Inspection·October 4, 2022

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to ensure an advanced beneficiary notice of non-coverage was completed. This affected one resident (Resident #36) out of three residents reviewed for beneficiary notice. The facility census was 40. Residents Affected - Few Findings include: Review of the medical record for Resident #36 revealed an admission date of 02/25/22. Diagnoses included major depressive disorder, dementia, squamous cell carcinoma, pressure ulcer of sacral region, stage four, and protein calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/01/22, revealed this resident had moderately impaired cognition. This resident was assessed to require extensive assistance with transfers, dressing, and toileting as well as supervision for eating. Review of form titled CRI Notification for Discharge of Therapy Services, dated 04/19/22, revealed Resident #36 was discharged from therapy services effective 04/21/22 because the resident achieved all goals and was not expected to make further progress. Interview on 09/29/22 at 2:50 P.M. with Regional Clinical Director #150 confirmed the advanced beneficiary notice was not completed and provided to Resident #36 but should have been when she was discharged from therapy by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 2 of 9 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 10/04/2022 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and medical record review, the facility failed to complete comprehensive person-centered care plans for two (Resident #14 and Resident #19) out of the four residents sampled. The facility census was 40. Findings include: 1. Review of medical record for Resident #14 revealed an admission date of 05/28/21. Review of the medical record revealed medical diagnoses of protein calorie malnutrition, major Depression, syncope and collapse, atrial fibrillation, anemia, hypertension and unspecified injury of head. Review of the medical record revealed the Minimum Data Set (MDS) dated [DATE] which stated Resident #14's Brief Interview for Mental Status (BIMS) score was three indicating Resident #14 had severely impaired cognition. The MDS revealed the resident required extensive staff assistance of two staff members for bed mobility and transfers and extensive assist of one staff member for toileting. The MDS revealed Resident #14 was dependent upon staff for personal cares. Further review of the medical record for Resident #14 revealed Hospice services were initiated on 03/23/22 with a primary terminal diagnosis of senile degeneration of the brain. The medical record did not support documentation that the facility collaborated with the Hospice provider to develop a comprehensive person-centered care plan that included measurable objectives and timeframes to meet Resident #14's psychosocial needs. Interview on 09/28/22 at 11:02 A.M. with Regional Nurse #150 confirmed Resident #14 did not have a comprehensive person-center care plan to support the services and cares provided by the Hospice provider. 2. Review of the medical record for Resident #19 revealed an admission date of 07/16/22. The medical record revealed medical diagnoses of protein calorie malnutrition, Adult Failure to Thrive (AFTT), pneumonia, Depression, and chronic obstructive pulmonary disease (COPD). Review of the medical record for Resident #19 revealed the MDS dated [DATE] which stated Resident #19's Brief Interview for Mental Status (BIMS) for was nine, indicating the resident had moderate cognitive impairment. Further review of the MDS revealed Resident #19 required extensive assistance of two staff members for bed mobility and transfers, and extensive assist of one staff member for toileting and locomotion on and off the unit. The MDS revealed the resident did not ambulate and was dependent for bathing. Further review of the medical record for Resident #19 revealed lack of documentation to support the facility had developed comprehensive person-centered care plans for Resident #19 Activities of Daily Living (ADLs) or activities and preferences. Interview on 09/27/22 at 2:48 P.M. with Regional Nurse #150 revealed the State Tested Nursing Assistance (STNAs) determined the amount of assistance Resident #19 required for ADLs from the ADL comprehensive person-centered care plan. Regional Nurse #150 confirmed the facility did not complete comprehensive person-centered ADL or Activity/preference care plan for Resident #14 in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 3 of 9 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 10/04/2022 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 record review, interviews, and policy review, the facility failed to complete quarterly care conferences for residents and family. This affected one (#39) of two residents reviewed for care plans. The facility census was 40. Findings include: Review of the medical record for Resident #39 revealed an admission date of 03/01/19. Diagnoses included dementia, Alzheimer's disease, fracture of right wrist and hand, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had severe cognitive impairment. This resident was assessed to require two-person extensive assistance with transfers, dressing, and toileting, supervision with eating, and two-person total dependence with bathing. Review of the care conferences for the last 12 months revealed Resident #39 had a care conference on 08/30/21, 06/28/22 and 09/06/22. Interview on 09/28/22 at 11:46 A.M. with social services director #350 revealed care conferences were to be completed quarterly. Social services director #350 reported Resident #39 only had three care conferences completed in the last 12 months. Review of the facility policy titled, Family Involvement in Resident Care, dated 11/2020 revealed residents and their representatives will be provided with an opportunity to participate in the care planning process and be included in decisions, changes of care, treatment, and/or interventions. Care plan meetings will be held to accommodate residents. Family