Inspection·May 23, 2019

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Closed medical record review for Resident #57 revealed an admission date of 02/23/19. Diagnoses included bacteremia, disorder of kidney and ureter, acute kidney failure, unspecified abdominal pain, disease of pancreas, alcoholic cirrhosis of liver without ascites, sepsis and acute pancreatitis without necrosis. Further review of the record revealed the resident was transferred to the hospital per squad after a significant change in condition on 02/28/19. The resident's wife was present at the time of the transfer. The medical record contained no documentation of the Ombudsman's office being notified of the resident's transfer to the hospital. Interview with Social Service Designee #510 on 05/22/19 at 10:07 A.M. verified the Ombudsman's office was not notified of the resident's transfer to the hospital on [DATE]. Review of a facility untitled and undated document revealed under section Copies of the Notice, the facility must distribute copies of this completed notice, at the time of transfer to: 1.) Original document is issued to resident/sponsor. 2.) A copy of the document is emailed to the Ombudsman. Based on medical and facility record review and staff interview, the facility failed to provide notification of resident's transfers to the hospital to the resident and/or representative and to the Office of the State Long-Term Care Ombudsman. This affected three (#24, #51 and #57) of three residents reviewed for hospitalization. The facility census was 57. Findings include: 1. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE]. Diagnoses included pressure ulcer sacral region, spina bifida unspecified, chronic osteomyelitis, paraplegia, morbid obesity, and neuromuscular dysfunction of the bladder. Review of the Minimum Data Set (MDS) assessment, dated 03/31/19, revealed the resident had no cognitive impairment. Further review of the record revealed Resident #24 was sent to the hospital on [DATE] for significant change in condition and returned to the facility on [DATE]. The medical record was silent of verification, that a notification of transfer, was provided in writing to Resident #24 and/or representative, and also sent to the Office of the State Long-Term Care Ombudsman. Interview on 05/21/19 at 12:01 P.M. with the Director of Nursing (DON) verified Resident #24 was transferred out of the facility on 04/08/19 and no notification of transfer was provided in writing to the resident and/or representative. The DON also verified the Ombudsman's office was not provided the required notification of the transfer. 2. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE]. Diagnoses included type two diabetes, chronic kidney disease stage three, heart failure, dementia. Review of the Minimum Data Set (MDS) assessment, dated 04/30/19, revealed the resident had moderate cognitive impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 2 of 10 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 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Further medical record review revealed Resident #51 was sent to the hospital on [DATE] for significant change in condition and returned to the facility on [DATE]. The medical record was silent of verification, that a notification of transfer, was provided in writing to Resident #24 and/or representative, and also sent to the Ombudsman's office. Interview on 05/21/19 at 12:01 P.M. with the DON verified Resident #24 was transferred out of the facility on 04/09/19 and no notification of transfer was provided in writing to the resident and/or representative. The DON also verified the Ombudsman's office was not provided the required notification of the transfer. Event ID: Facility ID: 365577 If continuation sheet Page 3 of 10 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 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of facility policy, the facility failed to notify the resident and/or representative of the facility's bed hold policy. This affected one (#57) of three residents reviewed for hospitalization. The facility census was 57. Findings include: Closed medical record review for Resident #57 revealed an admission date of 02/23/19. Diagnoses included bacteremia, disorder of kidney and ureter, acute kidney failure, unspecified abdominal pain, disease of pancreas, alcoholic cirrhosis of liver without ascites, sepsis and acute pancreatitis without necrosis. Further review of the record revealed the resident was transferred to the hospital per squad after a significant change in condition on 02/28/19. The resident's wife was present at the time of the transfer. The medical record contained no documentation of the resident and/or representative having been provided with the bed hold policy at the time of transfer. Interview with Social Service Designee #510 on 05/22/19 at 10:07 A.M. the resident and/or representative were not notified of the facility's bed hold policy at the time of the transfer to the hospital on [DATE]. Review of the facility's policy titled Bed Hold Authorization/Notification, dated 12/30/19, stated at the time of transfer to the hospital or therapeutic leave, the center will provide a copy of notification of Bed Hold. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 4 of 10 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 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 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 record review, staff interview and policy review, the facility failed to ensure the baseline care plan addressed the use of an anticoagulant for Resident #305. This affected one (#305) of 16 residents reviewed for care plans. The facility census was 57. Findings include: Review of the medical record for Resident #305 revealed an admission date of 05/10/19 with diagnoses including heart failure, respiratory failure, coronary artery disease, and chronic embolism and thrombosis of deep veins of lower extremity. Review of the medical record revealed an order dated 05/10/19 for Warfarin sodium, a medication used as a blood thinner, tablet six milligrams by mouth one time a day. Review of the baseline care plan for Resident #305, dated 05/10/19, revealed Warfarin use was not addressed on the baseline care plan. Interview on 05/23/19 at 10:48 A.M. with Director of Nursing (DON) verified Resident #305's baseline care plan did not address Warfarin use. During interview on 05/23/19 at 10:48 A.M. with DON, the DON agreed Resident #305's baseline care plan should have addressed the use of Warfarin. Review of the policy titled Care Plans- Baseline, last revised December 2016, revealed the interdisciplinary team will review the healthcare practitioner's orders and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: initial goals based on admission orders, physician orders, dietary orders, therapy services and social services, if applicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 5 of 10 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 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on record review, observation and staff interview, the facility failed to ensure one resident's behavior of picking at her skin and facial lesions was addressed on the resident's plan of care. This affected one (#38) of 16 care plans reviewed during the survey. Findings include: Review of Resident # 38's medical record revealed the resident was admitted to facility on 01/06/16. Diagnoses included dementia without behavioral disturbance, vitamin B12 deficiency and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment, dated 05/10/19, indicated the resident was severely cognitively impaired and required extensive assistance with activities of daily living including dressing and personal hygiene. Review of a weekly skin assessment, dated 05/22/19, indicated the resident had multiple scratches to her face. Review of the resident's care plan revealed it did not indicate the resident picked or scratched her face. Observation on 05/20/19 at 10:21 A.M. of Resident # 38 revealed she had lesions on her face. Interview on 05/22/19 at 1:45 P.M. with State Tested Nursing Assistant (STNA) #500 verified the resident had lesions on her face and stated the resident had them for months. STNA #500 stated the resident picks at the lesions. Interview on 05/23/19 at 11:54 A.M. with Licensed Practical Nurse (LPN) #506 verified the resident had lesions on her face and that the resident had a history of picking at her skin. Interview on 05/23/19 at 1:18 P.M. with the Director of Nursing (DON) verified the resident's care plan did not address the resident's scratching and picking of her skin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 6 of 10 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 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 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 policy review, record review, observation and staff interview, the facility failed to ensure one resident's facial lesions were documented in the medical record, treated and monitored for improvement and failed to have hospice progress notes available for review for another resident. This affected one (#38) of two resident's reviewed for non-pressure skin issues and one (#8) of two residents reviewed for hospice services. Residents Affected - Few Findings include: 1. Review of Resident #38's medical record revealed the resident was admitted to facility on 01/06/16. Diagnoses included dementia without behavioral disturbance, vitamin B12 deficiency and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment, dated 05/10/19, indicated the resident was severely cognitively impaired and required extensive assistance with activities of daily living including dressing and personal hygiene. Review of the resident's care plan revealed it did not indicate the resident picked or scratched her face. Review of weekly skin assessments, dated 05/13/19 and 05/20/19, revealed it did not indicate the resident had any scratches or lesions on her face. A weekly skin assessment, dated 05/22/19, indicated the resident had multiple scratches to her face. Review of physician orders, dated 05/22/19, revealed there was a treatment order for abrasions on the face, cleanse with normal saline, pat dry, apply triple antibiotic (TAO) and cover with small border gauze or other clean dry dressing until healed. Observation on 05/20/19 at 10:21 A.M. of Resident # 38 revealed she had pea size lesions on her face. Interview on 05/22/19 at 1:45 P.M. with State Tested Nursing Assistant (STNA) #500 verified the resident had lesions on her face and stated the resident had them for months. STNA #500 stated the resident picks at the lesions. Interview on 05/22/19 at 1:47 P.M. with Licensed Practical Nurse (LPN) #501 verified the resident had no treatment for the lesions and confirmed the lesions were not noted on the 05/20/19 weekly skin assessment. LPN # 501 stated she would contact the resident's physician for a treatment order. Interview on 05/23/19 at 12:08 P.M. with the Director of Nursing (DON) stated the physician had been contacted on 05/22/19 and a treatment order had been received. Review of the facility's undated policy, titled Skin Tears - Care of Abrasions and Minor Breaks, indicated the purpose of this procedure is to guide the prevention and treatment of abrasion, skin tears, and minor breaks in the skin. The policy indicated the facility would obtain a physician's order as needed. 