Inspection visit

Health inspectionDecember 6, 2021

PIKETON NURSING CENTERCMS #36596134 citations on this visit

34 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 34 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review for Resident #26 revealed this resident was admitted to the facility on [DATE] with diagnoses including non-displaced transverse fracture of right fibula, falls, muscle weakness, urinary tract infection, anxiety, morbid obesity, chronic pain, acute kidney failure, hypertension, bimalleolar fracture, and hyperlipidemia. This resident had no known drug allergies. Review of Resident #26's quarterly Minimum Data Set (MDS) assessment, dated 11/19/21, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. Resident #26 was admitted to the facility with a diagnosis of bilateral leg fractures and is currently in bed with a urinary catheter in place. Review of Resident #26's Physician Orders revealed an order was obtained on 11/03/21 for a urinary catheter due to recent acute kidney failure, resident request, and immobility. Order was obtained for 16 French urinary catheter with 10 ml balloon. Resident was explained risks and benefits. Review of Resident #26's care plan from 11/03/21 revealed catheter kept in place, catheter care each shift and change catheter tubing monthly. Observation of Resident #26 on 11/29/21 at 11:45 A.M. revealed this resident has a urinary catheter draining to a catheter bag that is not currently covered by a dignity bag. Interview with the DON and observation of Resident #26 on 11/29/21 at 11:50 A.M. verified this resident does not have a dignity bag in place as the facility does not have any in stock. Interview with Resident #26 on 11/29/21 at 12:00 P.M. revealed this resident stated it is a little embarrassing without having something to cover her catheter bag, as it can be seen from the hallway. Based on observation, resident interview, staff interview, medical record review, and policy review the facility failed to ensure residents were treated with dignity and respect regarding covering urinary catheter drainage bags and engaging with residents during meal time. This affected four of 22 sampled residents (Resident #7, Resident #24, Resident #26, and Resident #29). Findings include: 1. Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] revealed the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 58 Event ID: 365961 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some following. Resident #24's speech was clear, she rarely understood, rarely understands, she had short-term and long-term memory problems, no recall and her decision making was severely impaired. Resident #24 had no behaviors, she rejected care one to three days. Resident #24 was dependent on two staff for bed mobility, required extensive assistance of two staff to transfer, and dependent on one staff to eat, Observation of the common area by the nurses station on 11/21/21 at 11:36 A.M. revealed Resident #26 and Resident #29 were seated at the same table. Resident #26 was seated in a reclined specialized chair (Broda chair). At 11:54 A.M. Resident #29 was served her meal tray, Resident #24's tray was delivered at 11:47 A.M., but State Tested Nursing Assistant (STNA) #16 did not begin feeding Resident #26 until 12:00 P.M. STNA #16 did not talk with Resident #26 and was watching the television as she fed Resident #26. Resident #26 finished eating at 12:15 P.M., STNA #16 did not engage with Resident #26 during the time she fed her. Observation of Resident #26 on 11/23/21 at 8:06 A.M. revealed she was in a Broda chair that was laid back in a common area and STNA #18 was feeding Resident # 24. STNA #18 was standing next to Resident #26's feeding her and STNA #18 was talking with Resident #29. Observation of Resident #26 on 11/30/21 at 7:43 A.M. revealed Resident #26 was in bed and STNA #18 was feeding Resident #26. STNA #18 was standing next to Resident #26's bed holding a bowl of food feeding her. Resident #26's tray was placed in Resident #26's recliner chair, there was no overbed table in or chair in the room for STNA #18 to use. Interview of STNA #18 on 11/30/21 at 7:43 A.M. confirmed she was standing to feed Resident #26 and she should be seated, but there was no overbed table to put Resident #26's tray on and no chair for her to sit to fed her. STNA #18 stated she did not have time to find an over bed table and chair. Interview of the Director of Nursing (DON) on 12/01/21 at 2:30 P.M. confirmed staff should talk with the resident they were feeding and should be seated not stand over the resident they fed. Review of the facility's Quality of Life - Dignity policy dated April 2009 revealed residents would be treated with dignity and respect at all times. 2. Review of Resident #29's medical record revealed she was admitted on [DATE] with diagnoses that included: Alzheimer's disease, osteoarthritis, muscle weakness, difficult ambulation, COVID-19, irritable bowel syndrome, diabetes mellitis type II, depression, congestive heart failure, anxiety, dementia, urinary tract infection, anxiety, and hypertension. Review of Resident #29's quarterly MDS dated [DATE] revealed Resident #29's speech was clear sometimes she understands other, sometimes she was understood, and her cognition was severely impaired. Resident #29 required supervision with set-up help for bed mobility, to transfer, and to eat. Review of Resident #7's medical record reviewed she was admitted on [DATE] with diagnoses that included: pulmonary fibrosis, falls, dementia, and gastro-esophageal reflux disease. Review of Resident #7's quarterly MDS dated [DATE] revealed the following. Resident #7's speech was clear, she understands others, was understood, and her cognition was moderately impaired. Resident #7 did not reject care and she required extensive assistance of one staff for bed mobility to transfer and required supervision with set-up assistance to eat. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 2 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation of the lunch meal on 12/01/2021 at 11:31 A.M. revealed Resident #7 and Resident #29 were seated at a table with two other residents who had received their meal trays and were eating. Resident #7 was served at 11:30 A.M. and Resident #29 was served her meal at 11:39 A M. Interview of the Director of Nursing (DON) on 12/01/21 at 2:30 P.M. confirmed resident's seated at the same table should be served at the same or very close time. Review of the facility's Quality of Life - Dignity policy dated April 2009 revealed residents would be treated with dignity and respect at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 3 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation the facility failed to provide personal materials of the resident's choice as requested. This affected one resident(Resident #28) out of two residents reviewed for personal choices. The facility census was 34. Findings include: Record review for Resident #28 revealed this resident was admitted to the facility on [DATE] with diagnoses including diabetes mellitis type II, myositis, muscle weakness, hypertension, anxiety, osteoarthritis, urinary tract infection, dyspnea, depression, cardiac arrhythmias, bipolar disorder, muscle spasms, pain, constipation, Vitamin D deficiency, hyperlipidemia, thyroid disorders, hyperlipidemia, depression, atherosclerotic heart disease, atrial fibrillation, chronic obstructive pulmonary disease, pain syndrome, and cystocele. This resident had allergies to Ibuprofen. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/03/21, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. Interview with Resident #28 on 11/21/21 at 9:52 A.M. revealed she has asked repeatedly for wet wipes, and has been told none are available or in stock. Interview with Resident #28 on 11/22/21 at 3:55 P.M. revealed she has asked multiple staff members to obtain a package of wet wipes several times and has been told the facility is unable to obtain them. She stated she used wet wipes throughout the day at home before admission for personal use, and now cannot get them which are extremely important to her. Interview with State Tested Nursing Assistant #21 on 11/22/21 at 4:00 P.M. revealed Resident #28 had asked for a package of wet wipes about a week ago. This STNA stated she had told the resident the facility did not have any after looking for some. She stated she told the nurse on duty the resident wanted wet wipes but did not hear anything else about it. Interview with the Director of Nursing on 11/29/21 at 11:50 A.M. revealed she is unaware of this resident asking for personal wet wipes. She stated the facility does not have them, and does not think they have ever had them. She stated she is unsure about how to get them. Observation of Supply Room on 11/29/21 at 11:50 P.M. revealed no supply of wet wipes or cloths being stored in this room. This deficiency substantiates Complaint Number OH00114643. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 4 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure Witnessed Authorization Forms were completed and available for residents whose personal funds were being managed by the facility. This affected two (Resident #4, and #5) of the four residents reviewed for personal funds. The facility census was 34. Residents Affected - Some Findings include: Review of the resident personal funds account record for Resident #4 revealed the facility was managing a personal funds account for Resident #4, and failed to have a Witnessed Authorization Form on record for personal funds to be managed by the facility. Review of the resident personal funds account record for Resident #5 revealed the facility was managing a personal funds account for Resident #5, and failed to have a Witnessed Authorization Form on record for personal funds to be managed by the facility. Interview on 11/29/21 at 11:30 A.M. with Business Office Manager #76 confirmed Resident #4, and #5 did not have a Witnessed Authorization Form on record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 5 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Based on record review and interview the facility failed to provide receipts and/or book keeping records for all personal account activity. This affected three (Resident #4, #5, and #11) of the (4) four residents reviewed for personal funds. The facility census was 34. Findings include: Review of the resident personal funds revealed the facility failed to keep or provide records and/or receipts for purchases or withdrawals from resident personal funds accounts for Resident #4, #5, and #11 who were noted to have personal funds being managed by the facility. Interview on 11/29/21 at 11:30 A.M. with Business Office Manager #76 confirmed she was not able to locate any receipts for any purchases or cash withdrawals for Resident #4, #5, and #11. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 6 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure residents who formulated an advance directive had the directive honored. This affected two of five sampled residents (Resident #15 and Resident #24) reviewed for advance directives. Findings include: 1. Review of Resident #15's medical record revealed she was admitted on [DATE] with diagnoses that included: chronic obstructive pulmonary disease, heart failure, urinary incontinence, anxiety, hemiplegia and hemiparesis of right side, and psychosis. Resident #15 requested a do not resuscitate-comfort care (DNR-CC) order on 09/26/19. Review of Resident #15's quarterly Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #15's speech was clear, she was understood by others, understands others, her vision was adequate with no correction, and her cognition was intact. Resident #15 had a life expectancy of six months or less and she received hospice services. Review of Resident #15's signed October 2021 and November 2021 physician's orders revealed no DNR-CC order. Interview of Resident #15 on 11/21/21 at 2:26 P.M. revealed an advance directive for a DNR was in place and that was what she wanted. Interview of Regional Director of Clinical Operations (RDCO) #77 on 11/30/21 at 3:50 P.M. confirmed Resident #15 did not have an order for DNR-CC and without that order Resident #15 would be a full code. 2. Review of Resident #24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, and hypertension. On 10/07/2021 Resident #24's spouse elected an advance directive of DNR-CC. Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #24's speech was clear, was rarely understood, rarely understands, she had short-term and long-term memory problems, no recall and her decision making was severely impaired. Resident #24 had a life expectancy of six months or less and received hospice services. Review of Resident #24's signed November 2021 physician's orders revealed no DNR-CC order. Interview of Regional Director of Clinical Operations (RDCO) #77 on 11/30/21 at 3:50 P.M. confirmed Resident #24 did not have an order for DNR-CC and without that order Resident #24 would be a full code. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 7 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. 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, interview, and facility policy review, the facility failed to ensure a resident being discharged from a Medicare covered Part A stay with benefit days remaining was provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form, and a Notice of Medicare Non-Coverage-Forms, Center for Medicare and Medicaid Services (CMS) 10123-(NOMNC) form. This affected one resident of the three residents reviewed for Beneficiary Notifications (Resident #13). The facility census was 34. Residents Affected - Few Findings include: Review of the medical record for Resident #13 revealed an admission date of 09/24/20. Diagnoses included Parkinson's disease, acute and chronic respiratory failure, and drug induced acute dystonia (involuntary muscle contractions that cause repetitive or twisting movements). Review of Resident #13's Significant Change of Condition, Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 experienced long and short term memory problems and had moderately impaired cognition for daily decision making ability. Resident #13 required total dependence from one staff member for bed mobility, dressing, eating, toilet use, and personal hygiene, and total dependence from two staff members for bathing. Review of the Skilled Nursing Facility (SNF) Beneficiary Protection Notification review completed for Resident #13 revealed Medicare Part A skilled service episode start date was on 09/17/21 and the last covered day of Part A services was on 10/01/21. Resident #13 was noted on this form to have not received the SNF ABN form nor was the NOMNC form provided. Interview on 11/29/21 at 3:03 P.M. with MDS Coordinator #1 revealed Resident #13 was not provided either of these forms because he started receiving Hospice services. Interview on 11/29/21 at 5:00 P.M. with Regional Director of Clinical Operations #77 confirmed the facility did not provide Resident #13 with the required SNF ABN and NOMNC forms prior to his Skilled Part A services ending. Review of the facility policy titled Advance Beneficiary Notice-ABN, dated 11/30/14, revealed An ABN will be utilized to notify Residents of the possibility that Medicare will not pay for the item(s) or service(s) that are described on the form. The form will be reviewed with the Resident and/or authorized representative and a signature needs to be obtained. Review of the facility policy titled Notice of Medicare Provider Non-Coverage-Generic Notice, dated 11/30/14, revealed A notice of Medicare Provide Non-Coverage- Generic notice will be utilized to notify Residents of non-Medicare coverage. This form will be reviewed with the Resident and/or authorized representative and a signature needs to be obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 8 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, resident interview, group resident interview, staff interview, and policy review the facility failed to provide an adequate dining space that was clean, comfortable, and homelike. This affected 11 residents who routinely ate in the common area by the nurses station (Resident #6, Resident #8, Resident #18, Resident #23, Resident #31, Resident #24, Resident #29, Resident #13, Resident #7, Resident #3, and Resident #26) and one resident ( Resident #12) who was observed eating in the common area. The facility census was 34 residents. Findings include: Observation on 11/21/21 at 8:15 A.M. revealed a large dining room with the doors closed. The room was brightly lit, had seven tables of differing sizes, and other dining room furnishings (sideboards, china cabinets, etc.). At the time of the observation, Dietary Manager (DM) #11 confirmed it was the resident dining room, but it was closed to the residents and she did not know why. DM #11 revealed the residents had not used the dining room since June 2021. Observation on 11/21/21 at 11:49 A.M. revealed residents eating in a common area by the nurses station. The area was furnished with a variety of chairs, a small round table and three over bed tables. The floor carpet was dirty and stained. The area was not a homelike environment. Resident #7, Resident #24, Resident #29, and Resident #18 were seated around the small table, when meal trays were served starting at 11:50 A.M. Resident #24 was moved back from the table to make room for Resident #7, Resident #29, and Resident #18's meal trays. Resident #18 stated the table was small and it was difficult for them to eat together. Residents eating in this area were less than six feet apart. A resident group meeting was held on 11/22/21 at 9:02 A.M. with Resident #18, Resident #31, Resident #23, Resident #28, and Resident #29 revealed they want to return to eating meals in the dining room. Interview of the Administrator on 11/30/21 at 7:20 A.M. revealed they were in outbreak status since last week due to one staff positive for COVID-19. The Administrator stated she was unclear about residents using the dining room. The Administrator stated the recommendations change all the time it was not clear if the residents could eat in the dining room. The Administrator stated residents have used it for Resident Council meetings. The Administrator confirmed the dining room was larger and better suited for social distancing of six feet between residents. The Administrator could not explain why residents could share a communal meal in the smaller space by the nurses station and were not permitted to share a communal meal in the designated dining room. Observation at lunch meal on 12/01/21 at 11:31 A.M. revealed three residents ( Resident #6, Resident #7, and Resident #29) , seated in wheel chairs at a small round table in the common area by the nurses station. Resident #29 stated the table was not large enough for them all to eat especially when Resident #18 returned from having her blood sugar checked. The table was not large enough to accommodate four meal trays. At 11:32 A.M. Resident #18 returned to the common area seated in a wheel chair. For Resident #18 to wheel herself to the small dining table Resident #8, who was in a wheel chair, had to be moved by staff. Resident #18 was not able to get around Resident #8. In the common area Resident #6, Resident #31, Resident #24, Resident #13, Resident #3, and Resident #12 were also in the common area. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 9 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0584 Level of Harm - Minimal harm or potential for actual harm The facility identified Resident #6, Resident #8, Resident #18, Resident #31, Resident #24, Resident #29, Resident #13, Resident #7, Resident #3, and Resident #26 routinely ate in the dining room. The annual survey was conducted from 11/21/2021 to 12/01/2021 and no residents ate in the dining room. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 10 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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, and observation the facility failed to assess a resident's use of a specialty chair and failed to assure the resident's chair was not positioned to prevent the resident for getting out of the chair. This affected one of one residents (Resident #24) reviewed for restraints. Residents Affected - Few Findings include: Review of Resident #24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, and hypertension. Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #24's speech was clear, Resident #24 was rarely understood, rarely understands, she had short-term and long-term memory problems, no recall and her decision making was severely impaired. Resident #24 had no behaviors, she rejected care one to three days. Resident #24 was dependent on two staff for bed mobility, required extensive assistance of two staff to transfer, did not walk, and had no locomotion. Resident #24 used no restraints or alarms. Resident #24 received a specialty chair (Broda chair) on 11/04/21. There was no assessment of the Broda chair to determine whether it restricted Resident #24's freedom of movement. Observation of Resident #24 on 11/21/21 at 11:50 A.M. on 11/22/21 at 7:56 A.M., on 11/23/21 at 8:06 A.M., on 11/23/21 at 11:04 A.M., and 11/29/21 at 10:27 A.M. revealed she was in the Broda chair and it was reclined. Interview of the Director of Nursing (DON) on 11/29/21 at 10:15 A.M. revealed Resident #24 was placed in the Broda chair because the staff was afraid Resident #24 was unsafe in a wheel chair. She did not explain what was meant by unsafe. Interview of Licensed Practical Nurse (LPN) #32 on 11/29/21 at 12:46 P.M. revealed Resident #24 was able to walk and could get out of the Broda chair when it was upright, but not when it was reclined. Interview of State Tested Nursing Assistant (STNA) #18 on 11/30/21 at 8:30 A.M. revealed Resident #24 could walk. STNA #18 stated after Resident #24 had COVID-19 she was not herself, then one day it was like a light turned on and she got up and walked. STNA #18 stated Resident #24 was unsteady because she had not been up so much. STNA #18 stated Resident #24 could get out of the Broda chair when upright and she does, however when the Broda chair was reclined Resident #24 could not get out of the chair. Interview of Regional Director of Clinical Operations (RDCO) #77 on 11/30/21 at 11:16 A.M. confirmed no restraint/enabler assessment was conducted of Resident #24's use of a BRODA chair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 11 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of resident medical record and staff interview, the facility failed to document a discharge for a resident returning to the community. This affected one (Resident #34) of the two residents reviewed for discharging from the facility. The facility census was 34. Findings include: Review of the closed medical record for Resident #34 revealed an admission date on 02/24/21 and a discharge date of 08/31/21. Diagnoses included, dementia without behavioral disturbances, hypertension, and muscle weakness. Review of the Resident #34's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 07 indicating a severely impaired cognition for daily decision making abilities. Resident #34 required limited assistance from one staff member for bed mobility, transfers, ambulation, dressing, toilet use, and personal hygiene, and supervision with set up help only for eating. Review of Resident #34's MDS revealed Discharge, return not anticipated, dated 08/31/21. Review of Resident #34's physician orders for August 2021, revealed no order related to the resident's discharge. Review of Resident #34's nursing, dietary, and social services progress notes from 08/01/21 through 08/31/21, revealed no entries related to the resident's discharge from the facility or an overview of Resident #34's care received while at the facility. Continued review of Resident #34's medical record revealed no documented evidence a Discharge Summary was completed for the residents discharge from the facility. Interview on 11/30/21 at 2:20 P.M. with Regional Director of Clinical Operations #77 confirmed Resident #34's medical record did not reflect an accurate and complete discharge summary or documentation. Review of the facility policies revealed the facility was not able to provide a policy and/or procedure related to Residents Discharge. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 12 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 Resident #20's medical record revealed she was admitted on [DATE] with diagnoses that include: non displaced fracture of the right femur, cerebral palsy, paraplegia, contracture of left ankle, contracture of muscle multiple sites, postsurgical malabsorption, edema, anxiety disorder, disorder of psychological development, epilepsy, and constipation. Residents Affected - Few Review of Resident #20's annual Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #20 had no speech, was rarely understood, rarely understands others. Resident #20 had short-term and long-term memory impairment, did not have recall, and had severely impaired decision making. Resident #20 had no behaviors and did not reject care. Resident #20 was dependent on two staff for bed mobility, to transfer, and was dependent on one staff to eat. Resident #20 had no swallowing problems, was 60 inches tall, 118 pounds, had no significant weight changes, and received 51% or more of calories and fluid intake via a tube feeding. Review of Resident #20's physician orders dated 10/06/21 revealed enteral feeding order (Jevity 1.5) with fiber, 8 ounce carton, administer with syringe 4:00 A.M., 10:00 A.M., 4:00 P.M., and 10:00 P.M. to total 1200 milliliters (ml) of feeding. Review of Resident #20's November 2021 physician orders signed 11/23/2021 revealed the following enteral feeding orders. A bolus tube feeding six times daily was ordered, as well as total tube feeding solution each shift 720 ml, and Jevity 1.5 ml to run at 70 cubic centimeters (cc) at noon daily. Review of Resident #20's medication administration record (MAR) revealed a continuous enteral feeding of Jevity 1.5 at 70 cc per hour (cc/hr) from 11:00 A.M. to 6:00 A.M. Review of Resident #20's nutrition assessment dated [DATE] revealed Resident #20 received Jevity 1.5 300 ml four times a day. There was no nutritional assessment reflecting the 19 hours of continuous feeding. Observation of Resident #20 on 11/23/21 at 8:05 A.M. revealed Resident #20 was in bed on her back and the enteral feeding was turn off. Observation of Resident #20's enteral feeding at 11:20 A.M. revealed it was administered by a pump at 70 ml/hr Interview of Registered Nurse (RN) #12 on 11/23/21 at 2:27 P.M. revealed Resident # 20 received a tube feeding from 11:00 A.M. to 6:00 A.M. administered at 70 ml/hr. Interview of the Director of Nursing (DON) on 11/23/21 at 3:25 P.M. revealed the 10/06/21 enteral feeding orders were Resident #20's feeding orders when she was in the hospital and were not to be implemented in the facility. The DON confirmed the nutritional assessment was not accurate related to Resident #20's enteral feeding. Based on record review, observation, and interview the facility failed to provide appropriate dental and nutritional assessments to appropriately represent the residents health status. This affected two residents (Resident #4 and Resident #20) of 21 residents reviewed for accurate assessments. The facility census was 34. Findings include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 13 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 1. Record review for Resident #4 revealed this resident was admitted to the facility on [DATE] with diagnoses including Huntington's disease, lack of coordination, muscle weakness, dementia, dysphagia, abnormal posture, peripheral vascular disease, delusional disorders, depression, unspecified psychosis, paranoid personality disorder, Vitamin D deficiency, and shortness of breath. This resident had no known allergies. Residents Affected - Few Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/17/21, revealed this resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 8. Review of Annual Minimum Data Set Assessment Section L 0200 completed on 05/07/21 revealed the resident had obvious or likely cavity or broken natural teeth. Review of dental assessments revealed a completion on admission of 10/26/16, where the resident was assessed to be missing teeth. Review of dental assessments on 4/4/19, 6/27/19, 9/26/19, 1/2/20, 3/26/20, 6/25/20 revealed no problems or concerns. On the assessment completed 5/25/21, Resident #4 was assessed to have missing/broken teeth. No other dental assessments were provided. Interview with the Regional Director of Clinical Services #77 on 11/30/21 at 10:00 A.M. verified Resident #4 had been provided with eight quarterly dental assessments since her admission to the facility on [DATE] with the most recent one being completed on 05/25/21. She also verified the Resident #4 was assessed to have broken or chipped teeth on this assessment with no further assessments being done. The Regional Director of Clinical Services #77 also verified Resident #4 should have been provided with proper dental assessments quarterly each year. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 14 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to refer a resident for a level II pre-admission screening and resident review (PASRR) when the resident was newly diagnosed with a mental illness. This affected one of three sampled residents (Resident #24) reviewed for PASRR. Findings include: Review of Resident #24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, hypertension, schizoaffective disorder (10/26/21). Review of Resident #24's PASRR dated 03/17/21 revealed Resident #24 did not have any mental illness. Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident # 24 did not have a level II PASRR completed. There was no level II PASRR conducted after Resident #24 was newly diagnosed with a mental illness, schizoaffective disorder. Interview of Regional Director of Clinical Operations (RDCO) #77 on 11/30/21 at 11:16 A.M. confirmed no level II PASRR was conducted after Resident #24 was diagnosed with schizoaffective disorder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 15 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to notify the state mental health authority promptly after an significant change in a resident mental health, a resident with a newly diagnosed mental illness. This affected one of three sampled residents (Resident #24) reviewed for pre-admission screening and resident review (PASRR). Findings include: Review of Resident #24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, hypertension, schizoaffective disorder (10/26/21). Resident #24 received a new mental health diagnoses of schizoaffective disorder on 10/26/21. Resident #24 had no mental illness diagnoses identified prior. Interview of Regional Director of Clinical Operations (RDCO) #77 on 11/30/21 at 11:16 A.M. confirmed the state mental health authority was not notified of Resident #24's significant change in mental health. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 16 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of resident medical record and staff interview, the facility failed to complete a discharge summary for a resident returning to the community. This affected one (Resident #34) of the two residents reviewed for discharge from the facility. The facility census was 34. Findings include: Review of the medical record for Resident #34 revealed an admission date on 02/24/21 and a discharge date of 08/31/21. Diagnoses included, dementia without behavioral disturbances, hypertension, and muscle weakness. Review of the Resident #34's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 07 indicating a severely impaired cognition for daily decision making abilities. Resident #34 required limited assistance from one staff member for bed mobility, transfers, ambulation, dressing, toilet use, and personal hygiene, and supervision with set up help only for eating. Review of Resident #34's MDS revealed Discharge, return not anticipated, dated 08/31/21. Review of Resident #34's physician orders for August 2021, revealed no order related to the residents discharge. Review of Resident #34's nursing, dietary, and social services progress notes from 08/01/21 through 08/31/21, revealed no entries related to the resident's discharge from the facility or an overview of Resident #34's care received while at the facility. Continued review of Resident #34's medical record revealed no documented evidence a Discharge Summary completed for the residents discharge from the facility. Interview on 11/30/21 at 2:20 P.M. with Regional Director of Clinical Operations #77 confirmed Resident #34's medical record did not reflect an accurate and complete discharge summary or documentation. Review of the facility policies revealed the facility was not able to provide a policy and/or procedure related to Residents Discharge. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 17 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #8's medical record revealed he was admitted on [DATE] with diagnoses that included: COVID-19, essential hypertension, altered mental status, legal blindness, major depressive disorder recurrent, and dysphagia oropharyngeal. Residents Affected - Few Review of Resident #8's quarterly MDS dated [DATE] revealed his speech was clear, he makes self-understood, understands others, his vision was severely impaired and with no corrective lens, and his cognition was moderately impaired. Resident #8 did not reject care. Resident #8 required extensive assistance of one staff for bed mobility, transfers and eat.ing Resident #8 had no swallowing problems, was 66 inches, 179 pounds with no significant weight change. Review of Resident #8's plan of care for eating dated 06/30/21 revealed interventions to encourage the resident to eat, to keep needed items in easy reach, place food items in bowls, open and set up items, and provide positive feedback for efforts and accomplishments. Review of Resident #8's nutrition plan of care dated 06/29/21 revealed assist resident as needed to eat. Review of Resident #8's activities of daily living form for November 2021 revealed Resident #8 required supervision with set up help to eat. Observation of Resident #8 on 11/22/21 at 7:50 A.M. to 8:10 A.M. revealed STNA #16 served Resident #8 his meal tray. STNA #16 did not tell Resident #8 what foods he received or where they were located. Resident #8 received scrambled eggs, cereal, and toast each in a bowl and thickened milk, thickened juice, and thickened water. The beverages were not uncovered. At 7:56 A.M. Resident #8 stated he did not know where food was on his tray. Resident #8 was not told what food he had on his tray or where they were located to enable him to eat his meal. Interview with STNA #18 on 12/01/21 at 11:16 A.M. revealed Resident #8 received food in bowls, thickened liquids, and he did not like the thickened liquids. STNA #18 stated she would place a spoon in his right hand and a bowl of food in his left hand so he can hold it to eat. STNA #18 stated Resident #8 did not require assistance for eating just cueing. STNA #18 confirmed he had a difficult time locating food on tray. STNA #18 was supposed to be up in the chair to eat, he usually eats in the common area so they can keep an eye on him, but with short staffing he eats in his room sometimes. Interview with Registered Nurse (RN) #12 on 12/01/21 at 11:22 A.M. revealed Resident #8 received food in bowls and he did not require assistance to eat. Observation of Resident #8 on 12/01/21 at 11:26 A.M. revealed STNA #18 set Resident #8's tray up and handed him a bowl of meat and gravy and spoon to feed self. STNA #18 did not tell him the foods on his tray or where they were located. 4. Review of Resident #24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, and hypertension. Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #24's speech was clear, she was rarely understood, she rarely understands others, she had short-term and long-term memory problems, no recall and her decision making was severely (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 18 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few impaired. Resident #24 had no behaviors, she rejected care one to three days. Resident #24 was dependent on two staff for bed mobility, required extensive assistance of two staff to transfer, did not walk, had no locomotion, and was dependent on one staff to eat. Resident #24 had six months or less life expectancy, and was on hospice. Resident #24 received no restorative nursing services. Observation of Resident #24 on 11/21/21 at 11:50 A.M. on 11/22/21 at 7:56 A.M., on 11/23/21 at 8:06 A.M., on 11/23/21 at 11:04 A.M., and 11/29/21 at 10:27 A.M. revealed she was in a specialized chair (Broda chair) and it was reclined. Interview of Resident #24's spouse on 11/22/21 at 11:04 A.M. revealed Resident #24 needed services to help Resident #24 to walk. Interview of Licensed Practical Nurse (LPN) #32 on 11/29/21 at 12:46 P.M. revealed Resident #24 was able to walk and could get out of the Broda chair when it was upright, but not when it was reclined. LPN #32 stated Resident #24 was not steady on her feet because she did not walk that often. Interview of State Tested Nursing Assistant (STNA) #18 on 11/30/21 at 8:30 A.M. revealed Resident #24 could walk. STNA #18 stated after Resident #24 had COVID-19 she was not herself, then one day it was like a light turned on and she got up and walked. STNA #18 stated Resident #24 was unsteady because she has not been up so much. Interview of Regional Director of Clinical Operations (RDCO) #77 on 11/30/21 at 11:16 A.M. confirmed Resident #24 was not on a program to strengthen her ambulation abilities. Based on observations, interviews, and record reviews, the facility failed to ensure residents were provided with the necessary assistance to help maintain abilities in the area of eating and ambulation. This affected four of 22 residents (#7, #8, #12, and #24) reviewed for meal assistance. The facility census was 34. Findings include: 1. Record review for Resident #12 revealed this resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, hypertension, tremors, anxiety, depression, hypothyroidism, and malignant neoplasm of the breast. This resident had no known allergies. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 10/05/21, revealed this resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 06. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting, and set-up assistance with supervision for eating. This resident was assessed to be 64 inches tall and weigh 189 pounds. Review of the care plan, dated 10/11/21, revealed this resident had imbalanced nutrition. Interventions included to assist with eating as needed. Review of the facility Vital Signs and Weight Record for Resident #12 revealed the resident's documented weight on 09/29/21 was 189 pounds, 189 pounds on 10/05/21, 186.2 pounds on 10/12/21, 187 pounds on 10/19/21, and 173 pounds on 11/23/21 with a recorded wheelchair weight of 35.4 pounds. Review of the facility Nurse Tech Information Kardex revealed Resident #12 required set up and was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 19 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0676 dependent on staff for eating. Level of Harm - Minimal harm or potential for actual harm Review of the facility CNA - ADL Tracking form for 10/2021 revealed there were no recorded meal intake percentages or amount of assistance the resident required for eating from 10/01/21 through 10/15/21. Residents Affected - Few Documentation from 10/15/21 through 10/30/21 revealed the resident received set up assistance or limited assistance from one staff member and typically consumed 25 to 75 percent of meals. Review of the facility CNA - ADL Tracking form for 11/2021 revealed documentation the resident received limited to extensive assistance from one or two staff members and typically consumed 25 to 75 percent of meals. Observation on 11/21/21 at 11:36 A.M. revealed staff set-up the lunch tray of Resident #12 and left the room, leaving the resident unsupervised and without eating assistance. Observation on 11/21/21 at 12:01 P.M. revealed Resident #12 was reaching into an opened bag of Doritos chips and had consumed less than 25 percent of the bag. The remaining food items on the resident's tray had not been touched by the resident. Observation on 11/21/21 at 3:30 P.M. revealed the lunch meal tray for Resident #12 remained on the over the bed table in front of the resident. The remaining food items on the tray had been stacked on top of each other in the center of the tray. Interview with Licensed Practical Nurse (LPN) #88 on 11/21/21 at 3:35 P.M. verified Resident #12 received set up assistance for meals from staff in her room and typically ate by herself. LPN #88 verified Resident #12 had consumed less than 25 percent of her lunch meal which was usual for the resident. Interview with the Director of Nursing (DON) on 11/29/21 at 10:40 A.M. verified Resident #12 had a documented weight on 09/28/21 of 189.0 pounds and a documented weight on 11/23/21 of 173.0 pounds which was a 14.0 pound weight loss in 35 days. Observation of Resident #12 on 11/30/21 at 7:33 A.M. revealed Resident #12 was in bed with her tray set up on the overbed table. Resident #12 was feeding herself with a built up handle fork. The room door was shut. Resident #12 attempted to eat the scrambled eggs. At 7:50 A.M. Resident #12 was observed in bed, the room door was closed. Resident #12 stated she was done eating, but she might eat a little more. At 8:11 A.M. State Tested Nursing Assistant (STNA) #21 picked up Resident #12's tray. Resident #12 at 10% of her eggs, 25 % of her toast, 0% of cereal, 100 % juice, 0% milk. Interview with STNA #21 revealed Resident #12 does eat well on her own, but she did better with sandwiches and finger foods. Interview with STNA #18 on 11/30/21 at 8:25 A.M. revealed residents ate in their room as night staff did not get any resident's up because they were afraid day shift staff would not show up for work. Observation on 12/01/21 at 11:20 A.M. revealed Resident #12 was sitting her her wheelchair in the lobby with the lunch meal sitting in front of her on an over the bed table. Staff members were observed to be passing lunch meal trays to other residents and did not offer assistance or cueing to Resident #12 until 11:45 A.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 20 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Record review for Resident #7 revealed this resident was admitted to the facility on [DATE] and had diagnoses including unspecified dementia without behavioral disturbances, Alzheimer's disease, pulmonary fibrosis, and dysphagia. This resident had no known allergies. Review of the quarterly MDS assessment, dated 09/29/21, revealed this resident had mildly impaired cognition evidenced by a BIMS assessment score of 12. This resident was assessed to require extensive assistance from one staff member for bed mobility, transfers, and toileting and required set up assistance and supervision for eating. Review of the care plan, dated 07/24/20, revealed this resident had an Activities of Daily Living (ADL) self care deficit. Interventions included to monitor and report decline in abilities while eating. Review of the progress notes dated 10/11/21 through 11/20/21 revealed documentation on 11/30/21 of Resident #12 coughing. No other documentation of the resident coughing while consuming food or beverages was observed. Observation on 11/29/21 at 6:02 P.M. revealed Resident #7 was sitting at the table in the lobby consuming her dinner meal when she began coughing profusely. LPN #32 responded to assess the resident after being requested to three times by an STNA who was sitting at the table assisting another resident. Observation on 11/30/21 at 5:15 P.M. of Resident #12 revealed this resident was sitting at the table in the lobby consuming her dinner meal when she again began coughing profusely. LPN #4 responded to assist the resident and the resident stated It is stuck in my throat and I can't get it up. LPN #4 took Resident #12 to her room where she continued to cough and spit into the trash can. No food or debris were observed to come out while the resident was coughing. Interview with Registered Nurse (RN) #12 and LPN #36 on 11/30/21 at 9:35 A.M. verified Resident #12 had previously been prescribed a mechanical soft diet and had recently been upgraded to a regular diet. RN #12 stated Resident #12 had experienced episodes of coughing while eating and drinking over the previous week and had stated the food and beverages went down wrong while consuming them but had never lost consciousness. LPN #36 verified the resident continued to be prescribed a regular diet and had not received any new orders related to the resident coughing while eating and drinking. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 21 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide Activities of Daily Living (ADL) assistance and care for one dependent resident (Residents #11) of 21 residents reviewed for ADL assistance. The facility census was 34. Residents Affected - Few Findings include: Review of the medical record and face sheet revealed Resident #11 was admitted to the facility on [DATE] with the diagnosis of chronic kidney disease, difficulty walking, hemiplegia following cerebral vascular accident, dysphagia, peripheral vascular disease, and aphasia. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 was cognitively intact and was able to make needs known. Resident #11 required extensive assistance of one person assistance for personal hygiene care, including shaving and supervision for bathing. Review of the plan of care, revised on 10/07/21, identified Resident #11's need for extensive assistance of one staff with grooming. Interventions included explaining procedures prior to starting and providing items step by step. Resident #11 was observed on 11/29/21 at 10:00 A.M. through 12/01/21 at 3:00 P.M. to have beard growth. Resident #11 was interviewed on 11/29/21 at 10:00 A.M., 11/30/21 at 10:54 A.M. and 12/01/21 at 8:47 A.M. Resident #11 affirmatively nodded to interview questions he wanted to be showered and shaved and he had not refused showers and shaving on 11/29/21, 11/30/21 and 12/01/21. Review of the shower sheet schedule dated November 2021, revealed Resident #11 was scheduled for showers three times a week on day shift. Review of shower sheets dated 11/01/21 through 12/01/21 revealed Resident #11 did not receive showers three times a week. There was no shower sheets provided by Regional Clinical Nurse #77 for dates of 11/05/21, 11/12/21, 11/19/21, 11/24/21, 11/29/21 and 12/01/21. State tested nurse aide (STNA) #18 was interviewed on 12/01/21 at 11:42 A.M. She revealed Resident #11 was to be showered and shaved three times a week and documented on shower sheets. She verified Resident #11 had not been showered or shaved on 11/29/21, 11/30/21 or 12/01/21. STNA #18 stated she did not shave him unless he was scheduled a shower and had not provided a shower or shave on 11/30/21 or 12/01/21 due to insufficient staffing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 22 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, resident group meeting, and resident council minute review the facility failed to provide residents with a meaningful, varied activity program, and ongoing activities program that was tailored to the wants and needs of the residents living in the facility. This affected three of three sampled residents (Resident #6, Resident #20, and Resident #24) and five of five residents (Resident #18, Resident #31, Resident #23, Resident #28, and Resident #29) who attended the resident group meeting. Residents Affected - Few Findings include: 1. Review of Resident #20's medical record revealed she was admitted on [DATE] with diagnoses that include: non displaced fracture of the right femur, cerebral palsy, paraplegia, contracture of left ankle, contracture of muscle multiple sites, postsurgical malabsorption, edema, anxiety disorder, disorder of psychological development, epilepsy, and constipation. Review of Resident #20's annual Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #20 had no speech, she rarely was understood, rarely understands others, had short-term and long-term memory impairment, had no recall, and severely impaired decision making. Resident #20 had no behaviors and did not reject care. Resident #20's staff activity preference revealed she did not like reading material, keeping up with news, group activities, and spending time away from nursing home. Resident #20's staff interview revealed she liked listening to music, being around animals, like participating in favorite activities, and religious activities. Resident #20 was dependent on two staff for bed mobility, to transfer, did not walk, and was dependent on one staff for locomotion. Review of Resident #20's activity assessment dated [DATE] revealed Resident #20 had a need for one to one activities and had a need for acoustic stimulation. Movies and music were good sources of stimulation for Resident #20. Resident #20 was nonverbal, unable to express feelings or anything for that matter. Resident #20 watches television and movies. Review of Resident #20's plan of care dated 11/13/14 for activities revealed the following interventions: porch sitting- sitting outside and people watching, one to one activities, in room visits, massage/therapeutic touch, loves music, religious services, small group activities, provide an activities calendar, thank resident for attending activities, female directed activities including nails, makeup, sensory, and [NAME] and cartoon channels. Review of Resident #20's activity participation records for Resident #20 revealed the following. Resident #20 received 15 minutes of one to one activities on 10/25/21 to 10/29/21, 11/01/21 to 11/02/21, on 11/04/21, 11/07/21 to 11/20/21, 11/22/21 to 11/26/21, and on 11/29/21. Resident #20 for the month of November 2021 Resident #20 had daily friend visits, and television that she actively participated in, music was provided 15 of 29 days, three days movies were provided, and sensory was provided 11 of 29 days. Observation of Resident #20 on 11/21/21 at 10:30 A.M. at 3:35 P.M. revealed Resident #20 was in bed, the television was on with children's programing, Resident #20 was not watching the television. There were toddler toys