Health inspection·August 10, 2023

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few being provided. This affected two of two residents, (#61, #31) reviewed for planning and implementing care. The facility census was 70. Findings: 1. Record review of Resident #61 revealed an admission date of 05/01/23 with diagnoses including encephalopathy, gastrostomy tube, hemiplegia and hemiparesis following cerebral infarction affecting right side, chronic respiratory failure, seizures, chronic kidney disease, pressure ulcer of sacral region, anorexia, anemia, dysphagia, hypertension, aphasia, candidiasis of mouth and contracture of muscle of right hand. Review of Resident #61's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 61's Brief Interview for Mental Status (BIMS) score was not calculated due to the resident's inability to answer the question, indicating he had a severe cognitive impairment, assessment of his activities of daily living revealed total dependence with a two-person physical assist with bed mobility, transfers, dressing, toileting, personal hygiene, and total dependence of one for eating. Review of Resident #61's plan of care dated 06/02/23, revealed a deficit for impaired cognitive process for daily decision making and to be at risk for further decline in cognitive status related to his diagnosis and interventions in place to communicate with staff, family, MD/NP regarding resident's needs. Interview on 08/09/23 at approximately 3:05 P.M. with Resident #61 and his responsible party indicated a lack of neurological physician appointment that was ordered by facility nurse practitioner in June that had never been scheduled. Interview on 08/09/23 at approximately 4:10 P.M. with Director of Nursing, (DON) revealed a referral to Ohio State University Neurology department sent on 07/12/23, and was sent to Ohio State University because, they were the only place that took urgent referrals. Interview on 08/10/23 at approximately 10:28 A.M. with Resident #61's responsible party indicated a lack of knowledge or consent of the facility to initiate or provide a referral to the Ohio State University Neurology department and per Resident #61's responsible party, he would like to remain with his previous health care providers for neurological services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 2 of 25 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 365636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pickerington Care and Rehabilitation 1300 Hill Road North Pickerington, OH 43147 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to document communication of change of condition requiring new antibiotic treatments of one resident (#64) out of one resident reviewed for change in condition and failed to provide failed to provide documentation of communication for resident's dental service needs and antibiotic orders for one resident (#61) out of one reviewed for dental services. The facility census was 70. Findings include: 1.Resident #64 was admitted to the facility on [DATE]. Diagnoses included Acute Respiratory failure with hypoxia, critical illness myopathy, dependence on ventilator, obstructive sleep apnea, heart failure, hypertension, repeated falls, gastroesophageal reflux disease, obstructive and reflux uropathy, tracheostomy, gastrostomy, sepsis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #64 revealed mild cognitive impairment with no delirium or psychosis. Resident #64 had total dependence on assistance for bed mobility, personal hygiene and eating. Resident #64 did not get out of bed. Resident #64 had a tracheostomy and was ventilator dependent, had a PEG tube and received tube feedings, and an indwelling foley catheter. Resident #64 had no issues swallowing liquids. Review of physician progress note dated 07/10/23 revealed reason for visit was patient complained of suprapubic pain and diarrhea and follow-up for acute respiratory failure. Urinalysis was ordered and discussed with wife. Physician documented Resident #64 has had 2 - 3 loose stools without odor. On 07/11/23 the order for Cipro 500 milligrams (mg) twice a day for seven days indicated it was for a urinary tract infection but there is no progress note or documentation any notification to Resident#64 or family. Physician order review revealed on 07/30/23 the resident was started on Doxycycline 100 mg two times a day for 10 days for sepsis/infection. There is no documentation Resident #64, or his family were notified of the change in medication. On 08/07/23 Resident #64 was started on Zyvox 600 mg twice a day for 14 days, for upper respiratory infection. No indication of notification to family or Resident #64 was documented. Interview on 08/08/23 at 05:15 P.M. with Director of Nursing (DON) revealed the physician progress notes provided the documentation of rational for antibiotics since admission. The nursing staff do not always document but they do communicate verbally what is happening with residents. Interview on 08/09/23 at 07:57 A.M. with the Administrator confirmed the nurses were not always documenting notification of changes to families and education has been started to be sure family notifications are documented. 2. Record review of Resident #61 revealed admission dated of 05/01/23 with diagnoses including encephalopathy, gastrostomy tube, hemiplegia and hemiparesis following cerebral infarction affecting right side, chronic respiratory failure, seizures, chronic kidney disease, pressure ulcer of sacral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 3 of 25 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 365636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pickerington Care and Rehabilitation 1300 Hill Road North Pickerington, OH 43147 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few region, anorexia, anemia, dysphagia, hypertension, aphasia, candidiasis of mouth and contracture of muscle of right hand. Review of most recent MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was not calculated due to the resident's inability to answer the question, indicating he had a severe cognitive impairment. Resident # 61's assessment of his activities of daily living revealed total dependence with a two-person physical assist with bed mobility, transfers, dressing, toileting, personal hygiene, and total dependence of one for eating. Review of Resident #61's plan of care, (POC) dated 05/09/23, indicated a focus need for antibiotic therapy for an oral abscess and impaired dental status. Interventions in place included observing for possible side effects every shift related to antibiotic usage, arranging for periodic dental consultation, and to inspect oral mucous membranes and dental status during oral hygiene tasks. Review of Resident #61's record revealed a consent for treatment for dental services signed on 05/03/23. Further review revealed, physician order for nystatin suspension 100000 unit/ml four times a day starting on 05/23/23-05/29/23, record was absent for oral assessment or notification of responsible party of change of condition or consent for usage of medication. Physician order for Diflucan tablet 150 mg one by mouth daily starting 06/22/23-06/24/23, record was absent for nursing assessment for usage of medication. Physician order for Diflucan tablet 150 mg one by g-tube daily starting 07/11/23-07/13/23, record was absent for nursing assessment for usage of medication and notification of responsible party of change of condition or consent for usage of medication. Physician order for Diflucan tablet 150 mg one by mouth daily starting 08/01/23-08/03/23, record was absent for nursing assessment for usage of medication and notification of responsible party of change of condition or consent for usage of medication. Physician order