Inspection·June 18, 2025

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, and interviews the facility failed to ensure a comprehensive and resident centered treatment plan was implemented related to Resident #40's edema to her left hand and bilateral lower legs. This affected one (Resident #40) of one reviewed for edema. Residents Affected - Few Findings included: Medical record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including breast cancer, lymphedema, localized edema, acute kidney failure, acute embolism and thrombosis of left internal jugular vein, and history of venous thrombosis and embolism. a. Review of Resident #40's current plan of care for risk for alteration in skin integrity related to edema dated 10/24/24 and revised on 01/07/24 revealed on 04/16/25 a new intervention to measure girth of the left arm from the shoulder to wrist one time a day for edema. Notify the physician and family of changes as needed. Review of Resident #40's progress note dated 05/29/25 revealed the resident had swelling to the left arm and hand. The resident had plus four pitting edema (the most severe form of pitting edema, characterized by a deep indentation that takes more than 30 seconds to rebound after pressure is applied to the affected area) to the top of the hand. The nurse measured the circumference with the left hand at 7.5 inches, left forearm 11 inches and left upper arm 15 inches. The resident was educated on propping her arm up above her heart and monitoring for increased pain or development of redness. Review of Resident #40's progress note dated 05/30/25 revealed the nurse measured the left arm/hand and (there was) no change in circumference. Edema and plus three pitting edema to the top of the hand. No redness or warm to touch. The pulse to the right and left arm are equal. The resident denied increasing pain to area. Further review of Resident #40's medical record dated 05/31/25 to 06/18/25 revealed no evidence an assessment or measurements of the resident's left arm were obtained after 05/30/25. Observation and interview on 06/16/25 at 11:29 A.M., with Resident #40 revealed her left hand and arm had noted edema. The resident reported she had a history of blood clots in the right arm and left side of her neck, and she was concerned the facility was not adequately treating and monitoring her left arm and hand edema. The resident reported she had lymph nodes removed in the axillary area and the facility believed the edema was related to the removal of lymph nodes, however she didn't think it was related and was concerned. Interview on 06/17/25 at 1:21 P.M. with Resident #40 confirmed staff measured her arm/ hand once or twice and that was it. The resident confirmed that staff have not been monitoring or measuring the edema in her left arm/hand daily. The resident's arm/hand had noted edema during the interview. Interview of 06/17/25 at 1:24 P.M. with Licensed Practical Nurse (LPN) #226 confirmed the resident's current plan of care indicated to measure the resident's girth of her left arm from shoulder to wrist one time a day for edema. The LPN confirmed the resident's arm/hand had not been measured daily according to the plan of care. The LPN reported the resident had gone to the hospital recently and the order was not re-written when the resident returned. The LPN confirmed the resident had edema in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365891 If continuation sheet Page 2 of 15 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 365891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lafayette Pointe Nursing & Rehab Ctr 620 East Main Street West Lafayette, OH 43845 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 the left arm and hand and she would reach out to the physician to clarify the orders. Level of Harm - Minimal harm or potential for actual harm b. Review of Resident #40's current plan of care for risk for alteration in skin integrity related to edema dated 10/24/24 and revised on 01/07/24 revealed on 06/16/25 ace wraps to bilateral legs on in the morning and off at bedtime. Assess for pain and provide treatment per physician order(s). Residents Affected - Few Review of Resident #40's current orders dated 06/2025 revealed ace wraps to bilateral legs on in the morning and off at bedtime. Review of Resident #40's treatment administration records (TAR) dated 06/2025 revealed staff had been signing off the ace wraps were applied to bilateral legs in the morning and removed at night. Observation on 06/16/25 at 11:29 A.M. and 06/17/25 at 1:21 P.M., of Resident #40 revealed no evidence the resident had ace wraps in-place. The resident had noted edema in the bilateral lower extremities. Interview on 06/17/25 at 1:21 P.M. with Resident #40 confirmed staff don't apply ace wraps to her bilateral legs. The resident reported that the ace wraps make the edema worse. Interview of 06/17/25 at 1:24 P.M. with Licensed Practical Nurse (LPN) #226 confirmed the resident's current plan of care, orders, and TAR indicated staff had been applying ace wraps to the resident's bilateral legs, however the ace wraps were not in-place. c. Review of Resident #40's current orders dated 06/2025 revealed to consult cardiology for weight gain and bilateral