Inspection·July 31, 2023

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy titled Determining Resident's Preferences and Choices (dated 09/04/18) revealed it was the policy of the facility that a resident's reasonable preferences for everyday living and daily choices should be honored, when possible. The intent of the policy and procedure was to obtain information regarding the resident's preferences for his or her daily routine and activities. This is best accomplished when the information is obtained directly from the resident or through family or significant other, or staff interviews if the resident cannot report preferences. A resident's preferences should be obtained at the time the resident moves to the community, or shortly thereafter. The inter-disciplinary care team will incorporate the results of the resident preferences into the resident's care plan. The results of the resident's preferences will be maintained in the resident's electronic health record. Event ID: Facility ID: 366001 If continuation sheet Page 2 of 30 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 07/31/2023 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, interview, and policy review the facility failed to ensure transfer information was documented in the resident's medical record. This affected one resident (#75) of one reviewed for hospitalization. Findings included: Closed medical record review revealed Resident #75 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of large intestine, abdominal aortic aneurysm, dysphagia, stage two pressure ulcer, cachexia cancer, kidney failure, respiratory failure, congestive heart disease, atrial fibrillation, and sleep apnea. Review of progress notes dated 05/12/23 revealed the Nurse Practitioner was visiting and noticed a large amount of blood from the rectum. New orders were received to send the resident to the emergency room. Report was called to the emergency room and the resident's son was notified. Further review Resident #75's medical record revealed no documented evidence the required transfer information was provided to the hospital. The resident did not return to the facility. Interview on 07/27/23 at 10:36 A.M. with Registered Nurse (RN) #178 confirmed there was no documented evidence the required information was communicated to the hospital for a safe transfer. Review of the facility policy titled Admission/Transfer/Discharge Criteria Policy (dated 11/01/26 and revised 04/22) revealed the purpose of the policy was to ensure residents have a safe transition of care. To ensure a safe transition of care, documentation of all discharge/transfer may include but would not be limited following: reason for transfer by the physician, contact information of the practitioner responsible for the care, resident representative information including contact information, advance directive information, all special instruction or precautions for ongoing care, care plan goals, history of present illness and past medical history, and appeal rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 3 of 30 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 07/31/2023 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, interview, and policy review the facility failed to ensure residents and/or resident representatives were provided with transfer notice as required for a facility initiated transfer. This affected one resident (#75) of one reviewed for hospitalization. Findings included: Closed medical record review revealed Resident #75 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of large intestine, abdominal aortic aneurysm, dysphagia, stage two pressure ulcer, cachexia cancer, kidney failure, respiratory failure, congestive heart disease, atrial fibrillation, and sleep apnea. Review of progress notes dated 05/12/23 revealed the Nurse Practitioner was visiting and noticed a large amount of blood from the rectum. New orders were received to send the resident to the emergency room. Report was called to the emergency room and the resident's son was notified. Further review of Resident #75's medical record revealed no documented evidence the required transfer information was provided to the resident or the resident's representatives. The resident did not return to the facility. Interview on 07/27/23 at 10:36 A.M. with Registered Nurse (RN) #178 confirmed the resident nor the residents representative was provided a copy of the transfer notice in writing they could understand. Review of the facility policy titled Admission/Transfer/Discharge Criteria Policy (dated 11/01/26 and revised 04/22) revealed the purpose of the policy to ensure the residents have a safe transition of care. The resident and/or resident representative would be notified of the transfer and the reason of the transfer in writing. The information would include the specific reason for transfer, date, location of transfer, state entity contact information, information on how to request a appeal hearing, and information on obtaining assistance in completing and submitting the appeal hearing request. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 4 of 30 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 07/31/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #4 revealed an admission date of 06/17/23 and a diagnosis of fracture of right femur (prior to admission). Residents Affected - Few Review of a Minimum Data Set (MDS) assessment completed 06/23/23 revealed a Brief Interview for Mental Status score of 13, indicating intact cognition. The MDS further indicated the resident required extensive assistance from one staff for transfers, walking, locomotion, personal hygiene, and bathing. Review of the plan of care dated 06/18/23 revealed Resident #4 had an activities of daily living self care performance deficit related to recent right femur fracture. It stated the resident required limited to extensive assistance from staff with hygiene. Interview with Resident #4 on 07/25/23 at 10:50 A.M. revealed she needed her nails clipped and filed. She stated she had only had one shower since admission and nail care was not provided with the shower. She stated she had nails that were long and jagged. Observations on 07/25/23 at 10:50 A.M. revealed Resident #4's fingernails to be long and two of them were jagged on the ends. Interview with Registered Nurse #198 on 07/25/23 at 12:20 P.M. revealed she did not think that any nail care provided to residents was