Health inspection·September 7, 2023

F 0569 Level of Harm - Minimal harm or potential for actual harm Interview with the Administrator on 09/07/23 at 11:10 A.M. verified the spend down notice for Resident #28 did not provide evidence of the date it was issued or how or when it was provided to the resident. 3. Record review for Resident #31 revealed this resident was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease, dysphagia, and anemia. Residents Affected - Some Review of the annual MDS assessment, dated 08/25/23, revealed this resident had intact cognition evidenced by a BIMS assessment score of 15 out of 15. This resident was assessed to require limited assistance from one staff member for bed mobility, transfers, and toileting. Review of the facility Funds Balance Report, dated 09/06/23, revealed the balance in Resident #17's account was $2,442.41 Review of the facility Spend Down Notice for Resident #31 revealed the notice was not dated and did not provide evidence of how or when it was sent to the residents representative. Interview with the Administrator on 09/07/23 at 11:10 A.M. verified the spend down notice for Resident #31 did not provide evidence of the date it was issued or how or when it was provided to the resident. 4. Record review for Resident #24 revealed this resident was admitted to the facility on [DATE] and had diagnoses including dementia, depressive disorder, and anxiety. Review of the quarterly MDS assessment, dated 07/14/23, revealed this resident had mildly impaired cognition evidenced by a BIMS assessment score of 10 out of 15. This resident was assessed to require supervision for bed mobility, transfers, and toileting. Review of the facility Funds Balance Report, dated 09/06/23, revealed the balance in Resident #17's account was $2,176.44. Review of the facility Spend Down Notice for Resident #23 revealed the notice was not dated and did not provide evidence of how or when it was sent to the residents representative. Interview with the Administrator on 09/07/23 at 11:10 A.M. verified the spend down notice for Resident #24 did not provide evidence of the date it was issued or how or when it was provided to the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 2 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 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 record reviews and staff interview, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) specified the type of skilled services being discontinued. This affected one resident (#33) out of the three residents reviewed for NOMNC and SNFABN notices during the annual survey. The facility census was 40. Residents Affected - Few Findings include: Record review for Resident #33 revealed this resident was admitted to the facility on [DATE] and had diagnoses including dementia, glaucoma, and encephalopathy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/21/23, revealed this resident was rarely/never understood. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting. Review of the NOMNC and SNFABN, both signed on 01/20/23, revealed the type of service listed as ending had been written in as Skilled Services and did not specify the type of skilled services the resident was being cut from. Interview with the Administrator on 09/06/23 at 1:19 P.M. verified the NOMNC and SNFABN notices for Resident #33 did not specify the type(s) of skilled services the resident was being cut from. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 3 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff interviews and facility policy, the facility failed to develop resident centered care plans for behavioral interventions for three (Residents #2, #28 and #30) of the eight residents reviewed. The facility census was 40. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 10/25/22. Diagnoses included: anxiety disorder, unspecified intellectual disabilities, unspecified mental disorder due to known physiological condition and schizoaffective disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident is rarely/never understood. This resident was assessed to require extensive assistance with one-person physical assist with bed mobility, dressing, and toileting and extensive assistance with two-persons physical assist with transfers. The resident received antianxiety medication seven days. Review of Resident #2's physician orders dated for 10/25/22 revealed this resident was receiving the following medication: Haloperidol Decanoate 50 milligrams (mg) one time a day starting on the 28th and ending on the 28th every month by injection for schizoaffective disorder. Further review of this resident's physicians order dated for 07/31/23 revealed the following medication: Buspirone HCL 7.5 mg one tablet by mouth three times a day for anxiety disorder. Review of the physicians' orders for Resident #2 revealed no orders since admission on [DATE] for documentation of targeted behaviors as well as no non-pharmacological interventions for the facility staff to utilize. Review of the care plans for Resident #30 dated 08/01/23 revealed no evidence of a care plan containing non-pharmacological interventions as well as no target behaviors to be monitoring for. Interview with Licensed Practical Nurse (LPN) #130 on 09/07/23 at 10:44 A.M. revealed the care plans for each resident informs them of what target behaviors to look for as well as non-pharmacological interventions to use. Verified Resident #2's care plan does not have both non-pharmacological intervention and target behaviors. Interview with the Director of Nursing (DON) on 09/07/23 at 10:50 A.M. verified Resident #2's care plans do not include non-pharmacological interventions for behaviors and no target behaviors to observe for. 2. Review of the medical record for Resident #28, revealed an admission date of 03/10/21. Diagnoses included: dementia, major depressive disorder, weakness, anxiety disorder, and generalized anxiety disorder. Review of the most recent MDS 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 7 out of 15 indicating severe cognitive loss. This resident was assessed to require limited assistance with one-person physical assist with bed mobility and dressing and supervision with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 4 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 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 