for Diflucan tablet 150 mg one by mouth daily starting 08/04/23-08/10/23, record was absent for nursing assessment for usage of medication and notification of responsible party of change of condition or consent for usage of medication. Interview on 08/07/23 at approximately 12:11 P.M. with Resident #61 and his responsible party indicated a lack of dental appointment that was requested in July with concurrent treatment of dental and oral infections that were unresolved since May. Resident #61's responsible party further indicated the lack of knowledge of indication or consent for treatment of such medications related to his oral infections Interview with staff #113 on 08/10/23 approximately 10:15 A.M. revealed that on 08/09/23 Resident #61 was scheduled for an emergency dental appointment for 08/18/23 because of the previous inability to be seen by the dentist in July. Interview on 08/10/23 at approximately 10:28 A.M. with Resident #61's responsible party indicated a lack of knowledge of the emergency dental appointment for 08/18/23 that was obtained on 08/09/23 by the facility. Interview on 08/10/23 at approximately 3:10 P.M. with DON verified resident #61's medical record lacked documentation of nursing assessments for the usage of Diflucan and Nystatin and notification of Resident #61's responsible party for the usage of the medications or change of condition associated with his oral cavity. Review of facility policy, Notification of Changes dated 04/15/21 revealed, residents that were incapable of making decisions would have a representative to make decisions and would still be told (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 4 of 25 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 365636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pickerington Care and Rehabilitation 1300 Hill Road North Pickerington, OH 43147 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm what is happening to him or her. Further review revealed, the facility must inform the resident, consult with the resident's physician and or notify the resident's family member or legal representative when there is a significant change in the resident's physical, mental or psychosocial conditions, and circumstances that would require a need to alter treatment. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 5 of 25 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 365636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pickerington Care and Rehabilitation 1300 Hill Road North Pickerington, OH 43147 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, observations, and facility comprehensive care plan policy, this facility failed to develop a person center care plan to accurately reflect a resident target behavior of yelling. This affected one (Resident #30) of the two residents reviewed for mood and behavior care. The facility census was 70. Findings included: Review of the medical record for Resident #30 revealed an admission date of 05/24/23. Diagnosis included Alzheimer's disease, anxiety, Pseudobulbar Affect (symptoms include frequent and uncontrolled crying and/or laughing), and major depressive disorder recurrent with severe psychotic symptoms. Review of Resident #30's behavior monitoring order dated 05/25/23 and discontinued 08/09/23 revealed Behavior Monitoring due to anxiolytic medication, document number of episodes per shift of target behavior, target behavior includes, 1-withdrawn, 2-restlessness, 3-excessive worrying. Review of Resident #30's behavior monitoring order dated 08/09/23 revealed, Behavior monitoring-anxiolytic: Document number of episodes per shift of target behavior 1-withdrawn, 2-restlessness, 3-continuous yelling. Review of Resident #30's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating the resident with a severely impaired cognition for daily decision making abilities. No behaviors were noted with this assessment review. Resident #30 was noted to be receiving antipsychotic, antianxiety, and antidepressant medication daily. Review of the physician note dated 07/25/23 at 8:29 P.M. created by Certified Nurse Practitioner (CNP) #800 revealed, Stable , no new unusual behaviors noted per staff report. Per staff patient does have periods where she yells out but no acute changes noted. Review of the plan of care dated 08/07/23 revealed Resident #30 will remain safe in present environment, will adjust to nursing home placement, will have opportunities for freedom of expression and movement in a safe environment, and will maintain his/her normal living patterns. Due to Pseudobulbar effect, resident cries out without cause. Interventions include to allow adequate time to complete meals and other tasks, keep environment constant and dont make random changes, provide with sensory stimulation, remove resident to a quiet area with less stimulation if disruptive, and turn on music or television with in room. Review of the plan of care dated 08/09/23 revealed Resident #30 had the potential for mood and behavioral issues related to Alzheimer's disease, anxiety, pseudobulbar affect, depression. Interventions included to administer medication as ordered, attempt non-pharmacological interventions, attempt to provide a calm environment, follow up with psych services as needed, attempt to redirect, and if resistive to care reproach at a latter time. Observation on 08/07/23 10:01 A.M. of Resident #30 revealed resident laying supine in bed with her eyes closed. Resident #30 was noted to be yelling out every couple of seconds continuously for 10 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 6 of 25 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 365636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pickerington Care and Rehabilitation 1300 Hill Road North Pickerington, OH 43147 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 minuets. Continued observation at 12:01 P.M. revealed resident #30 laying in bed with her eyes closed yelling out every few seconds for another 5 minutes. Observation on 08/09/23 at 6:00 A.M. of Resident #30 revealed resident laying supine in bed with her eyes closed, yelling out every few seconds. No words were noted to be yelled and this lasted for 20 minutes. Residents Affected - Few Observation on 08/10/23 at 10:30 A.M. and again at 3:00 P.M. revealed Resident #30 laying in bed with her eyes closed, yelling out every few seconds. Each observation of yelling later between 10 to 15 minutes. Interview on 08/10/23 10:52 A.M. with the Director of Nursing (DON) revealed this resident has had these behaviors ever since she has been here. The staff have tried multiple attempts to help when she is yelling out including check and change if needed, repositioning, pain medication, one on one activities, getting up in the chair and it does not help. The DON claimed the residents daughter works in the facility during the day and will visit with the resident frequently during the day and it seems like the resident becomes sad in the evening hours her daughter leaves for the day, that is when the yelling seems to increase or be more frequent. The DON claimed they were going ot attempt another room change but not sure if that will help, they have done multiple room changes already and the current room mate seem to be ok with her yelling or it seems like it does not disturb her. When she starts the yelling staff will crack her door to help muffle the yell. Medications have been adjusted as well with some positive effects have come from this change, but not much. The DON confirmed the care plan did not directly address her yelling behavior and claimed the nursing behaviors monitoring was just updated on 08/09/23 to reflect the target behavior of yelling. Review of facility's policy titled Comprehensive Care Plans, dated 08/22/22 revealed 2.) The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. Other factors identified by the interdisciplinary team, or in accordance with the resident's preference will also be addressed in the plan of care. 3.) The Comprehensive care plan will describe, at a minimum, the following: f) Resident specific interventions that reflect the resident's needs and preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 7 of 25 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 365636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pickerington Care and Rehabilitation 1300 Hill Road North Pickerington, OH 43147 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, dialysis center interview, and facility Dialysis policy review, this facility failed to ensure Dialysis care plans were up to date to accurately reflect residents current Dialysis center and treatment days. This affected one (Resident #54) of the one resident reviewed for Dialysis care. Facility census was 70. Findings included: Review of the medical record for Resident #54 revealed an admission date of 11/16/22. Diagnoses included end stage renal disease, anemia, personal history of venous thrombosis and embolism, decreased white blood cell count, thrombocytopenia, dependence of oxygen, acute upper respiratory infection, and dependence on renal dialysis. Review of the plan of care dated 11/16/22 and revised on 12/02/22 revealed Resident #54 had potential for complications related to the diagnosis of renal failure/end stage renal disease requiring Dialysis treatment. Dialysis services were to be completed at Fresenius Kidney Care on Tuesday, Thursday, and Saturday at 10:40 A.M. Review of Resident #54's Dialysis orders for August revealed renal Dialysis was scheduled every Monday, Wednesday, and Friday at 10:30 A.M. at Davita Dialysis center. Review of Resident #54's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating an intact cognition for daily decision making abilities. Resident #54 was noted to be receiving diuretic medication daily and receiving Dialysis services. Interview on 08/09/23 at 9:30 A.M. with Fresenius Kidney Care center revealed Resident #54 was no longer a current patient at that facility. Interview on 08/09/23 at 10:41 A.M. with the Director of Nursing (DON) verified Resident #54's current care plan was not accurate and did not reflect residents current dialysis center or treatment dates. Review of facility's policy titled Dialysis Care, revised 01/2016, revealed 1.) The medical record will reflect the physicians' specific orders for each individual resident's needs for Dialysis including: a.) Orders may include fluid restriction, blood pressure, weights, labs, and days for treatment, Dialysis center of choice and medication administration of Dialysis days. 15.) Care planning for the Dialysis resident should include but not limited to: p.) Name of Dialysis Unit the resident will be receiving their treatment, days of their appointment and a phone number. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 8 of 25 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 365636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pickerington Care and Rehabilitation 1300 Hill Road North Pickerington, OH 43147 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, the facility failed to provide activities services for two out of two residents, (Resident #17 and #35 ) reviewed for activities services. The census was 70. Residents Affected - Few Findings: 1. Record review revealed Resident #17 was admitted to the facility 7/26/14 with diagnoses including Diabetes Mellitus, hemiplegia and hemiparesis, cerebrovascular disease, heart failure, major depressive disorder, chronic obstructive pulmonary disease, chronic pain syndrome, and cognitive communication deficit. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed resident was cognitively intact. Review of the annual activity evaluation completed on 09/01/22 revealed that Resident #17 preferred activities in own room and outside including spiritual or religious, walking/wheeling out or indoors, and watching TV. Review of plan of care dated 08/01/14 revealed an activity deficit, with interventions in place including providing 1 on 1 as needed and to invite or encourage or assist to group programs of interest. Review of Resident #17's activity logs from 06/28/23 to 08/08/23 was silent any activities attendance from 06/28/23 to 08/08/23. Interview with Resident #17 on 08/07/23 at 11:28 A.M. , stated that staff does not do activities with her anymore, that she would enjoy interaction with staff if someone would come in or be invited to go. Interview on 08/09/23 10:20 A.M. with Staff #135 verified accuracy of Resident #17's activity log, Resident #17 had not been provided with activities from 06/28/23 through 08/08/23. 2. Record review revealed Resident #35 was admitted to the facility 06/16/21 with diagnoses including, major depression, bipolar disorder, dementia, catatonic disorder, hypertension, anemia, adult failure to thrive, spinal stenosis and muscle weakness. Review of annual MDS dated [DATE] revealed resident was cognitively intact and activity preferences included, very important for Resident #35 to do her favorite activities, somewhat important to participate in religious services, go outside and get fresh air when the weather is good, to keep up with the news, and listen to music. Review of 05/27/22 activity evaluation revealed Resident #35 enjoys watching TV and staff will continue to encourage activities or 1 on 1 room visits. Review of Resident #35 plan of care dated 06/26/21 revealed interventions of 1-to-1 bedside/in room visit and activities if resident unable to attend out of room activities, turn on TV and music in room to provide sensory stimulation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 9 of 25 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 365636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pickerington Care and Rehabilitation 1300 Hill Road North Pickerington, OH 43147 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm Record review of Resident # 35's activity log revealed from 05/02/23 to 07/31/23 absent of documentation of any participation was provided to resident of any activities. Interview with Resident #35 on 08/07/23 at 2:20 P.M. revealed that she had not been provided with activities or 1 on 1 interaction for a long time. Residents Affected - Few Interview 08/09/23 at 10:20 A.M. with Staff #135 verified accuracy of Resident #35's activity log, Resident #35 had not been provided with activities from 05/02/23 through 07/31/23 and an annual activity evaluation had not been provided for Resident #35. Review of policies labeled as activity program dated 11/2020 with revision of 8/22 states that the facility provides activities that, reflect the choices of the residents, are offered at various hours including: morning, afternoon, evening, holidays, and weekends, attempt to reflect the interests' hobbies and personal preference of the resident and appeal to men and women as well as those of various age groups residing in the facility. The facility activity program consists of individual, small, and large group activities that are designed to meet the needs and interest of residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 10 of 25 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 365636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pickerington Care and Rehabilitation 1300 Hill Road North Pickerington, OH 43147 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to timely implement a new treatment for Resident #40's pressure ulcer as recommended by the wound doctor. This affected one resident (#40) of eight residents with pressure ulcers reviewed. The facility census was 70. Residents Affected - Few Findings include: Review of the medical record for Resident #40 revealed an admission date of 09/05/22 and diagnoses including anoxic brain damage, dependence on respirator, type two diabetes mellitus, contracture of bilateral hands and ankles, neuromuscular dysfunction of the bladder, anxiety, and cardiac arrest. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 was comatose. She was totally dependent on staff for all activities of daily living. Review of the plan of care dated 07/13/23 revealed Resident #40 had a pressure ulcer to her right buttock. Interventions included an air mattress as ordered, evaluating for pain and providing interventions, continuing wound treatment as ordered, nursing to observe wound dressing daily, observing and documenting the character of the wound weekly, observing for clinical changes, pressure reducing cushion to chair and bed, and reviewing nutrition and hydration status. Review of a physician order for Resident #40 dated 07/14/23 to 07/26/23 revealed an order for her right buttock. The wound was to be cleansed with wound cleanser, collagen was to be placed over wound bed, with calcium alginate placed over the collagen, the area was to be covered with a gauze island with a border every day shift and as needed for wound care. Review of the wound physician's note dated 07/19/23 revealed Resident #40 had a pressure ulcer to her right ischium. The physician indicated the treatment was to be changed to mesalt and a gauze island with a border to be applied once daily for 30 days. Review of the physician order for Resident #40 starting 07/27/23 revealed an order for her right buttock or ischium. The wound was to be cleansed with wound cleanser, patted dry, and mesalt was to be applied to the wound bed. The wound was to be covered with a gauze island with a border every day and as needed. Interview on 08/10/23 at 3:47 P.M. with the Director of Nursing (DON) verified there had been a delay in starting the new wound treatment for Resident #40, she was not able to identify a reason for the delay. This deficiency represents non-compliance investigated under complaint number OH00145266. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 11 of 25 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 365636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pickerington Care and Rehabilitation 1300 Hill Road North Pickerington, OH 43147 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 medical record review, observations, staff interview, facility fall investigations, and facility fall policy, the facility failed to ensure fall interventions were in place for residents with a history of falls or who were at risk for falls. This affected two (Resident #36 and #24) of the three residents reviewed for fall interventions. The facility census was 70. Findings include: 1) Review of the medical record for Resident #36 revealed an admission date of 11/15/22. Diagnoses included dementia without behavioral disturbances, encephalopathy, weakness, adult failure to thrive, repeated falls, abnormalities of gait, and unsteadiness on feet. Review of Resident #36's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 05 out of 15 indicating a severely impaired cognition for daily decision making abilities. Resident #36 required extensive assistance from one staff member for bed mobility, dressing, personal hygiene, and total assistance from two staff members for transfers and from one staff member for toilet use, and bathing. Resident #36 was noted to experience impairment to her bilateral lower extremities and requires the use of a wheelchair for mobility. Resident #36 was noted to always be incontinent of bowel and bladder function and was noted to be free of any falls for this assessment review. Review of the plan of care dated 06/14/19 revealed Resident #36 was at risk for falls. Interventions included to implement preventative fall interventions devices, keep a low bed with a fall mat beside bed while in bed, maintain call light within reach, maintain items in reach, and positioning pillows to prevent sliding. Review of the facility's un-witnessed fall report dated 01/13/23 revealed Resident #36 had experienced an un-witnessed fall. Description included, Resident observed on floor beside bed, laying on her right side. Resident states she was trying to go to the bathroom. Resident with Dementia and incontinent. Immediate action taken included a low bed with mat to side of bed. Review of a fall risk evaluation dated 05/08/23 revealed a score of 12 indicating Resident #36 was at a high risk for experiencing a fall. Observation on 08/07/23 at 9:30 A.M., at 11:20 A.M., and at 2:30 P.M. of Resident #36 revealed resident laying supine in bed, resting with her eyes opened. Resident #36's bed was noted to be raised up in the air at about hip height and no fall mats were observed on the right side of the bed on the floor. The left side of the bed was noted to be placed up against a wall. Observation on 08/10/23 at 10:20 A.M. of Resident #36 revealed resident's bed was up in the air again, not in the lowest position, and a fall mat was not on the floor next to the right side of the bed. Interview on 08/10/23 at 10:29 A.M. with the Assistant Director of Nursing (ADON) #207 confirmed Resident #36's bed was not placed in the lowest position and a fall mat was not placed on the right side of the bed on the floor as per care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 12 of 25 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 365636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pickerington Care and Rehabilitation 1300 Hill Road North Pickerington, OH 43147 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 2. Review of the medical record for Resident #24 revealed an admission date of 11/14/22 with diagnoses including dementia, psychosis, hypertension, depression, reduced mobility, cognitive communication deficit, and encephalopathy. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #24 had moderately impaired cognition. Review of the plan of care dated 07/07/21 revealed Resident #24 was at risk for falls related to history of falls, incontinence, and dependence on staff for all mobility and transfers. Interventions included anticipating and meeting resident needs, ensuring appropriate footwear, following therapy recommendations, keeping a low bed while in bed, placing call light within reach, and positioning pillows while in bed. Observation on 08/07/23 at 10:00 A.M., 1:53 P.M., and 2:50 P.M. and on 08/08/23 at 8:30 A.M., 10:40 A.M., 2:03 P.M., and 3:24 P.M. revealed Resident #24 in her bed, it did not appear to be in the lowest position. Interview on 08/08/23 at 3:24 P.M. with Licensed Practical Nurse (LPN) #114 verified Resident #24's bed was not in the lowest position; she demonstrated the bed could go lower. Review of the policy Fall Prevention Program dated 07/19/23, revealed the residents risk factors and hazards were to be evaluated when developing the comprehensive plan of care. Interventions were to be monitored for effectiveness and the plan of care was to be revised as needed. Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. This deficiency represents non-compliance investigated under complaint number OH00145437. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 13 of 25 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 365636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pickerington Care and Rehabilitation 1300 Hill Road North Pickerington, OH 43147 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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, Dialysis center agreement review and facility Dialysis policy, this facility failed to have a signed agreement between the facility and dialysis center affecting one (Resident #54) of the one resident reviewed for Dialysis services. The facility census was 70. Residents Affected - Few Findings included: Review of the medical record for Resident #54 revealed an admission date of 11/16/22. Diagnoses included end stage renal disease, anemia, personal history of venous thrombosis and embolism, decreased white blood cell count, thrombocytopenia, dependence of oxygen, acute upper respiratory infection, and dependence on renal dialysis. Review of Resident #54's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating an intact cognition for daily decision making abilities. Resident #54 was noted to be receiving diuretic medication daily and receiving Dialysis services. Review of Resident #54's Dialysis orders for August revealed renal Dialysis was scheduled every Monday, Wednesday, and Friday at 10:30 A.M. at DaVita Dialysis center. Review of the facility's Nursing Home Dialysis Transfer Agreement between the facility and DaVita (Dialysis center) revealed In witness whereof, the parties have executed this Agreement on the dates set forth by their respective names to be effective as of the Effective Date. Effective date was noted to be 08/10/23. Interview on 08/09/23 at 10:41 A.M. with the Director of Nursing (DON) verified the agreement between the facility and the Dialysis center was dated 08/10/23. Review of facility's policy titled Dialysis Care, revised 01/2016, revealed It is the policy of this facility to ensure residents that are undergoing Dialysis treatment are safe, well assessed and that the facility meet the needs of the resident in collaboration with the Dialysis Unit. 9.) There shall be a source of communication between the facility and the Dialysis Unit with each visit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 14 of 25 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 365636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pickerington Care and Rehabilitation 1300 Hill Road North Pickerington, OH 43147 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 interview and medical record review, the facility failed to ensure pain medication parameters were followed for Resident #62. This affected one resident (#62) of five residents reviewed for unnecessary medications. The facility census was 70. Residents Affected - Few Findings include: Review of the medical record revealed Resident #62 had an admission date of 05/05/23 with diagnoses including acute and chronic respiratory failure with dependence on respirator, paraplegia, total retinal detachment, traumatic cerebral edema, dysphagia, and depression. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #62 had intact cognition. Review of the plan of care dated 06/10/23 revealed Resident #62 had the potential for alteration in comfort or had actual alteration in comfort related to inability to move independently, skin alteration, surgical site, and trauma. Interventions included asking the resident regarding location, severity, and type of pain, attempting non-pharmacologic interventions prior to medicating, encouraging to request pain medication before it becomes severe, evaluating for effectiveness or need to have pain medication changed, offering analgesics per physician orders, and referring to pain management as indicated. Review of the physician order dated 05/05/23 revealed Resident #62 had an order for Acetaminophen 650 milligrams (mg) to be given every four hours as needed for a temperature of 100 degrees or above. Review of the Medication Administration Record (MAR) July 2023 revealed it was administered on 07/05/23 for a temperature of 98 degrees at 7:45 P.M. Review of the physician order dated 05/05/23 revealed Resident #62 had an order for Acetaminophen extra strength tablet 500 mg two tablets every eight hours as needed for pain. Review of the MAR for August 2023 revealed it Acetaminophen extra strength administered on 08/04/23 for a pain of four, on 08/04/23 for a pain of four, on 08/06/23 for a pain of eight, and on 08/07/23 for a pain of three. Review of the physician order dated 05/08/23 revealed Resident #62 had an order for Oxycodone capsule five mg two capsules to be given every six hours as needed for severe pain. Review of the MAR for July and August 2023 revealed two capsules of oxycodone were given on 07/16/23 for a pain of five, on 07/19/23 for a pain of six, on 07/20/23 for a pain of zero, and on 07/29/23 at 5:32 A.M. for a pain of zero and at 3:09 P.M. for a pain of six. Additional review revealed non-pharmalogical interventions were not attempted prior to administration of medication on 07/29/23. Review of the physician order dated 05/08/23 revealed Resident #62 had an order for Oxycodone capsule five milligrams, one capsule to be given every six hours as needed for moderate pain. Review of the MAR for July and August 2023 revealed one capsule of oxycodone was given 07/02/23 for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 15 of 25 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 365636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pickerington Care and Rehabilitation 1300 Hill Road North Pickerington, OH 43147 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a pain of six, on 07/03/23 for a pain of six, on 07/05/23 for a pain of three, on 07/09/23 for a pain of six, on 07/10/23 for a pain of two, on 07/15/23 for a pain of two, on 07/17/23 for a pain of six, on 07/22/23 for a pain of two, on 07/24/23 for a pain of one, on 07/25/23 for a pain of six, on 07/26/23 for a pain of five, on 07/27/23 for a pain of one, on 07/30/23 for a pain of six, on 07/31/23 for a pain of six, and on 08/08/23 at for a pain of eight. Additional review revealed non-pharmalogical interventions were not attempted prior to administration of medication on 07/05/23, 07/10/23, 07/15/23, 07/22/23, 07/24/23, and 07/27/23. Interview on 08/09/23 at 4:05 P.M. with the Director of Nursing (DON) verified a severe dose of oxycodone was provided for a pain of zero, five, and six, which would not be considered severe, and a moderate dose of oxycodone was given for pains of one, two, three, six, and eight. The moderate dose was given for pains that may be considered severe (eight), a dose that was also given for the severe medication (six), and pains that may not be considered moderate (one and two). It was also verified the Acetaminophen extra strength did not have a description for the pain it should be given for. The DON additionally verified the Acetaminophen dosed for a fever was provided when Resident #62 did not have a fever. This deficiency represents non-compliance investigated under complaint number OH00145437. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 16 of 25 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 365636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pickerington Care and Rehabilitation 1300 Hill Road North Pickerington, OH 43147 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #30 revealed an admission date of 05/24/23. Diagnoses included Alzheimer's disease, anxiety, Pseudobulbar Affect (symptoms include frequent and uncontrolled crying and/or laughing), and major depressive disorder recurrent with severe psychotic symptoms. Review of Resident #30's behavior monitoring order dated 05/25/23 and discontinued 08/09/23 revealed Behavior Monitoring due to anxiolytic medication, document number of episodes per shift of target behavior, target behavior includes, 1-withdrawn, 2-restlessness, 3-excessive worrying. Review of Resident #30's behavior monitoring order dated 08/09/23 revealed, Behavior monitoring-anxiolytic: Document number of episodes per shift of target behavior 1-withdrawn, 2-restlessness, 3-continuous yelling. Review of Resident #30's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 indicating the resident with a severely impaired cognition for daily decision making abilities. No behaviors were noted with this assessment review. Resident #30 was noted to be receiving antipsychotic, antianxiety, and antidepressant medication daily. Review of Resident #30's medication administration record (MAR) and treatment administration record (TAR) from 07/27/23 through 08/10/23 revealed no behaviors had been noted during these times of monitoring. Review of the plan of care dated 08/09/23 revealed Resident #30 had the potential for mood and behavioral issues related to Alzheimer's disease, anxiety, pseudobulbar affect, depression. Interventions included to administer medication as ordered, attempt non-pharmacological interventions, attempt to provide a calm environment, follow up with psych services as needed, attempt to redirect, and if resistive to care reproach at a latter time. Observation on 08/07/23 10:01 A.M. of Resident #30 revealed resident laying supine in bed with her eyes closed. Resident #30 was noted to be yelling out every couple of seconds continuously for 10 minutes. Continued observation at 12:01 P.M. revealed resident #30 laying in bed with her eyes closed yelling out every few seconds for another 5 minutes. Observation on 08/09/23 at 6:00 A.M. of Resident #30 revealed resident laying supine in bed with her eyes closed, yelling out every few seconds. No words were noted to be yelled and this lasted for 20 minutes. Observation on 08/10/23 at 10:30 A.M. and again at 3:00 P.M. revealed Resident #30 laying in bed with her eyes closed, yelling out every few seconds. Each observation of yelling later between 10 to 15 minutes. Interview on 08/10/23 10:52 A.M. with the Director of Nursing (DON) revealed yelling was a behavior for Resident #30 and has done this since she arrived here. As part of the nursing documentation and monitoring, they monitor the type of behavior each resident has and the number of occurence. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 17 of 25 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 365636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pickerington Care and Rehabilitation 1300 Hill Road North Pickerington, OH 43147 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 DON revealed the nursing behaviors monitoring for Resident #30 has just been updated on 08/09/23 to reflect the target behavior of yelling. Review of facility policy titled Use of Psychotropic Medication, dated 10/01/2022 revealed 11) The effects of the psychotropic medication on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis. Based on observation, interview, medical record review, and facility policy review, the facility failed to complete behavior monitoring for two residents (#16 and #30) on antianxiety medication. This affected two residents (#16 and #30) of two residents reviewed for mood and behavior. The facility census was 70. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 03/22/22 with diagnoses including acute and chronic respiratory failure with dependence on respirator, depression, type two diabetes, heart failure, chronic kidney disease, dysphagia, and traumatic subdural hemorrhage. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #16 had intact cognition. She received antianxiety and antidepressant medications. Review of the plan of care dated 04/07/22 revealed Resident #16 had a potential for adverse side effects of psychotropic drug use. She had anxiolytic and antidepressant drug therapy related to depression and anxiety. Interventions included documenting side effects of medication, notifying physician of changes in mental status, observing and documenting abnormal behavior or moods, observing for drug related complications, obtaining vital signs, reporting lab results, and reviewing for an ability to decrease dosage. Review of Resident #16's physician order dated 02/05/23 to 07/18/23 revealed an order for Buspirone 10 milligrams (mg) one tablet by mouth one time a day for anxiety. Review of the physician note dated 07/18/23 revealed they had been asked to see Resident #16 for increased anxiety. The physician indicated there was intermittent anxiety, particularly at night. They added an order for hydroxyzine. Review of Resident #16's physician order dated 07/07/23 to 07/21/23 revealed an order for hydroxyzine 25 mg one tablet by mouth every six hours as needed for anxiety for 14 days. Review of Resident #16's Medication Administration Record (MAR) from 07/01/23 to 07/18/23 revealed nothing related to monitoring for signs of anxiety. Additionally, 'as needed' hydroxyzine was not used during the 14 days it was ordered. Review of the physician note dated 07/18/23 revealed Resident #16 had intermittent anxiety, particularly at night. The physician indicated they would increase Buspirone to three times a day. Review of Resident #16's physician order dated 07/18/23 revealed an order for Buspirone tablet five mg two tablets to be given three times a day for anxiety. Review of Resident #16's MAR from 07/18/23 to 08/07/23 revealed nothing related to monitoring for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 18 of 25 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 365636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pickerington Care and Rehabilitation 1300 Hill Road North Pickerington, OH 43147 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 signs of anxiety. Level of Harm - Minimal harm or potential for actual harm Review of the progress notes from 07/01/23 to 08/07/23 revealed no documentation related to monitoring Resident #16 for signs of anxiety. Residents Affected - Few Interview on 08/09/23 at 4:05 P.M. with the Director of Nursing (DON) verified the only documentation indicating Resident #16's anxiety were the physician's notes. She reported she had interviewed staff and found that the resident had been fighting the ventilator at night. She was unsure why the hydroxyzine was not used when her anxiety continued. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 19 of 25 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 365636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pickerington Care and Rehabilitation 1300 Hill Road North Pickerington, OH 43147 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview ,record review, and facility policy review, the facility failed to document wound treatments as completed for three residents (#40, #48, and #60). This affected three residents (#40, #48, and #60) of eight residents reviewed for pressure ulcers. The facility further failed to provide documentation of oral assessments and usage of antibiotics and communication for resident's dental service needs and antibiotic orders for one resident (#61) out of one reviewed for dental services. The facility census was 70. Findings include: 1. Review of the medical record for Resident #40 revealed an admission date of 09/05/22 and diagnoses including anoxic brain damage, dependence on respirator, type two diabetes mellitus, contracture of bilateral hands and ankles, neuromuscular dysfunction of the bladder, anxiety, and cardiac arrest. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 was comatose. She was totally dependent on staff for all activities of daily living. Review of the physician order dated 05/10/23 to 07/13/23 revealed an order for Resident #40's left lower extremity (LLE) to be cleansed with wound cleanser, patted dry, covered with skin prep, and left open to air. Review of the physician order dated 07/07/23 to 07/13/23 revealed an order for Resident #40's right buttock wound. The order was to cleanse wound with wound cleanser, apply triad paste, and cover with adherent foam dressing daily. Review of the physician order dated 07/14/23 to 07/26/23 revealed an order for Resident #40's right buttock wound. The order was to cleanse the wound with wound cleanser, apply collagen to wound bed, place calcium alginate over collagen and cover with gauze island with border every day. Review of the physician order dated 07/27/23 revealed an order for Resident #40's right buttock or ischium wound. The order was to cleanse with wound cleanser, pat dry, apply mesalt to wound bed and cover with gauze island with border daily. Review of the physician order dated 07/21/23 revealed an order for Resident #40's left heel wound. The wound was to be cleansed with wound cleanser, patted dry, covered with collagen and calcium alginate and a gauze island with border every day. Review of the July 2023 Medication Administration Record (MAR) revealed one missing wound treatment to the LLE on 07/11/23. Wound treatments to the right buttocks were missing on 07/11/23, 07/21/23, 07/23/23, and 07/27/23. Additionally, documentation was missing for left heel wound treatment on 07/21/23, 07/23/23, and 07/27/23. Review of the physician order dated 07/27/23 revealed an order for Resident #40's right posterior leg wound. The order was to cleanse with wound cleanser, pat dry, apply collagen and calcium alginate, and cover with gauze island with border every day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 20 of 25 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 365636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pickerington Care and Rehabilitation 1300 Hill Road North Pickerington, OH 43147 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #40's August 2023 MAR revealed missing wound treatments to the left heel, right buttock or ischium, and right posterior leg on 08/03/23 and 08/04/23. 2. Review of the medical record for Resident #60 revealed an admission date of 03/03/23 with diagnoses including respiratory failure with dependence on respirator, encephalopathy, type two diabetes, stage four pressure ulcer of sacral region, anoxic brain damage, neuromuscular dysfunction of bladder, and cardiac arrest. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #60 was comatose. He had an indwelling catheter. Review of the physician order dated 07/08/23 to 07/26/23 revealed Resident #60 had an order related to his sacrum wound. Cleanse wound with wound cleanser, pat dry, pack with calcium alginate and silver, cover with bordered gauze island dressing every day and as needed. Review of the MAR for July 2023 revealed missing documentation on 07/11/23, 07/18/23, 07/21/23, and 07/23/23 for the sacrum wound order. Review of the physician order dated 07/27/23 revealed Resident #60 had an order related to his sacrum wound. Cleanse the wound with wound cleanser, pat dry, apply collagen to wound bed, place calcium alginate over collagen and cover with bordered gauze island dressing every day and as needed. Review of the MAR for August 2023 revealed missing documentation on 08/03/23 and 08/04/23. 3. Review of the medical record for Resident #48 revealed an admission date of 03/05/22 with diagnoses including acute and chronic respiratory failure with hypoxia with dependence on respirator, non-pressure chronic ulcer of right heel and midfoot with unspecified severity, nontraumatic intracerebral hemorrhage, peripheral vascular disease, type two diabetes, pressure ulcer of right buttock, hemiplegia and hemiparesis, and contracture's of both hands, both ankles, and left elbow. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #48 was rarely or never understood. She had one stage three pressure ulcer and a venous or arterial ulcer. Review of the physician order for Resident #48 dated 07/21/23 to 07/26/23 revealed there was a physician order for a wound to her right heel. The order was to cleanse wound with wound cleanser, pat dry, apply mesalt and cover with island gauze with border every day. Review of they physician order for Resident #48 dated 07/21/23 to 07/26/23 revealed there was a physician order for a wound to the sacrum. The order was to cleanse wound with wound cleanser, pat dry, apply calcium alginate to wound bed, and cover with gauze island with border every day. Review of the physician order for Resident #48 dated 07/27/23 revealed there was a physician order for a wound to her right heel. The order was to cleanse wound with wound cleanser, pat dry, apply santyl to wound bed, place calcium alginate over santyl and cover with island gauze with border every day. Review of the physician order for Resident #48 dated 07/27/23 revealed there was a physician order for a wound to her sacrum. The order was to cleanse wound with wound cleanser, pat dry, apply mesalt to wound bed and cover with gauze island with border daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 21 of 25 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 365636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pickerington Care and Rehabilitation 1300 Hill Road North Pickerington, OH 43147 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 0842 Level of Harm - Minimal harm or potential for actual harm Review of the July 2023 MAR revealed missing documentation for right heel and sacrum wound treatments on 07/21/23, 07/23/23, and 07/27/23. Review of the physician order for Resident #48 dated 08/03/23 revealed an order for the right calf wound. Cleanse the wound cleanser, pat dry, paint with betadine and leave open to air daily. Residents Affected - Few Review of the August 2023 MAR revealed missing documentation for the right calf, sacrum, and right heel on 08/03/23 and 08/04/23. Interview on 08/10/23 at 1:17 P.M. with the DON verified the documentation was not completed for wound treatments as it should have been. However, she knew the wound treatments had been completed based on observation and staff interview. 4. Record review of Resident #61 revealed admission dated of 05/01/23 with diagnoses including encephalopathy, gastrostomy tube, hemiplegia and hemiparesis following cerebral infarction affecting right side, chronic respiratory failure, seizures, chronic kidney disease, pressure ulcer of sacral region, anorexia, anemia, dysphagia, hypertension, aphasia, candidiasis of mouth and contracture of muscle of right hand. Review of most recent MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was not calculated due to the resident's inability to answer the question, indicating he had a severe cognitive impairment. Resident # 61's assessment of his activities of daily living revealed total dependence with a two-person physical assist with bed mobility, transfers, dressing, toileting, personal hygiene, and total dependence of one for eating. Review of Resident #61's plan of care, (POC) dated 05/09/23, indicated a focus need for antibiotic therapy for an oral abscess and impaired dental status. Interventions in place included observing for possible side effects every shift related to antibiotic usage, arranging for periodic dental consultation, and to inspect oral mucous membranes and dental status during oral hygiene tasks. Review of Resident #61's record revealed a consent for treatment for dental services signed on 05/03/23. Further review revealed, physician order for nystatin suspension 100000 unit/ml four times a day starting on 05/23/23-05/29/23, record was absent for oral assessment or notification of responsible party of change of condition or consent for usage of medication. Physician order for Diflucan tablet 150 mg one by mouth daily starting 06/22/23-06/24/23, record was absent for nursing assessment for usage of medication. Physician order for Diflucan tablet 150 mg one by g-tube daily starting 07/11/23-07/13/23, record was absent for nursing assessment for usage of medication and notification of responsible party