Health inspection·December 4, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete her room where CNA #110 fed the resident. LPN #115 wrote that she did not remember what she said. Resident #19's continuous screaming and the other residents getting upset took a toll on LPN #115. A handwritten statement revealed RN #116 interviewed Resident #69 (a resident on the memory care unit). Resident #69 stated nothing happened at lunch. When Resident #69 was asked if he heard yelling, he said yes, a lady was yelling. When asked if staff said anything, Resident #69 said staff did not do anything inappropriately. Resident #69 did state he did not see the staff member, but the staff member was on the other side of the room, but he did hear yelling from the staff member. Resident #69 did not know what the staff member yelled. A handwritten note by CNA #118 (no date) revealed they were walking down the hallway and heard yelling coming from the dining room but did not hear what was said. The facility investigation also included an email from a legal consultant dated 07/23/25 at 4:05 P.M. revealed the following topics should be covered with staff: customer service; abuse, neglect, mistreatment policy with emphasis on verbal abuse, and behavior management as it pertains to preventing abuse. It was recommended that the intradisciplinary team review the resident's chart, reasons for underlying behaviors, medications, other relevant items, and then review the resident's care plan to make sure it addresses the verbal behaviors and how to avoid. The facility should probably not say that Resident #19 was made to eat in her room due to verbal outbursts as it might sound like involuntary seclusion. It should be shown that the facility was working to address Resident #19's behaviors. A chart review would also serve to claim there was no adverse impact to the resident. It should also be said that social service designee checked on the resident to assure them she remained free of adverse physical or psychosocial effects and check on the resident periodically as needed. It was also recommended that audits be done to make sure staff understand what you trained them on to make sure they are good to go, free of abuse. This likely will not constituted a harm tag but having a good action plan in place might help avoid a deficiency altogether even if Ohio Department of Health (ODH) considers it abuse just because she used the words shut up. We will have to look at the wording on the conclusion. Even if we say unsubstantiated, we will want ODH to know that we are owning the situation and taking thorough action. An email from RN #116 to legal consultant dated 07/23/25 at 3:49 P.M. revealed LPN #115 was written up and moved to another unit and received education with a ten-question quiz. Resident #19 will eat all meals in her room due to screaming. LPN #115 was walked to the time clock and put off until the investigation was complete. An interview on 12/04/25 at 3:32 P.M. Administrator verified LPN #115 was unprofessional but stated abuse did not occur because Resident #19 did not have a negative outcome, and LPN #115 did not confirm that she said, shut up. The Administrator verified LPN #115 continued to work after the altercation in the dining room and did not clock out on 07/22/25 until 1:30 P.M. Review of the Policy and Procedure for Prevention of Mistreatment, Neglect, and abuse of Residents and Misappropriation of Resident Property, dated 12/29/16, revealed verbal abuse was defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or within their hearing distance regardless of their ability to comprehend. When staff members become aware of a possible abuse incident, they should report it to their department head or charge nurse. If the incident involved a possible staff to resident abuse, the administrator and department head will not permit the staff member to work while an investigation is conducted. This deficiency represents non-compliance investigated under Complaint Number 2623349. Event ID: Facility ID: 365429 If continuation sheet Page 2 of 8 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 12/04/2025 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of a self-reported incident (SRI), interviews, and policy review, the facility failed to ensure Resident #18 was not restrained in a wheelchair without adequate training, assessments, and orders. This affected one (Resident #18) out of three residents reviewed for abuse. The facility census was 70.Findings include:Review of the medical record revealed Resident #18 was admitted on [DATE] with diagnoses that included dementia, history of transient ischemic attack, down syndrome, type 2 diabetes, and dysphagia.Review of the plan of care dated 02/20/25 revealed Resident #18 had the potential for injury related to poor decision-making skills. An intervention dated 06/06/25 for the resident to have a custom fitted wheelchair with adaptations for safety when in chair to be delivered after measured and approved