0656 set up only for eating, toilet use and transfers. Level of Harm - Minimal harm or potential for actual harm Further review of the MDS dated [DATE] revealed antianxiety and antidepressant medications seven out of seven days. Residents Affected - Few Review of Resident #28's physician orders dated 05/25/22 revealed this resident was receiving Bupropion HCL 100 milligrams (mg) one tablet by mouth one time a day for behavior. Further review of Resident #28's physician orders dated 09/17/22 revealed this resident was receiving the follow medication: Buspirone HCL 10 mg one tablet orally a day for behavior. Review of the physicians' orders for Resident #28 revealed no orders since admission on [DATE] for documentation of targeted behaviors as well as no non-pharmacological interventions for the facility staff to utilize. Review of the care plans for Resident #28 dated 08/29/23 revealed no evidence of a care plan containing non-pharmacological interventions as well as no target behaviors to be monitoring for. Interview with LPN #130 on 09/07/23 at 10:45 A.M. revealed the care plans for each resident informs them of what target behaviors to look for as well as non-pharmacological interventions to use. Verified Resident #28's care plan does not have both non-pharmacological intervention and target behaviors. Interview with the DON on 09/07/23 at 10:51 A.M. verified Resident #28's care plans do not include non-pharmacological interventions for behaviors and no target behaviors to observe for. 3. Review of the medical record for Resident #30, revealed an admission date of 04/28/22. Diagnoses included: bipolar disorder, polyosteoarthritis, anxiety disorder, major depressive disorder, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of the most recent MDS 3.0 assessment dated [DATE] revealed a BIMS of 15 out of 15 indicating intact cognition. This resident was assessed to require supervision with set up only for: bed mobility, transfers, dressing and eating. Further review of the MDS dated [DATE] revealed antianxiety and antidepressant medications for seven out of seven days. Review of Resident #30's physician order dated 04/29/22 revealed Duloxetine 30 mg tablet, give 30 mg orally in the morning related to major depressive disorder. Further review for this resident's physician order dated 05/01/22 revealed Clonazepam 1 mg, give 1 tablet orally three times a day related to anxiety disorder. Review of the physicians' orders for Resident #30 revealed no orders since admission on [DATE] for documentation of targeted behaviors as well as no non-pharmacological interventions for the facility staff to utilize. Review of the care plans for Resident #30 dated 08/01/23 revealed no evidence of a care plan containing non-pharmacological interventions as well as no target behaviors to be monitoring for. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 5 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with LPN #130 on 09/07/23 at 10:46 A.M. revealed the care plans for each resident informs them of what target behaviors to look for as well as non-pharmacological interventions to use. Verified Resident #30's care plan does not have both non-pharmacological intervention and target behaviors. Interview with the DON on 09/07/23 at 10:52 A.M. verified Resident #30's care plans do not include non-pharmacological interventions for behaviors and no target behaviors to observe for. Review of the facility policy titled Behavioral Assessment, Intervention and Monitoring no dated stated the care plan will include as a minimum: non-pharmacological approaches will be utilized to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms and specific target behaviors and expected outcomes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 6 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #37 revealed an admission date of 06/08/22 with pertinent diagnoses of: schizophrenia, major depressive disorder, shortness of breath, urinary tract infection, benign prostatic hyperplasia, protein calorie malnutrition, constipation, tremor, chest pain, asthma, hyperlipidemia, age related osteoporosis, schizoaffective disorder, dysphagia, Barrett's esophagus with dysplasia, hypertension, hyponatremia, dry mouth, iron deficiency anemia, chronic peptic ulcer, esophageal obstruction, polyp of colon, and nausea. Residents Affected - Few Review of the 07/21/23 annual MDS assessment revealed the resident is cognitively intact and requires limited assistance for bed mobility, transfer, walk in room, dressing, toilet use, and personal hygiene. The resident uses a wheelchair to aid in mobility and is always incontinent of bladder and frequently incontinent of bowel. Review of the medical record on 09/05/23 revealed the resident was admitted to Hospice services on 08/02/22. There was no physicians order stating he was admitted to hospice in the electronic or paper record. Review of the medical record on 09/07/23 revealed there was no communication papers with the hospice company available. Interview with the Director of Nursing (DON) on 09/07/23 at 10:32 A.M. verified there was not a Physicians Order for Resident #37 to be on hospice services. The DON also verified they did not have communication from hospice readily available in the facility. 2. Review of the medical record for Resident #25 revealed an admission date of 04/25/23 with diagnoses including Alzheimer's disease, hypertension, anxiety disorder and season allergies. Review of the quarterly MDS dated [DATE] revealed Resident #25 had severe cognitive impairment. Resident #25 had no impairment to range of motion to bilateral upper extremities, and received no therapy services. Review of the physician orders for 09/23 revealed Resident #25 did not have any orders for range of motion, or resting hand splint to right hand. Review of the plan of care for Resident #25 revealed no plan of care addressing the right hand impaired range of motion or resting had splint. Observation on 09/06/23 at 9:18 A.M. revealed Resident #25 had on a blue resting hand splint to her right hand. Observation on 09/07/23 at 9:10 A.M. revealed Resident #25 had a black soft brace to her right hand. Interview on 09/07/23 at 9:12 A.M. with State Tested Nursing Assistant (STNA) #165 revealed Resident #25 had two braces (splints) for her right hand: a blue one for night time and a black one for day time. STNA #165 stated it was not on the kardex (STNA care plan) for Resident #25 to wear the braces. STNA #165 stated the nurse (not identified) told the STNA to put the braces on the resident. STNA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 7 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 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 #165 stated she did not complete any type of range of motion on Resident #25's right hand. Level of Harm - Minimal harm or potential for actual harm Interview on 09/07/23 at 10:15 A.M. with Certified Occupational Therapy Assistant (COTA) #166 revealed therapy was not providing any services for Resident #25 as she was on hospice care. COTA #166 observed and assessed Resident #25 right hand with surveyor. COTA #166 stated Resident #25 had decreased flexion in right wrist and thumb. The COTA observed the resting hand splint on Resident #25 bed side table and stated the device was used to prevent contracture's and was the correct splint for Resident #25 to wear. However, the therapy department did not provide the splint or any care and services to Resident #25. Residents Affected - Few Based on facility interviews, record reviews and Medscape, the facility failed to obtain orders, and/or create care plans, conduct assessments and conduct communications for the appropriate care for three (Resident #25, #37, and # 295) out of twenty five residents reviewed. The facility census was 40. Findings include: 1. Review of the medical record for Resident # 295, revealed an admission date of 08/24/23. Diagnoses included: acute osteomyelitis, essential hypertension, and type 1 Diabetes Mellitus (DM). Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating intact cognition. This resident was assessed to require limited assistance with one-person physical assist for bed mobility, transfer, dressing and supervision with set up only for eating. Review of the physician's order dated 08/25/23 for Resident #295 revealed an order for an Omnipod 5 G6 Intro (Gen 5) Kit (Insulin Infusion Disposable Pump) 1 unit every 72 hours as needed for type 1 diabetes and insulin aspart 100unit/ml via insulin pump two times a day related to type 1 DM. Further review of the physician orders dated 08/25/23 to 09/06/23 for this resident did not reveal the following orders: -no order for blood glucose checks and/or an order for the Dexcom continuous glucose monitor (CGM) for the facility staff to be aware of the resident's blood glucose levels. -no order for the basal rate of this resident's Omnipod insulin infusion disposable pump. -no order for the sliding scale coverage for this resident for coverage for meals and if blood glucose level is high. -no order for a Glucagon Emergency kit to treat severe low blood glucose as needed -no order to care for the Dexcom CGM and when to renew it Review of the medication administration record (MAR) and treatment administration record (TAR) for Resident #295 from the dates of 08/25/23 to 09/06/23 revealed the following: -no documentation of blood glucose checks and/or the Dexcom CMG results for the facility staff to be aware of this resident's blood glucose levels. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 8 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 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 -no documentation of the basal rate of the Omnipod insulin infusion disposable pump Level of Harm - Minimal harm or potential for actual harm -no documentation of the sliding scale coverage for this resident for coverage for meals and if blood glucose level is high. Residents Affected - Few -no documentation for the use of a Glucagon Emergency kit to treat severe low blood sugar as needed. -no documentation to care for the Dexcom CGM, when to renew it and location. -no documentation to care for the Omnipod insulin infusion disposable pump, when to renew it and location. -insulin aspart 100unit/ml via insulin pump two times a day at 0800 and 2000 related to Type 1 DM. Review of care plans dated 08/24/23 for Resident # 295 revealed no diabetic care was initiated and implemented as of 09/06/23. Resident refused an interview on 09/06/23 at 10:22 A.M. and refused on 09/07/23 at 9:10 A.M. Interview with LPN #130 on 09/07/23 at 11:08 A.M. confirmed Resident #295 does not have a care plan for her diabetes care as well as no orders/documentation's for the following: -blood glucose checks and/or the Dexcom continuous glucose monitor (CGM). -the basal rate of the Omnipod insulin infusion disposable pump. -the sliding scale coverage for meals and if blood glucose level is high. -a Glucagon Emergency kit to treat severe low blood glucose as needed. -how to care for the Dexcom CGM and when to renew it and location. -how to care for the Omnipod insulin infusion disposable pump, when to renew it and location. Interview with LPN #130 also verified on 09/07/23 at 11:12 A.M. she was not aware of how the Omnipod insulin infusion disposable pump and a Dexcom CGM works, how to change them if needed, and their location on this resident. She was unsure of how the disease process is different from a Type 1 diabetic resident to a Type 2 diabetic resident. Interview with the Director of Nursing (DON) on 09/07/23 at 11:18 A.M. confirmed Resident #295 does not have a care plan for her diabetes care as well as no orders/documentation's for the following: -blood glucose checks and/or the Dexcom continuous glucose monitor (CGM). -the basal rate of the Omnipod insulin infusion disposable pump. -the sliding scale coverage for meals and if blood glucose level is high. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 9 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 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 -a Glucagon Emergency kit to treat severe low blood glucose as needed. Level of Harm - Minimal harm or potential for actual harm -how to care for the Dexcom CGM and when to renew it and location. -how to care for the Omnipod insulin infusion disposable pump, when to renew it and location. Residents Affected - Few The DON also confirmed the order: insulin aspart 100unit/ml via insulin pump two times a day at 0800 and 2000 related to type 1 DM was not correct as the Omnipod insulin infusion disposable pump continuously maintains this resident's blood glucose level and boluses for meals and if needed for high blood glucose control. Interview with the DON on 09/07/23 at 11:22 A.M. stated when the orders came with her, the hospital did not send the orders for her diabetic care. She has a Dexcom CGM, and we check on her to make sure she is ok. If she was to get low, we would give her orange juice. Verified the facility staff is unaware of this resident's blood sugar levels unless asking the resident so unaware if the residents blood sugar levels are safe and the facility nursing staff were never given education on how the Dexcom CGM and the Omnipod insulin infusion disposable pump function as well as the difference in care for a type 1 DM resident to a type 2 DM resident. According to Medscape, type 1 diabetes is a chronic illness characterized by the body's inability to produce insulin due to the autoimmune destruction of the beta cells in the pancreas. Type 1 diabetics require lifelong insulin therapy. Type 2 diabetes mellitus consists of an array of dysfunctions characterized by hyperglycemia and resulting from the combination of resistance to insulin action, inadequate insulin secretion, and excessive or inappropriate glucagon secretion. Type 2 diabetes care includes: appropriate goal setting dietary and exercise modifications, medications, appropriate self-monitoring of blood glucose (SMBG), regular monitoring for complications and laboratory assessment. According to Medscape, a Continuous subcutaneous insulin infusion (Omnipod): Rapid-acting insulin infused continuously 24 hours a day through an insulin pump at 1 or more basal rates, with additional boluses given before each meal and correction doses administered if blood glucose levels exceed target levels. It replaces the need for multiple injections for short acting and long-acting insulins. According to Medscape, a Continuous Glucose Monitors (CGMs like Dexcom) contain transcutaneous or subcutaneous sensors-depending on whether the devices are externally worn or fully implantable, respectively-that measure interstitial glucose levels every 1-5 minutes, providing alarms when glucose levels are too high or too low or are rapidly rising or falling. CGMs transmit to a receiver, which either is a pager like device or is integral to an insulin pump. Looking at the continuous glucose graph and responding to the alarms can help patients avoid serious hyperglycemia or hypoglycemia. It replaces the need to often obtain 2-4 blood glucose levels each day, including fasting levels and levels checked at various other times that are required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 10 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 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 - Some 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** 4. Review of the medical record for Resident #11 revealed an admission date of 04/25/23 with diagnoses including Alzheimer's disease, Atrial Fibrillation, anxiety disorder, type two diabetes mellitus, and chronic obstructive pulmonary disorder. Review of the quarterly MDS dated [DATE] revealed Resident #11 had severe cognitive impairment with no behaviors noted. The assessment indicated Resident #11 had no psychiatric or mood disorder and did not receive any antipsychotic medications. Review of the physician orders for 09/23 revealed Resident #11 was ordered and received trazadone (antidepressant medication) 25 milligrams (mg) by mouth at bedtime for Alzheimer's disease. Review of the nursing progress notes from 08/08/23 through 09/07/23 revealed no documented behaviors. Review of the plan of care dated 02/13/23 revealed Resident #11 had a behavioral problem related to combative at times with the staff. Interventions included administer medication as ordered, monitor and document for side effects and effectiveness of medication and anticipate and meet the residents needs. Review of the plan of care dated 10/06/22 revealed Resident #11 received an antidepressant medication. Interventions included administer the antidepressant medication as ordered by the physician, monitor and document side effects and effectiveness every shift, monitor and report any adverse reactions to the antidepressant therapy. Review of the plan of care dated 10/06/22 revealed Resident #11 had a mood problem related to Alzheimer's disease. Interventions included administer medications as ordered, monitor and document for side effects and effectiveness, behavioral health consult as needed, monitor, record and report to the physician any acute episodes of feelings of sadness, loss of pleasure and other feelings of depression. Review of the task section of the STNA kardex revealed no abnormal behaviors documented for past 30 days. Observations of Resident #11 on 09/06/23 at 7:55 A.M., 09/07/23 at 8:45 A.M. revealed Resident #11 had no adverse behaviors. Interview on 09/07/23 at 9:15 A.M. with STNA #165 revealed Resident #11 yelled out at times but had no other adverse behaviors. STNA #165 stated behaviors would be documented on the task section of kardex. Interview on 09/07/23 at 9:31 with RN #138 revealed Resident #11 yelled out at night when the resident became anxious and confused but had no other behaviors. RN #138 stated all behaviors were documented in the nursing progress notes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 11 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 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 - Some Interview on 09/07/23 at 9:37 A.M. with the DON confirmed Alzheimer's disease was not a proper diagnosis for the use of trazadone an antidepressant medication. The DON stated the resident would hit her arms and hands against the wall in her room. The facility placed soft cushion like pads on the wall beside residents bed to help prevent injury. 