Inspection·July 14, 2022

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 07/07/22 at 2:25 P.M. interview with Resident #16 revealed she was not asked about her preferred shower frequency and times and her preference would be daily or every other day. Review of the Bathing Choice Policy dated 01/21 revealed the purpose of the policy is to establish frequency of bathing by resident choice. Residents are interviewed during the admission process regarding the frequency they want to bathe/shower. The frequency of the bath/shower is reviewed at least quarterly during the care planning conference with the resident. Changes are implemented if indicated by the resident's choice. This policy is reviewed during the resident admission process and quarterly thereafter. Event ID: Facility ID: 365461 If continuation sheet Page 2 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review the facility failed to ensure advanced directives were accurate and reflected resident wishes. This affected one resident (Resident #16) of two residents reviewed for advanced directives. The census was 45. Findings include: Review of Resident #16's medical record revealed an admission date of [DATE] with diagnoses including chronic atrial fibrillation, pacemaker, anxiety and heart failure. Review of the physician orders dated [DATE] revealed the resident was a Do Not Resuscitate Comfort Care Arrest (DNR-CCA) (permits the use of life saving measures before a person's heart or breathing stops. However, only comfort care may be provided after a person's heart or breathing stops). Review of the Multidisciplinary Care Conference Form dated [DATE] revealed the resident wished to be a full code and the resident/family expectations would be a full code status. Review of the my advance directive is DNR-CCA care plan dated [DATE] revealed intervention including advanced directive will be on the chart, Further review of the medial record revealed a Full Code Initiate Cardiopulmonary Resuscitation Call 911 document located in the front of the record with the resident's first and last name on the document. The document had a facsimile stamp at the top of the document from a sister facility dated [DATE]. Review of the Quarterly Minimum Data Set (MDS) 3.0 dated [DATE] revealed the resident had intact cognition and required staff assistance with activities of daily living. On [DATE] at 6:47 P.M. interview with Registered Nurse (RN) #50 revealed code status is noted in the front of the medical record and confirmed this is where she would go to determine the resident's code status especially in an emergency situation. The RN verified the paper located in the front of the medical record indicated the resident was a full code indication CPR was required but per the physician orders the resident was a DNR-CCA. On [DATE] at 7:02 P.M. interview with the Director of Nursing revealed code status is reviewed with residents and/or the responsible party on admission to the facility. A physician order and appropriate documentation would match according to the resident's wishes. The DON confirmed the resident had conflicting information in her medical record related to code status. Review of the Resuscitative Measures Identification Form Process Policy date 01/16 and revised 10/19 revealed the purpose was to identify residents immediately when resuscitative measures are required. Code status options are to be reviewed with the resident/designee at admission and at a minimum of quarterly at plan of care meetings. If the resident/designee does not select DNR/DNRCCA status they will be considered full code and identified as such. Code status will be audited at a minimum of quarterly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 3 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure preadmission screening and resident reviews were completed with a significant change in resident status. This affected one resident (Resident #35) of two residents reviewed for preadmission screening and resident review. The census was 45. Findings include: Review of Resident #35's medical record revealed an admission date of 08/15/03 with diagnoses including multiple sclerosis, major depression, dementia without behavioral disturbance, personality disorder and other specified mental disorders due to known physiological conditions. The last pre-admission screening review dated 08/27/03 revealed the resident had no indications of serious mental illness nor developmental disabilities. Further review of the medical record revealed the diagnosis of schizoaffective disorder depressive type dated 05/16/16 was added. Review of the physician orders revealed the resident received zyprexa (antipsychotic medication) by mouth every evening for schizoaffective disorder dated 10/31/21. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment and required extensive staff assistance with activities of daily living. The resident had a diagnosis of schizophrenia and received antipsychotic medication seven days during the assessment period. Further review revealed the MDS was coded to indicate the resident was not currently considered by the state level II preadmission screening and record review (PASRR) process to have serious mental illness and/or intellectual disability or a related condition. On 07/06/22 at 3:00 P.M. interview with Social Services Designee (SSD) #7 verified the last PASRR completed was in 2003 and a diagnosis of schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder such a depression or bipolar disorder) was added in 2016. SSD #7 verified a new PASRR would need completed when a new psychiatric disorder is identified. On 07/06/22 at 3:16 P.M. interview with Licensed Practical Nurse (LPN) #93 revealed she verifies a PASRR had been completed and then answers the question on the MDS under section A during a comprehensive MDS assessment (admission, annual and significant change in condition). LPN #93 confirmed she does not cross-reference the PASRR date and when diagnosis have been added to ensure the facility has completed the reviews when necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 4 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview, and record review the facility failed to ensure dependent residents were assisted with activities of daily living to include showers and nail care. This affected four residents (Residents #16, #26, #35, and #40) of five residents reviewed for activities of daily living. The census was 45. Residents Affected - Some Findings include: 1. Review of Resident #16's medical record revealed an admission date of 04/04/22 with diagnoses including chronic atrial fibrillation, pacemaker, anxiety, and heart failure. Review of the personal and cultural preferences plan of care initiated 04/08/22 revealed the resident preferred to shower on Wednesday and Sunday (twice per week). Review of the Quarterly MDS dated [DATE] revealed the resident had intact cognition and was dependent of one staff with bathing. On 07/05/22 at 10:33 A.M. interview with Resident #16 revealed she was not getting showers and today was the first shower she had in four weeks. The resident stated she maintained cleanliness by wiping off by herself. Review of the resident's shower documentation revealed the following weeks she did not get showers as scheduled: From 04/04/22 through 04/09/22 no showers were documented; 05/22/22 through 05/28/22 one shower on 05/26/22; 05/29/22 through 06/04/22 no showers were documented; 06/05/22 through 06/11/22 one shower on 06/06/22; 06/12/22 through 06/18/22 one shower on 06/17/22. Review of the progress notes revealed no documentation to support the resident refused to take her showers when offered. On 07/06/22 at 7:01 P.M. interview with State Tested Nursing Assistant (STNA) #7 verified Resident #16 was a night shift shower and often would not want her shower. The STNA stated this was reported to the nurse. On 07/07/22 at 8:46 A.M. interview with the Director of Nursing (DON) revealed Resident #16 varied on when she wanted her bath/shower and if she is refused when offered, this should be documented by the staff/nurse and follow up accordingly. The DON verified there was no documentation in the medical record from nurses or STNAs supporting the resident refused her showers when offered. A follow-up interview with the DON on 07/11/22 at 9:45 A.M. verified the resident was not getting her showers per her plan of care and shower schedule after reviewing the shower documentation. The DON verified there was no paper documentation supporting the resident received additional showers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 5 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 Residents Affected - Some 2. Review of Resident #35's medical record revealed an admission date of 08/15/03 with diagnoses including multiple sclerosis, major depression, dementia without behavioral disturbance and constipation. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment and required extensive assistance of one staff member with bed mobility and personal hygiene, dependent of two staff with transfers and dependent of one staff member with dressing and toilet use. The resident was always incontinent of bowel and bladder. Review of the State Tested Nursing Assistant (STNA) Tasks (un-dated) revealed the resident was to receive a shower on Sunday and Thursday night shift. Review of the shower documentation from 05/01/22 through 07/11/22 revealed the resident received one shower on 05/26/22. On 07/06/22 at 5:59 P.M. and 7:01 P.M. interviews with STNA #16 and #7 respectively revealed Resident #35 required the use of a mechanical (hoyer) lift and if there wasn't enough staff, the resident would not get a shower. On 07/11/22 at 2:45 P.M. interview with Resident #35 verified she had not received a shower in awhile and she would welcome one if it was offered. On 07/11/22 at 6:10 P.M. interview with the DON verified the resident did not receive showers per her schedule and only one shower was documented since 05/01/22. The DON verified there was no paper documentation supporting the resident received showers during the reviewed timeframe. 3. Review of Resident #26's closed medical record revealed an admission date of 12/27/18 with diagnoses including dementia without behavioral disturbance, chronic obstructive pulmonary disease, sleep apnea. In 2019, macular degeneration and changes in retinal vascular appearance bilaterally was added to her diagnoses list. Review of the physician orders revealed the resident was admitted to hospice services on 05/04/22 due to end stage chronic obstructive pulmonary disease. Review of the STNA Tasks revealed the resident received a bath or shower on Wednesday and Saturday day shift. Review of the personal and cultural preferences care plan dated 09/21/18 revealed the resident's activities of daily living preferences will be honored. Review of the alteration in thought process related to dementia, requires cues to perform activities of daily living, periods of forgetfulness plan of care dated 10/04/18 revealed interventions including allow the resident the opportunity to make choices regarding daily routines and showers given according to shower schedule. Review of the Shower/Bath documentation from 03/01/22 through 05/03/22 revealed the resident was not provided showers during the month of March, April or the first days of May. Per Hospice documentation, the resident received a shower on 05/09/22, 05/12/22, 05/13/22 and 05/20/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 6 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 Residents Affected - Some On 07/11/22 at 6:02 P.M., interview with the DON verified the resident was not provided showers as scheduled. 