Health inspection·December 26, 2024

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the physician Progress Note dated 10/17/24 revealed reason for the visit was to address chronic conditions including a sacral wound and to continue wound care and protein for healing. The present illness assessment included Resident #100 was nonverbal, did not follow commands and Assistant Director of Nursing (ADON) #202 reported concern for new abscess wound on the resident's bottom. Physician #201 documented upon assessment of the area, it was consistent with a chronic sacral ulcer and recommended the wound team to evaluate for possible debridement if noted to be appropriate. Review of the electronic Physician Orders revealed the sacral wound treatment dated 10/16/24 to cleanse, apply Calcium Alginate and cover had been discontinued on 10/18/24. Review of the CNP (certified nurse practitioner) Progress Note dated 10/21/24 revealed nursing requested Resident #100 be seen related to concerns including a possible wound infection. CNP #214 to continue wound treatment and have wound physician evaluate the resident. Review of Physician #201's Progress Note dated 10/22/24 revealed to continue wound treatment, protein for healing, and have the wound team evaluate. Review of the medical record revealed no documented evidence a wound treatment was completed to Resident #100's sacral pressure ulcer on 10/19/24, 10/20/24, 10/21/24 or 10/22/24. Review of the Specialty Physician Wound Evaluation & Management Summary dated 10/23/24 revealed initial assessment of Resident #100's sacral wound. Physician #213 assessed the sacral wound as a Stage IV sacrum pressure ulcer measuring 1.8 cm (l) by 4.0 cm (w) by 0.3 cm (d) with moderate serous exudate. Additional wound details included the family had insisted on lowering tube feed rate causing malnutrition. Treatment plan included Calcium Alginate once a day with gauze island with border. Review of the electronic Physician Orders dated December 2024 included an air mattress to bed (dated 03/22/24). The air mattress order did not include what setting the air mattress pump was to be set (i.e. static (firm) or low air loss alternating). A treatment dated 10/23/24 was ordered to cleanse the sacrum wound, pat dry, place Calcium Alginate to the wound bed and cover with gauze island with border daily and as needed. Review of the electronic Treatment Administration Record (TAR) dated 10/23/24 through 12/26/24 revealed the sacral pressure ulcer treatment was ordered to be completed daily; however, the order was entered in the computerized system to be every shift and the treatment was completed twice a day. Review of the care plan: Actual Area of Skin Impairment related to abscess to sacrum revised 12/11/24 revealed interventions including to continue treatment as ordered by the physician and nurse practitioner. Review of the care plan: Potential for Alteration in Skin Integrity revised 12/11/24 revealed Resident #100 required protective/preventative skin care maintenance related to bowel incontinence, decreased mobility, history of previous skin breakdown, impaired cognition, enteral nutrition and family placing copious blankets and pads under the resident despite education on risks. Interventions included an air mattress to promote comfort and prevent skin breakdown, encourage to float heels and to turn and reposition every two hours and as needed. On 12/26/24 at 10:05 A.M., observation revealed two pressure relief boots were in a chair in the resident's room. Resident #100 was observed lying in bed on an air mattress set to static (a firm (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 2 of 8 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 12/26/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few surface that makes it easier for the patient to transfer or reposition. The static mode prevents the patient from bottoming out when in a sitting position. The static button needed to be pressed again to switch back to alternating mode). Licensed Practical Nurse (LPN) #203 pulled back the resident's blanket and the resident had a pillow between his knees and under his left hip. Bilateral heels were observed pressed against the mattress, and this was verified by LPN #203 at the time of the observation. LPN #203 opened seven packages of split sponges, sprayed wound cleanser to the split sponges, removed her gloves and washed hands with soap and donned new gloves. LPN #203 then removed the old dressing exposing a large irregularly shaped sacral stage IV pressure ulcer measuring approximately 4.0 cm (l) by 6.0 cm (w) by 0.3 cm (d) with exposed bone, brown eschar, and moderate drainage with a foul odor. LPN #203 discarded the saturated dressing in the trash, used the split sponges to cleanse the wound by dabbing and wiping the wound in a downward motion. The split sponges did not appear to be overly wet and when LPN #203 wiped the entire length of the wound in a downward motion, red bleeding was observed. Hands were washed and new gloves donned, and LPN #203 ripped the upper aspect of the calcium alginate dressing leaving the edges frayed and placed it over the wound extending approximately 1.0 inch beyond the perimeter of the wound. The area was then covered with a gauze island with border. LPN #203 removed her gloves, washed her hands and positioned the resident. LPN #203 and LPN #206 left the room and Certified Nurse Assistant (CNA) #205 positioned the resident in bed and exited the resident's room. The trash with the soiled pressure ulcer dressing and supplies was left in the resident's room. An odor was noted coming from the soiled dressing in the trash. CNA #205 verified the soiled dressing and supplies were not removed from the room and reentered the room and stated she could take them to the soiled utility room for the nurse. On 12/26/24 at 2:06 P.M., interview with ADON #202 verified Resident #100's sacrum dressing changes were not completed as ordered. ADON #202 stated the wound was classified as a non-pressure wound due to starting as an abscess and turning and repositioning the resident due to his ventilator status was completed using subtle position changes. On 12/26/24 at 3:13 P.M., interview with LPN #203 verified the above treatment observation and verified Resident #100 was unable to transfer or reposition himself, was dependent on staff for all care, the resident was to be positioned at a 30 to 45 degree angle and the air mattress was firm. Review of the policy: Pressure Injury Prevention and Management revised 06/01/24 revealed the facility was committed to the prevention of avoidable pressure injuries unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. The facility was to establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. Review of the policy: Turning and Repositioning revised 06/01/24 revealed repositioning techniques in bed included to ensure heels were floating off the surface of the bed with pillows or devices designed to do so. Review of the Clinical UM Guideline: Pressure Reducing Support Surfaces - Groups 1, 2 & 3 revised 08/08/24 revealed a pressure reducing support surface is designed to prevent or promote the healing of certain types of pressure ulcers by reducing or eliminating tissue interface pressure. Most of these devices reduce interface pressure by conforming to the contours of the body so that pressure is distributed over a larger surface area rather than concentrated on a more restricted site. A Group 2 pressure reducing support surfaces included a powered pressure reducing mattresses, semi-electric (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 3 of 8 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 12/26/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hospital beds with powered pressure reducing mattresses, powered pressure reducing mattress overlays, advanced non-powered pressure reducing mattresses and advanced non-powered pressure reducing mattress overlays. A powered pressure reducing mattress (alternating pressure, low air loss, or powered flotation without low air loss) is characterized by all of the following: An air pump or blower that provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the mattress. Inflated cell height of the air cells through which air is being circulated is 5 inches or greater. Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure mattresses), and air pressure provide adequate member lift, reduce pressure, and prevent bottoming out and a surface designed to reduce friction and shear. It could be placed directly on a hospital bed frame. This deficiency represents noncompliance investigated under Complaint Number OH00160978. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 4 of 8 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 12/26/2024 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to ensure daily nursing staff data was posted as required. This had the potential to affect all 65 residents residing within the facility. Residents Affected - Many Findings include: On 12/26/24 at 8:10 A.M., observation of the reception area revealed the Daily Staffing Log posted was dated 12/24/24. This was verified by Business Office Manager (BOM) #211 at the time of the observation. On 12/26/24 at 9:17 A.M., interview with BOM #211 verified the nursing staff information had not been posted on 12/25/24 or 12/26/24 because staff responsible for posting the data was off on 12/25/24 due to the holiday and were just now returning to work. On 12/26/24 at approximately 4:15 P.M., interview with the Administrator stated the required nursing staff information was behind the posting dated 12/24/24 but had not been flipped over on 12/25/24. This deficiency was an incidental finding identified during the complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 5 of 8 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 12/26/2024 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 observation, medical record review, policy review and interview, the facility failed to maintain accurate medical records for Resident #100. This affected one resident (#100) of three residents sampled. The facility census was 65. Findings include: Medical record review revealed Resident #100 was admitted on [DATE] with diagnoses including aortic aneurysm, cerebral infarction, respiratory failure with ventilator dependence, functional quadriplegia and encephalopathy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #100 was severely impaired for daily decision-making, had no pressure ulcers and had a pressure relieving device on the bed. Review of the nursing Skin Grid Non-Pressure assessment dated [DATE] revealed Resident #100 developed a right lateral sacrum abscess 1.5 centimeters (cm) in length (l) by 1.0 (cm) in width (w). Review of the physician Progress Note dated 10/17/24 revealed reason