Inspection·June 6, 2024

F 0641 Level of Harm - Minimal harm or potential for actual harm Observation and interview with Resident #3 on 06/03/24 at 9:10 A.M. revealed he has difficulty hearing and has had pain in his right ear since he was admitted that he feels affects his hearing. He stated he has not had his hearing tested and feels nothing has been done about his pain and hearing issue, even though he had reported it to nursing staff. During the interview, the surveyor had to raise her voice so the resident could hear. Residents Affected - Few Observations on 06/04/24 at 9:44 A.M. Resident #3 was observed in his room with the television on and turned up very loud. Interview with Licensed Practical Nurse (LPN) #143 on 06/05/24 at 9:57 A.M. revealed Resident #3 has had trouble hearing since he was admitted . She stated you have to adjust your tone of voice for him to hear. She stated he turns the television up loud so he can hear it. She stated she thinks a lot of the time he reads your lips and you might have to use gestures, like pointing, so he can understand things. Interview with LPN #150 on 06/05/24 at 10:13 A.M. confirmed Resident #3 is hard of hearing and you have to raise your voice to speak to him. He also stated the resident turns up his television to very loud in order for him to hear it. Interview with Social Service Designee #102 on 06/05/24 at 10:05 A.M. confirmed the MDS assessments were not accurate for hearing for Resident #3. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365589 If continuation sheet Page 2 of 12 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 365589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hickory Creek of Athens 51 East 4th Street The Plains, OH 45780 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 ensure all resident Pre-admission Screening and Resident Review (PASRR) documents were accurate to resident current conditions and diagnoses. This affected two residents (Resident #45 and Resident #46) of three residents reviewed for PASRR documents. The census was 77. Findings Include: 1. Record review revealed Resident #45 was admitted to the facility on [DATE]. Her diagnoses were COPD, congestive heart failure, muscle weakness, cognitive communication deficit, hypertension, depression, anxiety disorder, atherosclerotic heart disease, atrial fibrillation, and bipolar disorder. Review of her Minimum Data Set (MDS) assessment, dated 03/04/24, revealed she was cognitively intact. Review of Resident #45's significant change PASRR document, dated 03/06/24, revealed under Section D, the diagnoses listed were mood disorder, panic or other severe anxiety disorder, other psychotic disorder, and bipolar disorder. But review of her diagnoses list, she did not have psychotic disorder listed in her diagnoses list, so it should not have been documented on her PASRR document. 2. Record review revealed Resident #46 was admitted to the facility on [DATE]. Her diagnoses were dementia, COPD, vitamin B12 deficiency, dysphagia, psychosis, peripheral vascular disease, Alzheimer's disease, constipation, hypertensive retinopathy, osteoarthritis, and onychogryphosis. Review of her Minimum Data Set (MDS) assessment, dated 03/11/24, revealed she had a severe cognitive impairment. Review of Resident #46's significant change PASRR document, dated 07/19/23, revealed under Section D, the diagnoses listed were mood disorder, panic or other severe anxiety disorder, other psychotic disorder, psychosis, major depressive disorder, and anxiety disorder. But review of her diagnoses list, she did not have anxiety disorder, panic or other severe anxiety disorder, other psychotic disorder, and mood disorder/major depressive disorder listed in her diagnoses list, so it should not have been documented on her PASRR document. Review of Resident #46's full diagnoses list since admission found the following diagnoses were removed and listed as being resolved: schizophrenia on 06/09/23, mental disorder on 12/12/23, major depressive disorder on 12/12/23, and schizoaffective disorder on 03/09/23. Interview with Corporate Registered Nurse (RN) #200 on 06/05/24 at 9:48 A.M. confirmed the PASRR documents provided were the most up to date. She confirmed both residents had diagnoses that should not have been listed on PASRR documents and should have been removed to make the document the most accurate when there were significant changes. She confirmed both resident PASRR documents provided were completed as significant changes, but still did not accurately reflect their diagnoses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365589 If continuation sheet Page 3 of 12 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 365589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hickory Creek of Athens 51 East 4th Street The Plains, OH 45780 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 medical record review, resident interview, staff interview, and observation, the facility failed to develop a comprehensive care plan in the area of hearing status. This affected one of four residents reviewed for communication (Resident #37). Findings include: Review of the medical record for Resident #37 revealed an admission date of 01/08/17. The resident had a diagnosis on 01/27/23 of sensorineural hearing loss bilaterally (hearing loss caused by damage to the inner ear or the nerve from the ear to the brain). Review of the annual Minimum Data Set (MDS) assessment completed 07/27/23 