Health inspection·May 9, 2022

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few an understanding of why he was prescribed the medication Cimetidine. Resident #12 also stated he was not aware of the side effects of taking the medication. Resident #12 revealed that he was not informed by the physician, nurse practitioner, social services or nursing staff the reason he was prescribed the medication or the side effect related to erectile dysfunction. An interview on 05/04/22 at 11:41 A.M. with STNA #126 revealed Resident #12 did not typically have behaviors except for removing his colostomy bag and playing with his own bowel movement. An interview on 05/05/22 at 1:45 P.M. with Unit Manager #186 revealed Resident #12 had sexual behaviors of masturbation when staff were providing care and inappropriate comments to female staff. The Unit Manager said he was started on the Cimetidine due to the sexual behaviors. The Unit Manager stated the Nurse Practitioner explained the medication to the resident and the side effects. However, the facility failed to provide evidence of this conversation. The Nurse Practitioner no longer worked at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365576 If continuation sheet Page 2 of 20 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 365576 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chillicothe Post Acute 1058 Columbus St Chillicothe, OH 45601 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 0606 Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Level of Harm - Potential for minimal harm Based on personnel file review and staff interview, the facility failed to ensure prospective employees were cross checked on all registries prior to hire. This affected two employee personnel files of 11 personnel files reviewed. This had the potential to affect all residents residing in the facility. The facility census was 75. Residents Affected - Many Findings include: Review of personnel records for the Administrator revealed a hire date of 01/04/21, and Human Resources Director # 166, hire date of 11/15/21, had no evidence they were checked against the State of Ohio Nurse Aide Registry. During an interview with Human Resources Director #166 on 05/05/22 at 2:49 P.M., verified the personnel files for the Administrator #146 and Human Resources Director #166 contained no evidence of pre-employment checks against the State of Ohio Nurse Aide Registry. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365576 If continuation sheet Page 3 of 20 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 365576 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chillicothe Post Acute 1058 Columbus St Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to refer a resident with a newly evident mental disorder for a level II resident review with a significant change in status assessment. This affected one resident (#55)of six residents reviewed for pre-admission screening and resident review (PASRR). The facility census was 75. Findings include: Review of Resident #55's medical record revealed he was admitted on [DATE]. Diagnoses included right lower leg fracture, hyperkalemia, paranoid personality, skin picking disorder, restless leg syndrome, depression, type II diabetes, and end stage renal disease. Review of Resident #55's PASRR dated 03/02/2022 revealed no mental illness diagnoses. Review of Resident #55's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #55 was not considered to have a serious mental illness. Resident #55's speech was clear, he made himself understood, he understands, and his cognition was intact. Review of Resident #55's progress notes revealed the following. On 04/01/2022 Resident #55 was paranoid, thought people were conspiring to kill him. Resident #55 reported hearing people behind him talking, only Resident #55 and the nurse were in the room. Resident refused medications, was awake all night. Resident #55 initially was anxious, he calmed down but continued with paranoia and thoughts of conspiracies. Review of Resident #55's physician orders revealed on 04/04/2022 an antipsychotic medication (Seroquel) 25 milligrams (mg) at bedtime for behaviors was ordered. Further review of Resident#55's physician orders revealed a new diagnosis of paranoia/delusional disorder. Review of Resident #55's behavior assessment dated [DATE] revealed Resident #55 had experienced thoughts or experiences of being out of touch with reality, has disorganized speech and behavior with decrease in activity of daily living and therapy participation. Resident #55 had difficulty with memory and concentration. Resident #55 had presence of hallucinations, (verbal and auditory). Resident #55 had beliefs people were after him and going to harm him. Resident #55 was confused disoriented and reality orientation was not accepted. Resident #55's thoughts and fearfulness caused him anxiety and mental anguish. No new PASRR was completed with the new emergent of Resident #55's paranoia and delusions. During an interview with the Admissions Director #160 on 05/05/22 10:10 A.M., verified when Resident #55 was newly diagnosed with paranoia and delusions a new PASRR was not submitted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365576 If continuation sheet Page 4 of 20 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 365576 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chillicothe Post Acute 1058 Columbus St Chillicothe, OH 45601 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #45's medical record revealed he was admitted on [DATE] with diagnoses syncope, ventricular tachycardia, dysphagia, major depressive disorder, dementia with Lewy body dementia, anxiety, psychotic disorder, and adult failure to thrive. Residents Affected - Few Review of Resident #45's annual Minimum Data Set (MDS) [DATE] revealed the following. Information regarding Resident #45's PASRR information was blank. Resident #45's speech was clear, he made himself understood, understands others, and his cognition was intact. Review of Resident #45's PASRR revealed he was admitted on [DATE] with a seven day emergency admission approved. Review of Resident #45's PASRR dated [DATE] revealed Resident #45 was approved for a 90 day nursing home placement. Resident #45 had no additional PASRRs submitted after the 90 day extension was approved. During an interview with the Admissions Director #160 on [DATE] 10:10 A.M., verified when Resident #45 approved 90 day PASRR extension expired no PASRR was submitted. Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure residents with diagnoses of mental disorders or intellectual disabilities were correctly identified during the Preadmission Screening and Resident Review (PASRR) and the facility failed to reassess residents with expired level one determinations. This affected two residents (#02 and #45) of seven residents reviewed during the annual survey for PASARR. The facility census was 75. Findings include: 1. Review of medical record for resident #02 revealed an admission date of [DATE]. Diagnoses included depressive disorder, dementia with behavioral disturbance, dementia without behavioral disturbance, psychosis not due to a substance or known disorder. Resident # 2 was diagnosed with cognitive communication deficit on [DATE]. Review of Resident #02's physician orders revealed an order for risperidone (antipsychotic medication) 0.5 milligrams one tablet by mouth once daily at bedtime for dementia with behaviors, an order for Zoloft 25 milligrams one tablet by mouth one time a day for depression, and an order to monitor two times daily for side effects related to use of psychotropic medications. Review of Resident #02's PASRR dated [DATE] indicated in section D Resident #02 did not have a diagnosis of dementia, indicated in section E(1) Resident #02 did not have any diagnoses of mental disorders, and indicated in section E(6) was unknown if Resident #02 had been prescribed any psychotropic medications. During an interview with the Admissions Director #160 on [DATE] at 3:40 P.M., verified Resident #02's diagnoses of dementia with behavioral disturbance, depressive disorder, and psychosis were absent from the PASRR dated [DATE]. She stated Resident #02 would require another PASRR level one screening to be completed to correct this. Review of the facilities Preadmission Screening and Resident Review (PASARR) policy dated, 08/2021, revealed the screening is accurate based on current information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365576 If continuation sheet Page 5 of 20 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 365576 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chillicothe Post Acute 1058 Columbus St Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #51 revealed an admission date of 06/09/21 with diagnosis including chronic peripheral venous insufficiency, weakness, atrial fibrillation and edema. Residents Affected - Few Review of the quarterly MDS dated [DATE] revealed Resident #51 was cognitively intact with no behaviors. Resident #51 required extensive assistance of two persons for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. Review of the May 2022 physician orders indicated Resident #51 received furosemide (a diuretic used to treat fluid retention or edema) 40 milligrams (mg) by mouth daily, was on a fluid restriction of 2000 milliliters (ml) daily, a low sodium diet, and on 10/30/21 a treatment of an Unna boot wrap (compression bandage) to bilateral lower extremities and feet, cover with an ace bandage and change every three days on night shift. Review of the nursing progress notes dated from 10/30/21 to 05/05/22 and the skin wound care assessments had no documentation regarding the edema to bilateral lower extremities, the condition of the residents skin or improvement. Review of Resident #51's plan of care revealed no documentation of the edema to the bilateral lower extremities or the treatment of. Observations on 05/02/22 at 12:05 P.M., on 05/03/22 at 2:01 P.M. and 05/04/22 at 9:04 A.M. revealed the resident had the Unna boot bandage and ace wraps to bilateral lower extremities. Resident #51 had four plus pitting edema to bilateral lower extremities. During an interview on 05/05/22 at 11:25 A.M., with Unit Manager #186 revealed Resident #51 has pitting edema to his bilateral lower extremities that was being treated with Unna boot and ace bandages. The Unit Manager verified there was not any documentation describing the edema, the skin of the bilateral lower extremities, if the skin was open, or healing. The Unit Manager also said the plan of care had not reflected the care of the edema. Based on medical record review, observations, and staff and resident interviews, the facility failed to ensure care planned skin alteration prevention interventions were in place and failed to ensure residents edema was being monitored. This affected two residents (#57 and #51) out of the five residents reviewed for edema and skin conditions. The facility census was 75. Findings include: 1. Record review for Resident #57 revealed this resident was admitted to the facility on [DATE] and had diagnoses including acute combined systolic and diastolic heart failure, cognitive communication deficit, polyneuropathy, recurrent depressive disorders, cerebral infarction, anxiety disorder, muscle weakness, repeated falls, dysphagia, hemiplegia and hemiparalysis affecting unspecified site, and osteoarthritis. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident #57 had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 10. This resident required extensive assistance from two staff members for bed mobility and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365576 If continuation sheet Page 6 of 20 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 365576 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chillicothe Post Acute 1058 Columbus St Chillicothe, OH 45601 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 transfers and extensive assistance from one staff member for toilet use. This resident had skin tears. Level of Harm - Minimal harm or potential for actual harm Review of the care plan, dated 06/26/17 and revised on 04/15/19, revealed Resident #57 was at risk for alteration in skin integrity. Interventions included to encourage resident to wear geri-sleeves, float heels as able, check wheel chair for cotton sleeving installed to arm rest, and staff will provide left arm sling for transfers and encourage use. Residents Affected - Few Review of the care plan, dated 04/20/22, revealed the resident had a skin tear to the top of the right hand. Interventions included to administer treatment