Health inspection·February 13, 2020

F 0583 Keep residents' personal and medical records private and confidential. 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 #76 revealed the resident was originally admitted to the facility on [DATE]. Diagnoses include osteomyelitis (infection into the bone) of the vertebrae, sacral and sacrococcygeal region, (tailbone) , pressure ulcers of the sacral region, paraplegia, urine retention, colostomy status, mental and behavioral disorders,, cramps and spasms, bilateral above the knee amputations and obesity. Residents Affected - Few Review of the quarterly MDS assessment, dated 01/29/20, revealed the resident had no cognitive deficits and was dependent for activities of daily living except for eating. It further revealed the resident had four pressure ulcers. Review of the physician orders, dated 01/22/20, revealed the resident had a wound vac to the sacral region pressure ulcer which was to be changed three times per week. The area was to be irrigated with Normal Saline and the area around the wound was to be washed with soap and water, rinsed and patted dry. Skin prep was to be applied around the wound. Agents were to be applied to ensure the edges would seal to the wound vac, and black sponge was to be applied to the wound bed, then the dressing was to be secured. Observation of the dressing change for Resident #76 on 02/12/20 at 3:20 P.M. revealed Licensed Practical Nurse (LPN) #444 and LPN #431 prepared the resident for the dressing change and closed the resident's door. The privacy curtain was taped back in a manner it could not easily be pulled to provide the resident privacy. The window blinds were left open. The resident laid naked in the bed during the dressing change. On two occasions, a staff member knocked on the resident's door. LPN #444 and #431 stated resident care but the State Tested Nursing Assistant (STNA) proceeded to come in and ask the nurses questions, while the resident was exposed. Additionally, during the dressing change, two males were observed to be walking outside the resident window and the blinds were not pulled closed. Interview with LPN #431 on 02/12/20 at 3:40 P.M. verified the resident was not provided privacy during the dressing change. She stated the blinds should have been pulled closed, and the STNA should not have been entering the room during the dressing change. She further stated she did not know why the privacy curtain was taped back and she did not pull the privacy curtain for the resident. Review of an undated facility policy titled Dignity revealed staff shall promote, maintain, and protect resident privacy, including bodily privacy assistance with personal care and during treatment procedures. Review of facility policy Dressings - Dry and Clean dated 09/2013 revealed part of the preparation for a dressing was to provide privacy to the resident. This deficiency substantiates Complaint Number OH00109754. Based on record review, observation, resident and staff interview and review of the facility's policy, the facility failed to provide reasonable privacy when a resident's door could not close and not shutting the window curtains when providing care. This affected two (Resident #76 and #85) of 26 residents observed in the initial and final sample pool. The facility census was 89. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 2 of 24 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 02/13/2020 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 0583 Findings include: Level of Harm - Minimal harm or potential for actual harm 1. Review of medical record for Resident #85 revealed an initial admission date of 01/29/20. Diagnosis included Alzheimer's disease, vascular dementia with behavioral disturbance, Parkinson's disease, generalized anxiety disorder, psychotic disorder with delusions due to known physiological condition, polyneuropathy and visual hallucinations. Residents Affected - Few Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/05/20, revealed the resident was cognitively intact. The resident required extensive one person assistance with bed mobility, transferring, walking in room and corridor, locomotion off and on the unit, dressing, toilet use, and personal hygiene. Intermittent observations from 02/10/20 at 10:17 A.M. to 02/12/20 at 5:07 P.M. revealed the position of Resident #85's bed prevented the resident room door from closing. The headboard of the bed was completely against the wall and the footboard would not allow the door to close by approximately twelve inches. Interview on 02/10/20 at 10:00 A.M. with Resident #85 revealed the resident's door would not close by approximately twelve inches due to the resident's bed positioning. Resident #85 expressed he would like the door to close and was expecting maintenance today to assist with room arrangement. On 02/11/20 at 6:18 P.M., subsequent interview with Resident #85 stated the resident would like for the resident's room door to shut for privacy. Resident #85 stated maintenance was supposed to fix it yesterday and today. Interview on 02/11/20 at 6:30 P.M. with State Tested Nursing Aide (STNA) #447 verified Resident #85's bed was preventing the resident's door to close. STNA #447 verified Resident #85's headboard was completely against the wall and the footboard would not allow the door to close. Interview on 02/12/20 at 5:07 P.M. with Maintenance Supervisor #492 verified Resident #85's resident room door was unable to close due to the positioning of the bed. Maintenance Supervisor was not aware and revealed no work order had been received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 3 of 24 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 02/13/2020 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 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 and resident interviews, and policy review, the facility failed to conduct quarterly care conferences. Additionally, the facility failed to ensure a resident and appropriate/required members of the interdisciplinary team (IDT) were invited to participate in the care planning process. This affected three (#8, #27, and #50) of four resident reviewed for care planning. The facility census was 89. Findings include: 1. Review of the medical record for Resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease, muscle weakness, venous insufficiency, diabetes mellitus type two, muscle wasting and atrophy, personality disorder, chronic embolism, heart failure, hypertension, chronic obstructive pulmonary disease, osteoarthritis, neuromuscular dysfunction of he bladder, Parkinson's disease, atrial fibrillation, anxiety, tremors, psychosis, morbid obesity, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/21/19, revealed Resident #8 had intact cognition. Review of the care plan conference summary, dated 10/09/19, revealed a care planning conference was conducted for Resident #8. Review of the summary revealed Social Service Director (SSD) #502, Licensed Practical Nurse (LPN) #414 and Activities Director (AD) #400 were in attendance. The document revealed no evidence Resident #8 was invited or refused to participate in the care planning process. Additionally, the documentation revealed no evidence a state tested nurse aide (STNA) or registered nurse (RN) participated in the care planning process. Review of a care plan conference summary, dated 01/15/20, revealed a care planning conference was conducted for Resident #8. Review of the summary revealed SSD #502 and AD #400 were