2. Review of the medical record for Resident #8 revealed an admission date of 05/20/08 with diagnoses including adult failure to thrive, heart failure, psychosis, and dementia. Review of the medical record revealed Resident #8 was admitted to hospice services on 03/04/18 with Hospice Entity #505. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 7 of 10 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 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Review of the hospice binder for Hospice Entity #505 revealed no hospice progress notes were available since 04/10/19. Interview on 05/22/19 at 11:45 A.M. with the Administrator and Director of Nursing verified no hospice progress notes since 04/10/19 were available in the facility. Residents Affected - Few Interview on 05/22/19 at 1:20 P.M. with Hospice Account Liaison #504 verified Hospice Entity #505 does not leave progress notes in the facility after each visit. Review of the facility hospice agreement with Hospice Entity #505, dated 06/01/16, revealed the facility and hospice will prepare and maintain complete medical records for hospice patients receiving facility services in accordance with this agreement and will include all treatments, progress notes, authorizations, physician orders and other pertinent information. Documentation of care and services provided by hospice will be filed and maintained in the facility chart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 8 of 10 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 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on record review and staff interview, the facility failed to ensure psychotropic medications were not administered for extended periods of time without attempts for gradual dose reductions for one (#14) of five residents reviewed for unnecessary medications. The facility census was 57. Findings include: Medical record review for Resident #14 revealed an admission date of 10/08/15. Diagnoses included major depressive disorder and generalized anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 03/12/19, revealed the resident had moderate cognitive impairment and had no mood or behavior issues. Review of quarterly social service progress notes, from 01/02/18 to 04/03/19, reflected the resident was without mood or behavior issues. Review of physician progress notes from 04/16/19 to 05/29/18 revealed the resident was pleasant, alert and were silent to any mood or behavior problems. Review of current physician orders for Resident #14 revealed the resident had orders to receive an antianxiety medication named Buspar five milligrams (mg.) twice daily since 04/15/18 and an antidepressant medication named Citalopram 20 milligrams daily since 04/15/18. Review of the medication regimen review (MRR), dated 04/18/19, revealed a recommendation that noted the resident had been receiving multiple psychotropics, Buspar five mg. twice daily and Citalopram 20 mg. daily since 04/2018. The pharmacist wrote a recommendation for the physician to please consider an attempted dose reduction or trial discontinuation as deemed appropriate. If this cannot be accomplished, please document risk vs. benefit of continued therapy with current regimen. Review of the physician's response to the MRR from 04/18/19 revealed he physician responded to continue same dose on 04/29/19. The medical record contained no documentation of clinical justification for the resident to receive the medications at this dosage without a trial reduction. Interview on 05/23/19 at 10:20 A.M. with Licensed Practical Nurse #506 stated the resident has no behaviors directed towards other residents or staff. Interview with the Director of Nursing on 05/23/19 at 12:51 P.M. confirmed there has been no attempts for a gradual does reduction of Buspar and Citalopram for Resident #14 since 04/2018. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 9 of 10 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 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 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 0838 Level of Harm - Potential for minimal harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on review of the facility assessment and staff interview, the facility failed to conduct and implement an annual facility assessment in a timely manner. This has the potential to affect all 57 residents residing in the facility. Findings include: Review of the facility's undated assessment revealed the facility's antibiotic stewardship program was noted as 'in progress' on the assessment tool. Further review of the assessment revealed the facility's 'Infection Preventionist' will be certified in 2018. Interview on 05/22/19 at 1:40 P.M. with the Administrator and the Director of Nursing (DON) verified the facility assessment had been completed by the prior Administrator and DON of the facility. The current DON verified she was not certified as the Infection Preventionist and stated the facility had completed an antibiotic stewardship program that was in place at the time of the survey. Per the Administrator and the DON, the previous administration had not completed an updated annual facility assessment since the last survey of 04/19/18 and the Administrator had not updated the facility assessment to date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 10 of 10