members will be invited to quarterly care plan meetings or care plan meetings that occur due to a change in resident condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 4 of 9 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 10/04/2022 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to provide fingernail care to one (Resident #14) out of the four residents sampled. This had the potential to affect all the residents in the facility. The facility census was 40. Residents Affected - Few Findings include: Review of medical record for Resident #14 revealed an admission date of 05/28/21. Review of the medical record revealed medical diagnoses of protein calorie malnutrition, major Depression, syncope and collapse, atrial fibrillation, anemia, HTN and unspecified injury of head. Review of the medical record revealed the Minimum Data Set (MDS) dated [DATE] which stated Resident #14's Brief Interview for Mental Status (BIMS) score was three indicating Resident #14 had severely impaired cognition. The MDS revealed the resident required extensive staff assistance of two staff members for bed mobility and transfers and extensive assist of one staff member for toileting. The MDS revealed Resident #14 was dependent upon staff for personal care. Review of the medical record revealed Resident #14 enrolled into Hospice services on 03/23/22. Per the medical record, Resident #14 was ordered a Hospice Home Health Aide (HHA) one day per week to assist Resident #14 with bathing and personal care. Further review of the medical record revealed a Hospice HHA visited Resident #14 weekly. The medical record did not have documentation to support the Hospice HHA or facility staff offered or completed fingernail care for Resident #14. Observation on 09/26/22 at 10:59 A.M. revealed Resident #14 to be laying in bed covered with blankets with her hands on top of the blankets. Resident #14's fingernails were noted to be long, chipped with sharp edges and there was visible dirt under all the fingernails. Observation and interview with Director of Nursing (DON) on 09/28/22 at 9:08 A.M. confirmed Resident #14's fingernails to be long, chipped with sharp jagged edges, and had visible dirt under the fingernails. DON was unable to provide documentation to support Resident #14 was offered or had nail care completed by the facility staff or Hospice HHA. DON stated the facility staff are to complete fingernail care on residents as needed even if the resident received Hospice services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 5 of 9 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 10/04/2022 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #20 revealed an admission date of 01/06/22. Diagnoses included congestive heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, anxiety disorder, hypothyroidism, major depressive disorder, atrial fibrillation, other disorder of lung, nonrheumatic aortic (valve) stenosis, anemia, vitamin b12 deficiency anemia, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, chronic obstructive pulmonary disease, mixed hyperlipidemia, and hypertension. Residents Affected - Few Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/20/22, revealed this resident had moderately impaired cognition. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, toileting, and personal hygiene. The resident was able to eat independently. Review of the plan of care dated 01/06/22 revealed the resident was at risk for malnutrition related to hypothyroidism and depression. Interventions included diet as ordered, medication as ordered, monitor meal consumption daily, and monthly weights. Review of the current physician orders revealed an order dated 05/09/22 to obtain monthly weight every day shift starting on the 2nd and ending on the 2nd every month for weight. Review of the Treatment Administration Record (TAR) from 08/01/22 through 09/28/22 revealed no monthly weights were documented. Review of the weights documented in the electronic health record revealed no weights were documented for August or September 2022. Interview on 09/28/22 at 2:15 P.M. with the Director of Nursing (DON) confirmed the facility had no documented weights for Resident #20 for the months of August or September 2022. The DON reported the monthly weights should have been obtained within the first several days of the month and acknowledged that obtaining weights had been an issue. 3. Review of the medical record for Resident #28 revealed an admission date of 08/02/22. Diagnoses included displaced spiral fracture of shaft of humerus, left arm, subsequent encounter for fracture with routine healing, hypertension, rhabdomyolysis, congestive heart failure, acute kidney failure, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 08/06/22, revealed resident had moderately impaired cognition. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, and toileting, limited assistance for personal hygiene, and was able to eat independently. Review of the plan of care dated 08/05/22 revealed the resident was at risk for malnutrition related to hypertension, rhabdomyolysis, congestive heart failure, acute kidney failure, and atherosclerotic heart disease. Interventions included monitor intake of meals and weights as ordered. Review of the current physician orders revealed no orders for weight monitoring. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 6 of 9 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 10/04/2022 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the weights documented in the electronic health record revealed the last weight documented was dated 08/21/22. Review of the weight note dated 08/26/22 revealed the weight obtained on 08/21/22 was thought to be inaccurate due to a weight loss of 6.1% in ten days with no changes in intakes. The recommendations were to continue regular diet and a reweigh was requested. Interview on 09/28/22 at 2:25 P.M. with the Director of Nursing (DON) confirmed there was no documentation that Resident #28 had been reweighed. The DON also confirmed the resident did not have an order in place to obtain weights. Review of the facility policy titled Weighing the Resident, revised 11/2019, revealed when there is a significant variance from the previous recorded weight the scale should be re-balanced and the resident re-weighed. It also revealed at a minimum, all residents of the facility shall be weighed upon admission and monthly unless ordered otherwise by the physician or as directed by the weight committee. Review of the facility policy titled, Weight Loss Prevention Program, revealed weights were obtained by the fifth of each month and ensure accurate weights and reweighs were timely. Consistent staff were to weigh residents weekly and monthly at consistent times. Weigh wheelchairs each time. Staff were to report weights to the DON and dietary manager for calculation of significant weight loss and input into tracking system. In-service staff on appropriate use of scales. Based on record review, interviews, and policy review, the facility failed to accurately monitor weights per nutritional parameters. This affected three (#8, #20, and #28) out of three residents reviewed for nutrition. The facility census was 40. Findings include: 1. Review of the medical record for Resident #8 revealed an admission date of 01/25/22. Diagnoses included Parkinson's disease, Alzheimer's disease, major depressive disorder, pneumonia, COVID-19, and dysphagia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had severe cognitive impairment. This resident was assessed to require two-person extensive assistance with transfers, dressing, and toileting, supervision with eating, and two-person total dependence with bathing. Review of the care plan dated 06/20/22 revealed Resident #8 had potential for inadequate food/beverage intake due to depression and parkinson's. Interventions included assist feed as tolerated and indicated. Staff to give diet as ordered. Staff to invite to food related activities. Staff to monitor meal consumption daily. Staff to obtain and update food/beverage preferences. Staff to offer fluids between meals and when rendering care. Staff to provide food substitutes. Review of the physician order dated 01/25/22 revealed Resident #8 was ordered a magic cup with lunch for supplement. Review of the physician order dated 01/25/22 revealed Resident #8 was ordered a multivitamin tablet, give one tablet by mouth one time a day for supplement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 7 of 9 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 10/04/2022 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 0692 Level of Harm - Minimal harm or potential for actual harm Review of the physician order dated 04/01/22 revealed Resident #8 was ordered a regular diet with regular texture. Review of the physician order dated 05/09/22 revealed Resident #8 was ordered weekly weights every Sunday during dayshift. Residents Affected - Few Review of the physician order dated 07/15/22 revealed Resident #8 was ordered a house supplement two times a day. Review of the progress note dated 07/15/22 at 11:29 A.M. revealed Resident #8 had unintended weight loss related to pneumonia with antibiotic treatment as evidenced by significant weight loss. Meal intake was 25-100% and received magic cup at lunch. Staff to monitor weights as ordered. Review of the progress note dated 07/27/22 at 3:02 P.M. revealed Resident #8 was receiving house supplement twice a day and magic cups once a day. Resident #8 had a deep tissue injury on her coccyx per wound care. Recommended adding Pro-stat 30 milliliters (ml) twice a day and will continue to monitor. Review of the weekly weights dated July 2022 through September 2022 revealed the facility obtained five out of 13 weights for Resident #8. Review of the weekly weights for Resident #8 revealed inconsistent weight fluctuations up to 30 pounds without a re-weight completed for accuracy. For example, on 06/27/22, Resident #8 weighed 148 pounds. On 07/04/22, Resident #8 weighed 167 pounds. On 07/10/22, Resident #8 weighed 132 pounds. Interview on 09/28/22 at 11:32 A.M. with the Director of Nursing (DON) revealed Resident #8 had fluctuations in her weight but no change in intake. The DON reported staff had not been completed weekly weights as ordered and were currently working to correct this concern with weights being completed every Sunday. Interview on 09/28/22 at 3:40 P.M. with Registered Dietician (RD) #250 revealed weekly weights were not getting completed per orders. RD #250 reported weights were not obtained accurately related to weight fluctuations with no change in intake from Resident #8. RD #250 stated Resident #8 was receiving med pass supplement twice a day and a magic cup at lunch to maintain weight. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 8 of 9 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 10/04/2022 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 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on record review and staff interviews, the facility failed to ensure the appointed Infection Preventionist had proper infection prevention and control training and certification. This had the potential to affect all the residents in the facility. The facility census was 40. Finding include: Record review revealed the Director of Nursing (DON) was the Infection Preventionist for the facility. Further record review revealed the DON had not completed specialized training in infection prevention and control. Interview on 09/29/22 at 9:33 A.M. with DON confirmed she was the appointed Infection Preventionist in the facility to manage the Infection Prevention Control Program (IPCP). The DON confirmed she had not completed specialized training in infection prevention and control. Interview on 09/29/22 at 10:02 A.M. with Regional Nurse #150 confirmed DON was the appointed Infection Preventionist for the facility and DON had not completed specialized training for infection prevention and control. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365368 If continuation sheet Page 9 of 9