Health inspection·December 4, 2023

F 0600 Interview on 11/28/23 at 10:45 A.M. with STNA #144 revealed she heard that STNA #111 was told by administration (not sure who) to take pictures of Resident #15 regarding poor incontinence care. Level of Harm - Actual harm Residents Affected - Few Telephone interview on 11/28/23 at 10:59 A.M. with STNA #111 revealed she came into work on 10/31/23 and discovered that Resident #15 had not received incontinence care. STNA #111 revealed it looked like Resident #15 had not had incontinence care all night as she was lying in urine and stool. STNA #111 revealed she was going to clean up Resident #15 and became so upset she went and got the current Administrator (who was then working as an administrative assistant). STNA #111 reported she and the Administrator went to Resident #15's room and once the Administrator saw the lack of incontinence care, the Administrator asked STNA #111 to take pictures of Resident #15 on her phone and send them to the Administrator. STNA #111 revealed she did take the pictures of Resident #15 without consent from the resident, her family or her guardian. She said the Administrator was in the room when she took the pictures. STNA #111 reported she sent the pictures to the Administrator by text and then about an hour later STNA #111 received a text back from the Administrator stating, I understand why you took these pictures, but you can't have pictures of residents on your phone. STNA #111 revealed she immediately deleted the pictures from her phone. STNA #111 reported she heard the Administrator printed the pictures out and showed them in the morning meeting. STNA #111 reported she heard that Regional Nurse #175 was present and asked who took the pictures and the Administrator responded, an aide. She reported she was not aware of any investigation regarding the pictures, and she had not received any discipline for taking the pictures. Review of Resident #15's progress notes, dated 10/31/23, revealed no documentation to support poor incontinence care or pictures being taken of the resident. Interview on 11/28/23 at 11:35 A.M. with the Administrator revealed the following staff attend morning meetings: Human Relations/Dietary Manger (HR/DM), Housekeeping/Laundry, Business Office Manager (BOM), Director of Nursing (DON), Maintenance Director (MD), Therapy Director (TD), Activities and the MDS Nurse. Interview on 11/28/23 at 11:38 A.M. with non-clinical anonymous Staff #140 revealed they were present at the 10/31/23 morning meeting. They reported the room was full and the staff present who were not clinical included the MD, the BOM, the Activities Director and the HR/DM. They reported the Administrator (who was then working as an administrative assistant) showed pictures of a resident, but they could not remember if the name of the resident was provided. They reported the resident was wearing a top, and what appeared to be an undergarment brief. Staff #140 reported the bed covers were pulled down exposing the Resident's undergarment brief and her legs. Staff #140 revealed the resident's feet were covered with bed linen. They did not remember seeing any of the resident's belly or chest. They reported the Administrator was showing the pictures and there were two or three pictures. Staff #140 revealed they were uncomfortable with the presentation and thought the Administrator should have known better. Staff #140 felt the resident's privacy and rights were violated by the pictures which were humiliating in nature. Staff #140 reported Regional Nurse #175 stopped the presentation and reported the facility and staff were not to take pictures of residents. Staff #140 revealed the facility policy on abuse (taking pictures of residents) was reviewed at the time. Interview on 11/28/23 at 12:08 P.M. with non-clinical anonymous Staff #176 revealed they were present at the morning meeting on 10/31/23. Staff #176 reported the Administrator (who was then working as an administrative assistant) was presenting pictures regarding poor resident incontinence care. They reported they did not look closely at the pictures because they were not clinical, and it was not part of her job. Staff #176 felt presenting pictures of the resident was not appropriate or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 2 of 36 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 12/04/2023 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 0600 Level of Harm - Actual harm Residents Affected - Few acceptable. They reported it would emotionally upset them to have humiliating pictures of poor incontinence care taken without consent and presented to staff in a meeting. Staff #176 reported they did not think the resident was identified by the Administrator during the meeting. Interview on 11/28/23 at 2:38 P.M. with STNA #144 revealed Resident #15 was interviewable and could process to answer questions with yes and no responses. Interview on 11/28/23 at 2:40 P.M. with Resident #15 revealed she did not remember anyone taking pictures of her. This surveyor asked Resident #15 if someone took a picture of her from the waist down with only her depends on would she be emotionally upset and humiliated and Resident #15 responded, Yes, I would. Interview on 11/29/23 at 7:10 A.M. with STNA #137 revealed pictures were taken of Resident #15 by STNA #111. STNA #137 revealed she was told by STNA #111, that she was directed to take the pictures by the current Administrator who was in the role of Administrative Assistant at the time. STNA #137 reported STNA #111 told her the pictures were of Resident #15 with urine and stool from the waist down and Resident #15 was wearing a depend undergarment. STNA #137 reported taking the pictures and also printing them out and presenting then a meeting went against the facility abuse policy. STNA #137 revealed there were times Resident #15 had logical conversations and when asked questions can respond appropriately. Interview on 11/29/23 at 9:19 A.M. with STNA #111 revealed on 10/31/23 she went to get the current Administrator regarding the incontinence condition she found with morning care for Resident #15. STNA #111 reported she pulled the current Administrator into Resident #15's room about 8:45 A.M. STNA #111 reported the current Administrator directed STNA #111 to take the pictures. STNA #111 didn't ask why she wanted the pictures and the current Administrator was in the room when the pictures of Resident #15 were taken. STNA #111 reported the pictures of Resident #15 were from the waist down. STNA #111 reported as soon as she took the pictures, the current Administrator directed her to text the pictures to her. STNA #111 reported she did not have the current Administrator's phone number so the current Administrator provided it and STNA #111 text messaged the pictures of Resident #15 to her. STNA #111 revealed she was not questioned, and she did not know of any investigation regarding the taking of the pictures by the current Administrator, Regional Nurse #175 or the acting Administrator #178 at the time. She reported she did not receive any training following the incident regarding not taking pictures of residents. Interview on 11/29/23 at 1:45 P.M. with the current Administrator revealed on 10/31/23 she had just walked through the door in the morning and STNA #111 came to her with a concern regarding resident care. The Administrator revealed she went with the STNA #111 to Resident #15's room and discovered poor incontinence care. The Administrator revealed she did not direct STNA #111 to take pictures of Resident #15 as STNA #111 had already taken the pictures. The Administrator verified she did ask STNA #111 to send her the pictures of Resident #15 to her via a text message. The Administrator then verified she printed out the pictures she received from STNA #111 and presented them to the staff present at the morning meeting on 10/31/23. She reported she did not realize she was breaking any rules. The Administrator verified presenting the pictures was not acceptable behavior. She reported she had worked in other facilities when pictures of residents were presented in meetings, and stated she had an ick feeling about it. The Administrator revealed she screwed up but stated there was no malicious intent. Interview on 11/28/23 at 1:45 P.M. with Regional Nurse #175 revealed there was an incident where a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 3 of 36 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 12/04/2023 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 0600 Level of Harm - Actual harm Residents Affected - Few photo of a resident in a brief was held up in a morning meeting on 10/31/23. She revealed no face was visible and she intervened and stopped the presentation of the picture. Regional Nurse #175 felt the purpose of the picture was for education and didn't view the issue as abuse. She reported there was immediate education for the staff in the morning meeting regarding the abuse policy and not taking pictures of residents. She reported then the entire facility received education on the abuse policy and not taking pictures of residents. Review of the form titled, Review Task Summary, undated, revealed STNA #111 had signed an acknowledgement of the Abuse Policy on 02/06/23. Review of the form titled, Review Task Summary, undated, revealed the Administrator had signed an acknowledgement of the Abuse Policy on 09/28/23. Review of the facility policy titled, Abuse, Neglect, and Exploitation of Residents and Misappropriation of Property, dated 05/2018, revealed it was the goal of the facility that its residents will be protected from verbal, mental, sexual, or physical abuse, corporal punishment, mistreatment, neglect, involuntary seclusion, exploitation, and misappropriation of property through development of operationalized policies and procedures. Residents will not be subjected to abuse, neglect, mistreatment, or misappropriation of property by anyone. Further review revealed the definition of mental abuse included but was not limited to humiliation, harassment, or threats of punishment or deprivation. Under Section F: Protecting Resident Privacy and Prohibiting Mental Abuse Related to Photographs and/or Recordings revealed taking or using photographs, videos or recordings of a resident or his/her private space in any manner that would demean or humiliate a resident is strictly prohibited. At no time are any photographic or recording devices permitted in any resident room or common areas. Examples include, but are not limited to, taking unauthorized photographs of a resident's room or furnishings (which may or may not include the resident), resident eating, or participating in an activity. This policy included employees, consultants, contractors, volunteers and other care givers. Staff must report to their supervisor any unauthorized (or suspected to be unauthorized) taking of photographs or videos as well the sharing of such recordings in any medium. Violations of this policy may result in disciplinary actions, including termination. Personal cell phones may only be used in designated employee break rooms. 2. Review of Resident #17's medical record revealed an initial admission date of 02/06/23 and a readmission date of 10/03/23 with diagnoses including chronic obstructive pulmonary disease, respiratory failure, essential hypertension, and dysphagia. Review of Resident #17's plan of care, dated 02/14/23, revealed she had a behavioral problem related to biting, hitting, kicking, scratching, and yelling. Interventions included attempt 1:1 when behaviors start, intervene and redirect resident as needed, listen to resident concerns, monitor and assess behaviors, provide a calm and relaxing environment, refer to psych as needed, and administer medications as ordered. Review of Resident #17's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/11/23, revealed the resident was cognitively impaired. Further review revealed she did not present physical behaviors towards others but did present verbal behaviors towards others daily. Review of Resident #17's progress notes for the month of November 2023 revealed four notes referring to behavioral concerns with staff only. Review of Resident #17's progress note, dated 11/23/23 at 4:26 A.M., revealed she yelled from her room and refused to use her call light. Resident #17 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 4 of 36 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 12/04/2023 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 0600 repetitive and used derogatory names toward staff members. Staff continued to use therapeutic communication to provide a quiet environment for the resident. Level of Harm - Actual harm Residents Affected - Few Review of Resident #17's progress note, dated 11/29/23 at 5:30 A.M., revealed STNA #102 was passing medications when another Resident (#22) was in Resident #17's room. Resident #22 was yelling and grabbing her (#17's) arms. Resident #22 was yelling, get out of my house. RN #183 was notified. Review of Resident #17's progress notes and evaluations revealed no head to toe physical assessment, psychosocial assessment, or pain assessment immediately following the incident. Review