lower extremity edema. The orders did not indicate parameters when to notify the cardiologist. Review of Resident #40 weights dated 06/01/25 to 06/17/25 revealed: 06/17/2025 214.8 pounds (lbs) 60/16/2025 214.2 lbs 06/15/2025 213.0 lbs 06/14/2025 209.6 lbs 06/13/2025 206.8 lbs 06/12/2025 214.2 lbs 06/11/2025 213.2 lbs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365891 If continuation sheet Page 3 of 15 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 365891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lafayette Pointe Nursing & Rehab Ctr 620 East Main Street West Lafayette, OH 43845 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 06/10/2025 215.2 lbs Level of Harm - Minimal harm or potential for actual harm 06/9/2025 215.4 lbs 06/8/2025 216.2 lbs Residents Affected - Few 06/7/2025 216.8 lbs 06/6/2025 216.4 lbs 06/5/2025 218.0 lbs 06/4/2025 214.4 lbs 06/3/2025 213.2 lbs 06/2/2025 213.0 lbs 06/1/2025 211.8 lbs Review of Resident #40's medical record revealed no evidence the cardiologist was notified of weight gain or bilateral lower extremity edema. Interview on 06/17/25 at 1:24 P.M., with LPN #226 confirmed the orders did not include weight parameters when notifying the cardiologist. The LPN confirmed she would call the cardiologist for clarification on weight parameters but confirmed the cardiologist was not notified of weight gains/edema. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365891 If continuation sheet Page 4 of 15 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 365891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lafayette Pointe Nursing & Rehab Ctr 620 East Main Street West Lafayette, OH 43845 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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, interview, and policy review the facility failed to ensure pain medication was administered as ordered and non-pharmacological interventions were offered prior to the administration of as needed pain medication. This affected four (Resident #2, #12, #16, and #40) of seven residents reviewed for medication use. Residents Affected - Some Findings included: 1. Medical record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including chronic pain, breast cancer, lymphedema, migraines, history of venous thrombosis and embolism, chest pain, intervertebral disc degeneration, and lumbosacral region with discogenic back pain. Review of Resident #40's at risk for alteration in comfort plan of care dated 10/24/24 revealed administer medication as ordered and to offer non-pharmacological intervention (quiet environment, repositioning, back rub, diversional actives). Review of Resident #40's orders dated 05/2025 and 06/2025 revealed to administer Roxicodone 15 milligrams (mg) one tablet every four hours as needed for mild to moderate pain rated one through four (on a 0-10 numerical pain rating scale with 0 representing no pain and 10 representing the most severe pain the resident has encountered) and two tablets every four hours as needed for severe pain rated six to ten (on a 0-10 numerical pain rating scale). There was no evidence of how many tablets to administer for a pain rating of five on a numerical pain rating scale. Review of Resident #40's May 2025 medication administration record (MAR) revealed to administer Roxicodone 15 milligrams (mg) one tablet every four hours as needed for mild to moderate pain one to four. On 05/09/25 and 05/17/25 staff only administered one tablet of Roxicodone 15 mg for a pain rating of seven, on 05/30/25 staff administered one tablet of Roxicodone 15 mg for a pain rating of six, on 05/18/25 staff administered one tablet of Roxicodone 15 mg for a pain rating of eight, and on 05/17/25 and twice on 05/30/25 staff administered one tablet of Roxicodone 15 mg for a pain rating of five. Further review revealed to administer two tablets of Roxicodone 15 mg every four hours for severe pain rated six to 10 on a numerical pain rating scale. On 05/02/25 two Roxicodone were administered for pain rating of five, on 05/04/25 two Roxicodone was administered for pain rating of four, on 05/05/25 two Roxicodone was administered for pain rating of four, on 05/06/25 staff administered two tablets for pain rating of five, on 05/07/25 twice staff administered two tablets for pain rating of four, on 05/09/25 two Roxicodone was administered for pain rating of five, on 05/10/25 two Roxicodone were administered for pain rating of four, on 05/11/25 two Roxicodone were administered twice for pain rating of five, on 05/16/25 two Roxicodone were administered for pain rating of five, on 05/17/25 two Roxicodone were administered for a pain rating of five and four, on 05/18/25 two Roxicodone were administered for pain rating of four, on 05/22/25 two Roxicodone were administered for pain rating of two, on 05/23/25 two Roxicodone were administered for pain rating of three and four, on 05/29/25 two Roxicodone were administered for pain rating of five, and on 05/30/25 two Roxicodone were administered for pain rating of five. Review of Resident #40's MAR dated 06/10/25 revealed staff administered two tablets for pain rating (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365891 If continuation sheet Page 5 of 15 