in attendance. The document revealed no evidence Resident #8 was invited or refused to participate in the care planning process. Additionally, the documentation revealed no evidence an STNA or RN participated in the care planning process for Resident #8. Interview on 02/10/20 at 10:38 A.M. with Resident #8 revealed the resident was unsure when he/she was last invited to participate in the care planning process. The resident stated if the facility staff would invite the resident to care conferences the resident would be willing to participate. Interview on 02/12/20 at 8:30 A.M. with SSD #502 revealed the care plan conferences were held for the residents every three months. The SSD revealed the care planning conferences were to include the residents representative, the resident, social services, activities, and someone from the nursing department, which was usually the MDS nurse. SSD #502 revealed the care conferences were documented on a care conference sheet. The care conference sheet would include the date of the conference, summary of the meeting and the signature of who attended the meeting. The SSD stated STNAs were not invited to participate with care conferences because the STNAs were busy providing resident care and it was hard for the STNAs to get away from their work. SSD verified the care planning conferences for Resident #8 conducted on 10/09/19 and 01/15/20 had no evidence of the resident being invited to participate in the care planning process. The SSD further verified there was no registered nurse or STNA in attendance. 2. Review of the medical record for Resident #27 revealed an admission date of 01/15/19 with diagnoses of chronic obstructive pulmonary disease, congestive heart failure, peripheral nervous system (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 4 of 24 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 02/13/2020 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few disorder, chronic viral hepatitis, hemiplegia and hemiparesis. Review of the annual MDS assessment, dated 12/31/19, revealed Resident #27 was cognitively intact with no deficits. Review of the care conference documentation revealed one care conference was held for Resident #27 on 10/09/19 with SSD #502, Activities Director #400, and MDS Coordinator #414. Resident #27 was not present and there was no evidence the resident was invited to participate or of the resident's refusal. Interview on 02/10/20 at 11:23 A.M. with Resident #27 revealed the resident has never been invited or attended a care conference. Interview on 02/12/20 at 4:25 P.M. with SSD #502 verified there was no documentation of the resident attending or refusing to attend a care conference since the admission date of 01/15/19. SSD #502 stated the care conferences were held on 04/10/19, 07/17/19, and 01/22/20 however there was no documentation. SSD #502 verified the care conference on 10/09/19 was only attended by SSD #502, Activities Director #400, and Minimum Data Set (MDS) Coordinator #414. 3. Review of medical record for Resident #50 revealed an initial admission date of 08/20/19. Diagnosis included essential (primary) hypertension, type two diabetes mellitus with hyperglycemia dysphagia, history of transient ischemic attack and cerebral infarction without residual deficits, muscle wasting and atrophy, muscle weakness, difficultly walking, allergic rhinitis, vitamin D deficiency, mastodynia, chronic kidney disease stage three, hyperlipidemia, functional intestinal disorder, unspecified mood disorder, acute kidney failure, anemia, constipation, obstruction of duodenum, bipolar disorder and glaucoma. Review of the MDS assessment, dated 01/08/20, revealed the resident was cognitively intact. Review of the care conference documentation revealed a care conference was held for Resident #50 on 11/20/10. There was no evidence the resident was invited to attend or refused to attend. There was no evidence there was a RN present during the care conference. Interview on 02/10/20 at 2:56 P.M. with Resident #50 revealed the resident has not been invited to or attended any care conferences. Interview on 02/12/20 at 4:23 P.M. with SSD #502 verified a care conference was held for Resident #50 on 11/20/19 and only attended by SSD #502 and Activities Director #400. There was no nursing staff present and no evidence of the resident attending or refusing to attend. Review of the facility's policy titled Care Planning, revised 09/2013, revealed the resident, the resident's family and/or the resident's legal guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 5 of 24 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 02/13/2020 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's policy and staff and resident interview, the facility failed to ensure residents were provided with comprehensive discharge summaries with the required information upon discharge from the facility. This affected five residents (#136, #137, #138, #139, #141) of six residents reviewed for discharge. The facility identified 20 residents discharged from the facility in the last 60 days. The facility census was 89. Findings include: 1. Review of the medical record for Resident #137 revealed the resident was admitted to the facility on [DATE] and discharged to home on [DATE]. Diagnoses included urinary tract infection, repeated falls, hypertension, anemia, muscle wasting, difficulty walking, joint pain, low back pain, allergic rhinitis, gastro-esophageal reflux disease and urine retention. Review of the discharge return not anticipated Minimum Data Set (MDS) assessment, dated 01/13/20, revealed the resident had intact cognition. The resident required extensive assistance of staff for bed mobility, dressing, toilet use, and personal hygiene. The resident required limited assistance for transfers and ambulation. Review of the physician note, dated 01/13/20, revealed the resident's discharge was anticipated for that day and the resident would be followed by urology. Review of a letter, dated 01/10/20, revealed Resident #137 was informed that on 01/13/20 their care was going to be transferred to home health care with a diagnosis of a fractured right femur. It revealed transportation was to be provided by a cab service. Home health was to be started on 01/14/20. Ordered equipment was listed. No contact information was provided regarding any of the resident's follow up needs. The letter was not signed by the resident to ensure it was provided prior to him leaving the facility. There was no medication recapitulation attached to the letter. Interview with Social Service Director (SSD) #502 on 02/12/20 at 3:00 P.M. revealed the letter provided to the resident before discharge did not meet the required criteria. She verified there was no medication recapitulation attached. 