revealed the resident had moderate difficulty hearing and had no hearing aid. Review of MDS assessments completed 10/16/23 and 04/15/24 revealed the resident had adequate hearing and no hearing aide. The MDS assessment on 04/15/24 stated a brief interview for mental status score of 15, indicating intact cognition. Observation and interview with Resident #37 on 06/03/24 at 2:21 P.M. revealed the resident to be very hard of hearing. The resident had her television volume turned up to 68. Observation and interview with Resident #37 on 06/04/24 at 10:11 A.M. revealed the resident to be in bed with her television volume on 80. She stated she can't hear and it is getting worse. The plan of care dated 05/08/23 stated the resident had sensorineural hearing loss and would participate in audiology services as needed. Interventions included: adequate hearing, encourage non verbal communication with resident, provide reassurance and patience when communicating with resident. There were no further interventions listed related to hearing for the resident. Interview with MDS Nurse #163 on 06/04/24 at 3:55 P.M. confirmed the plan of care does not include sufficient interventions for assisting staff in communicating with the resident related to hearing loss. She confirmed the words adequate hearing were not an intervention to assist staff in communicating with the resident. She stated she did not know what encouraging non verbal communication with the resident meant. She stated a communication board could be used but was not specified in the plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365589 If continuation sheet Page 4 of 12 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 365589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hickory Creek of Athens 51 East 4th Street The Plains, OH 45780 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, resident interview, staff interview, and observations, the facility failed to residents received proper treatment and assistive devices to maintain hearing abilities. This affected two of four residents reviewed for communication (Residents #3 and #37). Residents Affected - Few Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 07/03/23. A Minimum Data Set (MDS) assessment completed 04/04/24 documented a brief interview for mental status (BIMS) score of 15, indicating intact cognition. Review of the plan of care dated 07/12/23 revealed the resident had trouble hearing and would be referred to audiology for evaluation. Review of a consultation report revealed Resident #3 had an ear care exam on 12/06/23 by a nurse practitioner. The report stated the resident's tympanic membranes were visible in both ears. There was no evidence of a hearing evaluation and the fact that the resident had trouble hearing was not mentioned in the report. Interview with Resident #3 on 06/03/24 at 9:10 A.M. revealed he has difficulty hearing and has had pain in his right ear since he was admitted that he feels affects his hearing. He stated he has not had his hearing tested and feels nothing has been done about his pain and hearing issue, even though he had reported it to nursing staff. During the interview, the surveyor had to raise her voice so the resident could hear. Observations on 06/04/24 at 9:44 A.M. Resident #3 was observed in his room with the television on and turned up very loud. Interview with Licensed Practical Nurse (LPN) #143 on 06/05/24 at 9:57 A.M. revealed Resident #3 has had trouble hearing since he was admitted . She stated you have to adjust your tone of voice for him to hear. She stated he turns the television up loud so he can hear it. She stated she thinks a lot of the time he reads your lips and you might have to use gestures, like pointing, so he can understand things. Interview with LPN #150 on 06/05/24 at 10:13 A.M. confirmed Resident #3 is hard of hearing and you have to raise your voice to speak to him. He also stated the resident turns up his television to very loud in order for him to hear it. Interview with Social Service Designee #102 on 06/05/24 at 10:05 A.M. revealed the consulting audiology company was aware in December 2023 of Resident #3 having hearing loss and possibly needing hearing aids. She confirmed the consultation report from 12/06/23 did not address hearing loss. She confirmed Resident #3's hearing loss had not been evaluated. 2. Review of the medical record for Resident #37 revealed an admission date of 01/08/17. The resident had a diagnosis on 01/27/23 of sensorineural hearing loss bilaterally (hearing loss caused by damage to the inner ear or the nerve from the ear to the brain). The plan of care dated 05/08/23 stated the resident had sensorineural hearing loss and would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365589 If continuation sheet Page 5 of 12 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 365589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hickory Creek of Athens 51 East 4th Street The Plains, OH 45780 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0685 participate in audiology services as needed. Level of Harm - Minimal harm or potential for actual harm Review of the annual Minimum Data Set (MDS) assessment completed 07/27/23 revealed the resident had moderate difficulty hearing and had no hearing aid. The care area assessment stated referral was not necessary but there was no further explanation. Review of MDS assessments completed 10/16/23 and 04/15/24 revealed the resident had adequate