Inspection·August 1, 2019

F 0584 temperature reading. Level of Harm - Minimal harm or potential for actual harm Interview on 08/01/19 at 3:04 P.M., Licensed Practical Nurse (LPN) #53 reported the nurses keep the keys to the thermostat and can adjust temperatures when maintenance is not available. Residents Affected - Some Review of the undated facility policy titled Temperature revealed the facility will provide comfortable and safe temperature levels. Temperature throughout the facility shall be maintained at between 71 degrees and 81 degrees. Any temperature outside of this range requires specific intervention(s) to avoid potential negative impact on the residents' well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365878 If continuation sheet Page 2 of 4 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 365878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Ridge Skilled Nursing and Rehab 463 East Pike Street Morrow, OH 45152 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on medical record review and staff interview, the facility failed to timely act on a medication regimen review (MRR) for one (#26) of five residents reviewed for unnecessary medications. The census was 43. Residents Affected - Few Findings include: Medical record review for Resident #26 revealed an admission date of 09/28/18. Medical diagnosis included depression. Review of quarterly the Minimum Data Set (MDS) assessment, dated 06/10/19, revealed Resident #26 was cognitively intact. Review of physician order dated 09/28/18 revealed an order for the antideprassant citalopram 40 milligrams (mg) daily. Review of the MRR dated 01/16/19 revealed Resident #26 received citalopram 40 mg daily and the maximum recommended dose was 20 mg. The form asked the physician to please consider decreasing the dose to 20 mg per day. In the physician section it was check marked I agree with this recommendation and written on the form was to decrease citalopram to 30 mg by mouth every day. The form revealed the physician signed in the physician signature box, however there was no date indicating when the physician responded to the MRR. Review of MRR dated 03/18/19 revealed Resident #26 received citalopram 40 mg daily and to please evaluate the current dose and consider a gradual taper to ensure the resident was using the lowest possible effective/optimal dose. Under the physician response section of the form revealed a check mark for Other comment. The form was not signed by the physician nor dated. Review of the physician progress notes from 03/18/19 through 03/31/19 revealed no comments regarding this MRR. Review of physician orders dated 06/12/19 revealed to change Resident #26's citalopram to 30 mg every day. Review of the Medication Administration Record (MAR) from January 2019 through June 2019 revealed Resident #26 received citalopram 40 mg daily. The June 2019 MAR revealed on 06/12/19 the citalopram 40 mg was discontinued. Interview with the Director of Nursing (DON) on 08/01/19 at 2:11 P.M. verified the citalopram 40 mg wasn't decreased until 06/12/19 for Resident #26. The DON speculated the reason the orders on the 01/16/19 MRR were not implemented was because the physician did not address the MRR until 06/12/19. She said the process was for pharmacy to hand the MRRs to the DON and then she would immediately hand them to the nurse and the nurse would enter them into the electronic system. She stated sometimes the physician will leave them in his mailbox for three months and not address them. When asked about the MRR dated 03/18/19, she stated a nurse check marked the other comment and didn't follow through with what the comment was. She revealed she didn't know what the comment was either. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365878 If continuation sheet Page 3 of 4 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 365878 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Ridge Skilled Nursing and Rehab 463 East Pike Street Morrow, OH 45152 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm Based on resident interview, staff interviews and record review, the facility failed to arrange a dental appointment for an oral surgeon after a referral was ordered by the facility dentist. This affected one (#12) of two residents reviewed for dental. The facility census was 43. Residents Affected - Few Findings include: Review of the medical records for Resident #12 revealed an admission date of 09/05/17. Diagnoses included end stage renal disease (ESRD), diabetes mellitus type two, and dependence on renal dialysis. Review of the dental note dated 04/30/19, written by the facility dentist, revealed Resident #12's tooth #3 was broken and tooth #12 was only a root tip. The note documented the dental work needed to be done by an oral surgeon and the facility dentist had left a referral. The note indicated Resident #12 wished to have a new upper partial made. Interview on 07/29/19 at 10:56 A.M. with Resident #12 revealed he had not seen a dentist for four months. He stated he saw the facility dentist a few months ago and he was supposed to have a referral made to have dental work done. He further stated he has not heard about the appointment and his teeth are starting to hurt him now. Interview on 07/31/19 at 1:27 P.M. with Social Worker (SW) #100 verified Resident #12 had a referral from the facility dentist on 04/22/19. SW #100 verified an appointment was not made to an oral surgeon for dental work. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365878 If continuation sheet Page 4 of 4