Health inspection·November 15, 2019

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident # 17's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbance, senile dementia, major depression recurrent, anxiety disorder, macular degenerations, type two diabetes, femur fracture and peripheral vascular disease. Resident #17 resided on the secure care unit (SCU). Review of Resident #17's activity assessment, dated 07/07/15 revealed her past and present interests were card games, bingo, outdoors, television, music, religious, van outings, arts and crafts, reading, and discussion. Resident #17 wanted to walk and stay busy during the day. Record review revealed Resident #17 did not have a plan of care for activities. Review of Resident #17's annual MDS 3.0 assessment, dated 03/13/19 revealed her speech was clear she understands others, was understood and her cognition was severely impaired. Resident #17 had no behaviors, did not reject care, and wandered daily. Review of Resident # 17's activity interest revealed it was very important for her to have books/magazines, to listen to music, somewhat important for her to be around animals, not very important to keep up with the news, very important to do things with groups of people, to do favorite activities, to go outside, and somewhat important to participate in religious services. Resident # 17 was independent with no set up for bed mobility and to transfer. Review of Resident # 17's quarterly MDS 3.0 assessment, dated 09/02/19 revealed the resident no longer wandered. Interview with Activity Director (AD) #200 on 11/15/19 at 9:58 A.M. confirmed Resident #17 did not have an activity plan of care in place. 4. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included pneumonia, delusional disorder, glaucoma, essential hypertension, abnormal weight loss, dementia with behavioral disturbance, major depressive disorder, hypothyroidism and malignant neoplasm of female breast. Resident #21 resided on the SCU. Review of Resident #21's activity assessment dated [DATE] revealed her past and present interests were card games, bingo, sports, outdoors, music, religion, arts and crafts, gardening, parties, cooking, discussion and dancing. Resident #21 wanted to spend her day doing whatever she wanted. Record review revealed Resident #21 did not have an activity care plan. Review of Resident #21's admission MDS 3.0 assessment, dated 02/26/19 revealed her speech was clear, she understood, understands, and her cognition was severely impaired. Resident #21 had no behaviors, did not reject care and wandered one to three days. Review of Resident #21's activities interests revealed it was somewhat important for her to have books/magazine to read, to listen to music, be around pets, not very important to keep up on the news, somewhat important to do things in groups very important to do favorite activities, and to participate in religious services. Resident #21 required extensive assistance of two staff for bed mobility and to transfer. Review of Resident #21's quarterly MDS 3.0 assessment, dated 09/21/19 revealed the resident usually (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 2 of 28 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm understands, was usually understood, she had verbal behaviors one to three days a week and was independent in bed mobility and to transfer. Interview with Activity Director (AD) #200 on 11/15/19 at 9:58 A.M. confirmed Resident #21 did not have an activity plan of care in place. Residents Affected - Some Based on record review and interview the facility failed to ensure comprehensive care plans related to activities were developed for Resident #11, #15, #17, #20 and #21. This affected five residents (#11, #21, #17, #15 and #20) of 21 sampled residents whose care plans were reviewed. Findings Include: 1. Review of Resident #20's medical record revealed an original admission date of 01/30/18 with the latest readmission of 10/11/19 with readmitting diagnoses of acute impacted left femoral intertrochanteric fracture, unspecified fracture of the lower end of the right femur, dementia, diabetes mellitus and anxiety. Review of the resident's admission activities assessment dated [DATE] revealed the resident enjoyed exercises, outdoors, music, religious, arts and crafts and cooking. The assessment indicated the facility was unsure if the resident was interested in activities. Further review of the resident's medical record revealed no additional assessment involving the resident's family. Review of the resident's plan of care revealed no plan of care addressing the resident's activity deficit was developed. Review of resident's five day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had unclear speech, rarely/never understands others, rarely/never makes herself understood and had a severe cognitive deficit. Review of the mood and behavior section revealed she displayed indicators of depression and had both verbal and physical behaviors directed towards others. The resident required extensive assistance of two staff for bed mobility, personal hygiene and was dependent on two staff for transfers. On 11/15/19 01:30 P.M. interview with the Director of Nursing (DON) verified no activity plan of care had been developed for Resident #20. 2. Review of Resident #15's medical record revealed an admission date of 08/20/19 with the admitting diagnoses of anxiety, dementia and depression. Review of the resident's comprehensive MDS 3.0 assessment dated [DATE] revealed the resident had clear speech, usually understands others, makes himself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of one. Review of the mood and behavior section revealed the resident displayed indictors of depression and wandered on a daily basis. Review of the daily preferences revealed it was somewhat important to do his favorite activities. Review of the resident's plan of care revealed the resident had no plan of care addressing his activity deficit or preferences. On 11/14/19 at 1:57 P.M. with Activity Director #200 verified the resident did not have an activity plan of care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 3 of 28 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm 5. Review of the medical record for Resident #11 revealed an admission date of 12/14/18 with diagnoses of pain in her left shoulder, dementia with behavioral disturbances, anxiety and osteoarthritis. Review of Resident #11's activity assessment, dated 12/15/18 revealed the resident had interest in books, newspapers, magazines, music and fresh air when the weather was good. Residents Affected - Some Review of Resident #11's quarterly MDS 3.0 assessment, dated for 08/08/19 revealed resident with minimal difficulty in hearing, and impaired vision with the use of glasses. Resident #11 was impendent with bed mobility, walking, locomotion on and off the facility unit and eating. Review of Resident #11's care plan, dated 10/16/19 revealed no activity plan of care had been developed for the resident. Review of Resident #11's activity log for the month of 10/2019 and 11/2019 revealed the resident participated mostly in independent activities in her room. Resident #11 would occasionally attend group activities and would go outside for fresh air a few times a day. Interview on 11/14/19 at 2:30 P.M. with Activity Director #200 revealed she does not make a care plan care dedicated to activities if the resident was participating in activities. Activity Director #200 thought an activity care plan was only needed if the resident was not participating in activities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 4 of 28 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure care plans were revised for Resident #31 related to pain management, Resident #20 related to mobility devices and for Resident #197 related to Hospice services. This affected three residents (#31, #20 and #197) of 21 sampled residents whose care plans were reviewed. Findings Include: 1. Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, anorexia, mood disorder, hyperlipidemia, bradycardia, heart failure, osteoarthritis, essential hypertension, hypocalcemia, anemia and falls. Review of Resident #31's admission Minimum Data Set (MDS) 3.0 assessment, dated 02/14/19 revealed the resident's speech was clear, he usually understands, usually understood others, and his cognition was severely impaired. Per the assessment, Resident #31 was on scheduled pain medication and he was not in pain. Resident #31 did not reject care. Resident #31 required extensive assistance of one staff for personal hygiene. Resident #31 did not use oxygen. Review of Resident #31's plan of care, dated 02/08/19 revealed it did not address non-verbal expressions of pain. Interview with Resident #31's daughter on 11/12/19 at 2:18 P.M. revealed since the weekend she felt the resident was in pain. She stated she had reported this to the nurse but was not sure the nurses addressed this. Observation of Resident #31 during the interview revealed he was moaning. The resident's fists were observed to be clenched and he was observed groaning. Observation of Resident #31 on 11/13/19 at 1:43 P.M. revealed he was laying in bed on his back. The resident's fists were clinched and his arms were shaking. On 11/14/19 at 11:00 P.M. Resident #31 was observed in bed laying on his back with his fists clinched and his arms were shaking. Interview with the Director of Nursing (DON) on 11/15/19 at 9:06 A.M. confirmed Resident #31's care plan was not revised to include non-verbal expressions of pain. 2. Review of Resident #20's medical record revealed an original admission date of 01/30/18 with the latest readmission of 10/11/19 with re-admitting diagnoses of acute impacted left femoral intertrochanteric fracture, unspecified fracture of the lower end of the right femur, dementia, diabetes mellitus and anxiety. Review of the resident's plan of care, dated 01/31/18 revealed the resident had a self-care performance deficit related to dementia with progressive decline expected. An intervention, initiated on 04/17/18 was for the resident to be seated in a high back wheelchair with anti-thrust cushion, bilateral footrests and foot and leg supports with lift blocks when up. Review of resident's five day MDS 3.0 assessment dated [DATE] revealed the resident had unclear speech, rarely/never understands others, rarely/never makes herself understood and had a severe (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 5 of 28 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 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 cognitive deficit. Review of the mood and behavior section revealed she displayed indicators of depression and had both verbal and physical behaviors directed towards others. The resident required extensive assistance of two staff for bed mobility, personal hygiene and was dependent on two staff for transfers. Review of the resident's monthly physician's orders for November 2019 revealed no orders for positioning devices. On 11/13/19 at 10:37 A.M. observation of Resident #20 revealed she was sitting in a geriatric chair (a large, padded, comfortable reclining chair with casters designed to allow patients recovering from illness and surgery, or the elderly and infirm to get out of a bed and sit comfortably while being fully supported and transported to adjoining areas within a facility) with her feet elevated. On 11/15/19 at 8:19 A.M. observation of Resident #20 revealed she was sitting up in a geriatric chair in the dining room. On 11/15/19 at 1:30 P.M. interview with the Director of Nursing (DON) verified the resident no longer utilized the high back wheelchair and the resident's plan of care had not been revised to reflect the geriatric chair currently being used. 3. Review of Resident #197's medical record revealed an admission date of 11/01/19 with diagnoses of dementia without behavioral disturbance, hypertension and anxiety. Review of Resident #197's plan of care, dated 11/04/19 revealed many care areas including activities of daily living, and care provided for current diagnoses being provided by Hospice. Review of the physician's orders for Resident #197 revealed no current order or Hospice or palliative care. Review of Resident #197's admission MDS 3.0 assessment, dated 11/12/19 revealed the resident had minimal difficulty in hear and required the use of glasses. Resident #197 required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, and transfers per two staff members. Resident #197 also required the use of pressure reducing devices to her bed and chair and sensor alert to her bed and chair for safety. Interview on 11/13/19 at 4:10 P.M. with Assistant Director of Nursing (ADON) #154 revealed the resident was removed from Hospice on 11/05/19 per resident and family request and confirmed Resident #197's plan of care had not been revised to reflect the discontinuation of Hospice services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 6 of 28 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #21 and Resident #22 were provided the necessary care and services to maintain the resident's dining ability, ability to eat independently. This affected two residents (#21 and #22) of four residents reviewed for activities of daily living (ADL) care. Residents Affected - Few Finds Include: 1. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included pneumonia, delusional disorder, glaucoma, essential hypertension, abnormal weight loss, dementia with behavioral disturbance, major depressive disorder, hypothyroidism,and malignant neoplasm of female breast. Review of Resident #21's plan of care, dated 02/20/19 revealed to assist her as needed with her activities of daily living. Review of Resident #21's Minimum Data Set (MDS) 3.0 assessment, dated 02/26/19 and 09/21/19 revealed her speech was clear, she was understood, she understands, and her cognition was severely impaired. Resident #21 had no behaviors, did not reject care and wandered one to three days. Resident #21 required supervision with set up help to eat. Resident #21 had no swallowing problems and no significant weight changes. Review of Resident #21's November 2019 physician's orders revealed a regular diet and two nutritional supplement three times a day. Observation of Resident #21 on 11/12/19 from 11:34 A.M. to 12:12 P.M. revealed she was served a hamburger, mixed vegetables, potatoes, and diced peaches. Resident #21 did not eat, and she was not encouraged to eat. Resident #21 was again observed during the evening meal on 11/12/19 from 5:24 P.M. to 5:46 P.M. The resident was served broccoli, rice, chicken, and sherbet. The resident did not eat and was not encouraged to eat. Interview with State Tested Nursing Assistant (STNA) #185 on 11/13/19 at 2:56 P.M. revealed Resident #21 fed herself and if she did not eat then staff would give her a shake or something. STNA #185 stated sometimes Resident #21 was combative with care but she would eat if she was encouraged. Interview with the Director of Nursing (DON) on 11/13/19 at 3:22 P.M. revealed staff should have encouraged Resident #21 to eat during the meal observations noted above. 2. Review of Resident #22's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, anxiety disorder, insomnia, constipation, wandering, major depression, irritability, type two diabetes, essential hypertension, anemia and hypothyroidism. Review of Resident #22's annual MDS 3.0 assessment, dated 03/21/19 revealed the resident's speech was clear, she sometimes understands, sometimes understood and her cognition was severely impaired. Resident #22 had physical and verbal behaviors one to three days and did not reject care. Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 7 of 28 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676 Level of Harm - Minimal harm or potential for actual harm #22 required supervision with set up help to eat, had no swallowing problems, and no significant weight changes. Review of Resident #22's quarterly MDS dated [DATE] revealed the resident had physical and verbal behaviors daily, rejected care one to three days, and wandered one to three days. Residents Affected - Few Review of Resident #22's November 2019 physician's orders revealed a regular diet and a nutritional supplement twice daily. Observation of Resident #22 on 11/12/19 from 11:34 A.M. to 12:12 P.M. revealed she was served a hamburger, mixed vegetables, potatoes, and diced peaches. Resident #22 did not eat and she was not encouraged to eat. Resident #22 was again observed during he evening meal on 11/12/19 from 5:24 P.M. to 5:46 P.M. The resident was served broccoli, rice, chicken, and sherbet. The resident did not eat and was not encouraged to eat. Interview with STNA #126 on 11/15/19 at 7:47 A.M. revealed sometimes Resident #22 needed to be cued. She stated sometimes Resident #22 would eat and sometimes she would not. Interview with the Director of Nursing (DON) on 11/13/19 at 3:22 P.M. revealed staff should have encouraged Resident #22 to eat during meal observations noted above. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 8 of 28 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 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** 2. Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, anorexia, mood disorder, hyperlipidemia, bradycardia, heart failure, osteoarthritis, essential hypertension, hypocalcemia, anemia and falls. Residents Affected - Few Review of Resident #31's activity of daily living care plan, dated 02/08/19 revealed it did not address how often he wanted shaved. Review of Resident #31's admission MDS 3.0 assessment, dated 02/14/19 revealed the resident's speech was clear, he usually understands, usually understood others, and his cognition was severely impaired. Resident #31 did not reject care. Resident #31 required extensive assistance of one staff for personal hygiene. Review of Resident #31's quarterly MDS 3.0 assessment, dated 10/03/19 revealed the resident sometimes understands and he rejected care four to six days in a week. Observation of Resident #31 on 11/12/19 at 2:00 P.M. revealed he had facial hair that was long. Interview with Resident #31's daughter on 11/12/19 at 2:09 P.M. revealed her father did not like facial hair, and she had to complain to staff in order to get his face shaved. Observation of Resident #31 on 11/13/19 at 10:30 A.M. revealed he was not shaved. Observation of Resident #31 on 11/14/19 at 7:50 A.M. revealed he was not shaved. Observation of Resident #31 at 10:38 A.M revealed his face was shaven at this time. Interview with STNA #159 on 11/14/19 at 10:41 A.M. revealed she had shaved Resident #31 that morning. She confirmed he had several days growth of facial hair at that time. She stated she knows he was shaved on Saturday because she had shaved him then. STNA #159 stated Resident #31 used to reject care but in the last several weeks he did not reject care. STNA #159 stated she shaved men daily. Based on observation, record review and staff interview the facility failed to ensure Resident #15 and Resident #31, who were dependent on staff for activities of daily living received timely and adequate assistance with dressing and personal hygiene. This affected two residents (#15 and #31) of four reviewed for activities of daily living. Findings Include: 1. Review of Resident #15's medical record revealed an admission date of 08/20/19 with the admitting diagnoses of anxiety, dementia and depression. Review of the resident's plan of care, dated 08/21/19 revealed the resident had a self-care performance deficit related to Alzheimer's disease progression. Interventions included to set-up supplies for care and assist with activities of daily living. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 08/28/19 revealed the resident had clear speech, usually understands others, makes himself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of one. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 9 of 28 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 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 Level of Harm - Minimal harm or potential for actual harm Review of the mood and behavior section revealed he displayed indictors of depression and wandered on a daily basis. The resident required limited assistance of one for dressing. Review of the resident's progress notes from 08/20/19 through 11/14/19 revealed no documentation the resident refused to change his clothing. Residents Affected - Few Review of the resident's dressing documentation for the past 30 days revealed no episodes of the resident refusing to dress. On 11/13/19 at 10:34 A.M. observation of Resident #15 revealed the resident was sitting in a chair holding a cup of coffee. The resident was dressed in a gray long sleeved shirt, navy blue sweat pants, white socks and sandals. The resident was not interviewable. On 11/14/19 at 3:40 P.M. the resident remained dressed in the same gray long sleeved shirt, navy blue sweat pants, white socks and saddles. On 11/15/19 at 8:17 A.M. observation of the resident revealed he was sitting at the dining room table singing to himself. The remained dressed in the same gray long sleeved shirt, navy blue sweat pants, white socks and saddles. On 11/15/19 at 8:29 A.M. interview with State Tested Nursing Assistant (STNA) #104 revealed the resident required staff to assist him to dress and change his clothes. The STNA indicated the resident did not have pajamas and he slept in his clothing. The STNA verified she had not changed he resident's clothing on 11/13/19, 11/14/19 or 11/15/19 as of this time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 10 of 28 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to develop and implement a comprehensive activities program designed to meet the total care needs of all residents. This affected five residents (#15, #17, #20, #21 and #22) of nine sampled residents reviewed for activities. Residents Affected - Some Findings Include: 1. Review of Resident # 17's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbance, senile dementia, major depression recurrent, anxiety disorder, macular degenerations, type two diabetes, and femur fracture, and peripheral vascular disease. Resident #17 resided on the secure care unit (SCU). Review of Resident #17's activities assessment, dated 07/07/15 revealed her past and present interests were card games, bingo, outdoors, television, music, religious, van outings, arts and crafts, reading, and discussion. Resident #17 wanted to walk and stay busy during the day. Record review revealed Resident #17 did not have a plan of care for activities. Review of Resident # 17's annual Minimum Data Set (MDS) 3.0 assessment, dated 03/13/19 revealed the resident's speech was clear, she understands, was understood and her cognition was severely impaired. Resident #17 had no behaviors, did not reject care, and wandered daily. Review of Resident #17's activity interest revealed it was very important for her to have books/magazines, to listen to music, somewhat important for her to be around animals, not very important to keep up with the news, very important to do things with groups of people, to do favorite activities, to go outside, and somewhat important to participate in religious services. Resident # 17 was independent with no set up for bed mobility and to transfer. Review of the Activity calendar revealed activities were provided on the SCU at 9:00 A.M., 11:00 A.M. and 3:00 P.M. The activities listed included balloon valley ball, bingo, corn hole, sing along, and manicures. Review of Resident #17's activity participation log for August 2019 revealed of the 31 days she participated in activities on 17 days. In September 2019 of the 30 days she participated in activities on 11 days. In October 2019 of the 31 days Resident #17 participated in activities 18 days. In November 2019 of the 14 days she participated in activities on four days. Observation of Resident #17 on 11/13/19 between 10:14 A.M. to 11:28 A.M. revealed until 11:00 A.M. she was in her room laying on her bed with no stimulation. No book/magazines were observed in Resident #17's room. Her television was not on and there was no music in her room. At 11:00 A.M. Resident #17 walked to the dining room and Activity Aide (AA) #142 asked Resident #17 if she wanted to play bingo. Resident #17 played bingo. AA#142 was not observed on the unit until 11:00 A.M. No books, magazines, or other types of activities were available. The activity closet was locked and not available to residents. Observation on 11/13/19 from 1:50 PM until 3:00 P.M. revealed the television was on but Resident #17 was not watching it, she was sitting in a chair in the dining room. At 2:40 P.M. Resident #17 went back to her room. At 2:54 P.M. AA #142 arrived on the unit and turned the radio on while the television was still on. AA #142 left both devices on. No books, magazines, or other types of activities (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 11 of 28 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 were available. The activity closet was locked and not available to residents. Level of Harm - Minimal harm or potential for actual harm Observation on 11/14/19 from 9:11 A.M. to 10:03 A.M. revealed Resident #17 was in her room with no activities and staff did not offer or encourage the resident to participate in any activities. No book/magazines were observed in Resident #17's room. Her television was not on and there was no music in her room. AA #142 was not observed on the unit. No books, magazines, or other types of activities were available. The activity closet was locked and not available to residents. Residents Affected - Some Interview with AA #142 on 11/15/19 at 9:55 A.M. revealed Resident #17 was more with it than the other residents. AA #142 stated Resident #17 loved bingo otherwise she stayed her room. AA #142 stated she spends about four hours on the SCU as she had three activities daily and helped serve lunch. AA #142 stated she provided activities for the other two units in the facility as well. AA #142 stated residents on the SCU did not attend activities off the unit because there was too much stimulation for them. Interview with Activity Director (AD) #200 on 11/15/19 at 9:58 A.M. revealed SCU had their own activity calendar. The activities provided were more individualized addressing the things those residents liked. AD #200 stated the groups were smaller. AD #200 stated Resident #17 does not come out of her room much. On 11/15/19 at 1:30 P.M. interview with the Director of Nursing (DON) verified the secure care unit had little to no activities that met the resident's interests. 2. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included pneumonia, delusional disorder, glaucoma, essential hypertension, abnormal weight loss, dementia with behavioral disturbance, major depressive disorder, hypothyroidism and malignant neoplasm of female breast. Resident #21 resided on the SCU. Review of Resident #21's activity assessment, dated 02/19/19 revealed her past and present interests were card games, bingo, sports, outdoors, music, religion, arts and crafts, gardening, parties, cooking, discussion, and dancing. Resident #21 wanted to send her day doing whatever she wanted. Record review revealed Resident #21 did not have an activity care plan. Review of Resident #21's admission MDS 3.0 assessment, dated 02/26/19 revealed the resident's speech was clear, she understood, understands and her cognition was severely impaired, Resident #21 had no behaviors, did not reject care and wandered one to three days. Review of Resident #21's activities interests revealed it was somewhat important for her to have books/magazine to read, to listen to music, be around pets, not very important to keep up on the news, somewhat important to do things in groups very important to do favorite activities, and to participate in religious services. Resident #21 required extensive assistance of two staff for bed mobility and to transfer. Review of Resident #21's quarterly MDS 3.0 assessment, dated 09/21/19 revealed the resident usually understands, was usually understood, she had verbal behaviors one to three days a week and she was independent in bed mobility and to transfer. Review of the Activity calendar revealed activities were provided on the SCU at 9:00 A.M., 11:00 A.M. and 3:00 P.M. The activities listed included balloon valley ball, bingo, corn hole, sing along, and manicures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 12 of 28 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #21's activity participation log for August 2019 revealed of the 31 days she participated in activities on nine days. In September 2019 of the 30 days she participated 10 days. In October 2019 of the 31 days, Resident #21 participated in activities 10 days. In November 2019 of the 13 days she actively participated in activities on nine days. Observation of Resident #21 on 11/13/19 between 10:14 A.M. to 11:28 A.M. revealed until 11:00 A.M. she was sitting in a chair holding a baby doll asleep. At 11:00 A.M. AA #142 asked Resident #21 if she wanted to play bingo. Resident #21 sat at the bingo table and State Test Nursing Assistant (STNA) #128 placed chips on the bingo card as the resident just sat there. AA#142 was not observed on the unit until 11:00 A.M. No books, magazines, or other types of activities were available. The activity closet was locked and not available to residents. Observation on 11/13/19 from 1:50 PM until 3:00 P.M. revealed the television was on but Resident #21 was not watching it, she was sitting in a chair. At 2:54 P.M. AA #142 arrived on the unit and turned the radio on while the television was still on. AA #142 left both devices on and did not engage Resident #21. No books, magazines, or other types of activities were available. The activity closet was locked and not available to residents. Observation on 11/14/19 from 9:11 A.M. to 10:03 A.M. revealed Resident #21 was sleeping in a chair in the nurse's station, staff did not offer or encourage the resident to participate in any activities. No books, magazines, or other types of activities were available. The activity closet was locked and not available to residents. Interview with AA #142 on 11/15/19 at 9:55 A.M. revealed Resident #21 like her baby doll and she liked music and to dance. AA #126 stated Resident #21 would play bingo, but she could be very combative, so she had to be careful how she approached the resident. AA #126 stated Resident #21 could really beat on staff. AA #142 stated she spends about four hours on the SCU as she had three activities daily and helped serve lunch. AA #142 stated she provided activities for the other two units in the facility as well. AA #142 stated residents on the SCU did not attend activities off the unit because there was too much stimulation for them. Interview with AD #200 on 11/15/19 at 9:58 A.M. revealed SCU had their own activity calendar. The activities provided were more individualized addressing the things those residents liked. AD #200 stated the groups were smaller. AD #200 stated Resident #21 likes her baby dolls and to dance. On 11/15/19 at 1:30 P.M. interview with the Director of Nursing (DON) verified the secure care unit had little to no activities that met the resident's interests. 3. Review of Resident #22's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, anxiety disorder, insomnia, constipation, wandering, major depression, irritability, type two diabetes, essential hypertension, anemia and hypothyroidism. Review of Resident #22's activities assessment, dated 03/20/18 revealed the resident liked exercises, the outdoors, television, music, gardening, reading, and cooking. Resident #22 liked to spend her days outdoors. Review of Resident #22's annual MDS 3.0 assessment, dated 03/21/19 revealed the resident's speech was clear, she sometimes understands, sometimes understood, and her cognition was impaired. Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 13 of 28 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm #22 had physical behaviors, verbal behaviors, and rejected care one to three days. Resident #22's assessment for activities was conducted by interviewing staff. This assessment revealed Resident #22 liked reading books/magazines, listening to music, being around pets, doing things with groups of people, participating in favorite activities, and spending time outdoors. Resident #22 required limited assistance of two staff for bed mobility and was independent to transfer. Residents Affected - Some Review of Resident #22's quarterly MDS 3.0 assessment, dated 09/21/19 revealed the resident had physical and verbal behaviors daily, and required supervision of one staff for bed mobility. Review of Resident #22's activities plan of care, dated 11/14/19 revealed she did not participate in structured activities and she would have meaningful visits or show interest in activities two times a week. Review of the Activity calendar revealed activities were provided on the SCU at 9:00 A.M., 11:00 A.M. and 3:00 P.M. The activities listed included balloon valley ball, bingo, corn hole, sing along, and manicures. Review of Resident #22's activity participation log for August 2019 revealed of the 31 days she participated in activities on 19 days. In September 2019 of the 30 days she participated 12 days. In October 2019 of the 31 days Resident #21 participated in activities 19 days. In November 2019 of the 14 days she actively participated four days. Observation of Resident #22 on 11/13/19 between 10:14 A.M. to 11:28 A.M. revealed she was wandering without purpose on the SCU. At 11:00 A.M. AA #142 was observed playing bingo with three residents. AA#142 was not observed on the unit until 11:00 A.M. No books, magazines, or other types of activities were available. The activity closet was locked and not available to residents. Observation on 11/13/19 from 1:50 PM until 3:00 P.M. revealed the television was on but Resident #22 was not engaged in activities and she was wandering without purpose on and off. At 2:54 P.M. AA #142 arrived on the unit and turned the radio on while the television was still on. AA #142 left both devices on and did not engage Resident #22. No books, magazines, or other types of activities were available. The activity