by Medicaid. Review of a general progress note dated 06/02/25 at 6:00 A.M. revealed Resident #18 was on the floor in front of the chair. The resident had red drainage noted from the mouth. The resident had a one centimeter (cm) long, 0.1 cm wide, and 0.1 cm deep cut on the inner upper lip and an abrasion 2.0 cm long and 3.0 cm wide in the middle of the forehead. A general progress note dated 06/02/25 at 9:50 A.M. revealed Resident #18's sister requested the resident be sent to the hospital for evaluation. A general progress note dated 06/02/25 at 7:47 P.M. revealed Resident #18 returned to the facility at 7:40 P.M. A general progress note dated 06/03/25 at 2:48 P.M. revealed Resident #18's sisters were concerned about how Resident #18 fell out of her chair. It was explained that the resident went forward out of the chair. The Director of Nursing (DON) spoke to therapy to do a face-to-face so the resident could get a new wheelchair adapted for the resident's body size and with support straps if warranted for safety. Review of the facility SRI tracking #261249 dated 06/05/25 revealed on 06/02/25 Resident #18 lunged forward in chair and fell to the floor. Resident #18 was sent to the hospital for evaluation. On 06/04/25 at 8:45 P.M. the emergency doctor called the facility and reported Resident #18 had a cervical five fracture. Resident #18's family asked if a chest strap could be used while Resident #18 was in the Broda chair (a specialized positioning wheelchair). The DON informed the family that Resident #18 could not release the strap upon command, and it would be considered a restraint. The DON talked with therapy about a custom wheelchair that could be adapted to the resident and consist of lateral supports, tilt in space mechanics, chest harness, and lap belt to promote correct posture and allow Resident #18 to be up in a wheelchair safely and ensure hips remained in the proper position when in the chair to reduce the resident's fall risk. Review of the medical record revealed on 10/06/25 at 6:13 P.M. Resident #18 weighed 106 pounds and was 56 inches tall.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had severely impaired cognitive skills. The MDS also revealed the resident used a wheelchair and was dependent on staff for eating and transfers.Review of the quarterly fall risk tool dated 10/14/25 revealed Resident #18 did not have a fall in the last 30 days. The resident had agitated behavior that occurred less than daily and was confined to a chair and disoriented. The plan of care was ongoing. Review of a general progress note dated 10/21/25 at 12:07 P.M. revealed the DON was notified the new custom wheelchair would be delivered on 10/28/25 at 9:00 A.M. Resident #18's sister stated they would be present for the delivery and fitting of the wheelchair. The sister would be educated by the delivery representative on the safety features of the chair to include the harness which would allow the resident to be up in a chair longer and reduce leaning forward and to the side. In the resident's current chair, she scoots down and bends neck forward.Review of a general progress note dated 10/28/25 at 6:52 P.M. revealed Resident #18 received her new chair this morning. Resident #18 leaned to the right and forward and was repositioned several times.Review of a typed Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365429 If continuation sheet Page 3 of 8 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 12/04/2025 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few note (no date) revealed Resident #18's new chair ‘holister' is to be used only if needed. She does not need to be strapped in unless falling, combative, or leaning.Review of the Occupational Therapy (OT) evaluation dated 10/28/25 revealed treatment may include wheelchair management training. The reason for the referral was a new custom fit wheelchair delivered this date with vendors addressing education with Resident #18's family regarding fit, features/appliances and specialized seating. OT will be required to remain engaged with the wheelchair to promote highest comfort, skin integrity, and positioning in wheelchair. Occupational Therapist Registered (OTR) signed the evaluation and plan of treatment on 10/29/25 at 8:27 P.M. The OTR assessment summary revealed the OTR was not at the location when Resident #18 was fitted to the new wheelchair. Resident #18 was in bed and was no longer in custom wheelchair when OTR arrived to assess the resident. Review of a Safety Device Screen dated 10/29/25 at 4:56 P.M. revealed recommendations to achieve the residents highest physical, mental, and psychosocial well-being included a seat belt and harness to wheelchair for positioning. A summary/explanation of equipment/restraint revealed a new wheelchair was discussed with family and the family opted to proceed with having Resident #18 measured and authorized through Medicaid to get a new wheelchair. When the wheelchair arrived, it was a reclining back tilt in space adaptive