hearing and no hearing aide. The MDS assessment on 04/15/24 stated a brief interview for mental status score of 15, indicating intact cognition. Residents Affected - Few Observation and Interview with Resident #37 on 06/03/24 at 2:21 P.M. revealed the resident to be very hard of hearing. The resident had her television volume turned up to 68. The resident stated she had been seen by audiology but was still waiting on hearing aids. Observation and interview with Resident #37 on 06/04/24 at 10:11 A.M. revealed her to be in bed with her television volume on 80. She stated she can't hear and it is getting worse. Review of audiology consult reports revealed the following: 08/25/22 hearing difficulty per patient. Ear wax was removed. Report dated 01/27/23 revealed the patient would like time to think about hearing aid recommendation. Report dated 02/02/23 revealed the resident wants more time to think about hearing aides. Report dated 01/26/24 revealed impressions were taken for hearing aids. The hearing aids will be ordered pending insurance prior authorization. Hearing aid fitting in one month. Report dated 04/19/24 revealed pending hearing aides right and left per patient. Report dated 04/29/24 revealed still awaiting insurance approval. Review of nursing notes revealed on 05/30/24 at 12:48 P.M. Social Service Designee #102 documented she had spoken to care coordinator for the audiology service. Insurance has denied the resident a set of hearing aides at this time. Interview with Social Service Designee #102 on 06/04/24 at 3:35 P.M. revealed the facility had been working with their audiology consultants to get hearing aids for Resident #37. However, there had been issues with billing. She stated an HMO had been billed for the hearing aids and they were sending bills for $1900.00 and $400.00 in order for the resident to get hearing aids. She stated the resident was no longer under an HMO and was under Medicaid as of 04/01/24. She stated she did not know why Medicaid could not be billed for the hearing aids instead of the HMO. She stated the resident really needs hearing aids. She stated they should be covered by Medicaid. She stated she had gotten conflicting information from the audiology consultants on the status of the hearing aids. She stated on 04/29/24 she was notified by email by the audiology consulting company that the resident was getting the hearing aids that day. She stated the resident did not receive hearing aids and she was then later notified on 05/30/24 that insurance had denied the hearing aides. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365589 If continuation sheet Page 6 of 12 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 365589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hickory Creek of Athens 51 East 4th Street The Plains, OH 45780 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 record review, observation, staff interview, and policy review, the facility failed to ensure residents, who were at risk for falls and had a history of falls, had fall prevention interventions implemented as per their plan of care. This affected two (Resident #18 and #28) of three residents reviewed for accidents. Findings include: 1. Review of Resident #18's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included adult onset diabetes mellitus, unspecified psychosis, psychotic disorder with hallucinations, unspecified dementia, Parkinson's disease, insomnia, muscle weakness, unsteadiness on feet, and need for assistance with personal care. Review of Resident #18's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech. He was able to make himself understood and was usually able to understand others. His cognition was severely impaired and he was known to have other behaviors not directed at others. He also had a functional limitation in his range of motion of his bilateral lower extremities. Review of Resident #18's care plans revealed he had a care plan in place for being at risk for falls related to Parkinson's disease, decreased strength, impaired balance, personal history of falls, use of psychotropic medications, requiring assist with all mobility needs, and dizziness. The care plan was revised on 08/07/22. The goal was to minimize potential risk factors related to falls. The interventions included the need for his bed to be in its lowest position. That intervention was added on 08/04/21. On 06/03/24 at 9:45 A.M., an observation of Resident #18 noted him to be lying in bed. He was noted to have a fall mat on the floor on the left side of the bed towards the window. His bed was not noted to be in its lowest position. On 06/05/24 at 8:15 A.M., an observation of Resident #18 noted him to be lying in bed in a supine position with his eyes closed. His fall mat was on the floor to the left side of the bed. Again, his bed was not noted to be in its lowest position as it was at the height of a standard bed. On 06/05/24 at 8:20 A.M., an interview with Registered Nurse (RN) #142 revealed Resident #18 was considered to be at risk for falls. She was asked what fall prevention interventions were in place for the resident. She reported one of his fall prevention interventions was for his bed to be maintained in its lowest position. She verified the resident's bed was not in its lowest position. She noted the resident had the bed control in his right hand while he was sleeping in his bed. She stated she was not sure if the resident raised the bed or if it had been left up by someone else and his bed control was just left in his reach. She reported the bed control should be placed somewhere where the resident did not have access to so he could not raise the bed. She confirmed the resident had cognitive impairment and poor safety awareness. 