Inspection·January 30, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hand on her hips while talking. The CNA also asked the resident why she did not wipe herself and the resident said she had good and bad days and when someone talked to her like that it made her feel bad. Interview on 01/27/25 at 10:20 A.M. with Resident #5 revealed CNA #102 sprayed water on her face and was rough with care recently, and she felt like it was abusive. The resident confirmed she had reported the CNA to staff. Interview on 01/29/25 at 9:49 A.M. with Social Service (SS)/Registered Nurse (RN) #104 revealed Resident #5 had requested to speak to her on 01/15/25 regarding CNA #102. RN #104 reported she could not recall the details; however, she completed a form and gave it to the Director of Nursing (DON) to address. Interview on 01/29/25 at 9:55 A.M. with the DON confirmed RN #104 completed an employee disciplinary conference form on 01/15/25; however she went on vacation on 01/16/25 and did not have time to address the resident's concerns at the time. Interview on 01/29/25 at 11:25 A.M. with Social Service (SS)/Registered Nurse (RN) #104 confirmed she had filed the resident complaint on an employee disciplinary conference report per the facility's process. The RN reported that after she completed the employee disciplinary conference report, she gave it to the DON to investigate to determine if abuse occurred. The RN reported she did not have the authority to discipline staff and that was just the name of the form she completed to report complaints to the DON. The RN confirmed the resident had a history of hallucinations in the past, however she took everything reported to her seriously. Interview on 01/29/25 at 3:59 P.M. with the DON revealed she recalled RN #104 calling her via phone and reporting Resident #5's concerns, however she never mentioned abuse. The next day she found the employee's disciplinary conference report on her desk. The DON confirmed she had not spoken to CNA #102 regarding the employee disciplinary conference report yet because she had not seen CNA #102. The DON also stated the resident reported to her that the CNA must of had a bad day. The facility had initiated a Self-Reported Incident (SRI) since the resident had reported abuse to the surveyor. Review of the undated grievance process revealed that the resident, staff, or representative of a resident may file a grievance to assure that the facility management would address their concerns and ensure a prompt resolution. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365429 If continuation sheet Page 2 of 25 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 365429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, review of the facility investigation, resident interview, staff interview, and review of facility policy and procedure, the facility failed to ensure Resident #6 was not abused by a staff member. This affected one resident (Resident #6) of four residents reviewed for abuse. Findings included: Review of the medical record revealed Resident #6 was admitted to the facility on [DATE]. Diagnoses included hypertensive heart disease, depression, vitamin D deficiency, anxiety disorder, cirrhosis of the liver, malignant neoplasm of the large intestine, diabetes, heart failure, osteoarthritis of the hip, atrial fibrillation, lymphedema, adrenocortical insufficiency, and insufficiency. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #6 had intact cognition. Review of the progress note dated 09/11/24 at 8:45 P.M. revealed a Certified Nursing Assistant (CNA) #210)) was assisting Resident #6 in the shower when the resident started to get loud with the CNA because the CNA was washing her face with soap. A second nursing assistant (CNA #137) was called into the shower room to assist. Resident #6 then started complaining that she got a neck injury today and medicare paid the facility thousands of dollars just for all of the staff to torture her here. Review of the progress note dated 09/13/24 at 1:13 P.M. revealed Resident #6 asked to speak to the Director of Nursing (DON) about the shower she received two nights ago. She felt the nursing assistant verbally abused her when the resident stated she was going to report her, and the CNA told the resident to go ahead and report her. An investigation was initiated. Review of the facility investigation dated 09/13/24 revealed on 09/12/24 it was reported that a resident was yelling at an aide during her shower because the aides were using soap on her. The resident was yelling that her insurance paid thousands of dollars for her to be at the facility and they were torturing her. The DON and Social Services #190 both spoke to her and she made no allegation of abuse, however on 09/13/24 Resident #6 reported to the Unit Manager/Licensed Practical Nurse (LPN) #194 that she wanted to report an aide because when she was showering her, the aide wiped her face too hard with the wash cloth. The DON asked the Unit Manager to write a statement of what Resident #6 had told her. The DON then interviewed Resident #6 and she stated that the aide was giving her a shower and she rubbed her face too hard. The resident stated she had sensitive skin and did not want her to wash her face. The resident stated she told the aide she was going to report her and the aide told her to go ahead. The resident denied a second aide came into the room. The DON assessed her face while interviewing her and her face was free of any scrapes, scratches, bruising or rashes. The resident had makeup on which she wears daily and would take pride in doing herself. The DON stated to the resident she would speak to CNA #137 and complete staff education that the resident would prefer to wash her face by herself. The resident stated again that her insurance paid a lot of money to be here and she should not have her face rubbed that hard. The DON asked her if she was physically abused and she stated no, but she said she was verbally abused when the aide told her to go ahead and report her. The DON attempted to clarify with her, asking if the aide was inappropriate when she responded to her the way she did or did she abuse her. Resident #6 stated the aide verbally abused her when she told her to go ahead and report her. Resident #6 stated she did not want CNA #137 to take care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365429 If continuation sheet Page 3 of 25 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 365429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of her anymore and the DON reassured her she would not be her aide. Social Services #190 was informed to check on the resident on Monday to follow up to make sure she was free of any psychosocial issues from the incident. The DON spoke to four other residents on the hall to see if they had any issues with CNA #137 being verbally or physically abusive and they all stated they had no issues with the aide. The DON contacted the medication aide who was working that night. Medication Aide (MA) #135 stated she went into Resident #6's room and the resident told her the aide washed her face and she did not want it washed. MA #135 said she told Resident #6 there was food on her face and the aide needed to get it off. MA #135 stated there was not any abuse at all and stated that Resident #6 had never liked CNA #137 since day one and she did not know why. The DON spoke to CNA #137 and she stated it was CNA #210 who was showering Resident #6 and Resident #6 was yelling out, so she (CNA #137) entered the room to see what was going on. She stated Resident #6 was not cooperating with her shower and all she wanted to do was get rinsed off, so the aide told Resident #6 she needed to get washed off because she had