Inspection·August 6, 2021

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure residents had comprehensive assessments in the areas of activities, potential restraint use, and residing on a dementia unit. This affected two of 18 residents (Resident #22 and #67) reviewed for comprehensive assessments. Findings include: 1. Review of Resident # 67's medical record revealed she was admitted [DATE] with diagnoses that included: senile degeneration of brain, palliative care. dementia without behaviors, essential hypertension, insomnia, malignant neoplasm of breast, anxiety, and over active bladder. Review of Resident #67's admission Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #67's speech was clear, she made herself understood, she understands others, her cognition was severely impaired, and she had minimal depression. Resident #67 had delusions, other behaviors that occurred one to three days during the assessment period that did not impact her or other residents care, and she wandered four to six days during the assessment period. Resident #67 required limited assistance of one staff for bed mobility, to transfer, to walk, and for locomotion on the unit. Resident # 67 used no alarms. Review of physician orders revealed the following: memory support placement needed due to dementia and/or impaired judgement, high risk for elopement, and she was socially appropriate to participate in a memory support program, a sensor pad to bed every day and night shift to alert staff to resident's needs (ordered on 01/14/2021), and a sensor alarm to her chair every day and night shift for self-ambulation (ordered on 05/28/2021). Review of Resident #67's quarterly MDS assessment dated [DATE] revealed the following changes. Resident #67 had physical behaviors and other behaviors one to three days during the assessment period, and she wandered one to three days during the assessment period. Resident #67 required extensive assistance for bed mobility, to transfer, to walk, and for locomotion. Resident #67 used a bed and chair alarm daily. Review of the Enabler/Restraint Device Determination assessment dated [DATE] revealed the bed and/or chair alarm was an enabler used to alert staff of Resident #67 needing assistance due to poor safety awareness. There was no comprehensive assessment regarding Resident #67 requiring placement on a secure dementia unit. Interview of the Director of Nursing (DON) on 08/02/21 at 9:40 A.M. revealed Resident #67's alarms were not assessed as potential restraints. Additional interview of the DON on 08/02/21 at 4:38 P.M. confirmed there was no assessment of the resident requiring placement on a secure dementia unit. 2. Review of Resident #22's medical record revealed she was admitted on [DATE] with diagnoses that included: Alzheimer's disease, dementia without behaviors, hypertensive chronic kidney disease, hyperlipidemia, type two diabetes, stage four kidney disease, obesity, peripheral vascular disease, hypomagnesemia, polyosteoarthritis, and major depressive disorder single episode. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 2 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #22's annual MDS dated [DATE] revealed the following. Resident #22's speech was clear, she was usually understood, and she usually understands others, her cognition was severely impaired. Resident #22 had minimal depression, had delusions, other behaviors one to three days during the assessment period, that did not impact the resident or other residents, she did not reject care, and she wandered. It was not very important to have reading materials, very important to listen to music, to be around pets, to keep up with the news, to do things in group, to do favorite activities, to go outside in good weather, and religious service. There was no comprehensive assessment of Resident #22's activity interests and there was no comprehensive assessment of her needing to reside on a secure dementia unit. Interview of the DON on 08/02/21 at 4:38 P.M. confirmed there was no assessment of Resident #22 requiring a secure dementia unit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 3 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 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 - Some 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 staff interview and medical record review, the facility failed to ensure resident plans of care addressed resident's needs in the areas of activities, skin non-pressure, dementia care, eating, and device usage. This affected six of 18 sampled residents (Resident #4, #22, #44, #46, #67, and #274) whose care plans were reviewed. The census was 74. Findings include: 1. Review of Resident #22's medical record revealed she was admitted on [DATE] with diagnoses that included: Alzheimer's disease, dementia without behaviors, hypertensive chronic kidney disease, hyperlipidemia, type two diabetes, stage four kidney disease, obesity, peripheral vascular disease, hypomagnesemia, polyosteoarthritis, and major depressive disorder single episode. Review of Resident #22's annual minimum date set (MDS) assessment dated [DATE] revealed the following. Resident 322's speech was clear, she was usually understood, and she usually understands others, her cognition was severely impaired. Resident #22 had minimal depression, had delusions, other behaviors one to three days during the assessment period that did not impact the resident or other residents, she did not reject care, and she wandered. It was not very important to have reading materials, very important to listen to music, to be around pets, to keep up with the news, to do things in group, to do favorite activities, to go outside in good weather, and religious service. Review of Resident #22's physician orders revealed she required a dementia unit, she received two medications with blood thinning properties (Aspirin and Protonix). Review of Resident #22's plan of care revealed no plan to monitor for and to prevent bruising, an activity care plan, and the care plan identified she resided on The Haven (a dementia care unit), but her dementia care needs were not identified. Interview of the Director of Nursing (DON) on 07/29/21 at 9:27 A.M. confirmed Resident #22's plan of care did not address bruising, activities, and dementia care needs. 2. Review of Resident #46's medical record revealed she was admitted on [DATE] with diagnoses that included: atrial fibrillation, hypoosmolality and hyponatremia, gastro-esophageal reflux disease, malignant neoplasm of breast, acquired absence of right breast, and moderate protein calorie malnutrition. Review of Resident #46's admission Minimum Data Set (MDS) dated [DATE] revealed her speech was clear, she made herself understood, she understands others, her cognition was moderately impaired, and she had mild depression. Resident #46 had no indicators of psychosis, no behaviors and did not reject care. Resident #46 was independent with set up help to eat. Resident # 46 had difficulty chewing, her partials (dentures) fit, she had significant unplanned weight gain that was not planned and received a mechanically altered therapeutic diet. Resident #46 received no restorative therapy to eat. Review of Resident #46's physician orders revealed a regular diet mechanical soft diet with ground meat texture and thin consistency. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 4 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Review of Resident #46's oral assessment dated [DATE] revealed she had natural teeth, missing teeth, with full upper and lower dentures. Review of Resident #46's dietary assessment dated [DATE] revealed she had no natural teeth, she had dentures that fit. Residents Affected - Some Review of Resident #46's plan of care for oral care dated 06/16/2021 revealed she required extensive assistance and she had upper and lower partial plate. The plan of care did not address the residents loose partial plates and the effect it had on her ability to eat. Interview of the DON on 07/29/2021 at 11:00 A.M. confirmed Resident # 46's plan of care did not address the ill fitting partial plates and the impact on her ability to eat. 3. Review of Resident #67's medical record revealed she was admitted [DATE] with diagnoses that included: senile degeneration of brain, palliative care, dementia without behaviors, essential hypertension, insomnia, malignant neoplasm of breast, anxiety, and over active bladder. Review of Resident #67's admission Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #67's speech was clear, she made herself understood, she understands others, her cognition was severely impaired, and she had minimal depression. Resident #67 had delusions, other behaviors that occurred one to three days during the assessment period that did not impact her or other residents care, and she wandered four to six days during the assessment period. Resident #67 required limited assistance of one staff for bed mobility, to transfer, to walk, and for locomotion on the unit. Resident #67 used no alarms. Review of Resident #67's physician orders revealed the following: memory support placement needed due to dementia and/or impaired judgement, high risk for elopement, and she was socially appropriate to participate in a memory support program, a sensor pad to bed every day and night shift to alert staff to resident's needs (ordered on 01/14/2021), and a sensor alarm to her chair every day and night shift for self-ambulation (ordered on 05/28/2021). Review of Resident #67's quarterly MDS dated [DATE] revealed the following changes. Resident #67 had physical behaviors and other behaviors one to three days during the assessment period, and she wandered one to three days during the assessment period. Resident #67 required extensive assistance for bed mobility, to transfer, to walk, and for locomotion. Resident #67 used a bed and chair alarm daily. Review of the Enabler/Restraint Device Determination assessment dated [DATE] revealed the bed and/or chair alarm was an enabler used to alert staff of Resident #67's needing assistance due to poor safety awareness. There was no comprehensive assessment Resident #67 required a secure dementia unit. Review of Resident #67's plan of care revealed no activities care plan, the care plan identified she resided on The Haven, but her dementia care needs were not identified, and the care plan only addressed the use of alarms to prevent