as ordered by the physician. Review of the State Tested Nursing Assistant (STNA) kardex revealed instructions to encourage Resident #57 to have left hand palm guard in place as tolerated and to encourage the resident to wear geri-sleeves. Observation on 05/02/22 at 11:39 A.M. revealed Resident #57 was lying in bed. The resident did not have a palm guard in place to the left hand and was wearing a short sleeve shirt without geri-sleeves. The resident had multiple areas of bruising on both arms and hands and had a bandage in place to a skin tear on the right hand. During an interview with Resident #57 on 05/02/22 at 11:41 A.M., verified the resident did not have a palm guard located on her left hand and was unsure where it was located. Observation on 05/02/22 at 3:05 P.M. revealed Resident #57 was without a palm guard in place to her left hand and did not have geri-sleeves on. Observation on 05/03/22 at 8:16 A.M. revealed Resident #57 was sitting in a wheelchair and did not have a palm protector in place to the left hand and did not have geri-sleeves on either arm. Observation on 05/03/22 at 2:10 P.M. revealed Resident #57 was lying in bed and did not have a palm protector in place to the left hand and did not have geri-sleeves on either arm. Observation and interview with Registered Nurse (RN) #105 on 05/03/22 at 2:30 P.M. verified Resident #57 did not have a palm protector in place to the left hand and verified no palm protector could be located in the residents room. Observation and interview with STNA #190 on 05/03/22 at 2:42 P.M. verified Resident #57 did not have a palm protector in place to the left hand. STNA #190 stated staff had been unable to locate the palm protector since the previous week. STNA #190 stated she had worked at the facility for three years and could not recall Resident #57 ever wearing geri-sleeves and verified they were not in place on the residents arms or located in the residents room. Observation and interview with STNA #183 and STNA #121 on 05/04/22 at 9:09 A.M. verified neither employee could recall Resident #57 wearing geri-sleeves or being instructed to encourage the resident to wear geri-sleeves. During an interview with RN #186 on 05/05/22 at 11:10 A.M. verified Resident #57 had skin alteration prevention interventions in place on the care plan and STNA kardex which included a palm protector to the left hand as tolerated and encourage resident to wear geri-sleeves as tolerated. RN #186 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365576 If continuation sheet Page 7 of 20 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 365576 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chillicothe Post Acute 1058 Columbus St Chillicothe, OH 45601 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 verified there was no documentation available of the resident refusing to wear the geri-sleeves or palm protector. 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: 365576 If continuation sheet Page 8 of 20 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 365576 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chillicothe Post Acute 1058 Columbus St Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview the facility failed to ensure a resident's bed was positioned to prevent the resident from falling out of bed between the bed and the wall. This affected one resident (#04) of three sampled residents reviewed for accidents. The facility census was 75. Findings include: Review of Resident #04's medical record revealed he was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary, schizophrenia, and falls. Review of Resident #04's Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #04's speech was clear, he made himself understood, he usually understands others, and his cognition was intact. Resident #04 had no indicators of psychosis, no behaviors, did not reject care, and did not wander. Resident #04 required extensive assistance two staff for bed mobility, to transfer, and did not walk. Resident #04 had two or more falls with no injury and two or more falls with minor injury. Review of Resident #04's behavior assessment dated [DATE] revealed Resident #04 was non-compliant with care since admission. Resident #04 purposefully attempted to get out of bed or throw himself from a bed or a chair. Resident #04's falls and interventions included: medication adjustments and one to one staff were provided as necessary. Review of Resident #04's plan of care dated 01/28/22 revealed Resident #04 was at risk for falls due to muscle weakness, unsteady gait, use of psychotropic medications, poor safety awareness, and impulsive behaviors. The interventions listed included encourage Resident #04 to wear hipsters, may have one on one when restless or agitated intermittently, offer food and drink when restless, use a scoop defined perimeter mattress. Review of Resident #04's quarterly MDS dated [DATE] revealed no change. Review of Resident #04's progress notes dated 04/23/22 revealed Resident #04 was found in his room on the floor, between the bed and the wall. Resident #04 had a large red mark on right side of back, no bruising was evident, and five and a half centimeter (cm) abrasion on. Observation of Resident #04 on 05/03/2022 at 1:59 P.M. revealed he was in bed with a defined perimeter mattress. The left side of the bed was along the wall with a gap of approximately eight inches between the bed and the wall. Resident #04 was observed on 05/04/2022 at 7:15 A.M., 10:15 A.M., 12:26 P.M. in bed the bed was in the same position. Observation with the Director of Nursing (DON) on 05/04/2022 at 3:30 P.M. revealed Resident #04 was in bed with a defined perimeter mattress, the left side of the bed was along the wall with a gap of approximately eight inches between the bed and the wall. Interview of the DON at the above time revealed the bed was not supposed to be positioned along the wall but, perpendicular to the wall. The DON verified the gap posed a risk for Resident #04 being injured from a fall from the bed on the left side. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365576 If continuation sheet Page 9 of 20 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 365576 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chillicothe Post Acute 1058 Columbus St Chillicothe, OH 45601 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** 3. Review of medical record for resident #02 revealed an admission date of 11/25/21. Diagnoses included chronic obstructive pulmonary disease, other recurrent depressive disorders, atrial fibrillation, dementia, muscle weakness, cognitive communication deficit, gastrointestinal hemorrhage, dysphagia, and anemia. Residents Affected - Few Review of Resident #02's weights revealed on 04/07/2022 the resident weighed 158.2 pounds. On 04/27/2022, the resident weighed 149.0 pounds which is a -5.82 % loss. And further review of Resident #02's weights revealed on 01/07/2022 the resident weighed 177.0 lbs. On 04/27/2022, the resident weighed 149 pounds which is a -15.82 % loss. Review of Resident #02's orders revealed an order for ProMod Liquid 30 milliliters by mouth two times daily for wound healing and an order for Dronabinol 2.5 milligrams by two times daily for poor appetite. Review of Resident #02's care plan revealed interventions to administer appetite stimulant as ordered and an intervention to encourage and assist as needed to consume foods and supplements offered. Review of Resident #02's nutritional supplement and bedtime snack intake reveals documentation of Resident's acceptance of supplement. Documentation does not show what percentage of supplement or bedtime snack was consumed by the resident. Observation of STNA # 192 on 05/04/22 at 08:40 A.M. revealed nutritional supplement of Ensure Plus was provided on meal tray. During an interview with STNA #192 on 05/04/22 at 8:48 A.M., STNA #192 stated Resident #02's tray was prepared for him. The STNAs supervise his intake and encourage Resident #02 to consume more or assist if needed. During a follow-up interview with STNA #192 on 05/04/22 at 9:18 A.M., revealed the STNAs do not record the percentage of the supplement or bedtime snack consumed. STNA # 192 stated if a Resident drinks any of a supplement or consumes any of a bedtime snack, it is recorded as accepted in the documentation system. She also stated the amount of a liquid supplement is not calculated in the percentage of each meal consumed if provided on a meal tray. Based on observation, interview, and medical record review, the facility failed to ensure evidence of the amount of supplements consumed by residents. This affected three residents (#04, #42, and #46) out of four residents reviewed for nutrition. The facility census was 75. Findings include: 1. Record review for Resident #46 revealed this resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, schizophrenia, dysphagia following cerebral infarction, aphasia, adult failure to thrive, unspecified protein-calorie malnutrition, unspecified mood disorder, generalized anxiety disorder, major depressive disorder, schizoaffective disorder, muscle weakness, cognitive communication deficit, dysphagia, nicotine dependence, cramp and spasm, insomnia, and constipation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365576 If continuation sheet Page 10 of 20 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 365576 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chillicothe Post Acute 1058 Columbus St Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 13. The resident required extensive assistance from two staff members for bed mobility, limited assistance from two staff members for transfers, extensive assistance from one staff member for toilet use, and extensive assistance from one staff member for eating. Residents Affected - Few Review of the care plan dated 02/28/21 revealed the Resident #46 was at risk for alteration in nutritional status. Interventions included to encourage and assist as needed to consume foods and/or supplements and fluids offered, explain and reinforce the importance of maintaining the diet as ordered, honor food preferences, monitor for signs and symptoms of dysphagia, obtain and monitor diagnostic work as ordered. Review of the physicians order dated 12/15/21 revealed Resident #46 was ordered a nutritional treat twice a day as a supplement. Review of the documentation of supplement intake for the nutritional treat for Resident #46 dated 12/15/21 through 04/30/22 revealed the documentation only provided information regarding whether the resident accepted or refused the supplement and did not contain the amount of the supplement consumed by the resident. During an interview with STNA #183 on 05/04/22 at 1:03 P.M., verified staff only documented whether or not a resident accepted or refused a supplement and did not document the amount of the supplement which was consumed. STNA #183 stated documenting a resident had accepted a supplement did not mean the resident consumed any of the supplement, only the resident took the supplement from staff and did not refuse it. STNA #183 verified there was not a way to look back and view how much of a supplement a resident had consumed. During an interview with Registered Dietitian Nutritionist (RDN) #165 on 05/04/2022 at 1:10 P.M., revealed for supplements there was no way to put it in the tracker for the STNA's to document the amount the residents consumed and it was difficult to evaluate the effectiveness of a supplement as a nutritional intervention. During an interview with the Director of Nursing (DON) on 05/04/22 at 3:53 P.M., verified the supplement tracker did not allow for a percentage of intake making it difficult to evaluate the effectiveness of the supplement. 