Health inspection·March 7, 2019

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on medical record review, staff interview, and facility policy review, the facility failed to ensure Advanced Directives listed in the medical record were accurate for Resident #73. This affected one (Resident #73) of 32 residents review for Advanced Directives. The facility census was 94. Findings Include: Review of Resident #73's medical record revealed an admission date of 11/03/18. Diagnoses included pneumonia, pulmonary embolism, altered mental status, disorientation, schizophrenia, paranoid personality disorder, alcohol dependence with withdrawal, encephalopathy, bipolar disorder and depressive disorder Review of Resident #73's Minimum Data Set (MDS) assessment, dated 02/28/19, revealed the resident had severe cognitive impairment. Review of Resident #73's current care plan, dated 11/09/18, listed the resident as a full code. Review of Resident #73's physician order, dated 11/03/18, revealed an order for full code. Review of Resident #73's Medication Administration Record (MAR) dated March 2019 under Advanced Directives listed the resident as a full code. Review of Resident #73's Do Not Resuscitate (DNR) identification form, dated 11/06/18, listed the resident as Do Not Resuscitate Comfort Care (DNRCC-Arrest). The resident and physician had signed the form. Interview on 03/06/19 at 1:35 P.M. with Licensed Practical Nurse (LPN) #405 verified Resident #73's Advanced Directives do not match in the medical record. LPN #405 verified the resident had a signed DNRCC-Arrest and the physician order listed the resident as a full code. Review of facility policy titled Advance Directives dated December 2016 revealed information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 2 of 11 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 365843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenton Nursing and Rehabilitation Center 117 Jacob Parrott Boulevard Kenton, OH 43326 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 and staff interview, the facility failed to obtain Preadmission Screening and Resident Review (PASARR) for a resident. This affected one (Resident #73) of six residents reviewed for PASARR. The facility census was 94. Residents Affected - Few Findings include: Review of Resident #73's medical record revealed an admission date of 11/03/18. Diagnoses included pneumonia, pulmonary embolism, altered mental status, disorientation, schizophrenia, paranoid personality disorder, alcohol dependence with withdrawal, encephalopathy, bipolar disorder and depressive disorder Review of Resident #73's Minimum Data Set (MDS) assessment, dated 02/28/19, revealed the resident had severe cognitive impairment. The assessment listed the resident as having schizophrenia, bipolar, and depressive disorder. Review of the form titled Hospital Exemption from Preadmission Screening ([NAME]) dated 11/02/18 revealed a diagnosis of schizophrenia. No level two screening had been completed. Interview on 03/07/19 at 2:00 P.M. with Registered Nurse (RN) #406 verified Resident #73 did not have a PASARR level two completed based on the [NAME] dated 11/02/18. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 3 of 11 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 365843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenton Nursing and Rehabilitation Center 117 Jacob Parrott Boulevard Kenton, OH 43326 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview and review of social services job description, the facility failed to provide social services to assist in identifying a guardian for a cognitively impaired resident for decision making needs. This affected one (Resident #73) of one resident reviewed for social services. The facility census was 94. Residents Affected - Few Findings include: Review of Resident #73's medical record revealed an admission date of 11/03/18. Diagnoses included pneumonia, pulmonary embolism, altered mental status, disorientation, schizophrenia, paranoid personality disorder, alcohol dependence with withdrawal, encephalopathy, bipolar disorder and depressive disorder Review of Resident #73's Minimum Data Set (MDS) assessment, dated 02/28/19, revealed the resident had severe cognitive impairment. The assessment listed the resident as having schizophrenia, bipolar, and depressive disorder. Review of Resident #73's care plan, dated 11/09/18, under discharge planning listed the resident will be discharged to home. The resident had impaired cognition related to mental illness. Interventions included to assist as needed with decision making. Review of Resident #73's admission Record (face sheet) listed the resident as his own responsible party under contacts. Review of hospital discharge records, dated 11/03/18, for Resident #73 revealed a social and family history was unable to be obtained due to the resident's mental status. Review of Social Services note, dated 11/08/18, listed legal status for Resident #73 as himself. No information regarding family relationships and listed the resident as homeless. The note did list a brother. Review of Resident #73's physician progress note dated 12/01/18 revealed the resident was homeless and used to live under a bridge. Interview on 03/06/19 at 2:03 P.M. with Director of Social Services Registered Nurse (RN) #408 stated Resident #73 does have a brother and does not want to be involved with the resident. RN #408 verified she has not attempted to obtain a guardian for the resident's medical needs. Interview on 03/06/19 at 3:00 P.M. with Business Office Manager #600 stated she has tried to contact guardians for Resident #73 but had been unable to obtain a guardian. Business Office Manager #600 verified she did not have any documentation of the attempts made to provide the resident with a guardian. Interview on 03/07/19 at 2:00 P.M. with Registered Nurse (RN) #406 verified there had been no follow up regarding obtaining a guardian for Resident #73. Telephone interview on 03/07/19 at 2:40 P.M. with Physician #500 stated he had only assessed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 