falls, not the restriction of her movement Interview of the DON on 08/02/21 at 4:38 P.M. confirmed Resident #67's plan of care did not address activities, her dementia care needs, and the restriction of her movement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 5 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 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 - Some 4. Review of the medical record revealed Resident #4 was admitted on [DATE] with diagnoses including Alzheimer's disease, history of falls with injuries, and anxiety disorder. Review of the Activity Assessment 3.0 dated 01/08/21 revealed Resident #4 enjoyed puzzles and reading the newspaper. Vision was adequate with glasses, hearing was adequate. Resident able to make her own decisions regarding participation in activities, enjoys cross words and reading the newspaper. Enjoys reading, listening to music, and conversing with others, will continue to offer 1:1, individual and group activities per CDC regulations due to the COVID-19 Review of the medical record revealed no activity care plan. 5. Review of the medical record revealed Resident #44 was admitted on [DATE] with diagnoses including unspecified dementia without behavioral disturbances and Alzheimer's disease. Review of the Activity Participation Review dated 01/04/21 revealed Resident #44 participates in most one-on-one, group, and individual activities; unless she is napping. Resident #44 likes sensory activities hand lotions, back massages, sensory cloths, and perfume, listening to music, play trivia, name that phrase, bean bag toss, basketball, conversation, and watching TV. Resident #44 talks to her family weekly through virtual visits, spends most of her day in the living room, and opens and reads the mail by herself. Current plan of care remains appropriate/current. On 07/29/21 at 3:44 P.M., interview with Licensed Practical Nurse (LPN) #110 and Director of Resident Activities (DRA) #138 verified Resident #4 and Resident #44 did not have activity care plans because activities did not trigger from their Minimum Data Set assessment. 6. Medical record review revealed Resident #274 was admitted on [DATE] with diagnoses including malignant neoplasm of prostate and emphysema. The resident was receiving skilled therapy and planned to discharge from the facility. Review of the Activity Assessment 3.0 dated 07/02/21 revealed resident was alert and oriented, enjoys listening to bluegrass music, wood working, being with his friends, socializing and wrote a book about his mission in the military. The resident attends church and activity calendar was reviewed with Resident #274. Continue to offer one-on-one, individual and group activities and address any needs or concerns as they arise. Review of the medical record review revealed no evidence of an activity care plan. On 08/02/21 at 12:38 P.M., interview with the Director of Nursing verified Resident #274 did not have an activity care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 6 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 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** Based on resident interview, staff interview, medical record review, and observation the facility failed to maintain a resident's ability to eat. This affected one of five sampled residents (Resident #46) reviewed for nutrition. Residents Affected - Few Findings include: Review of Resident #46's medical record revealed she was admitted on [DATE] with diagnoses that included: atrial fibrillation, hypo-osmolality and hyponatremia, gastro-esophageal reflux disease, malignant neoplasm of breast, acquired absence of right breast, and moderate protein calorie malnutrition. Review of Resident #46's admission Minimum Data Set (MDS) dated [DATE] revealed her speech was clear, she made herself understood, she understands others, her cognition was moderately impaired, and she had mild depression. Resident #46 had no indicators of psychosis, no behaviors, and did not reject care. Resident #46 was independent with set up help to eat. Resident #46 had no difficulty chewing, her partials (dentures) fit, she had significant unplanned weight gain that was not planned and received a mechanically altered therapeutic diet. Resident #46 received no restorative therapy to eat. Review of Resident #46's physician orders revealed a regular diet, mechanical soft diet, with ground meat texture and thin consistency. Review of Resident #46's oral assessment dated [DATE] revealed she had natural teeth, missing teeth, with full upper and lower dentures. Review of Resident #46's dietary assessment dated [DATE] revealed she had no natural teeth, she had dentures that fit. Review of Resident #46's weights revealed: On 06/15/21 (admission) 137.4 pounds, on 07/20/2021- 127 pounds, on 07/21/2021-109.4 pounds (representing a 13 % severe weight loss), on 07/25/2021-106.6 pounds (representing a 16% severe weight loss), and on 07/27/2021- 103.7 pounds (representing a severe weight loss of 18 %). Review of Resident #46's plan of care for oral care dated 06/16/2021 revealed she required extensive assistance and she had upper and lower partial plate. Interview of Resident #46 on 07/27/2021 at 10:49 A.M. revealed she did not receive food she could eat and her partial plates that use to fit are now loose since she had lost weight. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 7 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 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 Observation of Resident #46 on 07/28/21 at 8:09 A.M. revealed she received a cheese omelet, cooked oats, Ensure Plus and apple juice. Resident #46 was not eating, she stated she drank about half of the Ensure Plus but it took all her pep to drink the Ensure. She stated her loose partial made it difficult to eat. Interview of State Tested Nursing Assistant (STNA) #201 on 07/28/21 at 8:54 A.M. revealed Resident #46 did not eat well, maybe a few bites, and STNA #201 encouraged the resident to consume the Ensure. STNA #201 stated Resident # 46's partial has not been fitting and it was loose for at least the last few weeks. STNA #201 stated when her partial fit she ate well. Interview of STNA #204 on 07/29/21 at 8:06 A.M. stated she was aware, about one and a half weeks ago Resident #46's partial was loose. Interview of Charge Licensed Practical Nurse (CLPN) #128 on 07/29/21 at 8:09 A.M. revealed on 07/23/2021 Resident # 46 complained her partial did not fit and an appointment with a dentist was scheduled on 08/03/2021. She confirmed no interventions were put into place when Resident #46 complained her partial plates were loose. CLPN #128 was not aware of Resident #46 experiencing significant edema recently. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 8 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 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** 2. Review of Resident #22's medical record revealed she was admitted on [DATE] with diagnoses that included: Alzheimer's disease, dementia without behaviors, hypertensive chronic kidney disease, hyperlipidemia, type two diabetes, stage four kidney disease, obesity, peripheral vascular disease, hypomagnesemia, polyosteoarthritis, and major depressive disorder single episode. Residents Affected - Some Review of Resident #22's annual MDS dated [DATE] revealed the following. Resident # 22's speech was clear, she was usually understood, and she usually understands others, her cognition was severely impaired. Resident #22 had minimal depression, had delusions, other behaviors one to three days during the assessment period, that did not impact the resident or other residents, she did not reject care, and she wandered. It was not very important to have reading materials, very important to listen to music, to be around pets, to keep up with the news, to do things in group, to do favorite activities, to go outside in good weather, and religious service. No activity assessment or plan of care was available for Resident #22. Resident #22 resided on The Haven (a dementia unit). Review of the May 2021, June 2021, and July 2021 activity calendars revealed two scheduled activities Monday through Friday and no activities were scheduled on the weekend. Five times a month, of the activities listed on the calendar, during the week were food activities. Observation of Resident #22 on 07/27/21 at 3:27 P.M. revealed she was seated in her wheel chair Resident #22 was not watching the television and staff were not prompting her to engage in an activity. On 07/28/21 at 7:58 A.M. revealed Resident #22 was in bed dressed, at 8:21 A.M. revealed she was in bed with no activity, at 8:29 A.M. she was in bed and refused breakfast when offered, and at 9:48 A.M. she was still in bed. At 11:53 A.M. Resident #22 was on unit the television was on but Resident #22 was not engaged. On 07/29/21 at 7:45 A.M. Resident #22 was in the common area the television was on Resident #22 was not engaged at 8:01 A.M. Resident #22 was still in the common area the television was on, but she was not engaged. Observation on 08/02/21 from 9:01 A.M. to 10:21 A.M. revealed she was seated in her wheel chair sleeping and staff did not attempt to engage her in any activities. On 08/02/21 at 11:22 A.M. Resident #22 was not participating in any activity, no activities were offered and she was asleep in her wheel chair. From 2:12 P.M. to 2:17 P.M. there was no staff present in common area, the television was on, but Resident #22 was not paying attention to what was on. Interview of Activity Director (AD) #138 on 07/29/21 at 1:27 P.M. revealed Resident #22 liked one to one visits, she enjoys sensor stimulations such as application of lotion and back rubs. She stated Resident #22 loved a variety of music and her and Resident #22 sang classic country (older ones) hymns, and Resident #22 would dance when she heard the music. AD #138 confirmed there were scheduled activities Monday through Friday two times a day and the weekend was an activity cart. AD #138 stated the food activities listed on the calendar consisted of staff passing out food to the residents. AD #138 stated The Haven was did not on have an activity cart, but The Haven, had coloring pages, crayons, colored pencils, and other individual activities pages for use on the unit. AD #138 stated it was just her and an activity aide. AD #138 stated most of the activity aides times was taken with resident visitation due to COVID-19 protocols. The State Tested Nursing Assistants (STNA) on the unit as well as the Chaplin helped with activities twice a week. AD #138 revealed one to one visits lasted from five to ten minutes. AD #138 stated on Tuesdays and Fridays she conducts the group activities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 9 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 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 - Some AD #138 confirmed there was not a whole lot of activities on The Haven. AD #138 revealed prior to 2018 she was responsible for the activities and memory care on The Haven since then she had less time to spend on The Haven. Interview of STNA #202 on 07/29/21 at 1:02 P.M. revealed Resident #22 was offered activities daily like BINGO and corn hole. STNA #202 revealed sometimes Resident#22 would play the games and sometimes not. STNA #202 stated Resident #202 rarely watched television. 