2. Review of Resident #04's medical record revealed he was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary, schizophrenia, and falls. Review of Resident #04's physician orders revealed a regular diet. Review of Resident #04's nutrition assessment dated [DATE] revealed his current body weight was 170.6 pounds and his Body Mass Index (BMI) was 25.2 indicating he was overweight. Resident #04 was scheduled a bedtime snack of a sandwich. Review of Resident #04's Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #04's speech was clear, he made himself understood, he usually understands others, and his cognition was intact. Resident #04 had no indicators of psychosis, no behaviors, did not reject care, and did not wander. Resident #04 required extensive assistance two staff for bed mobility, to transfer, did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365576 If continuation sheet Page 11 of 20 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 365576 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chillicothe Post Acute 1058 Columbus St Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm walk, and extensive assistance of one staff to eat. Resident #04 had no swallowing problems, was 69 inches, 169 pounds, had no significant weight changes. Resident #04 had six months or less life expectancy, was on hospice. Review of Resident #04's quarterly MDS dated [DATE] revealed no change. Residents Affected - Few Review of Resident #04's bedtime snack intake revealed on 05/03/2022 he accepted the bedtime sandwich. Observation of Resident #04 on 05/04/2022 at 12:26 P.M. revealed a meat sandwich was on his over bed table. The sandwich was in a sealed plastic bag. The plastic bag was labeled with Resident #04's name, bedtime snack, and dated 05/03/2022. Resident #04 would not respond to questions. During an interview of State Tested Nursing Assistant (STNA) #126 on 05/04/2022 at 1:05 P.M., verified Resident #04 had a meat sandwich from the night before on his overbed table. STNA #126 confirmed it was sealed. STNA stated Resident #04 likes food and will always wake up to eat. STNA #126 stated Resident #04 likes candy and pop. During an interview of Registered Dietitian Nutritionist (RDN) #165 on 05/04/2022 at 1:10 PM revealed for supplements there was no way to put it tracker for the STNA's no document the amount residents consumed. it was difficult to evaluate the effectiveness of a supplement as a nutritional intervention. RND #165 confirmed RND #165 stated the only way she knows how well Resident #04 consumes a supplement is to ask the STNA's. During an interview of the Director of Nursing (DON) on 05/04/22 03:53 P.M. revealed staff should not check accept on the supplement tracker if the resident did not eat it. The DON verified the supplement tracker did not allow for a percentage of intake and making it difficult to evaluate the effectiveness of the supplement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365576 If continuation sheet Page 12 of 20 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 365576 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chillicothe Post Acute 1058 Columbus St Chillicothe, OH 45601 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review the facility failed to evaluate a resident's need for an opioid analgesic prior to the administration of the medication. This affected one resident (#265) of one resident's reviewed for pain. The facility census was 75. Residents Affected - Few Findings include: Review of Resident #265's medical record revealed he was admitted on [DATE]. Diagnoses included osteomyelitis, alcohol use, type II diabetes, streptococcal infection, non-pressure chronic ulcer of foot with fat layer exposed, resistance to vancomycin, and altered mental status. Review of Resident #265's admission Minimum Data Set (MDS) dated [DATE] revealed his speech was clear, he made himself understood, understands others, and his cognition was intact. Resident #265 had no behaviors and did not resist care. Resident #265 required supervision of one staff for bed mobility, to transfer, and to walk. Resident #265 received scheduled pain medication, received as needed (PRN) pain medication, and non-medication intervention for pain, had pain in past five days, occasionally pain, the pain did not make it hard for him to sleep, and did not limit his day to day activities. Resident #265's pain level was four out of 10 on a 0-10 pain scale rating, representing moderate pain according to the Numeric Rating Scale (NRS). Resident #265 participated in the assessment. Review of Resident # 265's physician orders revealed an opioid analgesic (oxycodone) 10 milligrams (mg) every six hours for severe pain. Resident #265 also had orders for pain evaluation every day. Review of Resident #265's medication administration record (MAR) for April 2022 revealed the following dates Resident #265 received the PRN Oxycodone with no evidence of his pain rating: 04/14/22 one dose, 04/15/22 two does, 04/16/22 two dose, 04/17/22 and 04/18/22 one dose daily, 04/19/22 and 04/20/22 two doses, 04/21/22 through 04/24/22 three doses daily, 04/25/22 one doss, 04/26/22 three doses, 04/27/22 two doses, 04/28/2022 one dose, 04/29/22 and 04/30/22 three doses. Review of Resident #265's MAR for May 2022 revealed the following dates Resident #265 received the PRN Oxycodone with no evidence of his pain rating: 05/01/22 three dose, 05/02/22 and 05/03/22 one dose, and 05/04/22 two doses. Review of Resident #265 daily pain scale recordings from 04/15/22 to 05/15/22 revealed it ranged from 0 to 5 out of 10. A NRS of eight and above represents severe pain. During an interview with the Director of Nursing (DON) on 05/05/22 at 11:35 A.M., revealed Resident #265's pain was assessed daily and prior to administering pain medication. A follow-up interview with the DON at 3:55 P.M. verified no pain level was obtained prior to administering Resident #265's Oxycodone. Review of the facility policy titled Pain Management Guidelines dated 11/2021 revealed pain was evaluated daily for each patient and before and after the administration of PRN pain medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365576 If continuation sheet Page 13 of 20 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 365576 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chillicothe Post Acute 1058 Columbus St Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review the facility failed to ensure residents who received psychoactive medications identified specific target behaviors, reduced the medication when the reduction was not clinically contraindicated, and had not ruled out causes of newly emergent behaviors before administering psychoactive medications. This affected four residents (#04, #45, #46, and #55) of six sampled resident reviewed for unnecessary drugs. The facility census was 75. Findings include: 1. Review of Resident #04's medical record revealed he was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary, schizophrenia, and fall. Review of Resident #04's quarterly Minimum Data Set (MDS) date 04/18/2022 revealed the following. Resident # 04's speech was clear, he made himself understood, he usually understands others, and his cognition was intact. Resident #04 had no indicators of psychosis, no behaviors, did not reject care, and did not wander. Resident #04 required extensive assistance two staff for bed mobility, to transfer, and did not walk. Resident #04 had functional limitations of both sides of upper and lower extremities. Resident #04's had six months or less life expectancy, was on hospice. Resident #04 received an antipsychotic medication daily. Review of Resident #04's physician orders revealed he received the following antipsychotic medications: Haloperidol Decanoate Solution 150 milligrams (mg) injection every 28 for undifferentiated schizophrenia and or /behaviors and Haloperidol Lactate Concentrate 10 mg three times a day for schizophrenia. Behavior assessment dated [DATE] revealed Resident #04 was non-compliant with care since admission, he strikes out, yells, cusses' staff when attempting to do care delivery. Resident #04 purposefully throws himself from bed or chair, many attempts were provided to promote safety from falls and interventions were implemented including medication adjustments and one to one staffing was provided as necessary. Review of Resident #04's progress note dated 02/12/22 revealed the hospice nurse evaluated the resident after his fall. The hospice nurse reported Resident #04 was too alert and oriented with normal range of motion for a sitter at the time. The hospice nurse reported she would suggest a medication increase/review to the physician. The staff would continue to monitor the resident closely and sit with the resident intermittently as staffing allowed. Further review of Resident #04's progress notes revealed a new order for Haldol five mg three times a day. Review of Resident #04's progress note dated 02/14/22 revealed the writer spoke with hospice after review of falls over the weekend. Alternate placement for Resident #04 was pursued for him. The facility had implemented every possible fall prevention intervention for him. Resident #04 required one on one staff at intervals the facility was unable to provide. Further review of Resident #04's progress notes on this day revealed Haldol five mg three times a day was ordered. Review of Resident #04's 04/07/22 progress notes revealed Resident #04 was very rude toward staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365576 If continuation sheet Page 14 of 20 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 365576 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chillicothe Post Acute 1058 Columbus St Chillicothe, OH 45601 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 cursing, kicking at staff, and continued to refuse aerosol treatments every day. The hospice nurse was notified and new orders for Haldol 10 mg three times a day was obtained. Review of Resident #04's progress notes revealed his last behavior was on 04/23/22 when he was found between his bed and the wall. Residents Affected - Some During an observation of Resident #04 on 05/03/22 at 1:59 P.M., 3:48 P.M., on 05/04/2022 at 7:15 A.M., 10:15 A.M., 12:26 P.M. 2:48 P.M., and 4:15 P.M. revealed he was in bed asleep. During an interview of State Tested Nursing Assistant (STNA) #126 on 05/04/2022 at 1:05 P.M. stated Resident #04 liked food and would always wake up to eat. STNA #126 stated Resident #04 likes candy and pop. If he was told he was getting a pop or candy if he cooperated, then he would. Resident #126 wants to be left alone and he would throw himself to the floor at times but not lately. During an interview with the Hospice Registered Nurse (HRN) #300 on 05/05/22 at 9:44 A.M., revealed Resident #04 was an unhappy mad man. HRN #300 stated Resident #04 throws himself out of his bed, tells me to get the expletive out and leave him alone. HRN #300 stated Resident #04 gets the Haldol for behaviors and agitation. HRN #300 stated Resident #04 does sleep a lot, but if you go in, he will wake up and tell you to get the expletive out. 2. Review of Resident #45's medical record revealed he was admitted on [DATE]. Diagnoses included syncope, ventricular tachycardia, dysphagia, major depressive disorder, dementia with Lewy Body Dementia, anxiety, psychotic disorder, and adult failure to thrive. Review of Resident #45's annual Minimum Data Set (MDS) 07/23/21 revealed Resident #45 required supervision of one staff to eat, to transfer, to walk, required limited assistance of one staff to dress. Received an antipsychotic and an antidepressant for seven days, had a gradual dose reduction on 05/21/21 and not clinically contraindicated. Review of Resident #45's MDS dated [DATE] revealed Resident #45's speech was clear, he made himself understood, understands others, and his cognition was intact. Resident #45 had no behaviors, did not wander, and did not reject care. Resident #45 required extensive assistance of two staff for bed mobility to transfer, limited supervision of one staff to walk, for locomotion, extensive assistance of one staff for dressing, and supervision with set up help to eat. Review of Resident #45's physician orders revealed an antipsychotic medication (Seroquel) 50 mg at bedtime for Lewy Body Dementia with psychosis and an antidepressant (Effexor) 75 mg twice a day for depression and an antianxiety medication (Ativan) two mg per milliliter injection as needed (PRN) for seizures. Resident #45 did not have target behaviors identified for the use of the Seroquel and the Effexor. Review of Resident #45's pharmacy recommendations dated 09/19/21 revealed a recommendation that psychotropic medications used on a PRN basis must be limited to 14 days unless an extension beyond 14 days is determined to be appropriate. The physician's response was the medication was ordered for seizure activity not for behaviors. Review of Resident #45's the pharmacy recommendation dated 11/16/21 revealed a recommendation for a dose reduction for Seroquel 50 mg at bedtime and Effexor 75 mg twice daily. The physician responded regarding the Seroquel nursing staff reported attempts to adjust the medication/dose in the past (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365576 If continuation sheet Page 15 of 20 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 365576 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chillicothe Post Acute 1058 Columbus St Chillicothe, OH 45601 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 resulted in patient becoming withdrawn and refusing to take any of his medications. Regarding the Effexor Resident #45 still displayed symptoms of depression and a decrease may be detrimental to the resident. Review of Resident #45's progress notes from 01/01/22 to 05/05/22 revealed three behaviors noted. The behaviors were refusal of medication. Residents Affected - Some During an interview with Registered Nurse (RN) #151 on 05/05/22 at 10:33 A.M., revealed Resident #45 had no behaviors. During an interview with STNA #126 on 05/05/22 at 10:34 A.M., revealed Resident #45 had no behaviors. During an interview with the Director of Nursing (DON) on 05/04/22 at 9:20 A.M., revealed the facility did not identify target behaviors for psychoactive medications. The DON stated behaviors were documented in the nurse's notes. 