Health inspection·March 2, 2022

F 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. Level of Harm - Minimal harm or potential for actual harm Based on resident and staff interviews and review of the local post office business hours the facility failed to ensure residents received mail on Saturdays, delivered to the facility by the post office. This directly affected five residents (#03, #09, #20, #30, and #40) of 11 interviewed and had the potential to affect all 39 residents residing in the facility. Residents Affected - Some Findings include: Interview, during the resident council meeting, on 02/23/22 03:46 PM., revealed residents (#03, #09, #20, #30, and #40) stated no mail was delivered on Saturdays due to no business office staff in the building on Saturdays. The residents reported they received their mail from the activities department. Interview on 02/23/22 at 4:51 P.M., revealed the Activities Director (AD) #21 reported mail was delivered every other Saturday due to the Activity Aide (AA) #22's schedule. AA #22 delivers mail on the Saturdays she worked. AD #21 reported she works Monday through Friday and was not scheduled on Saturdays. Interview on 02/23/22 5:56 P.M., revealed the Administrator reported she was hiring a manager to work every weekend who would be responsible for delivering the residents mail every Saturday. Review of the local post office business hours revealed on Saturdays the post office was open from 9:00 A.M. through 12:00 P.M. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365878 If continuation sheet Page 2 of 22 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 03/02/2022 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on review of the resident council minutes, observation and resident and staff interviews the facility failed to ensure they had a grievance policy and procedure, posted information on how to file grievances and designate a Grievance Official. This directly affected five residents (#03, #09, #20, #30, and #40) of 11 interviewed and had the potential to affect all 39 residents residing in the facility. Findings include: Review of the resident council meeting minutes dated from 09/23/21 through 01/25/22 revealed no information was provided to residents on how to file a grievance, no information about how confidentially would be maintained if a grievance was filed. Interview on 02/23/22 03:46 P.M., revealed residents (#03, #09, #20, #30, and #40) complained they were unaware of how to file a grievance. The residents attending the council meeting reported they were not sure who to go to when and if they wanted to file a grievance. Interview on 02/23/22 at 4:51 P.M., the Activities Director (AD) #21 stated she facilitated the resident council meetings held once a month. The AD #21 reported she goes over every department to see if residents have any comments or concerns. The AD #21 denied informing residents during resident council meetings on how to file a grievance. The AD #21 revealed the facility had no designee at this time for residents to go to if they needed to file a grievance. AD #21 reported if a resident had an issue pertaining to a grievance, she thought they would go to the social services department. Interview on 02/23/22 at 5:00 P.M., the Social Services Designee (SSD) #03 denied assisting residents with grievances. The SSD #03 stated she was new in the position and was not informed of this duty but would be happy to assist with residents' grievances. The SSD #03 reported no one told her she was solely the designee for grievances and denied receiving any grievance issues form the previous designee. The SSD #03 stated the old management took all the documents therefore, she had no information on grievances at that time. Observation on 02/23/22 at 5:15 P.M., revealed there were no postings pertaining to how to file a grievance on the 300 hall. The AD #21 verified there were no postings. Interview on 02/23/22 5:56 P.M., the Administrator reported the social services department handled grievances. The facility was unable to provide a grievance policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365878 If continuation sheet Page 3 of 22 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 03/02/2022 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 0641 Ensure each resident receives an accurate assessment. 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 revealed Resident #12 was admitted on [DATE]. Diagnosis included congestive heart failure, asthma, diabetes, morbid obesity, acute respiratory failure with hypoxia, insomnia, chronic kidney disease, hypertension, atrial flutter, depression, anxiety disorder, and history of urinary tract infections. Residents Affected - Few Review of care plan dated 12/27/19 revealed Resident #12 was at risk for impaired skin integrity related to decreased mobility, underlying diseases, and refusal of care/treatment related to prevention of a stage two pressure injury. Review of the Discharge Return Anticipated MDS dated [DATE] revealed the section M related to skin conditions revealed Resident #12 had no pressure ulcers/injuries. Review of the Quarterly MDS dated [DATE] revealed the section M related to skin conditions revealed Resident #12 had no pressure ulcers/injuries. Review of health status note dated 08/30/21 revealed the wound doctor was in to see Resident #12 for a wound to the bottom of the right foot. The wound doctor gave an order to send Resident #12 to the emergency room for evaluation and treatment to the right foot wound and the right heel pressure ulcer. Continued review of health status notes dated 08/30/21 revealed Resident #12 was admitted