2. Review of the medical record for Resident #138 revealed the resident was admitted to the facility on [DATE] and was discharged to home on [DATE]. Diagnoses included aftercare of hip surgery, low back pain, muscle wasting, spinal stenosis, osteoarthritis and benign prostatic hypertrophy. Review of the discharge with return not anticipated Minimum Data Set (MDS) assessment, dated 12/23/19, revealed the resident had no cognitive deficits. The resident required extensive assistance with bed mobility, transfers, walking, dressing, toileting and hygiene and was independent with locomotion and eating. Review of the physician orders, dated 12/18/19, revealed the resident was to be discharged to home with home health, physical therapy, occupational therapy and bath aides if needed. Review of a letter, dated 12/23/19, revealed the resident was informed their care was being (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 6 of 24 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 02/13/2020 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 0661 Level of Harm - Minimal harm or potential for actual harm transferred to home health care following a hip joint prosthesis The form had no place for the resident to sign it had been received by the resident and there was no information that documented what nursing discussed with the resident. There was no contact information for the resident for an of the follow up care he was to receive. A separate form was provided to show medications were reviewed and was signed by the resident on 12/23/19. Residents Affected - Some Interview with SSD #502 on 02/12/20 at 2:48 P.M. verified the letter the resident received was the transfer form the residents were to receive when they were transferred to the hospital. She stated it was not the correct form for residents who were being discharged to home and it did not contain the required information. She stated as of the end of 01/2020, the facility had started to use a new form which included the discharge date , transportation, services requested, agencies utilized and contact information, medications, diet and a resident signature. 3. Review of the medical record for Resident #139 revealed the resident was admitted to the facility on [DATE] and was discharged to home on [DATE]. Diagnoses included volume depletion, chronic kidney disease stage III, ileostomy status, adrenocortical insufficiency, hypertension, chronic obstructive pulmonary disease, osteoarthritis, depression, migraines, opioid dependency, psychoactive substance abuse, viral hepatitis C, thrombophilia, protein calorie malnutrition and low back pain. Review of the physician orders, dated 01/13/20, revealed the resident could be discharged home with home health and medications on 01/15/20. Review of a letter, dated 01/16/20, which was provided to the resident revealed the resident's care was being transferred to home with home health for volume depletion. The resident was provided a summary of medications and the name of the physician and address. The form was not signed by the resident. No phone numbers were provided for the resident's follow up. Interview with SSD #502 on 02/12/20 at 2:55 P.M. revealed a discharge planning conference was held in the resident's room and went over everything the resident needed, but the information was not provided to the resident. She verified the wrong form was used and the resident did not receive the required discharge summary. 4. Review of the medical record for Resident #141 revealed the resident was admitted to the facility on [DATE] and discharged on 10/31/19. Diagnoses included fracture of the right femur, diabetes mellitus type II, hypertension, hyperlipidemia, muscle wasting, difficulty walking and repeated falls. Review of the physician orders, dated 10/30/19, revealed the resident could discharge to home when she was ready, with a two wheeled walker, home health and therapy. Review of a letter, dated 10/31/19, revealed the resident was informed their care was being transferred to home health for orthopedic issues. Transportation was to be provided by the resident's family. Home health was arranged and follow up appointments had been made. There was no contact information provided for the resident regarding the follow up care. The form revealed it had been given to the resident upon discharge but was not signed by the resident. Interview with SSD #502 on 02/12/20 at 3:05 P.M. revealed a discharge planning conference was held in the resident's room and went over everything there resident needed, but the information was not provided to the resident. She verified the wrong form was used and the resident did not receive the required discharge summary with the required information. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 7 of 24 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 02/13/2020 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. Review of the medical record for Resident #136 revealed an admission date of 01/08/19 and a discharge date of 02/04/20. Diagnosis included end stage renal disease, muscle wasting and atrophy, muscle weakness, arteriosclerotic heart disease of native coronary artery without angina pectoris, heart failure, muscle wasting and atrophy, difficulty walking, cognitive communication, dysphasia oropharyngeal phase, chronic obstructive pulmonary disease, type II diabetes, unspecified dementia, unspecified arthritis, hyperlipidemia, dependence on renal dialysis, epilepsy, encephalopathy, acquired absence of right toe and major depressive disorder. Review of the annual Minimum Data Set (MDS), dated [DATE], revealed the resident was unable to complete the interview. Review of the discharge summary for Resident #136 revealed a list of medication was not included on the discharge summary. There was no evidence the discharge summary was reviewed with the family. Interview on 02/12/20 at 4:30 P.M. with SSD #502 verified the discharge summary sheet was sent with transport and not reviewed with the family. SSD #502 revealed nursing would have provided a list of medications to the resident and their family but the information was not provided to SSD #502 to include. Review of the facility's policy titled Discharge Summary and Plan, dated 11/2014, revealed when the facility anticipated a resident's discharge to a private residence, a discharge summary and a post-discharge plan was to be developed which was to assist the resident to adjust to their new living environment. The discharge summary was to include a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge in accordance with the established regulations governing release of resident information. The summary was to include a medically defined condition and prior medical history, medical status measurement including but not limited to information on vital signs, clinical laboratory values, diagnostic testing, physical and mental functional status including the ability to perform activities of daily living including bathing, dressing, grooming, transferring ambulating, toileting, eating, and also the need for staff assistance with these areas. The summary was also to include sensory and physical impairment, nutritional status and requirements, special treatments or procedures, mental and psychosocial status, discharge potential , mental condition, activities potentials, rehabilitation potential, cognitive status and medication therapy. The information was to be provided to the resident and discussed with the resident 24 hours before the discharge was to take place. This deficiency substantiates Complaint Number OH00109754. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 8 of 24 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 02/13/2020 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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, observation, staff interview and facility policy review, the facility failed to complete accurate, routinely wound assessments for Resident #73. This affected one (#73) of four residents reviewed for non-pressure wounds. The facility census was 89. Residents Affected - Few Findings include: Review of the medical record for Resident #73 revealed an initial admission date of 10/23/19. Diagnoses included hemiplegia/hemiparesis, end-stage renal disease, diabetes, morbid obesity, peripheral neuropathy, cellulitis and malignant neoplasm of the bone and articular cartilage. Review of the admission Clinic Health Status form, dated 10/23/19, revealed Resident #73 had a second toe plantar side ulcer and redness of the coccyx noted on the skin assessment. The body diagram identified the toe ulcer on the left foot. There was no other wound assessment information included for the coccyx wound or the foot wound. The resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the admission Clinic Health Status, dated 12/03/19, revealed Resident #73 was readmitted to the facility with two by two pressure wound noted on the skin assessment. The body diagram identified the location at the coccyx area. The skin assessment noted an area eight by five surgical identified on the body diagram at Resident #73's right foot. There was no other wound assessment information included for the coccyx wound or for the foot wound. The resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the admission Clinic Health Status, dated 12/19/19, revealed Resident #73 was again re-admitted to the facility with surgical site as previous noted on the skin assessment. The body diagram identified the wound location on Resident #73's right foot. The nurse progress note indicated the surgical site to right foot improved. There was no other wound assessment information included for the foot wound. Review of the current physician orders, dated 02/2020, revealed there were wound vac orders were in place for Resident #73's right foot. She had a current order for barrier cream to her buttock every shift and as needed. Review of the facility's wound tracking form revealed one non-pressure wound assessment was completed on 02/02/20 in regard to the coccyx. The body diagram demonstrated four areas on the buttock, one on the left and three on the right. There were three partial assessments for the four areas. The assessments failed to identify the location of the wound, whether it was present on admission or the type of wound. The assessments were documented on a single form rather than an individual form for each separate wound. Observation of wound care on 02/12/20 at 11:35 A.M. with Wound Care Nurse Practitioner (NP) #399 and Licensed Practical Nurse (LPN) #410 revealed Resident #73 had three open areas on her right buttock, one open area on her left buttock and a wound vac in place on the right foot. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 9 of 24 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 02/13/2020 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with NP #399 at the time of the observation stated this was her first observation of the wounds. NP #399 assessed the buttock wounds and stated the wounds were moisture associated skin damage and ordered a new treatment to be initiated for wound care. Interview on 02/12/20 at 3:04 P.M. with LPN #410 verified upon Resident #73's initial admission to the facility (10/23/19) she had an unhealed wound to her right foot. About six weeks ago, Resident #73 had her right fifth toe amputated and currently has a wound vac in place at her surgical wound. LPN #410 verified Resident #73 had wounds on her buttock and the wounds had been there for quite a while. LPN #410 she verified wound assessments were not completed at a minimum of weekly for Resident #73. Interview with the Director of Nursing (DON) on 02/13/20 at 12:15 P.M. verified during Resident #73's stays at the facility from 10/23/19 to 11/27/19, 12/03/19 to 12/13/19 and from 12/19/19 to 02/12/20 there were no full, complete wound assessments. Review of the facility's policy titled Dressings, Dry/Clean, revised September 2013, revealed the following information should be recorded in the resident's medical record, treatment sheet or designated wound form: The date and time the dressing was changed; The wound appearance, including wound bed, edges, presence of drainage; The name and title (or initials) of the individual changing the dressing; The type of dressing used and wound care given; All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound; How the resident tolerated the procedure; Any problems or complaints (e.g., pain or discomfort) made by the resident related to the procedure; If the resident refused the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives. Document family and physician notification of refusal; and The signature and title (or initials) of the person recording the data. This deficiency substantiates Complaint Number OH00109754. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 10 of 24 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 02/13/2020 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, review of chemical warning labels, staff interview and facility policy review, the facility failed to have safe storage of chemicals. This had the potential to affect nine residents (#32, #33, #51, #58, #32, #36, #49, #33 and #83) who were both cognitively impaired and independently mobile as identified by the facility. The facility census was 89. Findings include: 1. Observation of the central Bath room on the 400 hall revealed the door was unlocked and partially opened. Further observation of a cart in the room revealed an opened container of Sani-cloth bleach germicidal wipes. The container had Caution keep out of reach of children on the label. Interview with Licensed Practical Nurse #444 on 02/12/20 at 1:10 P.M. verified the central bath room was to be locked at all times. She further verified the sani germicidal wipes were a hazardous chemical that was supposed to be locked up at all times and should have been in a locked cabinet. 2. Observation on 02/11/20 at 8:52 A.M. of the central bath located on the 100-hallway revealed the door was not locked. Observation of the 100-hallway central bath revealed a container of sani cloth bleach wipes and a container of super sani cloth germicidal disposable wipes was sitting on top of a cabinet, unsecured. Continued observation of the 100-hallway on 02/11/20 at 8:57 A.M. revealed the door for the soiled utility room was not locked. Located in the soiled utility room, sitting on top of the sink, was a spray bottle of deodorizer fresh scent which contained a blue liquid (the spray bottle was ¾ full of the liquid) and a container of Sani cloth wipes. Review of the review of the warning label located on the container of sani cloth bleach wipe revealed a precautionary statement which identified the contents of the container were hazardous to humans. The label revealed the contents causes moderate eye irritation, avoid contact with eyes or clothing, wash thoroughly with soap and water after handling and before eating, drinking, chewing gum, using tobacco, or using the toilet. The label identified to call poison control center or doctor for treatment advice. Review of the review of the warning label located on the container of super sani-cloth germicidal disposable wipes identified the contents were hazardous to humans. The warning included causes substantial but temporary eye damage. Do not get in eyes or on clothing. Avoid contact with skin. Wash hands thoroughly with soap and water after handling and before eating, drinking, chewing, gum, using tobacco, or using the restroom. Review and wash contaminated clothing before reuse. Review of the review of the warning label located on the container of deodorizer fresh scent in a spray revealed avoid breathing mist or spray and wear protective gloves, if on skin wash wash with plenty of soap and water. The label revealed if skin irritation or rash occur get medical advice/attention. Wash contaminated clothing before reuse. Interview on 02/11/20 at 8:53 A.M. with Employee #600 verified the utility room on the 100-hallway was not locked. The employee revealed the door had not function properly and was not able to be locked for approximately three months. Employee #600 further verified utility room contained chemicals that were being stored in an unsecured area. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 11 of 24 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 02/13/2020 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 02/11/20 at 8:58 A.M. with Licensed Practical Nurse (LPN) #439 verified the central bath located on the 100-hallway was unlocked and contained two containers of chemicals that were not being stored in a secured location. 3. Observation on 02/11/20 at 9:29 A.M. of the 400-hallway central shower room revealed the door was unlocked. Observation of the shower room revealed an unlocked cabinet which contained fingernail files, orange sticks, a box of disposable twin blade razors, mouth wash, and shaving cream. Further observation of the shower room revealed a bottle of ketoconazole shampoo. The prescription label that was located on the bottle of ketoconazole shampoo was worn off the bottle. Interview on 02/11/20 at 9:35 A.M. with Registered Nurse (RN) #418 verified the 400-hallway central shower room was unlocked. RN #400 further verified the cabinet located in the shower room which contained fingernail files, orange sticks, a box of disposable twin blade razors, mouth wash, and shaving cream was not locked. RN #400 verified the ketoconazole shampoo was unsecured in the shower room. The RN was unsure of which resident the shampoo was prescribed. Review of the facility's list of residents who were cognitively impaired and independently mobile revealed Resident #32, #33, #51, #58, #32, #36, #49, #33 and #83 were cognitively impaired and independently mobile. Review of the facilities chemical protocol, undated, revealed all chemicals are to be stored in a locked box. If chemicals are left in the janitors closet, the door must be locked. Review of the facilities undated policy and procedure titled, Hazardous Material Storage and Handling revealed never leave containers of cleaning chemicals or other hazardous materials unattended. Store chemicals an other supplies used for cleaning in locked cabinets and closets when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 12 of 24 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 02/13/2020 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview; the facility failed to obtain physician orders and provide care and services for a resident's indwelling urinary catheter. This affected one (#137) of three residents reviewed for urinary catheter. The facility identified eight residents with indwelling urinary catheters. The facility census was 89. Findings include: Review of the medical record for Resident #137 revealed the resident was admitted to the facility on [DATE]. Diagnoses included muscle wasting, lower back pain and retention of urine. Review of the admission assessment, dated 02/08/20, revealed Resident #137 was admitted to the facility with an indwelling urinary catheter. Review of the medical record for Resident #137, which included admission orders, physician telephone orders, progress notes, the medication and treatment records, dated 02/2020, the 48-hour baseline care plan, and nurse aid activities of daily living tracking form dated 02/2020 revealed there was no evidence of care and services provided for Resident #137's indwelling urinary catheter. Interview on 02/13/20 at approximately 4:00 P.M. with the Director of Nursing (DON) verified the facility failed to obtain orders for Resident #137's indwelling urinary catheter and for catheter care and services. The DON further verified the medical record for Resident #137 contained no evidence of the facility providing care and/or services for the residents urinary catheter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 13 of 24 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 02/13/2020 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observations, staff interviews and review of the facility's policy, the facility failed to timely implement nutritional recommendations for the residents. This affected two (#23 and #71) of three residents reviewed for nutrition. The facility censes was 89. Residents Affected - Few Findings Include: 1. Review of the medical record for the Resident #23 revealed an admission date of 12/16/19. Diagnosis included Alzheimer's disease, delirium, dementia, major depressive disorder, type two diabetes mellitus, atrial fibrillation, and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 01/01/20, revealed the Resident #23 required set up assistance for eating and substantial to maximal assistance for oral hygiene. Review of the care plan, dated 12/24/19, revealed the resident had imbalanced nutrition related to poor intake. Interventions included the facility would provide and serve supplements as ordered. The care plan was not updated to include the recommendations from 01/30/20 to 02/12/20. Review of the facility's form titled Medical Nutritional Therapy Recommendation, dated 01/30/20, revealed the form was signed by Registered Dietitian (RD) #506 and the recommendation was to discontinue med pass (a high calorie nutritional supplement), increase magic cup (a high calorie frozen nutritional supplement) to two times a day with lunch and dinner, and to start a nutritional juice (a high calorie nutritional supplement) three times a day with meals. Review of the physician orders, Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed the recommendation by RD #506 for Resident #23 had not been implemented from 01/30/20 to 02/12/20. Interview on 02/12/20 at 11:40 A.M. with RD #506 verified she had made a recommendation on 01/30/20 for Resident #23 and verified it was still not implemented as of 02/12/20. RD #506 revealed she had recommended a magic cup two times a day and a nutritional juice three times a day with meals. The RD revealed Resident #23's intake would increase to a total of 36 grams protein and 1200 calories daily. The RD revealed the recommendations were given to the Director of Nursing (DON) and the nurse manager on 01/30/20. The RD stated she had several recommendations not implemented for several residents. Interview on 02/12/20 at 1:24 P.M. the DON confirmed the medical nutrition therapy recommendation from RD #506, dated 01/30/20, had not been ordered or implemented for Resident #23 as of 02/12/20. 