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 365891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lafayette Pointe Nursing & Rehab Ctr 620 East Main Street West Lafayette, OH 43845 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 0697 of five on 06/05/25 twice, 06/06/25, and 06/07/25. Level of Harm - Minimal harm or potential for actual harm Review of Resident #40's medical record revealed no evidence non-pharmacological interventions were attempted prior to administering as needed pain medications. Residents Affected - Some Observation on 06/17/25 at 1:24 P.M., the resident approached the nurse's station and requested pain medication. Licensed Practical Nurse (LPN) #226 asked the resident the location and rate of pain. The LPN did not offer non-pharmacological intervention or assess if the resident had tried any non-pharmacological intervention prior to requesting the pain medication. Interview on 06/17/25 at 1:24 P.M., with LPN #226 revealed the resident requests pain medication right on the dot when it's due. Interview on 06/18/25 at 9:35 A.M., with Assistant Director of Nursing (ADON) #204 reviewed the MAR's and confirmed in May and June 2025 Resident #40's Roxocodone was not administered per parameters on 05/02/25, 05/04/25, 05/05/25, 05/06/25, 05/07/25, 05/09/25, 05/10/25, 05/11/25, 05/16/25, 05/17/25, 05/18/25, 05/22/25, 05/23/35, 05/29/25, 05/30/25, 06/05/25, 06/06/25, and 06/07/25. The ADON also confirmed she didn't realize there were no parameters on how many tablets to administer for pain rating of five. The ADON confirmed there was no documented evidence that non-pharmalogicals were attempted prior to administering pain medication per the resident's plan of care. 2. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including intervertebral disc degeneration, lumbar region with discogenic back pain and lower extremity pain, acute and chronic respiratory failure with hypoxia, fracture of orbital floor, anterior displaced type II dens fracture, fracture of nasal bones, fracture of left femur, and heart failure. Review of Resident #12's at risk for alteration in comfort plan of care revealed to offer non-pharmacological interventions (quiet environment, repositioning, back rub, diversional activities). Review of Resident #12's current orders dated 06/2025 revealed Tramadol 50 mg one every six hours as needed for pain. Review of Resident #12's MAR dated 06/2025 revealed the resident received Tramadol as needed daily. Review of Resident #12's medical record revealed no documented evidence non-pharmacological interventions were implemented prior to administration of Tramadol. Interview on 06/17/25 at 11:42 A.M., with Regional Nurse #226 confirmed there was no documented evidence non-pharmacological interventions were implemented prior to the administration of each as needed pain medication. The Regional Nurse reported staff complete a weekly pain assessment that indicates distractions, communication, and repositioning were used, however there was no documented evidence to support those non-pharmacological were attempted. 3. Review of the medical record for Resident #16 revealed an admission date of 08/24/21 with diagnoses including but not limited to unspecified dementia, disease of the pancreas, congestive heart failure (CHF), and type two diabetes (DM 2). Review of Resident #16's quarterly minimum data set (MDS) dated [DATE] revealed Section C (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365891 If continuation sheet Page 6 of 15 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 365891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lafayette Pointe Nursing & Rehab Ctr 620 East Main Street West Lafayette, OH 43845 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Cognitive Patterns marked with a brief interview of mental status (BIMS) of seven out of a possible score of 15, which indicated cognitive impairment. Further review revealed Section J - Health Conditions revealed Resident #16 received as needed (PRN) pain medication and had non-pharmacological interventions for pain management. Review of Resident #16's physician orders revealed an order dated 06/02/25 for pain medication Tramadol oral tablet 50 milligrams (mg) give one tablet by mouth every six hours as needed (PRN) for pain. Further review revealed a physician order dated 06/11/25 for pain medication Hydrocodone-Acetaminophen oral tablet 5-325 mg give one tablet by mouth every four hours PRN for pain. There were no non-pharmacological interventions noted on the orders. Review of Resident #16's Medication Administration Record (MAR) dated 06/01/25 to 06/17/25 revealed Resident #16 was administered Hydrocodone - Acetaminophen oral tablet 5-325 mg one tablet PRN 13 times from 06/05/25 to 06/11/25 for pain scale ranging from five to eight on a numerical pain rating scale. There were no non-pharmacological interventions documented as being attempted prior to the administration of the narcotic pain medication. Review of Resident #16's alteration in comfort care plan dated 06/05/25 revealed Resident #16 experienced chronic abdominal pain. Resident #16's approaches to pain management included offering non-pharmacological interventions such as quiet environment, repositioning, back rub, diversional activities. An interview on 06/17/25 at 1:13 P.M. with the Assistant Director of Nursing (ADON) confirmed non-pharmacological interventions for pain management were not documented prior to the administration of narcotic pain medication. The ADON stated the nurses should attempt up to three different non-pharmacological interventions prior to administering pain medication to a resident. 