for the right foot ulcer including muscle and right foot cellulitis. Interview on 02/24/22 at 12:35 P.M., with the Administrator verified that the MDS was coded incorrectly and that it should have indicated the pressure ulcer on Resident #12's right heel. Based on medical record review, observation and staff interview the facility failed to ensure Minimum Data Set (MDS) assessments were coded accurately. This affected two residents (#12 and #34) of three reviewed for MDS accuracy. The facility census was 39. Findings included: 1. Medical record review for Resident #34 revealed an admission on [DATE] with a readmission on [DATE]. Diagnoses included pneumonia, chronic respiratory failure, diabetes, repeated falls, anemia, hypertension, anxiety, hypothyroidism, gastro-esophageal reflux disease, major depressive disorder, and cancer of the mouth with gastrostomy tube placement. Review of the comprehensive MDS assessment dated [DATE] for Resident #34 revealed intact cognition. Resident #34 required supervision for bed mobility, transfers, eating and toilet use from one staff member. No dressing to the abdominal gastrostomy tube was coded during the look back period. Review of the plan of care for Resident #34 dated 07/01/19 without revisions revealed the resident prefers not to use gauze dressing to the gastrostomy tube, used a towel at times. Interventions included cleanse site and dry per orders, monitor for excoriation. Review of the physician's orders for the month of February 2022 revealed an order to cleanse area to the gastrostomy tube site with soap and water and pat dry. Apply four by four dressing to the area for protection. Change daily and as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365878 If continuation sheet Page 4 of 22 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 03/02/2022 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 0641 Level of Harm - Minimal harm or potential for actual harm Observation on 02/22/22 at 11:45 A.M. of Resident #34 self-administering her gastrostomy feeding. Resident #34 had a gauze dressing in place surrounding the gastrostomy insertion site. Interview on 02/22/22 at 2:19 P.M., with the Licensed Practical Nurse (LPN) #31 verified Resident #34 had a gauze dressing applied to the insertion site of her gastrostomy tube daily. Residents Affected - Few Interview on 02/24/22 at 3:19 P.M., with the Regional MDS Registered Nurse (RN) #30 verified the MDS assessment was not coded accurately to reflect the application of a dressing. Request for the policy related to the completion of the MDS during the survey revealed the facility follows the Resident Assessment Manual version 3.0 and does not have a specific policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365878 If continuation sheet Page 5 of 22 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 03/02/2022 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview the facility failed to complete a base line plan of care. This affected two residents (#15 and #293) of three sampled for a baseline plan of care. The facility census was 39. Findings include: 1. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included cute kidney failure, diabetes, carotid artery disease, hypertension, and heart block. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #15 had no cognitive deficits, and required extensive assistance with activities of daily living, and was occasionally incontinent of bladder and was always continent of bowel. Review of the record revealed there was no baseline care plan for Resident #15 who was a newly admitted resident. Interview on 02/24/22 at 12:30 P.M., with the Administrator verified baseline care plans were not located in the record and she believed they were not completed upon admission. 2. Review of the medical record for Resident #293 revealed an admission date of 02/16/22. Diagnoses included Acute Respiratory Failure with hypoxia, chronic obstructive pulmonary disease, diabetes mellitus, chronic kidney disease, and hypertension. Review of the 5-day MDS assessment dated [DATE] revealed Resident #293 had impaired cognition. No hallucinations, delusions, or rejection of care were noted on the assessment. The resident required extensive assistance for all activities of daily living (ADL's) except eating which he was independent. The assessment indicated Resident #293 required dialysis. Review of the baseline plan of care for Resident #293 dated 02/16/22 revealed no plan of care in place documented the resident's dialysis. Interview on 02/24/22 at 9:35 A.M., with the Administrator revealed the facility had no baseline care plan for dialysis in place for Resident #293 when the surveyors arrived at the facility on 02/22/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365878 If continuation sheet Page 6 of 22 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 03/02/2022 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, observations, and review of the Resident Assessment Instrument (RAI) manual version 3.0, the facility failed to develop a comprehensive care plan within 14 days after admission to the facility. This affected two residents (#06 and #22) of three reviewed for care plan completion. The facility census was 39. Findings included: 1. Medical record review for Resident #06 revealed an admission date on 11/02/21. Diagnoses included dehydration, dementia with behavioral disturbances, mood disorder, altered mental status and Covid-19. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #06 revealed the resident required supervision for bed mobility, transfers, toilet use and eating. Resident #06 walked independently. Review of the physician order dated February 2022 for Resident #06 revealed an order for a Wanderguard to the residents extremity. Verify placement of the Wanderguard every shift for confusion dated 11/02/21, an order for Miralax, give 17 grams by mouth in the morning for constipation dated 11/02/21, an order for senna tablet 8.6 milligrams (mg) by mouth at bedtime for constipation dated 11/02/21, Seroquel 25 mg one tablet three times a day for psychosis dated 11/02/21, hydroxyzine 25 mg three times a day for anxiety dated 11/02/21 and Ativan 0.5mg give one tablet two times a day by mouth dated 11/03/21. Review of the plan of care dated 11/02/21 revealed Resident #06 was at risk for elopement and wandering. Interventions included assess risk factors per facility procedures, attempt to involve in decision making, follow facility elopement procedures. The plan of care had no documentation for the placement of a Wanderguard security pendent, dementia related care, anxiety care and care of constipation. Observation on 02/24/22 11:20 A.M. revealed Resident #06 ambulated in the hallway of the facility. She was monitored by a one-to-one staff member at this time. Resident was clean, well-groomed and appropriately dressed. She was ambulating without purpose up and down the hallway. Interview on 02/24/22 at 11:25 A.M., with the Licensed Practical Nurse (LPN) #31 verified Resident #06 had a Wanderguard on in the past. LPN #31 said Resident #06 removed the Wanderguard last night and would not allow staff to reapply it. Interview on 02/24/22 at 3:19 P.M., with the Regional MDS Registered Nurse (RN) #30 verified the plan of care was not comprehensive and not completed in the required time frame. 2. Medical record review for Resident #22 revealed an admission date on 06/02/21. Diagnoses included Covid-19, chronic obstructive pulmonary disease (COPD), stroke, carpal tunnel syndrome, hypertension, dry eye syndrome, depression, anxiety, alcohol induced dementia, tremors, osteoarthritis, hyperlipidemia, acid reflux disease, benign prostatic hyperplasia, and insomnia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365878 If continuation sheet Page 7 of 22 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 03/02/2022 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 0656 Level of Harm - Minimal harm or potential for actual harm Review of the most recent MDS dated [DATE] revealed Resident #22 had intact cognition. Resident #22 exhibited no behaviors during the assessment period. Resident #22 required extensive assist for bed mobility, transfers, and toilet use. Resident #22 required supervision for eating. Resident #22 had functional limitations in range of motion on both upper and lower extremities. Resident #22 was assessed as receiving antidepressant, antianxiety and opioids during the look back period. Residents Affected - Few Review of the active physician orders for Resident #22 revealed an order for Flonase Suspension 50 micrograms (MCG), one spray in both nostrils two times a day for allergies dated 01/15/2022, wear a splint at all times, except when bathing and as instructed by the therapist or medical doctor dated 1/11/2022, Acetaminophen tablet give 650 milligrams (mg) by mouth every 6 hours related to osteoarthritis dated 01/05/22, a hand splint to be worn all night, taken off in the morning, applied again mid-day up to four hours if the patient can tolerate dated 12/29/21, Preparation H cream 5-14.4 percent apply to external hemorrhoids topically every six hours as needed for hemorrhoids dated 06/10/21, hydrocodone-acetaminophen (opioid pain medication) tablet 5-325 mg give one tablet by mouth every six hours as needed for pain when resident reports pain on a pain scale of seven-ten dated 12/21/21, buspirone tablet 15 mg give one tablet by mouth three times a day for major depressive order dated 12/14/21, Cymbalta capsule delayed release particles give 120 mg by mouth in the morning related to major depressive disorder dated 12/15/21, Tamsulosin capsule 0.4 mg give one capsule by mouth in the evening for retention related to benign prostatic hyperplasia dated 12/09/21, trazodone tablet 100 mg give one tablet by mouth in the evening for insomnia dated 12/09/21, Gabapentin capsule 300 mg give one capsule by mouth before meals for neuropathy dated 12/8/2021, sennosides-docusate sodium tablet 8.6-50 mg give two tablets by mouth two times a day for constipation dated 06/4/2021, Atorvastatin calcium tablet 40 mg give one tablet by mouth in the evening for hyperlipidemia dated 12/9/2021, Lisinopril tablet 10 mg give one tablet by mouth in the morning related to hypertension, dated 9/22/2021, Vitamin D capsule 1.25 mg (50000 UT) give one capsule by mouth in the morning every Monday for vitamin D deficiency dated 09/06/21, saline nasal spray solution give two sprays in each nostril every fours as needed for nasal congestion, may have nasal spray at bedside dated 8/18/2021, Pantoprazole sodium tablet delayed release 40 mg give one tablet by mouth in the morning for acid reflux disease dated 6/3/2021, Vitamin B12 tablet give 1000 mg by mouth in the morning for supplement dated 06/04/21, Tums tablet chewable give two tablets by mouth every six hours as needed for heartburn dated 06/02/21, Robafen syrup give 10 ml by mouth every four hours as needed for cough, dated 06/02/2021, Rivastigmine tartrate capsule 1.5 mg give one capsule by mouth two times a day for alcohol use related to alcohol use persisting dementia dated 06/02/21, Meloxicam tablet 7.5 mg give one tablet by mouth in the morning for arthritis dated 06/3/2021, Claritin tablet 10 mg give one tablet by mouth in the morning for allergies dated 