on Resident #20's night stand and they had not been moved from the first observation. Observation on 11/23/21 at 8:05 A.M. revealed Resident #20 was in bed, a child's program was on television and she was asleep. The toddler toys were on the night stand in the same location (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 23 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few they were in on 11/21/21. Observation of Resident #20 on 11/22/21 at 10:01 A.M. revealed she was in bed, the privacy curtain pulled to end of bed, a child's program was on the television and Resident #20 was asleep. At 11:00 A.M. the privacy curtain was pushed to the head of the bed, and a child program was on the television, Resident #20 was not watching the television. Resident #20 was observed at 12:50 P.M. and 2:00 P.M. the television was on children's programs, the toddler toys were in the same place on the night stand and Resident #20 was not engaged in any activity. Interview of Activity Director (AD) #2 on 11/23/21 at 1:49 P.M. revealed she was familiar with Resident#20. AD #2 stated Resident #20 did not talk she only yells out if touch on her leg with a brace. AD #2 stated Resident #20 had baby toys at the bedside and AD #2 try to give them to her daily. AD #2 stated she provided one to one visits daily for 15 to 20 minutes, but they were short staffed and she could not always do the one to one visits. AD #2 stated she put cartoons on the television for Resident #20. AD #2 stated it took two staff and Hoyer lift to get her out of bed. AD #2 stated there was not enough staff to get up out of bed. AD #2 confirmed Resident #20 was not out of bed on 11/21/2021 or 11/22/2021. Interview of State Tested Nursing Assistant (STNA) #18 on 11/23/21 at 1:55 P.M. revealed she did not have a care plan or a care sheet for any resident. STNA #18 was always told not to get in the resident's chart for information, she asks the nurse what care Resident #20 needed including activities. STNA #18 stated Resident #20 only got up on shower days and staff do not take her out of her room due to COVID and the personal protective equipment she needed to wear when out of her room. Additional interview of AD #2 on 11/23/21 at 2:35 P.M. stated she wanted to do sensory and aroma therapy with Resident #20, but she was tactically defensive so AD #2 was not sure that would work for Resident #20. AD #2 revealed television meant the television was on in the resident's room, friend visits was staff going into the room during the day. 2. Review of Resident #24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, hypertension, and schizoaffective disorder (10/26/21). Review of Resident #24's significant change MDS dated [DATE] revealed the following. Resident #24's speech was clear, rarely understood, rarely understands, she had short-term and long-term memory problems, no recall and her decision making was severely impaired. Resident #24 had no behaviors, but she rejected care one to three days. Resident #24's staff assessment of activity preferences revealed she liked reading books, listening to music, being around pets, participating in favorite activities, spending time away from the nursing home, spending time outdoors, and participating in religious practices. Resident # 24 was dependent on two staff for bed mobility, required extensive assistance of two staff to transfer, did not walk, and had no locomotion. Resident #24's activities assessment dated [DATE] revealed Resident #20 was very confused and needed help with games. Review of Resident #24's activity care plan dated 04/02/21 revealed the following interventions: porch sitting- sitting outside and people watching, one to one activities, board games, celebrations/parties, coffee hour, cookouts, encourage exercise, engage in activities with available staff, food and snacks, massage/therapeutic touch, music, pet therapy, religious services, small group activities, invite to schedule activities, provide an activities calendar, thank resident for attending activities, and explain to the resident the importance of activity participation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 24 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0679 Level of Harm - Minimal harm or potential for actual harm Review of Resident #24's October 2021 activity participation record revealed six days of television, four days of family/friend visits, two days of social/parties, and on day of group discussion. Review of Resident #24's November 2021 activity participation record revealed daily family/friend visits, television, 12 of 29 days music, nine of 29 days of socials/parties, four of 29 days of radio and group discussion, and three of 29 days beauty/barber. Residents Affected - Few Observation of Resident #24 on 11/23/21 at 9:06 A.M. to 11:04 A.M. revealed she was in a common area with no activity. Review of the Activity Calendar for 11/23/21 revealed at 9:00 A.M. BINGO was listed, this activity was not observed to occur. Observation on 11/29/21 from 7:42 A.M. to 10:27 A.M. Resident #24 was in a common area with no activity, no television or music on, and no staff in the area. On 11/29/21 at 10:27 A.M. the coffee cart was circulating. AD #2 offered resident's coffee or tea and the interaction was limited. Review of the Activity calendar for 11/29/21 revealed the activity of coffee cart at 8:45 A.M. Interview of AD #2 on 11/29/21 at 3:01 P.M. revealed Resident #24 liked nail care, television, music, social parties, small groups, and likes one to one visits. Further interview of AD #2 on 12/01/21 at 10:05 A.M. revealed television when the television was on, Resident #24's spouse visits almost daily. AD #2 stated she just got an activity assistant so more activities could be offered. AD #2 stated she got pulled to the floor so sometimes activities do not get done. 3. Review of Resident Council Meeting minutes dated 09/15/21 and 10/25/21 revealed no weekend activities, staff did not have time for activities, and activity staff were pulled from an activity and did not come back. A resident group meeting was held on 11/22/21 at 9:30 A.M. with Resident #18, #23, #28, #29, and #31. The residents stated there were no activities on the weekends and activities frequently did not happen or were interrupted due to Activity personnel being pulled to the floor to complete other tasks. The residents stated they would like activities other than BINGO. 4. Review of the Activity Calendar for October 2021 revealed on Sundays at 1:00 P.M. relaxation cloths were offered, on Mondays 6:00 P.M. world news, on Tuesday 9:00 A.M. BINGO at senior center, 1:30 P.M. manicures, 2:00 P.M. BINGO, 3:00 P.M. resident time, Wednesday no activity was listed, Thursdays 10:30 A.M. morning group and 1:00 P.M. store list run, Friday 10:00 A.M. morning group, 1:30 P.M. room visits, and 2:00 P.M. BINGO, and Saturday 2:00 P.M. BINGO. Review of the November 2021 activity calendar revealed Sundays, morning praise channel and 1:00 P.M. relaxation cloths, Monday 10:00 A.M. coffee cart, 1:00 P.M. a special activity, 6:00 P.M. world news, Tuesdays 9:00 A.M. BINGO at senior center, 1:30 P.M. manicures, 2:00 P.M. BINGO, 3:00 P.M. resident time, Wednesday, a special activity and a second special activity, Thursday 10:30 A.M. morning group, BINGO, and another activity, Fridays 10:30 A.M. morning group, 1:30 P.M. room visits, and 3:00 P.M. a food activity, and Saturday 10:00 A.M. movie and 3:00 P.M. activity cart. Interview of AD #2 on 12/01/21 at 10:05 A.M. revealed current events was the news or what they have on in the common room, relaxation clothes included warm, wet clothes on hands followed by lotion massaged onto hands. World news was watching the news on television, movie is a DVD put on, activity (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 25 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cart is taking a cart around with packets they can work on, and Sunday praise channel is a TV program. AD #2 confirmed there were no evening activities. AD #2 stated sometime activities did not occur because she was pulled to the floor, but that should be better now because she now had an activity aide. 5. Review of the medical record and face sheet revealed Resident #6 was admitted to the facility on [DATE] with a diagnosis of dementia, muscle weakness, unsteadiness on feet, hypertension, history of falls, and anxiety disorder. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had moderately impaired cognition, and delusions. Resident #6 preferred activities of music, socialization, magazines to review, animals, religion interests and outside activities. Review of plan of care updated on 05/11/21 addressed Resident #6's impaired cognition, thought processes and potential for wandering behaviors due to dementia, anxiety and ineffective coping skills. Interventions included to provide activities of interest such as books and newspapers, and a wanderguard alert bracelet. Review of November 2021 physician orders revealed medications of Amlodipine 5 mg two tabs daily, Hydroxyzine HCC 25mg two times a day, Lisinopril and Rivastigmine 3 mg twice a day. A wander guard alert bracelet was ordered. Review of activity assessment dated [DATE] revealed Resident #6 was assessed to enjoy TV, music, activity groups and card games. Review of Activity Director #2 participation log revealed no documentation of any activities from 11/18/21 through 11/30/21. Review of posted activity calendar of November 2021 revealed three activities from 10:00 A.M. to 3:00 P.M. Sunday through Saturday, with exception of additional 9:00 A.M. activity on Tuesdays. Activities were repeated weekly with little variety in subject or activity level Random observations of Resident #6 from 11/21/21 2:25 P.M. through 11/29/21 6:15 P.M. revealed Resident was not involved in music, magazine review, or socializing game activities. Observation on 11/23/21 at 10:00 A.M. of posted activity of Coffee Cart revealed the activity started at 10:22 P.M. with 10 residents waiting in the main lounge. Activity Director #2 provided coffee, tea , pop, from a cart provided by the kitchen. Within five minutes, Activity Director #2 left the 10 residents in lounge and took cart down hallway to residents' rooms. There was no other staff providing activity after the Activity Director #2 left the lounge. There was no engagement of residents during the Coffee Cart activity. Interview on 11/22/21 at 8:07 A.M. Resident #6 stated there was nothing to do. She stated she liked magazines. Interview on 11/22/21 at 11:03 A.M. with Resident #6 Power of Attorney, stated Resident #6 enjoys animal activities, reading or reviewing magazines, and socializing in groups. The Activity Director #2 was interviewed on 11/30/21 at 9:03 AM and verified no activities had been documented as provided to Resident #6 from 11/18/21 through 11/29/21. Activity Director #2 stated she has been working as a direct care giver due to insufficient staffing and was unable to provide (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 26 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0679 activities as posted on the November activity calendar. No individualized resident programming documentation was provided. 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: 365961 If continuation sheet Page 27 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, contract review, and staff interview the facility failed to provide necessary treatment and services to treat constipation, and hospice services. This affected three of three residents (Residents #15, #20, and #22) reviewed for constipation, one of one residents (Resident #15) reviewed for hospice services. Actual harm occurred to Resident #20 when the resident did not receive timely treatment for constipation that resulted in hospitalization of a bowel obstruction. Residents Affected - Few Findings include: 1. Review of Resident #20's medical record revealed she was admitted on [DATE] with diagnoses that include: non displaced fracture of the right femur, cerebral palsy, paraplegia, contracture of left ankle, contracture of muscle multiple sites, post-surgical malabsorption, edema, anxiety disorder, disorder of psychological development, epilepsy, and constipation. Review of Resident #20's annual Minimum Data Set (MDS) 3.0 dated 04/06/21 revealed Resident #20 had no speech, was rarely understood and rarely understands others. Resident #20 had short-term and long-term memory impairment, had no recall, and severely impaired decision making. Resident #20 had no behaviors and did not reject care. Resident # 20 was dependent on two staff for bed mobility and transfers, did not walk, was dependent on two staff for toilet use, and personal hygiene. Review of Resident #20's physician orders revealed if Resident #20 had no bowel movement by the third day administer milk of magnesia (MOM) milliliters (ml) daily as needed on the third day at 7:00 A.M. If the MOM was ineffective, administer Dulcolax suppository via the rectum at 1:00 P.M. If the Dulcolax suppository was ineffective, administer one bottle of magnesium citrate at 5:00 P.M. If the magnesium citrate was ineffective, administer a Fleet enema at 10:00 P.M. If there was no bowel movement after the enema, abdominal pain or distention, bowel sounds increase/decrease at any time notify the physician. At any time do not administer the above medication if any if the following were present: abdominal pain, vomiting and/or rectal bleeding. Review of Resident #20's bowel records revealed on 09/23/21 Resident #20 had a bowel movement. No bowel movements were documented from 09/24/21 to 10/03/21. Review of the bowel record on 09/30/21 LAXED was documented. Review of Resident #20's medication administration record (MAR) for September 2021 revealed no evidence the bowel protocol was implemented. Review of Resident #20's October 2021 MAR revealed no evidence the bowel protocol was implemented. Review of Resident #20's progress notes dated 10/01/2021 revealed Resident #20 had a distended abdomen and was sent to the local hospital. Review of Resident #20's hospital Discharge summary dated [DATE] revealed on 10/01/21 Resident #20 went to the emergency room with reported abdominal distention. A computed tomography (CT) scan revealed bowel obstruction and severe constipation. Resident #20 was treated with magnesium citrate and soapsuds enema. Resident #20 had multiple extremely large bowel movements. Review of Resident #20's progress notes revealed on 10/03/21 Resident #20 returned from the hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 28 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 Review of Resident #20's orders revealed magnesium citrate 296 ml every 72 hours was ordered and documented as administered as ordered. Level of Harm - Actual harm Residents Affected - Few Interview with the Director of Nursing (DON) on 11/23/21 at 3:25 P.M. confirmed the bowel protocol was not implemented in September 2021 and October 2021 when Resident #20 had no bowel movement from 09/24/21 to 10/01/21. The DON confirmed Resident #20 was admitted to the local hospital and was diagnosed with a bowel obstruction and severe constipation. 