Inspection·September 5, 2019

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 the resident fund accounts, staff interview and policy review, the facility failed to provide the resident's funds within 30 days from discharge from the facility. This affected one (Resident #194) of two residents reviewed for a closed fund account. The facility identified eight residents who had a fund accounts with the facility. The facility census was 39. Residents Affected - Few Findings include: Review of the resident's fund account information revealed Resident #194 was admitted to the facility on [DATE]. The resident discharged to a different facility on [DATE]. A check for a balance of $516.74 was sent to the resident on [DATE]. Interview with Business Office Manager (BOM) #51 on [DATE] at 11:45 A.M. verified that Resident #194 discharged to a different facility on [DATE]. BOM #51 verified a check for a balance of 516.74 dollars was sent to the resident/responsible party on [DATE] which was 66 days after discharge. Review of the facility's undated policy titled Patient Resident Trust Fund Policy revealed the BOM reviewed the accounts for discharged or deceased residents and closed the account within 30 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 2 of 6 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 09/05/2019 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on medical record review, staff and family interview and review of the facility policy, the facility failed to ensure a 48-hour baseline care plan was reviewed with the resident and their representative, and a copy of the care plan given to the resident or their representative. This affected one (Resident #15) out of 12 residents reviewed for baseline care plans. The facility census was 39. Findings include: Review of the medical record for Resident #15 revealed an admission date of 07/03/19. Diagnoses included malignant neoplasm of the hard palate, dysarthria and anarthria, dysphagia, blindness left eye, chronic hepatitis, benign prostatic hyperplasia, obstructive and reflux uropathy weakness and severe calorie malnutrition. Review of the 48-hour baseline care plan for Resident #15, dated 07/03/19, revealed the care plan was completed and signed by the Registered Nurse (RN). Further review of the care plan revealed no documentation that the plan had been reviewed with the resident or his representative. Review of the nursing progress notes dated 07/03/19 through 07/10/19, revealed no documentation that the 48-hour care plan for Resident #15 had been reviewed with the resident or his representative. Review of the 30-day Medicare Minimum Data Set (MDS) assessment, dated 07/31/19, revealed Resident #15 to have moderate cognitive impairment. He was also assessed to be totally dependent upon staff for his eating and nutrition and his weight loss was assessed as unknown. Interview on 09/04/19 at 4:05 P.M. with Resident #15's representative stated she had never received an initial care plan when they first arrived at the facility. She stated no one had reviewed the care plan with either her husband, Resident #15, or herself. Interview on 09/04/19 at 4:25 P.M. with the Director of Nursing (DON) confirmed 48-hour baseline care plans were to be completed within 48 hours and reviewed with the resident and their representative. The DON confirmed after the care plan was reviewed, the care plan was signed by either the resident or their representative, a copy was made, and the facility keeps a copy and a copy one was given to the resident and their representative. Interview on 09/04/19 at 4:33 P.M. with Social Service Designee (SSD) #68, confirmed she conducted a care conference with Resident #15 and his representative on 07/08/19, but denied reviewing the 48-hour baseline care plan with the his representative or giving her a copy of the plan. Review of the facility policy titled Baseline Care Plan and Summary, dated 01/01/18, revealed the facility's interdisciplinary team (IDT) would review, in person or via the phone, the summary of the baseline care plan, a copy would be given to the resident, family or responsible party and a note made in the resident's medical record regarding which method the summary was reviewed. It should also contain the time, date and with whom the baseline care plan summary was shared with. Within 48 hours, the base line care plan should be reviewed with the resident, family and or responsible party, and should receive a copy of the base line care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 3 of 6 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 09/05/2019 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 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, family and staff interviews and facility procedure review, the facility failed to provide timely and appropriate foot care a resident. This affected one (Resident #22) of one resident reviewed for activities of daily living care. The facility census was 39. Residents Affected - Few Findings include: Record review for Resident #22 revealed the resident was admitted to the facility on [DATE] with diagnoses including a stroke resulting in left sided hemiplegia and Parkinson's disease. Review of the Minimum Data Set (MDS) assessment, dated 07/04/19, revealed the resident was non-verbal with moderately impaired cognition. S he required the extensive assistance of one staff for hygiene. The resident's daughter was the responsible party. Review of a Health Care Services Consent Form, dated 08/12/19, revealed the resident's daughter signed a consent for audiology, optometry and podiatry services with a visiting mobile care group. Observation on 09/03/19 at 3:47 P.M. revealed Resident #22 was in bed with very long brown toenails and dry/flaky toes. At that time, a family interview with the resident's Daughter #251 was conducted and the daughter stated she was upset with condition of the resident's toenails/feet, and the resident needed podiatry care. Interview on 09/03/19 at 4:01 P.M. with Social Service Designee (SSD) #97 revealed the resident was not currently scheduled for podiatry services. SSD #97 revealed the resident's daughter approached her on 08/12/19 and signed a consent for podiatry care. SSD #97 verified the consent was not completed at the time of the resident's admission on [DATE]. Interview with the Administrator at that time verified the Health Care Services Consent Form should be completed at admission and resident receive appropriate care including podiatry in a timely manner. Observation with the Director of Nursing (DON) on 09/03/19 at 4:45 P.M. verified the resident's toenails needed to be trimmed and dry/flaky feet needed care. Review of the facility's procedure provided from the DON revealed the procedure was from the nursing care manual by [NAME], eighth edition 2019, page 51 under bed bath. The procedure stated, if possible place a basin on the resident's bed, flex the leg and place the foot in the basin and add warm water. Soak the resident's foot, wash and rinse it thoroughly. Remove the foot from the basin, dry it, and clean the toenails. Apply a hypoallergenic moisturizer as needed to areas of dry skin to prevent skin breakdown. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 4 of 6 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 09/05/2019 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, medical record review and staff and family interview, the facility failed to ensure Resident #15 received the prescribed amount of enteral nutrition. This affected one (Resident #15) out of one resident reviewed for enteral feeding. The facility identified four residents received tube feedings. The facility census was 39. Findings include: Review of the medical record for Resident #15 revealed an admission date of 07/03/19. Diagnoses included dysarthria and anarthria, dysphagia and severe calorie malnutrition. Review of the 30-day Medicare Minimum Data Set (MDS) assessment, dated 07/31/19, revealed Resident #15 to have moderate cognitive impairment. He was also assessed to be totally dependent upon staff for his eating and nutrition and his weight loss was assessed as unknown. Review of Resident #15's nutritional assessment, dated 07/11/19, revealed Resident #15 was currently receiving Jevity one point two calories at 55 ml/hr., with 30 ml. of water flush every hour. Nutritional summary documented by Licensed Dietitian (LD) #97, revealed the current rate of enteral nutrition did not provide the recommended nutrition. She recommended the tube feeding (TF) be increased to a rate of 65 ml/hr. She also assessed the resident as having no significant weight change and that he had good tolerance for tube feeding. Review of Resident #15's plan of care, dated 07/22/19, revealed he was totally dependent upon TF, due to inadequate food and beverage intake related to cancer, for his nutritional needs. His goals were documented to maintain nutritional status and body weight. Interventions included enteral formula and feedings as ordered, monitor lab data as available and weekly weights. Review of the results for Resident #15's comprehensive metabolic panel blood test, dated 07/26/19, revealed the resident's BUN (urea nitrogen) to be 32, and BUN/Creatinine ratio was 46. Both results were elevated. The normal lab value for BUN was seven through 25 milligram (mg) per deciliter (dL), (mg/dL). The normal lab value for a BUN/Creatinine ratio was six through 25. Resident #15's BUN and BUN/Creatinine ratio results were elevated which indicated possible dehydration. Review of the current physician's orders for Resident #15, identified Jevity (a tube formula) one point two calories, enteral feed (TF), every day and night shift, related to weakness and severe protein/calorie malnutrition, at continuous rate of 65 milliliters per hour (ml/hr) via gastric tube (g-tube) for 24 hours per day. Also identified was an order for water flush per gastrostomy tube at 40 ml. every hour per pump. Observation on 09/03/19 at 11:22 A.M. revealed Resident #15 sitting in his wheelchair with his wife and not connected to his TF pump. Interview on 09/03/19 at 11:30 A.M. with the resident's wife revealed she had arrived at the facility at 10:30 A.M. and Resident #15 was already disconnected from his TF pump. Interview on 09/03/19 at 12:07 P.M. with State Tested Nursing Assistant (STNA) #100 confirmed Resident #15 was not connected to his TF pump. Observation on 09/04/19 at 9:57 A.M. of Resident #15, revealed he was asleep in his bed. His TF was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 5 of 6 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 09/05/2019 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few connected and running per pump at 65 ml/hr. A bag of water was observed hanging on the pump and connected. The container of TF was labeled, Jevity one point two. A label on the container documented the TF was started at 1:30 A.M. on 09/04/19. Observation on 09/04/19 at 3:52 P.M. revealed Resident #15 and his wife were entering his room and Resident #15 was observed in his wheelchair, not connected to his tube feeding pump. Interview on 09/04/19 at 4:58 P.M. with the resident's wife confirmed Resident #15 remained unconnected from his tube feeding pump and had been unconnected since they had gone outside at 3:30 P.M. Observation on 09/04/19 at 6:20 P.M. of Resident #15 revealed Jevity one point two connected to the resident's gastrostomy tube and running at 65 ml/hr. per pump. Observation of the Jevity container revealed it to be the same one as observed at 9:57 A.M. The label of the Jevity container revealed it was started on 09/04/19 at 1:30 A.M. The container was observed with 210 ml remaining in the container. The resident was ordered enteral feed at 65 ml/hr. The length of time from 1:30 A.M. (start of the TF) to 6:30 P.M. (observation) equaled 17 hours. Calculation for 17 hours times 65 ml of TF per hour revealed the resident should have received 1105 ml. of TF. Interview on 09/04/19 at 6:27 P.M. with the Director of Nursing (DON) confirmed only 210 ml., was observed remaining in Resident #15's TF container. She also confirmed the resident had only received 790 ml. of Jevity for the period from 1:30 A.M. to 6:30 P.M. She confirmed the resident should have received a total of 1105 ml. in that time period. Observation on 09/05/19 at 10:01 A.M. revealed Resident #15's TF was observed connected to the resident. The container of Jevity one point two was observed running per pump at 65 ml/hr. The label on the container documented the start time of the TF as 1:45 A.M. on 09/05/19. Calculation for nine point five hours, at 65 ml/hr., of TF would equal 617.5 ml. the resident should have received during this time. Observation of the container revealed 600 ml. left in the container. Interview on 09/05/19 at 10:23 A.M. with the DON confirmed the enteral feeding for Resident #15 was started at 1:45 A.M. and the remaining amount in the container was 600 ml. She confirmed the resident should have received 617.5 ml of TF running at 65 ml/hr. She confirmed with 600 ml .remaining in the container and the resident only received 400 ml. of TF. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 6 of 6