Health inspection·July 23, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 07/12/21 at 10:57 A.M. interview with the Administrator confirmed any staff, resident or visitor could see Resident #311's nephrostomy collection bag and its' contents. The Administrator also revealed the bag should be placed in a privacy bag to ensure the resident's dignity related to the use of the device. Review of facility policy titled Quality of Life-Dignity, dated 08/2009 revealed demeaning practices and standards of care that compromise dignity were prohibited. Staff shall promote dignity and assist residents as needed by helping the resident to keep urinary, catheter bags covered. Event ID: Facility ID: 365485 If continuation sheet Page 2 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review the facility failed to notify the physician when Resident #19 experienced a significant weight loss. This affected one resident (#19) of 21 sampled residents. Findings include: Review of the medical record for Resident #19 revealed an admission date of 12/11/20 with diagnoses including chronic obstructive pulmonary disease, congestive heart failure, diabetes, dysphagia and adult failure to thrive. Review of a Minimum Data Set (MDS) 3.0 assessment, completed 12/23/20 revealed a Brief Interview for Mental Status score of 12, indicating moderately impaired cognitive status. The MDS revealed the resident was 69 inches tall, required supervision with eating and had experienced weight loss. Review of weight records revealed the resident weighed 149.8 pounds on admission on [DATE]. On 12/29/20 the resident weighed 133.6 pounds. A progress note by the dietician on 12/31/20 indicated the resident's weight had been stable for seven days. Meal intakes were 0-100%. The dietician recommended a liquid nutritional supplement (Ensure) twice daily. There was no evidence the physician was made aware of the recommendation. On 01/01/21 the resident weighed 133.8 pounds. On 01/02/21 the resident weighed 124.4 pounds. On 01/03/21 the resident weighed 122.2 pounds. This represented a 11.6 pound, 9% percent weight loss in two days. On 01/08/21 the resident weighed 118.2 pounds. On 01/18/21 the resident weighed 111 pounds. The next progress note by the dietician on 01/21/21 revealed the resident weighed 111 pounds and had experienced a 22.8 pound, 17% weight loss in 30 days. The resident's body mass index was 16.4 and reflected the resident was underweight for his age. Meal intakes were documented to be average at 26-50%. A mighty shake twice daily was recommended. There was no evidence the physician was notified of the significant weight loss between 12/31/20 and 01/18/21. On 07/19/21 at 2:45 P.M. interview with the Director of Nursing confirmed there was no evidence the physician was made aware of the recommendation for a nutritional supplement on 12/31/20 or that the physician was aware of the significant weight loss between 12/31/20 and 01/18/21. Review of the facility policy dated 2001 (revised May 2017) titled Change in a Resident's Condition or Status revealed the nurse would notify the resident's attending physician or physician on call when there had been a significant change in the resident's physical/emotional/mental condition or a need to alter the resident's medical treatment significantly. The policy revealed a significant change of condition was a major decline or improvement in the resident's status that will not normally (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 3 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 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 0580 resolve itself without intervention by staff. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 4 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 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 0583 Keep residents' personal and medical records private and confidential. 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, interview and facility policy review the facility failed to ensure residents were provided with personal privacy. This affected three residents (#5, #19 and #212) of three residents reviewed for privacy. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 12/11/20 with diagnoses including chronic obstructive pulmonary disease, congestive heart failure and adult failure to thrive. A Minimum Data Set (MDS) 3.0 assessment completed 04/08/21 indicated the resident had moderately impaired cognitive skills and required extensive assistance from two staff with transfers and walking. On 07/13/21 at 8:37 A.M. the surveyor was conducting an interview with Resident #19. Resident #19 was in bed and the room door was closed. At that time, Housekeeping Aide #13 opened the door to Resident #19's room and entered without knocking first. She proceeded into the bathroom to place soap and then left the room. She did not speak to the resident or the surveyor. On 07/13/21 at 8:37 A.M. interview with Resident #19 revealed staff do not always knock on closed doors before entering the room. On 07/13/21 at 8:50 A.M. interview with the Administrator confirmed Housekeeping Aide #13 should have knocked on the door and waited for permission to enter the room. Review of the facility policy titled Quality of Life-Dignity dated 2001 (Revised August 2009) revealed residents' private space and property shall be respected at all times. Staff would knock and request permission before entering residents' rooms. 2. Review of Resident #5's medical record revealed an original admission date of 09/20/16 with the latest readmission of 03/17/21 and admitting diagnoses of encephalopathy, malaise, contracture of right hand, intracerebral hemorrhage, cerebral vascular accident (CVA) with right sided hemiplegia, dysphagia, schizoaffective disorder, major depressive disorder, dementia with behavioral disturbances, anxiety disorder, hyperlipidemia, overactive bladder, aphasia and hypertension. Review of the plan of care, dated 12/11/19 revealed the resident had an activities of daily living (ADL) self-care performance deficit related to CVA, aphasia following CVA, hemiplegia and hemiparesis following CVA, depression, contractures, schizophrenia and dementia with behavioral disturbances. Interventions included the resident required extensive assist to total dependence from one to two staff for personal hygiene and/or grooming. Review of the resident's quarterly MDS 3.0 assessment, dated 03/31/21 revealed the resident had clear speech, sometimes understood others, sometimes made himself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of zero. Review of the mood and behavior section of the MDS revealed the resident displayed both verbal and physical behaviors directed towards others and rejected care. The resident required extensive assistance of two staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 5 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 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 0583 Level of Harm - Minimal harm or potential for actual harm with bed mobility, personal hygiene, dressing, was dependent on two staff for transfers, toilet use and was non-ambulatory. On 07/14/21 at 2:45 P.M. Resident #5 was observed positioned in his broda chair leaning to the right with his pants down exposing his buttocks to all passing in the hallway. Residents Affected - Few On 07/14/21 at 2:48 P.M. interview with State Tested Nursing Assistant (STNA) #81 verified the resident's buttocks were visible from the hallway to any resident, visitor or staff passing by the room. 3. Review of Resident #212's medical record revealed an admission date of 07/11/21 with the admitting diagnoses of acute respiratory failure, cardiogenic shock, chronic obstructive pulmonary disease, acute kidney failure, congestive heart failure, atrial fibrillation, diabetes mellitus, hypertension, obstructive sleep apnea and palliative care. Review of the admission assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident required extensive assistance with transfers and toilet use had no been assessed. The resident was continent of both bowel and bladder. Review of the plan of care, dated 07/14/21 revealed the resident had an activities of daily living (ADL) self-care performance deficit related to disease process. Interventions included he required limited assistance of one for transfers and extensive assistance of one for toileting use. On 07/19/21 at 10:35 A.M. observation of the resident revealed he was sitting on the bedside commode with his disposable brief down using the bathroom, yelling for someone to come into his room. The resident had no call light within reach and his buttocks were visible from the hallway by other residents, visitors and staff. On 07/19/21 at 10:40 A.M. interview with STNA #78 verified the resident's buttocks were visible from the hallway to any resident, visitor or staff passing by the room. Review of the facility policy titled Quality of Life, Dignity, dated 09/2009 revealed each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident would be assisted in maintaining and enhancing his or her self-esteem and self-worth. Staff shall promote, maintain and protect resident privacy including bodily privacy during assistance with personal care and during treatment procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 6 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 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 0636 Level of Harm - Minimal harm or potential for actual harm Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on observation, record review and interview the facility failed to comprehensively assess Resident #25's behavior patterns. This affected one resident (#25) of 21 sampled residents. Residents Affected - Few Findings include: Review of the medical record for Resident #25 revealed an admission date of 12/19/19 with diagnoses including schizoaffective disorder, dementia, major depressive disorder and anxiety disorder. The resident was receiving an antidepressant medication daily and was receiving Hospice services. Review of a Minimum Data Set (MDS) 3.0 assessment completed 04/20/21 revealed the resident had severely impaired cognition and no behaviors noted. On 07/13/21 at 8:30 A.M., 1:20 P.M. and 2:40 P.M., on 07/14/21 at 8:58 A.M. and 12:25 P.M. and on 07/15/21 at 8:38 A.M. and 10:05 A.M. Resident #25 was observed in bed with his head covered up with a blanket. On 07/15/21 at 10:45 A.M. interview with Registered Nurse (RN) #35 revealed Resident #25 refuses to get out of bed most of the time and always has his head under the covers. RN #35 revealed she did not know why he always kept his head covered up. On 07/15/21 at 11:05 A.M. interview with State Tested Nursing Assistant (STNA) #62 revealed Resident #25 does not like to get out of bed and keeps his head covered most of the time. The STNA revealed he did not know why the resident kept his head covered. Review of the medical record revealed it was silent to the resident refusing to get out of bed and keeping his head covered up most of the time. There was not a comprehensive assessment of the resident's behavior nor was it included on the most recent MDS assessment. On 07/15/21 at 11:10 A.M. interview with Social Service Director #43 confirmed Resident #25 does not like to get out of bed and also keeps his head covered with a blanket most of the time. She confirmed the medical record was silent to this and there was not a comprehensive assessment of this behavior. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 7 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident record review, interview interview and policy review this facility failed to ensure resident assessments were accurate to reflect each residents specific care needs. This affected one resident (#32) of 21 residents reviewed for assessments. Residents Affected - Few Findings include: Review of Resident #32's medical record revealed an admission date of 03/25/18 with diagnoses including protein-calorie malnutrition, dementia without behavioral disturbances and cognitive communication deficit. Review of Resident #32's compressive Minimum Data Assessment (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident with a moderately impaired cognition for decision making abilities. Resident #32 was noted to reject care. Resident #32 required supervision from one staff member for bed mobility and bathing and required limited assistance from one staff member for transfers, ambulation, dressing, toilet use and personal hygiene. Resident #32 was assessed with no impairment to bilateral upper or lower extremities and was noted to always be continue of bowel and bladder functions. Resident #32 was also assessed to receive a mechanically altered diet and to hold food in her cheeks or residual food in mouth after meals. Review of Resident #32's Oral Health Data Collection Tool dated 07/01/21 revealed the resident was edentulous and did not have dentures. On 07/14/21 at 9:07 A.M. observation of Resident #32 revealed the resident was sitting in her bed, completing independent activities. The resident was observed without any natural teeth or dentures. Continued observation of the resident's room revealed a blue denture cup located in resident's bathroom on the counter. A full set of upper and lower were observed inside the denture cup. On 07/14/21 at 9:10 A.M. interview with Resident #32 revealed she had all of her teeth pulled out years ago to allow room for her to wear dentures. Resident #32 revealed she had dentures but does not wear them because she lost weight and now they were loose and hurt her gums. Resident #32 revealed she keeps her dentures in a cup in the bathroom. When asked if she would like to see the facility dentist, the resident declined. On 07/14/21 at 10:28 A.M. interview with Minimum Data Set (MDS) Nurse #48 revealed when a resident assessment was completed, an interview with the resident was conducted and a brief observation of the resident's room was completed to help complete the assessments. When this assessment was completed, she noticed when the resident was talking that she did not have any dentures and a quick observation was made of the resident's room and bathroom and it was then assumed the resident did not have dentures. The assessment should have reflected the resident had dentures but did not wear them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 8 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on medical record review and staff interview the facility failed to refer a resident with a newly evident serious mental disorder to the appropriate State-designated authority for a Preadmission and Resident Review (PASRR) Level II assessment/determination upon change in status. This affected one resident (#7) of one resident reviewed for PASRR. Findings include: Review of the medical record for Resident #7 revealed an admission date of 09/24/19. Record review revealed PASRR results, effective 09/24/19 which indicated the resident had no indications of serious mental illness. Therefore, a PASRR Level II review was not warranted/completed. Further record review revealed the resident was admitted for an inpatient psychiatric stay from 03/25/20 to 04/09/20. A physician's progress note on 04/13/20 revealed the resident was recently back after a psychiatric hospitalization. Per staff he had been yelling, shouting and threatening staff and other residents. A diagnosis of schizophrenia with antipsychotic use was noted in the progress notes. A diagnosis of schizoaffective disorder was added to the diagnosis list in the medical record on 05/11/20. Review of a psychiatric progress note dated 06/14/21 revealed the resident continued to be evaluated by psychiatric services and was receiving antipsychotic medication for schizoaffective disorder. There was no evidence the resident was referred to the appropriate State-designated authority for a PASRR Level II resident review once the resident had the inpatient psychiatric stay from 03/25/20 to 04/09/20. As of 07/13/21, a Level II resident review had not been completed after the new mental disorder was identified. Interview with Social Service Director #43 on 07/13/21 at 11:19 A.M. confirmed the initial PASRR completed on admission in 2019 did not identify any serious mental illness. She confirmed the resident had a new diagnosis of schizoaffective disorder added on 05/11/20 after an inpatient psychiatric stay. Interview with Business Office Manager #37 on 07/14/21 at 10:28 A.M. confirmed the resident was not referred to the appropriate State-designated authority for a Level II resident review once the resident had an inpatient psychiatric stay from 03/25/20 to 04/09/20 with a new mental illness diagnosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 9 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on observation, medical record review and staff interview the facility failed to ensure Resident #59's baseline plan of care addressed the resident's bruising and skin tears. This affected one resident (#59) of 21 sampled residents who care plans were reviewed. Findings include: Review of Resident #59's medical record revealed an original admission date of 06/16/21 with the latest readmission of 07/11/21. The resident had diagnoses including rhabdomyolysis, left hip pressure ulcer, pressure ulcer of sacral region, abdominal aortic aneurysm, presence of artificial hip joint bilaterally, dysphagia and fall. Review of the resident's readmission assessment, dated 07/11/21 revealed the resident was readmitted to the facility with a pressure ulcer to his left hip measuring 18.0 centimeters (cm) in length by 9.0 cm width with no stage specified, a pressure ulcer to right heel measuring 1.0 cm by 1.5 cm with no stage specified. The resident also had a scab to the back of his right hand measuring 1.0 cm by 0.7 cm and the back of his left hand measuring 1.7 cm by 0.2 cm. The resident had bruising to the back of his left and right hand. The assessment indicated the resident had his own teeth with some being caried and/or broken. The resident's buccal cavity was described as being pink. Review of the resident's five day MDS 3.0 assessment, dated 06/23/21 revealed the resident had clear speech, usually understood others, made himself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of zero. The resident required extensive assistance of two staff for bed mobility, transfers, toilet use and was non-ambulatory. The assessment indicated the resident had skin tears. The resident had no plan of care to address bruising or skin tears. The resident's baseline plan of care failed to address the resident's bruising or skin tears. Review of the resident's monthly physician's orders for July 2021 failed to identify any orders addressing the resident's skin tears or bruising. On 07/12/21 at 10:55 A.M. observation of the resident revealed he had dark purple bruise on right hand/arm and a scabbed area on his right index finger. The resident also had multiple areas of bruising in various stages of healing on his left hand/arm with a scabbed area to his left hand. On 07/16/21 at 4:00 P.M. interview with the Director of Nursing (DON) verified resident's baseline plan of care failed to address the bruising or skin tears. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 10 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 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 - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #7 revealed an admission date of 09/24/19. Review of the MDS 3.0 assessment, dated 06/30/21 revealed the resident had moderate difficulty with hearing and had no hearing aids. The MDS also revealed the resident had moderately impaired vision and had no glasses. Review of a psychiatric progress note on 06/14/21 revealed the clinician documented the resident was seen for psychiatric medication management. The resident was seen for anxiety and mood swings. The clinician documented the resident was extremely hard of hearing making the exam difficult. On 07/14/21 at 9:30 A.M. the surveyor attempted to speak to the resident. The resident was noted to be extremely hard of hearing. On 07/15/21 at 10:00 A.M. interview with Registered Nurse #35 confirmed the resident had trouble hearing and seeing. Review of a consultation report revealed Resident #7 was seen by an optometrist on 03/31/21. The consult report revealed the resident had cataracts bilaterally that were visually significant. The note indicated to please schedule the resident for cataract evaluation with an ophthalmologist of facility choice. There was no evidence the facility had made any arrangements for the resident to see an ophthalmologist. Review of a consultation report revealed Resident #7 was seen by a nurse practitioner on 04/14/21 for an ear care exam. The note revealed the resident had severe hearing difficulty and used a hand held hearing amplifier. Resident was interested in audiology services and wanted hearing aids. The resident's ears were cleared of cerumen bilaterally. An audiology referral was recommended. There was no evidence the facility had made any arrangements for the resident to see an audiologist. Review of the resident's plan of care revealed no comprehensive and individualized plan of care had been developed for Resident #7 related to vision or hearing. Interview with Social Service Director #43 on 07/15/21 at 11:10 A.M. confirmed the resident's plan of care did not address any vision or hearing issues for Resident #7. 4. Review of the medical record for Resident #25 revealed an admission date of 12/19/19 and diagnoses including schizoaffective disorder, dementia, major depressive disorder, and anxiety disorder. The resident was receiving an antidepressant medication daily and was receiving Hospice services. Review of a MDS 3.0 assessment, dated 04/20/21 revealed the resident had severely impaired cognition and no behaviors. Observations on 07/13/21 at 8:30 A.M., 1:20 P.M. and 2:40 P.M., on 07/14/21 at 8:58 A.M. and 12:25 P.M. and on 07/15/21 at 8:38 A.M. and 10:05 A.M. revealed Resident #25 was in bed with his head (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 11 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 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 covered up with a blanket. Level of Harm - Minimal harm or potential for actual harm Interview with Registered Nurse #35 on 07/15/21 at 10:45 A.M. revealed Resident #25 refused to get out of bed most of the time and always had his head under the covers. She stated she did not know why he always kept his head covered up. Residents Affected - Some Interview with State Tested Nursing Assistant #62 on 07/15/21 at 11:05 A.M. revealed Resident #25 does not like to get out of bed and keeps his head covered most of the time. He stated he did not know why the resident kept his head covered. Review of the plan of care revealed it was silent to the resident refusing to get out of bed and keeping his head covered up most of the time. Interview with Social Service Director #43 on 07/15/21 at 11:10 A.M. confirmed Resident #25's plan of care was silent to the resident refusing to get out of bed and keeping his head covered up most of the time. Based on observation, medical record review and interview the facility failed ensure comprehensive and individualized care plans were developed for all residents. This affected four residents (#7, #25, #32 and #47) of 21 sampled residents who care plans were reviewed. Findings include: 1. Review of Resident #47's medical record revealed a re-admission to the facility on [DATE] and latest re-admission of 05/09/21. The resident had diagnoses including encounter for orthopedic aftercare, dysphagia, anxiety disorder, pressure induced deep tissue damage of right heel, anemia, urine retention, diabetes mellitus, encephalopathy, peripheral vascular disease, severe morbid obesity, repeated fall, atrial fibrillation and hypertension. Review of the resident's admission assessment dated [DATE] indicated the resident was incontinent of urine one or more times a shift and incontinent of bowel. Review of the resident's five day Minimum Data Set (MDS) 3.0 assessment, dated 05/16/21 revealed the resident had clear speech, usually understood others, made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of nine. Review of the mood and behavior section of the MDS revealed the resident had verbal behaviors directed towards others, behaviors not directed towards others and rejected care. The resident required extensive assistance of two persons for bed mobility and toilet use. The resident was dependent on two staff for transfers. The assessment indicated the resident had an indwelling urinary catheter and was frequently incontinent of bowel. Review of the resident's monthly physician's orders for July 2021 revealed an order, dated 05/09/21 for Melatonin (medication used to to treat insomnia) 3 milligrams (mg) by mouth daily at bedtime for insomnia. Review of the resident's plan of care failed to identify a comprehensive plan of care addressing the resident's bowel incontinence and insomnia. On 07/15/21 