closet was locked and not available to residents. Observation on 11/14/19 from 9:11 A.M. to 10:03 A.M. revealed Resident #22 was not engaged in activities and she was wandering without purpose on and off. No books, magazines, or other types of activities were available. The activity closet was locked and not available to residents. Interview with AA #142 on 11/15/19 at 9:55 A.M. revealed Resident #22 mostly wandered and she was difficult to get involved in activities. AA #142 stated Resident #22 could be very combative, so she had to be careful how she approached the resident. AA #142 stated Resident #22 could really beat on staff. AA #142 stated she spends about four hours on the SCU as she had three activities daily and helped serve lunch. AA #142 stated she provided activities for the other two units in the facility as well. AA #142 stated residents on the SCU did not attend activities off the unit because there was too much stimulation for them. Interview with AD #200 on 11/15/19 at 9:58 A.M. revealed SCU had their own calendar. The activities provided were more individualized addressing the things those residents liked. AD #200 stated the groups were smaller. AD #200 stated Resident #22 liked to garden. She confirmed there was no gardening activities for Resident #22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 14 of 28 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm On 11/15/19 at 1:30 P.M. interview with the Director of Nursing (DON) verified the secure care unit had little to no activities that met the resident's interests. 4. Review of Resident #15's medical record revealed an admission date of 08/20/19 with the admitting diagnoses of anxiety, dementia and depression. Residents Affected - Some Review of the resident's admission activity assessment, dated 08/20/19 revealed the resident had clear speech, with his past a and present interests of television and reading noted. The resident was unable to complete the remainder of the form. The medical record did not contain an interview with the family to establish the resident's activity preferences. Review of the resident's comprehensive MDS 3.0 assessment dated [DATE] revealed the resident had clear speech, usually understands others, makes himself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of one. Review of the mood and behavior section revealed the resident displayed indictors of depression and wandered on a daily basis. Review of the daily preferences revealed it was somewhat important to do his favorite activities. Review of the resident's plan of care revealed the resident had no plan of care addressing his activity deficit or preferences. Review of the resident's activity log revealed of the 12 days in August 2019 he participated six days. In September 2019 of the 30 days he participated 12 days. In October 2019 of the 31 days he participated 20 days. In November 2019 of the 14 days he participated five days. On 11/13/19 at 10:34 A.M. observation of Resident #15 revealed the resident was sitting in a chair holding a cup of coffee, the resident finished the coffee and told the surveyor he was ready to go. He was not engaged in any type of activity. The unit had no active activities going on at that time. One staff member was sitting in a chair working on an electronic tablet. The television was on with a movie playing, but no residents were watching it. On 11/13/19 at 2:18 P.M. observation of Resident #15 revealed the resident was sitting in a chair in the dining room/activity room eating a cookie and drinking a cup of coffee. There were no staff present and no activities occurring. On 11/14/19 at 1:50 P.M. the resident was sitting in a recliner in the dining room with his eyes closed. On 11/14/19 at 3:00 P.M., observation revealed Activity Director (AD) #200 woke the resident who was sleeping in the recliner and gave him a newspaper to read. The resident accepted the paper and read it for approximately two minutes and then got up and began walking about the secure unit. On 11/15/19 at 8:17 A.M. observation of the resident revealed he was sitting at the dining room table with his eyes closed singing to himself. A State Tested Nursing Assistant (STNA) retrieved a bucket of plastic clips to make chains from the activity storage closet and approached Resident #39 and asked if she wanted to play with them. No attempts were made to include the other residents, including Resident #15 sitting in the dining room in the activity. On 11/15/19 at 1:30 P.M. interview with the Director of Nursing (DON) verified the secure care unit had little to no activities that met the resident's interests. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 15 of 28 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. Review of Resident #20's medical record revealed an original admission date of 01/30/18 with the latest readmission of 10/11/19 with the re-admitting diagnoses of acute impacted left femoral intertrochanteric fracture, unspecified fracture of the lower end of the right femur, dementia, diabetes mellitus and anxiety. Review of the resident's admission activities assessment, dated 01/30/18 revealed the resident enjoyed exercises, outdoors, music, religious, arts & crafts and cooking. The assessment indicated the facility was unsure if the resident was interested in activities. Further review of the resident's medical record revealed no additional assessment involving the resident's family. Review of the resident's plan of care revealed no plan of care addressing the resident's activity deficit was in place. Review of resident's five day MDS 3.0 assessment, dated 10/18/19 revealed the resident had unclear speech, rarely/never understands others, rarely/never makes herself understood and had a severe cognitive deficit. Review of the mood and behavior section revealed she displayed indicators of depression and had both verbal and physical behaviors directed towards others. The resident required extensive assistance of two staff for bed mobility, personal hygiene and was dependent on two staff for transfers. Review of the resident's activity log revealed of the 27 days in August 2019 she participated in activities on seven days. In September 2019 of the 30 days she participated 19 days. In October 2019 of the 28 days she participated 16 days. In November 2019 of the 14 days he participated nine days. On 11/13/19 at 10:37 A.M. observation of Resident #20 revealed she was sitting in a geriatric chair with her feet elevated. The resident's eyes were closed but she was moaning periodically. There were no attempts made by staff to engage the resident in any type of activities. On 11/14/19 at 1:10 P.M. observation of the resident revealed she was sitting up in her geriatric chair with no staff interaction or activities observed. On 11/15/19 at 8:19 A.M. observation of Resident #20 revealed she was sitting up in her geriatric chair in the dining room. The activity person retrieved a bucket of plastic clips to make chains. She sat down at a table with three residents and began an activity. No attempt was made to involve the other residents, including Resident #20 in the dining area. On 11/15/19 at 1:30 P.M. interview with the Director of Nursing (DON) verified the secure care unit had little to no activities that met the resident's interests. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 16 of 28 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, anorexia, mood disorder, hyperlipidemia, bradycardia, heart failure, osteoarthritis, essential hypertension, hypocalcemia, anemia and falls. Review of Resident #31's fall risk assessment dated [DATE], 05/09/19, 07/09/19, 10/03/19 revealed he was assessed to be at high risk for falls. Review of Resident #31's current fall plan of care, dated 02/08/19 revealed the resident was at risk for falls due to confusion, gait /balance problems, and poor communication and comprehension, and unaware of safety needs. Resident #31 had falls on 03/10/19 with no injury, 04/13/19 resulting in a skin tear to his right cheek, 06/05/19 with no injury, 09/23/19 he was sent to the emergency room, and on 11/02/19 he was sent to the emergency room. The plan called for staff to review information on past falls and determine cause of falls. Record review revealed the resident utilized a wheelchair for mobility. Review of Resident #31's admission MDS 3.0 assessment dated [DATE] revealed the resident's speech was clear, he usually understands, usually understood others, and his cognition was severely impaired. Resident #31 had no behaviors, did not reject care, and wandered daily. Resident #31 required extensive assistance of two staff for bed mobility and transfer, extensive assistance of one staff to walk, and used a walker. Resident #31 had a history of falls. Review of Resident#31's progress notes revealed the following: On 08/06/19 at 10:51 P.M. Resident #31's call light was sounding. Resident #31 was laying on the floor with call light wrapped around his leg. Resident #31 stated he was fixing the bed control. On 09/23/19 at 7:22 P.M. Resident#31 was found on the floor due to a fall. He was sent to the emergency room (no injury identified). On 09/30/19 at 5:01 A.M. Resident #31 was laying on floor by his bed stating he was working on his car. Review of Resident #31's quarterly MDS 3.0 assessment, dated 10/03/19 revealed the resident sometimes understands, he rejected care four to six days in a week, had physical behaviors one to three days, and he had two falls with injury. On 11/02/19 at 10:30 P.M. Resident #31 was on the floor in the common area. He was bleeding from the nose and right eye brow and complained of his left arm hurting. He was sent to the emergency room and returned with stitches above his right eye. Interview with State Tested Nursing Assistant (STNA) #159 on 11/14/19 at 10:41 A.M. revealed the resident had a history of falls and was to have a mat to the floor as a fall risk intervention. Interview with the Director of Nursing (DON) on 11/15/19 at 9:06 A.M. revealed Resident #31 had sustained falls as noted above. The DON stated the facility had not identified any pattern to his falls. The DON had not identified the resident's falls were occurring in the evening. The DON stated Resident #31 did not get up until late and he stayed up later. The DON stated Resident #31 may be getting tired in the evening. The DON stated Resident #31 liked to fix things and that may be what he was doing when he had falls. The DON verified the facility had not comprehensively reviewed the information on the falls to determine a cause in order to implement individualized interventions to prevent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 17 of 28 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few additional falls for the resident. The DON revealed the facility had not identified the resident was trying to fix things at the time of some of the falls in order to possibly implement interventions to address this factor to prevent additional falls. Based on observation, review of the medical record, facility investigation, staff statements, facility Fall Risk Assessment/Reassessment and Prevention policy and staff interview the facility failed to ensure one resident (Resident #20) was provided assistance with bed mobility by two staff members, as assessed, during incontinence care. Actual Harm occurred when one staff member provided incontinence care to Resident #20 resulting in the resident falling from the bed and sustaining an acute impacted left femoral intertrochanteric fracture (occur when a force presses against both ends of the femur at the femoral neck, pushing the broken ends of the bone together) and unspecified fracture of the lower end of the right femur requiring surgical repair. In addition the facility failed to comprehensively investigate falls to determine trends and implement individualized interventions to prevent falls for Resident #31. This affected two residents (#20 and #31) of four residents reviewed for falls. Findings Include: 1. Review of Resident #20's medical record revealed an original admission date of 01/30/18 with the latest readmission of 10/11/19 with re-admitting diagnoses of acute impacted left femoral intertrochanteric fracture, unspecified fracture of the lower end of the right femur, dementia, diabetes mellitus and anxiety. Review of Resident #20's plan of care, dated 01/31/18 revealed the resident had a self-care performance deficit related to dementia with progressive decline expected. An intervention, initiated on 01/31/18 was to set-up supplies for care and assist with activities of daily living every shift and as needed. The plan of care did not specify the type and/or amount of assistance the resident required. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 02/06/19 revealed the resident had severely impaired cognition, was non-ambulatory and required extensive assistance of two staff for bed mobility and toileting. Review of the 08/02/19 discharge MDS 3.0 assessment revealed the resident had severely impaired cognition, was non-ambulatory and required extensive assistance from two staff for bed mobility and toileting. Review of the resident's progress note, dated 08/02/19 at 4:36 A.M. and authored by Licensed Practical Nurse (LPN) #109 revealed she was summoned to the resident's room because the resident rolled out of bed during rounds. State Tested Nursing Assistant (STNA) #145 reported she was doing rounds at 3:15 A.M., went to roll the resident back towards her after getting the feces cleaned up off her and she rolled off the side of the bed. When the nurse entered the room the resident was laying on the floor on her left side. The nurse assessed the resident and observed a skin tear to her left lower ankle. The resident's left shoulder was observed to be swollen and the resident was grabbing both legs yelling out when touched. The resident's physician was notified and the resident left the facility at 4:00 A.M. via 911. Review of the facility incident report dated 08/02/19 at 4:11 A.M. and revised on 10/11/19 at 1:46 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 18 of 28 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few P.M. revealed no injuries were observed post incident and fall precautions were in place at the time of the incident. The incident report documented the resident was confused, had impaired memory, had difficulty making her needs known and was incontinent. Review of STNA #145's undated handwritten statement revealed she went into Resident #20's room shortly after 3:00 A.M. on 08/02/19 to check her while her bed was in low position. The resident was wet and had a bowel movement. She went to get clean sheets, gown, pad and some washcloths and then placed the items at the foot of the bed. She then raised the bed and got the resident washed and the sheets changed. The statement revealed the resident was on her back in the center of the bed. The STNA documented she went to put the resident's brief on, when the resident kicked and turned over rolling over the wedge mattress hitting the wall then falling onto the floor. The nurse was notified and immediately arrived to resident's room. Review of the acute care hospital history and physical (H&P) dated 08/02/19 revealed Resident #20 was transferred to the emergency room (ER) for a fracture. The resident's family was at the bedside and provided a history. The resident at baseline was not verbal and many times she did not know anyone by name. The H&P documented the resident, who was usually wheelchair bound, was being cleaned and dressed at 3:00 A.M. and had a fall. A cat scan was completed and showed an acute impacted left femoral intertrochanteric fracture. Review of the orthopedic progress note dated 08/02/19 revealed the resident had an unspecified fracture of the lower end of the right femur. The note documented the resident required a total knee replacement (as a result of the fall). Review of the resident's most current MDS 3.0 assessment, dated 10/18/19, revealed the resident was non-ambulatory, required extensive assistance from two staff for bed mobility, toileting and was dependent on staff for transfers. She had functional limitation in range of motion her lower extremities on both sides. On 11/13/19 at 10:37 A.M. observation of Resident #20 revealed she was sitting in a geriatric chair with her feet elevated. The resident's eyes were closed but she was moaning and had facial grimacing periodically. On 11/14/19 at 8:36 A.M. interview with the Director of Nursing (DON) revealed at the time of the fall, the resident required either one or two staff for assistance with care. When asked how or who determined what the resident's needs were, the DON revealed it would be the STNA who determined when more than one staff member was utilized for care. She said one STNA was utilized if the resident had not had any behaviors and two staff would be required if the resident was having behaviors. She said the resident used pull up incontinence products and when STNA #145 was at the resident's feet putting the brief on, the resident kicked and rolled her shoulders over going up over the wedged mattress and falling onto the floor. She said raising the bed from the low position while providing care was a standard action. On 11/14/19 at 11:08 A.M. interview with STNA #145 revealed on 08/02/19 at approximately 3:00 A.M. she went in to change Resident #20 and check what linens she needed. She said she got the linens and laid them at the bottom of the bed. She said she got the resident changed, the linens were changed and when she went to put her incontinence pull up on, the resident kicked and rolled out of the bed and onto the floor. She said she kicked away from her and when she kicked her leg she just kept right on going and she couldn't catch her. She said the resident had a history of becoming agitated with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 19 of 28 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 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 care. Level of Harm - Actual harm Review of the facility policy titled, Fall Risk Assessment/Reassessment and Prevention dated 06/28/16 revealed it was the goal of the facility to evaluate each residents fall risk factors and to initiate appropriate safety measures to help prevent falls or injuries related to falls, while promoting the highest level of independence possible. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 20 of 28 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #31's oxygen tubing and humidification/water bottle were dated. This affected one resident (#31) of one resident reviewed for oxygen therapy. The facility identified seven residents received respiratory care. Residents Affected - Few Findings Include: Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, anorexia, mood disorder, hyperlipidemia, bradycardia, heart failure, osteoarthritis, essential hypertension, hypocalcemia, anemia and falls. Review of Resident #31's admission Minimum Data Set (MDS) 3.0 assessment, dated 02/14/19 revealed the resident's speech was clear, he usually understands, usually understood others, and his cognition was severely impaired. Resident #31 did not reject care. Resident #31 required extensive assistance of one staff for personal hygiene. The assessment revealed Resident #31 did not use oxygen. Review of Resident #31's physician's orders revealed on 10/09/19 an order for oxygen at two liters per minute as needed when his oxygen saturations levels were less than 92 percent. Observation of Resident #31 on 11/13/19 at 10:30 A.M. revealed his oxygen tubing and water bottle were not dated. The oxygen concentrator was on but the resident's nasal cannula was on the floor. At 11:28 A.M. the resident was observed wearing the nasal cannula. There was no date on the tubing at that time. Interview with Registered Nurse (RN) #150 on 11/13/19 at 2:23 P.M. confirmed Resident #31's oxygen with humidification was not dated. RN #150 was unaware the tubing needed to be dated. Additional interview with RN #150 at 3:02 P.M. revealed the tubing and water bottle were supposed to be dated when they were changed weekly on Sunday. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 21 of 28 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to implement a comprehensive and individualized pain management program for Resident #31. This affected one resident (#31) of one resident reviewed for pain. Residents Affected - Few Findings Include: Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, anorexia, mood disorder, hyperlipidemia, bradycardia, heart failure, osteoarthritis, essential hypertension, hypocalcemia, anemia and falls. Review of Resident #31's plan of care, dated 02/08/19 revealed it did not address non-verbal expressions of pain. Review of Resident #31's admission Minimum Data Set (MDS) 3.0 assessment, dated 02/14/19 revealed the resident's speech was clear, he usually understands, usually understood others, and his cognition was severely impaired. The assessment revealed Resident #31 was on scheduled pain medication and he did not have any pain. Resident #31 did not reject care. Resident #31 required extensive assistance of one staff for personal hygiene. Review of Resident #31's quarterly MDS 3.0 assessment, dated 10/03/19 revealed the resident was was unable to report if he was in pain. Review of Resident #31's November 2019 physician's orders revealed an order to monitor the resident for pain every shift. Document pain scale rating or faces scales every shift. Resident #31 received a pain medication (Meloxicam) 7.5 milligrams daily for pain. Review of Resident #31's medication administration record (MAR) for September, October, and November 2019 revealed Resident #31's pain was documentated to be 0. Interview with Resident #31's daughter on 11/12/19 at 2:18 P.M. revealed since the weekend she felt the resident had been in pain. She stated she reported this to the nurse but was not sure the nurses addressed it. Observation of Resident #31 during the interview revealed he was moaning, clenching his fists and groaning. Observation of Resident #31 on 11/13/19 at 1:43 P.M. revealed he was laying in bed on his back. The resident's fists were clenched and his arms were shaking. On 11/14/19 at 11:00 P.M. Resident #31 was observed laying in bed on his back with his fists clenched and his arms shaking. Interview with State Tested Nursing (STNA) #159 on 11/14/19 at 10:41 A.M. revealed in the past several weeks Resident #31's condition had declined. She stated he was no longer safe in a wheelchair because he was drawing up his arms and legs and his hands were in fists and were shaking. STNA #159 stated she did not know why this was happening. Interview with Registered Nurse (RN) #150 on 11/14/19 at 11:27 A.M. revealed Resident #31 had been clenching his fists since she started two weeks ago. RN #150 stated the resident was not able to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 22 of 28 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 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 0697 state whether or not he was in pain at this time. Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing (DON) on 11/15/19 at 9:06 A.M. revealed she did not think about Resident #31's clenching and shaking as pain. The DON stated the nurses needed to be educated related to non-verbal expressions of pain. The DON confirmed Resident #31 was not able to verbally express pain at this point. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 23 of 28 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure residents had adequate indication for the use of psychotropic medications and/or failed to ensure the justified use of an as needed (PRN) antipsychotic medication for greater than 14 days. This affected four residents (#21, #22, #31 and #197) of five residents reviewed for unnecessary medication use. Findings Include: 1. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included pneumonia, delusional disorder, glaucoma, essential hypertension, abnormal weight loss, dementia with behavioral disturbance, major depressive disorder, hypothyroidism and malignant neoplasm of female breast. Review of Resident #21's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident's speech was clear, she understood, understands, and her cognition was severely impaired. Resident #21 had minimal depression, no indicators of psychosis, no behaviors, did not reject care and wandered one to three days. Resident #21 received an antipsychotic medication and antidepressant medications daily. Review of Resident #21's plan of care, dated 04/15/19 revealed she had behavior problems of resistance to care and combativeness related to dementia. The care plan revealed Resident #21's daughter would confer with Resident #21's neurologist regarding behavior medications for suggestions. Resident #21 received Seroquel for behaviors. Review of Resident #21's quarterly MDS 3.0 assessment, dated 09/21/19 revealed the resident usually understands, usually understood, she had verbal behaviors one to three days a week and was independent in bed mobility and to transfer. Review of Resident #21's November 2019 physician's orders revealed an order for the antipsychotic medication, Seroquel 25 milligrams (mg) twice daily for dementia with behaviors. Resident #21 had target behaviors of hitting/kicking, spitting, and refusal of care. There was no evidence Resident #21 displayed symptoms to justify the use of the Seroquel. Interview with State Tested Nursing Assistant (STNA) #185 on 11/13/19 at 2:56 P.M. revealed Resident #21 would bite, spit, holler and was combative with care. STNA #185 stated Resident #21 did not hallucinate or have delusions. Interview with the Director of Nursing (DON) on 11/13/19 at 3:22 P.M. revealed the facility did not obtain documentation from Resident #21's neurologist, they just sent them changes in the medications. The DON confirmed there was no evidence to support the use of the Seroquel. 