Inspection·December 13, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of pharmacy delivery sheet dated 08/23/23 revealed Resident #79 received Compazine 25 mg suppository, Lorazepam two mg/ml, hyoscyamine 0.125 mg (levsin), and morphine sulfate 100 mg/five ml solution to station two. Review of Electronic Medication Administration Record (EMAR) progress note dated 08/30/23 at 8:13 A.M. for Resident #79 revealed Resident #79 took a sip of water and projectile vomited. Medications not administered. Review of Alert Note dated 08/30/23 at 10:28 A.M. for Resident #79 revealed nurse contacted son about change in condition. Contacting hospice to come in and check on resident. Review of Alert Note dated 08/30/23 at 12:52 P.M. for Resident #79 revealed hospice nurse arrived and is assessing resident. Review of Hospice visit summary on 08/30/23 revealed facility reporting multiple episodes of vomiting. On assessment patient resting in bed, no signs or symptoms of distress. Resident #79 had a small amount of emesis during assessment green/brown in color. Facility unable to find prochlorperazine suppositories. Spoke with pharmacy and suppositories were delivered but facility cannot find. Refill place on phone with pharmacy to have more suppositories delivered. Instructed facility nurse to use Lorazepam for vomiting until suppositories were delivered. Son at bedside throughout assessment. No other concerns or changes. Educated facility on calling hospice if vomiting not resolved. Review of Skilled Note dated 08/31/23 at 12:13 A.M. for Resident #79 revealed the resident having nausea and vomiting. Resident #79 has had significant decline. Vital signs were strong and is able to answer brief questions. Son spooned ginger ale to resident and resident did well with swallowing. Son then went home. Resident #79 has remained sleepy but easy to arouse. Denies needs at this time, call light in reach. Review of General Progress Note dated 08/31/23 at 3:15 A.M. for Resident #79 revealed the resident resting well. No further emesis. Woke when checked and changed. Drank two ounces of apple juice. Resident #79 has clear speech and offers cognitive answers to questions. Review of General Progress Note dated 08/31/23 at 2:14 P.M. for Resident #79 revealed nurse contacted hospice to visit. Resident #79 had refused medications and meals today. Hospice nurse arrived and son was present. Son agreed to discontinue supplements. Resident #79 had been drinking fluids, son is going to buy donuts to see if she will eat them. Review of Hospice Nursing Summary Note dated 08/31/23 revealed nurse arrived at facility with son concerned with Resident #79 still vomiting. Resident #79 gown had soiled with emesis and begins to vomit. This nurse cleaned resident up and changed gown and linen. Son concerned with Resident #79 not receiving Compazine suppository for vomiting. This nurse explained that Compazine was ordered on 08/22/23 and delivered to facility via pharmacy on day of admission. Facility nurse was able to locate Compazine suppository on another unit. This nurse administered. Resident #79 requesting something to drink. Son provides hot tea and patient drank without difficulty. Resident #79 requests cold water and drank entire cup. No further emesis during this nurse visit. Review of General Progress Note dated 08/31/23 6:55 P.M. for Resident #79 revealed son called nine-one-one (911) and wanted resident sent to hospital emergency room for treatment. Hospice notified by resident's son. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 2 of 5 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 12/13/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of medication administration record (MAR) for August for Resident #79 revealed no as needed medications were given on 08/30/23 or 08/31/23. Resident #79 refused routine by mouth medications on 08/30/21. Interview on 12/12/23 at 10:45 A.M. with Director of Nursing (DON) verified Resident #79's Compazine suppository was not documented on the MAR until 08/30/23. The DON stated she was unsure why it was not entered into the system on 08/22/23 when ordered by hospice but, she would look into it. Interview on 12/12/23 at 11:24 A.M. with DON stated that Resident #79's medications were on hold due to the residents son request. The DON showed surveyor the MedOne communication book for physician notification which had a note dated 08/24/23 hold all hospice medications per son request. Interview on 12/12/23 at 11:45 A.M. with DON who was on the phone with Hospice Nurse #09 that admitted Resident #79 stated to her that the son did not want the resident to take the medications in the hospice care pack. Stated that hospice archived the medication and the orders received on 08/22/23 and the facility could