wheelchair with a seatbelt and harness to be used for positioning. Resident #18 was not ambulatory and dependent on staff for all transfers; therefore, the use of the harness or seatbelt were not restraints. The seatbelt and harness were enablers to allow Resident #18 to sit up safely in the chair without fear of falling forward and to promote better posture so that the resident could set up after meals because of her severe dysphagia. Review of a general progress note dated 10/29/25 at 5:34 P.M. revealed Resident #18 continued in the new chair and was noted to be leaning more to the right side. The resident was repositioned multiple times and a pillow was placed on the resident's right side. Resident #18 removed the pillow multiple times. At one point the resident was completely sideways on her right side and was leaning all the way out where the resident's hand was on her wheel. Review of a physician order dated 10/29/25 at 6:07 P.M. revealed Resident #18 to be in adaptive wheelchair, with seatbelt, to aid in positioning and harness to be applied as needed for positioning if leaning over the side of the chair. The treatment administration record (TAR) was marked the evening of 10/29/25 and the morning and evening 10/30/25 that Resident #18 was in adaptive wheelchair, with seatbelt, to aid in positioning and harness to be applied as needed for positioning, if leaning over the side of the chair. Review of an OT treatment encounter note signed 10/29/25 at 7:27 P.M. authored by Certified Occupation Therapy Assistant (COTA) #120 revealed staff education and training on proper use, positioning, and safety features of the new wheelchair at 12:00 P.M. prior to lunch. Staff present for the initial training included Physician Therapy Assistant (PTA) #121, Certified Nursing Assistant (CNA) #113, and Restorative Aide/CNA #112. Upon arrival, Resident #18 was observed seated improperly in wheelchair, requiring repositioning with the use of mechanical lift pad to achieve proper alignment and postural support. The resident demonstrated agitation during the session; therefore, the harness was not applied to prevent escalation of behaviors and ensure resident safety. The therapist provided comprehensive education on correct harness placement, including securing harness across the back corner of the chair and fastening the zipper to ensure safe positioning while maintaining adequate comfort and trunk mobility. Instruction was provided on the proper alignment of the harness along the curved contour of the chair back to promote upright posture and reduce fall risk. The therapist also educated staff on appropriate use of the seat belt for positioning purposes, emphasizing its role in maintaining safety, comfort, and fall prevention. The wheelchairs reclining and tilt features were demonstrated to all staff, with detailed explanation of clinical indications for each function to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365429 If continuation sheet Page 4 of 8 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 12/04/2025 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few optimize pressure relief and postural stability. Licensed Practical Nurse (LPN) #102 received verbal education regarding the intended purpose and safe use of both harness and seat belt and agreed to place an order for as needed use of the harness for positioning and fall-prevention purposes, consistent with recommendations provided by the medical group during the initial wheelchair fitting. LPN #102 verbalized full understanding of the education provided. Therapists will continue to monitor staff compliance with harness and seat belt protocols, assess resident tolerance and positioning during ongoing sessions, and provide re-education as needed to ensure continued safe use in accordance with manufacturer and clinical guidelines. Review of the facility SRI tracking #266952 dated 10/30/25 revealed an allegation of neglect. On 10/29/25 the DON received a call that Resident #18's sister was upset about the new wheelchair. The resident's sister arrived at the facility and saw the harness strap was on Resident #18 and there was a red area on the resident's neck. The DON stated she had not seen the new wheelchair yet but would check it out as soon as she went back to work. The DON messaged LPN #102 and asked what was going on and that the resident's sister was upset over the harness and that Resident #18 had a red mark. LPN #102 stated the staff were educated to put the harness on when Resident #18 was in the chair and leaning over and when eating. Resident #18 was leaning so far over that LPN #102 thought the safest thing would be for the harness to be applied. Resident #18's sister took the harness off and said it was too tight and that was why there was a red mark. It was explained if Resident #18 was moving around that could cause the red mark. The therapy manager stated Resident #18 was to wear the seat belt for positioning and the harness was to only be worn as needed where