4. Review of the medical record for Resident #2 revealed an admission date of 05/31/24 with the following diagnoses including but not limited to pancreatitis, respiratory failure, right ankle fracture, and high blood pressure. Review of Resident #2's physician orders revealed an order dated 04/22/25 for narcotic pain medication Percocet Oral Tablet 5-325 milligram (mg) (Oxycodone w/ Acetaminophen) to give 1 tablet by mouth every 6 hours as needed (PRN) for moderate to severe pain. There were no non-pharmacological interventions documented in the order. Review of Resident #2's significant change minimum data set (MDS) dated [DATE] revealed Section C Cognitive Patterns a brief interview of mental status (BIMS) score of 15 out a possible score of 15 indicating the resident had intact cognition. In Section J - Health Conditions marked as receiving both scheduled and as needed (PRN) pain medications and had non-pharmacological interventions for pain management. Review of Resident #2's medication administration record (MAR) dated 05/01/25 to 05/31/25 revealed Resident #2 was administered narcotic pain medication Percocet Oral Tablet 5-325 milligram (mg) (Oxycodone w/ Acetaminophen) to give 1 tablet by mouth every 6 hours as needed (PRN) 75 times for pain scale ranging from five to ten. There were no non-pharmacological interventions documented as being attempted prior to the administration of the narcotic pain medication. An interview on 06/18/25 at 9:36 A.M. with the Assistant Director of Nursing (ADON) confirmed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365891 If continuation sheet Page 7 of 15 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 365891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lafayette Pointe Nursing & Rehab Ctr 620 East Main Street West Lafayette, OH 43845 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Resident #2 did not have documentation of any non-pharmacological interventions attempted prior to the administration of narcotic pain medication. Review on the facility's policy titled Pain Assessment and Management dated 03/31/16 revealed assessment and adequate treatment of pain is central to the management of the physical and psychological well-being of residents. Non-pharmacological methods to reduce pain in a resident may be implemented. Notify the physician as needed. Event ID: Facility ID: 365891 If continuation sheet Page 8 of 15 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 365891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lafayette Pointe Nursing & Rehab Ctr 620 East Main Street West Lafayette, OH 43845 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital records, review of quick note, interview, and policy review the facility failed to ensure medical records were complete and accurate. This affected three (Resident #12, #14, and #48) of 20 resident records reviewed. Findings included: 1. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including intervertebral disc degeneration, lumbar region with discogenic back pain and lower extremity pain, acute and chronic respiratory failure with hypoxia, fracture of orbital floor, anterior displaced type II dens fracture, fracture of nasal bones, fracture of left femur, heart failure, history of falling, age-related osteoporosis, osteoarthritis, and chronic pain. Review of Resident #12's progress note revealed the resident reported she couldn't breathe. Vital signs obtained: pulse oximeter on room air was 96%, temperature 98.0, blood pressure 155/102 (there was no evidence a pulse rate or respiration were obtained). The resident reported she usually slept with her mouth closed and was unable to completely close her mouth due to (wearing a) c-collar (type of neck brace to prevent certain movements). The resident admitted she may have some anxiety. The resident was asking for pain medication within one hour of administration of Tramadol (pain medications). On call physician contracted and new orders to continue Oxycodone 5 milligrams (mg) every six hours as needed for two more days and Hydroxyzine 25 mg every eight hours as needed. Review of Resident #12's progress note dated 05/05/25 revealed the nurse was in the room and helped aide walk resident to bathroom. The resident began straining on commode and nurse advised resident not to do that due to it possibly causing resident to have a vagal episode (stimulate the vagus nerve and pass out). Resident relaxed at this time, nurse asked resident how she was feeling and resident stated she felt lightheaded and then stated she felt like she was going to throw up. Resident had medium size emesis at this time. Nurse checked resident's pulse oximeter and obtained a reading of 78% on room air. Nurse placed resident on 3.5 liters of oxygen via nasal cannula. Nurse and aide transferred resident into wheelchair and then recliner. Resident