2. Review of Resident #15's medical record revealed she was admitted on [DATE] with diagnoses that included: chronic obstructive pulmonary disease, heart failure, urinary incontinence, anxiety, hemiplegia and hemiparesis, right side, and psychosis. Review of Resident #15's annual MDS dated [DATE] revealed the following Resident #15's speech was clear, she was understood, understands others, and her cognition was intact. Resident #15 had no behaviors and did not reject care. Resident #15 required extensive assistance of two staff for bed mobility, to transfer, did not walk, no locomotion, extensive assistance of two staff for toilet use, and personal hygiene. Resident #15 had a life expectancy of six months or less and was on hospice. Review of Resident #15's quarterly MDS dated [DATE] revealed Resident #15 rejected care one to three days. Review of Resident #15's physician orders revealed if Resident #15 had no bowel movement by the third day, administer milk of magnesia (MOM) milliliters (ml) daily as needed on the third day at 7:00 A.M. If the MOM was ineffective, administer Dulcolax suppository via the rectum at 1:00 P.M. If the Dulcolax suppository was ineffective, administer one bottle of magnesium citrate at 5:00 P.M. If the magnesium citrate was ineffective, administer a Fleet enema at 10:00 P.M. If there was no bowel movement after the enema, abdominal pain or distention, bowel sounds increase/decrease at any time notify the physician. At any time do not administer the above medication if any if the following were present: abdominal pain, vomiting and/or rectal bleeding. Review of Resident #15's bowel records revealed no evidence Resident #15 had a bowel movement from 11/08/21 to 11/12/21 and 11/15/21 to 11/26/21. Review of Resident #15's MAR revealed the ordered bowel protocol was not initiated. Interview with Regional Director of Clinical Operations (RDCO) #77 on 11/30/21 at 1:18 P.M. confirmed there was no evidence Resident #15 had a bowel movement from 11/08/21 to 11/12/21 and 11/15/21 to 11/26/21 and the bowel protocol was not implemented as ordered. Review of Resident #15's record revealed no current hospice care plan and there was no information from hospice provided to the facility. Review of the hospice contract with the hospice service that provided services to Resident #15 dated 10/10/17 revealed hospice would maintain a complete medical record for the hospice recipient and documentation would be maintained in the recipient's nursing home medical record. Interview with DROC #77 on 11/30/21 at 3:50 P.M. revealed Resident #15's hospice provider maintained electronic documentation and previously their documentation was not shared with the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 29 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Residents Affected - Few 3. Record review for Resident #22 revealed this resident was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, chronic pain disorder, and constipation. This resident had allergies to ibuprofen, levofloxacin, zosyn, vancomycin, amitriptyline, baclofen, tramadol, and effexor. Review of the quarterly MDS assessment, dated 10/13/21, revealed Resident #22 had intact cognition evidenced by a BIMS assessment score of 15. This resident was assessed to require limited assistance from one staff member for toileting and eating and to require supervision with set up assistance for bed mobility and transfers. Review of the care plan, dated 08/20/21, revealed Resident #22 was at risk for altered bowel elimination. Interventions included to provide medications as ordered. Review of Resident #22's active physicians orders revealed an order to implement the bowel protocol per facility policy if no bowel movement by the third day. Review of the facility Bowel and Bladder Elimination Pattern Evaluation for Resident #22 for 10/2021 revealed the resident was documented as not having a bowel movement from 10/01/21 through 10/09/21, 10/17/21 through 10/23/21, and 10/26/21 through 10/31/21. Review of Resident #22's Medication Administration Record (MAR) for 10/2021 revealed no documentation of the facility bowel protocol being implemented for Resident #22. Review of Resident #22's progress notes, dated 10/01/21 through 11/01/21, revealed an absence of documentation of Resident #22 not having a bowel movement or of the facility bowel protocol being implemented. Interview with Resident #22 on 11/30/21 at 2:30 P.M. revealed the resident had experienced episodes of constipation which had been reported to staff and had not received any additional medications or treatments for the constipation. Interview with the Director of Nursing on 11/30/21 at 4:45 P.M. verified Resident #22 had not been documented as having a bowel movement for more than three days on multiple occasions in 10/2021 and verified the MAR for 10/2021 contained no documentation of the facility bowel protocol being implemented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 30 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, and staff interview the facility failed to assess and provide vision services and devices as needed. This affected one of one residents reviewed for vision (Resident #15). Residents Affected - Few Findings include: Review of Resident #15's medical record revealed she was admitted on [DATE] with diagnoses that included: chronic obstructive pulmonary disease, heart failure, urinary incontinence, anxiety, hemiplegia and hemiparesis right side, and psychosis. Review of Resident #15's annual minimum Data Set (MDS) dated [DATE] revealed the following. Resident #15's speech was clear, she understood others, her vision was adequate with no correction, and her cognition was intact. Resident #15 had no behaviors and did not reject care. Resident #15 required extensive assistance of two staff for bed mobility and to transfer. Review of Resident # 15's quarterly MDS dated [DATE] revealed the following changes: rejected care one to three days, and for locomotion she required set up help with staff supervision. There was no comprehensive assessment of Resident #15's vision or need for glasses. Interview of Resident #15 on 11/21/21 at 2:42 P.M. revealed her vision was impaired and she needed glasses. Resident #15 stated and she had not seen the eye doctor in a long time. Interview of the Regional Director of Clinical Operations (RDCO) #77 on 11/30/21 at 3:50 P.M. revealed Resident #15 had no vision examination, she is scheduled for a vision examination next year. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 31 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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, and policy review the facility failed to complete fall investigations and assessments of residents after falls with head injuries. This affected one of three residents reviewed for falls and after fall assessments (Resident #384). Findings Include: Review of the closed medical record for Resident #384 revealed an initial admission date of 10/09/13, re-entry date on 11/01/13, and a discharge date on 05/19/21. Diagnoses included difficulty in walking, unsteadiness on feet, repeated falls, muscle weakness, abnormal posture, stiffness of the knees, transient ischemic attack (TIA), concussion without loss of consciousness, injury of the head, and contusion of the scalp. Review of Resident #384's quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating a moderately impaired cognition for daily decision making abilities. Resident #384 was noted to experience or express no behaviors. Resident #384 required extensive assistance from one staff member for bed mobility, transfers, dressing, and toilet use, and limited assistance from one staff member for ambulation, and personal hygiene. Resident #384 was noted with no impairments to bilateral upper or lower extremities, requires the use of a walker for ambulation, and was always continent of bowel and bladder function. Review of Resident #384's fall risk assessments dated 04/23/20 revealed a score of 19 indicating Resident #384 was at risk for falls. Assessments completed on 06/03/20 and 07/02/20 revealed a score of 11 indicating Resident #384 at risk for falls. Fall risk assessment completed on 01/04/21 revealed a score of 8 indicating Resident #384 was not at risk for falls. Review of Resident #384's physician orders for May 2021 included: -Vicodin (narcotic to treat pain) 5-325 milligram (mg) tablet, give one tablet twice a day, -Zestril (ACE inhibitor to treat high blood pressure) 2.5 mg tablet, give one tablet daily for hypertension, Metoprolol Succinate (Beta blocker to treat hypertension, and chest pain) 25 mg extended release (er) tablet, give one tablet daily for a-fib. Review of Resident #384's treatment orders for May 2021 included: -non-skid socks at night time -one side of bed against wall -non-skid strips in front to of high back chair, put non-skid strips in front of bed - dycem in chair due to falls and fall precautions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 32 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 Review of Resident #384's nursing progress note dated 07/02/20, no time noted, revealed, Resident found laying on floor. Gash on top of her head. States she hit her head on the bedside table. Contacted doctor, sending resident to ER to be checked out. Continued review revealed at 9:02 A.M. Patient returned from ER. Nurse called ER for report who states patient CT scan came back normal. Patient has a laceration to left head and received 4 staples, new order to monitor staples for signs and/or symptoms of infection. Cleanse with soap and water if needed. Remove staples in 10 days. Review of Resident #384's nursing progress note dated 07/31/20 at 6:40 A.M. revealed, Resident fell at 6:40 A.M. from chair. Resident hit head on bed side table. Resident has knot on top of her head. Resident sent to the ER for evaluation. Continued review revealed at 9:15 A.M. Patient arrived back to the facility, no new complaints of pain. Review of Resident #384's nursing progress note dated 11/20/20 at 7:20 A.M. revealed, Resident slid and fell out of recliner. Resident stated that she hit her head on her walker. Sent to ER for a CT. Review of Resident #384's nursing progress note dated 12/19/20 at 8:00 A.M. revealed Resident sitting in chair, contusion on left side of forehead. When asked what happened, resident stated she fell at 3:00 A.M. on Friday morning. Doctor called and suggested getting a CT scan. Review of Resident #384's nursing progress note dated 04/08/21 at 9:15 A.M. revealed, Resident fell out of bed without shell helmet on. Resident stated she hit her head. A knot was noted on the top of her head. After getting resident in bed, she vomited, her pupils were sluggish but reactive. Resident had a bruise noted above the coccyx after the fall. Resident was sent to the ER for further evaluation. Review of Resident #384's fall investigation dated 03/12/21 revealed, fall, blood pressure (B/P) 135/71 millimeter of mercury (mmHg), pulse-71 beats per minute, respiration-18 breaths per minute, temperature 97.3 degrees Fahrenheit (F), and oxygen saturations at 98% with 2 liters of supplemental oxygen via nasal cannula, weakness, knot on left frontal lobe, moaning, grimacing, flinching. Skin tear to arm, right upper arm, interventions is a table with wheel locks with supervision as needed. No new fall interventions were noted in this investigation or report. Review of the Skin Evaluation form from fall, dated 03/15/21, revealed, Resident has a hematoma back of head at crown approximate tennis ball. Fall on 03/15/21- previous fall on 03/13/21. Vital Signs, B/P-176/85 mmHg, pulse- 63 beats per minute, respiration 20 breaths per minute, temperature 97.3 degrees F, and oxygen saturation at 98%. Increased confusion, needs more assistance with activities of daily living (ADL), more than one fall, pain to the back of head at a level of 5 out of 10 on the numeric pain scale. (Resident fell out of recliner onto floor, head impact on feet of bed, hematoma, emergency room (ER).). No new fall interventions were noted in this investigation or report. Review of Resident #384's fall investigation dated 04/08/21 revealed, Fall B/P-159/77 mmHg, pulse-74, respirations-14, and oxygen saturation 97%, decreased level of consciousness, resident had a small bruise on coccyx, head. No new fall interventions were noted in this investigation or report. Review of Resident #384's fall investigation dated 04/20/21 revealed, B/P-159/77, pulse-55, respirations18, and oxygen saturations 98% on 2 liters of oxygen via nasal cannula. No new fall interventions were noted in this investigation or report. Review of Resident #384's emergency room (ER) visit summary dated 04/22/21 revealed, Based on this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 33 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 patient's presentation and physical exam as well as lab values, and imaging, she does have a rather large contusion on the anterior forehead. However here in the ER, during ER course, her behaviors been normal. She slept some of which has been good, she is having pain under control, she has a closed head injury. Patient will be returned back to the nursing home. Computed Tomography (CT) of head was negative for any intracranial abnormalities. Residents Affected - Few Continued review of Resident #384's medical record revealed neuro- checks had not been completed for fall where it was noted the Resident hit her head on 03/12/21, 03/15/21, and 04/08/21. Interview on 12/01/21 at 10:00 A.M. with Regional Director of Clinical Operations #77 confirmed fall investigations completed for Resident #384 were incomplete and did not include fall interventions. The Regional Director of Clinical Operations #77 confirmed neuro- checks were not completed for Resident #384 after multiple falls where it was indicated she hit her head. Review of the facility policy titled Accident and Incident-Investigating and Reporting, dated 07/2017, revealed The following data, as applicable, shall be included on the report form, any corrective actions taken., as well as the condition of the injured person, including his/her vital signs. This deficiency substantiates Complaint Number OH00111914. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 34 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, and staff interview the facility failed to assess and provide treatment and care to treat a resident's incontinence. This affected one of one residents reviewed for bladder function (Resident #15). Findings include: Review of Resident #15's medical record revealed she was admitted on [DATE] with diagnoses that included: chronic obstructive pulmonary disease, heart failure, urinary incontinence, anxiety, hemiplegia and hemiparesis right side, and psychosis. Review of Resident #15 annual minimum Data Set (MDS) dated [DATE] revealed the following. Resident #15's speech was clear, she understood others, and her cognition was intact. Resident #15 had no behaviors and did not reject care. Resident #15 required extensive assistance of two staff for bed mobility and to transfer. Resident #15 was not on a toileting program and was always incontinent of bladder, There was no comprehensive assessment of Resident #15's bladder function or bladder retraining potential. Interview of Resident #15 on 11/21/21 at 2:42 P.M. revealed she was incontinent of urine and was supposed to be on a toileting plan. Interview of the Regional Director of Clinical Operations (RDCO) #77 on 11/30/21 at 3:50 P.M. revealed Resident #15 had no bladder assessment and currently was not on a toileting plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 35 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, hypertension, schizoaffective disorder (10/26/21). Residents Affected - Some Review of Resident #24's weights revealed on admission she weighed 188.4 pounds, on 08/09/21 she weighed 173 pounds, on 09/06/21 171 pounds, on 10/04/21 she weighed 152 pounds. Resident #24 was diagnosed with COVID-19 and sent to another facility on 09/09/21 and returned on 10/01/21. Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #24's speech was clear, rarely understood, rarely understands, she had short-term and long-term memory problems, no recall and her decision making was severely impaired. Resident #24 had no behaviors, she rejected care one to three days. Resident #24 was dependent on two staff for bed mobility, required extensive assistance of two staff to transfer, and was dependent on one staff to eat. Resident #24 had no swallowing problems, was 62 inches tall, 152 pounds, had no weight loss, and was on hospice. Review of Resident #24's physician orders revealed a pureed diet and a liquid nutritional supplement (mighty shake) at each meal. On 11/28/21 Resident #24's diet was changed to a regular diet. Observation on 11/21/21 at 11:52 A.M. of Resident #24's lunch meal revealed she received mashed potatoes, pureed meat, pureed vegetable, and pureed fruit. There was no mighty shake on her tray. Observation of Resident #24's breakfast meal on 11/23/21 at 8:06 A.M. revealed she did not receive a mighty shake. Observation of Resident #24's breakfast tray on 11/30/21 at 7:43 A.M. revealed she did not receive a might shake. Interview of State Tested Nursing Assistant (STNA) #18 on 11/30/21 at 7:48 A.M. confirmed Resident #24 did not have mighty shake on her tray and did not receive one. Interview of Dietary Account Manager (DAM) #11 on 11/30/21 at 8:40 A.M. confirmed Resident #24 did not receive mighty shakes on her tray or from the kitchen. DAM #11 stated she was told since Resident # 24 was on hospice, hospice not the kitchen provided mighty shakes to the resident. Interview of Licensed Practical Nurse (LPN) #32 on 11/30/21 at 9:00 A.M. revealed the kitchen provided the mighty shake not nursing and nursing did not have mighty shakes in the medication refrigerator. 3. Record review for Resident #12 revealed this resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, hypertension, tremors, anxiety, depression, hypothyroidism, and malignant neoplasm of the breast. This resident had no known allergies. Review of the admission MDS assessment, dated 10/05/21, revealed this resident had moderately impaired cognition evidenced by a BIMS assessment score of 06. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting, and set-up assistance with supervision for eating. This resident was assessed to be 64 inches tall and weigh 189 pounds. Review of the care plan, dated 10/11/21, revealed this resident had imbalanced nutrition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 36 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 Interventions included to assist with feeding as needed and weigh per facility protocol. Level of Harm - Minimal harm or potential for actual harm Review of the Hospice Initial Visit note, dated 09/12/21, revealed Resident #12 had a documented weight of 148.0 pounds. Residents Affected - Some Review of the facility Vital Signs and Weight Record for Resident #12 revealed the resident's documented weight on 09/29/21 was 189 pounds, 189 pounds on 10/05/21, 186.2 pounds on 10/12/21, 187 pounds on 10/19/21, and 173 pounds on 11/23/21 with a recorded wheelchair weight of 35.4 pounds on 11/23/21. Review of the dietician progress note, dated 10/07/21, revealed Resident #12 was documented as weighing 189.4 pounds which put the residents Body Mass Index (BMI) at 32.5, indicating class one obesity. Interview with the Director of Nursing (DON) on 11/29/21 at 10:40 A.M. revealed the weight documented on the Hospice Initial Visit Note dated 09/12/21 was correct and the weights recorded by the facility on 09/29/21, 10/05/21, 10/12/21, and 10/19/21 were not documented accurately as they did not reflect the weight of the resident's wheelchair being subtracted. The DON verified the assessment completed by the Registered Dietician on 10/07/21 was also inaccurate due to the inaccurate documentation of Resident #12's weight by facility staff. The DON verified the MDS assessment completed on 10/05/21 was inaccurate as it listed the resident's weight as 189 pounds. Review of the facility policy titled Weighing and Measuring the Resident, revised 03/2011, revealed staff were to note and record the resident's weight and were to subtract the weight of the wheelchair prior to documenting the weight. Based on observation, interview and record review, the facility failed to provide a therapeutic diet for three residents, (Residents #6, #12 and #30,) and accurately monitor weights for one resident (Resident #24), as ordered by the physician for 21 residents reviewed for nutritional status. The facility census was 34. Findings include: 1. Review of the medical record and face sheet revealed Resident #30 was admitted to the facility on [DATE] with the diagnoses of chronic obstructive pulmonary disease, (COPD), dementia, SOB, gastritis, peripheral vascular disease, depressive disorder, nausea, reflux disease, fatigue, and muscle weakness. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 was moderately cognitively impaired, received a mechanically altered diet, was edentulous without pain., and had no depression. Review of plan of care updated on 09/15/21, addressed Resident #30's nutritional risk due to dementia, COPD, and edentulous assessment. Interventions included provide food preferences, Registered Dietitian., (RD) to evaluate and make diet changes, dental consult as needed, keep snacks in room, resident prefers sweet snack foods, and fortified food program started 03/09/20. Review of November 2021 physician orders revealed diet order of dysphagia advanced texture, fortified meals, thin liquids, and nutritional health shake three times daily with meals. Review of RD #78's quarterly progress notes dated 10/19/21 revealed Resident #30 was to receive a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 37 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 - Some dysphagia advanced texture diet with fortified foods and health shake supplement three times a day. Resident #30 meal intake was 50 to 75 %. Review of weight records revealed weights of 107 pounds on 04/08/21, 108 pounds on 05/03/21, 108 pounds on 06/01/21, 105 pounds on 07/05/21, 102 pounds on 08/02/21, 105 pounds on 09/16/21, 104 pounds on 10/07/21 and 99 pounds on 12/01/21. Resident #30 was 5 foot 11 inches tall. Review of nutritional laboratory value dated 07/01/21 revealed a slightly depleted protein value of 2.9, below normal value of 3.2 Review of Resident #30's breakfast, lunch and dinner meal tray cards listed dysphagia advanced texture diet with fortified foods, health shake at each meal, sweets at breakfast and two desserts at lunch and dinner. Resident #30's meals were observed on 11/23/21 at 7:40 A.M. breakfast, no health shake and no additional sweets were provided. On 11/29/21 at 11:55 A.M. at lunch meal, no health shake and no additional desserts were provided. State Tested Nurse Aide, (STNA) #18 verified no health shake was provided on 11/23/21 at breakfast. Resident #30 was interviewed on 11/23/21 at 7:40 A.M. He stated he liked the health shakes when he receives them. The Dietary Manager, (DM), #11 was interviewed on 11/30/21 at 10:24 A.M. and revealed she was unaware Resident #30 physician diet order included fortified foods and additional sweets at breakfast and additional desserts at lunch and supper. DM #11 further stated Resident #30 foods had not been prepared and served as fortified. DM #11 verified Resident #30 did not receive additional foods, as listed on the tray card, for meals served on 11/21/21 through 11/30/21. Review of facility policy titled Fortified Food Program undated, revealed the facility failed to implement the policy. 2 . Review of the medical record and face sheet revealed Resident #6 was admitted to the facility on [DATE] with a diagnosis of dementia, muscle weakness, unsteadiness on feet, hypertension, history of falls, and anxiety disorder. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had moderately impaired cognition. Review of plan of care updated on 09/15/21, addressed Resident #6 nutritional risk for imbalanced nutrition due to varied intake and dementia diagnosis. Intervention, dated 05/11/21 , included ice cream added to lunch and dinner meal. Review of November 2021 physician orders revealed diet order of Regular diet with ice cream at lunch and dinner. Review of Resident #6's breakfast, lunch and dinner meal tray cards listed Regular diet with ice cream at lunch and dinner meals. Observation of lunch meals 11/23/21, 11/29/21 and 11/30/21 revealed no ice cream on Resident #6's meal tray. Observation of dinner meal on 11/29/21 at 5:41 P.M. revealed no ice cream on dinner meal tray. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 38 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 Interview on 11/29/21 at 5:41 P.M., Resident #6 stated she liked ice cream. Level of Harm - Minimal harm or potential for actual harm The Diet Manager , (DM), #11 was interviewed on 11/30/21 at 10:24 A.M. and revealed she was unaware Resident #6's physician diet order included ice cream at lunch and supper. DM #11 verified Resident #6 did not receive ice cream as listed on the tray card, for lunch and dinner meals served on 11/21/21 through 11/30/21. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 39 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, hypertension, schizoaffective disorder (10/26/2021). Residents Affected - Some Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #24 used oxygen and on hospice. Review of Resident #24's monthly physician orders for November 2021 revealed oxygen at two liters per minute as needed for dyspnea and to change the oxygen tubing every week and as needed. Review of Resident #24's treatment administration record for November 2021 revealed oxygen ordered at two liters for per minute and to change the tubing every week. There was no evidence Resident #24's oxygen tubing was changed. Observation on 11/21/21 at 9:48 A.M. of Resident #24's room revealed an oxygen concentrator with tubing next to Resident #24's bed. The tubing attached to the concentrator was not dated. Observation of Resident #24's oxygen concentrator on 11/29/21 at 10:00 A.M. revealed the tubing on Resident #24's oxygen concentration was dated 11/21/21. Interview of the Director of Nursing (DON) on 11/29/21 at 10:15 A.M. confirmed Resident #24's oxygen tubing was dated 11/21/21 and was supposed to be changed on 11/28/21. Based on observation, interviews, and record reviews, the facility failed to obtain or implement physicians orders for oxygen therapy and failed to change tubing as ordered by the physician. This affected four residents (#12, #14,#24 and #30) of the five residents reviewed for respiratory services. The facility census was 34. Findings include: 1. Record review for Resident #12 revealed this resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, hypertension, depression, tremor, and hypothyroidism. This resident had no known allergies. Review of the admission Minimum Data Set (MDS) assessment, dated 10/05/21, revealed this resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 06. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting and set-up help with supervision for eating. Review of the care plan, dated 10/11/21, revealed this resident had the potential for an ineffective breathing pattern. Interventions included to administer oxygen as ordered. Review of the active physicians orders, signed on 11/11/21 by the physician, revealed an order to administer oxygen by nasal cannula at two liters per minute by nasal cannula. Review of the Medication Administration Record (MAR) for 11/2021 revealed documentation oxygen had been administered by nasal cannula to Resident #12 from 11/01/21 through 11/22/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 40 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Observation on 11/21/21 at 9:45 A.M. revealed Resident #12 was lying in bed with no oxygen being administered and no oxygen concentrator available in the room. Observation on 11/22/21 at 8:07 A.M. revealed Resident #12 was lying in bed with no oxygen being administered and no oxygen concentrator available in the room. Residents Affected - Some Observation on 11/22/21 at 3:41 P.M. revealed Resident #12 was lying in bed with no oxygen being administered and no oxygen concentrator available in the room. Interview with Licensed Practical Nurse (LPN) #36 on 11/22/21 at 3:45 P.M. verified there was not an oxygen concentrator located in the room of Resident #12 and the resident was not receiving oxygen therapy. LPN #36 then verified Resident #12 had active physicians orders for oxygen to be delivered at two liters per minute which was documented as being administered on the MAR for 11/2021 every shift by licensed nurses employed at the facility. 2. Record review for Resident #14 revealed this resident was admitted to the facility on [DATE] with diagnoses including sepsis, difficulty walking, bipolar disorder, hypertension, and shortness of breath. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/30/21, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. This resident was assessed to require set up assistance and supervision for bed mobility, transfers, and toileting. Review of the care plan, dated 07/14/20, revealed this resident had the potential for ineffective breathing patterns. Interventions included oxygen as ordered as needed. Review of the active physicians orders, signed by the physician on 11/11/21, revealed an absence of an order for oxygen administration for Resident #14. Review of the MAR for 11/2021 revealed an absence of documentation of oxygen administration to Resident #14. Observation on 11/21/21 at 12:09 P.M. revealed Resident #14 was lying in bed and had oxygen being administered by nasal cannula at a rate of two point five liters per minute. Observation on 11/29/21 at 3:53 P.M. revealed Resident #14 was lying in bed and had oxygen being administered by nasal cannula at a rate of two point five liters per minute. Interview with LPN #88 on 11/29/21 at 3:53 P.M. verified Resident #14 had oxygen being administered by nasal cannula at a rate of two point five liters per minute. LPN #88 verified Resident #14 did not have an order for oxygen administration or documentation of oxygen administration on the MAR. 4. Review of the medical record and face sheet revealed Resident #30 was admitted to the facility on [DATE] with the diagnosis of chronic obstructive pulmonary disease, (COPD), dementia, SOB, gastritis, peripheral vascular disease, depressive disorder, nausea, reflux disease, fatigue, and muscle weakness. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 was moderately cognitively impaired, and received oxygen per nasal cannula as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 41 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Review of plan of care updated on 09/15/21, addressed Resident #30 respiratory risk due to dementia, and COPD. Interventions included provide oxygen per nasal cannula as needed. Review of November 2021 physician orders revealed order of oxygen two liters per nasal cannula as needed to maintain 90% oxygen saturation. Change oxygen tubing every Sunday. Residents Affected - Some Observation on 11/21/21 at 10:00 A.M. revealed oxygen tubing dated 11/12/21. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 42 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on staff interview, review of time punch cards, and review of direct care staff schedule revealed the facility failed to ensure the facility had Registered Nurse (RN) coverage for a consecutive eight hours. This had the potential to affect all 34 residents. Findings include: Review of the nursing staff schedule from 11/01/21 through 11/30/21 revealed the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were scheduled on 11/25/21 day shift. Review of the time punch cards for the DON revealed zero accumulated hours for 11/25/21. Review of the time punch for the ADON revealed zero accumulated hours for 11/25/21. Interview on 12/01/21 at 3:00 P.M. with the Administrator and the Regional Director of Clinical Operations #77 confirmed there was no RN coverage for the facility on 11/25/21. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 43 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of pharmacy recommendations, and staff interview the facility failed to review a resident's drug regimen and make recommendations regarding drug irregularities. This affected one of six sampled residents (Resident #24) reviewed for unnecessary medications. Findings include: Review of Resident #24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, and hypertension. On 10/26/21 a diagnosis of schizoaffective disorder was added. Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #24 received an antipsychotic medication, an antidepressant medication, and an anticoagulant, 6 of 7 day assessment period and there was no dose reduction of the antipsychotic medication. Review of Resident #24's monthly physician orders revealed on admission an order for an antipsychotic medication (Risperdal) one milligram (mg) at bedtime. Review of Resident #24's July 2021, August 2021, October 2021, and November 2021 drug regimen reviews revealed no irregularities. No drug regimen reviews were provided prior to July 2021. These reviews were requested by the surveyor but none were provided. Record review revealed Resident #24 did not have an indication for the use of the antipsychotic medication and there were no target behaviors identified or tracked. Interview of Director of Nursing (DON) on 11/30/21 at 11:06 A.M. revealed drug regimen reviews for Resident #24 were not available prior to the July 2021 reviews. The DON verified there were no recommendations from the pharmacist regarding Resident #24's usage of Risperdal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 44 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 and staff interview the facility failed to ensure a resident did not receive an antipsychotic medication without an indication for its use. This affected one of six sampled residents (Resident #24) reviewed for unnecessary medications. Findings include: Review of Resident #24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, and hypertension. On 10/26/21 a diagnosis of schizoaffective disorder was added. Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #24 received an antipsychotic medication, an antidepressant medication, and an anticoagulant 6 of 7 day assessment period. There was no dose reduction of the antipsychotic medication. Review of Resident #24's monthly physician orders revealed on admission an order for an antipsychotic medication (Risperdal) one milligram (mg) at bedtime. Review of Resident #24's medical record revealed the resident did not have an indication for the use of the antipsychotic medication, there were no target behaviors identified or tracked. Interview Licensed Practical Nurse (LPN) #32 on 11/29/21 at 12:46 P.M. revealed Resident #24 had no behaviors and did not resist care. LPN #32 stated one time a hospice aid, who was trying to shower Resident #24 and the resident did not want showered, Resident #24 told her to stop or she would fist her. The aid did not stop and Resident #24 hit at the hospice aid. LPN #32 stated Resident #24 did not have delusions and she does not have mental illness like they to say she does. Resident #24 gets her words mixed up but that is dementia. Interview of State Tested Nursing Assistant (STNA) #18 on 11/30/21 at 8:30 A.M. revealed Resident #24 would resist care when staff tried to get her to do something she did not want to do. Resident #24 would resist care such as holding onto her brief when you go to change her if she did not know the aid. Interview of the Regional Director of Clinical Operations (RDCO) #77 on 11/30/21 at 11:16 A.M. confirmed no target behaviors were identified for Resident #24 and there was no tracking of behaviors for Resident #24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 45 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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** 2. Review of Resident #15's medical record revealed she was admitted on [DATE] with diagnoses that included: chronic obstructive pulmonary disease, heart failure, urinary incontinence, anxiety, hemiplegia and hemiparesis, right side, and psychosis. Residents Affected - Few Review of Resident #15's annual minimum Data Set (MDS) dated [DATE] revealed the following. Resident #15 had no swallowing problems, no significant weight changes, and was edentulous. Review of Resident #15's quarterly MDS dated [DATE] revealed Resident #15 rejected care one to three days during the assessment period. Review of Resident #15's quarterly clinical health status dated 05/25/21 and 07/21/21 revealed she was edentulous and these documents did not identify that Resident #15 had dentures or not. Review of Resident #15's dental plan of care did not identify the resident as having dentures. There was no comprehensive assessment of Resident #15's dental status, no documentation of the resident having dentures or using dentures. There was no evidence in Resident #15's medical record of her having a dental appointment. Interview of Resident #15 on 11/21/21 at 2:36 P.M. revealed she had dentures that did not fit and she was supposed to see the dentist when he next comes to the facility. Observation of Resident #15 on 11/23/21 at 8:05 A.M. revealed she did not have dentures. Interview of State Tested Nursing Assistant (STNA) on 11/30/21 at 2:27 P.M. revealed Resident #15 had dentures but she did not wear them. Interview of the Regional Director of Clinical Operations (RDCO) #77 on 11/30/21 at 3:50 P.M. confirmed Resident #15 had no dental assessment, no evidence Resident #15 saw the dentist, and now Resident #15 was scheduled for dental appointment next year. Based on record review, observation, and interview the facility failed to provide routine dental services for two residents. This affected two residents (Resident #4 and Resident #15) of four residents reviewed for routine dental services. The facility census was 34. Findings include: 1. Record review for Resident #4 revealed this resident was admitted to the facility on [DATE] with diagnoses including Huntington's disease, lack of coordination, muscle weakness, dementia, dysphagia, abnormal posture, peripheral vascular disease, delusional disorders, depression, unspecified psychosis, paranoid personality disorder, Vitamin D deficiency, and shortness of breath. This resident had no known allergies. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/17/21, revealed this resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 46 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 score of 8. Level of Harm - Minimal harm or potential for actual harm Review of Annual Minimum Data Set Assessment Section L 0200 completed on 05/07/21 revealed the resident had obvious or likely cavity or broken natural teeth. Residents Affected - Few Review of Resident #4's dental appointment log revealed the last dental appointment was on 01/20/21. A dentist recommendation was made to be seen in the office for her next appointment due to heavy plaque and gingivitis. No follow up appointments have been made for this resident since that time. Dentist last visit to the facility was on 06/21/21, with this resident not being seen from information provided. Facility provided the next appointment for this resident is currently scheduled for January 2022, with no appointment time provided, and to be seen in house. Facility provided no evidence of an outside dental appointment taking place following the recommendation on 01/20/21. Review of the Dental Summary Report completed on 01/20/21, stated Resident #4 has partial dentition and no dental x-rays were taken due to the resident being seen in their room. A recommendation was made to be brought to the dental clinic for their next visit. The notes reflect the dentist was unable to complete cleaning at the time of service as well. The dentist assessed the resident to have heavy plaque and gingivitis, and requires assistance for daily mouth care. Interview with the Director of Nursing on 11/23/21 at 2:25 P.M. verified Resident #4 had not been seen for a dental appointment since 1/20/21, even after receiving a recommendation by the dentist to be seen in the office on her next visit. She verified the last time the dentist was in the building was 06/21/21, and Resident #4 was not seen at that time. She verified Resident #4 has her next dental appointment for 360 care in January 2022 which she believes will be conducted in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 47 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, group resident interview, review of Resident Council Meeting Minutes, and a test tray the facility failed to serve food that was palatable and at an acceptable temperature. This had the potential to affect 33 of 34 resident (Resident #15 receives nothing from the kitchen) and specifically affected Residents #26, #10, #22, #15, #18, #23, #26, #28, #29, and #31. Residents Affected - Many Findings include: 1. Review of Resident Council meeting minutes revealed on 8/27/21 complaints of cold food, it was not the best food and the food was either over or under cooked. The 09/15/21 resident council minutes revealed the food was cold, the food tasted bad, the broccoli and cauliflower were overcooked, and served in big pieces. Interview of Resident #26 on 11/21/21 at 9:40 A.M. revealed sometimes the hot foods were served cold and were not good. Interview of Resident #10 on 11/21/21 10:30 A.M. revealed hot foods were served cold. Interview with Resident #22 on 11/21/21 at 10:53 A.M. revealed food was not served hot. Interview of Resident #15 on 11/21/21 at 2:35 P.M. revealed sometimes the hot food was not hot. A resident group meeting was held on 11/22/21 at 9:30 A.M. with Resident #18, #23, #28, #29, and #31 stated the hot foods were served cold and it did not taste good. A test tray was requested on 11/29/21. The cart containing the test tray arrived on the unit at 12:05 P.M. The last tray was delivered at 12:25 P.M. At 12:27 P.M. the following temperatures of the food items were obtained. The cheese pizza was 94 degrees Fahrenheit (F) it was cold to the taste, the cheese on the pizza was light brown, the sauce was absorbed by the crust, and the crust was tough and very dry. The green beans were 102 degrees F and cool to taste. The test tray was sampled by two surveyors. 2. Record review for Resident #22 revealed this resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, congestive heart failure, acute and chronic respiratory failure, difficult ambulation, parainfluenza, muscle weakness, lack of coordination, myocardial infarction, fatigue, shortness of breath, hypertension, anxiety, depression, asthma, fluid aspiration, diabetes mellitis type II, and hypertension. This resident had allergies to Ibuprofen, Levofloxicin, Zosyn, Vancomycin, Amytriptylline, Baclofen, Tramadol, and Effexor. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/13/21, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. Interview with Resident #22 on 11/21/21 at 10:53 A.M. revealed the facility does not provide hot food substitutions, and you have to ask for them. 3. Record review for Resident #26 revealed this resident was admitted to the facility on [DATE] with diagnoses including non-displaced transverse fracture of right fibula, falls, muscle weakness, urinary tract infection, anxiety, morbid obesity, chronic pain, acute kidney failure, hypertension, bimalleolar fracture, and hyperlipidemia. This resident had no known drug allergies. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/19/21, revealed this resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 48 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0804 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. Level of Harm - Minimal harm or potential for actual harm Interview with Resident #26 on 11/21/21 at 9:40 A.M. revealed the resident stated that some of the food is not very good, and is sometimes cold. Residents Affected - Many This deficiency substantiates Master Complaint Number OH00114643. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 49 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, resident interview, resident group interview, resident council meeting minutes, and staff interview the facility failed to ensure accommodation of resident food preferences and failed to offer a food substitute when a resident did not like the food served. This affected 33 of 34 residents (except Resident #15 who received nothing from the kitchen) and specifically affected Residents #7, #18, #23, #28, #29, #30, and #31 . Findings include: Review of Resident Council meeting minutes revealed on 09/15/21 resident council minutes revealed staff never asked the resident's food preferences. The residents stated they never served what is on the menu, and the residents did not have a copy of the menu to ask for a substitution. Observation on 11/21/21 at 12:12 P. M. revealed Resident #18 did not eat her soup and State Tested Nursing Assistant (STNA) #16 did not offer Resident #18 a substitute for the food she did not like. Resident #31 did not eat her chips, sandwich, or fruit and ate 50% of her soup. STNA #16 did not offer Resident #31 an alternate for the food items she did not eat Resident #29 did not eat her soup, or her fruit, she at 50 % of her sandwich, and a few chips. STNA #16 did not offer Resident #29 food substitutes for the items she did not eat. Resident #30 was served his meal tray and refused it. STNA #21 told STNA #16 that Resident #30 refused his meal. STNA #16 told STNA #21 she had to ask Resident #30 if he wanted a substitute because he would not ask for one. A resident group meeting was held on 11/22/21 at 9:30 A.M. with Residents #18, #23, #28, #29, and #31 stated they were not offered food substitutes. Observation of Resident #12's breakfast meal on 12/01/21 at 7:56 A.M. revealed Resident #12 ate 10 % of her eggs, 25% of her toast, 0% cooked cereal and 0% of her milk. Interview of STNA #66 revealed she did not offer Resident #12 a replacement meal as the resident was not a big eater. Observation at lunch revealed 12/01/21 at 11:38 A.M. Resident #7 refused her meat and rice and Resident #29 refused her steak, rice, and cooked spinach. STNA #21 did not offer Resident #7 or Resident #29 alternate food for the food items refused. Interview of the Director of Nursing (DON) on 12/01/2021 at 11:40 A.M. confirmed staff should ask residents if they wanted food substitutions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 50 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to maintain a sanitary kitchen and ensure safe storage of foods served to residents. This had the potential to affect 33 of the 34 residents (Resident #15 does not receive nutrition from the facility kitchen) and specifically affected Residents #29 and #30. Facility census was 34. Findings include: The kitchen was observed on 11/21/21 at 8:20 A.M. with food debris noted on the bottom shelf of the reach in freezer. The hand washing station had missing cove base, missing and loose caulking seal around the sink and a wall gouge measuring eight inches by 10 inches long. At the time of the observation, Diet Manager, (DM )#11 verified the findings and verified the surfaces were unable to be cleaned and sanitized. Observation on 11/29/21 at 10:45 A.M. of the kitchen revealed the wall behind the stove had green drippings which had a greasy consistency when touched. Observation on 11/29/21 at 11:45 A.M. during preparation of puree foods by [NAME] #15, the attic entry door in the ceiling above the food preparation area had condensation of a clear fluid which dripped onto the food preparation area. [NAME] #15 was observed to touch her face with gloved hands during puree food preparation. DM #11 was observed to send soiled puree blender canister though dishwasher without changing gloves after blender canister was cleaned. At the time of the observation, Dietary Manager , (DM )#11 verified the observations. Observation on 11/29/21 at 11:45 A.M. of the ceiling above the dish machine revealed an unwashable surface and separation of the ceiling wall board resulting in a hole of two foot in length by one half inch wide. At the end of the dish machine clean dish rack, the wall had peeling paint which had fallen on the clean dish rack. At the time of the observation, Dietary Manager, (DM )#11 verified the observations. Observation on 11/29/21 at 11:55 A.M. revealed the four bulb ceiling fixture had no cover or light bulb tube covers above the tray line where food was open and being served onto trays for residents. At the time of the observation, Dietary Manager , (DM )#11 verified the observations. Observation on 11/21/21 and 11/30/21 revealed Resident #30 and Resident #29 had personal refrigerators in their rooms. Observation of Resident #30 and Resident #29 personal refrigerators revealed they had incomplete temperature monitoring logs for November 2021. Resident #29 did not have a thermometer inside her refrigerator. There was an eight ounce carton of milk with expiration date 11/12/21 , and a cottage cheese container with expiration date of 11/15/21. Observation on 11/30/21 at 9:15 A.M. of resident refrigerator, used for food storage by nurses and resident visitors, revealed no thermometer monitoring log, open liter of pop without name and no open date, thicken liquid dated 10/22/21, liquid creamer no open date and no name, ketchup bottle with no open date, frozen meal with no name listed, and an open bag of dry cereal dated 10/15/21 with no name. At the time of the observation, State Tested Nurse Aide, (STNA) #18 , verified the findings. The Dietary Manager, (DM )#11 was interviewed on 11/29/21 at 5:11 P. M and revealed work orders for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 51 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the hand washing sink and light fixture had been submitted to the Maintenance Director #56 on 11/09/21 and no work had been completed. DM #11 revealed the policy for thickened juice disposal date is 10 days after the date marked on the container and foods stored in the refrigerator should be discarded after seven days or on or before expiration date. Interview on 11/30/21 at 3:25 P.M. with Maintenance Director #56 stated the nurses are responsible to monitor and document the resident refrigerator temperature onto monitoring sheets, and the STNA s are responsible to clean out resident refrigerators for expired or unlabeled foods. Review of policy titled, Food Preparation , dated September 2017, and Safe Handling for Foods from Visitors ,dated September 2017 verified the facility failed to follow the policies for food storage and sanitation. This deficiency substantiates Complaint Number OH00114643. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 52 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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** 2. Review of Resident #20's medical record revealed she was admitted on [DATE] with diagnoses that include: non displaced fracture of the right femur, cerebral palsy, paraplegia, contracture of left ankle, contracture of muscle multiple sites, postsurgical malabsorption, edema, anxiety disorder, disorder of psychological development, epilepsy, and constipation. Review of Resident #20's annual Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #20 had no swallowing problems, was 60 inches tall, weighed 118 pounds, had no significant weight changes, and received 51% or more of calories and fluid intake via a tube feeding. Review of Resident # 20's physician orders dated [DATE] enteral feeding order (Jevity 1.5) with fiber, 8 ounce carton, administer with syringe at 4:00 A.M., 10:00 A. M., 4:00 P.M., and 10:00 P.M. to total 1200 milliliters (ml) of formula. Review of Resident #20's [DATE] physician orders signed [DATE] revealed the following enteral feeding orders. A bolus tube feeding six times daily was ordered, as well as total tube feeding solution each shift 720 ml, and Jevity 1.5 ml to run at 70 cubic centimeters (cc) at noon daily. Review of Resident #20's medication administration record (MAR) revealed a continuous enteral feeding of Jevity 1.5 at 70 cc per hour (cc/hr) from 11:00 A.M. to 6:00 A.M. Review of Resident #20's nutrition assessment dated [DATE] revealed Resident #20 received Jevity 1.5, 300 ml four times a day. There was no nutritional assessment reflecting the 19 hours of continuous feeding. Observation of Resident #20 on [DATE] at 8:05 A.M. revealed Resident #20 was in bed on her back and the enteral feeding was turned off. Observation of Resident #20's enteral feeding at 11:20 A.M. revealed it was administered by a pump at 70 ml/hr Interview of Registered Nurse (RN) #12 on [DATE] at 2:27 P.M. revealed Resident # 20 received a tube feeding from 11:00 A.M. to 6:00 A.M. administered at 70 ml/hr. Interview of the Director of Nursing (DON) on [DATE] at 3:25 P.M. revealed the [DATE] enteral feeding orders were Resident #20's feeding orders when she was in the hospital and were not to be implemented in the facility. The DON confirmed the Resident #20's medical record did not contain the accurate enteral feeding order. This deficiency substantiates Master Complaint Number OH00114643. Based on medical record review, observation, and staff interview, the facility failed to ensure resident medical records reflected an accurate code status and enteral nutrition orders. This affected two residents (Resident #383, and #20) of the 23 resident records reviewed. The facility census was 34. Findings include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 53 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 1. Review of the closed medical record for Resident #383 revealed an admission date of [DATE], and a discharge date of [DATE]. Diagnoses include chronic kidney disease stage 3, hypokalemia, and heart disease. Review of Resident #383's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating an intact cognition for daily decision abilities. Resident #383 required supervision with no set up for bed mobility, transfers, locomotion, dressing, and personal hygiene. Resident #383 required supervision with set up assist for eating and toilet use. Review of Resident #383's physician orders for [DATE] revealed Resident #383's code status indicated full code where all life sustaining measure are to be implemented. Review of Resident #383's nursing progress note dated [DATE] at 1:20 P.M. revealed, Resident expired at 1:20 P.M. was released to funeral home at 3:25 P.M. Review of Resident #383's code status form dated [DATE] revealed a physician signed form indicating Resident #383's desired to be a Do Not Resuscitate-Comfort Care (DNRCC). Interview on [DATE] at 4:00 P.M. with the Director of Nursing (DON) and the Regional Director of Clinical Operations #77 confirmed Resident #383's medical record did not accurately reflect Resident #383's DNRCC code status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 54 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, policy review, and review of Centers for Disease Control information, and record reviews, the facility failed to implement transmission based precautions to prevent the spread of COVID-19. This had the potential to affect the 34 residents residing in the facility and specifically affected Resident #135. The facility census was 34. Residents Affected - Many Findings include: Record review for Resident #135 revealed this resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction, dysphagia, restlessness and agitation, and history of falls. This resident had no known allergies. Review of the admission Minimum Data Set (MDS) assessment, dated 11/22/21, revealed this resident had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 04. This resident was assessed to require extensive assistance from two staff members for bed mobility and transfers and extensive assistance from one staff member for toileting. Review of the physicians orders for Resident #135 revealed an absence of an order to be placed on transmission based precautions. Observation on 11/21/21 at 8:35 A.M. revealed no residents, including Resident #135, were currently on transmission based precautions for suspected or confirmed COVID-19. Interview on 11/21/21 at 8:37 A.M. with Licensed Practical Nurse (LPN) #88 verified the facility did not have any residents on transmission based precautions for COVID-19. Interview with the Director of Nursing (DON) on 11/30/21 at 9:33 A.M. verified Resident #135 did not have a physician order to be placed on transmission based precautions and was not fully vaccinated against COVID-19. The DON verified the facility policy was to place newly admitted , unvaccinated residents on isolation precautions for 14 days to prevent the spread of COVID-19. Review of the facility policy titled Piketon Nursing Center COVID-19 Policy and Procedure, updated on 08/30/21, revealed newly admitted or readmitted residents would be encouraged to self isolate in a room for a minimum of 14 days. Review of the Centers for Disease and Control (CDC) guidance, titled CDC Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes & Long-Term Care Facilities, updated 09/10/21, revealed if no additional cases are identified during the broad-based testing, room restriction and full Personal Protective Equipment (PPE) use by Health Care Personnel (HCP) caring for unvaccinated residents can be discontinued after 14 days and no further testing is indicated. This deficiency substantiates Complaint Number OH00114643. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 55 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the call light system in working order. This had the potential to affect the 34 residents residing in the facility. The facility census was 34. Residents Affected - Many Findings include: Observation on 11/29/21 at 12:43 P.M. revealed the call light system located at the nurses station was beeping and the light for room [ROOM NUMBER] was lit up but no lights outside resident rooms were lit up. Licensed Practical Nurse (LPN) #88 responded to room [ROOM NUMBER] and found the call light system had not been activated in the room. LPN #88 then began going from room to room searching for the activated call light. Interview with LPN #88 on 11/29/21 at 12:50 P.M. verified the call light system located at the nurses station was beeping and the indicator for room [ROOM NUMBER] was lighting up indicating the resident residing in that room had activated the call light system. LPN #88 then verified no call lights outside the resident rooms had been lit up and the call light had actually been activated by the resident residing in room [ROOM NUMBER], not room [ROOM NUMBER]. Observation on 11/30/21 at 5:05 P.M. revealed the call light system located at the nurses station was beeping and the lights for multiple rooms were lit up on the system. No lights were observed flashing outside resident rooms. Interview with LPN #4 on 11/30/21 at 5:05 P.M. verified multiple lights were lit up on the call system board located at the nurses station and were beeping but no lights were lit up in the hallways outside resident rooms. LPN #4 stated the call light system had not been operating functionally for a while and staff had to go room to room at times to find out who activated the call light system. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 56 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation on 11/30/21 between 4:15 P.M. and 4:22 P.M. State Tested Nursing Assistant (STNA) #18 entered the dining room banged on the kitchen door stating there was a fire and she needed a pitcher of water. This action was repeated twice. STNA #18 was questioned regarding the statement and she revealed there was a fire in the courtyard and there was smoke. The surveyors headed toward the courtyard, smoke was visible in the hallway as was an odor of burning debris. Upon exiting into the courtyard, the bottom of a smoking receptacle was smoldering. STNA #18 poured a pitcher of water on the smoldering cigarette butts. STNA #18 stated that was not enough water to put the fire out and she returned to the kitchen for a second pitcher of water. STNA #18 left the receptacle smoldering unattended. That pitcher was poured onto the smoldering cigarette butts. At 4:28 P.M. STNA #18 revealed the top was off the smoking receptacle and was smoldering when she went into the courtyard. The smoldering container was against the exterior wall of the building. There were dried leaves and cigarette butts on the ground around the receptacle. A fire extinguisher was mounted on the wall of the smoking [NAME] with a smoking apron draped over the fire extinguisher. On 11/30/21 observation of the courtyard between 4:28 P.M. and 4:40 P.M. revealed the courtyard densely littered with dried leaves, cigarette butts, cigarette ash, and paper products. The smoking [NAME] (a wooden structure with a wooden floor) had cigarette butts, ash, and paper cigarette cartoons on the floor. The waste can was over-flowing with paper waste. The wood brace above a smoking container had evidence of soot consistent with cigarette butts being snuffed out. The courtyard had a U shaped wooden raised flower bed with multiple cigarette buts and ash next to it. On 11/30/21 interview of STNA #18 at 4:40 P.M. revealed it was the responsibility of the maintenance staff to keep the smoking area clean and tidy. At 4:42 P.M. the Administrator stated it was the nursing assistants responsibility to keep the smoking area clean and tidy. Review of the facility policy titled Smoking Policy-Resident, dated 07/2017, revealed This facility shall establish and maintain safe resident smoking practices. Ashtrays are emptied only into designated receptacles. Based on observation and interview, and review of facility policy, the facility failed to maintain tile flooring in a resident room in safe condition and to ensure residents and staff smoking area was free of fire hazards This had the potential to affect all 34 residents residing at the facility. Findings include: 1. Observation on 11/21/21 at 9:48 A.M. of room [ROOM NUMBER] revealed there were five tiles located in the center of the room which were cracked and had raised corners coming off of the floor. Observation on 11/29/21 at 3:11 P.M. of room [ROOM NUMBER] revealed there were five tiles located in the center of the room which were cracked and had raised corners coming off of the floor. Interview with Maintenance Supervisor #56 on 11/29/21 at 3:11 P.M. verified the five tiles located in the center of room [ROOM NUMBER] were cracked and had raised corners which needed to be replaced. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 57 of 58 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 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Piketon Nursing Center 300 Overlook Drive Piketon, OH 45661 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 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and personnel file review, the facility failed to ensure direct care staff were provided dementia education. This affected one resident (Resident #24) of 11 residents with a dementia diagnosis. The facility census was 34. Findings include: Review of Resident # 24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, hypertension, schizoaffective disorder. Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #24 had short-term and long-term memory problems, no recall and her decision making was severely impaired. Resident #24 had no behaviors, she rejected care one to three days. Resident #24 was dependent on two staff for bed mobility, required extensive assistance of two staff to transfer, did not walk, no locomotion, required extensive assistance of two staff for dressing, was dependent on one staff to eat, for toilet use, and required extensive assistance of one staff for personal hygiene. Resident #24 was dependent on two staff for showering and had no limitations in range of motion. Observation on 11/23/21 at 8:06 A.M. revealed Resident #24 received staff assistance for meal time while staff was noted standing, and not talking or interacting with Resident #24. Observation on 11/29/21 at 7:42 A.M. of Resident #24 revealed her sitting in a geri chair in the common area. Continued observation at 8:30 A.M. revealed Resident #24 continued to sit in the common area, no activity noted, no television, music, or staff in the area Interview 11/29/21 12:46 P.M. with Licensed Practical Nurse (LPN) #32 revealed Resident #24 does not experience or display behaviors. Resident #24 does not have delusions and does not have a mental illness they like to say she does. Resident #24 gets her words mixed up but that is dementia. Interview on 11/30/21 at 8:30 A.M. with State Tested Nursing Assistant (STNA) #32 revealed the facility had not provided staff with dementia education or training. Review of direct care staff personnel files for eight staff members revealed no evidence of staff receiving education and training related to dementia. Interview on 11/29/21 at 12:30 P.M. with the Administrator confirmed staff had not received dementia education or training. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 58 of 58

Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.

Citations

34 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0568GeneralS&S Epotential for harm
F568 - Accounting and Records
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
0550GeneralS&S Epotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0578GeneralS&S Dpotential for harm
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
0582GeneralS&S Dpotential for harm
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
0646GeneralS&S Dpotential for harm
F646 - A nursing facility must notify the state mental health authority or state
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
0661GeneralS&S Dpotential for harm
F661 - Quality of life
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
0677GeneralS&S Dpotential for harm
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
0679GeneralS&S Dpotential for harm
F679 - Activities
Provide activities to meet all resident's needs.
0684SeriousS&S Gactual harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0692GeneralS&S Epotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0695GeneralS&S Epotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0727GeneralS&S Fpotential for harm
F727 - Except when waived under paragraph (f) or (g) of this section, the
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
0756GeneralS&S Dpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
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.
0806GeneralS&S Fpotential for harm
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0676GeneralS&S Dpotential for harm
F676 - Based on the comprehensive assessment of a resident and consistent with
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
0791GeneralS&S Dpotential for harm
F791 - Dental Services
Provide or obtain dental services for each resident.
0561GeneralS&S Dpotential for harm
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
0567GeneralS&S Epotential for harm
F567 - The resident has a right to manage his or her financial affairs
Honor the resident's right to manage his or her financial affairs.
0584GeneralS&S Epotential for harm
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
0604GeneralS&S Dpotential for harm
F604 - Respect and Dignity
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
0622GeneralS&S Dpotential for harm
F622 - Transfer and discharge-
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
0641GeneralS&S Dpotential for harm
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
0644GeneralS&S Dpotential for harm
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
0685GeneralS&S Dpotential for harm
F685 - Vision and hearing
Assist a resident in gaining access to vision and hearing services.
0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0690GeneralS&S Dpotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0804GeneralS&S Fpotential for harm
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
0842GeneralS&S Dpotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0880GeneralS&S Fpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0919GeneralS&S Fpotential for harm
F919 - Resident Call System
Make sure that a working call system is available in each resident's bathroom and bathing area.
0921GeneralS&S Fpotential for harm
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
0947GeneralS&S Epotential for harm
F947 - Training Requirements
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

FAQ · About this visit

Common questions about this visit

What happened during the December 6, 2021 survey of PIKETON NURSING CENTER?

This was a inspection survey of PIKETON NURSING CENTER on December 6, 2021. The surveyor cited 34 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at PIKETON NURSING CENTER on December 6, 2021?

Yes, 34 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·December 6, 2021