4. Review of the medical record for Resident #40 revealed an admission date of 01/10/22 with diagnoses including acute and chronic respiratory failure with hypoxia, congestive heart failure, malignant neoplasm of left lung, chronic obstructive pulmonary disorder, and type two diabetes mellitus. Review of the quarterly MDS dated [DATE] indicated Resident #40 was cognitively intact, required extensive assistance of one person for personal hygiene and was total dependent of one person for bathing. Review of the activities of daily living care plan did not indicate nail care would be provided as needed or on a regular basis. Review of Resident #40 shower sheets indicated he received a shower or bath on 06/05/22, 06/07/22, 06/14/22, 06/16/22, and 06/29/22. Resident refused shower or bath on 07/02/22. Observations of Resident #40 on 07/05/22 at 10:35 A.M., and on 07/11/22 at 10:11 A.M. revealed the resident to have long, jagged fingernails with a black and brown substance under the nail. An interview on 07/05/22 at 10:35 A.M. with Resident #40 revealed the resident would like to have his fingernails trimmed and cleaned. An interview on 07/07/22 at 2:00 P.M. with STNA #15 revealed bathing and showers included hair care, nail care, lotion and observation of skin. STNA #15 stated residents with diabetes would have their fingernails trimmed by the nurse. An interview on 07/11/22 at 10:06 A.M. with Registered Nurse (RN) #9 confirmed Resident #40 had long, jagged fingernails with a black and brown substance under the nails. Review of the facility policy titled Fingernail Care dated 10/2018 revealed the procedure for fingernail care included the fingernails of a diabetic resident were to be cut by a licensed nurse. Review of the facility policy titled Showering dated 11/2018 did not include providing nail care. This deficiency substantiates Complaint Number OH00133766. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 7 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the hospice agreement, review of hospice records, and staff interview, the facility failed to maintain an integrated medical record that included hospice nurse visit notes for the purposes of ensuring continuity of care between entities. This affected one (Resident #50) of one resident reviewed for hospice services. Residents Affected - Few Findings include: A review of Resident #50's medical record revealed he was admitted to the facility on [DATE] with the diagnoses of congestive heart failure (CHF) and emphysema. A review of Resident #50's physician's orders revealed he was admitted to hospice/ palliative care for the terminal diagnosis of CHF. The order was given on 06/03/22. A review of Resident #50's hospice plan of care revealed the resident was to receive one visit from the hospice nurse bi-weekly (every two weeks). A review of Resident #50's care plans revealed he had a care plan in place for receiving hospice services. The care plan was initiated on 05/27/22. The interventions included the need for hospice to collaborate care with facility staff. A review of a hospice binder kept at the nurses' station revealed hospice visit notes were maintained in that binder. The last visit note from a hospice nurse was on 06/14/22. There was no evidence of any subsequent visit notes being readily accessible or maintained as part of Resident #50's medical record. A review of the facility's agreement with the hospice company revealed the facility and hospice would prepare and maintain an integrated medical record for each resident who had elected hospice care pursuant to the agreement. Such records would be prepared and maintained in conformity with Federal and State law, rules, regulations procedures, policies, guidelines, and generally accepted medical record practices. All services provided to the resident who had elected hospice care, whether furnished directly by hospice or under the arrangements of hospice, would be documented in the medical records maintained for the resident by the facility. On 07/11/22 at 10:05 A.M., an interview with Licensed Practical Nurse (LPN) #73 revealed the hospice staff documented their visits on a visit note kept in the hospice binder at the nurses' station. He verified the last documented visit from a hospice nurse was on 06/14/22. He checked the resident's medical record and did not see any additional visit notes from a hospice nurse after 06/14/22. On 07/11/22 at 10:15 A.M., the DON was asked to provide any hospice nurse visit notes for Resident #50 for any visits occurring after 06/14/22. She confirmed the hospice nurse was scheduled to visit once every two weeks and those visits should be documented and part of the resident's medical record. She stated the most recent hospice visit notes should be in the hospice binders at the nurses' stations. On 07/11/22 at 1:10 P.M., a follow up with the DON revealed the Administrator called the hospice company and had them send in all the visit notes they had for Resident #50. The Administrator was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 8 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete present during the interview and reported the visit notes had been faxed to them from the hospice company but she forgot to provide them for review. She stated she had contacted the hospice company previously and informed them they were having their annual survey completed and the hospice company should have sent in any reports they had that were not already made available to the facility. She was upset that was not followed through with and confirmed hospice visit notes should be readily accessible and a part of the resident's medical record. Hospice nurse visit notes were obtained from the hospice company for 06/20/22 and 07/01/22 that were not included as part of the resident's medical record being maintained at the facility. Event ID: Facility ID: 365461 If continuation sheet Page 9 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, interview, and policy review the facility failed to ensure pressure ulcer care and interventions were implemented. This affected one resident (Resident #26) of three residents reviewed for pressure ulcers. The census was 45. Residents Affected - Few Findings include: Review of Resident #26's closed medical record revealed an admission date of [DATE] with diagnoses including dementia without behavioral disturbance and chronic obstructive pulmonary disease. Review of the at risk for impaired skin integrity related to decreased mobility, periods of bladder incontinence, oxygen per nasal cannula, fragile skin, history of pressure ulcers and resident noted to prefer to sit in a chair as opposed to laying in a bed initiated [DATE] with interventions including alternating air mattress to bed, barrier cream/ointment after each incontinence episode as needed; encourage fluids; encourage resident to elevate bilateral lower extremities while at rest; encourage resident to turn and reposition every two hours; encourage to float heels while in bed; encourage to remain in bed except for meals; inspect skin during routine daily care; lotion to skin as needed; pericare after each incontinent episode; pressure reduction devices if ordered; skin assessment as ordered; treatments per orders and pillows for positioning. Review of the physician orders revealed an alternating air mattress to the resident's bed, staff to check function every shift dated [DATE] and calmoseptine cream three times a day to the resident's coccyx for a pressure ulcer dated [DATE]. Review of the Progress Note dated [DATE] revealed Certified Nurse Practitioner (CNP) #600 saw the resident this date for routine monthly rounds. The resident had a large wound with scabbed areas to the buttocks. Calmoseptine was ordered for treatment of the pressure ulcer. Review of the facility pressure ulcer grids revealed no evidence the pressure ulcer diagnosed by the CNP was assessed by the facility or documented in the medical record. Review of the nurse progress notes dated [DATE] at 11:48 P.M. revealed the State Tested Nursing Assistant (not identified) reported to the nurse regarding a sore area on this resident's bottom. The nurse assessed the wound (no measurements or staging documented) and a dime size open area, no drainage, partially pink in color with the other half light purple in color. The resident denied pain from the wound. The nurse covered it with a border dressing and educated the resident to sleep on her side and turn every two hours and to avoid sleeping on the wound. The provider was made aware. Review of the skin grid pressure 3.0 V2 evaluation revealed a grid was completed on [DATE]- the wound started on [DATE] (no skin grid documentation and there are noted discrepancies in the dates) the wound was to the resident's coccyx and measured 2.4 centimeters (cm) in length and 1.4 cm in width and depth was unable to be determined. The resident has an unstageable wound (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown string like tissue) and/or eschar(tan, brown or black dead tissue)) to her coccyx and the wound is tan and brownish black in color. The resident was seen by the wound nurse practitioner on this day and the wound was debrided. A new order for medihoney and calcium alginate to the wound daily and nurse practitioner will call to follow up weekly. The wound was unchanged since the last assessment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 10 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the skin grid pressure 3.0 V2 evaluation dated [DATE] revealed the wound remained unstageable. The resident was seen by the wound NP on this day and was debrided. Area slightly larger from last week but wound was debrided both weeks which may contribute to increase size. Treatment of medihoney and calcium alginate to the wound daily. Wound Nurse Practitioner will continue to follow weekly. Review of the skin grid pressure 3.0 V2 evaluation dated [DATE] revealed the unstageable pressure ulcer remained to the coccyx. The wound is tan and brownish black in color. The resident was seen by the wound nurse practitioner on this day and the wound was debrided. The area was noted to have declined. The physician, resident and family were aware. Staff encourages the resident to only be out of bed for meals but she remains resistant. Area treatment of medihoney and calcium alginate daily. The wound NP will continue to follow weekly. Review of the Wound Care Wound Evaluation Notes dated [DATE] revealed the resident is sitting up in her recliner. The resident does report increased pain in her bottom and was assisted to bed for her exam. Staff does report she does not like to lay in bed, she likes to be up in her recliner most of the time. This is a hospice resident. Please consider up for meals, side to side turn, roho cushion (a pressure relieving cushion that is made of soft, flexible air cells connected by small channels) to chair. Review of the Nurse Progress Notes dated [DATE] revealed hospice was notified of needing a cushion for the resident's chair. Review of the Wound Care Wound Evaluation Notes dated [DATE] the resident has had an overall decline on condition and is not eating well and not as active. Staff reports she has been in bed more than up in the last week. Review of the skin grid pressure 3.0 V2 evaluation dated [DATE] revealed the wound to coccyx is unstageable. Staff encourages the resident to only be out of bed for meals but she remains resistant. Treatment of medi-honey and calcium alginate to the wound daily. The wound NP will continue to follow weekly. Review of the skin grid pressure 3.0 V2 evaluation dated [DATE] revealed the coccyx wound remains unstageable and is tan and brownish black in color. Wound is composed of 90% granulation tissue, 5 % eschar and 5% bone. Physician, resident and family aware. Staff encourages resident to only be out of bed for meals but she remains resistant. Treatment of medihoney and calcium alginate to wound daily. Wound NP will continue to follow weekly. Review of the skin grid pressure 3.0 V2 evaluation dated [DATE] revealed the wound to the resident's coccyx remained unstageable and was tan and brownish in color. Wound is composed of 90 % granulation tissue, 5 % eschar and 5 % bone. The physician, resident and family aware. Staff encourages the resident to only be out of bed for meals but she remains resistant. Treatment of medi-honey and calcium alginate to the wound daily. The wound NP will continue to follow weekly. Review of the skin grid pressure 3.0 V2 evaluation dated [DATE] revealed the wound measured 2.8 cm by 1.6 cm with depth unable to be determined. The resident has a stage IV pressure wound (full thickness tissue loss with exposed bone, tendon or muscles. Slough or eschar may be present on some parts of the wound bed. They often include undermining or tunneling) to her coccyx. Wound bed is red and yellow in color. Wound is composed on 90% granulation tissue, 5% eschar and 5% bone. The physician, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 11 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident and family were aware. Staff encourages the resident to only be out of bed for meals but she remains resistant. Treatment of mesalt to the wound daily. Wound NP will continue to follow weekly. Review of the Wound Care Wound Evaluation notes dated [DATE] revealed the wound had declined and was deemed unavoidable due to the resident's overall poor medical