documented when provided. Interview with Licensed Practical Nurse #155 on 07/25/23 at 1:00 P.M. confirmed Resident #4's nails needed trimmed and filed. Based on record review, review of the facility's shower schedules, observation, resident interview, staff interview and policy review, the facility failed to ensure residents who were dependent on staff for personal care received the assistance they needed with washing their hair and trimming their fingernails. This affected two residents (#4 and #129) of two residents reviewed for activities of daily living. Findings include: 1. A review of Resident #129's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included congestive heart failure, chronic neck/ back pain, and neuropathy. A review of Resident #129's care plans revealed he had an activities of daily living (ADL's) self care performance deficit that was initiated on 07/20/23. The care plan interventions indicated he was to have a bed bath, until cleared to shower, two to three times a week in the afternoon. He required a one to two person assist with bathing. A review of Resident #129's Kardex (care information used by the aides to identify the level of care required by each resident) revealed the resident preferred bed baths (until released to shower). The Kardex indicated the resident would would ask staff when he wanted a bed bath. Under ADL's, it indicated he was to have bed baths, until he was cleared to shower, two to three times a week, in the afternoon. It also identified him as needing a one to two person assist with bathing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 5 of 30 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 07/31/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident #129's bathing documentation under the task tab of the electronic health record (EHR) revealed there were not any bathing activities documented as having been provided to the resident since his admission to the facility on [DATE]. A review of the shower schedule for the rehabilitation unit revealed Resident #129 was listed as being a bed bath, but did not have any specified days. The schedule indicated the resident would ask when he wanted a bed bath. On 07/25/23 at 1:09 P.M., an interview with Resident #129 revealed he was okay with receiving bed baths until he was cleared to take showers. He indicated he was still too weak to stand to be able to get into the shower. His only concern with the bed baths he was receiving was that the staff did not wash his hair on the days he received the complete bed bath. He denied he has had his hair washed since he had been in the facility (six days ago). On 07/25/23 at 1:13 P.M., an interview with Licensed Practical Nurse (LPN) #197 revealed receiving bed baths was Resident #129's preference. She had not seen him working a whole lot with therapy, so she was not sure if he was able to get up for a shower or not. Therapy would be the one's to clear him to receive showers as soon as he was strong enough to safely do so. She was not sure how often the resident was to receive a complete bed bath, but indicated it should include the washing of his hair. She verified there was not any documentation under the task tab of the EHR to show any type of bathing activity had occurred for the resident since his admission on [DATE]. She reported the documentation they did have only included his morning and evening care when partial bed baths were given each day. She denied they would have washed his hair as part of those partial bed baths (A.M./P.M. care). She acknowledged it would be better to have the resident on a set schedule to receive complete bed baths instead of leaving it up to him to ask for them when he wanted. He may be reluctant to ask staff for assistance or be the type that did not want to be a bother to them. On 07/25/23 at 1:22 P.M., an interview with State Tested Nursing Assistant (STNA) #157 revealed that was the first day she had worked on Resident #129's unit that week, since he had been there. She typically worked on another unit. She indicated the resident preferred to receive bed baths, but was not sure what day he was to receive them. They typically had a shower list to go by to know when a resident was scheduled for a shower. She denied they had a shower scheduled for the rehabilitation unit (where the resident resided), like they did for the other units, until that day. She indicated the residents come and go on the rehabilitation unit, so it was difficult to keep a list up to date. They just went by the residents' preferences. She acknowledged they could have a shower schedule based on room numbers and adjust if a resident's preference was to receive more than two bathing activities each week. She confirmed they had wash basins in the shower room that could be used to wash the resident's hair. On 07/26/23 at 8:15 A.M., a follow up observation of Resident #129 noted him to have freshly washed hair that was still wet and neatly combed. He was appreciative of having his hair washed and reported he felt much better since having it done. A review of the facility's policy on bed baths that originated in 2002 revealed the procedure guide did not instruct the staff to wash a resident's hair as part of the bathing activity. It only mentioned hair care, in addition to oral care and nail care, but was not specific to actually washing the resident's hair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 6 of 30 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 07/31/2023 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #12 revealed an admission date of 10/31/22 with diagnoses including dementia, diabetes, and peripheral vascular disease. Residents Affected - Few A social service note on 11/04/22 stated there were no communication issues. Review of a Minimum Data Set (MDS) assessment completed 11/07/22 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. A MDS on 12/30/22 revealed the resident had minimal difficulty hearing and did not have hearing aides. A MDS on 06/03/23 revealed a BIMS score of 11, indicating moderately impaired cognition. It again indicated minimal difficulty with hearing. Observations during the lunch meal on 07/24/23 at 12:22 P.M. revealed staff to deliver Resident #12's meal to her room. The resident was having a lot of trouble hearing Nursing Assistant #147 when she was telling the resident what she was having for lunch, even when adjusting the tone of her voice louder. