Health inspection·April 24, 2025

F 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was assessed to have severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 7 out of 15. This resident was assessed to have an active diagnosis of PTSD. Review of the active care plans for Resident #18 revealed no plan of care was in place addressing the cause of PTSD, triggers which may cause re-traumatization, or interventions to reduce the risk of re-traumatization and provide care for PTSD. Review of two Trauma Informed Care Evaluations revealed no determination had been completed to identify the cause of PTSD for Resident #18 and to identify potential triggers which may cause re-traumatization. Interview with Social Services #570 on 04/23/25 at 11:00 A.M. verified the assessments did not capture actual cause of trauma and care plan did not accurately reflect triggers for recurrence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 2 of 5 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 04/24/2025 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 record reviews and staff interviews, the facility failed to ensure an order for the administration of as needed Ativan (an anti-anxiety medication) contained a stop date of 14 days or less. This affected one resident (#31) out of the five residents reviewed for unnecessary medications. The facility census was 43. Findings include: Record review for Resident #31 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included anxiety disorder, depression, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/27/25, revealed the resident was assessed to have intact cognition. The resident was assessed to have received anti-anxiety medications during the lookback period. Review of the active physicians order, dated 12/08/24, revealed Resident #31 was to be administered 0.5 milligrams (mg) of Ativan every two hours as needed for anxiety. The order did not contain a stop date. Review of the Medication Administration Records (MAR's) for Resident #31, dated 12/22/24 (14 days after the order for Ativan was implemented) through 04/22/25, revealed the resident was documented to have been administered 32 doses of as needed Ativan. Interview with Licensed Practical Nurse (LPN) #290 on 04/22/25 at 3:45 P.M. confirmed the Ativan ordered for Resident #31 was as needed and did not contain a date for which to stop the order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 3 of 5 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 04/24/2025 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure a medication was administered according to physicians order. This affected one resident (#31) out of the five residents reviewed for unnecessary medications. The facility census was 43. Residents Affected - Few Findings include: Record review for Resident #31 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included chronic pain due to trauma, anxiety disorder, depression, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/27/25, revealed the resident was assessed to have intact cognition. Review of the active physicians order, dated 12/24/24, revealed Resident #31 was to be administered one milliliter (ml) of Morphine Sulfate (an opioid medication) Oral Suspension 20 milligrams (mg) per five ml's (which was equivalent to four mg's per dose administered) every two hours as needed for breakthrough pain. Review of the facility Controlled Drug Receipt Record/Disposition Forms, dated 12/24/24 through 04/22/25, revealed bottles of Morphine Sulfate Oral Suspension supplied to the facility for administration to Resident #31 were 100 mg's per five ml's (which was equivalent to 20 mg per one ml). One ml of Morphine Sulfate Oral Suspension 100 mg's per five ml's (equaling 20 mg) was documented to have been removed from the bottles by multiple nurses over 300 times for administration to Resident #31. Review of the Medication Administration Records (MAR's) for Resident #31, dated 12/24/24 through 04/22/25, revealed one ml of Morphine Sulfate Oral Suspension 20 mg's per five ml's (equaling four mg's) was documented to have been administered to Resident #31 at each dose. Further record review for Resident #31 revealed the resident had not experienced any episodes of respiratory depression, oversedating, or other adverse side effects of medications between 12/24/24 and 04/22/25. Observation and interview with Licensed Practical Nurse (LPN) #290 on 04/22/25 at 3:45 P.M. confirmed the bottle of Morphine Sulfate Oral Suspension contained in the narcotic lock box on the medication cart used for Resident #31 was a strength of 100 mg's per five ml's which was equal to 20 mg's per one ml. LPN #290 confirmed one ml of the Morphine Sulfate Oral Suspension was removed from the bottle at each dose and administered to Resident #31 so the resident received 20 mg each time. LPN #290 further confirmed the physicians order for Resident #31 was for one ml of Morphine Sulfate Oral Suspension at a strength of 20 mg's per five ml's which was only equivalent to four mg's to be administered at each dose. LPN #290 confirmed the amount administered to the resident at each dose did not match the amount ordered by the physician. Observation of Resident #31 on 04/22/25 at 4:05 P.M. revealed the resident was lying in bed eating grapes and watching television and did not appear to be exhibiting signs or symptoms of pain. Interview with Resident #31 at the time of the observation confirmed facility staff administered pain medication which kept the residents pain at a manageable level and denied any concerns with adverse side (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 4 of 5 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 04/24/2025 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 0760 effects from medications. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Administering Medications, revised 04/2019, revealed medications are administered in accordance with prescriber orders, including any required time frames. The individual administering the medication checks the label THREE times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365961 If continuation sheet Page 5 of 5