for the visit was to address chronic conditions including sacral wound and to continue wound care and protein for healing. The present illness assessment included Resident #100 was nonverbal, did not follow commands and Assistant Director of Nursing (ADON) #202 reported concern for new abscess wound on the residents bottom. Physician #201 documented upon assessment of the area, it was consistent with a chronic sacral ulcer and recommended the wound team to evaluate for possible debridement if noted to be appropriate. Review of the Nursing Progress Note dated 10/22/24 by Licensed Practical Nurse (LPN) #203 revealed Resident #100's skin was intact. Review of the Specialty Physician Wound Evaluation & Management Summary dated 10/23/24 revealed a Stage IV sacrum pressure ulcer measuring 1.8 cm (l) 4.0 cm (w) by 0.3 cm (d) with moderate serous exudate. Review of Resident #100's medical record revealed weekly sacral wound nursing assessments completed 10/16/24 through 12/23/24 of the sacral pressure ulcer were documented as a non-pressure wound. On 12/26/24 at 9:48 A.M., interview with ADON #202 stated Resident #100's sacrum wound started off as an abscess and was documented as a non-pressure wound even though the sacrum wound was assessed by the physician to be consistent with a chronic pressure ulcer. On 12/26/24 at 12:38 P.M., interview with LPN #203 verified Resident #100's skin was not intact on 10/22/24. This deficiency was an incidental finding identified during the complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 6 of 8 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 12/26/2024 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** Based on observation, medical record review and interview, the facility failed to maintain acceptable infection control practices and ensure accurate isolation precaution sign were removed when ordered. This affected two residents (#9 and #103) during random observations. The facility census was 65. Residents Affected - Few Findings include: 1. Medical record review revealed Resident #103 was admitted on [DATE] with diagnoses including primary central nervous system lymphoma, altered mental status, anxiety disorder, malignant neoplasm of overlapping sites of the brain and depression. Review of the electronic Physician Orders dated December 2024 revealed Resident #103 utilized an air mattress to her bed. Review of the Braden Score Evaluation dated 12/21/24 revealed Resident #103 was at low risk for skin breakdown. On 12/26/24 at 8:12: A.M. and 9:58 A.M., observation of Resident #103's room revealed the footboard was missing and the air mattress pump was sitting on the floor with no barrier. The front of the air mattress pump could not be seen from the hallway, and it was unknown at that time if the pump was functioning. On 12/26/24 at 9:59 A.M. to 10:01 A.M., observation of Resident #103's room with Occupational Therapist (OT) #204 revealed Resident #103 was lying in bed on her back. OT #204 verified the footboard was missing from the resident's bed, and the air mattress pump was sitting on the floor without a barrier. Observation of the pump with OT #204 revealed the pump was not on and the air mattress was deflated. Resident #103 was asked if the bed was comfortable, and she stated the mattress was not comfortable. OT #204 verified the above at the time of the observation. On 12/26/24 at 11:29 A.M., interview with Registered Nurse (RN) #207 stated the pump was not functioning at the time of the observation because it had been determined that the electrical plug had been pulled out of the wall when moving the bed. RN #207 stated normally the air mattress pump attached to the footboard of the bed, but Resident #103's bed did not have one so that was why it was on the floor. RN #207 verified the air mattress pump should not have been sitting on the floor without a barrier. 2. Medical record review revealed Resident #9 was admitted on [DATE] with diagnoses including acute respiratory failure with ventilator dependence, heart failure, tracheostomy and pneumonia. Review of the Physician Orders dated 12/10/24 revealed Meropenem (antibiotic) one gram intravenous every eight hours for Klebsiella pneumoniae, extended-spectrum beta-lactamases (ESBL) for ten days. Contact and droplet isolation precautions were to be initiated through 12/20/24. On 12/26/24 at 1:37 P.M. and 2:00 P.M., observation revealed a droplet isolation sign was posted to Resident #9's door. A visitor was observed sitting next to the resident's bed in a chair without the use of any personal protective equipment (PPE). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 7 of 8 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 12/26/2024 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 Level of Harm - Minimal harm or potential for actual harm On 12/26/24 at 2:06 P.M., interview with the Assistant Director of Nursing (ADON) #202 verified the isolation precautions were posted on the resident's door and visitors should be wearing PPE if in a room of a resident on droplet isolation. ADON #202 checked the physician orders, confirmed the resident isolation precautions were ordered through 12/20/24 but the sign had not been removed from the resident's door. Residents Affected - Few This deficiency was an incidental finding identified during the complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365636 If continuation sheet Page 8 of 8