condition, the resident's poor compliance with offloading and poor nutritional intake. Orders were given to stop the medihoney and alginate and change the treatment to mesalt and cover with foam dressing daily and as needed. Review of the Wound Care Wound Evaluation notes dated [DATE] revealed to continue mesalt and the wound could be the start of a [NAME] ulcer. The resident expired on [DATE]. On [DATE] at 4:21 P.M. interview with the Director of Nursing verified the mesalt treatment was not implemented as ordered by the visiting wound care company and was to be implemented as ordered. On [DATE] at 2:43 P.M. interview with Licensed Practical Nurse #10 revealed the resident was non-compliant with pressure relieving interventions and spent the majority of her time up in a chair/recliner except when she slept. Further interview revealed if pressure relieving interventions were in place, there would be a physician's order, in the care plan or on the treatment administration record to document the intervention being in place. On [DATE] at 2:45 P.M. interview with the Director of Nursing verified there was no evidence the resident had the special cushion in her chair and no evidence of a recommended cushion until made by the nurse practitioner. The DON verified a pressure relieving cushion is part of the interventions to implement when identified for risk for pressure ulcer development or a pressure ulcer develops. Review of the un-dated Pressure Ulcer Prevention and Risk Identification Policy revealed the facility will assess each resident for risk of pressure ulcer development in an effort to establish measures to prevent the development of pressure ulcers within the facility or to prevent further decline of already existing pressure ulcers. The licensed nurse will perform a head to toe assessment upon admission and every seven days thereafter to identify any new skin areas. If a new skin area is identified on this assessment or during any other type of care or service, the licensed nurse will initiate a skin grid/measurement flow record. The skin grid will be updated every seven days until the area is resolved. Although there are several suggested and recommended treatment types based on the type of wound and its characteristics , the facility licensed nursing staff will ultimately follow the physician's order as provided. Interventions will be implemented as indicated by the physician and as determined by the interdisciplinary team. This deficiency substantiates Complaint Number OH00133766. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 12 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review the facility failed to ensure a comprehensive fall investigation was completed and interventions were implemented to prevent falls. This affected one resident (Resident #39) of three residents reviewed for accidents. The census was 45. Findings include: Review of Resident #39's medical record revealed an admission date of 02/06/19 with diagnoses including legal blindness and schizoaffective disorder. Review of the physician orders revealed no physician ordered fall prevention interventions. Review of the Fall Risk Evaluation- V2 completed 02/24/22 identified the resident as a fall risk. Review of the Fall Investigation dated 03/07/22 revealed the resident yelled and was observed lying at the foot of her bed with the bedside table extended to it's highest level. The resident had a history of non-compliance with medical recommendations/safety recommendations. The fall followed a pattern similar to the resident's previous falls but no root cause was identified and no new intervention to prevent falls was implemented. Review of the Nursing Progress Note dated 03/07/22 at 5:35 P.M. revealed staff heard a loud crash and found the resident lying on the floor at the foot of her bed with the overbed table at the highest level, next to the resident. The resident was assessed by the nurse and Director of Nursing and assisted up to her chair and her brace applied. Neurological checks were started and the Nurse Practitioner and power of attorney was notified. Review of the at risk for falls and potential injury related to weakness, blindness, hard of hearing and history of falls plan of care initiated 02/13/19 revealed no new interventions for fall prevention was implemented as a result of the 03/07/22 fall. Review of th Fall Investigation dated 06/12/22 revealed the resident was found on the floor, yelling for staff. The resident was found laying on her left side with her head toward the end of her bed. The resident did not know what happened. Further review of the investigation revealed no root cause was identified but a perimeter mattress was placed on the resident's bed as a fall prevention intervention. The intervention was also reflected on the plan of care. Review of the Nurse Progress Notes revealed the 06/12/22 was not documented in the progress notes. Review of the five-day Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment and required extensive assistance of two staff members with bed mobility, transfers, dressing and personal hygiene. The resident also required supervision with toilet use but is always incontinent of bowel and bladder. Lastly, the resident had experienced two or more falls since the last assessment without injuries. On 07/11/22 at 6:02 P.M. interview with the Director of Nursing verified thorough fall investigations were not completed regarding the 03/07/22 and 06/12/22 falls to determine the root cause of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 13 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few falls. The DON also verified a new intervention was not implemented for the fall occurring on 03/07/22 and both a thorough investigation and new intervention should be completed with each fall. Review of the facility Fall Prevention Policy dated 02/21 revealed the purpose of the policy is to promote resident safety and identify measures to be taken to prevent resident falls. Appropriate interventions will be initiated to prevent falls specific to the resident assessment. This deficiency substantiates Complaint Number OH00133766. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 14 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and policy review the facility failed to follow infection control guidelines related to incontinence care for a resident at risk for urinary tract infections. This affected one resident (Resident #35) of one resident observed for incontinence care. The census was 45. Findings include: Review of Resident #35's medical record revealed an admission date of 08/15/03 with diagnoses including multiple sclerosis, major depression, dementia without behavioral disturbance and constipation. Review of the alteration in elimination related to no control present with bowel and bladder initiated 03/24/14 with interventions including provide incontinence care as needed; check and change routinely and as needed; monitor for signs and symptoms of urinary tract infection. Review of the risk for infection related to incontinence of bowel and bladder with no sensation of need related to multiple sclerosis causing an increased risk of urinary tract infections initiated 03/24/14 with interventions including monitor for signs and symptoms of UTI including foul smelling urine, cloudy urine, sediment and decreased output. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment and required extensive assistance of one staff member with bed mobility and personal hygiene, dependent of two staff with transfers and dependent of one staff member with dressing and toilet use. The resident was always incontinent of bowel and bladder. Review of the Continence assessment dated [DATE] revealed the resident is does not request toileting and would be appropriate for a check and change program. On 07/07/22 at 10:45 A.M. Nurse Aide (NA) #82 was observed to prepare to provide incontinence care to Resident #35. NA #82 washed her hands, donned gloves and began to set up her supplies at Resident #35's bedside. NA #82 placed a water filled wash basin on the resident's overbed table, pulled the privacy curtain and adjusted the height of the resident's bed using her electric bed control and placing the bed at working level. NA #82 and Licensed Practical Nurse (LPN) #45 moved the bed away from the wall and uncovered the resident. Both staff then removed the resident's wet incontinence brief and positioned the resident on her back. NA #82 explained the procedure to Resident #35 and provided perineal/incontinence care to the resident's labia and groin creases using front to back motions. Once completed, the staff assisted the resident onto her left side, facing LPN #45. At 10:50 A.M. NA #82 wet a clean washcloth from the wash basin, applied soap and began to provide peri care/incontinence care to the resident's buttocks moving from the gluteal cleft/top of the resident's buttocks to the vaginal area, wiping in a back to front motion. The NA completed this three times and placed the washcloth into the soiled linen. The NA obtained a clean wash cloth, wet the wash cloth from the water basin and rinsed the resident's buttocks again moving from the gluteal cleft to the vaginal area, in a back to front motion. This was completed three times and the washcloth was placed in the soiled linen. The NA then obtained a clean towel and dried the resident's buttocks moving in the same direction, back to front. At 10:55 A.M. and while wearing the same gloves used to provide incontinence care to Resident #35, NA #82 repositioned the resident's covers and lowered the resident's bed using the electric bed control. The STNA then used the pull string to turn off the resident's overbed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 15 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few light, opened the privacy curtain and moved the resident's overbed table next to her bed. At 10:58 A.M. the NA entered the resident's bathroom, removed her gloves, and began to wash her hands. On 07/07/22 at 10:58 A.M. interview with NA #82 verified she did not wash her hands and change her gloves prior to completing perineal/incontinence care to Resident #35. NA #82 verified she touched items in the resident's room while wearing the same gloves she wore to provide incontinence care. NA #82 confirmed she did not provide incontinence care to the resident utilizing a front to back motion when she moved to cleaning the resident's buttocks and wiped from the top of the buttocks toward the vaginal area. Lastly, the NA verified she did not remove her gloves and complete hand hygiene after she provided the resident's perineal/incontinence care and touched the resident's blanket, bed control, bedside table and light chain. The NA verified her gloves should have been removed and hand hygiene completed before touching other items in the resident's room. On 07/07/22 at 1:47 P.M. interview with LPN #45 verified the NA did not follow appropriate infection control guidelines while providing incontinence care including not cleaning from front to back and not changing her gloves or performing hand hygiene before and after providing incontinence care. Review of the un-dated Perineal Care Policy revealed the purposes of this procedure are to provide cleanliness and comfort to the resident. to prevent infections and skin irritation and to observe the resident's skin condition. Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached. Wash and dry your hands thoroughly. Fill the wash basin. Place the wash basin on the bedside stand within easy reach. Avoid unnecessary exposure of the resident's body. Put on gloves. For a female resident, wet the washcloth and apply soap or skin cleansing agent. Wash the perineal area, wiping from front to back. Rinse the perineum thoroughly in the same direction, using fresh water and a clean washcloth. Gently dry the perineum. Instruct or assist the resident to turn on her side. Rinse the wash cloth and apply soap or a skin cleansing agent. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Rinse thoroughly using the same technique as washing the rectal area. Dry the area thoroughly. Discard the disposable items into designated containers. remove gloves and discard into designated container. Wash and dry your hands thoroughly. Reposition the bed covers. Make the resident comfortable. Place the call light within easy reach of the resident. Wash and dry your hands thoroughly. If the resident desires, return the door and curtains to the open position. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 16 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review and interview the facility failed to ensure comprehensive meal intake documentation was available to adequately monitor resident nutritional status. This affected one resident (Resident #26) of three residents reviewed for nutrition. The census was 45. Residents Affected - Few Findings include: Review of Resident #26's closed medical record revealed an admission date of 12/27/18 with diagnoses including dementia without behavioral disturbance, chronic obstructive pulmonary disease (COPD), and sleep apnea. In 2019, macular degeneration and changes in retinal vascular appearance bilaterally was added to her diagnoses list. Review of the potential for alteration in nutrition and hydration related to medical diagnoses, COPD needs higher, nutritional risk, therapeutic diets, history of protein storage depletion, history of significant weight changes implemented 12/27/18 with interventions including obtain food preferences, provide diet as ordered, dietician referral as needed, supplements and weights as ordered. Review of the physician orders revealed a mechanical soft diet with regular fluids and the food first program dated 04/06/22 which provided the resident with fortified cereal with breakfast, fortified hot chocolate with all three meals and ice cream with the evening meal. Hospice services were ordered on 05/06/22 due to end stage COPD. Review of the resident weights revealed: On 12/06/21 the resident weighed 162 pounds; 01/05/22 155 pounds; 02/02/22 150 pounds; 03/08/22 149 pounds; 04/04/22 143 pounds and 05/03/22 144 pounds Review of the Dietary Progress Notes revealed nutrition interventions were implemented with weight changes. Dietary identified the resident as a significant weight loss between 12/06/21 with a weight of 162 pounds and 03/09/22 148.8 pounds or 7.9 percent. Monitoring continued with weights and meal intake reviews via flow sheets. Review of meal intake documentation from 04/01/22 through 05/06/22, when hospice services were implemented, revealed: No meal documentation for 04/03/22 and 04/04/22; only one meal was documented on 04/02/22, 04/08/22, 04/12/22, 04/16/22, 04/17/22, 04/19/22, 04/24/22, 04/25/22, 04/28/22, 04/29/22, and 05/05/22; and only two meals documented on 04/13/22, 04/18/22, 04/27/22, 05/01/22 and 05/02/22. No meal refusals were documented on the listed days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 17 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident's cognition was intact with a score of 15. The resident required extensive assistance of two staff with bed mobility and transfers and required supervision of one staff while eating. The resident experienced a significant weight loss of five percent or more in the last month or 10 percent or more in the last six months and not on a prescribed weight loss regimen. On 07/11/22 at 6:08 P.M. interview with the Director of Nursing verified the resident's meal intakes were not consistently documented, even if the resident refused her meals. The meal intakes would be used to monitor the resident's nutrition status especially with weight loss. On 07/12/22 at 8:41 A.M. interview with Registered Dietician (RD) #500 revealed weight was the best indicator of nutritional status and meal intakes were reviewed as well with nutritional assessments. RD #500 verified Resident #26 experienced a significant weight loss prior to her hospice admission but nutritional interventions were in place in an attempt to prevent weight loss. The RD also verified meal intakes or refusals should be documented to be reviewed for nutritional status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 18 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 interview, observation, record review and facility policy review the facility failed to ensure a resident's oxygen flow rate was set as ordered and failed to provide education to a resident on the risks of increasing the flow rate with a diagnosis of chronic obstructive pulmonary disorder. This affected one resident (Resident #40) reviewed for respiratory care. The facility census was 45. Residents Affected - Few Findings include: Review of the medical record for Resident #40 revealed an admission date of 01/10/22 with diagnoses including acute and chronic respiratory failure with hypoxia, congestive heart failure, malignant neoplasm of left lung, chronic obstructive pulmonary disorder, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #40 was cognitively intact, had no impairment to range of motion to bilateral upper extremities and received oxygen therapy. Review of the current physician orders for 07/2022 revealed Resident #40 was to receive oxygen at two-three liters per minute via nasal cannula for shortness of breath or oxygen saturation below 90 percent. Review of the Treatment Administration Record (TAR) for 06/22 and 07/22 revealed nursing initials verified Resident #40 received oxygen at two-three liters a minute via nasal cannula for shortness of breath or oxygen saturation below 90 percent every shift. Review of the oxygen plan of care alteration in oxygen exchange and perfusion related to chronic obstructive pulmonary disorder revealed interventions that included oxygen as ordered to maintain oxygen saturation level at 90 percent or greater. The care plan did not address the resident adjusting his oxygen flow rate to five liters. Observations on 07/05/22 at 10:33 A.M. and on 07/11/22 at 10:01 A.M. revealed Resident #40's oxygen flow rate was set at five liters per minute via nasal cannula. An interview on 07/11/22 at 10:06 A.M. with Registered Nurse (RN) #9 confirmed Resident #40's oxygen flow rate was set at five liters per minute via nasal cannula. RN #9 also confirmed Resident #40 physician order stated oxygen at two-three liters per minute via nasal cannula for shortness of breath and Resident #40 had a diagnosis of chronic obstructive pulmonary disorder. RN #9 stated Resident #40 turned up his flow rate when he was short of breath. Further interview with RN#9 on 07/11/22 at 2:56 P.M. revealed she was not aware of any education provided to Resident #40 in regards to the risks of turning his oxygen flow rate up to five liters per minute. An interview on 07/12/22 at 10:14 A.M. with Resident #40 revealed he turned his flow rate up to five liters because it helped him breath easier and made him feel more comfortable. Resident #40 stated the flow rate had been set on five for a long time. Resident #40 stated that the nurses had not talked to him about turning his oxygen up or discussed the risks of such a high flow rate with his diagnosis. Review of the facility policy titled Oxygen Administration via Nasal Cannula with no date did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 19 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 address adjusting the flow rate of oxygen. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 20 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on review of staffing schedules for May 2022, review of daily nurse staffing postings for 05/28/22 thru 05/29/22, time reports and staff interview, the facility failed to ensure they had Registered Nurse (RN) coverage for eight consecutive hours seven days a week as required. This had the potential to affect all residents residing in the facility. Findings include: A review of the facility's nursing schedule for May 2022 revealed there was not a RN scheduled to work for either the day shift (7:00 A.M. to 7:00 P.M.) or night shift (7:00 P.M. to 7:00 A.M.) on 05/28/22 or 05/29/22. The scheduled identified which nurses were scheduled based on an x being placed across from their names in the boxes for a particular date. The empty box indicated the nurse did not work on those days. There were only two RN's included on the schedule for May 2022 with nine LPN's. A review of the daily nurse staffing posting for 05/28/22 and 05/29/22 revealed there were no RN hours recorded for either the day shift or the night shift on those dates. The daily nurse staff posting indicated the number and the actual hours worked for RN's, LPN's and STNA's. Nothing was marked in the columns across from the RN section reflecting no RN's were working. A review of the time reports provided for review for the RN's employed at the facility during 05/28/22 and 05/29/22 revealed none of them were indicated to have worked either of those two days. The facility's DON and prior ADON (who was an RN) was included in those time reports and neither were indicated to have worked on either of those two days. On 07/12/22 at 2:45 A.M. an interview with the DON verified over the Memorial Day weekend they did not have RN coverage despite them having the DON and an ADON at the time, who was also an RN, and two RN's (RN #9 and RN #80) who were floor nurses. The DON stated they have since hired more RN's but did not have adequate coverage at that time. This deficiency substantiates Complaint Number OH00133766. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 21 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to ensure pharmacy recommendations pertaining to gradual dose reduction (GDR) attempts for psychoactive medications were responded to by the physician and/ or psychiatrist to include a resident specific rationale as to why a GDR attempt was contraindicated. This affected two (Resident #7 and #40) of five residents reviewed for unnecessary medications. Findings include: 1. A review of Resident #7's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included major depressive disorder (MDD) and anxiety disorder. A review of Resident #7's physician's orders revealed the use of Duloxetine HCL (Cymbalta) 60 milligrams (mg) by mouth twice a day for MDD. The order had been in place since 11/17/21. A review of a pharmacy recommendation dated 05/12/22 revealed the facility's contracted pharmacist recommended Resident #7's physician consider a GDR for the use of Cymbalta as the resident had been on Cymbalta 60 mg twice a day since November 2021. The physician declined to address the recommendation and referenced to see the psychiatry note dated 05/18/22. A review of a psychiatry progress note by Psychiatrist #300 revealed Resident #7 was visited for medication management on 05/18/22. The psychiatrist indicated the resident was doing well on his current medication. He had been compliant with his medication and the medication was indicated to be working. He denied any side effects to the medication. The psychiatrist's plan was to continue the Cymbalta at 60 mg twice a day. He did not address the pharmacist's recommendation for a GDR consideration for the Cymbalta that was made on 05/12/22. The psychiatrist did not indicate in his progress note that a GDR attempt was contraindicated or provide a rationale as to why a dose reduction should not be attempted. A review of the facility's Psychoactive Medication Reduction policy dated April 2016 revealed the consulting pharmacist would review all medications on a monthly basis and make any recommendations to the attending physician. 