06/03/21, aspirin tablet chewable 81 mg give one tablet by mouth in the morning for embolism dated 06/03/21, Anoro Ellipta aerosol powder breath activated 62.5-25 mcg/inhalation one puff inhale orally in the morning for congestive obstructive pulmonary disease dated 06/03/21, pain monitoring every shift, if complaints or has signs and symptoms noted nursing must address dated 06/19/21, Ventolin aerosol solution 108 (90 Base) mcg two puffs inhale orally every four hours as needed for shortness of breath, may keep at bedside, dated 6/2/21. Review of the plan of care for Resident #22 revealed focused areas addressed included risk for falls and potential injury, alteration in comfort, risk for impaired skin integrity, risk of injury related to smoking, and potential for alteration in nutrition. Interview with the Regional MDS RN #30 on 02/24/22 at 12:35 P.M. verified the plan of care was not accurate or comprehensive and should have been personalized to the residents current health status. Review of the Centers of Medicare and Medicaid Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365878 If continuation sheet Page 8 of 22 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 03/02/2022 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 0656 Assessment Instrument (RAI) manual version 3.0, Chapter 2.3, page 2-16 states an admission assessment care plan must be completed within seven days after the completion of the comprehensive assessment. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365878 If continuation sheet Page 9 of 22 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 03/02/2022 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 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** 2. Review of the medical record revealed Resident #14 was admitted on [DATE]. Diagnoses included hyperlipidemia, extrapyramidal and movement disorder, dyskinesia, schizoaffective disorder, hypothyroidism, insomnia, anxiety, psychosis, depression, and dementia. Review of the Quarterly MDS dated [DATE] revealed Resident #14 was independent with locomotion, required limited assistance with dressing and extensive assistance with toilet use, and personal hygiene. Review of the Quarterly MDS dated [DATE] revealed Resident #14 had severe cognitive impairment, required supervision with locomotion, eating, extensive assistance with dressing, toilet use, and personal hygiene, and was frequently incontinent of bowel and bladder. Review of the care plan dated for the last revision on 04/08/19 revealed Resident #14 was at risk for a decline in activities of daily living function performance/participation related to current medical diagnoses, drug regimen, activities of living impairment, and overall general medical condition. Interview on 02/24/24 at 12:08 P.M., with the Interim Director of Nursing (DON) verified the care plan had not been updated because they had terminated the current MDS nurse, and she was the one who had updated care plans. Based on medical record review, resident and staff interview and policy review the facility failed to ensure residents were provided and involved in care conferences to allow resident input in their care. This affected two residents (#01 and #14) out of four residents reviewed. The facility census was 39. Findings include: 1. Medical record review revealed Resident #01 was admitted on [DATE]. Diagnoses included COVID-19, anemia, chronic obstructive pulmonary disease, type 2 diabetes, morbid, primary insomnia, major depressive disorder, gastrointestinal hemorrhage, paroxysmal atrial fibrillation, iron deficiency, chronic diastolic congestive heart failure, chronic kidney disease stage 3, dyspnea and hypertension. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #01 had no cognitive impairment and required supervision for activity of daily living. The record review revealed there was no evidence of a care conference. Interview with Resident #01 on 02/22/22 at 1:19 P.M., revealed she could not remember the last time she had participated or attended a care conference. Interview with the MDS Coordinator #23 on 02/23/22 at 9:39 A.M., revealed care conferences should be held at least once every three months. Interview with Social Services Designee #03 on 02/23/22 at 10:14 A.M., verified Resident #01 had not had a care conference since 06/01/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365878 If continuation sheet Page 10 of 22 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 03/02/2022 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 0657 Level of Harm - Minimal harm or potential for actual harm Review of facility policy titled Continuing Healthcare Solutions, undated revealed participants will be as follows, but not limited to: Resident and/or resident representative, nursing, dietary, social services, activities and therapy as needed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365878 If continuation sheet Page 11 of 22 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 03/02/2022 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 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, staff interview, observation and policy review the facility failed to follow physician ordered as needed pain medication. This affected one resident (#22) of three residents reviewed for pain management. The facility census was 39. Residents Affected - Few Findings include: Medical record review for resident #22 revealed an admission date on 06/02/21. Diagnoses included Covid-19, chronic obstructive pulmonary disease, stroke, carpal tunnel syndrome, hypertension, dry eye syndrome, depression, anxiety, alcohol induced