3. Review of Resident #55's medical record revealed he was admitted on [DATE]. Diagnoses included right lower leg fracture, hyperkalemia, paranoid personality, skin picking disorder, restless leg syndrome, depression, type II diabetes, and end stage renal disease. Review of Resident #55's significant change MDS dated [DATE] revealed the following. Resident #55's speech was clear, he made himself understood, he understands, and his cognition was intact. Resident #55 had other behaviors four to six times a week, that significantly interfered with care and significantly interfered with the resident's participation in activities or social interactions, that did not affect other residents, he did not wander, and he did not reject care. Resident #55 required extensive assistance of two staff for bed mobility, to transfer, extensive assistance of one staff for locomotion, and used a walker and wheelchair. Resident #55 received insulin injections, antipsychotic medication four days, and an antidepressant daily. Resident #55 was on dialysis. Review of a physician order start date 04/04/22 revealed Resident #55 was ordered an antipsychotic medication (Seroquel) 25 mg at bedtime for behaviors on 04/09/2022 the reason for the medication was changed to paranoid/delusional disorder. Review of Resident #55's progress notes dated 03/30/22 Resident #55 complained of pain radiating from his stomach up his chest and requested to be sent to the hospital. Resident #55 was sent out and returned on 03/31/22. On 04/01/22 Resident #55 heard people behind him talking when only Resident #55 and the nurse were in the room. Resident #55 refused to take his medications, was paranoid, and had thoughts of conspiracies affecting him. On 04/03/22 Resident #55 requested to go to the hospital stating it was his right. Resident #55 was assessed, and no irregularities were noted. Resident #55's provider was contacted and stated if he wants to go, he can call nine-one-one (911). Resident #55 called 911 was transport to the hospital and returned later that day with no findings. After this date there was no evidence Resident #55 had delusions or paranoia. Review of the medical record revealed there was no evidence other reasons for the new emergence of paranoid and delusional behaviors were ruled out prior to administering antipsychotic medication. Review of Resident #55's behavior assessment dated [DATE] revealed Resident #55 was experiencing thoughts or experiences that seem out of touch with reality, had disorganized speech and behavior with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365576 If continuation sheet Page 16 of 20 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 365576 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chillicothe Post Acute 1058 Columbus St Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some decrease in activity of daily living and therapy participation. Resident #55 had difficulty with memory, concentration, and hallucinations (verbal and auditory). Resident #55 believed that people were after him going to harm him. During an interview with STNA #138 on 05/04/22 at 9:06 A.M., revealed Resident #55 had expressed no hallucinations or delusions. During an interview with the DON on 05/04/22 at 9:20 A.M., revealed there was no evidence other issues were ruled out prior to administering the psychotropic medication. The DON revealed Resident #55 was not assessed by or provided mental health services when he had delusions and paranoid expressions. 4. Review of the medical record for Resident #46 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, schizophrenia, dysphagia following cerebral infarction, aphasia, adult failure to thrive, unspecified protein-calorie malnutrition, unspecified mood disorder, generalized anxiety disorder, major depressive disorder, schizoaffective disorder, muscle weakness, cognitive communication deficit, dysphagia, nicotine dependence, cramp and spasm, insomnia, and constipation. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 13. The resident required extensive assistance from two staff members for bed mobility, limited assistance from two staff members for transfers, extensive assistance from one staff member for toilet use, and extensive assistance from one staff member for eating. Review of the active physician order dated 02/24/21 revealed Resident #46 was ordered one tablet of 150 mg Extended Release Quetiapine Fumarate (an antipsychotic medication) at bedtime for schizoaffective disorder. An dated 06/04/21 revealed Resident #46 was ordered one tablet of 0.5 milligram (mg) Ativan three times a day for anxiety. Review of the pharmacist recommendation dated 12/21/21 revealed to attempt a gradual dose reduction by reducing the frequency of Resident #46's scheduled Ativan 0.5 mg tablets from three times a day to twice a day. The recommendation contained documentation by the Certified Nurse Practitioner (CNP) to decline the recommendation due to Patient is easily upset and becomes emotional/tearful over minor events. She needs to continue medication to prevent worsening anxiety. Review of the pharmacist recommendation dated 02/15/22 revealed to attempt a gradual dose reduction by reducing the prescribed dose of Quetiapine Fumarate from 150 mg once daily to 50 mg once daily. The recommendation contained documentation by the CNP to decline the recommendation due to Patients behaviors and psyche disorders are more manageable on current medications other medications have been ineffective. Review