3. Review of Resident #67's medical record revealed she was admitted [DATE] with diagnoses that included: senile degeneration of brain, palliative care. dementia without behaviors, essential hypertension, insomnia, malignant neoplasm of breast, anxiety, and over active bladder. Review of Resident #67's admission Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #67's speech was clear, she made herself understood, she understands others, her cognition was severely impaired, and she had minimal depression. Resident #67 had delusions, other behaviors that occurred one to three days during the assessment period, , that did not impact her or other residents, care, and she wandered four to six days during the assessment period. Resident #67 required limited assistance of one staff for bed mobility, to transfer, to walk, and for locomotion on the unit. Resident #67 used no alarms. Review of Resident #67's physician orders revealed the resident resided on the dementia unit (The Haven). Review of Resident #67's quarterly MDS dated [DATE] revealed the following changes. Resident #67 had physical behaviors and other behaviors one to three days during the assessment period, and she wandered one to three days during the assessment period. It was very important for Resident # 67 to have reading material, to listen to music she liked, not important at all to be around pets, very important to keep up with the news, somewhat important to do things in groups, very important to do favorite activities, to get fresh air, and participate in religious activities. Resident #67 required extensive assistance for bed mobility, to transfer, to walk, and for locomotion. Resident #67 used a bed and chair alarm daily. Review of Resident #67's quarterly MDS dated [DATE] revealed the following changes. Resident #67 had physical behaviors and other behaviors one to three days during the assessment period, and she wandered one to three days during the assessment period. Resident #67 required extensive assistance for bed mobility, to transfer, to walk, and for locomotion. Resident #67 used a bed and chair alarm daily. Review of the May 2021, June 2021, and July 2021 activity calendars revealed two schedule activities Monday through Friday and no activities were scheduled on the weekend. Five times a month of the activities listed on the calendar during the week were food activities. Review of Resident #67's plan of care revealed no activities care plan. Observation of Resident #67 on 07/27/2021 at 3:27 P.M. revealed she was seated in her chair the television was on, however, she was not watching it. On 07/28/2021 at 8:44 A.M. revealed Resident #67 was seated in chair in common area with no activity going on. At 9:48 A.M. Resident #67 was seated in a chair in the common area asleep. At 2:45 P.M. was sitting in the common area no activity was going on and the resident stated she was bored, there was nothing going on. On 07/29/2021 at 7:54 A.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 10 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 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 sitting at the table in dining room and no activity was provided. Observation on 08/02/2021 at 9:01 A.M. revealed Resident #67 was in a chair there was no activities and the television was on and she was asleep. From 10:21 A.M. to 11:22 A.M. she was in a chair not watching the movie that staff played last week and she was asleep. From 2:12 P.M. to 2:17 P.M. there was no staff present in common area, the television was on, but Resident #67 was not paying attention to what was on. Residents Affected - Some Interview of AD #138 on 07/29/21 at 2:15 P.M. revealed Resident #67 liked physical activities like ball toss, lateral golf, and such. Resident #67 loved trivia and she was very quick witted. Resident #67 loved to do anything and participated in everything. AD #138 stated Resident #67 had not been participating in activities like she used to, but she did not know why. AD #138 confirmed there were scheduled activities Monday through Friday two times a day and the weekend was an activity cart. AD #138 stated the food activities listed on the calendar consisted of staff passing out food to the residents. AD #138 stated The Haven did not on have an activity cart, but The Haven, had coloring pages, crayons, colored pencils, and other individual activities pages for use on the unit. AD #138 stated it was just her and an activity aide. AD #138 stated most of the activity aides times was taken with resident visitation due to COVID-19 protocols. The State Tested Nursing Assistants (STNA) on the unit as well as the Chaplin helped with activities twice a week. AD #138 revealed one to one visits lasted from five to ten minutes. AD #138 stated on Tuesdays and Fridays she conducts the group activities. AD #138 confirmed there was not a whole lot of activities on The Haven. AD #138 revealed prior to 2018 she was responsible the activities and memory care on The Haven since then she had less time to spend on The Haven. Interview of STNA #202 on 07/29/21 at 1:02 P.M. revealed Resident #67 was offered activities daily like BINGO and corn hole. STNA #202 revealed Resident #67 was sleeping more lately and not participating in activities like she used to. 4. Review of the medical record revealed Resident #44 was admitted on [DATE] with diagnoses including unspecified dementia without behavioral disturbances and Alzheimer's disease. Review of the annual Minimum Data Set 3.0 assessment (MDS) dated [DATE] revealed Resident #44 was severely impaired for daily decision-making, had adequate vision with glasses, was somewhat important to have books, newspapers and magazines to read, to keep up with the news, to do things with groups of people, and to do her favorite activities. It was very important to listen to music she liked, to get fresh air when the weather was good and to participate in religious services or practices. Review of the Activity Participation Review dated 01/04/21 revealed Resident #44 participates in most one-on-one, group, and individual activities; unless she is napping. Resident #44 likes sensory activities hand lotions, back massages, sensory cloths, and perfume, listening to music, play trivia, name that phrase, bean bag toss, basketball, conversation, and watching TV. Resident #44 talks to her family weekly through virtual visits, spends most of her day in the living room, and opens and reads the mail by herself. Current plan of care remains appropriate/current. Review of the medical record revealed no activity care plan. Review of the Activity Calendar dated July 2021 revealed no activities were offered on the secured unit after 2:00 P.M. on Monday, Tuesday, Wednesday and Fridays; no scheduled activities after 4:30 P.M. on Thursdays and no scheduled activities on Saturday or Sundays. On 07/28/21 at 3:55 P.M., interview with Director of Resident Activities (DRA) #138 stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 11 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 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 - Some facility has scheduled virtual visitation but they do not turn anyone away who would like to visit someone at the facility. There was one activity aide who works from 10:45 A.M. to 7:15 P.M. ;however, her primary role is to facilitate resident virtual and indoor visitations. DRA #138 stated she needs more staff to offer additional activities for the residents. DRA #138 verified there were few activities but she tries to spend at least five to 10 minutes with each resident, but would like to do more. Definitely would like to have more activities, verified there were limited activities, the residents would love to have more to do but there is just not enough staff to do that. The aides/Chaplin primarily have helped her facilitate activities as there is only her to do the activities and she has both the secured and long term care scheduled at the same time. After the scheduled 2:00 P.M. activities are done that is when she goes and completes her assessments, charting and any one-on-one visits. On the weekends, she handles the visitations including prescreening the resident family member and taking the resident and family to the visitation area. There is one activity cart on the long term side of the facility on weekends that has some activities residents can chose from but the activity cart does not go to the secured unit. The secured unit is dependent on the aides to complete any activities. Based on observations, medical record review, resident interview, staff interview, and facility policy review, the facility failed to provide meaningful activities to all residents. This affected four (Residents #18, #22, #44, and #67) of six residents reviewed for activities. The census was 74. Findings Include: 1. Observations from 07/26/21 at 11:00 A.M. to 08/02/21 at 3:30 P.M. revealed no group activities or activities outside of his room were offered to Resident #18. He remained in his bed the vast majority of the time. Record review revealed Resident #18 was admitted to the facility on [DATE]. His diagnoses were Alzheimer's disease, hypertensive retinopathy, dermatochalasis, chronic gastritis with bleeding, diverticulitis, iron deficiency anemia, metabolic encephalopathy, atrial fibrillation, osteoarthritis, hypothyroidism, dementia,unspecified psychosis, atherosclerotic heart disease, hypertension, and hyperlipidemia. His Brief Interview for Mental Status (BIMS) score