5. Record review for Resident #41 revealed this resident was admitted to the facility on [DATE] and had diagnoses including Schizophrenia, auditory hallucinations, and unspecified psychosis. Review of the quarterly MDS dated [DATE], revealed this resident had mildly impaired cognition evidenced by a BIMS assessment score of 12 out of 15. This resident was assessed to require extensive assistance from two staff members for bed mobility, to be dependent upon one staff member for toileting, to be dependent upon two staff members for transfers, and to require supervision with setup help only for eating. Review of the active care plan, dated 04/07/23, revealed this resident used anti-psychotic medication related to Schizophrenia. No target behaviors were specified in the care plan. Review of the active physicians order, dated 03/20/23, revealed this resident was ordered to be administered 50 milligrams (mg) of Seroquel (an anti-psychotic medication) once a day for a diagnosis of Schizophrenia. Review of the active physicians order, dated 03/21/23, revealed this resident was ordered to be administered two mg of Risperdal (an anti-psychotic medication) twice a day for a diagnosis of Schizophrenia. Interview with the Director of Nursing on 09/07/23 at 9:20 A.M. verified no target behaviors for Resident #41 had been identified in the residents plan of care. Interview with MDS Coordinator #121 on 09/07/23 at 9:30 A.M. revealed Resident #41 had not been referred to psychiatric services or had any behaviors since being admitted to the facility. Review of the facility policy titled Behavioral Assessment, Intervention and Monitoring no dated stated the care plan will include, as a minimum, a description of the behavioral symptoms (target Behaviors) in frequency intensity, duration, outcomes and location and the document any improvements or worsening in the individual's behavior, mood, and function. Based on interviews, record reviews and facility policy, the facility failed to identify target behaviors with documentation and/or provide an appropriate diagnosis for psychotropic medications for five (Resident #2, #11, #28, #30 and #41) of the eight residents reviewed. The facility census was 40. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 10/25/22. Diagnoses included: anxiety disorder, unspecified intellectual disabilities, unspecified mental disorder due to known physiological condition and schizoaffective disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident is rarely/never understood. This resident was assessed to require extensive assistance with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 12 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 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 - Some one-person physical assist with bed mobility, dressing, and toileting and extensive assistance with two person physical assist with transfers. Further review of the MDS revealed resident received antianxiety medication seven out of seven days. Review of Resident #2's physician orders dated for 11/28/22 revealed this resident was receiving the following medication: Haloperidol Decanoate 50 milligrams (mg) one time a day starting on the 28th and ending on the 28th every month by injection for schizoaffective disorder. Further review of this resident's physicians order dated for 07/31/23 revealed the following medication: Buspirone HCL 7.5 mg one tablet by mouth three times a day for anxiety disorder. Review of the physicians' orders for Resident #2 revealed no orders since admission on [DATE] for documentation of targeted behaviors. Review of the progress notes for Resident #2 for the past thirty days starting on 09/06/23 revealed no documentation of target behaviors from the facility staff. Review of the behavioral task documentation for Resident #2 for the past thirty days starting on 09/06/23 revealed no documentation for target behaviors from the facility staff. Review of Resident #2's care plan dated 08/01/23 revealed no evidence of a care plan containing target behaviors to be monitoring for. Interview with Registered Nurse (RN) #146 on 09/07/23 at 9:29 A.M. revealed the progress notes are where the facility nurses document observed targeted behaviors and under the tasks are where the State Tested Nursing Aides (STNA) document targeted behaviors. Verified for the past thirty days starting on 09/06/23, Resident #2 did not have any documentation in the progress notes from the facility nurses for target behaviors and no documentation under tasks from the facility's STNAs for target behaviors. Interview with STNA #161 on 09/07/23 at 9:45 A.M. revealed the behavioral task charting is newer for the facility staff and stated We have only been doing this for about a month the computer charting, in the past I just tell the nurse about behaviors. I do not know where the target behaviors are, but the nurses tell me and if a resident is screaming or crying out that is a behavior. Verified STNA #161 is unsure of where the Resident #2's target behaviors are in the chart and the behavior tasks for the past thirty days since 09/06/23 were blank. Interview with Licensed Practical Nurse (LPN) #130 on 09/07/23 at 10:44 A.M. revealed the care plans for each resident informs them of what target behaviors to look for and in the progress notes are where the documentation of them go for nurses and the task section are for the STNA's. Verified Resident #2's care plan does not have target behaviors to observe for and the progress notes as well as the behavioral task notes for the past thirty days starting 09/06/23 does not have documentation of target behaviors. Interview with the Director of Nursing (DON) on 09/07/23 at 10:50 A.M. verified Resident #2's care plans do not include target behaviors to observe for and the progress notes as well as the behavioral task notes for the past thirty days starting 09/06/23 does not have documentation of target (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 13 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 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 behaviors. Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record for Resident #28, revealed an admission date of 03/10/21. Diagnoses included: dementia, major depressive disorder, weakness, anxiety disorder, and generalized anxiety disorder. Residents Affected - Some Review of the most recent MDS 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 7 out of 15 indicating severe cognition. This resident was assessed to require limited assistance with one-person physical assist with bed mobility and dressing and supervision with set up only for eating, toilet use and transfers. Further review of the MDS revealed antianxiety and antidepressant medications were used seven out of seven days. Review of Resident #28's physician orders dated 05/25/22 revealed this resident was receiving Bupropion HCL 100 milligrams (mg) one tablet by mouth one time a day for behavior. Further review of Resident #28's physician orders dated 09/17/22 revealed this resident was receiving the follow medication: Buspirone HCL 10mg one tablet orally a day for behavior. Review of the physicians' orders for Resident #28 revealed no orders since admission on [DATE] for documentation of targeted behaviors for facility to observe. Review of the care plans for Resident #28 dated 08/29/23 revealed no evidence of a care plan containing target behaviors to be monitoring for. Interview with RN #146 on 09/07/23 at 9:30 A.M.,verified for the past thirty days starting on 09/06/23, Resident #28 did not have any documentation in the progress notes from the facility nurses for target behaviors and no documentation under tasks from the facility's STNAs for target behaviors. Interview with STNA #161 on 09/07/23 at 9:45 A.M. revealed the STNA #161 is unsure of where the Resident #28's target behaviors are in the chart and the behavior tasks for the past thirty days since 09/06/23 were blank. Interview with LPN #130 on 09/07/23 at 10:45 A.M. revealed Resident #28's care plan does not have target behaviors to observe for and the progress notes as well as the behavioral task notes for the past thirty days starting 09/06/23 does not have documentation of target behaviors. Interview with the DON on 09/07/23 at 10:51 A.M. verified Resident #28's care plans do not include target behaviors to observe for and the progress notes as well as the behavioral task notes for the past thirty days starting 09/06/23 does not have documentation of target behaviors. 3. Review of the medical record for Resident #30, revealed an admission date of 04/28/22. Diagnoses included: bipolar disorder, polyosteoarthritis, anxiety disorder, major depressive disorder, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of the most recent MDS 3.0 assessment dated [DATE] revealed resident was cognitively intact. This resident was assessed to require supervision with set up only for: bed mobility, transfers, dressing and eating. Review of Resident #30's physician order dated 04/29/22 revealed Duloxetine 30 mg tablet, give 30 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 14 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 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 mg orally in the morning related to major depressive disorder. Level of Harm - Minimal harm or potential for actual harm Further review for this resident's physician order dated 05/01/22 revealed Clonazepam 1 mg, give 1 tablet orally three times a day related to anxiety disorder. Residents Affected - Some Review of the physicians' orders for Resident #30 revealed no orders since admission on [DATE] for documentation of targeted behaviors for facility to observe. Review of the care plans for Resident #28 dated 08/01/23 revealed no evidence of a care plan containing target behaviors to be monitoring for. Interview with RN #146 on 09/07/23 at 9:31 A.M. verified for the past thirty days starting on 09/06/23, Resident #30 did not have any documentation in the progress notes from the facility nurses for target behaviors and no documentation under tasks from the facility's STNAs for target behaviors. Interview with STNA #161 on 09/07/23 at 9:47 A.M. revealed STNA #161 is unsure of where the Resident #30's target behaviors are in the chart and the behavior tasks for the past thirty days since 09/06/23 were blank. Interview with LPN #130 on 09/07/23 at 10:47 A.M. verified Resident #30's care plan does not have target behaviors to observe for and the progress notes as well as the behavioral task notes for the past thirty days starting 09/06/23 does not have documentation of target behaviors. Interview with the DON on 09/07/23 at 10:52 A.M. verified Resident #30's care plans do not include target behaviors to observe for and the progress notes as well as the behavioral task notes for the past thirty days starting 09/06/23 does not have documentation of target behaviors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 15 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, and record review the facility failed to ensure medication error rates were not greater than five percent when Resident #95 did not receive their dose of Eliquis (an anticoagulant blood thinner medication) and gave Resident #37 the wrong dose amount of Vitamin D3. This affected two (Resident #37, and #95) of four residents reviewed for medication administration. The facility had two errors out of 25 opportunities for a medication error rate of eight percent. The facility census was 40. Residents Affected - Few Findings include: 1. Record review of Resident #95 revealed an admission date of 09/01/23 with pertinent diagnosis of: cellulitis, cirrhosis of liver, thrombocytopenia, atherosclerotic heart disease of native coronary artery, atrial fibrillation, type two diabetes mellitus, anemia, and congestive heart failure. Review of a Physicians Order dated 09/01/23 revealed to give apixaban (Eliquis) five milligrams one half tab by mouth every 12 hours. Observation on 09/06/23 at 7:54 A.M. revealed Registered Nurse (RN) #138 administering medications to Resident #95 for morning medication pass. RN #138 administered nine medications but did not administer Eliquis. RN #138 verified she had given all the resident's morning medication and did not give anything earlier on 09/06/23 at 8:09 A.M. Interview with RN #138 on 09/06/23 at 10:20 A.M. verified she did not give Resident #95's morning Eliquis she had just missed the medication. 2. Record review of Resident #37 revealed an admission date of 06/08/22 with pertinent diagnosis of: schizophrenia, major depressive disorder, shortness of breath, urinary tract infection, benign prostatic hyperplasia, protein calorie malnutrition, constipation, tremor, chest pain, asthma, hyperlipidemia, age related osteoporosis, schizoaffective disorder, dysphagia, Barrett's esophagus with dysplasia, hypertension, hyponatremia, dry mouth, iron deficiency anemia, chronic peptic ulcer, esophageal obstruction, polyp of colon, and nausea. Review of the 07/21/23 annual Minimum Data Set (MDS) assessment revealed the resident is cognitively intact and requires limited assistance for bed mobility, transfer, walk in room, dressing, toilet use, and personal hygiene. The resident uses a wheelchair to aid in mobility and is always incontinent of bladder and frequently incontinent of bowel. Review of a Physicians Order dated 06/09/22 revealed to give cholecalciferol (vitamin D3) 1000 units one time a day for supplement. Observation on 09/06/23 at 8:13 A.M. revealed RN #138 administering medications to Resident #37 for morning medication pass. RN #138 administered cholecalciferol (vitamin D3) 400 units to Resident #37. Interview with RN #138 on 09/06/23 at 10:20 A.M. verified she gave Resident #37 the 400 units of cholecalciferol (vitamin D3) instead of 1000 units. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 16 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect 39 residents who received meals from the kitchen. The facility census was 40. Residents Affected - Some Findings include: Initial observation on 09/05/23 at 8:30 A.M. revealed the heating/air conditioning vents in the ceilings were rusty, with brown fuzzy like substance noted on the vents and around the vents on the ceiling. Observation on 08/07/23 at 10:30 A.M. revealed the heating/air conditioning vents in the ceiling remained soiled and blowed air over the food preparation and serving areas. The drain pipes under the sinks and dish tank were rusty, black and green like they leaked. The floor had black areas under the drains and the ice machine. Also the corners of the floor were dusty, dirty and black. The wall behind the steam/food holder was streaked with black and brown greasy like substance. The large plastic containers that contained flour and sugar were dusty on top with black like grime. Interview on 09/07/23 at 11:20 A.M. with the Regional Director (cook for the day) confirmed all areas that needed attention and cleaned. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 17 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 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 - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility daily staffing sheets, and staff interviews, the facility failed to ensure resident medical records were maintained in an accurate manner and failed to ensure staff did not document the administration of medications using another staff members name and credentials. This affected the four residents (#2, #10, #28, and #295) reviewed for accurate documentation of medication and treatments. The facility census was 40. Findings include: 1. Record review for Resident #2 revealed this resident was admitted to the facility on [DATE] and had diagnoses including anxiety, depression, and delirium. Review of the annual Minimum Data Set (MDS) assessment, dated 08/06/23, revealed this resident was rarely/never understood. This resident was assessed to require extensive assistance from one staff member for bed mobility and toileting and to require extensive assistance from two staff members for transfers. Review of the Medication Administration Record (MAR) for 08/2023 revealed documentation Resident #2 had been administered medications by LPN #199 on 08/07/23, 08/11/23, 08/12/23, 08/13/23, 08/14/23, 08/16/23, 08/17/23, 08/18/23, 08/19/23, 08/20/23, 08/23/23, 08/26/23, 08/27/23, 08/28/23, 08/30/23, and 08/31/23. Review of the MAR for 09/2023 revealed documentation Resident #2 had been administered medications by LPN #199 on 09/01/23. Review of the facility daily staffing sheets from 08/01/23 through 09/05/23 revealed Licensed Practical Nurse (LPN) #199 was not documented to have worked at the facility. 2. Record review for Resident #10 revealed this resident was admitted to the facility on [DATE] and had diagnoses including Schizophrenia, hypothyroidism, and depressive disorder. Review of the quarterly MDS assessment, dated 07/16/23, 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 supervision for bed mobility, transfers, and toileting. Review of the daily staffing sheets from 08/01/23 through 09/05/23 revealed LPN #199 was not documented to have worked at the facility. Review of the MAR for 08/2023 revealed documentation Resident #10 had been administered medications by LPN #199 on 08/06/23, 08/11/23, 08/12/23, 08/13/23, 08/16/23, 08/17/23, 08/21/23, 08/22/23, 08/25/23, 08/26/23, 08/27/23, 08/30/23, and 08/31/23. Review of the MAR for 09/2023 revealed documentation Resident #10 had been administered medications by LPN #199 on 09/01/23. 3. Record review for Resident #28 revealed this resident was admitted to the facility on [DATE] and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 18 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 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 had diagnoses including unspecified dementia, major depressive disorder, and weakness. Level of Harm - Minimal harm or potential for actual harm Review of the annual MDS assessment, dated 08/24/23, revealed this resident had moderately impaired cognition evidenced by a BIMS assessment score of 07. This resident was assessed to require limited assistance from one staff member for bed mobility and supervision for transfers and toileting. Residents Affected - Some Review of the daily staffing sheets from 08/01/23 through 09/05/23 revealed LPN #199 was not documented to have worked at the facility. Review of the MAR for 08/2023 revealed documentation Resident #28 had been administered medications by LPN #199 on 08/09/23, 08/11/23, 08/12/23, 08/13/23, 08/16/23, 08/19/23, 08/20/23, and 08/31/23. 4. Record review for Resident #295 revealed this resident was admitted to the facility on [DATE] and had diagnoses including acute osteomyelitis, hypertension, and depressive disorder. Review of the admission MDS assessment, dated 08/31/23, revealed this resident had intact cognition evidence by a BIMS assessment score of 15. This resident was assessed to require limited assistance from one staff member for bed mobility, transfers, and toileting. Review of the daily staffing sheets from 08/01/23 through 09/05/23 revealed LPN #199 was not documented ot have worked at the facility. Review of the MAR for 08/2023 revealed documentation Resident #295 had been administered medications by LPN #199 on 08/25/23, 08/26/23, 08/27/23, and 08/31/23. Review of the MAR for 09/2023 revealed documentation Resident #295 had been administered medications by LPN #199 on 09/01/23. Interview with Medical Records Employee #125 on 09/06/23 at 10:45 A.M. revealed LPN #199 worked at the facility through an agency but had not worked a shift in several months. Interview with the Director of Nursing (DON) on 09/06/23 at 2:15 P.M. verified LPN #199 had not worked