lethargic and only answering a few times when asked questions. Pulse oximeter rechecked and obtained reading of 99% on oxygen, vitals also obtained at this time: 101/69, 88, 98.2, 99% on oxygen. Nurse called Certified Nurse Practitioner (CNP) regarding resident and advised CNP that resident stated she started feeling like this when she started taking the small pain pill. Nurse was advised by CNP after advising her of resident's symptoms to administer Narcan to resident to see if it reverses possible opiate reaction, obtain STAT completed metabolic panel (CMP) and basic metabolic panel (BMP) and chest x-ray of resident. CNP also advised to discontinue Oxycodone and Vistaril and restart Tramadol every six hours as needed for pain. Further review revealed the nurse administered one dose of Narcan in the resident's left nostril at 1:45 P.M., resident began to talk more and became more alert with staff. The Director of Nursing (DON) was monitoring pulse ox and removed oxygen after several minutes and continued monitoring and the resident remained at 99% on room air. Nurse administered second dose of Narcan in resident right nostril at 1:49 P.M. Resident became even more alert with staff after a couple minutes and was talking and stating she felt a little better but still felt lightheaded and in pain. Nurse and Administrator in room and resident stated she was going to throw up, resident had two large emesis at that time. Resident's pulse also showed that resident was in atrial fibrillation at this time. Nurse called (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365891 If continuation sheet Page 9 of 15 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 365891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lafayette Pointe Nursing & Rehab Ctr 620 East Main Street West Lafayette, OH 43845 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few squad and they arrived and transported resident via stretcher at this time to hospital for evaluation. Nurse called and gave report to emergency room. Review of Resident #12's hospital records revealed per notes the resident was having severe pain from resident fall with fractures and was receiving Tramadol, however pain was not controlled. The resident was switched to Oxycodone on 05/03/25 and subsequently developed increased confusion and hypoxia. The resident was given Narcan time two at the nursing facility and had nausea and vomiting after receiving the Narcan. Review of CNP quick note dated 05/05/25 revealed the nurse called and reported the resident was having increased confusion and hypoxia. Oxygen sats in the 80's with three liters of oxygen and increased to four liters and pulse ox in the mid 90's. Recently re-admitted and was given Tramadol for pain until Saturday when she was switched for Oxycodone. The last Oxycodone was administered at 8:00 A.M. today. The nurse was concerned that the Oxycodone was too much and increasing the symptoms. Ordered to give Narcan, stat Completed Blood Count (CBC), CMP, B-type Natriuretic Peptide (BNP), chest-x-ray, neuro checks ever hour time three, then every shift, if worsening neuro status or no improvement after Narcan, send to emergency room. Review of Resident #12's orders dated 05/01/25 to 06/17/25 revealed no written orders for the two Narcan doses administered. Interview on 06/17/25 at 1:43 P.M., with Regional Nurse #410 confirmed the nurse had administered two Narcan doses on 05/05/25 to Resident #12, however didn't write an order she had received verbally from the CNP. The resident did not have the stat testing completed because she was sent to the emergency room. Interview on 06/18/25 at 7:42 A.M., with the Director of Nursing (DON) confirmed she was present when the nurse had spoken to the CNP. The CNP had ordered to administer one Narcan and if the first Narcan didn't work, and a second dose could be administered even though the CNP quick note didn't indicate to administer a second dose. 2. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE]. Diagnoses included end stage renal disease, diabetes, reduced mobility, dysphagia, generalized anxiety disorder, dependent on renal dialysis, heart failure, dementia, edema, major depressive disorder, iron deficiency anemia, epilepsy, breast cancer, vertigo, hypertension, and osteoarthritis. Review of the weights in the medical record revealed on 04/01/25 Resident #14 weighed 188.4 pounds, on 05/01/25 weighed 178.4 with no reweigh, and on 05/22/25 weighed 201.8 with no reweigh. Review of the dialysis weights revealed on 04/28/25 Resident #14 weighed 200.64, on 04/30/25 weighed 197.78, and on 05/02/25 weighed 194.26. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #14 had intact cognition, weighed 188 pounds and did not trigger on the assessment for a significant weight loss or gain. Review of the progress note dated from 04/20/25 to 05/04/25 revealed no documentation of a reweigh obtained to clarify the 178.4 weight. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365891 If continuation sheet Page 10 of 15 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 365891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lafayette Pointe Nursing & Rehab Ctr 620 East Main Street West Lafayette, OH 43845 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 06/17/25 at 11:50 A.M. an interview with Dietary Technician #360 revealed the 178.4 weight on 05/02/25 for Resident #14 was an error. She stated the dialysis center reweighed Resident #14 on 05/02/25 however she verified it was the facility's responsibility to reweigh for weight loss or gain. She verified the loss of 10 pounds was not addressed by her or the facility staff and if they had addressed it they would have figured out the weight of 178 pounds was an error. She stated they usually obtain a reweigh if there was a loss or gain of five or more pounds from the previous weight. Review of the facility policy titled,Weight Monitoring, dated 02/15/24 revealed the facility would ensure all residents maintained acceptable parameters of nutritional status. 3. Review of the medical record revealed Resident #48 was admitted to the facility on [DATE]. Diagnoses included pulmonary edema, protein-calorie malnutrition, diabetes, vascular dementia, hallucinations, major depressive disorder, atrial fibrillation, pacemaker, peripheral vascular disease, hypertension, heart failure, vertigo, chronic pain, cerebral aneurysm , and nonrheumatic aortic stenosis. She was discharged to the psychiatric hospital on [DATE]. Further review of the medical record revealed there was no written physician's order to send Resident #48 to the psychiatric hospital. On 06/18/25 at 7:30 A.M. an interview with the Director of Nursing verified there was no order written to transfer Resident #48 to the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365891 If continuation sheet Page 11 of 15 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 365891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lafayette Pointe Nursing & Rehab Ctr 620 East Main Street West Lafayette, OH 43845 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. Review of the infection control logs dated 04/2025 to 06/2025 revealed that in April 2025 there were five urinary tracts infections (UTI), one left knee infection, one left hand infection, one sacral wound infection, and one other infection. There was no evidence of the type of infection or organism. Residents Affected - Many In May 2025 there was one nose infection, 10 UTI's, one eye infection, one toe infection, and one other infection. There was no evidence of the type of infection or organism. In June 2025 there were six UTI's and one eye infection. There was no evidence of the type of infection or organism. Review of the trending dated 04/2025 to 06/2025 revealed the facility was using maps of the building to trend the infections. The maps only indicated the site of the infection. Interview on 06/18/25 at 10:28 A.M., with the Director of Nursing (DON) and Corporate Nurse #410 confirmed the infection control log (tracking) nor the maps (trending) were comprehensive to include all infections. The DON reported that moving forward she would complete the culture results on the log and ensure the map included the infection as well. The DON confirmed she was also the facility's Infection Preventionist and responsible for tracking and trending infections. Review of the infection control policy dated 08/18/10 revealed it was the facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection. Surveillance included a system of surveillance was utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. The Infection Preventionist (IP) serves as the leader in surveillance activities, maintains documentation of incidents, finding, and any corrective actions made by the facility and reports surveillance finding to the facility's quality Assessment and Assurance Committee. The Registered Nurses (RN's) and Licensed Practical Nurses (LPN's) participate in surveillance through assessment of residents and reporting changes in condition to the residents' physicians and management staff. Please note, the policy did not include a procedure for how the facility was tracking and trending infections as part of the infection control program. Based on observations, review of medial records, review of the infection control logs, review of the facility policy and interview the facility failed to ensure hand hygiene and infection control was maintained during medication administration and failed to ensure a comprehensive infection control program to include adequate tracking of infections. This affected two residents ( Resident #3 and #19) of three observed for medication administration, however had the potential to affect all residents in the facility related to the lack of a comprehensive infection control program. The facility census was 47. Findings included: 1. Observation on 06/17/25 at 10:45 A.M. revealed Licensed Practical Nurse (LPN) #321 started to prepare medication for Resident #3, dropped a tablet of tramadol on the top of the medication cart and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365891 If continuation sheet Page 12 of 15 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 365891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lafayette Pointe Nursing & Rehab Ctr 620 East Main Street West Lafayette, OH 43845 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many picked up, placed it in the medicine cup and proceeded to administer