of the pharmacist recommendation dated 03/22/22 revealed the suggestion to attempt a gradual dose reduction by reducing the prescribed frequency of Resident #46's scheduled Ativan 0.5 mg tablets from three times a day to twice a day. The recommendation contained documentation by the CNP to decline the recommendation due to Her level of anxiety is severe even with medication. It would be detrimental to her quality of life if medication was decreased. During an interview with Registered Nurse (RN) #186 on 05/05/22 at 11:10 A.M., verified Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365576 If continuation sheet Page 17 of 20 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 365576 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chillicothe Post Acute 1058 Columbus St Chillicothe, OH 45601 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 #46 had been receiving Ativan since 06/24/21 and Quetiapine Fumarate since 02/24/21 with no gradual dose reductions attempted despite pharmacy recommendations. RN #186 verified there was no evidence available of adverse side effects related to previous reduction attempts related to Resident #46's Ativan or Quetiapine Fumarate medication therapy. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365576 If continuation sheet Page 18 of 20 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 365576 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chillicothe Post Acute 1058 Columbus St Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and policy review the facility failed to ensure medications were administered without error. There were 38 opportunities for error with three observed errors for a calculated error rate of 7.89 percent. This affected one resident (#17) of three residents observed for medication administration. The facility census was 75. Residents Affected - Few Findings included: Review of the medical record for Resident #17 revealed an admission date of 10/18/18. Diagnoses included glaucoma, macular degeneration and type two diabetes mellitus. Review of the admission assessment dated [DATE] indicated Resident #17 required assistance with medication administration. Review of the physician orders for May 2022 revealed Resident #17 was ordered Artificial Tears instill two drops to both eyes two times daily, Timolol Maleate (a medication to decrease pressure inside the eye) 0.5% instill one drop to both eyes two times daily, Brimonidine (a glaucoma medication) 0.2% instill one drop to both eyes two times daily and Latanprost (a medication to treat pressure inside the eye) 0.005% instill one drop to each eye at bedtime. Review of the plan of care revealed the resident was at risk for impaired vision related to glaucoma and macular degeneration. Interventions included administering medications as ordered. During an observation on 05/04/22 at 7:50 A.M. of Licensed Practical Nurse (LPN) #309 administering medications to Resident #17. Resident #17 was ordered Artificial Tears instill two drops to both eyes, Timolol Maleate 0.5% instill one drop to both eyes, Brimonidine 0.2% instill one drop to both eyes. LPN #309 administered one drop of the Artificial tears, Timolol Maleate and Latanaprost 0.005% to each eye consecutively without allowing the ordered time between each drop. Also, the Latanaprost was ordered for hour of sleep only and Resident #17 did not receive the Brimonidine as ordered. During an interview on 05/04/22 at 7:58 A.M., with LPN #309 verified the eye drops were given consecutively with no time between each drop. LPN #309 also confirmed she administered the wrong eye drops as the Latanaprost was to be given at bedtime and the Brimonidine was to be administered two times daily, morning and evening. LPN #309 said she was going to notify the physician. During an interview on 05/04/22 at 9:44 A.M., with the Director of Nursing (DON) verified administering eye drops consecutively without a wait time was not a standard of practice or policy. Review of the facility policy titled Medication Administration: eye drops and ointment dated 06/21 revealed the procedure was to verify the physicians orders and to wait three to five minutes between each different eye medication administration if more than one medication ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365576 If continuation sheet Page 19 of 20 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 365576 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chillicothe Post Acute 1058 Columbus St Chillicothe, OH 45601 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 Based on observation, interview and policy review the facility failed to ensure the glucometer was cleaned effectively between use. This had the potential to affect 12 residents (#27, #49, #17, #32, #35, #53, #20, #28, #215, #07, #25 and #14) of 22 residents residing on the hallway who required blood glucose monitoring. The facility census was 75. Residents Affected - Some Findings include: During an observation on 05/04/22 at 7:50 A.M. with Licensed Practical Nurse (LPN) #309 cleaned the glucometer, after use, with an alcohol wipe pad. LPN #309 wiped the glucometer off once over and placed it on top of the medication cart. During an interview on 05/04/22 at 7:51 A.M., with LPN # 309 verified the glucometer was cleaned with an alcohol wipe pad. LPN #309 said she always cleaned the glucometer with an alcohol wipe and was not aware of the facility policy on cleaning/sanitizing glucometers. LPN #309 proceeded to the supervisor for instruction. During an interview on 05/04/22 at 9:44 A.M., with the Director of Nursing (DON) revealed cleaning the glucometer with an alcohol wipe was not standard practice or proper infection control. The DON stated the glucometer should be cleaned with a bleach wipe or a germicidal wipe, with a dwell time of five minutes, wipe off excess liquid with clean paper towel, then place the glucometer back in the drawer of the medication cart. Review of the facility policy titled Glucose Blood Monitoring dated 02/11 revealed the blood glucose meter should be cleaned with an Environmental Protection Agency (EPA) approved hypochlorite solution (1:10 bleach) wipe or approved germicidal disinfectant per the manufacturer instructions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365576 If continuation sheet Page 20 of 20