2. Review of Resident #22's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, anxiety disorder, insomnia, constipation, wandering, major depression, irritability, type two diabetes, essential hypertension, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 24 of 28 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 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 0758 anemia and hypothyroidism. Level of Harm - Minimal harm or potential for actual harm Review of Resident #22's plan of care, dated 03/19/19 revealed the resident had behavior problems of hitting self, striking out at others, exit seeking, throwing objects and placing herself on the floor. The care plan revealed the resident received Seroquel, Ativan and Zoloft for these behaviors. Residents Affected - Some Review of Resident #22's annual MDS 3.0 assessment, dated 03/21/19 revealed the resident's speech was clear, she sometimes understands, sometimes understood, and her cognition was severely impaired. Resident #22 had minimal depression, no indicators of psychosis, had physical behaviors, and verbal one to three days, that did not significantly impact the resident or others, rejected care one to three days and did not wander. Resident #22 received an antipsychotic medication, an antianxiety medication, and an antidepressant medication daily. Review of Resident #22's quarterly MDS 3.0 assessment, dated 09/21/19 revealed the resident had physical and verbal behaviors daily, rejected care one to three days and wandered one to three days. Review of Resident #22's November 2019 physician's orders revealed she had an order for Seroquel 50 mg twice daily related to irritability and anger, an order for the antianxiety medication, Ativan 0.5 mg for anxiety and an order for the antidepressant medication, Zoloft 50 mg daily for major depression. Resident #22's target behaviors were urinating on the floor and bowel movements in the sink, hitting, throwing objects, yelling, placing self on floor, beating doors, and exit seeking and attempting to or causing harm to herself or others. Review of Resident #22's behavior tracking revealed she had no targeted behaviors in October 2019. From 11/01/19 to 11/14/19 the resident displayed two episodes of attempting to cause harm to herself or others and three episodes of anxiety. There was no evidence Resident #22 expressed symptoms to justify the use of the Seroquel. Interview with STNA #185 on 11/13/19 at 10:52 A.M. revealed Resident #22's behaviors included fiddling with things. The STNA stated she takes the stop sign off other resident's doors and could be combative with care. Interview with the DON on 11/14/19 at 3:29 P.M. confirmed there was no evidence to support the use of Seroquel for Resident #22. 3. Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, anorexia, mood disorder, hyperlipidemia, bradycardia, heart failure, osteoarthritis, essential hypertension, hypocalcemia, anemia and falls. Review of Resident #31's admission MDS 3.0 assessment, dated 02/14/19 revealed the resident's speech was clear, he usually understands, usually understood, his cognition was severely impaired, and he had minimal depression. Resident #31 had no indicators of psychosis, no behaviors, did not reject care and wandered daily. Resident #31 received a daily antipsychotic medication and one day of an antidepressant. Review of Resident #31's quarterly MDS 3.0 assessment, dated 10/03/19 revealed the resident sometimes understands others, had physical behaviors one to three days and rejected care four to six days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 25 of 28 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 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 0758 The assessment revealed Resident #31 received an antidepressant medication daily. Level of Harm - Minimal harm or potential for actual harm Review of Resident #31's physician's orders for November 2019 revealed the resident had an order for the antipsychotic medication, Seroquel 25 mg twice daily and Seroquel 12.5 mg daily for mood disorder, and an order for the antidepressant medication, Trazadone 50 mg daily for anxiety. Resident #31 had target behaviors of elopement, threats or attempts of hitting staff during care, yelling out, and cursing. Residents Affected - Some Review of Resident #31's current plan of care revealed Resident #31 received Seroquel for behaviors. Review of Resident #31's behavior grids revealed in October 2019 revealed the resident had one episode of attempted elopement and one episode of putting himself on the floor. From 11/01/19 to 11/13/19 the resident had no documented behaviors. Interview with STNA #159 on 11/14/19 at 10:41 A.M. revealed Resident #31 had behaviors in the past but no longer exhibited any behaviors. She stated Resident #31 had no delusions or hallucinations. Interview with Registered Nurse (RN) #150 on 11/14/19 at 11:27 A.M. revealed Resident #31 had no behaviors and no delusions or hallucinations. Interview with the DON on 11/15/19 at 9:06 A.M. revealed Resident #31 did not express behaviors that justified the use of Seroquel. 4. Review of Resident #197's medical record revealed an admission date of 11/01/19 with diagnoses of dementia without behavioral disturbances, muscle weakness and anxiety. Review of Resident #197's physician's orders revealed an order, dated 11/02/19 for the antipsychotic medication, Haloperidol 0.5 milligrams (mg) 1 tablet by mouth every two hours as needed for anxiety with no stop dated noted. Review of Resident #197's plan of care, dated 11/04/19 revealed impaired cognitive function/dementia or impaired thought process related to dementia. Review of Resident #197's admission MDS 3.0 assessment, dated 11/12/19 revealed the resident required extensive assistance for bed mobility, dressing, toilet use, and transfers with two staff member assistance. Review of Resident #197's Medication Administration Record (MAR) for 11/2019 revealed resident received Haloperidol 0.5 mg on 11/12/19 at 8:19 P.M., on 11/10/19 at 8:43 P.M. and again on 11/08/19 at 8:20 P.M. for anxiety. Review of the behavior log for Resident #197 revealed a documented behavior of yelling and screaming on 11/09/19 only. Review of the behavior log for 11/12/19, 11/10/19, and 11/08/19 revealed no evidence of any behaviors which would indicate the use of the as needed Haloperidol. Observation on 11/12/19, 11/13/19, 11/14/19, and 11/15/19 between 9:00 A.M. and 5:00 P.M. of Resident #197 revealed the resident was not exhibiting any type of behaviors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 26 of 28 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 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 0758 Level of Harm - Minimal harm or potential for actual harm Interview on 11/13/19 at 4:10 P.M. with Assistant Director of Nursing (ADON) #154 revealed the resident was prescribed Haloperidol for an inappropriate diagnoses, was prescribed the medication for longer than 14 days and was administered the medication without proper indication or documentation of behaviors. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 27 of 28 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 365431 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jenkins Care Community 142 Jenkins Memorial Road Wellston, OH 45692 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. Based on record review and interview the facility failed to ensure Resident #197's medical record was accurate to reflect the discontinuation of Hospice services. This affected one resident (#197) of 24 residents whose medical records were reviewed. Findings Include: Review of the medical record for Resident #197 revealed an admission date of 11/01/19 with diagnoses of dementia without behavioral disturbances, hypertension and anxiety. Review of the progress notes for Resident #197 revealed multiple notes including notes on 11/12/19, and 11/13/19 revealing the resident was receiving Hospice services. Interview on 11/13/19 at 4:10 P.M. with Assistant Director of Nursing (ADON) #154 revealed Resident #197 was discharged from Hospice on 11/05/19. However, nursing staff continued to document the resident was receiving Hospice services after this date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365431 If continuation sheet Page 28 of 28