food hardened on her face. CNA #137 stated she gently washed the residents face and the resident was upset and said she was going to report her, and CNA #137 told her to go ahead. The DON called CNA #210 to get her statement and she stated she was doing the shower and Resident #6 did not want soap and just wanted to get rinsed off. Resident #6 start yelling and CNA #137 came in and spoke to her and Resident #6 agreed to have soap on her. Then CNA #137 washed her face and she was not rough. Resident #6 stated she was going to report CNA #137 and CNA #137 told her to go ahead. CNA #210 stated CNA #137 did tell Resident #6 they could not leave food on her face. Review of the undated, unsigned, text message witness statement from CNA #210 revealed she was giving Resident #6 a shower and the resident just got herself wet with water and said she was done. CNA #210 called CNA #137 in the shower room to ask her if she could use soap and wash her body and Resident #6 allowed her to. CNA #137 then asked to wash her face to get the food off and she let her wash one side of her face. Then Resident #6 began to yell about her makeup, so CNA #137 quickly washed the other side of her face and Resident #6 started screaming at CNA #137. The statement stated nothing was verbally abusive from CNA #137. Review of the undated, printed, text message witness statement signed by CNA #137 revealed CNA #210 was showering Resident #6 and put the call light on to ask for help because Resident #6 would not wash with soap. Resident #6 eventually agreed to wash with soap. The CNA told Resident #6 she had food on her face and they could not leave it. Resident #6 stated she had wipes in her room. CNA #137 stated she told the resident the wipes she saw in her room were not made for her face so why not use just a wash cloth with water, because they could not leave food on her face. Resident #6 became very angry and stated she was going to report her. CNA #137 stated she told Resident #6 to go ahead and report her, but that she could not leave food on her face. Review of the handwritten witness statement from LPN #194 dated 09/13/24 revealed the nurse went into the room of Resident #6 to ask if she was ready for her morning medications. Resident #6 stated that CNA #137 had abused her and explained she washed her face too hard and when she told her to stop, the aide told her no, it needed done. On 01/28/25 at 9:40 A.M. an interview with Resident #6 revealed a few months ago staff came and got her for a shower. She stated she could not believe how CNA #137 had acted. She stated she told both of them (CNA #210 and CNA #137) that she did not want her hair or face washed because she got her hair done at the beauty shop and she liked to wash her face with the makeup wipes in her room. She stated CNA #137 told her she needed to wash her face and get the make up off. Resident #6 told the CNA no, but she did it anyways and she started to scrub her face hard. The resident stated she kept telling the CNA to stop, but she just said she was going to get it off her face. The resident stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365429 If continuation sheet Page 4 of 25 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 365429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she was in shock. She stated she told CNA #137 that she was going to report her and CNA #137 told her go ahead and report her because she did not care. The resident stated she had a dermatologist for her eczema and she had issues with some soaps irritating her skin. She stated CNA #137 was not allowed in her room anymore, but she came in one time since the incident to answer her roommate's call light and the resident stated to her roommate she (CNA #137) better get out of here because she was not allowed in here. On 01/29/25 at 12:27 P.M. an interview with the Director of Nursing revealed she had not completed a formal write up for CNA #137, but like the Self-Reported Incident stated, she spoke to her one-on-one about it and informed her Resident #6 did not want her to care for her anymore. On 01/29/25 at 7:45 P.M. an interview with CNA #137 revealed another aide was completing Resident #6's shower and the resident did not want to use any soap. She stated the other aide called her into the shower room to see if she could convince her to use soap. She stated the resident still had food on her face from dinner time and she offered her a wash cloth to wash her face. She stated Resident #6 started to argue with her, telling her that she was verbally abusing her and she would use the wipes in her room. She stated she told Resident #6 the wipes (baby wipes) in her room were not really made to be used on her face and they could harm her face. She stated Resident #6 stated she was going to report her, and she told her to go ahead. She stated she did not press the issue anymore, and she left the room without washing the residents face. She stated she told the medication aide what had happen and spoke to the Director of Nursing the next day and was told to not go into the residents room to avoid any conflict with Resident #6. On 01/29/25 at 7:51 P.M. an interview with CNA #210 revealed she was giving Resident #6 a shower and she would not let her wash her face so she called CNA #137 in to see if she could talk her into washing her face. She stated the resident became really upset, started yelling at them, and did not want to wash her face. She stated CNA #137 walked out, CNA #210 got her dressed, and took her back to her room. After questioning CNA #210 about her witness statement, CNA #210 changed her story and verified CNA #137 did wash the food off of Resident #6's face and the resident was yelling at her to stop the whole time. She stated CNA #137 never used soap on her face, only a wet wash cloth. She stated they were now not allowed to wash the residents face, and just to offer to wash her face, but she did not allow staff to wash her face. She stated CNA #137 was not allowed to go into the residents room to provide care. Review of the facility policy titled, Policy and Procedure for Prevention of Mistreatment, Neglect and Abuse of Resident and Misappropriation of Resident Property, revealed all residents in the facility would be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, mistreatment, neglect and misappropriation of property, exploitation and adverse events. The definition of abuse was the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Willfully, as used in the definition of abuse, meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365429 If continuation sheet Page 5 of 25 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 365429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832 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 0625 Level of Harm - Potential for minimal harm Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on record review and interview, the facility failed to provide a bed hold notice to Resident #61 who was hospitalized . This affected one (Resident #61) of two residents reviewed for hospitalization. Residents Affected - Some Findings include: Review of Resident #61's medical record revealed an admission date of 11/26/24 and diagnoses including vitamin D deficiency, disorders of bone density and structure, diabetes mellitus, and displaced fracture of the surgical neck of the left humerus (long bone in the arm or forelimb that runs from the shoulder to the elbow). A discharge summary note dated 12/16/24 at 11:46 A.M. indicated Resident #61 participated well with therapy on 12/12/24, walking more than she ever did. Later in the day on 12/12/24, Resident #61 complained of groin pain. An x-ray indicated Resident #61 had a right hip fracture. Resident #61 was transferred to the emergency room for admission and surgical repair. Review of the discharge and transfer notice dated 12/12/24 revealed it was signed by Resident #61's spouse on 12/12/24. Further review of the medical record revealed no documentation was able to be located regarding Resident #61 or her responsible party being provided a written bed hold notification. Interview on 01/28/25 at 2:48 P.M., Medical [NAME] Specialist #125 stated bed hold notices were only provided to residents receiving Medicaid. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365429 If continuation sheet Page 6 of 25 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 365429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832 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 review of medical records, resident interview, representative interview, and staff interview, the facility failed to ensure residents and/or resident representatives were provided a written summary of the baseline care plan. This affected two (Residents #61 and #165) of six residents reviewed for baseline care planning. Findings include: 1. Review of Resident #61's medical record revealed an admission date of 11/26/24 with diagnoses including displaced fracture of the base of the neck of the right femur, depression, vitamin D deficiency, hyperlipidemia, hypertension, diabetes mellitus and displaced fracture of the surgical neck of the left humerus. The medical record revealed no indication that Resident #61 or her representative were provided a summary of the baseline care plan. Interview on 01/27/25 at 10:28 A.M., Resident #61's representative revealed he did not recall receiving a summary of the plan of care. Interview on 01/30/25 at 7:17 A.M., the Director of Nursing (DON) verified she was unable to locate evidence that a summary of the baseline care plan was provided to Resident #61 and/or her responsible party. 2. Review of Resident #165's medical record revealed an admission date of 01/01/25. Resident #165's diagnoses included malignant neoplasm of the right ovary, insomnia, sepsis, gastrointestinal hemorrhage, heart failure, type two diabetes mellitus, adult failure to thrive, anemia, protein-calorie malnutrition, vitamin D deficiency, and fistula (an abnormal connection of two body cavities or a body cavity and the skin) of the intestine. There was no indication Resident #165 or her representative were provided a summary of the baseline care plan. Interview on 01/27/25 at 10:28 A.M., Resident #165 revealed she did not recall receiving a summary of the baseline plan of care. Interview on 01/30/25 at 7:17 A.M., the Director of Nursing (DON) verified she was unable to locate evidence that a summary of the baseline care plan was provided to Resident #165 and/or her responsible party. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365429 If continuation sheet Page 7 of 25 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 365429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832 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** 2. Review of Resident #61's medical record revealed an admission date of 11/27/24 with medical diagnoses including diabetes mellitus and urinary tract infection (UTI). Resident #61 admitted with orders for Cefdinir (antibiotic) 300 milligrams (mg) twice a day for UTI for five days. Review of Resident #61's care plan initiated 11/27/24 indicated a potential for alteration in bowel function related to Resident #61 needing assistance with mobility. Interventions indicated Resident #61 needed maximal assistance with toileting hygiene. Staff were instructed to apply protective ointment as ordered, assist to the bathroom upon request, assist on and off the bedpan per request, encourage fluids, and provide incontinence care as needed. Review of an acute care plan initiated 11/27/24 indicated Resident #61 had an alteration of the urinary system. Interventions included administering medications as ordered, encouraging fluids, monitoring and reporting change of condition, monitoring labs as ordered and monitoring for odor, color and painful urination. The goal indicated Resident #61 would have no signs/symptoms of infection. Review of a nursing note dated 12/15/24 at 7:05 P.M. indicated an unnamed Certified Nursing Assistant (CNA) alerted the nurse that Resident #61's urine was dark and Resident #61 complained of her bladder burning. A urinalysis and culture and sensitivity was ordered for 12/16/24. On 12/18/24, the results were sent to the Certified Nurse Practitioner (CNP). A new order was received for Nitrofurantoin (antibiotic) 100 mg every six hours for five days for a UTI. Review of Resident #61's acute care plan dated 12/18/24 revealed another acute care plan for alternation of the urinary system was initiated with the same goals and interventions as the care plan developed on 11/27/24. Review of a nursing note dated 01/16/25 at 5:37 A.M. indicated a new order was received for Resident #61 to have a urinalysis and culture and sensitivity test performed on 01/17/25 due to frequency of urination, burning and pain. Review of Resident #61's acute care plan dated 01/19/25 revealed the same goals and interventions as those initiated on 11/27/24 and 12/18/24. A nursing note dated 01/19/25 at 6:07 P.M. indicated the CNP was notified of the urinalysis and culture and sensitivity results. A new order was received for Cefdinir 300 mg twice a day for ten days for a UTI. Interview on 01/29/25 at 2:43 P.M. with the DON revealed the DON was questioned regarding the lack of care planning for recurrent UTIs. The DON staff did acute care plans which addressed UTIs and antibiotic use. Interview on 01/30/25 at 7:31 A.M. with Registered Nurse (RN) #105 verified Resident #61 had recurrent UTIs and had multiple antibiotics ordered since November 2024. When asked if the interdisciplinary team (IDT) had addressed the recurrent UTIs and investigated the cause and any additional preventative measures as each acute care plan had the exact same interventions, RN #105 stated she would have to check. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365429 If continuation sheet Page 8 of 25 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 365429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832 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 Follow up interview on 01/30/25 at 9:08 A.M. with RN #105 revealed interventions beyond what was on the acute care plans for UTIs included encouraging Resident #61 to use the call light when her brief was wet and toileting her every two hours. RN #105 verified those interventions had not prevented UTIs. She also stated that staff provided incontinence care. RN #105 stated after discussing the recurrent UTIs, Resident #61 was placed on the nurse practitioner's list to see if she might benefit from use of a cranberry tablet and staff could start using anti-bacterial wash for perineal care due to the propensity for UTIs. Based on observation, staff interview, and medical record review, the facility failed to ensure comprehensive care plans were revised timely. This affected two residents (Residents #10 and #61) of 24 residents reviewed for care plans. The facility census was 62. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 10/24/22. Diagnoses included hemiplegia affecting the left side, actinic keratosis, bipolar disorder, chronic obstructive pulmonary disorder, peptic ulcer disease diabetes, anxiety disorder, osteoarthritis, benign prostatic hyperplasia, chronic pain, insomnia, hypertension, atherosclerotic heart disease, major depressive disorder, cerebrovascular disease, and paralytic syndrome. Review of the plan of care dated 10/27/22 revealed Resident #10 was a smoker and required a smoking apron. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #10 had intact cognition and had one side upper extremity impairment. Review of the smoking assessment dated [DATE] revealed Resident #10 did not have any dexterity problems, he could light his own cigarette, he required a smoking apron and supervision. In the comment section of the assessment it stated Resident #10 had been wearing a smoking apron due to a recent report of him dropping a cigarette on himself. Resident #10 denied the occurrence. The assessment noted on the day the resident dropped the cigarette on himself, it was very windy outside and he stated he dropped it due to the wind. Resident #10 had been reassessed for smoking and was monitored for safety and he did demonstrate safe actions when smoking. He could go without an apron with the understanding if he dropped another cigarette he would be required to wear the apron. Observation of the resident smoking area on 01/27/25 at 11:15 A.M. revealed the Resident #10 was outside on the patio with supervision provided by Housekeeper #201. Housekeeper #201 lit Resident #10's cigarette, but did not put a smoking apron on him. Interview on 01/27/25 at 2:00 P.M. with Housekeeper #201 revealed residents only wore a smoking apron if the resident was dropping stuff on themselves. Interview on 01/28/25 at 8:55 A.M. with the Director of Nursing (DON) revealed she did not know why they were charting Resident #10 as needing a smoking apron because on 05/21/24 she reassessed him and felt he was fine without one. A follow up interview on 01/28/25 at 2:30 P.M. with the DON verified the plan of care for Resident #10 was incorrect in indicating the resident needed a smoking apron. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365429 If continuation sheet Page 9 of 25 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 365429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832 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 medical record review, interview, observation, and review of facility policy, the facility failed to ensure Resident #49 received assistance with oral care. This affected one (Resident #49) of four residents reviewed for activities of daily living. The facility census was 62. Residents Affected - Few Findings include: Review of Resident #49's medical record revealed an admission date of 12/19/24 with diagnoses including diabetes, severe protein-calorie malnutrition, adult failure to thrive, kidney disease, gastro-esophageal reflux, weakness, and heart disease. Review of Resident #49's Minimum Data Set (MDS) dated [DATE] revealed the resident was dependent on staff for oral care. There was no evidence of refusals or rejection of care. Review of Resident #49's interdisciplinary team (IDT) progress note dated 01/17/25 revealed the resident required set up assistance for oral hygiene. Review of Resident #49's care plan indicated the resident had an alteration in dental status related to own teeth. The resident's plan of care stated to assist the resident twice daily with oral care. Review of Resident #49's task documentation for CNA's dated 12/28/24 to 01/27/25 revealed no documented evidence oral care was completed on 12/28/24, 12/29/24, 12/30/24, 01/03/25, 01/04/25, 01/08/25, 01/11/25, 01/13/25, 01/16/25, 01/21/25, 01/22/25, 01/23/25, 01/24/25, 01/25/25, 01/26/25, and 01/27/25. Observation on 01/27/25 at 10:33 A.M., revealed Resident #49 had build up on her bottom teeth. Observation on 01/28/25 at 10:39 A.M. of Resident #49 with Certified Nursing Aide (CNA) #112 confirmed the resident had build up on her bottom teeth. The CNA reported that the resident had refused oral care earlier that morning. The Occupational Therapist (OT) was present and assisted the resident with oral care. The resident had a battery-operated toothbrush in her bathroom and the toothpaste appeared unused. The resident confirmed she had seven natural teeth on the bottom and no teeth on the top. The CNA reported she did not report refusal of oral care to the nurse. Interview on 01/28/25 at 3:22 P.M., with the Director of Nursing (DON) confirmed there was no documented evidence Resident #49 had received oral care 12/28/24, 12/29/24, 12/30/24, 01/03/25, 01/04/25, 01/08/25, 01/11/25, 01/13/25, 01/16/25, 01/21/25, 01/22/25, 01/23/25, 01/24/25, 01/25/25, 01/26/25, and 01/27/25. The DON reported the facility had removed the task that included oral care on 01/21/25 due to the amount of charting the CNA's had to do, however she was going to add the task back. Review of the undated policy titled Activities of Daily Living (ADL) revealed residents would be provided with care, treatment, and services as appropriate to maintain and improve their ability to carry out activities of daily living (ADL). Residents who are unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. If a resident with cognitive impairment or dementia resist care, staff would attempt to identify the underlying cause of the problem and not just assume the resident was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365429 If continuation sheet Page 10 of 25 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 365429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832 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 refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365429 If continuation sheet Page 11 of 25 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 365429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interview, and review of facility policy, the facility failed to ensure residents with non-pressure related skin issues were comprehensively assessed and treated in a routine manner. This affected two (Residents #51 and #165) of two residents reviewed for non-pressure related skin impairment. The facility census was 62. Residents Affected - Few Findings include: 1. Review of Resident #165's medical record revealed an admission date of 01/01/25. Medical diagnoses included malignant neoplasm of the right ovary, methicillin resistant staphylococcus aureus (MRSA), adult failure to thrive, diabetes mellitus type two, anemia, and fistula of the intestine. A pre-admission hospital history and physical dated 12/25/24 indicated an abdominal drain in the right lower quadrant of the abdomen had accidentally been pulled out ten days previous. A Computed Tomography (CT) scan showed a complex right cystic lower abdominal intraperitoneal mass likely ovarian origin which appeared to have a fistula tract through the anterior abdominal wall exiting the skin on the right side. Review of Resident #165's admission assessment on 01/01/25 indicated Resident #165 had pus in an area on the right lower quadrant of the abdomen. A nursing note dated 01/01/25 at 6:35 A.M. indicated Resident #165 had a wound to the right lower quadrant with moderate serosanguineous drainage. A nursing note dated 01/01/25 at 3:02 P.M. indicated the wound nurse practitioner consulted regarding the fistula on the right abdomen and a new treatment order was obtained and completed. Review of wound Nurse Practitioner (NP) #300's consultation note dated 01/01/25 indicated Resident #165 had an area on the right upper quadrant of the abdomen and referred to it as a surgical site with full thicken loss measuring 0.6 centimeters (cm) x 0.7 cm x 0.1 cm with mucoid drainage. A treatment was recommended with alginate and to cover with a foam dressing to be changed every day and as necessary. Documentation on a wound/skin healing record revealed on 01/01/25 the area had a moderate amount of purulent and serosanguineous drainage. The skin surround the area was dark red/purple. A second assessment dated [DATE] indicated there was a large amount of serosanguineous drainage with