2. Review of the medical record for Resident #71 revealed an admission date of 01/17/20. Diagnosis included diabetes mellitus, anxiety disorder, renal insufficiency with dependence on renal dialysis and abnormalities of gait and mobility. Review of the five-day Minimum Data Set (MDS) assessment, dated 01/24/20, revealed Resident #71 was cognitively intact and was independent for eating. The resident had two stage two pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 14 of 24 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 02/13/2020 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 0692 Level of Harm - Minimal harm or potential for actual harm Review of the plan of care, dated 01/24/20, revealed the resident had potential for imbalance nutrition related to inadequate intakes and increased nutrient needs. Review of the physician orders, dated 02/01/20, revealed an order to administer a high protein nutritional supplement named Prostat 30 milliliters (ml.) by mouth daily. Residents Affected - Few Review of the Medical Nutritional Therapy Assessment, dated 01/28/20, revealed RD #506 recommended Prostat 30 ml. three times a day and to start large portions at breakfast and lunch of the entrée only. The diet recommendations were not implemented until 15 days later on 02/12/20. Review of the facility's Diet Requisition form, dated 02/12/20, revealed Resident #71 had a diet change to increase to large portions. Review of the physician orders, dated 02/12/20, revealed an order to increase the Prostat to 30 ml. three times a day (TID). Observation on 02/12/20 at 12:19 P.M. of Resident #71 revealed he was eating lunch independently in his room. He had a cervical contracture and appeared to have difficulty feeding himself. Interview on 02/12/20 at 12:21 P.M. with Resident #71 revealed he was trying to stay as independent as possible and it was very difficult for him to eat. He stated he did not usually eat all his meals because of the difficulty. Interview on 02/12/20 at 3:52 P.M. with RD #506 revealed Resident #71 had increased nutritional needs related to dialysis and had a diet recommendation to increase Prostat from 30 ml. daily to 30 ml. TID and to increase the portion size of the entree for breakfast and lunch. The RD stated there were several diet recommendations that took on average two to four weeks to be implemented by the facility. Interview on 02/12/20 at 1:25 P.M. with the DON confirmed the medical nutrition therapy recommendation from RD #506, dated 01/28/20, and the physician order dated 02/01/20 had not been followed for Resident #71 as of 02/12/20. Review of the facility's undated policy titled, Nutritional Impaired/Unplanned Weight Loss-Clinical Protocol, revealed the physician would authorize and the staff would implement general cause effective interventions based on factors such as nutritional needs, resident choice, functional factors and supplemental strategies etc. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 15 of 24 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 02/13/2020 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 staff interview, the facility failed to change oxygen supplies as physician ordered. This affected one (#8) of two residents reviewed for respiratory care. The facility identified 10 residents who receive respiratory care. The facility census was 89. Residents Affected - Few Findings include: Review of the medical record for Resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnoses included heart failure, chronic obstructive pulmonary disease (COPD) and morbid obesity. Review of the plan of care, with implementation date of 10/23/14 with a target date of 02/21/20, revealed the resident had ineffective breathing pattern related to COPD and a history of pneumonia and as evidenced by cough, abnormal lung sounds, and a drop in oxygen saturation during rest and activity. Interventions included continuous oxygen at four liters per minute per nasal cannula and change oxygen supplies every week on Thursday. Review of the treatment administration record (TAR), dated 11/2019, revealed Resident #8 was to be administered oxygen at four liters per minute per nasal cannula. Documentation revealed the oxygen supplies were to be changed every week on Thursday 11/07/19, 11/14/19, 11/21/19, and 11/28/19. Review of the TAR revealed no evidence the oxygen supplies were changed. The TAR, dated 12/2019, revealed oxygen supplies were changed on the first Thursday of the month, however there was no documentation to verify oxygen supplies were changed for the remainder of 12/2019. The TAR, dated 01/2020, revealed there was no evidence of Resident #8's oxygen tubing being changed. The medical record did not have evidence of changing oxygen supplies on a consistent basis as ordered for Resident #8 during the months of 11/2019, 12/2019, and 01/2020. Observation on 02/10/20 at 10:48 A.M. of Resident #8 revealed the resident had an oxygen concentrator set to deliver oxygen at the rate of four liters per minute (LPM) via a nasal cannula. The resident was being administered the oxygen via nasal cannula. The observation revealed the nasal cannula was not dated. Interview on 02/10/20 at 10:38 A.M. with Resident #8 revealed the resident was unsure of when the oxygen tubing was last changed. The resident reported oxygen tubing was not changed weekly. Interview on 02/11/20 at 9:25 A.M. with Registered Nurse (RN) #419 revealed oxygen therapy and oxygen tubing changes are documented for residents with oxygen orders on the resident's TAR. Observation of Resident #8 completed with RN #419 during the interview verified the resident oxygen tubing was not dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 16 of 24 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 02/13/2020 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. 2. Observation during medication administration on 02/12/20 at 8:16 A.M. with Licensed Practical Nurse (LPN) #431 revealed there were three Tums tablets (antacids) in a medication cup on the tray table in Resident #26's room. Interview with Resident #26 at the time of the observation she stated she got them this morning and stated she would take them when she was ready. Interview with LPN #431 at the time of the observation verified the medication was Tums and verified they were unattended and on Resident #26's tray table. LPN #431 verified Resident #26 had an order for Tums, as needed, but did not know why they were left with the resident and verified medications were not to be kept by the residents. The nurses were expected to ensure all medications were consumed when administered. Review of the facility's undated policy titled Administering Medications revealed medications shall be administered in a safe and timely manner and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. This deficiency substantiates Complaint Number OH00109754. Based on medical record review, observation, review of the facility's policy and staff interview, the facility failed to follow a pharmacy recommendation and physician order. In addition, the facility failed to ensure medications were not left unattended at the resident's bedside. This affected one resident (#1) of five residents reviewed for unnecessary medications and affected one (#26) of 26 residents observed on the initial and final sample. The facility census was 89. Findings include: 1. Review of the medical record for the Resident #1 revealed an admission date of 08/08/19. Diagnosis included heart failure, type two diabetes, dysphagia, urgency of urination, benign prostatic hyperplasia, and essential hypertension. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/12/19, revealed the resident had intact cognition and no behaviors exhibited in the seven-day look-back period. Review of the pharmacy recommendation, dated 10/30/19, for Omeprazole (treats heartburn) 20 milligrams (mg.) capsule to be given by mouth daily and to be taken 30 minutes before meals. Review of the physician order, dated 11/05/19, and signed by the doctor, revealed per pharmacy recommendation Omeprazole 20 mg capsule by mouth daily 30 minutes before meals. Review of the Medication Administration Record (MAR), dated 01/2020 and 02/2020, revealed Omeprazole 20 mg, capsule was given daily at 8:00 A.M. and not 30 minutes before meals. Interview on 02/13/20 at 11:16 A.M. with Registered Nurse (RN) #418 revealed Omeprazole 20 mg. was given at 8:00 A.M., along with other 8:00 A.M. medications. The RN #418 confirmed there was no indication to give Omeprazole 20 mg. before meals. The RN #418 confirmed the order for Omeprazole 20 mg. was not followed as the pharmacy recommended or the physician ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 17 of 24 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 02/13/2020 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 medical record review, observation, staff interview and facility policy review, the facility failed to maintain a medication error rate less than 5%. There were three medication errors out of 32 opportunities, which was a 9.38% medication error rate. This affected two (#26 and #76) of four residents observed for medication administration. The facility census was 89. Residents Affected - Few Findings include: 1. Observation of medication administration on 02/11/20 at 8:22 A.M. with Registered Nurse (RN) #418 revealed she completed an accucheck with a result of 183 for Resident #76's blood sugar level. RN #418 then obtained medications for Resident #76, including Novolog insulin per flexpen, two units and one multivitamin tablet. RN #418 verified all the medications, then administered Resident #76's medications, including the multivitamin tablet and the insulin per subcutaneous injection at his right mid-abdomen. Review of the most recent recapitulated physician orders, dated 01/22/20 and signed by the physician on 01/28/20, revealed Novolog Flexpen administration to inject subcutaneously per sliding scale four times daily. The order did not include sliding scale parameters. Additionally, there was no current order for multivitamin. Review of the hand-written physician order, dated 01/22/20, also included Novolog flexpen per sliding scale, to be determined. There was no defined sliding scale. Interview on 02/11/20 10:35 A.M. with Director of Nursing (DON) verified there was no defined sliding scale for the current physician order for Novolog insulin. The DON verified there was no current order for the multivitamin. 2. Observation of medication administration on 02/12/20 at 8:16 A.M. with Licensed Practical Nurse (LPN) #431 for Resident #26 revealed LPN #431 administered Tylenol 500 milligrams (mg.), two tablets for Resident #26. Review of the most recent recapitulated signed physician orders, dated 02/01/20, revealed Tylenol 325 mg., two tablets by mouth every four hours as needed. Interview with LPN #431 on 02/12/20 at 9:00 A.M. verified she had administered Tylenol 500 mg, two tablets and the current order was for Tylenol 325 mg. two tablets. Review of the facility's undated policy titled Administering Medications revealed medications must be administered in accordance with the orders. This deficiency substantiates Complaint Number OH00109754. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 18 of 24 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 02/13/2020 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of manufacturer's recommendations and review of facility policy, the facility failed to properly date and store medications. This affected two of three medication rooms and two of five medication carts. The facility census was 89. Findings include: Observation of the 100 hall medication room on [DATE] at 10:03 A.M. with Registered Nurse (RN) #418 revealed in the refrigerator, there was one opened and undated vial of Tuberculin purified protein. RN #418 verified the Tuberculin purified protein was opened and undated. Observation of the 200 hall medication cart and the 200 hall medication storage room on [DATE] at 10:11 A.M. with Licensed Practical Nurse (LPN) #431 revealed one Albuterol duoneb (treats bronchospasm) vial in the top drawer of the medication cart not in its prescription package and one Bisacodyl (laxative) 10 milligrams (mg.) suppository not in its package. LPN #431 verified the Albuterol was not in a prescription package and Bisacodyl was not in its original package. In the 200 hall medication storage room, there was one opened and undated bottle of Iron Supplement Elixir with an expiration date of 10/2018. LPN #431 verified the Iron supplement was opened, undated and had an expiration date of 10/2018. Observation of the 400 hall medication cart on [DATE] at 10:31 A.M. with LPN #430 revealed three vials Ipratropium/Albuterol sulfate 0.5/3 mg. solution not in the prescription package; one Levemir flextouch insulin labeled with an expiration date of [DATE] for Resident #73; one Budesonide (treats certain bowel conditions) and Formoterol (treats lung problems) 80/4.5 inhaler for Resident #73, opened and undated; one Basaglar Kwikpen for Resident #73, opened and undated; one Humulin R insulin vial for Resident #76, opened and undated; one Basaglar Kwikpen for Resident #76, opened and undated; and two bottle Latanoprost Ophthalmic eye drops for Resident #17, both in one prescription box, both opened and undated. LPN #430 verified the above findings. Review of the manufacturer's recommendations revealed Tuberculin purified protein should be discarded 30 days after being opened. Review of the manufacturer's recommendations revealed Ipratropium/Albuterol sulfate 0.5/3 mg. solution should be stored in the foil pouch. Review of the manufacturer's recommendations revealed Budesonide and Formoterol 80/4.5 inhaler to discard the inhaler when the label number of inhalations have been used or within three months of opening the foil pouch. Review of the manufacturer's recommendations revealed Latanoprost Ophthalmic eye drops should be refrigerated until opened and may be stored at room temperature for six weeks after opening. Review of the facility's pharmacy policy titled Stability of Common Insulins in Vials and Pens, updated 11/2019, revealed Humulin R insulin and Basaglar Kwikpen expired 28 days after opening. Levemir flextouch insulin expired 42 days after opening. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 19 of 24 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 02/13/2020 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 0761 Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy titled Storage of Medications, revised 04/2019, revealed drugs and biologicals are stored in the packaging, containers or other dispensing systems in which there are received. Discontinued, outdated or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 20 of 24 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 02/13/2020 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtained physician ordered laboratory blood tests. This affected one (#8) of five residents reviewed for unnecessary medication. The facility census was 89. Residents Affected - Few Findings include: Review of the medical record for Resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease, muscle weakness, venous insufficiency, diabetes mellitus type two, muscle wasting and atrophy, personality disorder, chronic embolism, heart failure, hypertension, chronic obstructive pulmonary disease (COPD), osteoarthritis, neuromuscular dysfunction of the bladder, Parkinson's disease, atrial fibrillation, anxiety, tremors, psychosis, morbid obesity, and major depressive disorder. Review of the physician orders, dated 12/30/19, revealed Resident #8 was to have the laboratory test