2. Review of Resident #28's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia with psychotic disturbance, unspecified psychosis, anxiety disorder, restlessness and agitation, and mild cognitive impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365589 If continuation sheet Page 7 of 12 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 365589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hickory Creek of Athens 51 East 4th Street The Plains, OH 45780 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 Review of Resident #28's annual MDS assessment dated [DATE] revealed the resident did not have any communication issues and her cognition was moderately impaired. No behaviors or rejection of care was noted. Review of Resident #28's care plans revealed she had a care plan in place for being at risk for falls and had a history of falls with potential for injury. Her fall risk was related to the use of medications that increased her risk for dizziness and sedation, being bed bound per her choice., and being wheelchair bound when she was out of bed. The care plan was last revised on 03/15/23. The goal was to minimize potential risk factors related to falls. The interventions included the use of a pressure sensitive alarm (PSA) alarm to her bed. They were to check the placement and the function of the PSA every shift. That intervention was added to the care plan on 11/24/23, after the resident had a fall while trying to get out of bed. On 06/04/24 at 9:46 A.M., an observation of Resident #28 noted her to be lying in bed in a supine position with her head of bed elevated. Her eyes were closed but she was able to awaken without difficulty when spoken to. Her PSA was noted to not be plugged in to the alarm box making ineffective. The PSA pad was under her but the wire was not plugged into the alarm box that was sitting on her bedside chair. She did not have any other alarm boxes in the room and the wire was clearly not plugged into anything as it was wrapped around the assist bar on the side of the bed. On 06/04/24 at 9:59 A.M., an interview with State Tested Nursing Assistant (STNA) #114 revealed Resident #28 was considered to be a fall risk. She reported the resident was on an alarm to prevent her from falling. She was asked to accompany the surveyor to the resident's room. She confirmed the PSA was not in working order as the wire was not plugged into the alarm box making the alarm ineffective. She denied she was the one that unplugged it and also denied the resident had been out of bed that day. She claimed she had checked on her earlier that day and the other STNA working had been in there and changed her. She connected the pressure sensitive alarm to the alarm box by plugging the wire into the alarm box. She was not sure how it got unplugged. Review of the facility's policy on Fall Management (dated 10/17/16) revealed it was the intention of the facility to promote programs geared to improving mobility and reduce the risk of falls through a comprehensive, interdisciplinary process of assessment, care plan development, and implementation with ongoing monitoring and review. An interdisciplinary plan of care would be developed, implemented, reviewed, and updated as necessary to reflect each resident's current safety needs and fall reduction interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365589 If continuation sheet Page 8 of 12 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 365589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hickory Creek of Athens 51 East 4th Street The Plains, OH 45780 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to adequately review all medications for proper justification via pharmacy monthly reviews. This affected one (Resident #12) of five residents reviewed for medications. The census was 77. Findings Include: Record review revealed Resident #12 was admitted to the facility on [DATE]. Her diagnoses were type II diabetes, hemiplegia and hemiparesis, chronic bronchitis, COPD, epileptic seizures, allergic rhinitis, hypertension, personal history of traumatic brain injury, insomnia, obesity, age related nuclear cataract, macular degeneration, osteoarthritis of knee, presbyopia, hallux valgus, and dysphagia. Review of her minimum data set (MDS) assessment, dated 04/15/24, revealed she was cognitively intact. Review of Resident #12's physician orders revealed she was prescribed and administered Rifaximin Tablet 550 milligrams (mg) twice daily for prevention. This order was originally put in place on 12/14/20. Review of Resident #12's monthly pharmacy reviews and pharmacy recommendations, dated June 2023 to May 2024, revealed no documentation to support the pharmacist questions the diagnosis, the length of time, or any testing that was/was not being completed for her use of Rifaximin, which is an antibiotic. Interview with Director of Nursing (DON) and Corporate Nurse #200 on 06/05/24 at 3:02 P.M. and 06/06/24 at 2:19 P.M. confirmed there was no documentation to support the pharmacy had questioned or made any recommendations regarding the use or, and length of time Resident #12 had been on Rifaximin. Review of facility Antibiotic Stewardship Program, (dated 11/28/17), revealed the medical director, consultant pharmacist, and attending physicians support the program via participation in developing promoting, and implementing a facility-wide system for monitoring the use of antibiotics. Consultant pharmacist reviews antibiotics prescribed to residents during their medication regimen reviews and serves as resource for questions related to antibiotics. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365589 If continuation sheet Page 9 of 12 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 365589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hickory Creek of Athens 51 East 4th Street The Plains, OH 45780 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, staff interview, and policy review, the facility failed to maintain an infection prevention and control program to prevent the development and transmission of diseases and infections. This affected one of nine residents on enhanced barrier precautions (Resident #11), one of two residents receiving glucometer checks on the Brookside wing (Resident #15), and one of two residents reviewed for indwelling catheters (Resident #18). Residents Affected - Some Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 05/10/24 and diagnoses including dementia, diabetes, and alcoholic cirrhosis. The resident also had gastrostomy tube for nutrition. Observations of medication administration on 06/04/24 at 11:30 A.M. revealed Licensed Practical Nurse (LPN) #150 to administer medication through Resident #11's gastrostomy tube. Upon entering the room there was a sign on the door indicating the resident was on enhanced barrier precautions. LPN #150 did not apply a gown or gloves to administer the medications through the gastrostomy tube. The sign on the door stated staff must wear gloves and a gown for high-contact resident care activities including care or use of feeding tubes. Review of the facility policy titled Standard and Transmission-based precautions (dated 05/05/17 and updated 03/24/24) revealed enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Interview with LPN #150 on 06/04/24 at 11:40 A.M. confirmed he did not wear a gown or gloves to administer the medications through Resident #11's feeding tube and should have. 2. Review of the medical record for Resident #15 revealed an admission date of 05/10/24 and diagnoses including diabetes, chronic obstructive pulmonary disease, and neoplasm of the trachea/lung. The resident had a physician's order for insulin per sliding scale before meals and at bedtime. Observations on 06/04/24 at 11:55 A.M. revealed LPN #147 to perform a blood glucose check for Resident #15 using a glucometer machine. After performing the blood sugar test, LPN #147 cleaned the glucometer machine with an alcohol prep pad and then placed it back into the basket containing the other blood sugar supplies (extra alcohol prep pads and lancets). LPN #147 stated the glucometer machine is used for any resident that requires their blood sugar to be taken. (Each resident does not have their own glucometer machine). The surveyor asked LPN #147 if the facility policy included the use of alcohol prep pads for cleaning glucometers. LPN #147 then stated she was supposed to use a bleach disinfectant wipe to clean the glucometer. She then quickly wiped off the glucometer with a bleach disinfectant wipe and let the machine set on the top of the medication cart to dry. Review of the facility policy titled Cleaning and Disinfection of Capillary-blood sampling devices (i.e. Blood Glucose Meter) and dated 08/21/13 and revised 04/15 revealed staff were to cleanse the glucometer with a disinfectant wipe. Allow surfaces to remain wet based on the manufacturer guidelines. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365589 If continuation sheet Page 10 of 12 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 365589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hickory Creek of Athens 51 East 4th Street The Plains, OH 45780 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with Corporate RN #200 on 06/04/24 at 4:45 P.M. confirmed staff are to use a bleach disinfectant wipe to clean the glucometer and follow the instructions on the disinfectant wipe label. Review of the bleach disinfectant wipe label revealed to wipe the surface to be disinfected. Use enough wipes for treated surface to be visibly wet for the contact time listed on the label. Then let air dry. The label stated 30 second contact time for HIV and one minute contact time for Hepatitis B. The longest time was three minutes for TB and Clostridium Difficile. 3. Review of Resident #18's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included obstructive and reflux uropathy, benign prostatic hypertrophy (BPH) with lower urinary tract symptoms, and the need for assistance with personal care. Review of Resident #18's physician's orders revealed he had the use of an indwelling urinary catheter to straight drain due to an enlarged prostate. The order had been in place since 09/16/23. Review of Resident #18's care plans revealed he had a care plan in place for an alteration in elimination with use of a indwelling urinary catheter related to obstructive and reflux uropathy, BPH with obstruction, and the need for the catheter for effective emptying of his bladder. He was known to have urinary tract infections by history. The care plan was initiated on 08/04/21. The goal was for him to be free of complications related to appliance