of Resident #22's medical record revealed an admission date of 12/04/22 with diagnoses including Alzheimer's disease, unspecified dementia, unspecified psychosis not due to a substance or known physiological condition, unspecified anxiety disorder, and essential hypertension. Review of Resident#22's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/22/23, revealed the resident was not cognitively intact. Further review revealed she did not exhibit physical or verbal behavioral symptoms towards others. Review of Resident #22's comprehensive plan of care revealed no care plan regarding aggressive verbal or physical behaviors toward other residents or staff. Review of Resident #22's progress notes for the month of November 2023 revealed 14 notes referring to behavioral concerns with residents and staff. Review of Resident #22's progress note, dated 11/15/23 at 9:52 A.M., revealed she became verbally aggressive towards her roommate and staff. Resident #22 took items from her roommate and began yelling at her roommate stating the roommate had stolen them from her. Resident #22 was not easily directed and insisted that her roommate did not sleep in her room or pay the bills. Resident #22 became agitated over her roommate using a nebulizer, as she thought it was hers. Resident #22 refused to leave the door open to accommodate heating issues for the room. Resident #22 was educated numerous times on both topics. Resident #22 was delusional and had auditory hallucinations of babies crying. The staff used therapeutic communication during the episode and distracted the resident with food and drink. Review of Resident #22's progress note, dated, 11/17/23 at 6:34 A.M., revealed that during the shift she had wandered through the hallways asking staff repetitive questions regarding children and babies crying. Resident #22 was delusional and not easily reoriented. Resident #22 would refuse care at times and was forgetful. Resident #22 accused staff of stealing her items and lying. She refused to keep the door open to her room to keep it heated. Resident #22 did not get along with her roommate and believed she was stealing her items. The staff continued to use distraction techniques and therapeutic communication. Review of Resident #22's progress note, dated 11/23/23 at 4:28 A.M., revealed she wandered throughout the halls yelling at staff members and telling them they didn't do their jobs. Resident #22 was delusional and believed there were kids outside crying. She attempted to wander into other residents' rooms and staff intervened. Resident #22 was unable to be reoriented and became aggressive. Staff provided a quiet environment for the resident, along with food/drink and therapeutic communication. Review of Resident #22's progress note, dated 11/24/23 at 2:37 A.M., revealed she was agitated with staff. Resident #22 was yelling and combative with staff for no known reason. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 5 of 36 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 12/04/2023 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 0600 Level of Harm - Actual harm Residents Affected - Few Review of Resident #22's progress note, dated 11/29/23 at 5:30 A.M., revealed STNA #102 was passing medications when Resident #22 was in another Resident's (#17) room, grabbing the resident's arms and yelling, get out of my house. Registered Nurse (RN) #183 was notified. Review of Resident #22's progress notes and evaluations revealed no head to toe physical assessment, psychosocial assessment, or pain assessment immediately following the incident. Further review of Resident #22's progress notes revealed the last documented note regarding physician notification of her behaviors was 10/30/23. An order for Melatonin, a sleep aide, was ordered at the time. Interview on 11/29/23 at 7:30 A.M. with LPN #177 revealed he was passing medication at 5:30 A.M. when he was informed by STNA #102 that Resident #22 was in Resident #17's room and Resident #22 was holding onto Resident #17's arms. LPN #177 reported STNA #102 reported Resident #22 then attempted to get aggressive with STNA #102. LPN #177 reported that by the time he had walked down the hallway, Resident #22 had left Resident #17's room. He reported both Residents #17 and #22 appeared aggravated with each other. LPN #177 reported he assessed Resident #17's arms and didn't find any concerns. LPN #177 reported he immediately called RN #183 to let her know and she directed for LPN #177 and STNA #102 to complete witness statements. LPN #177 reported he did not receive any directives to separate the two residents, assess the two residents, or place Resident #22 on any type of observation. LPN #177 reported Resident #22 was able to walk the facility freely. Interview on 11/29/23 at 7:35 A.M. with STNA #137 revealed she had heard Resident #22 had entered Resident #17s room and was holding her arms and yelling at her this morning. Observation on 11/29/23 at 7:55 A.M. revealed Resident #22 and Resident #17 were sitting at the same table, side by side, in the dining room. Interview on 11/29/23 at 7:57 A.M. with Resident #17 revealed Resident #22 came into her room and attacked her. Resident #17 was able to point to Resident #22 as the resident who came into her room. Resident #17 reported she was afraid and scared when Resident #22 grabbed her arms. Telephone interview on 11/29/23 at 7:59 A.M. with STNA #102 revealed she was passing medications and heard screaming and yelling coming from Resident #17's room. STNA #102 reported she entered Resident #17's room and saw Resident #22 holding Resident #17's arms and trying to pull her up out of her wheelchair. Resident #22 was stating, It is my house, and you need to get out of here. Resident #17 was yelling, Help, she is beating me up. STNA #102 revealed Resident #22 then started walking aggressively toward her. STNA #102 reported Resident #22 didn't touch her but exited the room. STNA #102 reported Resident #22 did have a history of getting physical with staff. STNA #102 reported that on 11/26/23, Resident #22 grabbed her ponytail and almost pulled STNA #102 to the ground. STNA #102 reported that Resident #22 has a history of yelling at other residents and staff, but this past week she started putting hands on staff and today on another resident. STNA #102 revealed LPN #177 notified RN #183 and the directive she received regarding the incident was to complete a witness statement. STNA #102 reported she did not receive any directive to separate the two residents, or place Resident #22 on any type of observation. STNA #102 reported Resident #22 was able to walk the facility freely. Interview on 11/29/23 at 9:55 A.M. with STNA #137, who was working the hall of Residents #17 and Resident #22, revealed she had not received any directive regarding increased observation of Resident #22 either continuous or periodically for safety of other residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 6 of 36 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 12/04/2023 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 0600 Level of Harm - Actual harm Residents Affected - Few Interview on 11/29/23 at 10:58 A.M. with STNA #111, who was working the hall of Residents #17 and Resident #22, revealed she had not received any directive regarding increased observation of Resident #22 either continuous or periodically for safety of other residents. Interview on 11/29/23 at 1:55 P.M. with the Administrator revealed she had contacted psychiatry in the A.M. regarding the behaviors of Resident #22 toward Resident #17. The Administrator revealed she received an order at 8:30 A.M. for 15 minute observations for Resident #22 and a stat urinalysis to be collected. She reported she received and reviewed the written statements from STNA #102 and LPN #177. Interview on 11/29/23 at 2:00 P.M. with RN #183 revealed she received a call earlier in the A.M. from both STNA #102 and LPN #177. She reported the directive she gave them was to make sure and document the occurrence in a progress note and complete witness statements. She reported she was not informed that Resident #22 had placed hands on Resident #17. Review of the Personal Witness Statement, dated 11/29/23 and timed 5:30 A.M. by LPN #177, revealed he was passing medications and heard Resident #17 and #22 yelling at each other. Upon walking up to the room Resident #22 came out of Resident #17's room and was trying to hit STNA #102. RN #183 was called regarding the incident. Review of the Personal Witness Statement, dated 11/29/23 and timed 5:30 A.M. by STNA #102, revealed she was passing medications when she heard yelling coming from Resident #17's room. When STNA #102 arrived to the room Resident #22 had hold of Resident #17's arms yelling at her to get out of her house. STNA #102 documented that when she entered the room, Resident #22 came at her swinging, then calmed down and walked away. Interview on 11/29/23 at 3:15 P.M. with LPN #181 revealed she received notice that 15 minutes checks were to be initiated for Resident #22 in the morning. LPN #181 reported she and RN #183 had discussed a plan for completing the 15 minute checks and LPN #181 thought the RN #183 was going to complete the 15 minute checks. LPN #181 had no documentation, either in the electronic health record or on paper, to support 15 minute checks had been completed on Resident #22. Observation on 11/29/23 at 3:17 P.M. revealed LPN #181 started 15 minute check documentation for Resident #22. Interview on 11/30/23 at 12:14 P.M. with anonymous Nurse #182 verified upon her review of Resident #17 and #22's medical records, there was no head to toe skin assessment for Resident #17 since 11/22/23 or for Resident #22 since 11/16/23. Anonymous Nurse #182 also verified no psychosocial or pain assessments for either resident since the resident to resident incident on 11/29/23 at 5:30 A.M. She verified there should have been a full body assessment (head to toe), a psychosocial assessment, and a pain assessment on both residents. Telephone interview on 12/01/23 at 1:46 P.M. with the Administrator verified Resident #22's physician had been contacted on 10/30/23 regarding trouble sleeping and then not again until 11/29/23 at 8:39 A.M. following the incident with Resident #17. Review of the facility policy titled, Abuse, Neglect, and Exploitation of Residents and Misappropriation of Property, dated 05/2018, revealed it was the goal of the facility that its residents will be protected from verbal, mental, sexual, or physical abuse, corporal punishment, mistreatment, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 7 of 36 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 12/04/2023 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 0600 Level of Harm - Actual harm Residents Affected - Few neglect, involuntary seclusion, exploitation, and misappropriation of property through development of operationalized policies and procedures. Residents will not be subjected to abuse, neglect, mistreatment, or misappropriation of property by anyone. Further review revealed the definition of abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This deficiency represents noncompliance investigated under Complaint Number OH00148026. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 8 of 36 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 12/04/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, resident record review, review of abuse policy acknowledgement, review of the facility's Self-Reported Incidents (SRIs), and facility policy review, the facility failed to report an occurrence of abuse and failed to report an occurrence of abuse timely to the state survey agency. This affected two residents (#15 and #17) of three residents reviewed for abuse. The facility census was 47. Findings included: 1. Review of Resident #15's medical record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, unspecified psychosis not due to a substance or known physiological disorder, hypothyroidism, and essential hypertension. Review of Resident #15's Clinical Resident Profile revealed she had a guardian. Review of Resident #15's significant change Minimum Data Set (MDS) 3.0 assessment, dated 09/01/23, revealed the resident was cognitively impaired. Further review revealed she was sometimes able to express ideas and wants and was able to sometimes understand verbal content. Additionally, the assessment revealed she was always incontinent of her bladder and frequently incontinent of her bowel. Review of Resident #15's plan of care, dated 09/24//20, revealed she had an alteration in communication and was usually able to verbally or nonverbally express thoughts and ideas, and was sometimes able to understand others through verbal and non-verbal communication. Telephone interview on 11/28/23 at 10:59 A.M. with State Tested Nurse Aide (STNA) #111 revealed she came into work on 10/31/23 and discovered that Resident #15 had not received incontinence care. STNA #111 revealed it looked like Resident #15 had not had incontinence care all night as she was lying in urine and stool. STNA #111 revealed she was going to clean up Resident #15 and became so upset she went and got the current Administrator (who was then