at 4:00 P.M. interview with the Director of Nursing (DON) verified the facility had not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 12 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 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 developed a comprehensive plan of care addressing the resident's bowel incontinence and insomnia. Level of Harm - Minimal harm or potential for actual harm 2. Review of Resident #32's medical record revealed an admission date of 03/25/18 with diagnoses including protein-calorie malnutrition, dementia without behavioral disturbances and cognitive communication deficit. Residents Affected - Some Review of Resident #32's compressive MDS 3.0 assessment, dated 04/29/21 revealed a BIMS score of 13 indicating the resident had moderately impaired cognition for decision making abilities. Resident #32 was assessed to reject care. Resident #32 required supervision from one staff member for bed mobility and bathing and required limited assistance from one staff member for transfers, ambulation, dressing, toilet use and personal hygiene. Resident #32 was assessed with no impairment to bilateral upper or lower extremities and was noted to always be continue of bowel and bladder functions. Resident #32 was noted to receive a mechanically altered diet and to hold food in her cheeks or residual food in mouth after meals. Review of Resident #32's Oral Health Data Collection Tool, dated 07/01/21 revealed the resident was edentulous and did not have dentures. Review of Resident #32's plan of care revealed no plan related to the resident being edentulous and refusing or not being able to wear her dentures. On 07/14/21 at 9:07 A.M. Resident #32 was observed sitting in her bed, completing independent activities. Resident was observed to not have any natural teeth or dentures. Continued observation of resident's room revealed a blue denture cup located in resident's bathroom on the counter. A full set of upper and lower dentures were observed in the cup. On 07/14/21 at 9:10 A.M. interview with Resident #32 revealed she had all of her teeth pulled out years ago to allow room for her to wear dentures. Resident #32 revealed she has dentures but does not wear them because she lost weight and now they were loose and hurt her gums. Resident #32 revealed she keeps her dentures in a cup in the bathroom. When asked if she would like to see the facility dentist, the resident declined. On 07/14/21 at 10:28 A.M. interview with Minimum Data Set (MDS) Nurse #48 confirmed if a resident was edentulous and/or had dentures, that resident would need to have a plan of care in place to reflect this. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 13 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility to revise Resident #47's plan of care to reflect the resident's incontinence of bladder. This affected one resident (#47) of 21 sampled residents whose care plans were reviewed. Findings include: Review of Resident #47's medical record revealed a re-admission to the facility on [DATE] with a latest re-admission of 05/09/21. The resident had diagnoses including encounter for orthopedic aftercare, dysphagia, anxiety disorder, pressure induced deep tissue damage of right heel, anemia, urine retention, diabetes mellitus, encephalopathy, peripheral vascular disease, severe morbid obesity, repeated fall, atrial fibrillation and hypertension. Review of the resident's admission assessment, dated 03/31/21 indicated the resident was incontinent of urine one or more times a shift and incontinent of bowel. Review of the plan of care, dated 04/27/21 revealed the resident was incontinent of bladder. Interventions included notify nursing if resident was incontinent during activities, disposable briefs for comfort and dignity, clean peri-area with each incontinence episode, encourage fluids during the day to promote prompted voiding responses, ensure resident has unobstructed path to bathroom, monitor and document intake and output as per facility policy, monitor/document for signs/symptoms of urinary tract infection and toilet upon rising, before and after meals and at bed time. Review of the resident's five day Minimum Data Set (MDS) 3.0 assessment, dated 05/16/21 revealed the resident had clear speech, usually understood others, made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of nine. Review of the mood and behavior section of the MDS revealed the resident had verbal behaviors directed towards others, behaviors not directed towards others and rejected care. The resident required extensive assistance of two persons for bed mobility and toilet use. The resident was dependent on two staff for transfers. The assessment indicated the resident had an indwelling urinary catheter and was frequently incontinent of bowel. On 07/15/21 at 4:00 P.M. interview with the Director of Nursing (DON) verified the resident's plan of care had not been updated to reflect the resident's incontinence of bladder once the urinary catheter had been removed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 14 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview the facility failed to ensure Resident #5 and Resident #47, who required staff assistance for activities of daily living received timely and adequate personal care/shaving assistance to maintain good hygiene. This affected two residents (#5 and #47) of five residents reviewed for activities of daily living (ADL) care. Residents Affected - Few Findings include: 1. Review of Resident #5's medical record revealed an original admission date of 09/20/16 with the latest readmission of 03/17/21 and admitting diagnoses of encephalopathy, malaise, contracture of right hand, intracerebral hemorrhage, cerebral vascular accident (CVA) with right sided hemiplegia, dysphagia, schizoaffective disorder, major depressive disorder, dementia with behavioral disturbances, anxiety disorder, hyperlipidemia, overactive bladder, aphasia and hypertension. Review of the plan of care, dated 12/11/19 revealed the resident had an activities of daily living (ADL) self-care performance deficit related to CVA, aphasia following CVA, hemiplegia and hemiparesis following CVA, depression, contractures, schizophrenia and dementia with behavioral disturbances. Interventions included the resident required extensive assist to total dependence of one to two staff for personal hygiene and/or grooming. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/31/21 revealed the resident had clear speech, sometimes understood others, sometimes made himself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of zero. The resident required extensive assistance of two staff for bed mobility, personal hygiene, dressing, was dependent on two staff for transfers, toilet use and was non-ambulatory. On 07/13/21 at 3:58 P.M. observation of the resident revealed he had several days of facial hair growth. On 07/14/21 at 10:36 A.M. observation of the resident revealed his long facial hair remained and his hair was unkempt. On 07/15/21 at 2:36 P.M. observation of the resident revealed he remained unshaved of the long facial hair. On 07/15/21 at 3:48 P.M. interview with the Director of Nursing (DON) revealed all residents should be shaved upon request or at the minimum of with showers. On 0715/21 at 4:00 P.M. interview with the DON verified the resident was unshaven. There was no evidence provided to indicated the resident refused personal care or shaving. 2. Review of Resident #47's medical record revealed a re-admission to the facility on [DATE] with a latest re-admission of 05/09/21. The resident had diagnoses including encounter for orthopedic aftercare, dysphagia, anxiety disorder, pressure induced deep tissue damage of right heel, anemia, urine retention, diabetes mellitus, encephalopathy, peripheral vascular disease, severe morbid obesity, repeated fall, atrial fibrillation and hypertension. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 15 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the plan of care, dated 04/14/21 revealed the resident had an ADL self-care performance deficit related to disease process. The resident required staff assist to complete ADL tasks. Fluctuations were expected related to diagnosis. The care plan revealed the resident was at risk for decline in physical function, fatigue, impaired balance, right hip fracture with repair and may refuse care on occasion. Interventions included to avoid scrubbing and pat dry sensitive skin, check nail length and trim and clean on bath day and as needed. The care plan revealed the resident was dependent on two staff for mobility, allow sufficient time for dressing and undressing and assist the resident to choose simple comfortable clothing that enhanced the resident's ability to dress self. The care plan also reflected the resident was dependent on staff for dressing; encourage resident to utilize the call light to call for assistance as needed, encourage resident to discuss feelings about self-care deficit as needed, and encourage resident to participate to the fullest extent possible with each interaction. The care plan revealed the resident was dependent on staff for personal hygiene/grooming, dependent for toileting and dependent on two staff for transfers with mechanical lift. Review of the resident's five day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, usually understood others, made himself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of nine. The assessment revealed the resident required extensive assistance of two persons for personal hygiene. On 07/12/21 at 3:35 P.M. observation of the resident revealed he had various links of facial hair growth. On 07/12/21 at 4:02 P.M. interview with the resident's family revealed the resident had almost a full beard and never had one before. On 07/14/21 at 8:43 A.M. observation of the resident revealed he remained unshaved. On 07/15/21 at 3:10 P.M. observation of the resident revealed he remained unshaved. On 07/15/21 at 4:00 P.M. interview with the DON verified the resident had not been shaved. The DON was unable to provide evidence the resident had refused care or refused to be shaved. This deficiency substantiates Complaint Number OH00123985. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 16 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record for Resident #11 revealed an admission date of 12/04/20 with diagnoses including dementia, anxiety disorder and depressive disorder. Residents Affected - Few Review of an activity assessment, dated 12/07/20 revealed the resident's faith was rated on a scale of one to ten (with one being not religious and ten being very religious) as being a ten. The assessment indicated it was very important to the resident to be around animals such as pets, to do her favorite activities (not noted what those were), go outside for fresh air when the weather was good, and participate in religious services. Current interests marked on the assessment were music, religious activities, going outdoors, watching TV and movies and talking/conversing. Review of the MDS 3.0 assessment, dated 07/02/21 indicated the resident had a BIMS score of two, indicating severe cognitive impairment. The MDS further revealed the resident was totally dependent on staff for transfers and locomotion and had physical and verbal behaviors. On 07/12/21 at 10:00 A.M. Resident #11 was observed sitting in a wheelchair in the lounge by the nurse's station. The resident had her legs down through a space in the wheelchair between the seat and the foot rest (an area her legs were not meant to be). The resident was yelling out repeatedly. A nurse was sitting at the nurses's station, but did not respond to the resident. No activities were observed for the resident. On 07/13/21 at 7:59 A.M., 8:04 A.M., 1:20 P.M. and 2:50 P.M. Resident #11 was observed sitting in a wheelchair in the lounge. The TV was on but the resident did not appear to be watching. No other activities were observed for the resident during those times. On 07/14/21 at 8:59 A.M. the resident was sitting in a wheelchair in the lounge. The TV was off. No other activities were observed. On 07/14/21 at 10:44 A.M. Resident #11 was observed sitting in the wheelchair in the lounge. The resident kept yelling out and repeating, where am I, I don't know where I am at. There were no activities for the resident. The TV had a picture on the screen that said 70's soul but there was no music or sound playing. There was no staff in the lounge. On 07/14/21 at 10:49 A.M. the resident was taken to the dining