the skin surrounding the area being normal. It was measured as 0.6 cm x 0.7 cm. The assessment indicated the area was a fistula and there was fat tissue in the wound bed. The fistula went to the mass. A subsequent assessment dated [DATE] indicated the area was 0.5 cm x 0.7 cm with copious amounts of purulent and serosanguineous drainage. The surrounding skin was black/brown. The assessment indicated the area was improved. An entry dated 01/15/25 indicated the fistula was not followed by the facility's wound nurse. There was no evidence nurses were completing comprehensive assessments of the open area following 01/08/25. Interview on 01/27/25 at 2:54 P.M. with Resident #165 revealed she previously had a drain in her abdomen which had been pulled out by mistake at another healthcare facility, and it left a hole. Interview on 01/28/25 at 12:40 P.M. with the Director of Nursing (DON) revealed she understood the concerns raised regarding monitoring the open area and evaluation of the current treatment. The DON stated nurses observed the area daily and would know if there was a change in condition or if the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365429 If continuation sheet Page 12 of 25 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 365429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832 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 0684 treatment did not appear to be effective. Level of Harm - Minimal harm or potential for actual harm Observation on 01/30/25 at 8:50 A.M. revealed Licensed Practical Nurse (LPN) #149 changed Resident #165's abdominal dressing. A small opening to the skin was noted to the right abdomen with serous drainage. The skin was pink to the right side and above the open area. Residents Affected - Few Interview on 01/30/25 at 9:00 A.M. with LPN #149 revealed she worked three to four days a week and the color of the wound was the same. LPN #149 stated generally, when the dressing was changed once a day, there was usually a stronger odor and more drainage than what was observed during the dressing change which had just been completed. LPN #149 stated she believed the reason there was not as much drainage and odors was the night shift had changed the dressing for some reason. LPN #149 stated it was her understanding the nurse practitioner no long followed the wound because it was a non-healing wound. LPN #149 stated the nurses monitored the area with dressing changes and Resident #165 also had outside appointments (unsure if oncology or surgeon) but her appointment the week of 01/20/25 had been rescheduled due to weather. On 01/30/25 at 10:15 A.M., Wound Nurse Practitioner (NP) #300 verified she did not follow Resident #165's abdominal wound because it was a surgical wound. Nurses should be assessing for changes, drainage, and any changes in appearance. Wound NP #300 stated due to Resident #165's ovarian cancer, which had developed into a fistula and would always have a foul odor, drainage, and would not improve. Wound NP #300 stated nurses should be monitoring the area, as the wound may eventually need pouched. Skin surrounding the area should be monitored for breakdown. It should also be monitored to determine if the dressing was able to hold the drainage. The information should be included in the resident's wound documentation. 2. Review of Resident #51's medical record revealed admission date 02/25/22 with diagnoses including but not limited to unspecified dementia, anxiety, high blood pressure, repeated falls, and anemia. Resident #51 was severely cognitively impaired with a Brief Interview of Mental Status (BIMS) score of three out of a possible 15 dated 12/24/24. Resident #51 used a walker and wheelchair for mobility assistance, required assistance for toilet use and personal hygiene care. Review of Resident #51's at risk for injury care plan dated 02/27/22 revealed Resident #51 was at risk for injury related to decreased cognition, decreased mobility, and poor safety awareness. Interventions included for Resident #51 to wear long sleeved shirts to help protect from accidental bruising and skin tears to Resident #51's upper extremities. Review of Resident #51's iron level and complete blood count (CBC) laboratory results dated [DATE] revealed Resident #51's iron level result was at 81 (normal), Hemoglobin level results were low at 12, and Hematocrit level results were low at 36.1 which indicated Resident #51 was considered anemic and had the potential to bruise easily. Review of Resident #51's progress notes dated 01/06/25 at 1:25 P.M. authored by Licensed Practical Nurse (LPN) #101 revealed a bruised area to Resident #51's right elbow was observed with a small open area in the middle of the bruise. The area was cleaned and covered with a foam dressing. Further review of Resident #51's progress notes dated 01/07/25 to 01/28/25 revealed no further entries or documentation related to monitoring of the bruise and open area to Resident #51's right elbow. Review of Resident #51's physician orders dated 01/06/25 to 01/28/25 revealed no treatment order was implemented on 01/06/25 for treatment of the bruise with an open area observed on Resident #51's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365429 If continuation sheet Page 13 of 25 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 365429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832 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 0684 right elbow. Level of Harm - Minimal harm or potential for actual harm Review of Resident #51's Treatment Administration Record (TAR) dated 01/01/25 to 01/28/25 revealed there were no treatment orders to be completed regarding the bruise and open area located on Resident #51's right elbow which was first observed on 01/06/25. Residents Affected - Few A review of the bruise investigation form dated 01/06/25 at 1:35 P.M. completed by LPN #101 revealed staff observed blood on the floor in Resident #51's room. Resident #51 was in the common area at the time of the discovery. LPN #101 assessed Resident #51 and observed the skin had cracked and there was a small bruise surrounding the cracked skin on Resident #51's right elbow. The area was cleaned, and a foam dressing was placed to the area. Observation on 01/28/25 at 8:15 A.M. revealed Resident #51 was sitting in a wheelchair located in the dining room eating the breakfast meal. Resident #51 was wearing a long-sleeved sweatshirt and sweatpants. Interview on 01/28/25 at 1:00 P.M. with LPN #123 revealed the facility has a standard physician order which is used when there has been skin impairment observed. The facility wound nurse will be notified, as well as the physician and family member. The nurse will assess, treat and implement treatment orders as needed upon the initial observation. Interview on 01/28/25 at 2:21 P.M. with the Director of Nursing (DON) confirmed Resident #51 did not have any treatment order initiated or implemented for the cracked skin with bruise observed on 01/06/25. The DON stated when there's an area identified which requires a treatment order, the assessing nurse should implement a treatment order initially and then continue to monitor and document on the area until it is healed. A review of the facility policy Skin Assessments dated 01/19 revealed a treatment will be initiated as ordered by the either the physician or nurse practitioner to promote healthy skin integrity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365429 If continuation sheet Page 14 of 25 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 365429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interviews, the facility failed to ensure splints/braces were applied per orders and plan of care. This affected one (Resident #18) of one resident reviewed for positioning/mobility. The facility census was 62. Findings include: Review of Resident #18's medical record review revealed an admission date of 08/02/22 with diagnoses including Parkinsonism, chronic pain, rhabdomyolysis, and limited range of motion. Review of Resident #18's Minimum Data Set (MDS) dated [DATE] revealed the resident had impaired range of motion to bilateral upper extremities. The resident had no rejection/refusal of care. Review of Resident #18's active physician's orders revealed an order dated 02/12/24 to apply wrist braces daily at 8:00 A.M. and remove daily at 8:00 P.M. The order indicated the braces could be removed for meals. The order did not specify which wrist, or both, the brace/braces should be applied to. An additional order dated 05/13/24 stated to place finger splints on left fingers one hour per day for boutonniere deformities with the instructions for application listed as, in the bag with the splints. Review of Resident #18's care plan dated 07/24/22 revealed the resident had an alteration in ability to perform activities of daily living (ADL) related to generalized weakness. Listed interventions included to place finger splints on left fingers one hour per day for boutonniere deformities (instructions in bag with splints), to apply wrist brace daily at 8:00 A.M. and remove at 8:00 P.M. and may remove for meals. Review of Resident #18's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated January 2025 revealed staff signed off the resident's wrist splint was applied daily, except on 01/26/25, 01/28/25, and 01/29/25 when there was no documented evidence that the wrist splint was applied, and on 01/27/25 when staff documented the resident refused the wrist splint. There was no evidence of the finger splints order being listed on the MAR/TAR to ensure it was applied or refused. Review of Resident #18 task tab for Certified Nursing Assisting (CNA) charting revealed no evidence of wrist or finger splints. Interview and observation on 01/27/25 at 10:14 A.M., of Resident #18 revealed she had pain, especially in her hands and fingers, and was not receiving therapy, restorative, or any type of services to prevent further decline in limited range of motion. The resident had no splints in-place at the time of interview. There were no splints observed in the resident's room. Observation on 01/28/25 at 8:41 A.M., of Resident #18 revealed the resident was in bed, eating breakfast. Resident #18 utilized a cup with a lid and was noted to have limited range of motion in her hands and fingers. Resident #18 was not wearing any splint or brace. Observation of Resident #18 and interview on 01/29/25 at 11:41 A.M., with Licensed Practical Nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365429 If continuation sheet Page 15 of 25 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 365429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (LPN) #147, CNA #112, and CNA #161 confirmed Resident #18 did not have a wrist splint in place. CNA #161 reported she forgot to put the wrist splint on today because the resident usually refuses to wear it. CNA #161 reported she didn't know the frequency or time the splint was to be worn. CNA #112, CNA #161, and LPN #147 reported that the CNAs were responsible for applying the splints. The splints were not on the task tab for the CNAs to document or see the orders for the splints. LPN #147 reported the finger splints were not on the TAR to sign off when the finger splints were applied, however the splint to the wrist was listed on the TAR. Staff could not locate the wrist or finger splint initially. CNA #161 later found the wrist splint in a chair under a pile of linen; however, the CNA could not locate the finger splints. The wrist splint was marked with an R (right). CNA #161 applied the splint to the resident's right wrist. CNA #112 returned to the resident's room and found the finger splint. CNA #112 reported she would apply the finger splints after lunch. Interview on 01/29/25 at 12:09 A.M., with LPN #106 confirmed the order, TAR, and care plan for Resident #18's wrist splint don't indicate which wrist to apply the splint to and verified the application of the finger splints were not listed on the TAR. The CNAs were responsible for applying the splints; however, the splints were not on the task for the staff to sign off that the splints were applied. Interview on 01/29/25 at 12:32 P.M. and 1:25 P.M. via email with the Director of Nursing (DON) confirmed the range of motion assessment was inaccurate and Resident #18 had limited range of motion in the wrist and fingers. The facility did not have access to therapy notes prior to October 2024 as the facility had switched therapy companies. The DON stated the facility was going to have occupational therapy to evaluate the resident to see what splints were needed or not needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365429 If continuation sheet Page 16 of 25 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 365429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832 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 - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and review of the facility policy, the facility failed to ensure fall interventions were in place for a resident at risk for falls. This affected one (Resident #42) of three residents reviewed for accidents. The facility census was 62. Findings include: Review of the medical record revealed an admission date of 12/16/24. Diagnoses included Alzheimer's disease, anxiety disorder, paroxysmal atrial fibrillation, type two diabetes mellitus, hypertension, chronic lung disease and depression. Review of the Minimum Data Set (MDS) 3.0 significant change assessment dated [DATE] revealed Resident #42 had a Brief Interview for Mental Status (BIMS) Score of 5, indicating severely impaired cognition. Resident #42 was assessed to require assistance with activities of daily living (ADLs) including setup for eating and oral care and hands-on assistance with bathing, dressing, and transfers. Resident #42 used a wheelchair for mobility. Further review revealed the resident had fallen prior to the assessment and had experienced two or more falls since the last assessment. Resident #42 was frequently incontinent of bowel and bladder. Review of Resident #42's care plan dated 02/16/24 revealed the resident was care planned as at risk for injury related to decreased safety awareness. Listed interventions included to keep call light in reach, monitor the environment for any potential hazards, and for signage in room as a reminder to ring for help. On 06/21/24, an additional intervention of dycem was to be applied underneath the (incontinence) bed pad. On 07/06/24, an additional intervention to place a sign in the room to remind the resident to use his walker was placed. On 08/17/24, Resident #42's bed was moved to the side of the wall. On 09/30/24, dycem was applied to Resident #42's wheelchair. Review of Resident #42's active physician's orders revealed an order dated 09/30/24 for dycem to the resident's wheelchair as a fall intervention. Observation on 01/30/25 at 8:04 A.M. of Resident #42 revealed the resident was seated in his wheelchair in the hallway. Certified Nursing Assistant (CNA) #193 was attaching leg rests to the resident's wheelchair. There was no dycem observed in the wheelchair. CNA #193 pushed the resident in his wheelchair to the dining room. Observation of the resident's room revealed no signs were posted in the resident's room as indicated in the care plan as fall prevention interventions. The resident's bed was not against the wall, and no dycem was noted to the resident's bed underneath the pad as specified