working as an administrative assistant). STNA #111 reported she and the Administrator went to Resident #15's room and once the Administrator saw the lack of incontinence care, the Administrator asked STNA #111 to take pictures of Resident #15 on her phone and send them to the Administrator. STNA #111 revealed she did take the pictures of Resident #15 without consent from the resident, her family or her guardian. She said the Administrator was in the room when she took the pictures. STNA #111 reported she sent the pictures to the Administrator by text and then about an hour later STNA #111 received a text back from the Administrator stating, I understand why you took these pictures, but you can't have pictures of residents on your phone. STNA #111 revealed she immediately deleted the pictures from her phone. STNA #111 reported she heard the Administrator printed the pictures out and showed them in the morning meeting. Interview on 11/28/23 at 11:35 A.M. with the Administrator revealed the following staff attend morning meetings: Human Relations/Dietary Manger (HR/DM), Housekeeping/Laundry, Business Office Manager (BOM), Director of Nursing (DON), Maintenance Director (MD), Therapy Director (TD), Activities and the MDS Nurse. Interview on 11/28/23 at 11:38 A.M. with non-clinical anonymous Staff #140 revealed they were present at the 10/31/23 morning meeting. They reported the room was full and the staff present who were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 9 of 36 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 12/04/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not clinical included the MD, the BOM, the Activities Director and the HR/DM. They reported the Administrator (who was then working as an administrative assistant) showed pictures of a resident, but they could not remember if the name of the resident was provided. They reported the resident was wearing a top, and what appeared to be an undergarment brief. Staff #140 reported the bed covers were pulled down exposing the Resident's undergarment brief and her legs. They reported the Administrator was showing the pictures and there were two or three pictures. Staff #140 revealed they were uncomfortable with the presentation and thought the Administrator should have known better. Staff #140 felt the resident's privacy and rights were violated by the humiliating pictures. Interview on 11/28/23 at 12:08 P.M. with non-clinical anonymous Staff #176 revealed they were present at the morning meeting on 10/31/23. Staff #176 reported the Administrator (who was then working as an administrative assistant) was presenting pictures regarding poor resident incontinence care. They reported they did not look closely at the pictures because they were not clinical, and it was not part of her job. Staff #176 felt presenting pictures of the resident was not appropriate or acceptable. They reported it would emotionally upset them to have humiliating pictures of poor incontinence care taken without consent and presented to staff in a meeting. Interview on 11/28/23 at 2:40 P.M. with Resident #15 revealed she did not remember anyone taking pictures of her. This surveyor asked Resident #15 if someone took a picture of her from the waist down with only her Depends on would she be emotionally upset and humiliated and Resident #15 responded, Yes, I would. Interview on 11/29/23 at 1:45 P.M. with the current Administrator revealed on 10/31/23 she had just walked through the door in the morning and STNA #111 came to her with a concern regarding resident care. The Administrator revealed she went with the STNA #111 to Resident #15's room and discovered poor incontinence care. The Administrator revealed she did not direct STNA #111 to take pictures of Resident #15 due to STNA #111 had already taken the pictures. The Administrator verified she did ask STNA #111 to send her the pictures of Resident #15 to her via a text message. The Administrator then verified she printed out the pictures she received from STNA #111 and presented them to the staff present at the morning meeting on 10/31/23. She reported she did not realize she was breaking any rules. The Administrator verified presenting the pictures was not acceptable behavior. She reported she had worked in other facilities when pictures of residents were presented in meetings, and she had an ick feeling about it. The Administrator verified she screwed up but there was no malicious intent. Interview on 11/28/23 at 1:45 P.M. with Regional Nurse #175 revealed there was an incident where a photo of a resident in a brief was held up in a morning meeting on 10/31/23. She revealed no face was visible and she intervened and stopped the presentation of the picture. Regional Nurse #175 felt the purpose of the picture was for education and didn't view the issue as abuse. Therefore, it was not reported to the state survey agency. Review of the State of Ohio Self-Reported Incidents filed by the facility revealed there was no evidence they reported this abuse incident which occurred on 10/31/23. 2. Review of Resident #22's medical record revealed an admission date of 12/04/22 with diagnoses including Alzheimer's disease, unspecified dementia, unspecified psychosis not due to a substance or known physiological condition, unspecified anxiety disorder, and essential hypertension. Review of Resident#22's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/22/23, revealed the resident was not cognitively intact. Further review revealed she did not exhibit physical or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 10 of 36 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 12/04/2023 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 0609 verbal behavioral symptoms towards others. Level of Harm - Minimal harm or potential for actual harm Review of Resident #22's progress notes for the month of November 2023 revealed 14 notes referring to behavioral concerns with residents and staff. Residents Affected - Few Review of Resident #22's progress note, dated 11/29/23 at 5:30 A.M., revealed State Tested Nursing Assistant (STNA) #102 was passing medications when Resident #22 was in another Resident's (#17) room, grabbing their arms and yelling, get out of my house. Registered Nurse (RN) #183 was notified. Review of Resident #22's progress notes and evaluations revealed no head to toe physical assessment, psychosocial assessment, or pain assessment immediately following the incident. b. Review of Resident #17's medical record revealed an initial admission date of 02/06/23 and a readmission date of 10/03/23 with diagnoses including chronic obstructive pulmonary disease, respiratory failure, essential hypertension, and dysphagia. Review of Resident #17's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/11/23, revealed the resident was cognitively impaired. Further review revealed she did not present physical behaviors towards others but did present verbal behaviors towards others daily. Review of Resident #17's progress notes for the month of November 2023 revealed four notes referring to behavioral concerns with staff only. Review of Resident #17's progress note, dated 11/29/23 at 5:30 A.M., revealed STNA #102 was passing medications when another Resident (#22) was in Resident #17's room. Resident #22 was yelling and grabbing her (#17's) arms. Resident #22 was yelling, get out of my house. RN #183 was notified. Review of Resident #17's progress notes and evaluations revealed no head to toe physical assessment, psychosocial assessment, or pain assessment immediately following the incident. Interview on 11/29/23 at 7:35 A.M. with STNA #137 revealed she had heard that Resident #22 had entered Resident #17s room and was holding her arms and yelling at her this morning. Observation on 11/29/23 at 7:55 A.M. of Resident #22 and Resident #17 sitting at the same table, side by side, in the dining room. Interview on 11/29/23 at 7:57 A.M. with Resident #17 revealed Resident #22 came into her room and attacked her. Resident #17 was able to point to Resident #22 as the resident who came into her room. Resident #17 reported she was afraid and scared when Resident #22 grabbed her arms. Telephone interview on 11/29/23 at 7:59 A.M. with STNA #102 revealed she was passing medications and heard screaming and yelling coming from Resident #17's room. STNA #102 reported she entered Resident #17's room and saw Resident #22 holding Resident #17's arms and trying to pull her up out of her wheelchair. Resident #22 was stating, It is my house, and you need to get out of here. Resident #17 was yelling, Help, she is beating me up. Review of the Personal Witness Statement, dated 11/29/23 and timed 5:30 A.M. by STNA #102, revealed she was passing medications when she heard yelling coming from Resident #17's room. When STNA #102 arrived to the room Resident #22 had hold of Resident #17's arms yelling at her to get out of her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 11 of 36 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 12/04/2023 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 0609 house. Level of Harm - Minimal harm or potential for actual harm Interview on 11/29/23 at 2:19 P.M. with the Administrator revealed she entered the facility at around 6:45 A.M. and LPN #177 informed her of the occurrence between Resident #17 and Resident #22. The Administrator reported corporate had directed her to do a quick response and send it to legal to decide if a self-reported incident needed to be initiated. She had not received a directive to complete a SRI and she verified she had not submitted a SRI for the occurrence between Resident #17 and #22. The Administrator reported she felt the occurrence the A.M. of 11/29/23 between Residents #22 and #17 was resident to resident abuse and should have been reported to the Ohio Department of Health and an SRI investigation initiated within two hours of the occurrence. Residents Affected - Few Interview on 11/30/23 at 12:14 P.M. with anonymous Nurse #182 verified upon her review of Resident #17 or #22's medical records, there was no head to toe skin assessment for Resident #17 since 11/22/23 and for Resident #22 since 11/16/23. Anonymous Nurse #182 also verified no psychosocial or pain assessments for either resident since the resident to resident incident on 11/29/23 at 5:30 A.M. She verified there should have been a full body assessment (head to toe), a psychosocial assessment, and a pain assessment on both residents. Review of the State of Ohio Self-Reported Incidents filed by the facility revealed they did not report this abuse incident (between Residents #22 and #17) until 11/29/23 at 6:37 P.M. and it occurred on 11/29/23 at 5:30 A.M. Review of the facility policy titled, Abuse, Neglect, and Exploitation of Residents and Misappropriation of Property, dated 05/2018, revealed it was the goal of the facility that its residents will be protected from verbal, mental, sexual, or physical abuse, corporal punishment, mistreatment, neglect, involuntary seclusion, exploitation, and misappropriation of property through development of operationalizes policies and procedures. Residents will not be subjected to abuse, neglect, mistreatment, or misappropriation of property by anyone. Further review revealed the definition of mental abuse included but was not limited to humiliation, harassment, or threats of punishment or deprivation. Under Section F: Protecting Resident Privacy and Prohibiting Mental Abuse Related to Photographs and/or Recordings revealed taking or using photographs, videos or recordings of a resident or his/her private space in any manner that would demean or humiliate a resident is strictly prohibited. At no time are any photographic or recording devices permitted in any resident room or common areas. Examples include, but are not limited to, taking unauthorized photographs of a resident's room or furnishings (which may or may not include the resident), resident eating, or participating in an activity. This policy included employees, consultants, contractors, volunteers and other care givers. Staff must report to their supervisor any unauthorized (or suspected to be unauthorized) taking of photographs or videos as well the sharing of such recordings in any medium. Violations of this policy may result in disciplinary actions, including termination. Personal cell phones may only be used in designated employee breakrooms. Further review revealed under Section Seven: Reporting: All allegations that involve abuse or result in serious bodily injury will be reported to the Ohio Department of Health as soon as possible, but no more than two hours after the alleged incident is discovered. This deficiency represents an incidental finding investigated under Complaint Number OH00148026. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 12 of 36 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 12/04/2023 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, resident record review, review of abuse policy acknowledgement, review of the facility's Self-Reported Incidents (SRIs), and facility policy review, the facility failed to thoroughly investigate resident abuse. This affected two residents (#15 and #17) of three residents reviewed for abuse. The facility census was 47. Residents Affected - Few Findings included: 1. Review of Resident #15's medical record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, unspecified psychosis not due to a substance or known physiological disorder, hypothyroidism, and essential hypertension. Review of Resident #15's Clinical Resident Profile revealed she had a guardian. Review of Resident #15's significant change Minimum Data Set (MDS) 3.0 assessment, dated 09/01/23, revealed the resident was cognitively impaired. Further review revealed she was sometimes able to express ideas and wants and was able to sometimes understand verbal content. Additionally, the assessment revealed she was always incontinent of her bladder and frequently incontinent of her bowel. Review of Resident #15's plan of care, dated 09/24//20, revealed she had an alteration in communication and was usually able to verbally or nonverbally express thoughts and ideas, and was sometimes able to understand others through verbal and non-verbal communication. Telephone interview on 11/28/23 at 10:59 A.M. with State Tested Nurse Aide (STNA) #111 revealed she came into work on 10/31/23 and discovered that Resident #15 had not received incontinence care. STNA #111 revealed it looked like Resident #15 had not had incontinence care all night as she was lying in urine and stool. STNA #111 revealed she was going to clean up Resident #15 and became so upset she went and got the current Administrator (who was then working as an administrative assistant). STNA #111 reported she and the Administrator went to Resident #15's room and once the Administrator saw the lack of incontinence care, the Administrator asked STNA #111 to take pictures of Resident #15 on her phone and send them to the Administrator. STNA #111 revealed she did take the pictures of Resident #15 without consent from the resident, her family or her guardian. She said the Administrator was in the room when she took the pictures. STNA #111 reported she sent the pictures to the Administrator by text and then about an hour later STNA #111 received a text back from the Administrator stating, I understand why you took these pictures, but you can't have pictures of residents on your phone. STNA #111 revealed she immediately deleted the pictures from her phone. STNA #111 reported she heard the Administrator printed the pictures out and showed them in the morning meeting. Interview on 11/28/23 at 11:35 A.M. with the Administrator revealed the following staff attend morning meetings: Human Relations/Dietary Manger (HR/DM), Housekeeping/Laundry, Business Office Manager (BOM), Director of Nursing (DON), Maintenance Director (MD), Therapy Director (TD), Activities and the MDS Nurse. Interview on 11/28/23 at 11:38 A.M. with non-clinical anonymous Staff #140 revealed they were present at the 10/31/23 morning meeting. They reported the room was full and the staff present who were not clinical included the MD, the BOM, the Activities Director and the HR/DM. They reported the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 13 of 36 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 12/04/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Administrator (who was then working as an administrative assistant) showed pictures of a resident, but they could not remember if the name of the resident was provided. They reported the resident was wearing a top, and what appeared to be an undergarment brief. Staff #140 reported the bed covers were pulled down exposing the Resident's undergarment brief and her legs. They reported the Administrator was showing the pictures and there were two or three pictures. Staff #140 revealed they were uncomfortable with the presentation and thought the Administrator should have known better. Staff #140 felt the resident's privacy and rights were violated by the humiliating pictures. Interview on 11/28/23 at 12:08 P.M. with non-clinical anonymous Staff #176 revealed they were present at the morning meeting on 10/31/23. Staff #176 reported the Administrator (who was then working as an administrative assistant) was presenting pictures regarding poor resident incontinence care. They reported they did not look closely at the pictures because they were not clinical, and it was not part of her job. Staff #176 felt presenting pictures of the resident was not appropriate or acceptable. They reported it would emotionally upset them to have humiliating pictures of poor incontinence care taken without consent and presented to staff in a meeting. Interview on 11/28/23 at 2:40 P.M. with Resident #15 revealed she did not remember anyone taking pictures of her. This surveyor asked Resident #15 if someone took a picture of her from the waist down with only her Depends on would she be emotionally upset and humiliated and Resident #15 responded, Yes, I would. Interview on 11/29/23 at 1:45 P.M. with the current Administrator revealed on 10/31/23 she had just walked through the door in the morning and STNA #111 came to her with a concern regarding resident care. The Administrator revealed she went with the STNA #111 to Resident #15's room and discovered poor incontinence care. The Administrator revealed she did not direct STNA #111 to take pictures of Resident #15 due to STNA #111 had already taken the pictures. The Administrator verified she did ask STNA #111 to send her the pictures of Resident #15 to her via a text message. The Administrator then verified she printed out the pictures she received from STNA #111 and presented them to the staff present at the morning meeting on 10/31/23. She reported she did not realize she was breaking any rules. The Administrator verified presenting the pictures was not acceptable behavior. She reported she had worked in other facilities when pictures of residents were presented in meetings, and she had an ick feeling about it. The Administrator verified she screwed up but there was no malicious intent. Interview on 11/28/23 at 1:45 P.M. with Regional Nurse #175 revealed there was an incident where a photo of a resident in a brief was held up in a morning meeting on 10/31/23. She revealed no face was visible and she intervened and stopped the presentation of the picture. Regional Nurse #175 felt the purpose of the picture was for education and didn't view the issue as abuse. Therefore, an investigation was not completed. 2. Review of Resident #22's medical record revealed an admission date of 12/04/22 with diagnoses including Alzheimer's disease, unspecified dementia, unspecified psychosis not due to a substance or known physiological condition, unspecified anxiety disorder, and essential hypertension. Review of Resident#22's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/22/23, revealed the resident was not cognitively intact. Further review revealed she did not exhibit physical or verbal behavioral symptoms towards others. Review of Resident #22's progress notes for the month of November 2023 revealed 14 notes referring to behavioral concerns with residents and staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 14 of 36 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 12/04/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #22's progress note, dated 11/29/23 at 5:30 A.M., revealed State Tested Nursing Assistant (STNA) #102 was passing medications when Resident #22 was in another Resident's (#17) room, grabbing their arms and yelling, get out of my house. Registered Nurse (RN) #183 was notified. Review of Resident #22's progress notes and evaluations revealed no head to toe physical assessment, psychosocial assessment, or pain assessment immediately following the incident. b. Review of Resident #17's medical record revealed an initial admission date of 02/06/23 and a readmission date of 10/03/23 with diagnoses including chronic obstructive pulmonary disease, respiratory failure, essential hypertension, and dysphagia. Review of Resident #17's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/11/23, revealed the resident was cognitively impaired. Further review revealed she did not present physical behaviors towards others but did present verbal behaviors towards others daily. Review of Resident #17's progress notes for the month of November 2023 revealed four notes referring to behavioral concerns with staff only. Review of Resident #17's progress note, dated 11/29/23 at 5:30 A.M., revealed STNA #102 was passing medications when another Resident (#22) was in Resident #17's room. Resident #22 was yelling and grabbing her (#17's) arms. Resident #22 was yelling, get out of my house. RN #183 was notified. Review of Resident #17's progress notes and evaluations revealed no head to toe physical assessment, psychosocial assessment, or pain assessment immediately following the incident. Interview on 11/29/23 at 7:35 A.M. with STNA #137 revealed she had heard that Resident #22 had entered Resident #17s room and was holding her arms and yelling at her this morning. Observation on 11/29/23 at 7:55 A.M. of Resident #22 and Resident #17 sitting at the same table, side by side, in the dining room. Interview on 11/29/23 at 7:57 A.M. with Resident #17 revealed Resident #22 came into her room and attacked her. Resident #17 was able to point to Resident #22 as the resident who came into her room. Resident #17 reported she was afraid and scared when Resident #22 grabbed her arms. Telephone interview on 11/29/23 at 7:59 A.M. with STNA #102 revealed she was passing medications and heard screaming and yelling coming from Resident #17's room. STNA #102 reported she entered Resident #17's room and saw Resident #22 holding Resident #17's arms and trying to pull her up out of her wheelchair. Resident #22 was stating, It is my house, and you need to get out of here. Resident #17 was yelling, Help, she is beating me up. Review of the Personal Witness Statement, dated 11/29/23 and timed 5:30 A.M. by STNA #102, revealed she was passing medications when she heard yelling coming from Resident #17's room. When STNA #102 arrived to the room Resident #22 had hold of Resident #17's arms yelling at her to get out of her house. Interview on 11/29/23 at 2:19 P.M. with the Administrator revealed she entered the facility at around 6:45 A.M. and LPN #177 informed her of the occurrence between Resident #17 and Resident #22. The Administrator reported corporate had directed her to do a quick response and send it to legal to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 15 of 36 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 12/04/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few decide if a self-reported incident needed to be initiated. She had not received a directive to complete a SRI and she verified she had not submitted a SRI for the occurrence between Resident #17 and #22 and had not immediately started an abuse investigation. The Administrator reported she felt the occurrence the A.M. of 11/29/23 between Residents #22 and #17 was resident to resident abuse and should have been reported to the Ohio Department of Health and an SRI investigation initiated within two hours of the occurrence. Interview on 11/30/23 at 12:14 P.M. with anonymous Nurse #182 verified upon her review of Resident #17 or #22's medical records, there was no head to toe skin assessment for Resident #17 since 11/22/23 and for Resident #22 since 11/16/23. Anonymous Nurse #182 also verified no psychosocial or pain assessments for either resident since the resident to resident incident on 11/29/23 at 5:30 A.M. She verified there should have been a full body assessment (head to toe), a psychosocial assessment, and a pain assessment on both residents. Review of the facility policy titled, Abuse, Neglect, and Exploitation of Residents and Misappropriation of Property, dated 05/2018, revealed it was the goal of the facility that its residents will be protected from verbal, mental, sexual, or physical abuse, corporal punishment, mistreatment, neglect, involuntary seclusion, exploitation, and misappropriation of property through development of operationalizes policies and procedures. Residents will not be subjected to abuse, neglect, mistreatment, or misappropriation of property by anyone. Further review revealed the definition of mental abuse included but was not limited to humiliation, harassment, or threats of punishment or deprivation. Under Section F: Protecting Resident Privacy and Prohibiting Mental Abuse Related to Photographs and/or Recordings revealed taking or using photographs, videos or recordings of a resident or his/her private space in any manner that would demean or humiliate a resident is strictly prohibited. At no time are any photographic or recording devices permitted in any resident room or common areas. Examples include, but are not limited to, taking unauthorized photographs of a resident's room or furnishings (which may or may not include the resident), resident eating, or participating in an activity. This policy included employees, consultants, contractors, volunteers and other care givers. Staff must report to their supervisor any unauthorized (or suspected to be unauthorized) taking of photographs or videos as well the sharing of such recordings in any medium. Violations of this policy may result in disciplinary actions, including termination. Personal cell phones may only be used in designated employee breakrooms. Further review revealed under Section Seven: Reporting: All allegations that involve abuse or result in serious bodily injury will be reported to the Ohio Department of Health as soon as possible, but no more than two hours after the alleged incident is discovered. This deficiency represents an incidental finding investigated under Complaint Number OH00148026. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 16 of 36 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 12/04/2023 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review revealed Resident #17 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, respiratory failure, schizoaffective disorder and dementia. Review of Resident #17's Progress Notes revealed she was evaluated at the emergency room on [DATE], 10/03/23 and 10/05/23 for changes in condition. Review of the record revealed no evidence of a written transfer or bedhold notice was provided to the resident or the resident representative. On 11/30/23 at 9:17 A.M., during interview, Registered Nurse #183 verified the facility was unable to find a written transfer/bedhold notice for Resident #17's discharges to the hospital during October 2023. This deficiency represents non-compliance investigated under Master Complaint Number OH00148522. Based on interview, record review, facility transfer/discharge documentation, facility bed hold documentation, and facility policy review, the facility failed to ensure residents received appropriate notice of transfer/discharge and bed hold and failed to ensure the Ombudsman was notified. This affected two residents (#17 and #48) of three residents reviewed for transfer/discharge and bed hold notice. The facility census was 47. Findings included: 1. Review of Resident #48's medical record revealed an initial admission date of 07/22/23 and readmitted on [DATE] with diagnoses including Arnold Chiari Syndrome with hydrocephalus, type two diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, stage four (sever), and chronic congestive heart failure. Review of Resident #48's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/01/23, revealed the resident was cognitively intact. Review of Resident #48's progress note, dated 11/02/23 and timed 10:56 A.M., revealed she was complaining of chest pain/tightness and shortness of breath. The physician was notified, made aware of her symptoms, and the order was received to send her to the local emergency department for evaluation and treatment. Report was called to the emergency department at 10:56 A.M., the emergency medical service (EMS) providers arrived at the facility at 11:00 A.M. and Resident #48 was transferred to hospital at 11:07 A.M. Review of Resident #48's progress note, dated 11/02/23 and timed 4:55 P.M. revealed the facility called the local hospital for follow up with Resident #48 and was informed she was being admitted due to low hemoglobin level of six. Review of the facility transfer/discharge notice and bed hold notice documentation for Resident #48 revealed she was not informed of her transfer/discharge and bed hold rights until 11/15/23, 12 days after her transfer and this was not timely. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 17 of 36 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 12/04/2023 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 0623 Level of Harm - Minimal harm or potential for actual harm Interview on 11/29/23 at 1:03 P.M. with Social Services Designee (SSD) #130 revealed she had worked at a sister facility prior to being assigned at this facility on 09/18/23. SSD #130 reported she did not do discharge tracking at the sister facility and was not informed until 11/28/23 that she was to complete discharge tracking. SSD #130 reported she had not been notifying the Ombudsman of transfers or discharges. Residents Affected - Few Interview on 11/30/23 at 1:20 P.M. with Regional Nurse #175 verified Resident #48 should have received a transfer/discharge and bed hold notice on 11/03/23 and did not. Review of the facility policy titled, Admission, Discharge and Transfer, (undated), revealed staff would complete the Transfer/Discharge Notice at the time of discharge or transfer. Further review revealed if the discharge or transfer is emergency in nature, staff will follow up with the family via phone and review the Transfer/Discharge Notice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 18 of 36 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 12/04/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review revealed Resident #17 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, respiratory failure, schizoaffective disorder and dementia. The resident was admitted to hospice services on 07/18/23. Review of the electronic Physician Orders dated October 2023 revealed narcotic pain medications for Resident #17 included Morphine Sulfate as needed (ordered 07/18/23), MS Contin (ordered 09/30/23) twice a day, and Tramadol 50 milligrams twice daily (ordered 08/15/23). A severe allergy to morphine and related propensity to adverse reactions was ordered on 10/02/23. Review of Resident #17's Medication Administration Records and the Controlled Drug Receipt/Record/Disposition Forms revealed Morphine Sulfate (MSO4) 15 milligrams (mg) ER (extended release) was administered twice on 10/02/23 and MSO4 20 mg/milliliter (ml), administer 0.25 ml every four hours as needed for pain was administered on 11/04/23. Review of the medical record revealed no evidence of a pain management care plan for Resident #17. On 11/30/23 at 10:23 A.M., interview with Registered Nurse #182 verified there was no evidence Resident #17 had a pain management care plan. This deficiency represents non-compliance investigated under Complaint Number OH00148026. Based on interview, resident record review, and facility policy review, the facility failed to ensure residents had comprehensive care plans developed and implemented. This affected two residents (#17 and #22) of seven residents reviewed for care planning. The facility census was 47. Findings included: 1. Review of Resident #22's medical record revealed an admission date of 12/04/22 with diagnoses including Alzheimer's disease, unspecified dementia, unspecified psychosis not due to a substance or known physiological condition, unspecified anxiety disorder, and essential hypertension. Review of Resident#22's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/22/23, revealed the resident was not cognitively intact. Further review revealed she did not exhibit physical, verbal or other behavioral symptoms towards others. Review of Resident #22's progress notes for the month of November 2023 revealed 14 notes referring to behavioral concerns with residents and staff. Review of Resident #22's progress note, dated 11/15/23 at 9:52 A.M., revealed she became verbally aggressive towards her roommate and staff. Resident #22 took items from her roommate and began yelling at roommate stating the roommate had stolen them from her. Resident #22 was not easily directed and insisted that her roommate did not sleep in in her room or pay the bills. Resident #22 became agitated over her roommate using the nebulizer, as she thought it was her. Resident #22 refused to leave the door open to accommodate heating issues for the room, Resident #22 was educated numerous times on both topics. Resident #22 was delusional and had auditory hallucinations of babies crying. The staff used therapeutic communication during the episode and distracted the resident with good and drink. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 19 of 36 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 12/04/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #22's progress note, dated, 11/17/23 at 6:34 A.M., revealed that during the shift she had wandered through the hallways asking staff repetitive questions regarding children and babies crying. Resident #22 was delusional and not easily reoriented. Resident #22 would refuse care at times and was forgetful. Resident #22 accused staff of stealing her items and lying. She refused to keep the door open to her room to keep it heated. Resident #22 did not get along with her roommate and believe she was stealing her items. The staff continued to use distraction techniques and therapeutic communication. Review of Resident #22's progress note, dated 11/23/23 at 4:28 A.M., revealed she wandered throughout the halls yelling at staff members and telling them they didn't do their jobs. Resident #22 was delusional and believe there were kids outside crying. She attempted to wander into other residents' rooms and staff intervened. Resident #22 was unable to be reoriented and became aggressive. Staff provided a quiet environment for the patient along with food/drink and therapeutic communication. Review of Resident #22's progress note, dated 11/24/23 at 2:37 A.M., revealed she was agitated with staff. Resident #22 was yelling and combative with staff for no known reason. Review of Resident #22's progress note, dated 11/29/23 at 5:30 A.M., revealed STNA #102 was passing medications when Resident #22 was in another resident's room (Resident #17), grabbing their arms and yelling, get out of my house. The Assistant Director of Nursing (ADON) was notified Review of Resident #22's comprehensive plan of care revealed no care plan regarding aggressive verbal or physical behaviors toward other residents or staff. Interview on 11/30/23 at 10:19 A.M. with the anonymous Nurse #182 revealed Resident #22 did not have a behavior plan of care until this AM on 11/30/23 and should have based on the behaviors which were documented in her progress notes. Review of the facility policy titled, Behavior Care Plan and Advanced Care Plan Process, (undated), revealed the interdisciplinary team will coordinate with the resident and/or their responsible party if the resident is unable to participate an appropriate care plan for the resident's needs or wishes specific to person centered care based on the assessment and reassessment process within the required time frames. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 20 of 36 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 12/04/2023 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 Based on observation, interview, and resident record review, the facility failed to ensure supervision for a resident while eating as recommended by the speech therapist. This affected one resident (#17) of twelve residents reviewed for quality of care. The facility census was 47. Residents Affected - Few Findings included: Review of Resident #17's medical record revealed an initial admission date of 02/06/23 and a readmission date of 10/03/23 with diagnoses including chronic obstructive pulmonary disease, respiratory failure, essential hypertension, and dysphagia. Review of Resident #17's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/11/23, revealed the resident was cognitively impaired. The resident needed supervision with setup help only with eating and did not have a swallowing disorder. Review of Resident #17's physician order, dated 09/05/23 to November 2023 revealed a regular diet, regular texture and regular (thin liquid) consistency, no straws. Review of Resident #17's Speech Therapy Treatment Encounter Note, dated 09/11/23, revealed speech therapy discharge completed and recommendations include supervision for meals. Review of Resident #17's physician order, dated 09/11/23, identified discontinue speech therapy services effective 09/11/23 and diet clarification: regular solids and thin liquids. Recommend supervision as resident will allow. Review of Resident #17's plan of care, dated 02/08/23, revealed she had the potential for alteration in nutrition and dehydration. One of the interventions included encouraging the resident to go to the dining room for all meals to supervise intake and risk for choking. Review of the Diet Type Report provided by the facility, dated 11/28/23, revealed Resident #17 had the additional directive of no straws. Interview on 11/28/23 at 7:22 A.M. with Resident #17 revealed she gets her meals in her room, and no one stays to observe her while she eats. Observation on 11/28/23 at 8:02 A.M. of the breakfast meal being served to Resident #17 by State Tested Nursing Assistant (STNA) # 141. STNA #141 set Resident #17's meal on the overbed table, took off the lids of the food and drink then left the room. STNA #141 did not encourage Resident #17 to go to the dining room or offer to observe food intake in her room. Resident #17 wheeled herself over to the overbed table and started to eat. Continuous observation continued and at 8:09 A.M. Resident #17 coughed while eating a hard-boiled egg. Resident #17 was able to clear the egg and continued to eat. Resident #17 continued to eat her breakfast meal in her room until she was finished at 8:25 A.M. There was no meal observation by facility staff or offering of meal intake observation for safety by facility staff. Review of the Resident #17's tray ticket from her breakfast tray dated 11/28/23 revealed she was to receive a regular diet, regular texture, and thin liquid meal. Also noted was that all meals, snacks, and drinks with supervision. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 21 of 36 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 12/04/2023 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 Interview on 11/28/23 at 8:30 A.M. with STNA #106 revealed any resident who needs assistance with eating or supervision when eating is to eat in the dining room for safety. She verified residents who are to have supervision with meals and snacks should not eat alone in their rooms. Resident #17's meal ticket was reviewed with STNA #106, and she verified Resident #17 should be supervised during food intake. Interview on 11/28/23 at 8:33 A.M. with STNA #109 verified she was the STNA on Resident #17's unit during breakfast and there was no supervision of food intake for Resident #17 during breakfast and based on the resident's tray ticket there should have been observation of food intake for safety. Interview on 11/28/23 at 9:26 A.M. with Therapy Director #174 verified based on the speech therapy treatment encounter note, dated 09/11/23, Resident #17 was to have supervision for meals. She also verified there is no additional documentation after 09/11/23. Interview on 11/28/23 at 10:45 A.M. with STNA #144 revealed Resident #17 did have a directive for supervised meals and staff have not been observing or offering observation to the resident for safety. She reported the tray cards are to be reviewed with each meal to make sure the appropriate care is provided. This deficiency represents non-compliance investigated under Complaint Number OH000148026. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 22 of 36 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 12/04/2023 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, medical record review, policy review and interview, the facility failed to provide appropriate urinary incontinence care. This affected one of one resident (#40) observed for incontinence care. The facility census was 47. Findings include: Medical record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, dementia, schizoaffective disorder and constipation. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #40 was severely impaired for daily decision-making, required staff to assist with personal hygiene, and was always incontinent of bowel and bladder. Review of the care plan: Alteration in Elimination: No control present with bowel and bladder, dependent on staff for peri-care and toileting needs (revised 04/05/18) revealed interventions including to apply barrier cream to peri area as prevention and provide incontinent care as needed. On 11/28/23 between 11:03 A.M. and 11:31 A.M., observation of Resident #40's incontinence care revealed State Tested Nurse Aide (STNA) #144 gathered Resident #40's incontinence supplies, raised the bed and used a washcloth to wipe the groin that revealed a dark brown/black smear of stool on the washcloth. STNA #144 then took a new washcloth and wiped the outer aspect of the labia with one wipe. Stool was observed on the rag. STNA #144 was not observed washing the labia minora, urethral or vaginal opening. STNA #144 removed her gloves and donned new gloves without washing her hands and placed a new incontinence product on the resident without applying barrier cream, removed her gloves and then washed her hands at the sink. On 11/28/23 at 11:31 A.M., interview with STNA #144 verified the above observation. Review of the undated policy and procedure: Incontinence care revealed after each episode of incontinence: greet resident, explain procedure, wash hands and don gloves, cleanse area with perineal wash or mild cleanser, pat dry, apply a protective barrier ointment to protect the skin, change linens and clothing as needed provide absorbent under pad and briefs as needed, dispose of gloves and wash hands and report reddened areas or skin breakdown to the nurse. This deficiency represents non-compliance investigated under Complaint Number OH00148026. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 23 of 36 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 12/04/2023 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 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure physician progress notes were readily available for review. This affected one resident (#17) of three residents reviewed for discharge/transfer/bedhold notice. The facility census was 47. Findings include: Medical record review revealed Resident #17 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, respiratory failure, schizoaffective disorder and dementia. Review of Resident #17's Progress Notes revealed she was evaluated at the emergency room on [DATE], 10/03/23 and 10/05/23 for changes in condition. Review of the medical record revealed no physician progress notes for review. On 11/30/23 at 10:23 A.M., interview with Registered Nurse (RN) #182 verified there were no physician progress notes available for review on the medical record. On 11/30/23 at 12:48 P.M., interview with RN #182 verified there was no documented evidence in the electronic or paper medical record of an assessment or progress note from Resident #17's physician. RN #182 stated the facility called the physician's office today to see if they had any other notes for review but the office was not answering their calls. RN #182 stated the only physician notes were from the emergency room hospital evaluations and behavioral health. On 11/30/23 at 3:00 P.M., interview with Regional Nurse #175 verified there were no attending physician notes for review for Resident #17. This deficiency is cited as an incidental finding under Complaint Number OH00148026. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 24 of 36 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 12/04/2023 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 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure physician and nurse practitioner (NP) visits alternated as required. This affected one resident (#17) of three residents reviewed for discharge/transfer/bedhold notice. The facility census was 47. Residents Affected - Few Findings include: Medical record review revealed Resident #17 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, respiratory failure, schizoaffective disorder and dementia. Review of the Nurse Practitioner (NP) #184 Progress Note dated 07/28/23, 08/31/23 and 10/12/23 revealed an assessment and treatment plan was documented. Review of the electronic and paper medical record revealed no physician progress notes for review. On 11/30/23 at 10:23 A.M., interview with Registered Nurse (RN) #182 verified there was no evidence the physician evaluated Resident #17 or alternated evaluations/assessments with NP #184. On 11/30/23 at 12:48 P.M., interview with RN #182 verified there was no documented evidence in the electronic or paper medical record of an assessment or progress note from Resident #17's physician. RN stated the facility called the physician's office today to see if they had any other notes for review but the office was not answering their calls. RN #182 stated the only physician notes were from the emergency room hospital evaluations and behavioral health physician. On 11/30/23 at 3:00 P.M., interview with Regional Nurse #175 verified there were no attending physician visits alternating with NP #184 for Resident #17. This deficiency is cited as an incidental finding to Complaint Number OH00148026. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 25 of 36 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 12/04/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, personnel record review, job description review and interview, the facility failed to ensure nurse staff administering medications were competent in their duties and ensured the medications were administered appropriately. This affected one resident (#8) of four residents observed for medication administration. The facility census was 47. Findings include: Review of State Tested Nurse Aide (STNA) #143's personnel record revealed she was licensed by the State of Ohio as a Certified Medication Aide on 08/17/23. Review of the certified medication aide Job Description signed 08/17/23 revealed essential duties and responsibilities included to report to the nurse the following: a resident refusal of medications, any deviation from the delegated medication administration, any unanticipated resident reaction to the medication administration, or anything that causes concern about the condition of the resident. On 11/28/23 at 7:34 A.M., observation revealed STNA #143 administered oral medications to Resident #8 and offered Miralax (laxative) as ordered to Resident #8. The resident refused the Miralax stating she did not need it. STNA #143 left the resident room and stated she documented the resident refused the Miralax in the electronic Medication Administration Record (eMAR). There was no evidence STNA #143 informed Resident #8's nurse of the resident's refusal of medications. Review of Resident #8's electronic Medication Administration Record (eMAR) revealed the Miralax was administered. There was no evidence in the medical record the Miralax was refused by the resident on 11/28/23. On 11/28/23 at 3:31 P.M., interview with Licensed Practical Nurse (LPN) #136 stated she was the charge nurse for the day and was responsible for administering all injections and narcotics to all residents because the only other staff administering medications was STNA #143. LPN #136 stated she was unaware Resident #8 had refused any medications on 11/28/23. On 11/28/23 at 3:40 P.M., interview with Registered Nurse #183 stated it was the expectation for STNA #143 to report refusal of medications to her assigned nurse for follow-up. RN #183 stated she was not aware Resident #8 had refused an ordered dose of Miralax during the morning medication administration. On 11/28/23 at 4:01 P.M., interview with STNA #143 stated she was to report medication refusals to the nurse and verified she did not report Resident #8 refused her Miralax this morning. Employee #143 stated it slipped my mind. This deficiency was cited as an incidental finding during the investigation of Complaint Number OH00148026. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 26 of 36 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 12/04/2023 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staffing schedule review, time card report review, facility assessment review, policy review and interview, the facility failed to provide registered nurse (RN) coverage daily for a minimum of eight consecutive hours. This affected all 47 residents residing within the facility. Findings include: Review of the Staffing Schedules dated September 2023, October 2023 and November 2023 revealed no evidence a RN was scheduled on 09/16/23, 09/17/23, 09/30/23, 10/01/23, 10/15/23, 10/28/23, 10/29/23 or 11/19/23. Review of the staffing Time Card Reports dated 09/16/23, 09/17/23, 09/30/23, 10/01/23, 10/15/23, 10/28/23, 10/29/23 and 11/19/23 revealed no evidence a RN worked the required minimum of eight consecutive hours. Review of the Facility assessment dated [DATE] revealed the facility provided a RN for at least eight hours daily. Review of the undated policy: Minimum Staffing Requirements revealed the facility will maintain sufficient staffing to provide, in a timely manner, adequate services and care to meet the needs of the residents admitted to or retained in the nursing facility. On 11/30/23 at approximately 2:45 P.M., interview with Dietary Manager # 140 verified there was no evidence of eight hour consecutive RN coverage on the above dates. This deficiency was cited as an incidental finding under Complaint Number OH00148026. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 27 of 36 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 12/04/2023 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Based on interview and resident record review, the facility failed to provide appropriate behavioral care when Resident #22 was presenting with escalating behavioral needs. This affected one resident (#22) of three residents reviewed for abuse. The facility census was 47. Findings included: Review of Resident #22's medical record revealed an admission date of 12/04/22 with diagnoses including Alzheimer's disease, unspecified dementia, unspecified psychosis not due to a substance or known physiological condition, unspecified anxiety disorder, and essential hypertension. Review of Resident#22's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/22/23, revealed the resident was not cognitively intact. Further review revealed she did not exhibit physical or verbal behavioral symptoms towards others. Review of Resident #22's comprehensive plan of care revealed no care plan regarding aggressive verbal or physical behaviors toward other residents or staff. Review of Resident #22's progress notes for the month of November 2023 revealed 14 notes referring to behavioral concerns with residents and staff. Review of Resident #22's progress note, dated 11/15/23 at 9:52 A.M., revealed she became verbally aggressive towards her roommate and staff. Resident #22 took items from her roommate and began yelling at her roommate stating the roommate had stolen them from her. Resident #22 was not easily directed and insisted that her roommate did not sleep in in her room or pay the bills. Resident #22 became agitated over her roommate using a nebulizer, as she thought it was her. Resident #22 refused to leave the door open to accommodate heating issues for the room. Resident #22 was educated numerous times on both topics. Resident #22 was delusional and had auditory hallucinations of babies crying. The staff used therapeutic communication during the episode and distracted the resident with food and drink. Review of Resident #22's progress note, dated, 11/17/23 at 6:34 A.M., revealed that during the shift she had wandered through the hallways asking staff repetitive questions regarding children and babies crying. Resident #22 was delusional and not easily reoriented. Resident #22 would refuse care at times and was forgetful. Resident #22 accused staff of stealing her items and lying. She refused to keep the door open to her room to keep it heated. Resident #22 did not get along with her roommate and believed she was stealing her items. The staff continued to use distraction techniques and therapeutic communication. Review of Resident #22's progress note, dated 11/23/23 at 4:28 A.M., revealed she wandered throughout the halls yelling at staff members and telling them they didn't do their jobs. Resident #22 was delusional and believed there were kids outside crying. She attempted to wander into other residents' rooms and staff intervened. Resident #22 was unable to be reoriented and became aggressive. Staff provided a quiet environment for the resident, along with food/drink and therapeutic communication. Review of Resident #22's progress note, dated 11/24/23 at 2:37 A.M., revealed she was agitated with staff. Resident #22 was yelling and combative with staff for no known reason. Review of Resident #22's progress note, dated 11/29/23 at 5:30 A.M., revealed State Tested Nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 28 of 36 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 12/04/2023 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assistant (STNA) #102 was passing medications when Resident #22 was in another Resident's (#17) room, grabbing their arms and yelling, get out of my house. Registered Nurse (RN) #183 was notified. Review of Resident #22's progress note, dated 11/29/23 at 8:39 A.M., revealed she was to be on 15 minute checks due to behaviors for 72 hours. Then she was to be reevaluated. Physician was contacted for medication evaluation. The resident's behaviors continued and escalated in November 2023. Further review of Resident #22's progress notes revealed the last documented note regarding physician notification of her behaviors was 10/30/23. An order for Melatonin, a sleep aide, was ordered at the time. Telephone interview on 11/29/23 at 7:59 A.M. with STNA #102 revealed she was passing medications and heard screaming and yelling coming from Resident #17's room. STNA #102 reported she entered Resident #17's room and saw Resident #22 holding Resident #17's arms and trying to pull her up out of her wheelchair. Resident #22 was stating, It is my house, and you need to get out of here. Resident #17 was yelling, Help, she is beating me up. STNA #102 revealed Resident #22 then started walking aggressively toward her. STNA #102 reported Resident #22 didn't touch her but exited the room. STNA #102 reported Resident #22 did have a history of getting physical with staff. STNA #102 reported that on 11/26/23, Resident #22 grabbed her ponytail and almost pulled STNA #102 to the ground. STNA #102 reported that Resident #22 has a history of yelling at other residents and staff, but this past week she started putting hands on staff and today on another resident. Interview on 11/29/23 at 1:55 P.M. with the Administrator revealed she had contacted psychiatry in the A.M. regarding the behaviors of Resident #22 toward Resident #17 on 11/29/23. Telephone interview on 12/01/23 at 1:46 P.M. with the Administrator verified Resident #22's physician had been contacted on 10/30/23 regarding trouble sleeping and then not again until 11/29/23 at 8:39 A.M. following the incident with Resident #17. This deficiency represents an incidental finding investigated under Complaint Number OH00148026. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 29 of 36 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 12/04/2023 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, medication error log review, policy review, and interview, the facility failed to ensure Resident #17 received adequate monitoring following administration of a narcotic medication and a benzodiazepine medication simultaneously. In addition, the facility failed to ensure medications listed as an allergy were not administered to the resident. This affected one resident (#17) of three residents reviewed for change in condition. The facility census was 47. Residents Affected - Few Actual harm occurred to Resident #17 on 10/01/23 when the resident was administered a narcotic medication (MS Contin) and a benzodiazepine medication (Ativan) simultaneously and failed to adequately monitor the resident for sedation as ordered by the prescriber resulting in the resident requiring administration of Narcan (opiate antagonist) and transfer to the hospital for evaluation. Findings include: Medical record review revealed Resident #17 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, respiratory failure, schizoaffective disorder and dementia. The resident was admitted to hospice services on 07/18/23. Review of the care plan: Alteration in Respiratory Function (revised 09/25/23) revealed nursing to monitor resident and assess for effectiveness of respiratory treatment, target oxygenation 88-92% and encourage use of oxygen. Review of the electronic Physician Orders (dated 09/30/23) revealed MS Contin 15 milligrams (mg) was ordered twice a day, once in the morning and once between 4:00 P.M. and 6:00 P.M Nursing staff was ordered to monitor for over sedation with new hospice medication orders and to report any signs of this to the hospice team immediately. Review of the Progress Notes revealed the following: -On 09/30/23 at 12:19 P.M., hospice called with updated medication orders. New orders placed and staff to monitor for over sedation. -On 10/01/23 at 11:15 P.M., resident had an altered level of consciousness, increased confusion, lethargic, shortness of breath with decreased oxygenation to 79% on four liters of oxygen. Medication changes in the past week included MSContin 15 mg and Ativan 0.5 mg twice a day. The resident's POA requested her to be sent to the emergency room for evaluation. -On 10/01/23 at 11:16 P.M., Resident #17 remained lethargic with an oxygen saturation of 74% on oxygen at 2L/min via nc and raise it to 4L/min bringing her oxygen saturation up to 79%. Message left with Hospice about concerns. -On 10/01/23 at 11:18 P.M., staff spoke with Hospice regarding concerns with medication. Hospice stated family should be called as resident may be actively dying and to call back with any concerns. -Late entry dated 10/02/23 at 12:31 A.M. revealed Nurse Practitioner #184 was made aware of resident status, power of attorney request, Hospice made aware and 911 was called. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 30 of 36 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 12/04/2023 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 0757 Level of Harm - Actual harm Residents Affected - Few -On 10/02/23 at 1:14 A.M., Report received from emergency room (ER) stating that the squad had to administer Narcan to the resident in route to the ER, oxygen therapy was given at the hospital and that resident was back to base line and would be returning back to our facility. There was no evidence staff completed monitoring for over sedation of Resident #17 between 9:00 A.M. and 11:15 P.M. on 10/01/23 as ordered. Review of a the Treatment Administration Record (TAR) revealed a once a shift initial for 10/01/23. Review of the Medication Administration Record (MAR) and the Controlled Drug Receipt Record/Disposition Forms dated 10/01/23 revealed both MS Contin 15 mg ER and Ativan 0.5 mg were administered at 9:00 A.M. and 5:30 P.M Review of Resident #17's Hospital Discharge paperwork dated 10/02/23 revealed the resident was evaluated at the emergency room for respiratory arrest and opioid overdose. On 11/29/23 at 2:30 P.M., interview with Registered Nurse (RN) #182 verified there was no evidence of increased monitoring for over sedation of Resident #17 after the resident received Ativan and MS Contin routinely as ordered by hospice, the resident had a decrease in oxygenation, a significant change in condition requiring Narcan and evaluation at the hospital. In addition, review of Resident #17's Progress Notes revealed the resident was evaluated at the emergency room for respiratory arrest, opioid overdose and behavioral changes on 10/01/23. A medication allergy was noted on 10/02/23 for morphine sulfate and related medications. Review of the Physician Orders dated November 2023 revealed allergies included morphine (opioid) and related derivatives. Review of the Medication Administration Record dated November 2023 revealed Morphine (MSO4) 20 mg/milliliter (ml) administer 0.25 ml was administered on 11/04/23. On 11/30/23 at 10:53 A.M., interview with Registered Nurse #182 verified Resident #17 was administered MSO4 on 11/04/23 and MSO4 was listed as a severe allergy and the administration of this medication could cause a severe adverse reaction for the resident. This deficiency represents non-compliance investigated under Complaint Number OH00148026. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 31 of 36 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 12/04/2023 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, medication insert review, policy review and interview, the facility failed to ensure both rapid-acting and long-acting insulin's were administered timely and inhalation medications were administered without error. This affected two residents (#2 and #39) of four residents. Three errors were observed during 26 opportunities resulting in a medication administration error rate of 11.54%. Residents Affected - Few Findings include: 1. Medical record review revealed Resident #39 was admitted on [DATE] with diagnoses including type 2 diabetes mellitus and Alzheimer's disease. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #39 received daily insulin injections for diabetes mellitus. On 11/28/23 at 7:41 A.M., observation revealed State Tested Nurse Aide (STNA) #143 prepared Resident #39's oral medications. STNA #143 stated she was also a certified medication aide (MA-C) and could not administer insulin and Licensed Practical Nurse (LPN) #136 would come to the unit to administer the insulin. Review of Resident #139's Physician Orders dated 11/28/23 revealed the following insulins were to be administered: Novolin R (short acting insulin) 7 units subcutaneous before meals and Levemir (long acting insulin) 32 units subcutaneous in the morning. Review of the electronic Medication Administration Record revealed Levemir and Novolin R insulins had not been administered as of 9:45 A.M. on 11/28/23. On 11/28/23 at 10:03 A.M., interview with STNA #143 verified Resident #39 had already eaten her breakfast and still had not received the ordered Novolin R insulin or Levemir insulin. STNA #143 stated LPN #136 had her own hall to do first and then would administer any injections and narcotics on the other units. On 11/28/23 at 3:31 P.M., interview with LPN #136 verified she did not administer insulin as ordered for Resident #39. LPN #136 stated the insulins had not been administered timely because she was completing her own medication administration. Review of the Job Description: Certified Medication Aide (MA-C) dated 08/17/23 revealed essential duties and responsibilities included but were not limited to, reporting to the nurse resident refusal of medications. The MA-C was able to dispense oral, inhalation and topical medications under direct supervision of a licensed nurse unless otherwise allowed by state law. 2. Medical record review revealed Resident #2 was admitted on [DATE] with diagnoses including mild intellectual disability, chronic obstructive pulmonary disease (COPD), chronic bronchitis and a history of COVID-19. Review of the monthly Physician Orders dated November 2023 revealed Resident #2 was ordered to receive Breo Ellipta (an inhaled asthma combination aerosol) Powder Breath-Activated 100-25 micrograms per inhalation. The resident was to receive one puff orally in the morning and the resident was to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 32 of 36 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 12/04/2023 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 rinse her mouth and spit after each dose. Level of Harm - Minimal harm or potential for actual harm Review of the care plan: Alteration in Health Maintenance related to COPD, dyspnea, shortness of breath (revised 04/28/23) revealed interventions including to administer medications as ordered. Residents