prothrombin time and international normalized ratio (PT/INR) completed on 01/02/20. (PT/INR is laboratory blood tested used to help detect and diagnose a bleeding disorder. The results are also used to monitor how well the blood thinning medication coumadin is working to prevent blood clots.) Review of a physician progress note, dated 12/30/19, revealed Resident #8 was to have a PT/INR test completed on 01/02/20 due to Coumadin hold days. Review of the medical record for Resident #8 revealed no evidence of a PT/INR laboratory test completed on 01/02/20. Interview on 02/12/20 at 1:11 P.M. with the Director of Nursing verified there was no PT/INR testing completed for Resident #8 on 01/02/20 as ordered by the physician. The DON did not know why the PT/INR was not assessed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 21 of 24 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 02/13/2020 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 review of the facility's policy, the facility failed to properly label and date opened food items in the upright kitchen refrigerator. This had potential to affect 87 of 88 residents who receive food from the kitchen. The facility identified one resident (Resident #21) did not receive food from the kitchen. Findings include: Observation of the facility's kitchen on 02/10/20 from 8:10 A.M. through 9:30 A.M., revealed an upright refrigerator with an opened block of cheese uncovered set in the original wrapper with no date, a bowl of noodles undated and unlabeled, a container of a dark gravy or meat like substance unlabeled and undated, and a small personal size container of ice cream in the refrigerator. Interview on 02/10/20 at 8:25 A.M. with Kitchen Manager #550 verified the opened block of cheese, undated and unlabeled bowl of noodles, and undated and unlabeled container of dark gravy or meat like substance and ice cream in the refrigerator. Kitchen Manager #550 immediately threw away the ice cream and removed the bowl of noodles. Review of the facility's policy titled Receiving, revised 09/2017, revealed all food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 22 of 24 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 02/13/2020 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 2. Observation of medication administration on 02/12/20 at 8:16 A.M. with Licensed Practical Nurse (LPN) #431 for Resident #26 revealed LPN #431 obtained her ordered Risperdal (antipsychotic) one milligram (mg.) from the cart. When attempting to pop the Risperdal into the pill cup, LPN #431 dropped the pill on the cart then picked it up with her bare fingers and placed it in the pill cup, then continued to obtain medications. LPN #431 then administered all the medications including the Risperdal to Resident #26. Interview at the time of the observation LPN #431 verified she dropped the Risperdal, picked it up with her fingers from the top of the medication cart, put back in the pill cup and administered it to Resident #26. Residents Affected - Many Review of the facility's undated policy titled Infection Control revealed standard precautions will be used in the care of all residents in all situations. This deficiency substantiates Complaint Number OH00109754. Based on observation, staff interview, review of facility's maintenance documents, and review of the facility's policy, the facility failed to have appropriate Legionella monitoring. In addition, the facility failed to maintain infection control for one (Resident #26) of four residents observed for medication administration. This had the potential to affect all 89 residents residing in the facility. Findings include: 1. Review of the facility's monitoring control measures to prevent growth and spread of Legionella revealed no evidence of water temperatures being done in rooms or water heaters, no evidence of flushing of resident rooms/unused rooms, no evidence disinfectant level control, and no evidence of environmental testing for pathogens. Interview on 02/13/20 at 4:16 P.M. with Maintenance Supervisor #492 verified there was no evidence of Legionella prevention and Maintenance Supervisor #492 was not aware of the requirement until last month. Review of the facility's policy titled, Legionella Water Management Program, revised July 2017, revealed the water management program implements specific measures used to control the introduction and/or spread of Legionella (e.g. temperature, disinfectants). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 23 of 24 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 02/13/2020 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 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on facility record review, observation and staff interview, the facility failed to maintain a clean and sanitary environment. This had the potential to affect all 89 residents residing in the facility Residents Affected - Many Findings include: 1. Observation of the smoking shelter house for resident use on 02/11/20 at 2:00 P.M. revealed multiple shingles had come off the shelter house and were scattered in the yard around the shelter house. It further revealed a large area on one side of the roof, approximately eight foot square had a bowed in, concave appearance, with the center of the area being more caved in. The underside of the roof from the inside of the shelter house revealed dark rings with open areas in the wood. This area was in close approximation to the deep concave area on the roof. Interview with Maintenance Supervisor #492 on 02/12/20 at 1:10 P.M. verified the roof to the smoking shelter had been leaking for over a year. He verified an area approximately eight foot long by eight foot wide was concave and multiple shingles were lying on the ground. He further verified the smoking shelter roof had leaks that went completely through the roof, the wood was coming off and it would get wet inside the shelter when it rained. He stated he had obtained quotes to get the shelter roof fixed but had not received approval at this time. He further verified residents continued to use the shelter for smoking and that was the only area smoking was permitted. Interview with the Administrator on 02/12/20 at 1:35 P.M. revealed he was aware of the smoking shelter roof that appeared to be caving in and was waiting for approval to get it fixed. Review of the quotes for the smoking shelter house revealed the repair quotes had been obtained on 10/09/19, 11/05/19 and 12/05/19. None of the quotes had been signed as authorized by the facility. 2. Observation of the activity room on 02/11/20 at 4:15 P.M. revealed four square ceiling vents with black stains on the vents and also extending away from the vents onto the ceilings. Observation of the dining room on 02/11/20 at 4:20 P.M. revealed three veiling vents with a black substance on the vents, which also extended onto the ceiling surrounding two sides of the vents. Interview with the Administrator on 02/11/20 at 4:25 P.M. verified the black stains had been present on the vents and ceiling since he had started working there. He stated they had washed them and it would not come off. Interview with Maintenance Supervisor #492 on 02/12/20 at 2:00 P.M. revealed he had used a power wash and could not get the ceiling vents clean. He verified the stains were very obvious to people when they walked into the room. This deficiency substantiated Complaint Number OH00109754. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365843 If continuation sheet Page 24 of 24