at the facility in several months and other staff members had been using LPN #199's credentials to document medication administration to residents. The DON stated she just found out on 09/02/23 from an agency staff member that reported RN#134 was using LPN #199's badge. She verified that RN#134 did not report to her that her badge was not working The DON stated she was on vacation and when she returned on 09/06/23 she had a new badge delivered for Registered Nurse (RN) #134. The DON stated the process was to program badges for each separate staff member to identify each individuals name and license including agency staff. Telephone interview with RN #134 on 09/07/23 at 1:38 P.M. verified she had been using LPN #199's badge to document medication administration to residents as RN #134's badge was not working. She stated she had went prn (as needed) and returned to help out full time and when she returned to work on night shift her badge did not work so she grabbed an angency nurse badge to use. She verified she did not report her broken badge to the DON or Administrator. This deficiency represents non-compliance investigated under Complaint Number OH00146104. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 19 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm Based on record reviews and staff interview, the facility failed to ensure arbitration agreements provided to residents included written notice of the residents right to rescind the agreement within 30 days of signing. This affected the ten residents (#7, #8, #18, #21, #26, #30, #31, #34, #37, and #41) who the facility identified as having signed arbitration agreements. The facility census was 40. Residents Affected - Some Findings include: Review of the facility provided list of residents who had signed arbitration agreements with the facility revealed there were ten residents ((#7, #8, #18, #21, #26, #30, #31, #34, #37, and #41) who had signed the agreements. Review of the facility Optional Arbitration Agreement form, revised 04/2017, revealed the agreement did not contain notice of the residents rights to rescind the arbitration agreement within 30 days of signing the agreement. Interview with the Administrator on 09/07/23 at 10:00 A.M. verified the facilities written arbitration agreement form did not contain notice of the residents right to rescind the arbitration agreement within 30 days of signing the agreement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 20 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 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 Based on observation, staff interview, record review, and policy review the facility failed to to provide a sanitary environment to prevent the spread and development of communicable disease and infections when they did not cleanse blood glucose monitoring machines appropriately after resident use for Resident #95. The facility identified three Residents (#5, #9, #11) on the 19-27 hallway who received blood glucose monitoring checks. The facility census was 40. Residents Affected - Few Findings include: Record review of Resident #95 revealed an admission date of 09/01/23 with pertinent diagnosis of: cellulitis, cirrhosis of liver, thrombocytopenia, atherosclerotic heart disease of native coronary artery, atrial fibrillation, type two diabetes mellitus, anemia, and congestive heart failure. Review of a Physicians Order dated 09/03/23 revealed to inject novolog insulin per sliding scale before meals and at bedtime. Observation on 09/06/23 at 7:54 A.M. revealed Registered Nurse (RN) #138 used the glucometer to check Resident #95 blood sugar level. RN #138 cleaned the glucometer with alcohol after she was done. Interview with RN #138 on 09/06/23 at 8:21 A.M. verified she cleaned the glucometer with alcohol and when questioned what she uses to clean the glucometer she stated alcohol or a bleach wipe. The Surveyor informed RN #138 that alcohol does not kill blood born pathogens such as human immunodeficiency virus, and hepatitis. RN #138 did not have any bleach containing wipes in her cart and they had to be retrieved out of the storage area. Review of the Assure Prism Multi Glucometer Reference Manual dated 03/01/21 revealed to minimize the risk of transmitting blood-borne pathogens, the cleaning and disinfection procedure should be performed as recommended. A variety of the most commonly used EPA-registered wipes have been tested and approved for cleaning and disinfecting of the Assure Prism multi Blood Glucose Monitoring System. The disinfectant wipes listed below have been shown to be safe for use with this meter. Please read the manufacturer's instructions before using their wipes on the meter: Clorox germicidal wipes, Dispatch hospital cleaner disinfectant towels and bleach, PDI Super Sani-Cloth germicidal disposable wipes, and Caviwipes1. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 21 of 22 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365961 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2023 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 - Some 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** Based on staff interview and observation the facility failed to provide a safe comfortable environment for residents when the wall was scratched in room [ROOM NUMBER] and 20. The toilet seat was soiled in room [ROOM NUMBER], and there was cracked floor tiles in room [ROOM NUMBER]. This affected seven residents (#10, #11, #17, #20, #23, #37, and #95) living in those rooms. The facility census was 40. Findings include: Observation with the Maintenance Director #122 on 09/07/23 from 2:19 P.M. to 2:26 P.M. revealed room [ROOM NUMBER], where Resident #17 and #23 resides, had wall scratches and missing caulking around the toilet. Observation of room [ROOM NUMBER], where Resident #95 resides, had wall scratches behind the resident's bed. Observation of room [ROOM NUMBER], where Resident #20 and #37 resides, had a dark brown substance dried on the the raised toilet seat. Observation of room [ROOM NUMBER], where Resident #10 and #11 resides, revealed a large crack in the floor covering multiple floor tiles. Interview with Maintenance Director #122 on 09/07/23 from 2:19 P.M. to 2:26 P.M. verified the observations and stated he was unaware of these items that needs fixing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 22 of 22