Affected - Few On 11/28/23 between 8:22 A.M. through 8:29 A.M., medication administration observation revealed LPN #136 approached Resident #2 who was sitting at a table outside the main dining room eating breakfast. LPN #136 administered oral medications and asked the resident if she wanted her inhaler now or later in her room. Resident #2 stated she would take the inhalation medication and LPN #136 instructed the resident to take a deep breath at the count of three and administered one puff of the medication. The resident was observed to inhale and quickly exhale allowing a puff of the medication to be expelled into the air. LPN #136 instructed Resident #2 to slowly take a breath in on the count of three and administered the second puff of the inhalation medication. At that time, LPN #136 put the cap on the inhaler. LPN #136 was not observed offering or prompting Resident #2 to rinse and spit water from her mouth after the administration of the aerosol. On 11/28/23 at 8:32 A.M., interview with LPN #136 verified she did not cue Resident #2 to rinse her mouth with water and spit it out stating 'the resident would have just swallowed it'. LPN #136 also verified a second dose was administered and it was unknown how much of the first dose was administered and the order was for only one dose. On 11/28/23 at 2:45 P.M., interview with Registered Nurse #183 verified the resident should have been offered water to rinse her mouth after the administration of the aerosol treatment. Review of the Breo Ellipta manufacturer insert revised January 2019 revealed instructions for use for oral inhalation included to rinse your mouth with water after inhalation. Do not swallow the water. Review of the undated policy: Medication Administration - General Guidelines revealed medications were to be administered as prescribed in accordance with good nursing principles and practices. Medications were to be administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. This deficiency represents non-compliance investigated under Complaint Number OH00148026. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 33 of 36 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 12/04/2023 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 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, review of facility documentation of abuse training, record review, and facility policy review, the facility failed to ensure training was provided to staff following an incident of resident abuse. This affected all 47 residents residing in the facility. Findings included: Review of Resident #15's medical record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, unspecified psychosis not due to a substance or known physiological disorder, hypothyroidism, and essential hypertension. Review of Resident #15's Clinical Resident Profile revealed she had a guardian. Review of Resident #15's significant change Minimum Data Set (MDS) 3.0 assessment, dated 09/01/23, revealed the resident was cognitively impaired. Further review revealed she was sometimes able to express ideas and wants and was able to sometimes understand verbal content. Additionally, the assessment revealed she was always incontinent of her bladder and frequently incontinent of her bowel. Review of Resident #15's plan of care, dated 09/24//20, revealed she had an alteration in communication and was usually able to verbally or nonverbally express thoughts and ideas, and was sometimes able to understand others through verbal and non-verbal communication. Review of Resident #15's progress notes, dated 10/31/23, revealed no documentation to support poor incontinence care or picture taking. Interview on 11/28/23 at 10:45 A.M. with State Tested Nursing Assistant (STNA) #144 revealed she heard that STNA #111 was told by administration (not sure who) to take pictures of Resident #15 regarding poor incontinence care. Telephone interview on 11/28/23 at 10:59 A.M. with STNA #111 revealed she came into work on 10/31/23 and discovered that Resident #15 had not received incontinence care. STNA #111 revealed it looked like Resident #15 had not had incontinence care all night as she was lying in urine and stool. STNA #111 revealed she was going to clean up Resident #15 and became so upset she went and got the current Administrator (who was then working as an administrative assistant). STNA #111 reported she and the Administrator went to Resident #15's room and once the Administrator saw the lack of incontinence care, the Administrator asked STNA #111 to take pictures of Resident #15 on her phone and send them to the Administrator. STNA #111 revealed she did take the pictures of Resident #15 without consent from the resident, her family or her guardian. She said the Administrator was in the room when she took the pictures. STNA #111 reported she sent the pictures to the Administrator by text and then about an hour later STNA #111 received a text back from the Administrator stating, I understand why took these pictures, but you can't have pictures of residents on your phone. STNA #111 revealed she immediately deleted the pictures from her phone. STNA #111 reported she heard the Administrator printed the pictures out and showed them in the morning meeting. STNA #111 reported she heard that Regional Nurse #175 was present and asked who took the pictures and the Administrator responded, an aide. She reported she was not aware of any investigation regarding the pictures, and she had not received (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 34 of 36 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 12/04/2023 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 0943 any discipline for taking the pictures. Level of Harm - Minimal harm or potential for actual harm Interview on 11/28/23 at 11:35 A.M. with the Administrator revealed the following staff attend morning meetings: Human Relations/Dietary Manger (HR/DM), Housekeeping/Laundry, Business Office Manager (BOM), Director of Nursing (DON), Maintenance Director (MD), Therapy Director (TD), Activities and the MDS Nurse. Residents Affected - Many Interview on 11/28/23 at 11:38 A.M. with non-clinical anonymous Staff #140 revealed they were present at the 10/31/23 morning meeting. They reported the room was full and the staff present who were not clinical included the MD, the BOM, the Activities Director and the HR/DM. They reported the Administrator (who was then working as an administrative assistant) showed pictures of a resident, but they could not remember if the name of the resident was provided. They reported the resident was wearing a top, and what appeared to be an undergarment brief. Staff #140 reported the bed covers were pulled down exposing the Resident's undergarment brief and her legs. Staff #140 revealed the resident's feet were covered with bed linen. They did not remember seeing any of the resident's belly or chest. They reported the Administrator was showing the pictures and there were two or three pictures. Staff #140 revealed they were uncomfortable with the presentation and thought the Administrator should have known better. Staff #140 felt the resident's privacy and rights were violated by the humiliating pictures. Staff #140 reported Regional Nurse #175 stopped the presentation and reported the facility and staff were not to take pictures of residents. Staff #140 revealed the facility policy on abuse (taking pictures of residents) was reviewed at the time. Interview on 11/28/23 at 12:08 P.M. with non-clinical anonymous Staff #176 revealed they were present at the morning meeting on 10/31/23. Staff #176 reported the Administrator (who was then working as an administrative assistant) was presenting pictures regarding poor resident incontinence care. They reported they did not look closely at the pictures because they were not clinical, and it was not part of her job. Staff #176 felt presenting pictures of the resident was not appropriate or acceptable. They reported it would emotionally upset them to have humiliating pictures of poor incontinence care taken without consent and presented to staff in a meeting. Staff #176 reported they did not think the resident was identified by the Administrator during the meeting. Interview on 11/28/23 at 2:38 P.M. with STNA #144 revealed Resident #15 was interviewable and could process to answer questions with yes and no responses. Interview on 11/28/23 at 2:40 P.M. with Resident #15 revealed she did not remember anyone taking pictures of her. This surveyor asked Resident #15 if someone took a picture of her from the waist down with only her depends on would she be emotionally upset and humiliated and Resident #15 responded, Yes, I would. Interview on 11/29/23 at 1:45 P.M. with the current Administrator revealed on 10/31/23 she had just walked through the door in the morning and STNA #111 came to her with a concern regarding resident care. The Administrator revealed she went with the STNA #111 to Resident #15's room and discovered poor incontinence care. The Administrator revealed she did not direct STNA #111 to take pictures of Resident #15 due to STNA #111 had already taken the pictures. The Administrator verified she did ask STNA #111 to send her the pictures of Resident #15 to her via a text message. The Administrator then verified she printed out the pictures she received from STNA #111 and presented them to the staff present at the morning meeting on 10/31/23. She reported she did not realize she was breaking any rules. The Administrator verified presenting the pictures was not acceptable behavior. She reported she had worked in other facilities when pictures of residents were presented in meetings, and she had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 35 of 36 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 12/04/2023 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 0943 an ick feeling about it. The Administrator verified she screwed up but there was no malicious intent. Level of Harm - Minimal harm or potential for actual harm Interview on 11/28/23 at 1:45 P.M. with Regional Nurse #175 revealed there was an incident where a photo of a resident in a brief was held up in a morning meeting on 10/31/23. She revealed no face was visible and she intervened and stopped the presentation of the picture. Regional Nurse #175 felt the purpose of the picture was for education and didn't view the issue as abuse. She reported there was immediate education for the staff in the morning meeting regarding the abuse policy and not taking pictures of residents. She reported then the entire facility received education on the abuse policy and not taking pictures of residents. Residents Affected - Many Interview on 11/29/23 at 2:15 P.M. with the Administrator revealed she had reached out to interim Director of Nursing (DON) #180 and the Registered Nurse (RN) #183 and neither one of them had completed the whole house training regarding staff not taking photos of residents as was directed by the Administrator. Review of facility documentation for training titled, In-Service Attendance Sign-in Sheet, dated 10/31/23 and timed for 3:00 P.M. regarding not taking pictures of residents revealed staff present for the morning meeting received training. The facility was not able to provide any documentation regarding all staff receiving the training. Review of the facility policy titled, Abuse, Neglect, and Exploitation of Residents and Misappropriation of Property, dated 05/18, revealed it was the goal of the facility that its residents will be protected from verbal, mental, sexual, or physical abuse, corporal punishment, mistreatment, neglect, involuntary seclusion, exploitation and misappropriation of property through development of operationalized policies and procedures. Residents will not be subjected to abuse, neglect, mistreatment, or misappropriation of property by anyone. Under Section F: Protecting Resident Privacy and Prohibiting Mental Abuse Related to Photographs and/or Recordings revealed taking or using photographs, videos or recordings of a resident or his/her private space in any manner that would demean or humiliate a resident is strictly prohibited. At no time are any photographic or recording devices permitted in any resident room or common areas. Examples include, but are not limited to, taking unauthorized photographs of a resident's room or furnishings (which may or may not include the resident), resident eating, or participating in an activity. This policy included employees, consultants, contractors, volunteers and other care givers. Staff must report to their supervisor any unauthorized (or suspected to be unauthorized) taking of photographs or videos as well the sharing of such recordings in any medium. Violations of this policy may result in disciplinary actions, including termination. Personal cell phones may only be used in designated employee breakrooms. Additionally, under Section II: Training, the policy revealed all on-going employees will be in-serviced on this policy and procedure at least annually and as needed. This deficiency represents an incidental finding investigated under Complaint Number OH00148026. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365461 If continuation sheet Page 36 of 36