could be picked back up for therapy if the lift was functional. Interview on 08/30/18 at 9:46 A.M. with the Administrator stated she was not aware that a cord for the sit to stand lift had not been ordered, and a resident was waiting on that to re-attempt therapy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 22 of 22