4 of 11 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 365843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenton Nursing and Rehabilitation Center 117 Jacob Parrott Boulevard Kenton, OH 43326 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 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Resident #73 one time and the resident did have cognitive impairment possibly from alcohol withdrawal. Physician #500 stated he would need to see if his cognition improved next visit to determine if the cognitive impairment was due to alcohol withdrawal. Review of Director of Resident and Family Services job description undated revealed social services will ensure that medically related emotional and social needs of the resident are met/maintained on an individual basis. Event ID: Facility ID: 365843 If continuation sheet Page 5 of 11 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 365843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenton Nursing and Rehabilitation Center 117 Jacob Parrott Boulevard Kenton, OH 43326 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview and review of manufacturer guidelines, the facility failed to properly administer medications to residents. This affected two (Resident #40 and #54) of four residents observed for medication administration. The facility census was 94. Residents Affected - Few Findings include: Observation of the medication pass on 03/06/19 at 7:28 A.M. revealed Licensed Practical Nurse (LPN) #200 administered vilanterol/Fluticasone furoate (Breo Ellipta) (corticosteriod) 25 micrograms (mcg.) with 100 mcg. per inhalation to Resident #40 and did not instruct the resident to rinse his mouth with water and spit it out. Interview on 03/06/19 at 7:28 A.M. with LPN #200 further verified she had not instructed Resident #40 to rinse his mouth and spit after the administration of the inhaled medication. Observation of the medication pass on 03/06/19 at 7:41 A.M. revealed LPN #210 administered Flovent HFA (corticosteriod) 220 mcg. inhalation, one inhalation, to Resident #54 and did not instruct the resident to rinse and spit afterward. Interview on 03/06/19 at 7:44 A.M. with LPN #210 verified the lack of instructing Resident #54 to rinse and spit following the administration of the Flovent. Review of manufacturers guidelines revealed after each dose of Flovent HFA, the mouth should be rinsed with water and spit out, not swallowed. Review of the manufacturers guidelines for Breo Ellipta, revealed after administration, the mouth should be rinsed with water and spit out, not swallowed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 6 of 11 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 365843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenton Nursing and Rehabilitation Center 117 Jacob Parrott Boulevard Kenton, OH 43326 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to provide residents who required mechanically altered diets with meals of the proper texture. This affected one (Resident #7) of four residents reviewed for nutrition. The facility identified 10 residents who received a mechanically altered diet. The facility census was 94. Findings include: Review of Resident #7's medical record revealed an admission date of 04/12/18. Diagnoses included cerebral infarction, type II diabetes, muscle weakness, moderate protein calorie malnutrition, neuropathy, pseudo bulbar affect and muscle spasms. Review of Resident #7's Minimum Data Set (MDS) assessment, dated 02/22/19, revealed a Brief Interview for Mental Status (BIMS) score of nine indicating Resident #7 was moderately cognitively impaired. Resident #7 received a mechanically altered and therapeutic diet. Resident #7 was totally dependent on staff for eating. Review of Resident #37's care plan updated 02/09/19 revealed supports and interventions for nutrition and hydration. Resident #7 was dependent on staff for eating meals and was to receive diet as ordered. Review of Resident #37's physician's orders revealed an order dated 04/12/18 for Resident #7 to receive a no added salt, carbohydrate controlled diet, mechanical soft texture with nectar thick liquids. Interview on 03/05/19 at 12:48 P.M. with Dietician #400 revealed Resident #7 was on a mechanical soft diet with nectar thick liquids. Observation on 03/05/19 at 1:22 P.M. found Resident #7 seated in the dining room with State Tested Nursing Assistant (STNA) #200 seated next to her providing bites of lunch which consisted of mechanical soft chicken, baked beans, and coleslaw. Observation on 03/05/19 at 1:24 P.M. found Resident #7 reach into her mouth, pull out a quarter sized piece of cabbage from the coleslaw and threw it across the room. Resident #7 stated she couldn't eat it, it was too hard. Interview on 03/05/19 at 1:31 P.M. with Resident #7 revealed she liked the taste of the coleslaw but wasn't able to eat it because it was too big and too hard. Resident #7 said she was sorry and shouldn't throw food. Evaluation of a test sample of the coleslaw on 03/05/19 at 1:40 P.M. revealed the coleslaw was chopped and not shredded. The cabbage was crunchy and crisp. The texture would not be consistent with the definition of mechanical soft. Comparison found Resident #7's coleslaw appeared to be the same texture as the test sample. Interview on 03/05/19 at 1:50 P.M. with [NAME] #235 verified the mechanical soft coleslaw was no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 7 of 11 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 365843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenton Nursing and Rehabilitation Center 117 Jacob Parrott Boulevard Kenton, OH 43326 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete different from the regular coleslaw. [NAME] #235 stated she chopped the cabbage and thought the pieces would be fine enough. Review of the facility policy titled, Therapeutic Diets revised November 2015 revealed mechanically altered diets as well as diets modified for medical or nutritional needs will be considered therapeutic diets. Examples included altered consistency diets. The Food Services