in the resident's care plan. Observation and interview on 01/30/25 at 8:13 A.M. with Registered Nurse (RN) #104 confirmed Resident #42's dycem was not in his wheelchair, on the bed, and there were no signs placed in the room as stated in the resident's care plan. RN #104 stated the resident's care plan needed to be updated to reflect the current fall interventions. Interview on 01/30/25 at 9:10 A.M. with the Director of Nursing (DON) revealed the process for completing fall investigations included the nurse assessment at the time of the fall and initiation of the post fall packet. Every morning, the shift report was reviewed for incidents and interventions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365429 If continuation sheet Page 17 of 25 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 365429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832 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 - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Falls were reviewed with residents, if able, and a root cause analysis was performed. Afterwards, the intervention was added to the resident's plan of care. Care plans were then reviewed and revised monthly or with interdisciplinary team (IDT) meeting to monitor for effectiveness of interventions. Review of the undated policy titled Falls revealed the policy provided guidelines to investigate and document falls in an attempt to reduce and prevent injury from further falls. The procedure indicated after a fall, nursing staff was to initiate an immediate intervention to prevent another incident. The intervention must be appropriate. The interventions must be documented in the nurses' notes and placed on the resident's care plan and CNA worksheets. It stated to monitor the effectiveness of the intervention to prevent further incidents, document effectiveness and/or lack of effectiveness of intervention in the resident's record, notify the supervisor if the intervention was not effective and another intervention would need initiated to prevent resident injury. Event ID: Facility ID: 365429 If continuation sheet Page 18 of 25 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 365429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to ensure nurse staffing information was posted. This had the potential to affect all residents residing in the facility. The facility census was 62. Residents Affected - Many Findings include: On 01/27/25 at 8:59 A.M., observations revealed the only staffing information posted was dated 01/24/25. On 01/27/25 at 8:59 A.M., Business Office Personnel #157 verified the information posted was dated 01/24/25. She was unaware who was responsible for posting the staffing information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365429 If continuation sheet Page 19 of 25 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 365429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and review of facility policy, the facility failed to ensure multi-dose insulin pens were dated as to when they were first accessed. This affected two residents (Resident #32 and #166) out of 11 residents identified by the facility as receiving insulin injections. The facility census was 62. Findings include: Observation on 01/27/25 at 11:20 A.M. of the rehabilitation hall medication cart with Licensed Practical Nurse (LPN) #158 revealed two multi-dose insulin pens were accessed but were not dated as to when they were first opened and accessed. The two pens were Resident #32's Glargine Solostar (insulin) 100-unit pen and Resident #166's Tresiba (insulin) 200-unit pen. Interview on 01/27/25 at 11:30 A.M. with LPN #158 confirmed the two multi-dose insulin pens were not dated as to when they were first opened and accessed. An interview on 01/30/25 at 10:26 A.M. with the Director of Nursing (DON) revealed all insulin was to be dated when accessed for the first time. Review of the facility policy titled, Multi-dose Pens of Injectable Medications, dated 06/02/15 revealed pens were to be dated when opened and have the initials of the first person to use the pens recorded on the multi-dose pen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365429 If continuation sheet Page 20 of 25 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 365429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, psychiatrist billing list, and interview, the facility failed to ensure residents records were complete and included in-house psychiatric progress notes and Nurse Practitioner (NP) notes. This affected two (Resident #5 and #18) of five residents reviewed for unnecessary medications. The facility census was 62. Findings include: 1. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including schizophrenia, dementia with psychotic disturbance, depression, coronary artery dissection, Alzheimer's disease, allergic rhinitis, constipation, ulcerative colitis, anxiety, insomnia, chronic kidney disease, heart disease, mood disorder, gout, gastro-esophageal reflux, hyperlipidemia, hypothyroidism, overactive bladder, sleep apnea, Parkinsonism, anemia, and atrial fibrillation. Review of the psychiatrist billing list dated 01/17/24 to 12/20/24 revealed Resident #5 was seen by the psychiatrist on 09/25/24, 10/23/24, and 11/20/24. Review of Resident #5's medical record revealed no evidence of psychiatrist notes for 09/25/24, 10/23/24, and 11/20/24. Interview on 01/30/25 at 7:48 A.M., with the Director of Nursing (DON) confirmed the resident was seen by psychiatry, however the notes were not in the resident medical record, and she had reached out to the psychiatrist office for progress notes. Interview on 01/30/25 at 11:39 A.M., with Licensed Practical Nurse (LPN) #106 confirmed the Resident #5 was seen by psychiatry on 09/25/24, 10/23/24, 11/20/24, and in January 2025. However, the psychiatrist office only sent over the 09/25/24 visit due to the 10/23/24 and 11/20/24 notes had not been typed and were unavailable. 2. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including Parkinsonism, insomnia, bipolar, anxiety, chronic pain, hypotension, dementia with behavioral disturbance, schizoaffective disorder, anemia, suicidal ideations, hemorrhage, psychotic disorder with hallucination, bipolar, acute kidney failure, low back pain, gastro-esophageal reflux, heart disease, and hyperlipidemia. A. Review of psychiatry billing list dated 01/17/24 to 12/20/24 revealed the resident was seen by psychiatry on 01/17/24, 03/19/24, 05/22/24, 06/21/24, 08/26/24, 10/23/24, and 11/20/24. Review of Resident #18's medical record revealed no evidence of psychiatrist notes for 01/17/24, 03/19/24, 05/22/24, 06/21/24, 08/26/24, 10/23/24, and 11/20/24. Interview on 01/30/25 at 11:39 A.M., with Licensed Practical Nurse (LPN) #106 confirmed Resident #18 was seen by psychiatry on 01/17/24, 03/19/24, 05/22/24, 06/21/24, 08/26/24, 10/23/24, and 11/20/24. However, the progress notes were not provided to the facility. The psychiatry office was contacted and faxed over the progress notes for 01/17/24, 03/19/24, 05/22/24, 06/21/24, and 08/26/24. The progress notes for 10/23/24 and 11/20/24 had not been typed and were unavailable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365429 If continuation sheet Page 21 of 25 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 365429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete B. Review of Resident#18's primary provider notes revealed the resident had not been seen by her primary provider since September 2024. Interview on 01/30/25 at 10:11 A.M. with the DON verified the resident's medical record contained no evidence she had been seen by her primary provider since September 2024. The DON stated she had called the provider's office, and the office reported