dementia, tremors, osteoarthritis, hyperlipidemia, benign prostatic hyperplasia, and insomnia. Review of the most recent Minimum Data Set (MDS) dated [DATE] revealed Resident #22 had intact cognition. Resident #22 required extensive assistance for bed mobility, transfers, and toilet use. Resident #22 required supervised eating. Resident #22 had functional limitations in range of motion on both the upper and the lower extremities. Resident #22 was assessed for pain and reported no pain during the last five days. Resident #22 was coded as receiving a scheduled medication regimen, received as needed pain medication and received non pharmacological interventions for pain. Review of the active physician orders for Resident #22 revealed an order for pain monitoring every shift if complaints or signs and symptoms noted nursing must address dated 06/02/21, Tylenol 650 milligrams by mouth every six hours related to osteoarthritis dated 01/05/22, meloxicam 7.5 milligrams give one tablet by mouth in the morning for arthritis, and hydrocodone-acetaminophen 5-325 milligrams every six hours as needed for pain rated a seven to 10 on pain scale of one to 10 with 10 being the worst pain dated 12/21/21. Review of the plan of care for Resident #22 revealed an alteration in comfort related to polyneuropathy (damage to peripheral nerves) osteoarthritis, and chronic pain. Interventions include one to one visits to allow the resident to share feelings, calming music or television per request, medications as ordered to manage pain, monitor for levels of increased pain and notify the physician, monitor for side effects of anti-inflammatory medication, pain assessment per facility policy, provide quiet environment and use the pain scale as reported by resident. Review of the Medication Administration Record dated February 2022 for Resident #22 revealed pain monitoring was completed daily. Resident received hydrocodone-acetaminophen 5-325 mg tablet seventeen times when the pain rating was below the prescribed pain scale indications. Interview on 02/22/22 at 2:19 P.M., with the Licensed Practical Nurse (LPN) #31 verified the medication was not given as ordered. LPN #31 said Resident #22 would demand the medication be given as it was the only medication that worked. Interview on 03/01/22 at 3:30 P.M., with the Administrator verified Resident #22 would demand medication be administered when he complained of pain and the medication needed to be re-evaluated for the continued usage. Review of the facility policy titled Pain Management, undated revealed the facility will modify the interventions or approaches as appropriate. Further review of the facility policy revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365878 If continuation sheet Page 12 of 22 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 03/02/2022 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 0684 nurse will explore pharmacological and non-pharmacological intervention as appropriate. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365878 If continuation sheet Page 13 of 22 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 03/02/2022 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, observation, review of the hospital discharge notes and policy review the facility failed to assess a resident for elopement before applying a security system pendent. This affected one resident (#06) of one reviewed for elopement. The facility census was 39. Findings include: Medical record review for Resident #06 revealed an admission date on 11/02/21. Diagnoses included dehydration, dementia with behavioral disturbances, mood disorder, altered mental status and Covid-19. Review of the comprehensive Minimum Data set (MDS) assessment dated [DATE] revealed revealed Resident #06 had impaired cognition. Resident #06 required supervision for bed mobility, transfers, eating and toilet use. Resident #06 was always continent of bowel and bladder. Review of the most recent quarterly MDS assessment dated [DATE] revealed Resident #06 had impaired cognition. Resident #06 required supervision for bed mobility, transfers, eating and toilet use. No wandering behavior was coded during the look back period. Review of the plan of care dated 11/02/21 revealed Resident #06 was at risk for elopement and wandering. Interventions included assess the risk factors per facility procedures, attempt to involve in decision making and follow facility elopement procedures. Review of the hospital discharge notes dated 11/02/21 revealed Resident #06 was found wandering in a parking lot looking for her car that had been repossessed. Resident #06 was confused and did not know where she was. Observation on 02/23/22 at 2:17 P.M. revealed Resident #06 ambulated independently in the hallway of the facility. She ambulated without purpose up and down the hallway. Resident #06 would stop in the middle of the hallway and turn around without reason. Interview on 02/23/22 at 2:17 P.M., with Licensed Practical Nurse (LPN) #20 verified Resident #06 had a Wanderguard security pendent on her ankle. LPN #20 said Resident #06 was admitted to the secured unit initially and was an elopement risk. Interview on 02/24/22 at 11:01 A.M., with the Director of Nursing (DON) verified the electronic health record had no elopement assessment completed at the time of admission. The facility completed an assessment on 02/23/22 after the surveyor questioned the facility. Review of the facility policy titled Elopement, undated revealed residents will be assessed by the licensed nurse for elopement risk and annually and with significant change using the elopement risk assessment and will be reviewed by the interdisciplinary team. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365878 If continuation sheet Page 14 of 22 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 03/02/2022 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview, review of hospital documentation and policy review the facility failed to consistently monitor and provide interventions to prevent resident weight loss. This affected one resident (#35) of four residents reviewed for nutrition. The facility census was 39. Residents Affected - Few Findings included: Review of the medical record for Resident #35 revealed an admission date of 12/14/21. Diagnoses included Hypertension, atrial fibrillation, hyperlipidemia, mood disorder, diabetes mellitus, restless leg syndrome, chronic pain, and vitamin D deficiency. Review of the admission nursing assessment for Resident #35 identified the resident was admitted with a weight of 185 pounds (lbs.) on 12/15/21. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #35 dated 01/30/22 revealed the resident had intact cognition. a brief interview for mental status (BIMS) score of 15. No hallucinations, delusions, or rejection of care was noted on the assessment. The resident was independent for eating. The assessment indicated the resident had a weight of 136 pounds, had no significant weight loss, and has no specialized or mechanical soft diet. Review of the nutrition risk assessment attached to the admission assessment for Resident #35, dated 12/15/21 revealed the resident was at risk for malnutrition. Review of the facility weights revealed an admission weight on 12/15/21 of 185 lbs. Subsequent weights of 136 lbs. on 01/10/22, 135.8 lbs. on 02/15/22, and 148 lbs. on 02/23/22. Review of the hospital documentation provided by the facility dated 11/30/21, Resident #35 had a weight of 166 lbs. This weight combined with the most recent weight of Resident #35 at 148 lbs. on 02/23/22 equals about a 10.9% weight loss. Review of the plan of care for Resident #35 dated 01/02/22 revealed the resident had a potential for alteration in nutrition and hydration related to diabetes, nutritional risk, teeth infection, and surgical removal. Interventions included offering meal alternate if resident refuses meal, supplements as ordered, and medications as ordered. Review of the physician orders for Resident #35 upon admission in December 2021 revealed an order for weekly weights times four weeks, then monthly. Review of the medication administration record (MAR) for Resident #35 in December 2021 and January 2022 revealed no weekly weights were completed. Review of the dietary notes for Resident #35 dated 01/13/22 at 11:25 A.M. revealed the dietician suggested no new orders but suggested a reweigh of the resident along with continued weekly weights per order. Review of dietary communication sheets given to facility administrative staff, provided by Diet Technician (DT) #40 dated 01/13/22 revealed the facility was to obtain a reweigh ASAP on Resident #35. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365878 If continuation sheet Page 15 of 22 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 03/02/2022 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 02/24/22 at 11:03 A.M., with DT #40 revealed the facility process when they receive a new admission. An initial weight was obtained by the facility and collaboration between the staff and the dietician help determine the resident diet while following orders from the hospital. At risk residents were usually weighed once weekly for the first month to rule out any further concerns. These weights are reviewed weekly by dietary staff and during the weekly managers meeting at the facility. DT #40 confirmed Resident #35 was not weighed weekly as ordered. Resident #35 was receiving magic cups with his meals as of 02/17/22. Diet Tech #35 confirmed the facility staff had no where in the medical record to document how much of the magic cup, Resident #35 would eat. If there were to be a reweigh needed at the facility, that was communicated to the Director of Nursing or the management staff via email. The DT #40 agreed facility staff should follow their policies and doctor's orders when caring for the residents. Review of facility policy titled Weight Policy, dated 01/2021 revealed Weekly weights will be completed in time for review at the Risk Management Meeting each week. Re-weights will be completed on any weight change of 5% or more. Re-weights will be done immediately. (Within 72 hours) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365878 If continuation sheet Page 16 of 22 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 03/02/2022 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and policy review the facility failed to evaluate a resident for self-administration of gastrostomy nutritional feedings. Additionally, the facility failed to obtain physician orders for self-administered gastrostomy solutions. This affected one resident (#34) of one reviewed for nutritional need via a feeding tube. The facility census was 39. Findings included: Medical record review for Resident #34 revealed an admission on [DATE] with a readmission on [DATE]. Diagnoses included pneumonia, chronic respiratory failure, diabetes, repeated falls, anemia, hypertension, anxiety, hypothyroidism, gastro-esophageal reflux disease, major depressive disorder, and cancer of the mouth with gastrostomy tube placement. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had intact cognition. Resident #34 required supervision for bed mobility, transfers, eating and toilet use from one staff member. Resident #34 was coded as receiving nutritional solution via a gastrostomy tube. Review of the nutritional plan of care for Resident #34 dated 03/30/18 with revisions on 1/27/22 revealed the resident was at risk for malnutrition and compromised hydration per inability to consume oral nutrition due to dysphagia and history of oral cancer. Resident #34 had a strong preference to self-administer her own formula and declined any changes to formula since she reported this was the best formula to reduce her GI distress. Interventions included assess for signs and symptoms of aspiration, tube feed tolerance, elevate head of bed as ordered, medications as ordered, diet as ordered, and tube feeding as ordered. Review of the physician's orders for the month of February 2022 for Resident #34 revealed an order dated 09/26/21 for 240 milliliters (ml) flush gastrostomy tube with water three times a day and bolus (at one time feedings, three times a day with osmolyte 1.2 480 ml bolus three times a day. Observation on 02/22/22 at 11:45 A.M. Resident #34 self-administered her gastrostomy feeding without facility staff present for supervision. Interview on 02/22/22 at 2:19 P.M., with the Licensed Practical Nurse (LPN) #20 verified Resident #34 self-administered gastrostomy feedings independently. Interview on 02/23/22 at 2:17 P.M., with the LPN #31 verified Resident #34 could administer her gastrostomy feeding without any assistance from staff. Interview on 02/24/22 at 3:19 P.M., with the Regional MDS Registered Nurse #30 verified the last self-administration assessment for Resident #34 was in July 2019. Additionally, verified Resident #34 has had multiple hospitalizations since 2019. Further verified there was no physician orders which indicated the resident could self-administer the gastrostomy feedings independently. Review of the facility policy titled Self-Administration by Resident, dated 2007 revealed residents are permitted to self-administer with a prescribes orders and if the nursing care center (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365878 If continuation sheet Page 17 of 22 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 03/02/2022 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 0693 Level of Harm - Minimal harm or potential for actual harm interdisciplinary team has determined that the practice would be safe. Additionally, the interdisciplinary team will determine the resident's ability to self-administer by means of a skill assessment conducted as part of the care planning process. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365878 If continuation sheet Page 18 of 22 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 03/02/2022 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and staff interview the facility failed to ensure as needed psychotropic medications were limited to 14 days and not continued unless the prescribing physician evaluated the appropriateness of the medication. This affected one resident (#02) of five residents reviewed for unnecessary medication. The facility census was 39. Findings include: Medical record review for Resident #02 revealed an admission date of 06/24/22. Diagnoses included diabetes, anemia, heart disease, dementia, Alzheimer and schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had impaired cognition. Resident #02 required extensive assistance for bed mobility and transfers. Review of the plan of care for Resident #02 dated 02/04/22 revealed the resident was at risk for exhibiting side effects of psychotropic medication related to the use of antipsychotic medication. Routine Xanax (antianxiety medication) 0.5 milligram (mg) three times daily, Interventions included collaboration with hospice, monitor, document and report as needed any adverse side effects, administer medication as ordered, consult with pharmacy to consider dose reduction when clinically appropriate, and discuss with the physician and the family the ongoing need for the use of the medication. Review of the active physician's orders for Resident #02 revealed an order for Xanax 0.5 mg every four hours as needed for anxiety dated 12/07/21 no stop date was noted. Review of the physician progress notes had no documentation regarding the specific condition for the use of Xanax, or the re evaluation of the medication to determine the need for the extended time frame. Observation on 02/22/22 at 12:26 P.M. revealed Resident #02 was resting in bed with eyes closed without signs and symptoms of distress. Interview with the Director of Nursing (DON) on 02/23/22 at 3:30 P.M., verified the physician had not included a 14-day limit to the Xanax order. The DON further verified the monthly visit note did not include the rationale needed to support the extended time frame. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365878 If continuation sheet Page 19 of 22 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 03/02/2022 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 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 medical record review, staff and resident interview, observations and policy review the facility failed to ensure prescribed medications were not left at the bedside for self-administration without assessment or physician's orders. This affected one resident (#22) of 16 reviewed for medication storage. In addition, expired medications were observed on two of two medications carts and one medication room. This had the potential to affect 13 residents (#05, #09, #16, #19, #20, #22, #29, #32, #33, #36, #39, #40 and #42) who had orders for the expired stock medications. The facility census was 39. Findings include: Medical record review for resident #22 revealed an admission on [DATE]. Diagnoses included Covid-19, chronic obstructive pulmonary disease, stroke, carpal tunnel syndrome, hypertension, dry eye syndrome, depression, anxiety, alcohol induced dementia, tremor, osteoarthritis, hyperlipidemia, benign prostatic hyperplasia and insomnia. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #22 had intact cognition. Resident #22 required extensive assistance for bed mobility, transfers, and toilet use. Resident #22 required supervision for eating. Review of the plan of care for Resident #22 had no plan for self-administration of medication. Review of the active physician orders for Resident #22 revealed an order for Flonase Suspension 50 microgram (mcg) one spray in both nostrils two times a day for allergies dated 01/15/22, Saline Nasal Spray Solution two sprays in each nostril every four hours as needed for nasal congestion, may have nasal spray at the bedside dated 08/18/2021, and Anoro Ellipta Aerosol Powder Breath Activated 62.5-25 mcg inhalation one puff inhale orally in the morning for congestive obstructive pulmonary disease dated 06/03/21, Ventolin Aerosol Solution 108 (90 Base) mcg, inhale two puffs orally every four hours as needed for shortness of breath, may keep at bedside, dated 06/02/21. Review of the electronic health record assessment tab revealed no assessments were completed for Resident #22 to self-administer medications. Observation on 02/21/22 at 11:07 A.M. Resident #22's bedside stand revealed an inhaler labeled Anoro Ellipta Aerosol Powder Breath Activated 62.5-25 mcg/inhalation, and a nasal spray labeled Flonase Suspension 50 mcg unsecured. Interview on 02/21/22 at 11:15 A.M., with Resident #22 stated he was allowed to keep the medication at the bedside. He said he took the medication daily and has been since he arrived at the facility. Interview on 02/21/22 at 1:30 P.M., with the Director of Nursing (DON) verified the resident should not have medications at bedside. The DON advised the nurse working the unit to remove the medications from Resident #22's room. Review of the facility policy titled Medication Administration, dated 2017 revealed if the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365878 If continuation sheet Page 20 of 22 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 03/02/2022 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some desires to self-administer mediations an assessment is conducted by the interdisciplinary team of the residents cognitive, physical, and visual ability to care out the responsibility during the care planning process. 2. Observation on 02/23/22 at 8:45 A.M. with Licensed Practical Nurse (LPN) #32 of the 200/300 hallway medication room revealed four unopened bottles of milk of magnesia with an expiration date of 12/2021, two unopened bottles of Loperamide liquid with an expiration date of 09/2021, one box of hemorrhoid suppositories with an expiration date of 05/2021, and two unopened bottles of Dairy Aide with an expiration date of 09/2021. Interview on 02/23/22 at 8:45 A.M. during the observation LPN #32 verified all outdated items located in the 200/300 hallway medication room. Observation on 02/23/22 at 8:50 A.M. with LPN #32 of the 300-hallway medication cart revealed one opened bottle of fish oil with an expiration date of 12/2021, and one opened bottle of Loperamide liquid with an expiration date of 09/2021. Interview on 02/23/22 at 8:50 A.M. during observation LPN #32 verified all outdated items located on the 300-hallway medication cart. Observation on 02/23/22 at 9:20 A.M. with LPN #20 of the 100-hallway medication cart revealed one opened bottle of milk of magnesia with an expiration date of 01/2022. Interview on 02/23/22 at 9:20 A.M. during the observation LPN #20 verified the opened bottle of milk of magnesia was outdated. Review of the facility policy titled Storage of Medication, dated 09/2018 revealed outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365878 If continuation sheet Page 21 of 22 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 03/02/2022 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interview the facility failed to provide routine dental services including inspection of the oral cavity at least annually. This affected one resident (#12) of 16 residents reviewed for dental services. The facility census was 39. Residents Affected - Few Findings include: Review of Resident #12's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic diastolic congestive heart failure, methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere, unspecified asthma, diabetes mellitus, major depressive disorder recurrent, anxiety disorder, and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had intact cognition. Further review of Resident #12's medical record revealed the last dental visit was dated 03/04/19. Review of a social services note dated 07/30/19 at 2:49 P.M. revealed Resident #12 had complained of an aching tooth. Resident #12 agreed to see a community dentist. Review of a social services notes dated 07/31/19 at 11:57 A.M., revealed a dental appointment was scheduled on 08/05/19. No follow-up information was documented. Interview on 02/22/22 at 10:28 A.M., revealed Resident #12 reported she had not seen a dentist for a couple of years. Resident #12 reported she needed special oral care which required her gums scraped. Telephone interview on 02/24/22 at 12:32 P.M., with Social Services Designee (SSD) #03 reported she was not an employee of the facility during the time of Resident #12's complaints and verified she had not had dental appointments for several years. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365878 If continuation sheet Page 22 of 22