use. The interventions included the need to keep the indwelling urinary catheter bag below the level of the bladder to prevent backflow. That intervention had been in place since 08/04/21. On 06/04/24 at 10:32 A.M., an observation of Resident #18 noted him to be sitting up in a recliner in his room with his feet elevated. His indwelling urinary catheter's collection bag was hanging off the side of the trash can that was sitting next to his recliner. The clip to the collection bag was overtop of the side of the trash can and the collection bag was on the outside of the trash can. The collection bag was also noted to be in direct contact with the floor. On 06/04/24 at 11:05 A.M., an interview with LPN #147 revealed Resident #18 did have the use of an indwelling urinary catheter and also had a history of UTI's. She reported the catheter's collection bag should be maintained below the level of his bladder and should also be secured so it was not dragging on the floor. She was asked to accompany the surveyor to the resident's room. She verified his indwelling urinary catheter's collection bag was resting on the floor. She reported he normally had a taller trash can that was in his room and kept the collection bag off the floor when it was hung over the side of the larger trash can. She searched the room and could not find it. She obtained one from the area behind the nurses' station and returned it to the resident's room. She hung the clip at the top of the collection bag over the top of the larger trash can elevating it off the floor. She was not concerned with the trash can being used to hang the collection bag from as long at the catheter bag did not touch the floor. She acknowledged an increased risk of UTI's by allowing the catheter's collection bag to rest on the floor. Review of the facility's policy on Use of Indwelling Urinary Catheters (dated 03/07/15) revealed for residents with an indwelling catheter they were to use appropriate infection control practices regarding hand washing, catheter care, tubing, and the collection bag. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365589 If continuation sheet Page 11 of 12 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 365589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hickory Creek of Athens 51 East 4th Street The Plains, OH 45780 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 0881 Implement a program that monitors antibiotic use. 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 facility policy review, the facility failed to provide adequate justification and monitoring regarding the use of an antibiotic. This affected one (Resident #12) of five residents reviewed for medications. The census was 77. Residents Affected - Few Findings Include: Record review revealed Resident #12 was admitted to the facility on [DATE]. Her diagnoses were type II diabetes, hemiplegia and hemiparesis, chronic bronchitis, COPD, epileptic seizures, allergic rhinitis, hypertension, personal history of traumatic brain injury, insomnia, obesity, age related nuclear cataract, macular degeneration, osteoarthritis of knee, presbyopia, hallux valgus, and dysphagia. Review of her minimum data set (MDS) assessment, dated 04/15/24, revealed she was cognitively intact. Review of Resident #12's physician orders revealed she was prescribed and administered Rifaximin (broad spectrum antibiotic) Tablet 550 milligrams (mg) twice daily for prevention. This order was originally put in place on 12/14/20. Also, there was no evidence of laboratory services ordered or completed to monitor the effectiveness and need for Rifaximin. Review of Resident #12 progress notes, care plan, and diagnoses list found no evidence of justification for the use of Rifaximin. Interview with Director of Nursing (DON) and Corporate Nurse #200 on 06/05/24 at 3:02 P.M. and 06/06/24 at 2:19 P.M. confirmed they got an order to add liver disease to Resident #12 diagnoses list to provide justification for the use of Rifaximin. But, they also confirmed there were no physician notes, physician orders, justification on the physician orders, and laboratory services orders to monitor and determine the justification for the use of the antibiotic. They confirmed there should have been proper orders and justification for the use of this medication. Review of facility Antibiotic Stewardship Program, (dated 11/28/17), revealed the medical director, consultant pharmacist, and attending physicians support the program via participation in developing promoting, and implementing a facility-wide system for monitoring the use of antibiotics. Medical director serves as the primary medical point of contact for the program and serves as a liaison between the facility and other medical staff members. Licensed nurses participate in the program through assessment of residents and following protocols as established by the program. Prescriptions for antibiotics shall specify the dose, duration, and indication for use. Reassessment of empiric antibiotics is conducted for appropriateness and necessity, factoring in results of diagnostic tests, laboratory reports, and/or changes in the clinical status of the resident. Random audit of antibiotic prescriptions shall be performed to verify completeness and appropriateness (process measure). Attending physicians shall be provided feedback on his/her antibiotic use data. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365589 If continuation sheet Page 12 of 12