Manager will establish and use a tray identification system to ensure that each resident received his or her diet as ordered. Event ID: Facility ID: 365843 If continuation sheet Page 8 of 11 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 365843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenton Nursing and Rehabilitation Center 117 Jacob Parrott Boulevard Kenton, OH 43326 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview and facility policy review, the facility failed to clean and store dishes and utensils under sanitary conditions. This had the potential to affect 92 residents of 92 residents receiving their meals from the facility kitchen. Residents #15 and #67 did not receive meals from the kitchen. The facility census was 94. Findings include: Observations of dish washing on 03/06/19 at 11:17 A.M. revealed Dietary Aid (DA) #222 was handling dirty dishes, rinsing them with water then loading them in trays to wash them in the facility dish machine. DA #222 proceeded to run the dish machine until the were three trays of clean dishes on the clean side of the dish machine. DA #222 then proceeded to clean dishes on the other side of the dish machine without washing her hands. DA #222 emptied the clean dishes from the trays and stacked them for resident use. The dishes included plastic plate holders and metal plate holders that were still wet from the dish machine. RA #222 stacked the metal and plastic plate holders in an up-right position while they were still wet. Interview with DA #222 at the time of the observation verified she had not washed her hands after handling dirty dishes and prior to handling the clean dishes. She stated nobody washes there hands when moving from dirty side to clean side. DA #222 verified the plastic and metal plate holders were not dry when she stacked them with the other clean dishes. Upon further observation of the stacked plate holders, it was revealed there was water pooled in the plates and they were still wet. DA #222 verified the plates had water pooled in them and they were still wet. DA #22 stated that when the trays come out of the dish machine, the staff empty the trays and everyone stacks them when they are wet. Interview with Dietary Manager (DM) #234 on 03/06/19 at 11:30 A.M. verified staff were required to wash their hands after handling dirty dishes and prior to the handling of clean dishes. DM #234 verified failure to hand-wash as described would cause cross -contamination of the clean dishes. DM #234 also verified dishes should be thoroughly dry prior to stacking them to prevent water pooling inside the clean dishes. Review of the facility policy titled Warewashing, revised 09/2017, revealed all dishware, serviceware and utensils will be cleaned and sanitized after each use. The dining serviced staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine and proper handling of sanitized dishware. All dishware will be air dried and properly stored. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 9 of 11 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 365843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenton Nursing and Rehabilitation Center 117 Jacob Parrott Boulevard Kenton, OH 43326 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 0850 Hire a qualified full-time social worker in a facility with more than 120 beds. Level of Harm - Potential for minimal harm Based on staff interview and review of facility bed capacity, the facility failed to ensure a Licensed Social Worker (LSW) was employed by the facility. This had the potential to affect all 94 residents who reside in the facility. Residents Affected - Many Findings include: Review of the facility's bed capacity revealed the facility was certified for 125 beds. Interview on 03/06/19 at 2:03 P.M. with Director of Social Services Registered Nurse (RN) #408 stated she provides any needed social services for the residents. RN #408 stated the facility has one LSW that visits the facility once a week. Interview on 03/07/19 at 2:00 P.M. with RN #406 verified the facility does not have a LSW on staff and the facility has been having difficulty finding a LSW. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 10 of 11 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 365843 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenton Nursing and Rehabilitation Center 117 Jacob Parrott Boulevard Kenton, OH 43326 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 Based on observation, staff interview, and policy review, the facility failed to maintain infection control practices during medication administration when nursing touched oral medications intended for oral administration. This affected two (Resident #40 and #54) of four residents observed for medication administration. The facility census was 94. Residents Affected - Few Findings include: Observation of the medication pass on 03/06/19 at 7:28 A.M. revealed Licensed Practical Nurse (LPN) #200 touched the Buspar (antianxiety) five milligram (mg.) tablet and the Venlafaxine (antidepressant) 37.5 mg. tablet, intended for Resident #40, with her bare hands. She approached Resident #40 with the medications and was stopped by this surveyor before administering the contaminated medications. Interview on 03/06/19 at 7:28 A.M. with LPN #200 provided verification of the break of infection control practices when she touched the Buspar and Venlafaxine. Observation of the medication pass on 03/06/19 at 7:41 A.M. revealed LPN #210 touched the aspirin 81 mg. tablets intended for administration to Resident #54. She approached Resident #54 and was stopped by this surveyor. Interview on 03/06/19 at 7:44 A.M. with LPN #210 provided verification of the break of infection control practices when she touched the aspirin tablets intended to be administered to residents. Review of the facility policy titled Administering Medications, dated 12/2012 revealed staff should follow established infection control procedures, examples of antiseptic technique, for the administration of medications, if applicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 11 of 11