of change of condition or consent for usage of medication. Physician order for Diflucan tablet 150 mg one by mouth daily starting 08/01/23-08/03/23, record was absent for nursing assessment for usage of medication and notification of responsible party of change of condition or consent for usage of medication. Physician order for Diflucan tablet 150 mg one by mouth daily starting 08/04/23-08/10/23, record was absent for nursing assessment for usage of medication and notification of responsible party of change of condition or consent for usage of medication. Interview on 08/07/23 at approximately 12:11 P.M. with Resident #61 and his responsible party indicated a lack of dental appointment that was requested in July with concurrent treatment of dental and oral infections that were unresolved since May. Resident #61's responsible party further indicated the lack of knowledge of indication or consent for treatment of such medications related to his oral infections (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 22 of 25 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 365636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pickerington Care and Rehabilitation 1300 Hill Road North Pickerington, OH 43147 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with staff #113 on 08/10/23 approximately 10:15 A.M. revealed that on 08/09/23 Resident #61 was scheduled for an emergency dental appointment for 08/18/23 because of the previous inability to be seen by the dentist in July. Interview on 08/10/23 at approximately 10:28 A.M. with Resident #61's responsible party indicated a lack of knowledge of the emergency dental appointment for 08/18/23 that was obtained on 08/09/23 by the facility. Interview on 08/10/23 at approximately 3:10 P.M. with DON verified resident #61's medical record lacked documentation of nursing assessments for the usage of Diflucan and Nystatin and notification of Resident #61's responsible party for the usage of the medications or change of condition associated with his oral cavity. Review of facility policy, charting and documentation dated July 2017 revealed, that all treatments and services provide to the resident, progress toward the care plan goals or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 23 of 25 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 365636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pickerington Care and Rehabilitation 1300 Hill Road North Pickerington, OH 43147 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** 2. Review of the medical record for Resident #60 revealed an admission date of 03/03/23 with diagnoses including respiratory failure with dependence on respirator, encephalopathy, type two diabetes, stage four pressure ulcer of sacral region, anoxic brain damage, neuromuscular dysfunction of bladder, and cardiac arrest. Residents Affected - Few Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #60 was comatose. He had an indwelling catheter. Observation on 08/07/23 at 9:53 A.M. and 11:50 A.M., on 08/09/23 at 3:30 P.M., and 08/10/23 at 9:10 A.M., 10:15 A.M., and 11:20 A.M. of Resident #60 revealed his foley catheter urine collection bag was lying or partially lying on the floor. Interview on 08/10/23 at 11:38 A.M. with Respiratory Therapist #122 verified Resident #60's collection bag was on the floor and should not have been there. Based on observation and interviews the facility failed to ensure the urine collection bags were kept off the floor. This was observed for two residents (#33 and #60) out of 14 residents with indwelling catheters. The facility census was 70. 1. Resident #33 was admitted to the facility on [DATE] with the most recent readmission [DATE]. Diagnoses include acute and chronic respiratory failure with hypoxia, dependence on ventilator, dementia, myoclonus, dysphagia, seizures, chronic kidney disease, contracture of left knee, left shoulder, and right shoulder, cystostomy, neurogenic bladder and urine retention, tracheostomy, and gastrostomy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 is in a persistent vegetative state with no discernible consciousness. Resident #33 is totally dependent for all mobility and sell care categories. Resident #33 has an indwelling catheter and is always incontinent of stool. Observation on 08/09/23 at 09:34 A.M. revealed Resident #33 resting quietly positioned on right side, bed in low position, urine collection bag covered and hooked on bed frame but folded and laying on floor. Interview on 08/09/23 at 09:36 A.M. with State Tested Nursing Assistant (STNA) #134 verified urine collection bag was laying on floor. STNA#134 changed the bag position so that is remained below the bladder but was hanging on the bed frame higher so that it was not touching the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 24 of 25 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 365636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pickerington Care and Rehabilitation 1300 Hill Road North Pickerington, OH 43147 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 antibiotic stewardship policy review, the facility failed to ensure residents who had orders for receiving antibiotic cream had the location for the cream to be applied and a stop date for the antibiotic cream. This effected one (Resident #222) of the five residents reviewed for appropriate medication regimen. The facility census was 70. Residents Affected - Few Findings included: Review of the medical record for Resident #222 revealed an admission date of 07/26/23. Diagnoses included a stable burst fracture of first lumbar vertebra, confusion of part of head, laceration without foreign body of right hand, and falls. Review of Resident #222's 5-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating an intact cognition for daily decision making abilities. Review of Resident #222's physician orders for August 2023 revealed a order for Bacitracin ointment, 500 units per gram. Apply to per additional direction topically every day shift. Review of the plan of care dated 08/07/23 revealed Resident #222 was on a Antibiotic Therapy related to right hand skin tear. Interventions include to administer medication as ordered, antibiotics are non-selective and may result in the eradication of beneficial microorganisms and the emergence of undesired ones, causing secondary infections such as oral thrush colitis and vaginitis, any antibiotic may cause diarrhea, nausea vomiting, anorexia, and hypersensitivity/allergic reactions, observe every shift for adverse reaction. Observe for possible side effects every shift, report pertinent lab results to the physician. Interview on 08/09/23 at 8:34 A.M. with the Director of Nursing (DON) confirmed Resident #222's antibiotic cream order did not provide a location as to where the cream was to be applied nor did it provide a stop date for this medication. The DON claimed when the facility's wound doctor made his weekly rounds he would stop in to see her and indicate a stop time and date. The DON claimed the wound doctor was scheduled to see this resident today, 08/09/23 and this would be the first time he had assessed her. Review of Resident #222's wound notes with the DON revealed the wound doctor was in the facility on 08/02/23, assessed the resident, and at that point no information was documented to acknowledge the use of a antibiotic cream, the location, or a stop date. Review of facility's policy titled Antibiotic Stewardship, dated 10/2017 revealed under section iv. Antibiotic time-out. At 72 hours after antibiotic initiation or first dose in the facility, each resident will be reassessed for consideration of antibiotic need, durations, selection, and de-escalation potential. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 25 of 25