implement them when the son decided Resident #79 could have the medications. DON stated that all the medications ordered were in the emergency box at the facility except the Compazine suppositories so they would be readily available. Stated all the nurses would know where the orders were in the chart, and they could have entered them at any time. Verified the orders received on 08/22/23 including admit to hospice were not entered into Resident #79's electronic record when written by hospice. Verified they were not entered due to medications being archived by hospice and son did not want resident to receive. The DON confirmed Resident #79's medical record does not contain documentation regarding which medications the family wanted or didn't want administered. Interview on 12/12/23 at 5:30 P.M. with Resident #79's son stated he had informed hospice that he did not want his mom to receive morphine since she had a reaction to morphine when she had her surgery. Resident #79's son stated the Compazine suppository was fine. Resident #79's son stated the facility could not locate the Compazine suppository when she was vomiting. Resident #79's son stated she had nausea and vomiting for three days, and he finally called 911. This deficiency represents non-compliance investigated under Complaint Numbers OH00148600 and OH00148765. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 3 of 5 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 12/13/2023 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, review of manufacturer's directions, and review of facility policy, the facility failed to prime an insulin pen prior to administration per manufacturer recommendation. This affected one (Resident #27) of four residents observed during medication administration. The facility census was 59. Residents Affected - Few Findings include: Review of the medical record for Resident #27 revealed an admission date of 10/06/23 with diagnoses included acute kidney failure, anemia, type two diabetes, hypertension, cellulitis, and unspecified open wound of scrotum and testes. Review of December physician orders for Resident #27 revealed humano kwikpen 100 units/milliliter (ml) per slicing scale 150-200 give 2 units, 201-250 give 4 units, 251-300 give 6 units, 301-350 give 8 units, and 351-400 give 10 units. Any blood sugar above 400 and below 60 notify the physician. Twice daily. Insulin Glargine (lantus) subcutaneous solution pen-injector 100 unit/ml, inject 32 units subcutaneously one time a day for diabetes type two. Review of the Care Plan dated 10/27/23 for Resident #27 revealed the resident has diabetes mellitus type two. Interventions included check all body for breaks in skin and treat promptly as ordered by doctor, check and monitor temperature related to bathing/showering, inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness, monitor blood sugar levels, cover abnormal levels per sliding scale ordered by physician, monitor for adverse effects of medication, document and notify physician, and nurse to educate resident and family on signs and symptoms of hypo/hyperglycemia. Observation on 12/12/23 at 7:46 A.M. of medication administration for Resident #27 revealed Registered Nurse (RN) #524 preparing to administer lantus. RN #524 did not prime the insulin pen prior to dialing up 32 units to administer to the resident. Interview on 12/12/23 at 7:54 A.M. with RN #524 verified she did not prime the lantus pen prior to dialing up and administering the ordered dose. RN #524 stated she did not always prime insulin pens. Interview on 12/12/23 at 12:42 P.M. with Director of Nursing (DON) verified nurses should prime insulin pens unless contraindicated by manufacturer or physician orders. Review of the lantus solstar pen insert manufacturer's directions on lantus.com revealed step three included dial a test dose of two units, hold the pen with needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. If no insulin comes out, repeat the test two more times. If there is still no insulin coming out, use a new needle and do the safety test again, Always perform the safety test before each injection. Review of policy titled Administering Medications revised December 2012 revealed insulin pens containing multiple doses of insulin are for single resident use only. Changing the needle does not make it safe to use insulin pens for more than one resident, insulin pens will be clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 4 of 5 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 12/13/2023 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 0760 pen, the nurse will verify that the correct pen and dose is used for that resident. 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: 365577 If continuation sheet Page 5 of 5