2. Review of the medical record for Resident #40 revealed an admission date of 01/10/22 with diagnoses of anxiety and major depressive disorder. Review of the quarterly MDS dated [DATE] indicated Resident #40 was cognitively intact with mood symptoms and verbal behaviors directed at others. Resident #40 received an antidepressant medication seven days of the seven day assessment period. Review of the current active physician orders for 07/2022 revealed Resident #40 received Citalopram Hydrobromide (antidepressant medication) 10 milligrams (mg) by mouth at bedtime for depression. Review of the plan of care for psychoactive medications revealed there were not any interventions related to gradual dose reduction or pharmacy recommendations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 22 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the pharmacy recommendations dated 05/12/22 for Resident #40 revealed the pharmacist recommended the physician consider a dose reduction of the antidepressant medication Citalopram Hydrobromide 10 mg. The recommendation was not addressed or signed by the physician as of 07/12/22. Interview on 07/12/22 at 12:23 P.M. with the Director of Nursing (DON) confirmed the recommendation on 05/12/22 to consider a dose reduction of Citalopram Hydrobromide 10 mg was not addressed by the physician. Event ID: Facility ID: 365461 If continuation sheet Page 23 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 - Few 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. Based on record review, interview and policy review the facility failed to ensure gradual dose reductions were attempted for residents receiving antipsychotic medications. This affected one resident (Resident #22) of five residents reviewed for unnecessary medications. The census was 45. Findings include: Review of Resident #22's medical record revealed an admission date of 11/30/17 with diagnoses including diabetes, depression, schizophrenia and atrial fibrillation, Review of the physician orders revealed zyprexa (antipsychotic medication) 20 milligrams (mg) one tablet by mouth daily written on 01/16/20. The medication was scheduled for administration at bedtime. Review of the pharmacy recommendation dated 04/19/22 revealed the resident has been taking the antipsychotic medication, Zyprexa 20 mg every night at bedtime since January 2020. Please evaluate the current dose and consider a dose reduction. The physician response dated 05/17/22 revealed no changesee psych note and medical record review- 04/20/22. Review of the psychiatry note dated 04/20/22 revealed no evidence a GDR was contraindicated or an order for a GDR. The note stated to continue Zyprexa 20 mg daily. Review of additional psychiatry notes dated 08/18/21, 11/17/21 and 02/16/22 contained no evidence of GDR contraindication or orders for a GDR. Review of the Quarterly Minimum Data Set (MDS) Assessment 3.0 dated 06/21/22 revealed the resident was cognitively intact and required limited assistance of one staff with bed mobility and toilet use. The resident required supervision with transfers, dressing, eating and personal hygiene. The resident had a diagnosis of schizophrenia and received antipsychotic medication on a routine basis during the assessment period. No gradual dose reduction (GDR) was attempted and the last documentation of a GDR being contraindicated was 06/16/21. Review of the alteration in mood with depression/anxiety related to depression, dementia with behaviors, schizophrenia and delusional disorder plan of care implemented 01/16/20 revealed interventions including ensure resident psychological needs are met and medications are administered per physician orders. On 07/07/22 at 5:29 P.M. interview with Licensed Practical Nurse (LPN) #45 verified the psychiatry note dated 04/20/22 did not address a GDR and did not contain information to clarify why a GDR would be contraindicated. On 07/11/22 at 1:56 P.M. interview with the Director of Nursing verified there was no attempted GDR or evidence of documentation regarding why the GDR would be contraindicated since June of 2021. The DON verified the pharmacy recommendation dated 04/19/22 was not addressed. Review of the Psychoactive Medication Reduction Policy dated 04/16 revealed reductions will be made according to physician order and after evaluation of the resident's behavior. The consultant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 24 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 pharmacist will review all medications on a monthly basis and make any recommendations to the attending physician. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 25 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 0759 Ensure medication error rates are not 5 percent or greater. 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, product instructions for use, staff interview and policy review, the facility failed to ensure their medication error rate did not exceed 5%. The facility had three errors out of 29 opportunities for error for a medication error rate of 10.3%. This affected two (Resident #6 and #44) of three residents observed for medication administration. Residents Affected - Few Findings include: 1. A review of Resident #44's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (COPD) and hypertension (HTN). A review of Resident #44's physician's orders revealed the resident had an order to receive Metoprolol Tartrate (a beta blocker used in the treatment of hypertension) 25 milligrams (mg) by mouth (po) twice a day for HTN. The orders included parameters to hold the medication if the resident's systolic blood pressure (SBP) was less than 90 millimeters of mercury (mm/hg) or her pulse was less than 50 beats per minute (BPM). The resident also had an order to receive Symbicort (a bronchodilator used in the treatment of COPD) Aerosol 160-4.5 micrograms (mcg)/ ACT two inhalations inhaled orally twice a day for COPD. The orders included instructions to have the resident rinse her mouth with water and spit it out after each dose. On 07/06/22 at 7:45 A.M., a medication administration observation was completed for Resident #44. Licensed Practical Nurse (LPN) #75 was the nurse who administered the resident her morning medications. The resident was given Metoprolol Tartrate 25 mg po as ordered twice a day. The resident also received Symbicort inhaler 160-4.5 mcg/ ACT receiving two puffs as ordered twice a day. The label on the blister pack the Metoprolol Tartrate came in included the parameters to hold the medication if the resident's SBP was less than 90 mm/hg or her pulse was less than 50 BPM. The box the Symbicort inhaler came in included a label with instructions to have the resident rinse her mouth with water and spit it out after each use. The nurse was not noted to obtain the resident's blood pressure or pulse prior to the administration of the Metoprolol Tartrate nor was she noted to provide the resident any instructions to rinse her mouth with water and spit it out after taking the Symbicort inhaler. The resident took her medications that came in pill form first followed by her Symbicort inhaler. The resident then proceeded to eat her breakfast that had been served. On 07/06/22 at 7:50 A.M., an interview with LPN #75 revealed she did not check the resident's blood pressure or pulse before giving Resident #44 her Metoprolol Tartrate. She checked with the nursing assistants and confirmed they had not obtained the resident's vital signs either. She denied the electronic medication administration record (eMAR) required them to put in a blood pressure or a pulse prior to the administration of the Metoprolol Tartrate. She acknowledged the resident's physician's orders did include parameters to hold the medication if her SBP was less than 90 mm/hg or her pulse was less than 50 BPM. She also confirmed she did not provide the resident any instructions to rinse her mouth with water and spit it out after use of her Symbicort inhaler. She was asked what the purpose of that was and knew the risk of the resident getting Thrush (a yeast infection in the mouth) with the inhaler's use. She acknowledged the physician's order and the box the Symbicort inhaler came in included instructions to have the resident rinse her mouth with water and spit it out after the use of the Symbicort inhaler. A review of the Instructions for Use (package insert) that was included in the box Resident #44's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 26 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 0759 Level of Harm - Minimal harm or potential for actual harm Symbicort inhaler came in revealed directions on how to use Symbicort and instructions to follow after the use of her Symbicort inhaler. The directions instructed the user to rinse their mouth with water, spit out the water, and do not swallow after they finished taking the Symbicort. Side effects listed for Symbicort included a fungal infection in the mouth or throat (thrush). Again it indicated the need to rinse the mouth with water without swallowing after using Symbicort to help reduce the chance of getting thrush. Residents Affected - Few 2. A review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included morbid obesity, muscle weakness, abnormalities of gait and mobility, chronic pain, dementia with behavioral disturbances and melena (dark, sticky feces containing partly digested blood). A review of Resident #6's physician's orders revealed the resident had an order to receive Colace (a stool softener) 100 mg po twice a day. The order had been in place since 12/09/21. On 07/06/22 at 8:09 A.M., a medication administration observation was completed for Resident #6. Her morning medications were administered by LPN #13. The resident was not given Colace 100 mg as ordered twice a day with the seven other medications that had been given. On 07/06/22 at 8:32 A.M., an interview with LPN #13 confirmed he did not give Resident #6 Colace 100 mg as ordered twice a day. He acknowledged he had signed off the eMAR as if the Colace had been given but he verified he gave the resident a total of seven tablets/ capsules which did not include Colace, which would have made it eight. He reported he must have just missed it. A review of the facility's policy on Medication Administration- General Guidelines undated revealed medications were to be administered in accordance to written orders of the attending physician. The policy did not address the need to obtain relevant vital signs if the order included parameters in which the medication should be held. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 27 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review the facility failed to ensure follow-up occurred related to consultation recommendations and dental extraction aftercare. This affected two residents (Resident #26 and #46) of four residents reviewed for dental services. The census was 45. Residents Affected - Few Findings include: 1. Review of Resident #26's closed medical record revealed an admission date of 12/27/18 with diagnoses including dementia without behavioral disturbance and chronic obstructive pulmonary disease. Review of the resident is at risk for oral/dental health problems related to having top and bottom partials; staff assistance provided daily with oral hygiene and denture care implemented on 09/21/21 with interventions including encourage application of dental adhesive to assist with eating Review of the Clinical Notes Report dated 12/29/21 revealed the resident needed all of her remaining teeth extracted and referred for dentures. Tooth #10, #11, #24, #25, #26 and #27. No aftercare instructions were noted in the medical record. Review of the Summary Report dated 02/21/22 revealed the resident was edentulous. She just had all her remaining teeth extracted last week. Evaluate healing at next visit for dentures, Today her gum tissue was in need of healing. Review of the Summary Report dated 03/16/22 revealed the resident and facility was informed that a dentist was not present today and services today were performed by a licensed dental hygienist and are preventative in nature. The services do not constitute comprehensive dental diagnoses and care. While the resident was recently had an examination by the staff dentist in the event the hygienist observes any presence of caries and/or abnormalities the staff dentist will be notified. The resident is edentulous with partial upper and lower dentures. The resident was cooperative and was seen in her room today. The resident's extraction sites are healing but still red and a bit swollen. Further review of the medical record revealed no documentation related to the extractions on 02/16/22, no assessment of the resident's gums during the healing process and no attempt to reach the dental office regarding any extraction aftercare. Review of the significant change MDS dated [DATE] revealed the resident's cognition was intact with a score of 15. The resident required extensive assistance of two staff with bed mobility and transfers and extensive assistance of one staff member with dressing, toilet use and personal hygiene. And the resident was not edentulous. On 07/11/22 at 6:20 P.M. interview with the DON revealed the resident did have her teeth extracted but the medical record did not contain evidence aftercare instructions were provided or the nursing staff attempted to obtain aftercare instructions from the dentist. The DON confirmed the nursing staff should have been monitoring the resident's oral status during the healing process to ensure the resident did not encounter any issues and there should have been post-extraction care instructions from the dentist. 2. Review of Resident #46's medical record revealed an admission date of 10/21/20 with diagnoses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 28 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 0791 Level of Harm - Minimal harm or potential for actual harm including acute respiratory failure with hypoxia, embolus of pulmonary artery, diabetes, depression,and difficulty walking. Review of the physician orders revealed eliquis (blood thinning medication) five milligrams orally twice per day ordered 10/27/20. Residents Affected - Few Review of the at risk for oral/dental health problems related to having her own teeth with poor dentition noted implemented 10/30/21 with interventions including coordinate arrangements for dental care and transportation as needed or as ordered. Review of the Oral and Maxillofacial Surgery Request dated 03/01/22 revealed an area dentist was referring the resident to any of the five surgeons with this practice for extractions due to the resident's medical history (no specifics were provided). On 07/05/22 at 10:46 A.M. interview with Resident #46 revealed has been to two area dentists for dental extractions and the last one referred her to an oral surgeon but she was unsure if the facility made a follow-up appointment. On 07/06/22 at 5:10 P.M. interview with Licensed Practical Nurse #79 revealed Resident #46 wanted her teeth pulled but no one would would pull her teeth while taking a blood thinning medication and the resident's physician would not take her off of the blood thinning medication. On 07/07/22 at 9:23 A.M. interview with Social Service Designee (SSD) #7 revealed the resident had seen two area dentists and a referral had been made to an oral surgeon, however she was unaware of the referral request which was dated 03/01/22. The SSD stated nursing was responsible for addressing consults outside of the facility but she was unable to locate any documentation related to the oral surgeon referral. The SSD stated the resident wanted her teeth extracted and to obtain dentures. Lastly, the SSD confirmed she was made aware of the resident's concerns regarding the oral surgeon referral on 07/06/22 and was waiting on a return call from the oral surgery office. The SSD confirmed the referral should have been addressed and discussed with the resident sooner than four months after the referral was recommended. On 07/07/22 at 2:15 P.M. interview with Resident #46 revealed she wanted her teeth extracted as they were in poor condition and she wanted dentures. The resident stated the area dentist wanted to pull her teeth while she was awake and she didn't want that so they referred her to the oral surgeon. The resident was unsure of the referring office sent the document to the oral surgeon or if the facility was to follow-up but the dentist provided her with the form at her appointment on 03/01/22. On 07/11/22 at 6:01 P.M. interview with the Director of Nursing verified the oral surgeon referral should have been followed-up by someone to ensure the oral surgeons office received the request and to provide the resident information regarding the pending appointment. Review of the Dental Services Policy dated 05/18 revealed routine and emergency dental services are available to meet the resident's oral health in accordance with the resident's assessment and plan of care. The staff is responsible for notifying Social Services of a resident's need for dental services. Social Services personnel will be responsible for assisting the resident/family with dental services. This deficiency substantiates Complaint Number OH00133766. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 29 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Immediate jeopardy to resident health or safety Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, The Department of Health and Human Services, Center for Medicare and Medicaid (CMS) Memo QSO 20-20-ALL dated 03/20/20, Nursing Home Guidance from the Centers for Disease Control (CDC), record review, review of the facility COVID-19 timeline, review of the county community COVID-19 transmission rate, review of staff time sheets, review of staff screening forms, review of resident and staff COVID-19 rapid point of care (POC) test results, review of the facility COVID-19 procedure policy and staff interview the facility failed to implement effective and recommended infection control practices to prevent the spread of COVID-19 as evidenced by the facility's failure to ensure staff did not provide direct resident care to residents while symptomatic of COVID-19, failure to ensure staff were properly screened for COVID-19 upon entrance into the facility and failed to ensure all staff utilized appropriate personal protective equipment (PPE) during a COVID-19 outbreak to help reduce the spread of COVID-19 throughout the facility. This resulted in Immediate Jeopardy when State Tested Nursing Assistant (STNA) #34 entered the facility on 06/07/22 with signs and symptoms of COVID-19, failed to wear appropriate PPE and provided direct care for residents including Residents #40 and #47 who were diagnosed with COVID-19 on 06/09/22. The lack of effective infection control practices placed all residents at the facility at risk for serious life-threatening harm, complications and/or death related to the facility's failed practice of infection control. This affected Residents #31, #38, #1, #36, #11, #34, #47, #12, #40, #18, #45, #16, #32, #35, #13, #27, #20, #3, #98, #99, #33, #39, #7, #43, #2, #8, #17, #4, #28, #33, #37, #5, #10, #18, #19, #21, #24, #6, #23, #30, #9, #46 and #29. The facility census was 45. Residents Affected - Many On 07/07/22 at 4:10 P.M. the Administrator and Director of Nursing (DON), Assistant Director of Nursing (ADON), the Administrator in Training, and the Regional Quality Assurance (RQA) (Registered Nurse (RN) #99) were notified that Immediate Jeopardy began on 06/07/22 when the facility failed to implement appropriate and recommended infection control practices after STNA #34 had signs and symptoms of COVID-19 and failed to wear proper PPE while providing care to 17 residents on Dodge Hall. The Immediate Jeopardy continued when the facility established outbreak status of COVID-19 and failed to implement policies to prevent exposure of non-infected (COVID-19 negative) residents from staff who were not donning and doffing appropriate PPE, sanitizing face shields, or changing N95 masks upon departure of resident rooms who were in isolation with confirmed COVID-19. The facility's continued failure for effective infection control practices continued the residents' risk for hospitalization, serious harm and/or death related to a COVID-19 outbreak in the facility. The Immediate Jeopardy was removed on 07/08/22 when the facility implemented the following corrective actions: • On 07/07/22 at 1:47P.M., a QAPI meeting was held with the Administrator, Regional Quality Assurance (RQA) Nurse/RN #99, Director of Nursing (DON), Assistant Director of Nursing (ADON), Administrator in Training (AIT), and the Medical Director via phone to review the policies for screening staff upon entry/ start of shift, not permitting staff to work if symptomatic for signs and symptoms of COVID-19, and proper PPE use via video with post-test. • On 07/07/22 at 2:30 P.M., the RQA Nurse/RN #99 educated the Administrator, AIT, DON, and ADON on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 30 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 0880 Level of Harm - Immediate jeopardy to resident health or safety policies for screening of staff and screeners not permitting staff to work with symptoms consistent with COVID- 19. Further education was provided on proper PPE use and isolation procedures for COVID-19 positive/ suspected residents and proper disinfection of face shields when leaving isolation rooms of those in droplet precautions. • Residents Affected - Many On 07/07/22 at 4:30 P.M., the RQA Nurse/RN #99 or /Designee initiated an audit of all staff currently at the facility for screening of COVID-19 symptoms. No screenings or interviews revealed anyone working in house with symptoms. Staff included four nurses, five nurse aides, three dietary staff, one activity staff, one housekeeping/laundry, and eight management staff were included. • On 07/07/22 at 4:35 P.M., the DON/Designee initiated education to all staff on what symptoms of COVID-19 to report and when staff were not permitted to enter the building. They also received education regarding proper use of PPE including when and what type to wear, and proper procedure for disinfecting face shields between COVID-19 positive and COVID-19 negative residents, especially during outbreak. In addition, the staff were educated on staff screening procedures. Education included 14 nurses (seven RNs and seven LPNs), 18 nurse aides, eight dietary staff, three activities, three housekeeping/laundry, and five management staff were included in the training. • On 07/07/22 at 7:00 P.M., seven residents who have been free of COVID-19 were rapid tested for COVID-19 and no new positives were found. Testing was completed by the DON and/ or designee. All staff were tested for COVID-19 on this date and were negative. • On 07/08/22 at 5:00 A.M., re-education was initiated by the DON/designee of all staff on the screening process emphasizing no staff member was permitted to work if they had any symptoms of COVID-19, or if they checked having any symptoms on the screening log. Videos on proper PPE use to be watched by all staff with post-test on 7/08/22 or before returning from a leave of absence (LOA). Education included 13 nurses (six RNs and 7 LPNs), 16 nurse aides, eight dietary staff, three activities, three housekeeping/laundry, and six management staff were included in the training. • On 07/08/22 at 5:00 A.M., the DON/Designee had all staff perform competency testing on donning and doffing PPE, hand washing, COVID-19 testing, and COVID-19 screening. All other staff will be checked for competency before returning from a LOA. Education included 13 nurses (six RNs and seven LPNs), 16 nurse aides, eight dietary staff, three activities, three housekeeping/laundry, and six management staff were included in the training. • Beginning on 07/08/22 (time not identified), the DON/Designee will perform ongoing audits of screening logs three times per week for four weeks, then randomly thereafter to monitor for proper (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 31 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 0880 Level of Harm - Immediate jeopardy to resident health or safety screening procedures ensuring symptomatic staff/visitors were not entering the facility. Audits will include ensuring the screening log was filled out in its entirety and that staff who were symptomatic or positive for COVID-19 were not permitted to work. Results of audits will be reviewed in QAPI for further recommendations. • Residents Affected - Many Beginning 07/08/22 (time not identified), the LNHA/designee will audit five random employees three times per week for four weeks on their knowledge of the signs and symptoms of COVID-19, whom to report COVID-19 symptoms to, and if they know not to work with symptoms. Results of audits will be reviewed in QAPI for further recommendations. • Beginning 07/08/22 (time not identified), the LNHA/Designee will complete audits of five residents' rooms of those in isolation three times a week for four weeks, then randomly thereafter to monitor for proper PPE use including donning, doffing, mask use, face shield cleaning and disposal of supplies. Results of audits will be reviewed in QAPI for further recommendations. • On 07/08/22 at 1:00 P.M., the LNHA reviewed with the DON and Human Resource Director of new hires receiving education on infection control practices including isolation procedures, cleaning face shields, mask usage, Covid-19 symptoms, and the screening process. • On 07/11/22 from 10:18 A.M until 10:43 A.M., surveyor interview of STNA #15, RN #9, Laundry Staff #19, STNA #11, STNA #40, and LPN #73 was completed to determine if education was received and staff was knowledgeable about donning and doffing PPE, disinfecting the face shield, proper mask to wear, signs and symptoms of COVID-19, the screening process and when not to enter the facility or resident care areas. All staff had received the education and were knowledgeable. Although the Immediate Jeopardy was removed on 07/08/22, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure ongoing compliance. Findings Include: 1.Observation on 07/05/22 at 8:00 A.M. revealed the facility was in outbreak status via a sign posted on the front door. At the time of the observation, interview of Activities Director #48 (assigned as the facility infection control screener) revealed the facility currently had two residents positive for COVID-19. Interview on 07/06/22 at 10:30 A.M. with the Director of Nursing (DON) revealed the facility was providing COVID-19 testing two times a week, on