was five, which indicated he had a severe cognitive impairment. The assessment was completed on 07/06/21. Review of Resident #18's medical records revealed from May 2021 to July 2021 there were a total of 138 total activities documented. Of those 138 documented activities, 111 activities were identified as reminiscing/conversing, watching television, and people watching. Also, of the activities that were offered during the survey (07/26/21 to 08/02/21), there were no documented efforts to invite/offer for Resident #18 to attend any of those activities. Finally, in review of Resident #18 care plans, there was nothing listed as far as a care plan related to activities. Interview with State Tested Nursing Aide (STNA) #179 on 08/02/21 at 10:30 A.M. confirmed that they do not offer the group activities to Resident #18 because he doesn't like doing them and he doesn't want to go to them. She confirmed that's why they don't ask him anymore. Interview with Director of Nursing (DON) on 08/02/21 at 3:21 P.M. confirmed that if the resident had an activity care plan, it would be in their medical care plan. She confirmed there was not a care plan for activities in Resident #18 records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 12 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review the facility failed to ensure a resident receiving medications with blood thinning properties had a means in place to prevent bruising. This affected one of six residents (Resident #22) reviewed for unnecessary medication. Residents Affected - Few Findings include: Review of Resident #22's medical record revealed she was admitted on [DATE] with diagnoses that included: Alzheimer's disease, dementia without behaviors, hypertensive chronic kidney disease, hyperlipidemia, type two diabetes, stage four kidney disease, obesity, peripheral vascular disease, hypomagnesemia, polyosteoarthritis, and major depressive disorder single episode. Review of Resident #22's annual minimum date set (MDS) dated [DATE] revealed the following. Resident # 22's speech was clear, she was usually understood, and she usually understands others, her cognition was severely impaired. Resident #22 had minimal depression, had delusions, other behaviors one to three days during the assessment period that did not impact the resident or other residents, she did not reject care, and she wandered. Resident # 22 required extensive assistance of one staff for bed mobility, to transfer, to walk in room, to walk in corridor, for locomotion on the unit, did not go off the unit, used a walker and a wheelchair for mobility. Review of Resident #22's physician orders revealed she received two medications with blood thinning properties (Aspirin and Protonix) daily. Review of Resident #22's plan of care revealed no plan to monitor for and prevent bruising. Observation of Resident #22 on 07/27/21 at 8:48 A.M. revealed she was seated in her wheel chair. The arms of wheel chair had torn fabric exposing the foam and the side of the arms had a hard plastic coating. Resident #22 was bumping her arm near the elbow on the plastic coating on the wheel chair arm Resident #22 had a bruise on her arm near when she was bumping it on the wheel chair. Interview of State Tested Nursing Assistant (STNA) #202 on 07/29/21 at 1:02 P.M. revealed Resident #22 bumped her elbow on the arm of wheel chair often. STNA #202 confirmed Resident #22 stated the resident wore short sleeves at times. Interview of Registered Nurse (RN) #165 on 08/02/21 at 9:00 AM confirmed Resident #22 bumped her elbows on the arms of chair and Resident #22 also flings her arms with staff during care that caused bruises. RN #165 confirmed there were no measures in place to prevent bruising. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 13 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 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 ensure proper supervision was provided to a resident that was a high fall risk. This affected one (Resident #28) of two residents reviewed for accidents. The census was 74. Findings Include: Record review revealed Resident #28 was admitted to the facility on [DATE]. Her diagnoses were hemiplegia and hemiparesis, neuromuscular dysfunction of the bladder, atrial fibrillation, dysarthria, dysphagia, chronic kidney disease (stage III), morbid obesity, major depressive disorder, type II diabetes, chronic obstructive pulmonary disease. Her Brief Interview for Mental Status (BIMS) score was 15, which indicated she was cognitively intact. The assessment was completed on 05/25/21. Review of Resident #28's medical records revealed on 06/23/21, staff heard her yelling from her bathroom. When they responded, they found Resident #28 face down on the ground. She stated she was leaning forward to wipe and fell off the toilet; causing a hematoma to her head. She was fully assessed and no other injuries were noted. She was sent to the emergency room for precautionary reasons; no other injury was noted. According to her fall risk assessment (dated 05/18/21), she had a score of 14, which indicated she was a high risk for falls. Also, according to her Minimum Data Set (MDS), Section G (dated 05/25/21 and 07/07/21), it indicated that Resident #28 needed extensive assistance with two person physical assistance while using the toilet. Interview with Restorative Aide (RA) #116 and State Tested Nursing Aide (STNA) #179 on 08/02/21 from 10:30 A.M. to 11:12 A.M. revealed that if a resident is deemed a high risk for falls, and they are taken to the bathroom, they should not be left alone while on the toilet. If a resident was a high risk for falls, but they wanted alone time in the bathroom, they would stand outside the bathroom door, with the door closed/cracked open, and wait for the resident to call for them. RA #116 confirmed that Resident #28 was not to be left alone in the bathroom; it had been that way for a while. Review of facility Fall Management policy (dated 03/03/17) revealed the facility is dedicated to providing the best possible care to the residents. Safety is a priority. The efforts will be made to minimize fall risk and fall related injuries, while maximizing individual dignity, freedom, and quality of life. The fall risk assessment will include assessment of medications, vision, mobility, unsafe behavior, pain, and activities of daily living (ADL) functional status. The following are utilized in the prevention of falls: assistance with ambulation and transfers for unsteady residents, assess for physical and/or occupational therapies, toileting programs, and other preventions as deemed necessary by the interdisciplinary team. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 14 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 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** Based on observations, medical record review, resident interview, staff interview, and facility policy review, the facility failed to implement nutritional recommendations/interventions for residents who lost a significant amount of weight. Also, the facility failed to monitor significant weight loss and then did not provide meals as indicated on the menu to a resident. This affected three of five residents reviewed for nutrition (Residents #18, #46, #274). The census was 74. Residents Affected - Few Findings Include: 1. Record review revealed Resident #18 was admitted to the facility on [DATE]. His diagnoses were Alzheimer's disease, hypertensive retinopathy, dermatochalasis, chronic gastritis with bleeding, diverticulitis, iron deficiency anemia, metabolic encephalopathy, atrial fibrillation, osteoarthritis, hypothyroidism, dementia,unspecified psychosis, atherosclerotic heart disease, hypertension, and hyperlipidemia. His Brief Interview for Mental Status (BIMS) score was five, which indicated he had a severe cognitive impairment. The assessment was completed on 07/06/21. Review of Resident #18 medical records revealed the following weights documented in the electronic medical record system: 06/11/21 (180.6 pounds), 07/13/21 (167.4 pounds, loss of 7.31%), and 07/21/21 (164.4 pounds, loss of 8.97%). According to the nutritional progress notes (dated 07/14/21), Dietitian #210 acknowledged the significant weight loss. The recommendations that she put into place were to obtain a re-weight to verify the significant weight loss and if the weight loss was confirmed, to increase the Ensure pudding supplement from one time per day to twice per day. A re-weight was not taken until 07/21/21, when it indicated Resident #18 had lost three more pounds. On 07/21/21, the Ensure pudding twice daily was implemented with weekly weights to be taken as well. On 07/27/21, Resident #18's weight was taken again and indicated it was 167.8 pounds (gain of 3.4 pounds). According to his Minimum Data Set (MDS), section G (dated 07/06/21) revealed he needed extensive, one person physical assistance for eating. Observation on 08/02/21 from 9:04 A.M. to 9:17 A.M. revealed Resident #18's breakfast sitting on his bedside table, in front of him; none of the food had been eaten. At approximately 9:17 A.M., staff took his food away without him eating any breakfast. There were no observations made of staff encouraging him to eat, or physically assisting him with eating. Interview with Restorative Aide (RA) #116 and State Tested Nursing Aide (STNA) #179 on 08/02/21 from 10:30 A.M. to 11:12 A.M. revealed they both stated Resident #18 as independent with his eating abilities; so they do not need to physically assist him. STNA #179 confirmed that his food was taken away without him eating any; she stated he was not hungry. Interview with Director of Nursing (DON) on 08/02/21 at 3:21 P.M. confirmed that nutritional orders/recommendations will be put into the electronic records when they are to be implemented. She also stated the dietary staff will send out an email to the management team if they have recommendations, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 15 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few so everyone is aware. She confirmed the new interventions are typically put into place within the next business day. Review of facility Weight Change policy (dated March 2018) revealed significant weight loss is defined as five percent in one month, 7.5 percent in three months, or ten percent in six months. Weight rechecks are to be obtained for a five pound weight loss or gain if a resident weighs over 100 pounds. A five pound weight gain/loss will be reported to the dietitian and the physician. The dietitian or registered dietetic technician will review the weight changes and make recommendations to the neighborhood nurse for follow-up with the physician as needed. 