a Nurse Practitioner (NP) had seen the resident on 11/05/24 and the office was going to fax over the progress notes for the resident medical record. Event ID: Facility ID: 365429 If continuation sheet Page 22 of 25 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 365429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, policy review, and interview, the facility failed to ensure antibiotics were utilized only when medically necessary. This affected one (Resident #61) of two residents reviewed for antibiotic use. The facility census was 62. Residents Affected - Few Findings include: Review of Resident #61's medical record revealed an admission date of 11/26/24 and diagnoses including urinary tract infection, fracture of the surgical neck of the left humerus (long bone in the arm that runs from the shoulder to the elbow), and diabetes mellitus. Resident #61 was sent to the hospital 12/12/24 for an acute fracture of the proximal right femur (thigh bone). Resident #61 returned to the facility 12/14/24 with orders for Doxycycline (antibiotic) 100 milligrams (mg) twice a day for post-operative infection prevention to the right hip for a total of 19 administrations. A nursing progress note dated 12/15/24 at 7:05 P.M. indicated an unnamed Certified Nursing Assistant (CNA) alerted the nurse Resident #61's urine was dark colored. Resident #61 complained of her bladder burning. A nursing progress note dated 12/15/24 at 7:57 P.M. indicated an order was received for a urinalysis and culture and sensitivity the following day. Review of Resident #61's urinary analysis with culture and sensitivity if indicated, the specimen collection and received date was 12/16/24 and the results reported to the facility date of 12/18/24, revealed the urine culture read that 40 to 50,000 colony forming unit per milliliter (CFU/ml) enterococcus faecium and less than 10,000 CFU/ml gram negative rods (GNR) were noted in the urine. It stated no sensitivity would be completed. Review of the Urinary Tract Infection (UTI) without Catheter form revealed hand written writing at the top that stated Resident #61's name, 40 to 50,000 CFU/ml enterococcus faecium, Nitrofurantoin for five days, and 12/18-12/23. The form was used to assist the physician in decision making if the resident had a UTI or not. Under the Laboratory Results section of the form, it asked if the urine sample had at least 100,000 CFU/ml of no more than two species of microorganisms and No=NO UTI was check marked. If yes had been check marked, it stated to evaluate for symptoms of UTI. Under the Signs and Symptoms of UTI section of the form, question number one, it asked if the resident had acute dysuria or acute pain, swelling or tenderness of the testes, epididymis, or prostate and Yes=UTI was check marked. Under the Signs and Symptoms of UTI section of the form, question number two, it asked if the resident had a fever or leukocytosis AND one of the following: acute costovertebral angle pain or tenderness, suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marker increase in urgency, or new or marked increase in frequency. It stated if the answer was yes, to update the doctor and document or no, and no meant no UTI. No was check marked. A nursing progress note dated 12/18/24 at 1:34 P.M. indicated the nurse practitioner reviewed the urine culture and gave orders for Nitrofurantoin (antibiotic) for five days due to a urinary tract infection. On 01/28/25 at 4:09 P.M., Licensed Practical Nurse (LPN) #106 acknowledged when she evaluated Resident #61's December 2024 urinalysis laboratory tests she determined the resident did not meet the criteria for treating the resident's UTI with antibiotic therapy. LPN #106 verified there was no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365429 If continuation sheet Page 23 of 25 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 365429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832 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 0881 Level of Harm - Minimal harm or potential for actual harm documentation indicating she had contacted the nurse practitioner or doctor about the results and the infection criteria not being met. LPN #106 acknowledged the risk for multi-drug resistant organisms due to frequent antibiotic use as Resident #61 had been admitted to the facility on antibiotics in November 2024, had prophylactic antibiotics ordered after her hip surgery, and received Nitrofurantoin when UTI treatment criteria was not met. Residents Affected - Few On 01/29/25 at 12:07 P.M., LPN #106 verified the facility's antibiotic stewardship policy did not address the use of prophylactic antibiotics. Review of the facility policy Antibiotic Stewardship (signed by a physician on 07/02/18) revealed the infection control nurse would evaluate all new admissions and determine if the resident met the McGeer's criteria for the antibiotic use and if they did not, they would contact the physician and/or Certified Nurse Practitioner (CNP) as soon as possible to see if they wanted the antibiotic continued or discontinued. The facility recognized that even though a resident was not meeting the McGeer's criteria, the physician had the right to order the antibiotic based on other clinical signs and symptoms. The facility would establish protocols utilizing the McGeer's guidelines in order to determine if a resident had an infection or not. The information from those guidelines have been communicated to the facility physicians/CNP to help them in determining if an antibiotic should be used. The policy indicated the facility would monitor all antibiotics used and communicate with the physician if an antibiotic was started prior to any testing results and the results came back all within normal limits to see if the physician wanted the antibiotic to continue or not. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365429 If continuation sheet Page 24 of 25 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 365429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Manor Nrsg & Rehab Ctr 1100 East State Road Newcomerstown, OH 43832 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 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview with staff, and review of the facility policy, the facility failed to maintain a safe and clean environment free from discarded cigarette butts in the resident smoking area. This had the potential to affect all residents residing in the facility. The facility census was 62. Residents Affected - Many Findings include: Observation on 01/27/25 at 11:15 A.M. the resident smoking area with Housekeeper #201 revealed several cigarette butts on the concrete pad under the awning and in the stones by the building where the residents smoked. There were several leaves laying around the area which could catch on fire. Interview on 01/27/25 at 11:20 A.M. with Housekeeper #201 confirmed the cigarettes were not discarded properly in the fireproof container. Review of the undated policy titled, Smoking/Electronic Cigarettes revealed the purpose was to educate all staff and residents on the policy and procedure in regard to smoking and electronic cigarettes. The policy made no mention of proper discarding of cigarettes. Review of the undated policy Staff Smoking revealed cigarettes were to be discarded in a metal self-closing ash tray. No paper was to be placed inside the ash tray. Maintenance would check ash tray and empty as needed. A fire extinguisher was available and located in the staff smoking area for use if necessary. The policy stated to discard cigarette butts in the ash tray and to not throw cigarette butts on the ground. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365429 If continuation sheet Page 25 of 25