there was a danger of falling. The resident's sister wanted the state agency notified and an investigation completed for abuse because Resident #18 was restrained. A meeting was held on 10/30/25 and it was agreed that the harness and seatbelt would not be used. The DON discussed the safety features of the wheelchair and the fact that Resident #18 was so small she was at risk of choking herself if she slid down into the chair like she did in the Broda chair. The DON explained she was under the impression Resident #18 was to wear the harness at all times in the chair. The Administrator, DON, and Resident #18's sisters went to observe the resident. Resident #18 was in the new wheelchair with the seatbelt on. The chair was reclined; however, the resident was sitting straight up. It was observed at there was a notable gap between the arm rest and the chair back that the resident's body most definitely could fit in between and did not appear safe. Resident #18 was transferred back to her old Broda chair until the wheelchair representative could be contacted about more adaptations. The staff were informed that the new wheelchair was not to be used.Review of a handwritten statement dated 10/29/25 by CNA #108 revealed Resident #18 was leaning in her wheelchair with her head hanging way over the side. The staff were concerned for the resident's safety so the harness was placed on the resident on 10/29/25. On 10/28/25 when the new wheelchair arrived, staff put the harness on the resident at 3:45 P.M. when the resident was got up for dinner because she was leaning. PTA #121 came to the memory care unit on 10/29/25 and said the harness could be put on the resident for meals because the resident needed to sit up straight when she ate. A handwritten statement dated 10/29/25 by CNA #109 revealed Resident #18 was sideways in her chair leaning to the right. The nurse and CNA's thought it was in the resident's best interest to use the harness for the resident to sit upright to eat dinner. The harness was adjusted by therapy, and it seemed tight so CNA #109 and another CNA loosened it. The harness was loose enough for the resident to still move around. CNA #109 went to get Resident #18's dinner tray and when she came back Resident #18's sister was livid and demanded to talk to someone in charge because Resident #18 was not to be in the harness at all. The sister stated the seatbelt would keep the resident from falling out of the chair. The sister then said it was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365429 If continuation sheet Page 5 of 8 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 12/04/2025 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few okay for the resident to be in harness if absolutely needed but not all the time. A handwritten statement (no date) by CNA #110 revealed on 10/28/25 Resident #18 was fitted for a new wheelchair that was equipped with a harness. Resident #18 was up at 3:45 P.M. (on 10/28/25) and the harness was placed on the resident by the CNA's and nurse. Resident #18's sister arrived at approximately 5:00 P.M. and stated they did not want the harness on the resident except in really bad situations and if it was absolutely necessary. CNA #108 and CNA #111 came over, and they all agreed to pass on the sister's request. On 10/29/25 around 3:15 P.M. CNA #110 and CNA #109 got Resident #18 out of bed. Around 4:15 to 4:20 P.M. CNA #109 noticed Resident #18 was leaning significantly. CNA #108, CNA #109, and LPN #102 discussed the harness. CNA #110 told them about the conversation with Resident #18's sister on 10/28/25 and that the family did not want the harness used. It was stated that PTA #121 educated them (staff) this morning and proceeded to fasten the harness. The restraint seemed higher up on Resident #18's body than yesterday but they thought they were able to adjust it properly. At approximately 4:30 P.M. Resident #18's sister arrived and was upset that the harness was on and there was a red mark on the resident. Abuse concerns were discussed. There was a note at the desk that stated the harness could be used in certain situations. The sign was made and signed by CNA #111 and approved by the resident's sister on 10/28/25. Review of a typed statement dated 10/30/25 by CNA #112 revealed on the afternoon of 10/28/25, Resident #18 was observed in the hallway wearing a harness, and it appeared tight. CNA #112 asked CNA #108 and CNA #110 what the contraption was, and CNA #110 said apparently this is Resident #18's new chair but no one showed us how she is supposed to be in it. CNA #112 stated that she did not think it was safe and looked like it was pinching the resident's neck. CNA #110 unzipped the harness and took Resident #18 to her room to put the resident in bed. During morning meeting on 10/29/25, CNA #112 asked what the harness was because it looked tight. PTA #121 said it was a new chair and had a harness and seatbelt. It was stated in morning meeting that the restraint should not be on. PTA #121 stated the wheelchair people said it was fine due to positioning. It was discussed how it needed to be looked at if it was a restraint or an order had to put in for safety. Around 11:45 A.M. PTA #121 and COTA #120 asked CNA #112 if she wanted to come back and be educated about the new wheelchair. Resident #18 was in the activity room and did not have a seatbelt or harness on. PTA #121 then showed how the chair worked with the tilt back and recline and showed the seatbelt and the left harness strap. It was not physically put on the resident, but it was shown how it wrapped around the wheelchair. PTA #121 asked who else could be trained because the regular aides on the memory unit were not there. CNA #113 went into the activity room as PTA#121 and COTA #120 were putting the seat belt on Resident #18. PTA #121 explained to CNA #113 how the chair worked and how the harness went around the chair but did not apply the harness. CNA #113 asked if Resident #18 was to wear the harness when eating. PTA #121 said yes that she believed it would be a good idea. Social Worker (SW)/RN #123 walked in the room and PTA #121 was explaining to SW/RN #123 about the harness and seatbelt and how it could be written up as an order so it was not referred to as a restraint. SW/RN #123 was unsure if that was acceptable. Resident #18 continued to wear the seatbelt, but the harness was never applied. Review of a general progress note dated 11/04/25 at 10:24 revealed the DON, wheelchair representative, and Resident #18's two sisters met and reviewed the new wheelchair. The wheelchair was modified and adaptations were made to allow the chair to be tilted but not reclined. This prevented Resident #18 from having access to lean over the side between the back and arm rest. An interview on 12/04/25 at 11:30 A.M. CNA #110 verified they were not educated on how to put the harness on Resident #18. CNA #110 verified the staff should have waited, but the purpose of new wheelchair was to have the harness. Therapy had educated some of the staff, so they used the harness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365429 If continuation sheet Page 6 of 8 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 12/04/2025 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete There was conflicting information because the family wanted the harness and then only wanted the harness used in extreme situations. CNA #110 verified Resident #18 would lean forward and to the right a lot. An interview on 12/04/25 at 11:39 A.M. SW/RN #123 verified she questioned the harness and seatbelt being a restraint. SW/RN #123 stated the harness was not used that she knew of. An interview on 12/04/25 at 11:44 A.M. LPN #102 stated it was explained to her how the wheelchair/harness/seatbelt worked and it was ready. The harness had straps that were hooked in the front. LPN #102 stated Resident #18's family removed the harness when they arrived. The family wanted the harness and then did not want it used. Interviews on 12/04/25 at 11:53 A.M. COTA #120 and PTA #121 verified staff were not supposed to put the harness and seatbelt on Resident #18 until therapy evaluated the wheelchair. The harness was only to be used if Resident #18 would not sit up straight. The people of the wheelchair company put the harness on the wheelchair and OT was not even aware the wheelchair would have a seatbelt and/or harness. There was nothing in the notes. COTA #120 and PTA #121 verified they gave verbal education to some of the staff but never put the harness on Resident #18 to show how it should fit. Additional training needed to be completed, but the nursing staff started using the harness and seatbelt before giving therapy time to evaluate how the harness would fit Resident #18. An interview on 12/04/25 at 1:17 P.M. Resident #18's Sister #300 verified Resident #18 was wearing the harness on 10/28/25. Sister #300 told the staff not to use the harness and had a CNA write a note to put at the nurse's station. The next day Sister #301 arrived at the facility and saw Resident #18 had the harness on and there was a red mark on the resident's neck. Sister #300 stated a new wheelchair was ordered because Resident #18 was so small and they hoped it would help keep the resident from falling out of the chair. The staff at the nursing home started using the wheelchair immediately. Therapy staff stated they trained staff, but the nursing staff stated they were not trained. The harness and seatbelt were no longer being used due to fear of choking the resident when the resident slid down in the chair. An interview on 12/04/25 at 2:49 P.M. Administrator verified therapy was not present when the wheelchair arrived on 10/28/25. Resident #18's family were educated by the wheelchair company. An interview on 12/04/25 at 2:50 P.M. DON verified the orders and assessments for the harness and seatbelt were not completed until after the harness and seatbelt were used. An additional interview on 12/04/25 at 3:57 P.M. PTA #121 verified