Tuesday and Thursday with no set time, due to the county transmission rate was red or greater than ten percent. The DON stated night shift employees could test the morning after their shift on Tuesday and Thursday. The DON also stated when the county (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 32 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 0880 Level of Harm - Immediate jeopardy to resident health or safety positivity rate was green or yellow the staff were required to wear only a surgical mask. When the positivity rate goes to red or the facility was in outbreak status, the staff were required to wear N95 mask and face shield. Review of the facility provided weekly transmission data calendars indicated the county transmission rate every week since 05/23/22 was high (red). Residents Affected - Many Review of the CMS COVID-19 Nursing Home data website https://covid.cdc.gov/covid-data-tracker/#county-view of the county transmission rate for 06/02/22 through 06/09/22 revealed the facility's transmission rate was colored red, indicating high transmission rate. Review of the facility provided employee screening logs for COVID-19 dated 06/07/22 through 06/10/22 revealed STNA #34 was screened on 06/07/22 (no time indicated) by Licensed Practical Nurse (LPN) #78. STNA #34 responses included: • answered Yes to the following questions: Are you up to date with vaccination? Do you have congestion and/or runny nose? • answered No to the following questions: Do you have a cough? Do you have a sore throat? Do you have a new onset of shortness of breath or difficulty breathing? Do you have chills or repeated shaking with chills? Do you have fatigue? Do you have muscle pain? Do you have nausea, vomiting and or diarrhea? Do you have a headache? Do you have a new onset of loss of taste or smell? Have you been in contact with anyone Covid positive? Have you travelled within the last 14 days? If yes to previous question, were you wearing PPE? Have you had a recent Covid 19 test? If yes, date and results. Are you able to provide results of test? Review of the undated, untitled document (identified via interview with the RQA/RN#99 as the facility COVID-19 timeline) provided by the Regional Quality Nurse acting as the Infection Preventionist revealed the following information: The staff listed as follows, were asked three questions. a. Do you use PPE when at work-when needed or as ordered? b. Have you been around family/friends that's been positive with Covid-19? c. Have you been to large activities with large crowds? • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 33 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many On 06/07/22 STNA #34 said she went to a graduation for her grandkids and no family was positive with COVID-19. STNA #34 said she used her PPE and had no signs and symptoms when tested. There was no evidence contact tracing was completed. Surveyors requested evidence of contact tracing being completed and none was provided. Interview on 07/06/22 at 10:26 A.M. with Activity Director #48 revealed the front office staff screened staff and visitors as they entered the facility through the front door. Activity Director #48 stated the procedure was to write down the person's name, take (their) temperature, ask if they were vaccinated and then ask them about the symptoms listed on the log. If a staff member presented with any symptoms or sounded hoarse with cough for example, Activity Director #48 stated she would ask the staff to stay there in the front lobby as she called the nurse manager on duty. Interview on 07/06/22 at 2:42 P.M. with LPN #78 (responsible for screening STNA #34 on 06/07/22) revealed she must have marked yes to runny nose/congestion in error. LPN #78 stated she did not notice the STNA having a runny nose and denied the STNA reported she had a runny nose. LPN #78 stated if a staff member presented at screening with any signs and symptoms of COVID-19, the staff would be sent home. LPN #78 stated she did not feel STNA #34 needed to be sent home at that time. Interview on 07/06/22 at 2:46 P.M. with the DON revealed staff typically call off when they have any symptoms as they don't want to work. The DON stated the staff should report to the DON or charge nurse if they have any symptoms of COVID-19 prior to the start of their shift. The DON or Infection Preventionist was responsible to review the screening logs to ensure the screening logs were completed accurately and appropriate action was taken as appropriate/necessary. Interview on 07/06/22 at 6:52 P.M. with STNA #34 revealed she had a cough, vomiting, diarrhea, headache, and dizziness on 06/05/22 and 06/06/22 before coming back to work on Tuesday 06/07/22. STNA #34 stated when LPN #78 screened her in, she reported to the LPN she had a runny nose. LPN #78 asked if the STNA had allergies and she stated yes. STNA #34 denied any other symptoms at that time. STNA #34 stated the staff were wearing surgical masks the night she tested positive with no face shields. STNA #34 stated when she started her shift on 06/07/22 no nurse or staff member informed her the facility was in outbreak status. Further interview revealed LPN #13 asked STNA #34 if she wanted a COVID-19 test, not because she had symptoms or was told she had to be tested but was offered because they were in outbreak status and LPN #13 wanted to offer her a test. LPN #13 tested STNA #34 and the Point of Care (POC) test was positive, however, LPN #13 said nothing and went back to giving report. STNA #34 then asked LPN #71 to test her again and the second POC also showed positive results. LPN #71 instructed STNA #34 to go home. Further interview with STNA #34 revealed the DON completed COVID-19 testing on Tuesday and Thursday in her office from 9:00 A.M. through 3:00 P.M. and staff had to obtain special permission from their shift nurse to complete the test at a different time if night shift were unable to be tested during those hours. STNA #34 stated when she clocked in, she reported to her hall, Dodge. Residents #38, #1, #36, #11, #34, #47, #12, #40, #18, #16, #32, #35, #13, #27, #20, #3 and #29 resided on this hall and received care from STNA #34. STNA #34 did not divulge what time she tested positive on 06/07/22. A follow-up interview with STNA #34 on 06/07/22 at 6:52 P.M. revealed when she was screened in for her shift on 06/07/22, LPN #78 asked if her runny nose was due to allergies to which she told LPN #78 yes. During the interview, STNA #34 denied thinking her runny nose was a symptom of COVID-19 despite having a cough and other symptoms on 06/05/22 and 06/06/22. STNA #34 contributed her cough to smoking but confirmed she treated the cough with cough medicine so she could get some rest when she laid down those nights. STNA #34 denied reporting her other symptoms because those were resolved at the time of her screening, and she did not feel it was related to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 34 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 0880 COVID-19 or her runny nose. Level of Harm - Immediate jeopardy to resident health or safety Review of the employee timesheet verified STNA #34 did not clock in and out on 06/05/22 and 06/06/22 and had clocked in for work on 06/07/22 (the date she tested positive) at 5:51 P.M. and clocked out at 7:52 P.M. Residents Affected - Many Review of the COVID-19 POC Test Log revealed on 06/07/22, no time indicated, STNA #34 tested positive for COVID- 19. On 06/09/22, resident testing was completed per outbreak testing protocol and three residents, Resident #40, #45 and #47, tested positive and were placed in airborne precautions. Review of the facility resident testing records revealed between 06/10/22 and 06/27/22, 35 additional residents tested COVID-19 positive (Residents #33, #39, #7, #36, #43, #2, #8, #13, #17, #27, #4, #12, #28, #33, #37, #38, #5, #10, #18, #19, #34, #98, #3, #21, #24, #6, #11, #20, #23, #30, #7, #9, #16, #46, and #31). There were no associated deaths. Physician #125, also the facility Medical Director, was contacted on 07/07/22 at 9:42 A.M., and again on 07/07/22 at 1:15 P.M,. with a message and return number left via voicemail. No return call was provided. Review of the un-dated facility policy titled Employee Screening revealed all staff will be screened upon entrance to the facility for their shift. They will complete the screening questions and have their temperature taken. Temperatures and answers to screening questions will be recorded on the Employee Screening Log. Employees with a temperature of 100.0 degrees Fahrenheit or greater, or who answer affirmatively to any screening question will not be permitted to enter facility and begin their shift. They will need to immediately speak to Infection Control regarding need for testing for COVID-19. If any employee begins to experience any of the symptoms during their shift the facility should have the employee leave the facility immediately and notify key management. Review of the facility policy titled COVID-19 Testing of Staff and Residents reviewed on 03/22 revealed at a minimum all residents and facility staff, including individuals providing services under arrangement and volunteers, the facility will conduct testing based on parameters set forth by the Centers for Medicare and Medicaid Services (CMS) and the Ohio Department of Health (ODH) and conduct testing in a manner that is consistent with current standards of practice for conduction COVID-19 tests. For each instance of testing: document that testing was completed and the results of each staff test and document in the residents record that testing was offered, completed and the results. Upon the identification of an individual specified in this paragraph with symptoms consistent with COVID-19 or who tests positive for COVID-19, take actions to prevent the transmission of COVID-19. The facility will conduct COVID-19 testing in accordance with the standards of practice as follows: staff with signs or symptoms of COVID-19 must be tested and should be restricted pending results. If confirmed, follow the CDC guidelines for return to work. Staff and residents will be tested in response to an identified outbreak, defined as the identification of a single new case. Routine testing for staff will be based on the County positivity rate from the previous week to determine needed testing frequency. Facility will monitor positivity rate and adjust according to guidance on frequency. Review of the facility COVID-19 testing cadence Up to Date facts sheet (not dated) stated any resident or staff member with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test as soon as possible. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 35 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Review of the facility policy title COVID-19 Employee Reporting to Work and Return to Work reviewed 03/21 revealed the facility would actively encourage sick employees to stay home. Employees who have symptoms (fever, cough, or shortness of breath) should notify their supervisor and stay home. Employees who appear to have symptoms upon arrival to work or who become sick during the day should immediately be separated from others and sent home. 2. Observation on 07/05/22 at 10:45 A.M., noted Activities Assistant #18 enter the room of Resident #31. Resident #31 was in contact/droplet isolation precautions for being COVID-19 positive. Activities Assistant #18 entered the room only wearing a N95 mask and a face shield. Activities Assistant #18 did not don a gown or gloves before entering that room. She was then observed to exit that room without doffing her N95 mask and getting a new one or to disinfect her face shield as part of the doffing process before going to other areas of the facility. Resident #31's room was clearly marked as being in isolation with signs posted on the wall and a PPE cart outside the room. Interview on 07/05/22 at 10:47 A.M., with Activity Assistant #18 revealed she was not sure why Resident #31 was in isolation or if the sign posted outside his room was for him or the room next to him. Activity Assistant #18 acknowledged the signs posted were next to his entry way and not by the resident's entry way beside him. She confirmed where the signs were posted and the presence of a PPE cart outside Resident #31's room it was likely that he was the one in isolation, but she would have to check to see. Activities Assistant #18 stated they should don gloves and gowns in addition to their N95 mask and face shield when entering the room of residents in isolation for COVID-19. Activity Assistant #18 denied she had donned a gown or gloves before she entered Resident #31's room. She also denied she doffed her N95 mask when leaving his room nor did she disinfect her face shield after leaving that room before going to other non-COVID-19 areas of the facility. Activities Assistant #18 found disinfectant wipes in the PPE cart and acknowledged she should have disinfected her face shield. Observation on 07/05/22 at 11:51 A.M,. revealed Resident #98 was in droplet precautions for being COVID-19 positive. He was served his meal and STNA #77 was observed to don PPE before entering the room. STNA #77 already had a N95 mask and face shield on and was noted to don a gown, gloves, and a surgical mask over top of her N95 mask. When leaving the room, STNA #77 doffed her PPE by disposing of her gown, gloves and the surgical mask that was over top of her N95 mask. STNA #77 then disinfected her face shield using a disinfectant wipe in the PPE cart. STNA #77 was not observed to dispose of her N95 mask and don a new one before proceeding on to other areas of the facility. Interview on 07/05/22 at 12:01 P.M., with STNA #77 revealed they had not been instructed to don a new N95 mask when leaving a resident's room who was in isolation for COVID-19. STNA #77 stated they were told to put a paper mask over top of her N95 mask and to remove the paper mask when leaving the isolation room while keeping the same N95 mask on. STNA #77 stated she did not think they were supposed to do that but was following what she was told to do. STNA #77 denied the facility had a shortage of PPE. Observation on 07/05/22 at 11:53 A.M., noted STNA #5 to enter the room of Resident #99 to serve her meal tray (this resident was in an isolation room due to a 14-day quarantine period following a recent admission). STNA #5 was already wearing a N95 mask and face shield and donned a gown, gloves and a surgical mask over top of her N95 mask. STNA #5 was then observed to exit the room after serving the tray, doffing her gown, gloves and surgical mask. STNA #5 did not put a new N95 mask on when leaving the room nor did she disinfect her face shield after leaving the room. STNA #5 went down to the end of the hall and donned PPE before entering the room of Resident #31 at 11:56 A.M., (this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 36 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 0880 Level of Harm - Immediate jeopardy to resident health or safety resident was in droplet isolation precautions for being COVID-19 positive). STNA #5 again donned a gown, gloves, and surgical mask over her N95 mask that she was already wearing. STNA #5 continued to have a face shield on and entered the room to provide the resident with his meal tray. STNA #5 was observed to doff her PPE by removing gown, gloves and the surgical mask from over top of her N95 mask. STNA #5 did not remove her N95 mask and get a new one nor did she disinfect her face shield before leaving the area to other non-COVID-19 areas of the facility. Residents Affected - Many Interview on 07/05/22 at 11:58 A.M,. with STNA #5 revealed she did don a surgical mask over top of her N95 mask when entering the rooms of Resident #99 and #31 to serve them their meal trays. She confirmed both residents were in isolation either for being COVID-19 positive or as part of a 14-day quarantine following a new admission. STNA #5 denied that she changed out her N95 mask after leaving those isolation rooms and did not disinfect her face shield either as part of her doffing process. STNA #5 stated they had been told to put a surgical mask over top of their N95 and she just forgot to disinfect her face shield both times when leaving the isolation rooms. Interview on 07/05/22 at 12:08 P.M. with LPN #78 revealed staff were instructed to don surgical mask over top of their N95 mask when entering the rooms of residents who were in isolation for COVID-19. LPN #78 denied they were instructed to get a new N95 mask when leaving those rooms and were only to remove the surgical mask as part of the doffing process. LPN #78 confirmed they were to disinfect their face shields with a disinfectant wipe when leaving an isolation room. LPN #78 denied any shortages of N95 masks and reported they had plenty available. Interview on 07/06/22 at 3:02 P.M. with the RQA/RN #99 (acting Infection Preventionist) revealed the DON, ADON and herself provided the staff education related to transmission-based precautions, donning and doffing PPE, hand washing, social distancing, and cough etiquette. RQA/RN #99 stated she was aware the staff were currently and during the outbreak wearing a surgical mask over the N95 mask and she did not discourage or encourage this practice as the staff felt it was an extra layer of protection. Further interview with RQA/RN #99 revealed the facility was not operating in crisis capacity for PPE and the expectation was for staff to change their N95 mask before exiting a COVID-19 positive room and to clean the face shield as well. RQA/RN #99 stated if staff did not enter a COVID-19 positive room during their shift, the N95 mask would be changed daily. An observation of the stock room with Supply Clerk #90 on 07/07/22 at 10:32 A.M. revealed the facility had three boxes of 100 each POC COVID-19 tests, seven boxes of 100 each disposable isolation gowns plus three packages of 10, 150 face shields, one case of 200 Niosh-N95 masks plus three boxes of 20, seven cases of various sizes of vinyl gloves, and 24 containers of bleach wipes. Observation on 07/07/22 at 10:32 A.M. revealed a facility posting (posted on the wall outside the isolation room doors) titled: Use of PPE When caring for Patients with Confirmed or Suspected Covid-19 revealed donning the proper PPE: 1. Identify and gather the proper PPE to don. 2. Perform hand hygiene using hand sanitizer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 37 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 0880 3. Level of Harm - Immediate jeopardy to resident health or safety Put on isolation gown, tie all the ties on the gown. Residents Affected - Many Put on NIOSH approved N95 filtering facepiece respirator or higher (may use a face mask if a respirator is 4. not available). 5. Put on face shield or goggles. 6. Perform hand hygiene before putting on gloves. 7. May now enter the room Doffing PPE: 1. Remove gloves 2. Remove gown and dispose in trash receptacle. 3. May now exit the room. 4. Perform hand hygiene. 5. Remove face shield or goggles. 6. Remove and discard respirator or facemask. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 38 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 0880 7. Level of Harm - Immediate jeopardy to resident health or safety Perform hand hygiene after removing the respirator. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 39 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to ensure residents received the Influenza and Pneumococcal vaccines when consenting to receive them. This affected two (Resident #7 and #10) of five residents reviewed for immunizations. Residents Affected - Few Findings include: 1. A review of Resident #7's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included morbid obesity, adult onset diabetes mellitus, and stage 3 chronic kidney disease. A review of Resident #7's Influenza vaccine consent form revealed the resident consented to receive the Influenza vaccine. The form was dated and signed by the resident on 10/25/21. A review of Resident #7's Immunization Report revealed the resident last received the Influenza vaccine on 10/01/20. There was no documented evidence of the resident receiving the Influenza vaccine after he had consented to receive it on 10/25/21. On 07/12/22 at 10:30 A.M., an interview with the Director of Nursing revealed they did not have any documented evidence of Resident #7 receiving the Influenza vaccine for the 2021 Influenza season after the resident had signed consent to receive it on 10/25/21. She was not sure why the Influenza vaccine was not given as requested. 2. A review of Resident #10's medical record revealed the resident was originally admitted to the facility on [DATE]. She had a readmission to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease, congestive heart failure, chronic kidney disease, atrial fibrillation, presence of a cardiac pacemaker and chronic rhinitis. A review of Resident #10's Pneumococcal Polysaccharide vaccine consent form revealed the resident consented to receive the Pneumococcal Polysaccharide vaccine. The form was dated 10/25/21 and was signed by the resident. A review of Resident #10's Immunization Report revealed no documented evidence of the resident ever receiving the Pneumococcal Polysaccharide vaccine in the past. It did not show she was administered the vaccine after 10/25/21 when she consented/ requested to receive it. On 07/12/22 at 10:30 A.M., an interview with the DON revealed they could not find any documented evidence of Resident #10 being given the Pneumococcal Polysaccharide vaccine even after she signed consent on 10/25/21. She was not able to explain why it was not given after consent was received. A review of the facility's Immunization Policy undated revealed in an effort to decrease the incidence of preventable infections, the facility has implemented an immunization program. The immunization program would immunize against Influenza, Pneumococcal, and other immunizations as prescribed. Education would be provided and consents must be obtained prior to administration. Those vaccines would be given to all persons upon admission and according to Centers for Disease Control (CDC) guideline schedules. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 40 of 41 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 365461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Muskingum Skilled Nursing & Rehabilitation 501 Pinecrest Drive Beverly, OH 45715 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 0886 Perform COVID19 testing on residents and staff. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure reasons for obtaining a COVID-19 test, date the COVID-19 test was performed, and the results of the COVID-19 test were documented in the resident's medical record as required. This affected one (Resident #31) of one residents reviewed for transmission based precautions related to COVID-19. Residents Affected - Few Findings include: A review of Resident #31's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included end stage renal disease, dependence on renal dialysis, hypertension, and morbid obesity. His diagnoses list was updated to reflect he was COVID-19 positive on 06/27/22. A review of Resident #31's physician's orders revealed an order for the resident to be placed in droplet isolation for 10 days due to being COVID-19. The order was given on 06/27/22. A review of Resident #31's nurses' progress notes revealed there was no documentation to show why the resident was tested for COVID-19. The progress notes also failed to document when the COVID-19 test was performed and what the results of the COVID-19 test was. The first progress note that mentioned anything about him having COVID-19 was a nurse's progress note dated 07/01/22 at 3:46 P.M. by the Director of Nursing (DON) that revealed the resident was in isolation due to being COVID-19 positive. Findings were verified by the Assistant Director of Nursing (ADON). Observations of Resident #31 on 07/05/22 at 10:45 A.M. and again on 07/06/22 noted him to be in droplet isolation precautions with signs posted outside his door and a personal protective equipment (PPE) cart in the hall outside his room. He remained in droplet isolation precautions until they were discontinued on 07/06/22. On 07/12/22 at 10:00 A.M., an interview with the ADON revealed she was not sure why Resident #31 was tested for COVID-19 on 06/27/22. She stated she would have to follow up with the Director of Nursing (DON) to see why the COVID-19 test was performed. On 07/12/22 at 10:30 A.M., an interview with the DON revealed they were not able to find any documentation in Resident #31's medical record indicating why he was tested for COVID-19 on 06/27/22. She also confirmed the medical record did not mention he was tested for COVID-19 and did not document the results of the COVID-19 test after it had been performed. She stated she thought he was tested for COVID-19 as part of the facility's outbreak testing but confirmed the obtaining of the COVID-19 test and the results of the test should have been documented in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 41 of 41