room where a group of residents were playing cards at a table. The resident was placed near the table but did not participate in the activity. Resident #11 asked where she was. The Activity Director told the resident she was in the dining room where a card game was going on. On 07/14/21 at 11:03 A.M. the resident remained in the dining room where the card game continued. (she was not participating). The resident was sitting more quietly and said she was ok. On 07/15/21 at 10:05 A.M. and 11:02 A.M. Resident #11 was observed sitting in a wheelchair in the lounge. The TV was off. There were no activities for the resident. Review of the activity calendar for July 2021 revealed there were 3-4 scheduled activities per day. However, most of the activities that were scheduled were designed for residents who were cognitively intact such as bingo, card games, trivia contest, and Yahtzee. Church service was noted on the calendar every Sunday. Review of activity participation records for Resident #11 for the past 30 days revealed, for group activities, not applicable or not available was frequently documented. (27 times). Church was marked as refused on 07/18/21. On 07/04/21 and 07/11/21 it was not indicated if the resident was provided (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 17 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm the opportunity for church service. For individual activities, lounge area was documented 16 times. For one to one activities, not applicable was documented 23 times. Interview with the Director of Nursing on 07/19/21 at 3:00 P.M. revealed Resident #11 frequently had anxiety about food and calls out for her children. Residents Affected - Few Review of the current plan of care for Resident #11 revealed the resident repeatedly yells out where am I or I don't know where I am. Interventions included to provide a program of activities that was of interest and accommodated the resident's status. Interview with the Activity Director (AD #71) on 07/19/21 at 3:00 P.M. revealed she had only worked at the facility for four weeks. She stated she was the only activity staff person to provide activities for the facility. She stated Resident #11 spends the majority of her time in the lounge listening to the TV or socializing with other residents (the resident was never observed to socialize with any other resident during observations). She confirmed the facility did not have any organized group activities for residents with dementia. She stated only one to one activities were provided for residents with dementia. On 07/20/21 at 9:20 A.M. during a follow up interview, the Activity Director revealed the individual activities of TV or movie documented for Resident #11 were her being in the lounge. She stated the resident was passive for any group activities she would attend as she could not participate in scheduled Bingo, card games, etc. due to her cognition. Based on observation, record review and interview the facility failed to develop and implement individualized and meaningful activities to meet the total care needs of Resident #11 and Resident #53. This affected two residents (#11 and #53) of three residents reviewed for activities. Findings include: 1. Review of Resident #53's medical record revealed an admission date of 06/06/21 with diagnosis including adult failure to thrive, local infection of the skin and subcutaneous tissue, pressure ulcer of the sacral region, deep tissue damage of the left heel and pressure ulcer of the right heel. Review of Resident #53's Activity Assessment/Evaluation, dated 06/07/21 revealed the resident's current interests included arts/crafts, sports, music, spiritual/religious activities, walking/wheeling outdoors, watching television, watching movies, talking/conversing, listening to the radio, and groups and organizations. Resident #53 did not take naps throughout the day. Review of the plan of care, dated 06/07/21 revealed Resident #53 had impaired cognitive and thought processes related to difficulty making decisions, and long/short term memory loss. The resident needed support with all decision making. Resident #53 had a plan of care, dated 06/07/21 which indicated the resident had a potential for psychosocial well being problem related to ineffective coping, recent admission, memory deficits, depression and insomnia diagnoses. Interventions included to allow resident time to answer questions and to verbalize feeling, perceptions and fears. Encourage participation from resident who depends on others to make own decisions and increase communication. Resident #53 also had a plan of care, dated 06/07/21 related to the use of antidepressant medication related to depression and poor nutrition. Interventions included to educate resident and family support about risk and benefits and the side effect of the medications and to monitor/document/report (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 18 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ongoing sign and symptoms of depression such as fatigue, increased sleep, lethargy and not enjoying usual activities. Review of Resident #53's compressive Minimum Data Set (MDS) 3.0 assessment, dated 06/13/21 revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating the resident had moderately impaired cognition for daily decision making abilities. Resident #53 required extensive assistance from two staff members for bed mobility and transfers and extensive assistance from one staff member for dressing, eating and toilet use. Resident #53 was assessed without impairments to bilateral upper or lower extremities and required the use of a wheelchair for mobility. Resident #53 had an indwelling catheter for bladder elimination and was frequently incontinent of bowel function. Resident #53 had one unstageable wound which was present upon admission and one deep tissue injury which was present upon admission. Pressure prevention interventions included a pressure reducing device to residents chair and bed, nutrition and/or hydration interventions to manage skin problems, and pressure ulcer injury care. Review of Resident #53's progress notes revealed no activity notes were completed for the resident to detail activities planned or provided to the resident or the resident's response to activities. On 07/12/21, 07/13/21, 07/14/21, 07/15/21, 07/19/21 and 07/20/21 observations made of Resident #53 between 10:00 A.M. and 4:00 P.M. revealed the resident was observed during all observations laying supine in bed, resting quietly with his eyes closed, with the light and television turned off and his window blinds partially opened. No staff were observed completing one on one activities or interacting with the resident during the observations made. In addition, no independent activities were observed in the resident's room. On 07/19/21 at 2:00 P.M. interview with Activity Director (AD) #71 revealed she was currently the only activity staff member at the facility. Activity Director #71 revealed she does chart on each resident when they were admitted and with quarterly assessments. AD #71 revealed the last few months she had not been to complete activity charting. AD #71 revealed when she was able to document, she used different code numbers. Review of Resident #53's coding with AD #71 revealed most days activity participation was coded with an 87 which indicated non-applicable. Per AD #71, when this was marked it was not because the resident refused to participate in the activity, but because she was not able to see the resident that day to complete a activity or resident's were not provided an activity for that day. Activity Director #71 also revealed that due to her being the only activity staff member, if she identified a resident who was awake versus one who was asleep, she would direct her attention towards the resident who was awake. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 19 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 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, record review and interview the facility failed to assess and monitor Resident #59 related to bruising and skin tears. This affected one resident (#59) of two residents reviewed for skin conditions. Residents Affected - Few Findings include: Review of Resident #59's medical record revealed an original admission date of 06/16/21 with the latest readmission of 07/11/21 and diagnoses including rhabdomyolysis, left hip pressure ulcer, pressure ulcer of sacral region, abdominal aortic aneurysm, presence of artificial hip joint bilaterally, dysphagia and fall. Review of the resident's five day Minimum Data Set (MDS) 3.0 assessment, dated 06/23/21 revealed the resident had clear speech, usually understood others, made himself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of zero. The resident required extensive assistance of two staff for bed mobility, transfers, toilet use and was non-ambulatory. The assessment indicated the resident had skin tears. Review of the resident's readmission assessment, dated 07/11/21 revealed the resident was readmitted to the facility with a pressure ulcer to his left hip measuring 18.0 centimeters (cm in length by 9.0 cm width with no stage specified, a pressure ulcer to right heel measuring 1.0 cm by 1.5 cm with no stage specified. The resident had a scab to the back of his right hand measuring 1.0 cm by 0.7 cm and the back of his left hand measuring 1.7 cm by 0.2 cm. The resident also had bruising to the back of his left and right hand. The assessment indicated the resident had his own teeth with some being caried and/or broken. The resident's buccal cavity was described as being pink. Record review revealed the resident had no plan of care to address the bruising or skin tears identified. The resident's baseline plan of care also failed to address the resident's bruising or skin tears. Review of the resident's monthly physician's orders for July 2021 failed to identify any orders addressing the resident's skin tears or bruising. On 07/12/21 at 10:55 A.M. observation of the resident revealed he had dark purple bruise on right hand/arm and a scabbed area on his right index finger. The resident also had multiple areas of bruising in various stages of healing on his left hand/arm with a scabbed area to his left hand. On 07/16/21 at 4:00 P.M. interview with the Director of Nursing (DON) verified the lack of assessment and monitoring for the skin tears and bruising to the resident's arms. This deficiency substantiates Complaint Number OH00123985. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 20 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review and staff interview the facility failed to ensure Resident #7 received proper treatment to maintain vision and hearing abilities. This affected one resident (#7) of one resident reviewed for communication. Residents Affected - Few Findings include: Review of the medical record for Resident #7 revealed an admission date of 09/24/19. Review of a psychiatric progress note, dated 06/14/21 revealed the clinician documented the resident was seen for psychiatric medication management. The resident was seen for anxiety and mood swings. The clinician documented the resident was extremely hard of hearing making the exam difficult. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 06/30/21 revealed the resident had moderate difficulty with hearing and had no hearing aids. The MDS also revealed the resident had moderately impaired vision and had no glasses On 07/14/21 at 9:30 A.M. the surveyor attempted to speak to the resident. The resident was noted to be extremely hard of hearing. Interview with Registered Nurse #35 on 07/15/21 at 10:00 A.M. confirmed the resident had trouble hearing and seeing. Review of a consultation report revealed Resident #7 was seen by an optometrist on 03/31/21. The consult report revealed the resident had cataracts bilaterally that were visually significant. The note indicated to please schedule the resident for cataract evaluation with an ophthalmologist of facility choice. There was no evidence the facility had made any arrangements for the resident to see an ophthalmologist. Review of a consultation report revealed Resident #7 was seen by a nurse practitioner on 04/14/21 for an ear care exam. The note revealed the resident had severe hearing difficulty and used a hand held hearing amplifier. Resident was interested in audiology services and wanted hearing aids. The resident's ears were cleared of cerumen bilaterally. An audiology referral was recommended. There was no evidence the facility had made any arrangements for the resident to see an audiologist. Interview with Social Service Director #43 on 07/15/21 at 9:30 A.M. confirmed there had been no follow up by the facility to arrange for the resident to see an ophthalmologist or an audiologist. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 21 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to adequately and comprehensively assess pressure ulcers for Resident #47 and Resident #59 upon admission and/or re-admission to the facility. This affected two residents (#47 and #59) of four residents reviewed for pressure ulcers. Residents Affected - Few Findings include: 1. Review of Resident #47's medical record revealed the resident was re-admitted to the facility on [DATE] and had a latest re-admission of 05/09/21 with diagnoses including encounter for orthopedic aftercare, dysphagia, anxiety disorder, pressure induced deep tissue damage of right heel, anemia, urine retention, diabetes mellitus, encephalopathy, peripheral vascular disease, severe morbid obesity, repeated fall, atrial fibrillation and hypertension. Review of the resident's admission assessment, dated 03/31/21 revealed the resident was admitted to the facility with a SDTI to the right heel measuring 7.8 centimeters (cm) in length by 8.0 cm width. The assessment failed to contain any additional description of the wound. The assessment also noted the resident was incontinent of urine one or more times a shift and incontinent of bowel. Review of the plan of care, dated 04/14/21 revealed Resident #47 had a skin injury/potential for skin injury of the right posterior lower leg related to chronic edema, diabetes, morbid obesity and SDTI to the right heel. Interventions included weekly skin assessment as ordered and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observation. Review of the resident's acute care Discharge summary, dated [DATE] revealed the resident was admitted to the hospital and found to have an open wound to the right heel that was treated with antibiotics. The wound was evaluated by podiatry with recommendations for local wound care. Review of the readmission assessment, dated 05/09/21 revealed the resident was readmitted with a SDTI to his right heel measuring 3.5 cm by 6.0 cm by 0.1 cm with no additional description of the wound. Review of the resident's five day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, usually understood others, made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of nine. The resident required extensive assistance of two persons for bed mobility and toilet use. The resident was dependent on two staff for transfers. The assessment indicated the resident had an indwelling urinary catheter and was frequently incontinent of bowel. The resident was assessed as being at risk for skin breakdown and had one deep tissue injury that was not present on admission. The facility implemented pressure reducing device to bed/chair, nutrition or hydration intervention, pressure ulcer/injury care, surgical wound care and application of dressings to feet. Review of the resident's Braden scale assessment, dated 07/07/21 revealed a score of 13 indicating the resident was at moderate risk for skin breakdown. On 07/14/21 at 3:15 P.M. observation of Registered Nurse (RN) #50 and Licensed Practical Nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 22 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (LPN) #64 provide the physician ordered treatment to the resident's right heal revealed the nurses entered the room and the required supplies were set-up on a barrier on the resident's bedside table. The nurses washed their hands and applied gloves. The RN removed the heel protector and help the resident's right leg up. The LPN removed the soiled dressing. A dried blood soaked 4X4 remained adhered to the wound. The LPN soaked the 4X4 off using normal saline and washed her hands, donned gloves. She then measured the wound at 3.5 cm by 4.0 cm by 0.2 cm. She then cleansed the wound with wound cleanser, applied a NS soaked 4X4 to the wound, covered the wound with an ABD pad and wrapped it in Kerlix. On 07/15/21 at 1:56 P.M. interview with Assistant Director of Nursing (ADON) #38 verified the readmission assessments, dated 03/31/21 and 05/09/21 lacked a comprehensive assessment, including a description of the SDTI to the resident's right heel. Review of the facility policy titled Pressure Ulcer/Skin Breakdown, dated 07/2017 revealed the nursing staff and the attending physician would assess and document an individual's significant risk factors for developing pressure ulcers. In addition the nurse shall describe and document/report the following, a full assessment of the pressure sore including the location, stage, width, depth, exudates or necrotic tissue. 2. Review of Resident #59's medical record revealed an original admission date of 06/16/21 with the latest readmission of 07/11/21 and diagnoses including rhabdomyolysis, left hip pressure ulcer, pressure ulcer of sacral region, abdominal aortic aneurysm, presence of artificial hip joint bilaterally, dysphagia and fall. Review of the resident's admission assessment, dated 06/16/21 revealed the resident was admitted to the facility with an unstageable pressure ulcer to his left hip measuring 12.5 cm by 7.5 cm and a pressure ulcer to the coccyx measuring 3.0 cm by 0.5 cm by 0.2 cm. There were no additional descriptions of either ulcer no staging of the pressure ulcer to the resident's coccyx. Review of the plan of care, dated 06/17/21 revealed Resident #59 had actual skin integrity problem related to fragile skin, history of falls and decreased mobility and unstageable pressure ulcer to left hip. Interventions included to weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Review of the resident's five day MDS 3.0 assessment, dated 06/23/21 revealed the resident had clear speech, usually understood others, made himself understood and had a severe cognitive deficit as indicated by a BIMS score of zero. The resident required extensive assistance of two staff for bed mobility, transfers, toilet use and was non-ambulatory. The assessment indicated the resident was always incontinent of both bowel and bladder. The assessment indicated the resident was assessed as big at risk for skin breakdown, had one Stage II pressure ulcer and one unstageable pressure ulcer present on admission. The facility implemented a pressure reducing device in bed, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care, application of non-surgical dressings and application of ointments/medications. Review of the resident's Braden Scale dated 06/23/21 revealed a score of 11 indicating the resident was at high risk for skin breakdown. Review of the resident's readmission assessment, dated 07/11/21 revealed the resident was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 23 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm re-admitted to the facility with a pressure ulcer to his left hip measuring 18.0 cm by 9.0 cm with no stage specified and a pressure ulcer to right heel measuring 1.0 cm by 1.5 cm with no stage specified or description of the wound. On 07/15/21 at 8:55 A.M. observation revealed Resident #59 had a wound vacuum to the right hip. Residents Affected - Few On 07/16/21 at 4:00 P.M. interview with the DON verified the admission assessment and re-assessment for Resident #59 lacked staging and/or a comprehensive description of the resident's pressure ulcers. Review of the facility policy titled Pressure Ulcer/Skin Breakdown, dated 07/2017 revealed the nursing staff and the attending physician would assess and document an individual's significant risk factors for developing pressure ulcers. In addition the nurse shall describe and document/report the following, a full assessment of the pressure sore including the location, stage, width, depth, exudates or necrotic tissue. This deficiency substantiates Complaint Number OH00123985. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 24 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure the resident environment remained free of accident hazards related to smoking. This affected one resident (#34) of two residents reviewed for accidents. Findings include: The facility identified two residents who smoked cigarettes, Residents #34 and #162. The facility identified smoking times for residents were at 7:00 A.M., 11:00 A.M., 3:00 P.M., 7:00 P.M. and 9:00 P.M. each day. Review of the medical record for Resident #34 revealed an admission date of 11/08/20 with diagnoses including diabetes, peripheral vascular disease and right above the knee amputation. Review of a plan of care, revised on 03/18/21 revealed Resident #34 was a smoker. The goal was for the resident not to sustain harm or injury related to unsafe smoking practices. Interventions included to assess for changes in mental status that would effect his ability to smoke safely, educate resident on smoking policies, monitor for burn holes in clothing, burn marks, etc., monitor for instances of non compliance and smoking assessment quarterly. A Minimum Data Set (MDS) 3.0 assessment completed 05/08/21 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognitive status. The MDS revealed the resident required supervision only with transfers and locomotion. Review of a smoking safety evaluation, dated 07/08/21 revealed Resident #34 was safe to smoke unsupervised (no staff supervision). The evaluation revealed the resident he did not require a smoking apron and the facility stored smoking materials. On 07/12/21 at 12:03 P.M. Resident #34 was observed to be outside smoking a cigarette without staff supervision. The resident had three cigarette butts laying on the thigh area of his fleece pajama pants. He was not observed to use an ash tray to put cigarette ashes in (flipped on asphalt driveway). He then put out the cigarette he was smoking and placed all four cigarette butts back in the cigarette box holding his unsmoked cigarettes. Resident #34 stated, at that time, he places his smoked cigarettes back in the box and takes it back into the facility. He stated he was supposed to give his cigarettes and lighter to the nurse when he was done smoking. However, Resident #34 was observed to take the box containing the cigarette butts and his lighter to his room and shut the door. There was one tall receptacle for cigarette butts noted in the smoking area. There were no ash trays noted and no metal container with closing lid. On 07/12/21 at 12:40 P.M. interview with Licensed Practical Nurse (LPN) #36 revealed Resident #34 was an unsupervised smoker. The LPN revealed the resident was to put his cigarette butts in the butt container outside and to bring his cigarettes and lighter to her when he was done smoking. The LPN confirmed the resident did not give her his cigarettes and lighter after returning from smoking at 12:03 P.M. LPN #36 then went to Resident #34's room. The box containing the cigarette butts and unsmoked cigarettes and his lighter were laying in the seat of the resident's wheelchair. The resident was in bed. Resident #34 stated he forgot to take the cigarettes and lighter to the nurse. LPN #36 confirmed there were eight cigarette butts in the cigarette box with the unsmoked cigarettes. Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 25 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #34 stated it was easier for him to put them in the cigarette box than it was for him to put them in the cigarette butt container outside. LPN #34 confirmed it was a fire hazard for Resident #34 to bring the cigarette butts back into the facility. Interview with the Administrator on 07/13/21 at 3:30 P.M. revealed residents were to put their ashes and butts in the tall receptacle in the smoking area. The Administrator confirmed the facility did not have ash trays. The Administrator also was not aware of a metal container with self closing lid. Interview with the Maintenance Director (MD) on 07/14/21 at 8:00 A.M. confirmed the facility had one tall open cigarette butt receptacle in the resident smoking area. The MD confirmed there were no ash trays and no metal container with closing lid where Resident #34 smoked. The MD confirmed he saw where residents were putting cigarette ashes and cigarette butts on the ground in the smoking area where Resident #34 smoked. (4-5 cigarette butts were observed on the ground at that time). The MD further confirmed it was a fire/burn hazard for the resident to lay cigarette butts on his leg and then take the cigarette butts back into the facility. Review of the facility policy titled Smoking, dated 04/01/20 revealed it was the policy of the facility to allow residents who wished to smoke to do so in a safe manor, while respecting the resident's rights and ensuring facility safety. Smoking was only permitted in designated resident smoking areas, which were located outside the building. Metal containers, with self-closing cover devices were available in smoking areas. Ashtrays were emptied only into designated receptacles. Residents who had independent smoking privileges were not permitted to keep cigarettes and other smoking articles in their possession. They must be kept in a lock box at the nurses station. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 26 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to implement timely and effective interventions to ensure Resident #19 maintained acceptable parameters of nutritional status, such as body weight. This affected one resident (#19) of three residents reviewed for nutrition. Residents Affected - Few Findings include: Review of the medical record for Resident #19 revealed an admission date of 12/11/20 with diagnoses including chronic obstructive pulmonary disease, congestive heart failure, diabetes, dysphagia and adult failure to thrive. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 12/23/20 revealed a Brief Interview for Mental Status (BIMS)score of 12 indicating moderately impaired cognitive status. The MDS revealed the resident was 69 inches tall, required supervision with eating and had experienced weight loss. Review of the weight records revealed the resident weighed 149.8 pounds on admission on [DATE]. On 12/14/20 the resident weighed 132.2 pounds (a weight loss of 17.6 pounds in three days). A progress note by the dietician on 12/15/20 indicated a 17.6 pound, 11% percent weight loss in three days. The dietician indicated the resident's body mass index was 19.5 which reflected the resident was underweight for age. Intakes were 51-100% with 0-26% at two meals. Diuretics were in place. The note revealed the weight loss was possibly due to fluid shift and/or inadequate calorie intake. Pudding was recommended twice daily. The pudding was ordered by the physician. The resident was re-weighed on 12/15/20 at 137 pounds. On 12/29/20 the resident weighed 133.6 pounds. A progress note by the dietician on 12/31/20 indicated the resident's weight had been stable for seven days. Meal intakes were 0-100%. The dietician recommended a liquid nutritional supplement (Ensure) twice daily. Review of a nutritional recommendation form, dated 12/31/20 revealed Ensure twice daily was recommended for Resident #19 due to varied meal intakes with weight loss. There was no evidence the physician was made aware of the recommendation or that the nutritional supplement (Ensure) was implemented. On 01/01/21 the resident weighed 133.8 pounds. On 01/02/21 the resident weighed 124.4 pounds. On 01/03/21 the resident weighed 122.2 pounds. This represented a 11.6 pound, 9% percent weight loss in two days. On 01/08/21 the resident weighed 118.2 pounds. On 01/18/21 the resident weighed 111 pounds. The next progress note by the dietician on 01/21/21 revealed the resident weighed 111 pounds and had experienced a 22.8 pound, 17% weight loss in 30 days. The note revealed the resident's body mass index was 16.4 which was underweight for age. Meal intakes were 26-50% average. A mighty shake twice daily was recommended. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 27 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Record review revealed the mighty shakes were implemented at that time. Level of Harm - Minimal harm or potential for actual harm The resident's current weight was 115.9 pounds. Residents Affected - Few Interview with the dietician on 07/19/21 at 11:15 A.M. revealed there was no evidence the nutritional supplement (Ensure) was implemented as recommended on 12/31/20. The dietician confirmed he did not re-evaluate the resident again until 01/21/21 and by that time the resident had lost an additional 22 pounds and 17% of his body weight. He confirmed this was a significant weight loss and a nutritional supplement was not started until 01/19/21. The dietician revealed the physician was to be notified of a three pound weight loss. He confirmed this was not part of the facility policy regarding weight loss but was standard protocol. Interview with the Director of Nursing on 07/19/21 at 2:45 P.M. confirmed there was no evidence the physician was made aware of the recommendation for a nutritional supplement on 12/31/20 or that the physician was aware of the weight loss between 12/31/20 and 01/18/21. Review of the facility undated policy titled Weighing and Measuring the Resident revealed significant weight loss was to be reported to the nurse supervisor. Significant weight loss was identified as 5% in one month, 7.5% in three months and 10% in six months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 28 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview the facility failed to implement a comprehensive and individualized plan for Resident #11, who had a diagnosis of dementia to ensure the resident received the appropriate treatment and services to attain or maintain her highest practicable physical, mental, and psychosocial well-being. This affected one resident (#11) of five residents reviewed for unnecessary medication use. Residents Affected - Few Findings include: Review of the medical record for Resident #11 revealed an admission date of 12/04/20 with diagnoses including dementia, anxiety disorder, and depressive disorder. The resident was currently receiving an antianxiety medication, Buspar three times daily. The anti-anxiety medication had been started on 12/14/20 and then increased on 12/21/20 and 04/28/21. An admission Minimum Data Set (MDS) 3.0 assessment, dated 12/11/20 indicated the resident had severely impaired cognition and had physically inappropriate behaviors and socially inappropriate behaviors. A quarterly MDS 3.0 assessment on 07/02/21 indicated the resident had physically and verbally inappropriate behaviors. Review of the current plan of care for Resident #11 revealed the resident repeatedly yells out where am I or I don't know where I am. Interventions included to provide a program of activities that was of interest and accommodated the resident's status. Review of nurses notes revealed the following: On 12/14/20 at 2:44 P.M. the nurse practitioner was in and updated on resident with increased anxiety. New orders for Buspar and Vistaril. (There were no notes to describe what the increased anxiety was). On 01/27/21 at 3:06 A.M. resident noted to yell out at intervals during the night. On 02/11/21 at 6:15 A.M. resident yelling out at intervals during the night. On 03/02/21 at 4:04 P.M. resident has been yelling out a person's name again today. Resident stayed up in chair and sat in the lounge for a while but started yelling for help and moving restlessly around in wheelchair so she was put back in bed and is resting comfortably. On 04/13/21 at 10:30 A.M. resident has been yelling out for help most of the morning. Resident ate breakfast in the dining room then came to the lounge and yelled she had not eaten for days. Resident is calm for a few minutes then starts yelling again. On 04/28/21 at 2:45 P.M. power of attorney notified of increase in antianxiety medication for increased anxiety/yelling out. On 05/30/21 at 2:08 P.M. resident has been yelling all day, repeats the same thing most of the time: come find me, I don't know where I am. Staff tries to calm resident down by explaining where she is and what is happening but resident only stops yelling for a few minutes then starts again. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 29 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 07/06/21 at 5:10 P.M. resident continues yelling a person's name and also yells someone find me most of the day. On 07/12/21 at 10:00 A.M. Resident #11 was observed to be sitting in a wheelchair in the lounge by the nurse's station. The resident had her legs down through a space in the wheelchair between the seat and the foot rest (an area her legs were not meant to be). The resident was yelling out repeatedly. A nurse was sitting at the nurses's station, but did not respond to the resident. On 07/14/21 at 10:44 A.M. Resident #11 was observed sitting in the wheelchair in the lounge. The resident kept yelling out and repeating, where am I, I don't know where I am at. Review of behavior assessments completed on 12/05/20, 03/04/21, 04/01/21 and 06/24/21 failed to identify the resident exhibited any type of behaviors or implement a comprehensive and individualized plan for the resident to ensure she received appropriate treatment and services to attain or maintain her highest practicable physical, mental, and psychosocial well-being. On 07/19/21 at 3:00 P.M. interview with the Director of Nursing revealed Resident #11 frequently had anxiety about food and calls out for her children. She further confirmed the behavior assessments were not accurate as they did not identify the anxious behavior the resident displays which then had the potential to result in the resident not receiving appropriate treatment and services to attain or maintain her highest practicable physical, mental, and psychosocial well-being related to her diagnosis of dementia. On 07/19/21 at 3:00 P.M. interview with the Activity Director (AD #71) revealed she had only worked at the facility for four weeks. She stated she was the only activity staff person to provide activities for the facility. She stated Resident #11 spends the majority of her time in the lounge listening to the TV or socializing with other residents (the resident was never observed to socialize with any other resident during observations). She confirmed the facility did not have any organized group activities for residents with dementia. She stated only one to one activities were provided for residents with dementia. On 07/20/21 at 9:20 A.M. during a follow up interview, the Activity Director revealed the individual activities of TV or movie documented for Resident #11 were her being in the lounge. She stated the resident was passive for any group activities she would attend as she could not participate in scheduled Bingo, card games, etc. due to her cognition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 30 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed the Resident #7 received Metformin (an oral medication used to lower blood sugar) 1000 milligrams twice daily). Review of a pharmacy note to the attending physician on 03/10/21 for Resident #7 revealed to please consider drawing a Hemoglobin A1c every three months to monitor the resident's diabetic therapy. (A Hemoglobin A1c is a test to measure average blood sugar levels over the past three months). Record review revealed was no evidence the physician reviewed the recommendation until 05/10/21 (two months later). On 05/10/21, the physician ordered a Hemoglobin A1c in the morning and then every six months. There was no evidence the lab test was done. On 06/10/21 the pharmacist made a request for nursing to be sure the Hemoglobin A1c results were posted in the chart, as they were unavailable during the time of review. Record review revealed there was no evidence the Hemoglobin A1c blood test was completed until 07/02/21. The results were 6.2 with normal listed as 4.1-5.6. Interview with Assistant Director of Nursing #38 on 07/15/21 at 10:15 A.M. confirmed the pharmacy recommendations from 03/10/21 were not reviewed by the physician until 05/10/21. Interview with the Director of Nursing (DON) on 07/15/21 at 9:15 A.M. confirmed there was no evidence the Hemoglobin A1c test was completed until 07/02/21. On 07/15/21 at 3:48 P.M. interview with the DON further revealed the facility expectation was the physician should address the pharmacy recommendation within 30 days. Based on record review and staff interview the facility failed to ensure pharmacy recommendations for Resident #7 and Resident #38 were addressed timely by the physician. This affected two residents (#7 and #38) of three residents reviewed for unnecessary medications. Findings include: 1. Review of Resident #38's medical record revealed an original admission date of 01/08/18 with the latest readmission of 11/08/19 and admitting diagnoses of cirrhosis of liver, chronic kidney disease, vascular dementia, cerebrovascular disease, dementia encephalopathy, convulsions, atrial fibrillation, major depressive disorder, generalized muscle weakness, dysphagia, insomnia and benign prostatic hyperplasia. Review of a pharmacy recommendation, dated 03/08/21 revealed the pharmacist recommended a gradual dose reduction (GDR) for the resident related to an order for Trazadone. The physician failed to address the recommendation until 05/10/21 at which time the physician agreed with the recommendation and reduced the medication to 25 milligrams (mg) daily at bedtime. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, usually understood others, usually made himself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of nine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 31 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm On 07/15/21 at 3:48 P.M. interview with the Director of Nursing (DON) revealed the facility policy expected the physician to address pharmacy recommendations within 30 days. She verified the pharmacy recommendation was not addressed within the 30 days causing the resident to receive the higher dose of the medication Trazadone. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 32 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 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 - Minimal harm or potential for actual harm Based on record review, facility policy and procedure review and interview the facility failed to ensure medications were administered only when necessary and with adequate and appropriate monitoring including laboratory testing to monitor for effectiveness and optimal dose. This affected two residents (#7 and #38) of five residents reviewed for unnecessary medication use. Residents Affected - Few Findings include: 1. Review of Resident #38's medical record revealed an original admission date of 01/08/18 with the latest readmission of 11/08/19 and admitting diagnoses of cirrhosis of liver, chronic kidney disease, vascular dementia, cerebrovascular disease, dementia encephalopathy, convulsions, atrial fibrillation, major depressive disorder, generalized muscle weakness, dysphagia, insomnia and benign prostatic hyperplasia. Review of the resident's plan of care revealed the resident was on anticoagulant therapy related to atrial fibrillation. Interventions included to administer medication as ordered, monitor as ordered by physician, labs as ordered, report abnormal lab results to physician, monitor/document/report as needed adverse reaction. Review of the resident's monthly physician's orders revealed an order, (dated 02/28/20) for a Keppra level every six months in March and September and an order (dated 05/05/21) for a lipid level, complete blood count (CBC) and complete metabolic panel (CMP) every six months related to medications ordered for the resident. Record review revealed a lack of evidence of the laboratory testing being completed as ordered. The resident had an order on 06/02/21 to start Eliquis (an anti-coagulant medication) 5 milligrams (mg) by mouth twice daily and an order on 06/07/21 that indicated if the resident's International Normalized Ratio (INR) (laboratory testing) was less than 1.8 or greater than 1.8 call the physician. An order was also noted to hold the Eliquis if the INR was above 1.8. Review of the Prothrombin Time (PT)/INR results, dated 06/07/21 revealed the resident's INR was 2.8. Review of the resident's June 2021 Medication Administration Record (MAR) revealed the resident received the Eliquis medication on 06/07/21 at 8:00 A.M. and 8:00 P.M. despite the INR being above the designated parameter of 1.8. Review of the medical record failed to provide evidence of a Keppra level in March 2020 and March 2021. Further review revealed no evidence the CBC, CMP and lipids were completed in February 2021 to monitor for the effectiveness and optimal doses of the resident's medications. On 07/13/21 at 4:05 P.M. interview with the Director of Nursing (DON) verified the Eliquis was administered despite the physician's order to hold if INR level was above 1.8 in June 2021. On 07/14/21 at 12:05 P.M. interview with the DON verified the March 2020 and 2021 Keppra levels and the February 2021 CBC, CMP and lipid panel were not obtained as ordered. The laboratory testing was necessary to monitor for the effectiveness of the resident's medication and to ensure medications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 33 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 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 were ordered at optimal doses. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Lab and Diagnostic Test Results, dated 09/2012 revealed the physician would identify and order diagnostic and lab testing based on diagnostic and monitoring needs. The staff would process test requisitions and arrange for tests. Residents Affected - Few 2. Review of the medical record for Resident #7 revealed an admission date of 09/24/19. The resident had a diagnosis of diabetes. The resident received Metformin (an oral medication used to lower blood sugar) 1000 milligrams twice daily. Review of a pharmacy note to the attending physician on 03/10/21 revealed to please consider drawing a Hemoglobin A1c every three months to monitor the resident's diabetic therapy. (A Hemoglobin A1c is a test to measure average blood sugar levels over the past three months). There was no evidence the physician reviewed the recommendation until 05/10/21 (two months later). On 05/10/21, the physician ordered a Hemoglobin A1c in the morning and then every six months. There was no evidence the lab test was done. On 06/10/21 the pharmacist made a recommendation to nursing to be sure the Hemoglobin A1c results were posted in the chart, as they were unavailable during the time of review. Record review revealed there was no evidence the Hemoglobin A1c blood test was completed until 07/02/21. The results were 6.2 with normal listed as 4.1-5.6. Interview with the Director of Nursing on 07/15/21 at 9:15 A.M. confirmed there was no evidence the Hemoglobin A1c test was completed until 07/02/21. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 34 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on observation, record review and interview the facility failed to implement behavioral interventions, including non pharmacological approaches prior to administering psychoactive medications and failed to timely evaluate the effectiveness of psychoactive medications for Resident #11. This affected one (Resident #11) of five residents reviewed for unnecessary medication use. Findings include: Review of the medical record for Resident #11 revealed an admission date of 12/04/20 with diagnoses including dementia, anxiety disorder and depressive disorder. Record review revealed the resident was currently receiving the antianxiety medication, Buspar 15 milligrams (mg) three times daily. The antianxiety medication had been started on 12/14/20 at 10 milligrams twice daily and then increased on 12/21/20 to 10 milligrams three times daily and then on 04/28/21 was increased to 15 milligrams three times daily. A nursing progress note, dated 12/14/20 at 2:44 P.M. revealed the nurse practitioner was in and updated on resident with increased anxiety. New orders for Buspar and Vistaril. (There were no notes to describe what the increased anxiety was). Vistaril (an antihistamine which can be used to treat anxiety) 25 mg was ordered every eight hours as needed for anxiety. There were no nursing progress notes or physician progress notes on 12/21/20 to indicate why the Buspar was increased to 10 milligrams three times daily at that time. A nurse's note, dated 01/27/21 at 3:06 A.M. revealed the resident was noted to yell out at intervals during the night. A nurse's notes, dated 02/11/21 at 6:15 A.M. revealed the resident was noted yelling out at intervals during the night. Review of medication administration records revealed Vistaril was administered seven times in December 2020, one time in January 2021 (on 01/02/21) and five times in February 2021 (on 02/07, 02/08, 02/09, 02/14 and 02/15/21) before it was discontinued on 02/18/21. There was no documentation, at the times the medication was given, to indicate why the medication was given, or that any behavioral interventions or non pharmacological approaches were tried prior to administering the medication. Further review of the nursing progress notes revealed: On 03/02/21 at 4:04 P.M. resident has been yelling out a person's name again today. Resident stayed up in chair and sat in the lounge for a while but started yelling for help and moving restlessly around in wheelchair so she was put back in bed and is resting comfortably. On 04/13/21 at 10:30 A.M. resident has been yelling out for help most of the morning. Resident ate breakfast in the dining room then came to the lounge and yelled she had not eaten for days. Resident is calm for a few minutes then starts yelling again. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 35 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 04/28/21 at 2:45 P.M. power of attorney notified of increase in antianxiety medication for increased anxiety/yelling out. (There were no further notes related to the increase in antianxiety medication to indicate that any other behavioral interventions or non pharmacological approaches had been attempted). On 05/30/21 at 2:08 P.M. resident has been yelling all day, repeats the same thing most of the time: come find me, I don't know where I am. Staff tries to calm resident down by explaining where she is and what is happening but resident only stops yelling for a few minutes then starts again. On 06/02/21 at 4:45 P.M. physician in to visit and received order for anti-anxiety medication, Ativan 0.25 milligrams twice daily as needed for anxiety. Review of a physician's progress note on 06/02/21 revealed an assessment of anxiety. The note revealed Buspar was increased two weeks ago, at max dosing. Will add low dose of Ativan 0.25 milligrams two times daily as needed. The note revealed the resident was sitting in the main room watching TV, yelling out where am I, I am here, not disruptive but yelling most of the time. Per nurse unable to redirect at times, has difficulty calming down. Review of the medication administration record revealed the Ativan was administered eight times in June 2021. There was no documentation, at the times the medication was given, to indicate why the medication was given, or that any behavioral interventions or non pharmacological approaches were tried prior to administering the medication. The Minimum Data Set (MDS) 3.0 assessment, dated 07/02/21 indicated the resident had a Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. The MDS revealed the resident was totally dependent on staff for transfers and locomotion and had physical and verbal behaviors. A nursing progress note, dated 07/06/21 at 5:10 P.M. revealed resident continues yelling a person's name and also yells someone find me most of the day. On 07/12/21 at 10:00 A.M. Resident #11 was observed sitting in a wheelchair in the lounge by the nurse's station. The resident had her legs down through a space in the wheelchair between the seat and the foot rest (an area her legs were not meant to be). The resident was yelling out repeatedly. A nurse was sitting at the nurses's station, but did not respond to the resident. On 07/14/21 at 10:44 A.M. Resident #11 was sitting in the wheelchair in the lounge. The resident kept yelling out and repeating, where am I, I don't know where I am at. On 07/14/21 at 10:49 A.M. the resident was taken to the dining room where a group of residents were playing cards at a table. The resident was placed near the table but did not participate in the activity. Resident #11 asked where she was. The Activity Director told the resident she was in the dining room where a card game was going on. On 07/14/21 at 11:03 A.M. the resident remained in the dining room where the card game continued. The resident was sitting more quietly and said she was ok. Review of behavior assessments completed 12/05/20, 03/04/21, 04/01/21 and 06/24/21 revealed no evidence the resident was identified to have any behavior symptoms. There was no evidence the facility was tracking how frequently the behaviors were occurring to evaluate the effectiveness of the medications based on the behaviors being exhibited. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 36 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview with the Director of Nursing (DON) on 07/19/21 at 3:00 P.M. revealed Resident #11 frequently had anxiety about food and calls out for her children. She further confirmed the behavior assessments were not accurate as they did not identify the anxious behavior the resident displayed. The DON confirmed there was no evidence of any behavior interventions, including non pharmacological approaches prior to the use of medications as noted above. The DON also confirmed the facility was not tracking how frequently the behaviors were occurring to evaluate the effectiveness of the medications based on the behaviors that were exhibited. During the course of the resident's admission, additional psychoactive medications and increased doses were added to the resident's medication regimen without adequate justification for optimal use. Event ID: Facility ID: 365485 If continuation sheet Page 37 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Based on record review and interview the facility failed to ensure physician ordered laboratory testing was completed as ordered and/or failed to ensure the physician was promptly notified of resident laboratory results which fell outside the clinical reference ranges. This affected two residents (#5 and #7) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 09/24/19. a. The resident had physician's orders dated 12/29/20 for the medication Depakote (valproic acid) 125 milligrams three times a day for schizoaffective disorder and Lipitor 80 milligrams daily for hyperlipidemia (high lipids in the blood). The resident had a physician's order, dated 02/25/21 for a lipid panel and valproic acid level to be drawn every six months. A lipid panel is a blood test that measures lipids such as triglycerides and high-density lipoprotein (HDL). A valproic acid level measures the amount of valproic acid medication in the blood stream. Review of laboratory test results, dated 03/05/21 revealed Resident #7's triglyceride level was 165 (normal listed as <=150). The HDL level was 32 (normal listed as >=60. The valproic acid level was 25.7 (normal listed as 50-100. There was no evidence the physician was notified of the results which fell outside of the clinical reference range. Interview with the Director of Nursing on 07/15/21 at 9:15 A.M. confirmed there was no evidence the physician was notified of the laboratory results on 03/05/21. b. Record review revealed the Resident #7 received Metformin (an oral medication used to lower blood sugar) 1000 milligrams twice daily). Review of a pharmacy note to the attending physician on 03/10/21 for Resident #7 revealed to please consider drawing a Hemoglobin A1c every three months to monitor the resident's diabetic therapy. (A Hemoglobin A1c is a test to measure average blood sugar levels over the past three months). Record review revealed was no evidence the physician reviewed the recommendation until 05/10/21 (two months later). On 05/10/21, the physician ordered a Hemoglobin A1c in the morning and then every six months. There was no evidence the lab test was done. On 06/10/21 the pharmacist made a request for nursing to be sure the Hemoglobin A1c results were posted in the chart, as they were unavailable during the time of review. Record review revealed there was no evidence the Hemoglobin A1c blood test was completed until 07/02/21. The results were 6.2 with normal listed as 4.1-5.6. Interview with Assistant Director of Nursing #38 on 07/15/21 at 10:15 A.M. confirmed the pharmacy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 38 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 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 0773 recommendations from 03/10/21 were not reviewed by the physician until 05/10/21. Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing (DON) on 07/15/21 at 9:15 A.M. confirmed there was no evidence the Hemoglobin A1c test was completed until 07/02/21. Residents Affected - Few 2. Review of Resident #5's medical record revealed an original admission date of 09/20/16 with the latest readmission of 03/17/21 and admitting diagnoses of encephalopathy, malaise, contracture of right hand, intracerebral hemorrhage, cerebrovascular accident (CVA) with right sided hemiplegia, dysphagia, schizoaffective disorder, major depressive disorder, dementia with behavioral disturbances, anxiety disorder, hyperlipidemia, overactive bladder, aphasia and hypertension. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/31/21 revealed the resident had clear speech, sometimes understood others, sometimes made himself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of zero. Review of the resident's monthly physician's orders for July 2021 revealed an order (initiated 03/18/21) for a completed blood count (CBC) and complete metabolic panel (CMP) every six months in October and April and an order (initiated 05/26/21) for a lipid Panel & HgbA1c every six months. Review of the laboratory results printed on 07/14/21 for the 05/12/21 and 05/27/21 laboratory results for the CBC, CMP, Lipid panel and HgbA1c revealed no evidence the physician was notified of abnormal laboratory results which were identified at the time the laboratory testing was completed. On 0715/21 at 4:00 P.M. interview with the DON verified the resident's physician was not notified of the abnormal laboratory results from the testing comleted on 05/12/21 and 05/27/21. Review of the facility policy titled Lab and Diagnostic Test Results, dated 09/12 revealed the physician would identify and order diagnostic and lab testing based on diagnostic and monitoring needs. The staff would process test requisitions and arrange for tests. A nurse would review all laboratory results. A physician could be notified by phone, fax, voicemail, e-mail, pager or a telephone message to another person acting as the physician's agent. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 39 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the medical record for Resident #37 revealed an admission date of 06/17/21. Review of the physician's orders revealed an order, dated 07/02/21 for the resident to be in contact precautions due to Methicillin-resistant Staphylococcus aureus (MRSA) in the urine. Residents Affected - Many On 07/12/21 at 12:12 P.M. STNA #79 was observed to deliver Resident #37's meal tray to his room and set up the tray. STNA #79 was wearing a surgical mask when she entered the room but did not apply any further personal protective equipment prior to entering the room. A sign was observed on the door that indicated the resident was on contact precautions. The sign indicated to wear a gown and gloves when entering the room. When STNA #79 exited the room, she confirmed she was to wear additional personal protective equipment when entering the room. On 07/12/21 at 12:15 P.M. interview with Licensed Practical Nurse #36 confirmed Resident #37 was on contact precautions and STNA #79 should have worn a gown and gloves when entering the room. Review of the facility policy titled Isolation-Categories of Transmission-Based Precautions dated 2001 (Revised January 2012) revealed in addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. The policy revealed to wear gloves when entering the room and remove before leaving the room, then perform hand hygiene. The policy also indicated to wear a disposable gown upon entering the Contact Precaution room. 4. Record review revealed Resident #212 was in quarantine for COVID-19 precautions at the time of the survey. On 07/12/21 at 10:20 A.M. STNA #78 was observed to place an N95 mask over her surgical mask and entered room [ROOM NUMBER]'s room to provide care for the resident. Upon exiting the room, the STNA verified she had placed an N95 mask over a surgical mask which rendered it ineffective as the mask did not have the proper seal. Following the interview, the STNA proceeded to walk down the hallway wearing the same mask and carrying goggles. The STNA indicated she had to go to the nurse's station to obtain disinfectant to sanitize her goggles as there was none stored at the resident's room. Based on observation, record review, facility policy and procedure and interview, the facility failed to maintain acceptable infection control practices including proper procedures for residents in droplet isolation and/or quarantine to prevent the spread of infection including COVID-19. This affected five residents (#37, #212, #311, #312 and #313) and had the potential to affect all 66 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #311 revealed an admission date of 07/02/21 with diagnoses including sepsis due to Escherichia coli (E-coli), lobar pneumonia and droplet precautions due to new admission COVID-19 quarantine. On 07/12/21 at 9:30 A.M. Maintenance Director #16 was observed standing in Resident #311's room assisting the resident with her television. Maintenance Director #16 was observed wearing only a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 40 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many surgical mask. On Resident #311's door prior to entering the room was a sign indicating to wear a gown, gloves, N-95 mask and goggles prior to entering the room. On 07/12/21 at 9:46 A.M. interview with the Administrator confirmed Resident #311 was on droplet precautions due to being a new resident who had not received their COVID-19 vaccine and per facility policy this resident was required to be in quarantine for 14 day. The Administrator also confirmed Maintenance Director #16 was standing in Resident #311's room without the proper personal protective equipment (PPE) being worn. On 07/12/21 at 11:38 A.M. Staffing Coordinator #47 was observed entering Resident #311's room to deliver her meal tray and did not place an N-95 mask on as per the facility policy. On 07/12/21 at 11:45 A.M. interview with Assistant Director of Nursing #38 confirmed the above observation. Review of the facility policy titled Isolation - Categories of Transmission - Based Precautions, revised 01/2012 revealed under section titled Airborne Precautions- Signs- The facility would implement a system to alert staff to the type of precaution resident required. Review of the facility droplet precaution sign indicated staff were to wear, a gown, gloves, N-95 mask and goggles prior to entering residents room. 2. Review of the medical record for Resident #312 revealed an admission date of 07/09/21 with diagnoses including cellulitus of the left lower limb, pleural effusion, and quarantine for COVID-19 (droplet precaution) due to resident being a new admission for 14 days. On 07/12/21 at 11:38 A.M. State Tested Nursing Assistant (STNA) #56 was observed entering Resident #312's room to deliver her lunch tray and did not place an N-95 mask on prior to entering the room. On 07/12/21 at 11:45 A.M. interview with Assistant Director of Nursing #38 confirmed the above observation. Review of the facility policy titled Isolation - Categories of Transmission - Based Precautions, revised 01/2012 revealed under section titled Airborne Precautions- Signs- The facility would implement a system to alert staff to the type of precaution resident required. Review of the facility droplet precaution sign indicated staff were to wear, a gown, gloves, N-95 mask and goggles prior to entering residents room. 3. Review of the medical record for Resident #313 revealed an admission date of 07/05/21 with diagnoses including acute respiratory failure, pneumonia and 14 day quarantine for COVID-19 with droplet precautions due to being a new admission. On 07/12/21 at 11:50 A.M. Staffing Coordinator #47 was observed entering Resident #313's room to deliver his lunch meal tray. The coordinator did not apply an N-95 mask prior to entering the resident's room which was part of the PPE required to use for a resident with droplet precautions. On 07/12/21 at 11:45 A.M. interview with Assistant Director of Nursing #38 confirmed the above observation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365485 If continuation sheet Page 41 of 42 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 365485 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flint Ridge Nrsg & Rehab Ctr 1450 West Main Street Newark, OH 43055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy titled Isolation - Categories of Transmission - Based Precautions, revised 01/2012 revealed under section titled Airborne Precautions- Signs- The facility would implement a system to alert staff to the type of precaution resident required. Review of the facility droplet precaution sign indicated staff were to wear, a gown, gloves, N-95 mask and goggles prior to entering residents room. Event ID: Facility ID: 365485 If continuation sheet Page 42 of 42