the wheelchair was not evaluated by therapy on 10/28/25. The OTR would have to be the person to evaluate the proper use of the harness. Review of the undated Restraint Management and Reduction policy revealed residents have the right to function at their highest practicable level in the least restrictive environment possible. Restraints/seclusion will not be used unless the facility's interdisciplinary team has completed an assessment and evaluation to determine causative medical factors and consider less restrictive alternative approaches. Restraint or seclusion must not result in harm or injury to the resident. In the event the resident if found incapable of making decisions, the responsible party will exercise the right to refuse or accept the use of restraints. A physical restraint is any manual method, physical or mechanical device, material, or equipment attached or adjacent to the resident's body in a way that the individual cannot easily remove, which restricts freedom of movement or normal access to one's body. This deficiency represents non-compliance investigated under Complaint Number 2623349. Event ID: Facility ID: 365429 If continuation sheet Page 7 of 8 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 12/04/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of self-reported incidents (SRI), interviews and policy review, the facility failed to ensure allegations of verbal abuse by staff towards Resident #19 were immediately reported. This affected one (Resident #19) out of three reviewed for abuse. The facility census was 70.Findings include:Review of the medical record revealed Resident #19 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia and hemiparesis, dementia, anxiety, bipolar disorder, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of nine out of 15 which indicated cognitive impairment. Resident #19 had verbal behaviors one to three days during the seven-day assessment period. Review of SRI tracking #263082 dated 07/22/25 at 2:49 P.M. revealed Resident #19 was sitting in the dining room with other residents getting ready to eat lunch. Resident #19 began screaming. Certified Nursing Assistant (CNA) #110 said Resident #19's name. Licensed Practical Nurse (LPN) #115 yelled, (Resident #19's name) shut up. Resident #19 was taken out of the dining room and placed in common area by LPN #115. Resident #19 continued to yell, and LPN #115 took the resident to her room. CNA #110 fed Resident #19 in her room. CNA #110 updated a Registered Nurse (RN) that LPN #115 verbally abused Resident #19. The facility investigation revealed a handwritten interview with LPN #115 by RN #116. LPN #115 stated Resident #19 was yelling in the dining room with other residents around. LPN #115 stated she probably told Resident #19 to shut up. LPN #115 verified she took Resident #19 out of the dining room into the common area and Resident #19 continued to yell. LPN #115 then took Resident #19 to her room and CNA #110 fed the resident her lunch. A written statement dated 07/22/25 by CNA #110 revealed they took Resident #19 to the dining room for lunch and she began screaming loudly. CNA #110 and LPN #115 were in the dining room. CNA #110 shouted Resident #19's name because the resident would often stop when she heard her name. LPN #115 then yelled (Resident #19's name) shut up really loud. LPN #115 then took Resident #19 to the lobby area. Resident #19 continued screaming so LPN #115 took the resident to her room. CNA #110 served lunch and fed residents as needed and reported the incident as soon as they were able to do so. A handwritten statement by LPN #115 dated 07/22/25 revealed Resident #19 had been screaming since before breakfast. When Resident #19 was brought to the dining room at lunch, the resident continued screaming. Two residents at another table started telling Resident #19 to shut up. LPN #115 removed Resident #19 from the dining room and put the resident at a table in the common area. Resident #19 continued to scream in the common area. LPN #115 then took Resident #19 to her room where CNA #110 fed the resident. LPN #115 wrote that she did not remember what she said. Resident #19's continuous screaming and the other residents getting upset took a toll on LPN #115. The employee timesheet revealed LPN #115 worked on 07/22/25 at 6:45 A.M. to 1:30 P.M.An interview on 12/04/25 at 3:32 P.M. Administrator verified CNA #110 did not immediately report the allegation of abuse. LPN #115 moved Resident #19 from the dining room to the common area and then to the resident's room after allegedly verbally abusing Resident #19. The Administrator verified allegations of abuse should be reported to the Administrator or designee immediately. If the allegation involved a staff member, the staff member should be removed from the facility immediately until an investigation was completed. This deficiency represents non-compliance investigated under Complaint Number 2623349. Event ID: Facility ID: 365429 If continuation sheet Page 8 of 8