3. Medical record review revealed Resident #274 was admitted on [DATE] with diagnosis including severe protein-caloric malnutrition, dysphagia, and malignant neoplasm of prostate. Review of the 5-day MDS 3.0 assessment dated [DATE] revealed Resident #274 was moderately impaired for daily decision-making, was 71 inches tall and weighed 121 pounds (lbs), was on a mechanically altered, therapeutic diet and had a significant weight loss within the last month of greater than 5%. Review of the Dietary assessment dated [DATE] revealed Resident #274's weight was 131# at the hospital with a height of 71. The resident's BMI was 16.9 (underweight) and his ideal body weight was 172 lbs. The estimated caloric needs was 1650 to 1925 Kcal. Review of the care plan: Potential Nutritional Problem dated 07/02/21 included goals to have no unplanned significant weight changes of 5% in 30 days and explain/reinforce the importance of maintaining the diet ordered and encourage him to comply. Interventions included a lidded take-and-toss cup for all liquids, provide and serve diet as ordered. Review of the Physician Orders dated July 2021 included the resident was to use a lidded take-and-toss cup (a plastic cup with a nozzle to slow down the amount of liquids taken) for all liquids, patient and family aware of risk of aspiration and weight monthly unless otherwise indicated. Review of Resident #274's weights revealed a weight of 121 lbs on 06/29/21, 118 lbs on 07/13/21 and 116.2 lbs on 07/27/21. Review of the Speech Therapy SLP Evaluation and Plan of Care dated 06/29/21 revealed strategies and supervision was to be maintained to ensure alternate bites and liquids, decrease rate and bolus size, clear oral cavity after each bite and use of proper positioning with oral intake. Review of the ST (speech therapy) Discharge summary dated [DATE] revealed recommendations including distant supervision and continue with control flow cup for liquids. Recommend lingual sweep/re swallow, alternation of liquids/solids, bolus size modifications, chin tuck and second dry swallow upright posture during meals and upright for greater than 30 minutes after meals. Review of the Diet Spreadsheet: Cycle 11 for lunch meal on 08/02/21 revealed meal was to consist of veal [NAME], parmesan noodles, italian green beans, choice of roll, pudding, margarine and coffee/tea. Observation of breakfast on 07/28/21 and lunch on 08/02/21 revealed the resident was eating in his room without distant supervision, no swallowing precautions were being implemented by the resident. The lunch meal on 08/02/21 was served without the bread, margarine or drinks. Interview on 08/02/21 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 16 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few at 12:03 P.M. the resident stated his lunch meal did not come with all the requested items and no one had asked him how his meal was until the surveyor had asked him. Resident #274 stated he would likely eat it and it would taste better if he had some milk and bread with butter to go along with the noodles, gravy and meat. Observation on 08/02/21 at 12:50 P.M. revealed a coffee mug with 3/4 coffee uncovered and a glass of water with no lid on the over bed tray. Resident #274 stated both drinks were from breakfast and the coffee was cold and others were not fresh. On 08/02/21 at 12:54 P.M., interview with Social Service Designee #118 verified the resident was able to have bread and liquids with meals and those food items not served would provide additional calories and would be beneficial for Resident #274. On 08/02/21 at 5:03 P.M., interview with Rehab Director #211 stated the resident was to be taken out into the dining area for meals and was doing very well with the swallowing precautions and slow-rate drinking cups. Rehab Director #211 was unaware the staff had not been providing the slow-rate drinking cups with all liquids, supervising, or cueing the recommended swallowing precautions for Resident #274. 2. Review of Resident #46's medical record revealed she was admitted on [DATE] with diagnoses that included: atrial fibrillation, hypoosmolality and hyponatremia, gastro-esophageal reflux disease, malignant neoplasm of breast, acquired absence of right breast, and moderate protein calorie malnutrition. Review of Resident #46's admission Minimum Data Set (MDS) dated [DATE] revealed her speech was clear, she made herself understood, she understands others, her cognition was moderately impaired, and she had mild depression. Resident #46 had no indicators of psychosis, no behaviors and did not reject care. Resident #46 was independent with set up help to eat. Resident #46 had no difficulty chewing, her partial dentures fit, she had significant unplanned weight gain that was not planned and received a mechanically altered therapeutic diet. Resident #46 received no restorative therapy to eat. Review of Resident #46's physician orders revealed ProSource twice daily for wound healing, a regular diet mechanical soft diet with ground meat texture and thin consistency. Review of Resident #46's oral assessment dated [DATE] revealed she had natural teeth, missing teeth, with full upper and lower dentures. Review of Resident #46's dietary assessment dated [DATE] revealed she had no natural teeth, she had dentures that fit, she was overweight, had a Stage II and an Unstageable pressure ulcer, and edema. Resident #46 had no chewing or swallowing issues on current nutrition prescription. At the hospital, Resident #46 weighed 121 pounds on 06/07/21 and weighed 137.4 pounds on 06/16/21. Resident #46's current body weigh reflected a weight gain of 15 pounds (a 12.4% severe weight gain) since hospitalization. The weight differences was likely due to a discrepancy between the hospital and facility scales. Resident #46's body mass index (BMI) was 29.4, indicating the resident was overweight. Resident #46 received a diuretic that might cause weight fluctuation with fluid shifts. Review of Resident #46's plan of care for oral care dated 06/16/2021 revealed she required extensive assistance and she had upper and lower partial plates. Review of Resident #46's dietary notes dated 07/11/2021 revealed an unplanned significant weight loss of 11.2 pounds (8.2% in 30 days). Weight loss was likely due to resolving fluids. There were no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 17 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 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 nutrition recommendations at that time. Level of Harm - Minimal harm or potential for actual harm Review of Resident #46's dietary note dated 07/20/2021 revealed a significant weight loss that was previously identified. Resident #46 weighed 127.0 pounds and no recommendations were made. Residents Affected - Few Review of Resident #46's weights revealed the following: 06/15/21 (admission) -weighed 137.4 pounds, 07/20/21- 127 pounds, 07/21/21- 109.4 pounds (representing a 13 % severe weight loss), 07/25/21- 106.6 pounds (representing a 16% severe weight loss), and 07/27/21-103.7 pounds (representing a severe weight loss of 18 %). There was no evidence the dietitian was notified of the severe weight loss on 07/21/2021. Review of Resident #46's meal intakes revealed from admission [DATE]) to 07/13/21 she mostly ate 75% or greater. From 07/14/21 to 07/18/21 she mostly ate 50 to 75%. After 07/18/21 her intake mostly ranged from 25 to 50%. Interview of Resident #46 on 07/27/21 at 10:49 A.M. revealed she did not receive food she could eat and her partial plates that use to fit are now loose since she had lost weight. Observation of Resident #46 on 07/28/21 8:09 AM revealed she received a cheese omelet, cooked oats, Ensure Plus (supplement) and apple juice . Resident #46 was not eating. She stated she drank about half of the Ensure Plus but it took all her pep to drink the Ensure. She stated her loose partial made it difficult to eat and she just did not have the energy to eat. Interview of State Tested Nursing Assistant (STNA) #201 on 07/28/21 at 8:54 A.M. revealed Resident #46 did not eat well, maybe a few bites, and STNA #201 encouraged the resident to consume the Ensure. STNA #201 stated Resident # 46's partial had not been fitting and it was loose for at least the last few weeks. STNA #201 stated when her partial fit she ate well. Interview of Charge Licensed Practical Nurse (CLPN) #128 on 07/29/21 at 8:09 A.M. revealed on 07/23/21 Resident # 46 complained her partial did not fit and her intake seemed to decrease. CLPN confirmed the dietitian was not notified of the 07/21/2021 severe weight loss. Interview of Registered Dietitian Nutritionist (RDN) #210 on 08/04/21 at 10:13 A.M. revealed Resident #46's weight loss was due to shift in her edema and that was why she lost the weight. Resident #46 was having edema noted by the nurses after 07/21/21. RDN #210 did agree the edema noted by the nurses was noted as significant edema and she also agreed if the resident had significant edema a weight gain would have been expected, not a loss. RDN #210 was not aware of the loose partial that affected Resident #46's ability to eat. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 18 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, activity calendar review, and memory brochure the facility failed to ensure residents who were diagnosed with dementia received memory care to support the resident's well-being. This affected two of three sampled residents (Resident #22 and #67) reviewed for dementia care. Residents Affected - Few Findings include: 1. Review of Resident #22's medical record revealed she was admitted on [DATE] with diagnoses that included: Alzheimer's disease, dementia without behaviors, hypertensive chronic kidney disease, hyperlipidemia, type two diabetes, stage four kidney disease, obesity, peripheral vascular disease, hypomagnesemia, polyosteoarthritis, and major depressive disorder single episode. Review of Resident #22 annual minimum data set (MDS) dated [DATE] revealed the following. Resident # 22's speech was clear, she was usually understood, and she usually understands others, her cognition was severely impaired. Resident #22 had minimal depression, had delusions, other behaviors one to three days during the assessment period that did not impact the resident or other residents, she did not reject care, and she wandered. It was not very important to have reading materials, very important to listen to music, to be around pets, to keep up with the news, to do things in group, to do favorite activities, to go outside in good weather, and religious service. Review of Resident #22's physician orders revealed the resident resided on the dementia unit (The Haven). There was no assessment of Resident #22's need for and benefit from a dementia unit. There was no assessment to identify Resident #22's specific memory care needs. Review of the facility's brochure revealed The Haven offered memory care for individuals with dementia. The Haven provided services included comfort matters, opening minds through art, music, and memory. The brochure listed activities such as baking with staff, planting flowers, and making crafts. Review of the May 2021, June 2021, and July 2021 activity calendars revealed two schedule activities Monday through Friday and no activities were scheduled on the weekend. Five times a month of the activities listed on the calendar during the week were food activities. The activity calendar for The Haven was the same as the activity calendar for the rest of the nursing home. The activities listed were not structured for residents who had dementia. Observation of Resident #22 on 07/27/21 at 3:27 P.M. revealed she was seated in her wheel chair. Resident #22 was not watching the television and staff were not prompting her to engage in an activity. On 07/28/21 at 7:58 A.M. revealed Resident #22 was in bed dressed, at 8:21 A.M. revealed she was in bed with no activity, at 8:29 A.M. she was in bed and refused breakfast when offered, and at 9:48 A.M. she was still in bed. At 11:53 A.M. Resident #22 was on unit, the television was on, but Resident #22 was not engaged. On 07/29/21 at 7:45 A.M. Resident #22 was in the common area the television was on, Resident #22 was not engaged. At 8:01 A.M. Resident #22 was still in the common area the television was on, but she was not engaged. Observation on 08/02/21 from 9:01 A.M. to 10:21 A.M. revealed she was seated in her wheel chair, sleeping, and staff did not attempt to engage her in any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 19 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few activities. On 08/02/21 at 11:22 A.M. Resident #22 was not participating in any activity, no activities were offered and she was asleep in her wheel chair. From 2:12 P.M. to 2:17 P.M. there was no staff present in common area, the television was on, but Resident #22 was not paying attention to what was on. Interview of Activity Director (AD) #138 on 07/29/21 at 1:27 P.M. revealed Resident #22 liked one to one visits, she enjoys sensor stimulations such as application of lotion and back rubs. She stated Resident #22 loved a variety of music and her and Resident #22 sang classic country (older ones) hymns, and Resident #22 would dance when she heard the music. AD #138 confirmed there were scheduled activities Monday through Friday two times a day and the weekend were an activity cart. AD #138 stated the food activities listed on the calendar consisted of staff passing out food to the residents. AD #138 stated The Haven was did not on have an activity cart, but The Haven, had coloring pages, crayons, colored pencils, and other individual activities pages for use on the unit. AD #138 stated it was just her and an activity aide. AD #138 stated most of the activity aides times was taken with resident visitation due to COVID-19 protocols. The State Tested Nursing Assistants (STNA) on the unit as well as the Chaplin helped with activities twice a week. AD #138 revealed one to one visits lasted from five to ten minutes. AD #138 stated on Tuesdays and Fridays she conducts the group activities. AD #138 confirmed there was not a whole lot of activities on The Haven. AD #138 revealed prior to 2018 she was responsible the activities and memory care on The Haven since then she had less time to spend on The Haven and she had less time to address memory care. Interview of STNA #202 on 07/29/21 at 1:02 P.M. revealed Resident #22 was offered activities daily like BINGO and corn hole. STNA #202 revealed sometimes Resident#22 would play the games and sometimes not. STNA #202 stated Resident #202 rarely watched television. Interview of the Administrator on 08/03/2021 at 11:38 A.M. revealed Comfort Matters was the program used on The Haven. Comfort Matters was used to provide residents on The Haven with memory care and included items that were individualized for the residents who lived on The Haven and were used by staff to provide the memory care the resident needed. The Administrator confirmed this was not completed for Resident #22. 2. Review of Resident #67's medical record revealed she was admitted [DATE] with diagnoses that included: senile degeneration of brain, palliative care. dementia without behaviors, essential hypertension, insomnia, malignant neoplasm of breast, anxiety, and over active bladder. Review of Resident #67's admission Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #67's speech was clear, she made herself understood, she understands others, her cognition was severely impaired, and she had minimal depression. Resident #67 had delusions, other behaviors that occurred one to three days during the assessment period that did not impact her or other residents care, and she wandered four to six days during the assessment period. It was very important for Resident #67 to have reading material, to listen to music she liked, not important at all to be around pets, very important to keep up with the news, somewhat important to do things in groups, very important to do favorite activities, to get fresh air, and participate in religious activities. Resident #67 required limited assistance of one staff for bed mobility, to transfer, to walk, and for locomotion on the unit. Resident #67 used no alarms. Review of Resident #67's physician orders revealed the resident resided on The Haven. Review of Resident #67's quarterly MDS dated [DATE] revealed the following changes. Resident #67 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 20 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had physical behaviors and other behaviors one to three days during the assessment period, and she wandered one to three days during the assessment period. Resident # 67 required extensive assistance for bed mobility, to transfer, to walk, and for locomotion. Resident # 67 used a bed and chair alarm daily. Review of the May 2021, June 2021, and July 2021 activity calendars revealed two schedule activities Monday through Friday and no activities were scheduled on the weekend. Five times a month of the activities listed on the calendar during the week were food activities. There was no assessment of Resident #67's need for and benefit from placement on a dementia unit. There was no assessment to identify Resident #67's specific memory care needs. Observation of Resident #67 on 07/27/2021 at 3:27 P.M. revealed she was seated in her chair, the television was on, however she was not watching it. On 07/28/2021 at 8:44 A.M. revealed Resident #67 was seated in a chair in the common area with no activity going on. At 9:48 A.M. Resident #67 was seated in a chair in the common area asleep. At 2:45 P.M. was sitting in the common area, no activity was going on and the resident stated she was bored, there was nothing going on. On 07/29/2021 at 7:54 A.M. sitting at the table in dining room and no activity was provided. Observation on 08/02/2021 at 9:01 A.M. revealed Resident #67 was in a chair, there was no activities, the television was on, and she was asleep. From 10:21 A.M. to 11:22 A.M. she was in a chair not watching the movie that staff played last week and she was asleep. From 2:12 P.M. to 2:17 P.M. there was no staff present in common area, the television was on, but Resident #67 was not paying attention to what was on. Interview of AD #138 on 07/29/21 at 2:15 P.M. revealed Resident # 67 liked physical activities like ball toss, lateral golf, and such. Resident #67 loved trivia and she was very quick witted. Resident #67 loved to do anything and participated in everything. AD #138 stated Resident #67 had not been participating in activities like she used to, but she did not know why. AD #138 confirmed there were scheduled activities Monday through Friday two times a day and the weekend was an activity cart. AD #138 stated the food activities listed on the calendar consisted of staff passing out food to the residents. AD #138 stated The Haven did not on have an activity cart, but The Haven, had coloring pages, crayons, colored pencils, and other individual activities pages for use on the unit. AD #138 stated it was just her and an activity aide. AD #139 now handles resident visitation. The State Tested Nursing Assistants (STNA) on the unit as well as the Chaplin helped with activities twice a week. AD #138 revealed one to one visits lasted from five to ten minutes. AD #138 stated on Tuesdays and Fridays she conducts the group activities. AD #138 confirmed there was not a whole lot of activities on The Haven. AD #138 revealed prior to 2018 she was responsible the activities and memory care on The Haven since then she had less time to spend on The Haven and she had less time to address memory care. Interview of STNA #202 on 07/29/21 at 1:02 P.M. revealed Resident #67 was offered activities daily like BINGO and corn hole. STNA #202 revealed Resident #67 was sleeping more lately and not participating in activities like she used to Interview of the Administrator on 08/03/2021 at 11:38 A.M. revealed Comfort Matters was the program used on The Haven. Comfort Matters was used to provide residents on The Haven with memory care and included items that were individualized for the residents who lived on The Haven and were used by staff to provide the memory care the resident needed. The Administrator confirmed this was not completed for Resident #67. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 21 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review and interview, the pharmacy failed to ensure controlled drug records were maintained and periodically reconciled for accuracy. This affected one (Resident #52) of two residents reviewed for controlled substances. The census was 74. Findings include: Medical record review revealed Resident #52 was admitted on [DATE] with diagnoses including complex regional pain syndrome I, osteoarthritis, and a history of COVID-19. Review of the electronic Medication Administration Record (eMAR) dated July 2021 revealed Resident #52 was administered Ultram 50 milligrams (mg) three times a day and Lyrica 75 mg twice a day for pain. The medications were documented as administered on 07/11/21. Review of the Individual Certificate of Disposition for Control Drugs dated 07/05/21 through 07/13/21 revealed Ultram was administered at 8:00 A.M. and 12:06 P.M A single dose of Ultram 50 mg was documented as wasted/refused on 07/11/21 with no time documented. There was no account of the evening/8:00 P.M. dose on the disposition form. Review of the Individual Certificate of Disposition for Control Drugs dated 07/05/21 through 07/13/21 revealed a single dose of Lyrica 75 mg was administered on 07/11/21 at 8:00 A.M There was no account of the evening dose on the disposition form. Review of the policy: Controlled Substance Count dated November 2014 revealed shift counts are conducted by the on-coming nurse and the off-going nurse to verify the inventory of the controlled substances, accuracy of the documented count and release of the off-going nurse responsibility for the controlled substances. All narcotic discrepancies in the end-of-shift count must be resolved at the time discovered (if found during end of shift count) and documented on the report form. Licensed nurses should never accept a shift count that is inaccurate or incomplete. On 07/28/21 at 12:29 P.M., review of the controlled substance cards and sheet records with the Director of Nursing (DON) verified the count was inaccurate. The DON stated these records were maintained at the facility and were not sent back or reviewed by the pharmacy. The DON stated it was her responsibility to ultimately ensure accuracy, it was the same nurses who were not completing the form correctly but no one had noticed the errors. 2. Review of the Shift Change Controlled Substance Inventory Count Sheets revealed sheets dated 07/02/21 through 07/08/21 revealed the following: On 07/03/21, Resident #52 received 15 Lyrica and 22 tramadol (Ultram) that was sealed in one bag. This was counted as one card/container and two count sheets after the above medications were returned to the facility when the resident returned for a leave of absence (LOA). There was no documented evidence the medications returned were actually the medications given to the resident when signed out for the LOA but then returned prior to using any of the medication. On 07/28/21 at 11:32 A.M., interview with the DON verified the above medications were dispensed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 22 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some into a white envelope and labeled for the resident's family for her LOA; however, the family decided to bring the resident back. The nurse should have destroyed the returned controlled medications with another nurse but instead listed a bulk number on the count sheet. The DON verified the above controlled drug records and reconciliation forms were not accurate and ultimately it was her responsibility to ensure compliance. Review of the policy: Narcotic Count dated 2002 revealed to keep and maintain an accurate count of narcotics. This is completed by the off-going and on-coming shifts counting narcotics. Review of the policy: 6.0 General Dose Preparation and Medication Administration revised 01/01/13 revealed to administer medications within timeframes specified by facility policy. Document the administration of controlled substances in accordance with applicable law. Review of the policy: Inventory Control of Controlled Substances dated 2017 revealed a facility representative should regularly check the inventory records to reconcile inventory. Facility should regularly reconcile current and discontinued inventory of controlled substances to the log used in facility's controlled medication inventory system. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 23 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 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 and staff interview the facility failed to ensure an identified drug irregularity was addressed by the physician that included the rational for rejecting the recommendation. This affected one of six sampled residents (Resident #67) reviewed for unnecessary medications. Findings include: Review of Resident #67's medical record revealed she was admitted [DATE] with diagnoses that included: senile degeneration of brain, palliative care. dementia without behaviors, essential hypertension, insomnia, malignant neoplasm of breast, anxiety, and over active bladder. Review of Resident #67's admission Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #67's speech was clear, she made herself understood, she understands others, her cognition was severely impaired, and she had minimal depression. Resident #67 had delusions, other behaviors that occurred one to three days during the assessment period that did not impact her or other residents care, and she wandered four to six days during the assessment period. Resident #67 required limited assistance of one staff for bed mobility, to transfer, to walk, and for locomotion on the unit. Resident #67 used no alarms. Review of Resident #67's quarterly MDS dated [DATE] revealed the following changes. Resident #67 had physical behaviors and other behaviors one to three days during the assessment period, and she wandered one to three days during the assessment period. Resident #67 required extensive assistance for bed mobility, to transfer, to walk, and for locomotion. Resident #67 used a bed and chair alarm daily Review of Resident #67's physician orders revealed the following: two antianxiety medications (buspirone 10 milligrams (mg) two times a day and Ativan 0.5 mg two times a day), a sleep inducing medication (Restoril 15 mg at bedtime), and an antipsychotic medication (Zyprexa 2.5 mg one time a day). Review of Resident #67's 05/20/2021 monthly drug regimen review revealed recommendation to change Restoril to as needed with a duration of 90 days. This recommendation was not accepted and no rational was provided as to why it was declined. Interview of the Director of Nursing on 08/03/2021 at 9:07 A.M. confirmed no rational was provided as to why the Restoril recommendation was not attempted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 24 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 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** 2. Review of Resident #67's medical record revealed she was admitted [DATE] with diagnoses that included: senile degeneration of brain, palliative care. dementia without behaviors, essential hypertension, insomnia, malignant neoplasm of breast, anxiety, and over active bladder. Review of Resident #67's admission Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #67's speech was clear, she made herself understood, she understands others, her cognition was severely impaired, and she had minimal depression. Resident #67 had delusions, other behaviors that occurred one to three days during the assessment period that did not impact her or other residents care, and she wandered four to six days during the assessment period. Resident #67 required limited assistance of one staff for bed mobility, to transfer, to walk, and for locomotion on the unit. Resident #67 used no alarms. Review of Resident #67's quarterly MDS dated [DATE] revealed the following changes. Resident #67 had physical behaviors and other behaviors one to three days during the assessment period, and she wandered one to three days during the assessment period. Resident #67 required extensive assistance for bed mobility, to transfer, to walk, and for locomotion. Resident #67 used a bed and chair alarm daily Review of Resident #67's physician orders revealed an antipsychotic medication (Zyprexa) 2.5 mg one time a day for dementia. Interview of the Director of Nursing on 08/03/2021 at 9:07 A.M. confirmed Resident #67 did not have an appropriate indication for the use of an antipsychotic medication. Based on medical record review and staff interview, the facility failed to provide adequate justification for the use of anti-psychotic medications. This affected two (Residents #10 and #67) of six residents reviewed for unnecessary medications. The census was 74. Findings Include: 1. Record review revealed Resident #10 was admitted to the facility on [DATE]. His diagnoses were Alzheimer's disease, melanoma in right ear, anxiety disorder, dementia with behavioral disturbances, vascular dementia with behavioral disturbances, major depressive disorder, and hemiplegia and hemiparesis. His Brief Interview for Mental Status (BIMS) score was four, which indicated he had a severe cognitive impairment. The assessment was completed on 04/20/21. Review of Resident #10 medical records revealed he was prescribed Zyprexa (since 12/05/17), with dosages changing over time and the justification changing as well. From 04/12/18 to 03/09/21, he was prescribed and administered Zyprexa five milligrams (mg) for vascular dementia with behavioral disturbances. Then, on 03/09/21, the dose was changed to 10 mg for the same justification. According to Resident #10's medical records, he did not have any medical diagnoses to justify the use of an anti-psychotic medication. Interview with Director of Nursing (DON) on 07/29/21 at 1:46 P.M. confirmed that the diagnosis of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 25 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 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 dementia is not a justification for using an anti-psychotic medication. She confirmed that they will have to review all those that have been prescribed an anti-psychotic (or any psychotropic medication) to ensure that they are being used for appropriate reasons; including Resident #10. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 26 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, medication administration guidance review, policy review, and interview, the facility failed to ensure a medication error rate was not 5% or greater. There were 32 opportunities for error with three actual errors resulting in a 9.38 % medication error rate. This affected three (Resident #15, #30 and #59) of five residents observed during medication administration. The census was 74. Residents Affected - Few Findings include: 1. Medical record review revealed Resident #15 was admitted on [DATE] with diagnoses including malignant neoplasm of the brain and major depressive disorder. Review of the electronic Physician Orders dated July 2021 revealed to administer Potassium Chloride (KCL) 20 miliequivalents (mEq) extended-release twice a day for hypokalemia (low potassium level). On 07/27/21 at 3:29 P.M., observation revealed Licensed Practical Nurse (LPN) #119 placed a KCL extended-release 20 mEq in 15 ml of water in a medication cup, dissolved the tablet which formed into a slurry and mixed it with chocolate pudding. LPN #119 then entered Resident #15's room and spooned the medication into the residents mouth. LPN #119 verified the above at the time of the preparation and observation. Review of Medscape revised 2021 revealed do no crush, chew or suck on a KCL tablet or capsule. 2. Medical record review revealed Resident #30 was admitted on [DATE] with diagnoses including diabetes mellitus. Review of the electronic Physician Orders dated July 2021 revealed to administer 12 units of Aspart (Novolog) three times a day at 7:00 A.M., 12:00 P.M. and 5:00 P.M On 07/29/21 at 8:37 A.M., observation revealed LPN #155 administered 12 units of Aspart (Novolog) subcutaneous in the left lower quadrant of Resident #30's abdomen. At the time of the observation, the resident stated she had already eaten breakfast earlier. Review of the meal Serving Times revealed residents on the Pleasant View was served their breakfast at 7:25 A.M. Review of the Aspart (Novolog) Manufacturer guidance revealed Insulin Aspart (Novolog) should be administered subcutaneous within five to 10 minutes before a meal. 3. Medical record review revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including epilepsy and cerebral infarction. Review of the electronic Physician Orders dated July 2021 revealed Resident #59 was to receive aspirin 325 mg daily. On 07/29/21 at 8:48 A.M., observation of Resident #59's medication administration revealed LPN #155 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 27 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 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 Level of Harm - Minimal harm or potential for actual harm administered medications including aspirin enteric-coated 325 milligrams (mg) to Resident #59. LPN #155 verified the above at the time of the observation. Review of the policy: 6.0 General Dose Preparation and Medication Administration revised 01/01/13 revealed to administer medications within timeframes specified by facility policy. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 28 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure documentation in a resident's record was accurate. This affected one of 18 sampled residents (Resident #22). Findings include: Review of Resident #22's medical record revealed she was admitted on [DATE] with diagnoses that included: Alzheimer's disease, dementia without behaviors, hypertensive chronic kidney disease, hyperlipidemia, type two diabetes, stage four kidney disease, obesity, peripheral vascular disease, hypomagnesemia, polyosteoarthritis, and major depressive disorder single episode. Review of Resident #22 annual minimum data set (MDS) dated [DATE] revealed the following. Resident #22's speech was clear, she was usually understood, and she usually understands others, her cognition was severely impaired. Resident #22 had minimal depression, had delusions, other behaviors one to three days during the assessment period that did not impact the resident or other residents, she did not reject care, and she wandered. Resident #22 required extensive assistance of one staff for bed mobility, to transfer, to walk in room, to walk in corridor, for locomotion on the unit, used a walker and a wheelchair for locomotion. Resident #22 had a history of falls and she did not use alarms. Review of Resident #22's progress notes dated 08/01/2021 revealed on 07/30/2021 Resident #22 had a fall. The note stated the resident's bed sensor alarm was working properly to alert the staff of Resident #22's needs. Interview of Registered Nurse (RN) #165 on 08/02/2021 at 9:00 A.M. confirmed Resident #22 did not use a sensor alarm when she was in bed. Interview of the Director of Nursing on 08/03/21 on 9:45 A.M. confirmed the documentation regarding Resident #22 using a sensor alarm was inaccurate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 29 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, hospice contract review, and medical record review the facility failed to maintain hospice communication in the resident's medical record. This affected one of one sampled resident's (Resident #67) reviewed for hospice. Findings include: Review of Resident #67's medical record revealed she was admitted [DATE] with diagnoses that included: senile degeneration of brain, palliative care, dementia without behaviors, essential hypertension, insomnia, malignant neoplasm of breast, anxiety, and over active bladder. Review of Resident #67's quarterly Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #67's speech was clear, she made herself understood, she understands others, her cognition was severely impaired, and she had minimal depression. Resident #67 was on hospice. Review of Resident #67's medical record revealed there were no hospice notes available for review. Interview of the Director of Nursing on 08/02/2021 at 1:30 P.M. revealed the hospice notes were not available in the facility when they were requested. Review of the facility's hospice contract dated 03/08/2021 revealed hospice services would be documented in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 30 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 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, medical record review, policy review and interview, the facility failed to follow acceptable infection control practices during a dressing change. This affected one (Resident #47) of one resident observed for a dressing change. The facility census was 74. Residents Affected - Few Findings include: Medical record review revealed Resident #47 was admitted on [DATE] and readmitted on [DATE] with diagnoses including a Stage II pressure ulcer to the right heel and osteomyelitis. Review of the electronic Physician Orders dated 07/26/21 revealed daily treatments to the right heel included the following: cleanse right heel with soap and water then saline wound wash, pat dry, apply the ordered dressing, cover with gauze then wrap with kerlix. On 07/29/21 between 2:20 P.M. and 2:41 P.M., observation of Licensed Practical Nurse (LPN) #123 complete Resident #47's right heel dressing change revealed the following: LPN #123 gathered supplies, washed her hands, applied gloves, and placed a clean towel on the bed under the resident's foot. LPN #123 removed the pressure relieving boot from the resident's right foot, reached in her pocket, pulled out a pair of scissors, cut the soiled dressing off and put the scissors back in her pocket. The bandage scissors were not cleaned prior to or after cutting off the resident's dressing. LPN #123 removed and donned new gloves, lifted the resident's foot off the towel and bloody drainage was observed on the towel. The wound was cleansed as ordered and then LPN #123 placed the resident's cleansed heel back on the soiled towel. LPN #123 changed gloves without washing her hands, applied the treatment, gathered supplies and placed the soiled items in a trash bag. LPN #123 rearranged the resident's linens, opened the curtain and door, walked down the hall and placed the trash bag in the soiled linen closet. The above observation was then verified by LPN #123. Review of the undated Procedure for Clean Dressing Treatment revealed hands were to be washed prior to donning gloves and after removal of gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 31 of 32 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 366001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmar Place Rehab & Extended Care 401 Harmar Street Marietta, OH 45750 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. 2. The following observations were made on The Haven (the dementia unit): Observation of Resident #22 on 07/27/2021 at 8:48 A.M. revealed she was seated in a wheel chair in a common area. The covering on the arms of Resident #22's wheel chair were cracked exposing foam. Observation of Resident #48 on 07/26/21 at 3:43 P.M. revealed the covering on foot rest on the recliner chair Resident #48 was sitting in was cracked exposing the foam and wood support. Observation of Resident #67 on 07/27/21 at 10:02 A.M. revealed the chair Resident #67 was sitting in had ripped and torn upholstery on the sides and back. Interview of the Administrator on 08/03/21 at 9:40 A.M. confirmed the observations of the furniture on the Haven. Based on observations and staff interview, the facility failed to maintain a living environment free from needing repair. This affected seven (Residents #5, #7 #19, #22, #47, #48, and #67) of 74 residents in the facility. Findings Include: 1. Observations on 07/27/21 between 10:30 A.M. and 11:00 A.M. revealed the following issues in Resident #5, Resident #7, Resident #19, and Resident #47 rooms: chunks of dry wall missing from the wall behind Resident #5 and Resident #47 door (cased by the door handle), and large black marks and chunks of dry wall missing from the back wall of Resident #7 and Resident #19 room. Interview with Maintenance Staff #108 on 08/02/21 at 4:50 P.M. confirmed the chunks of drywall missing in all four resident's rooms. He stated the facility uses an electronic maintenance system to report and confirm work completed. He confirmed all staff have access to it, and items that need to be fixed in the rooms could/should be reported by the direct care staff; the maintenance staff are not in each resident's room each day. Depending on the item that needs to get fixed will dictate the length of time it takes to get a project fixed. Holes in the wall could be anywhere from a few hours to a couple days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 32 of 32