the medication to Resident #3. LPN #321 then placed lip balm on the lips of Resident #3. LPN #321 went out into the hallway to the medication cart without washing or sanitizing her hands. She moved the medication cart down the hallway and started to pull the medications for Resident #19. She proceeded to take the medications into Resident #19 and administered the medications to Resident #19. LPN #321 went back out into the hallway and pushed the medication cart down the hallway to another resident's room and then sanitized her hands from the bottle of hand sanitizer located on the top of her medication cart. On 06/17/25 at 10:58 A.M. an interview with LPN #321 verified she picked up the tramadol for Resident #3 with her bare hands and administered the Tramadol to Resident #3 and she had not washed her hands between medication administration for Resident #3 and #19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365891 If continuation sheet Page 13 of 15 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 365891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lafayette Pointe Nursing & Rehab Ctr 620 East Main Street West Lafayette, OH 43845 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 0881 Implement a program that monitors antibiotic use. 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, review of hospital records, review of the infection control log, interview, and policy review the facility failed to ensure resident met criteria for antibiotic treatment. This affected two (Resident #6 and #42) of three residents reviewed for antibiotic stewardship. Residents Affected - Few Findings included: 1. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including acute cholecystitis, diabetes, heart failure, overactive bladder, and chronic kidney disease. Review of Resident #6's hospital discharge note dated 04/18/25 revealed the resident's urine culture was growing mixed skin and fecal flora. The resident had dysuria (painful urination) and suprapubic tenderness on admission. Will complete a short course of Keflex 500 milligrams (mg) four times daily for 16 doses for bladder inflammation. The resident's cholecystitis (inflammation of the gallbladder) versus symptomatic cholelithiasis (gall stones) would be treated with a low-fat diet for which the resident could tolerate with minimal abdominal pain. Review of Resident #6's orders and medication administration records (MAR) dated 04/2025 revealed the resident received Keflex 500 mg from 04/18/25 to 04/22/25 for bladder inflammation. Review of the infection control log dated 04/2025 revealed the resident was treated with Keflex 500 milligrams four times a day for four days for cholecystitis. Review of Resident #6's Loeb's (minimum criteria for initiating antibiotic therapy) undated revealed the form was completed for UTI and the only indication marked was acute dysuria. The instruction indicated a urine culture should be sent prior to starting antibiotics. Interview on 06/18/25 at 12:06 P.M., with the Director of Nursing (DON) confirmed the infection control log was inaccurate due to the resident was ordered the Keflex for bladder inflammation not cholecystitis. The DON also confirmed the resident did not meet criteria for treatment due to a urine culture was never received to ensure the resident met criteria for treatment. 2. Review of closed record revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, heart failure, and muscle weakness. Review of Resident #50's orders dated 06/06/25 revealed the resident was ordered Cipro 500 mg twice daily for a UTI. Review of Resident #50's MAR dated 06/2025 revealed the resident received Cipro 500 mg from 06/06/25 till 06/11/25 for a UTI. Review of the infection control log dated 06/2025 revealed the resident was admitted with diagnoses with UTI and ordered Cipro 500 mg twice daily. There was no evidence that a urine or culture was obtained to ensure the resident met criteria for antibiotic treatment. Review of Resident #50's Loeb's (minimum criteria for initiating antibiotic therapy) undated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365891 If continuation sheet Page 14 of 15 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 365891 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lafayette Pointe Nursing & Rehab Ctr 620 East Main Street West Lafayette, OH 43845 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 0881 revealed the form was blank except for a note on the bottom indicating awaiting culture from hospice. Level of Harm - Minimal harm or potential for actual harm Interview on 06/18/25 at 12:06 P.M., with the DON confirmed there was no evidence the resident met criteria for antibiotic treatment. The DON confirmed the resident received Cipro 500 mg twice daily for five days without documented justification for use. Residents Affected - Few Review of the facility's policy and procedure titled Antibiotic Stewardship Program dated 11/28/17 revealed the Loeb criteria was used to determine whether or not to treat an infection with antibiotics. Laboratory testing shall be in accordance with current standard of practices. The purpose of the program was to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365891 If continuation sheet Page 15 of 15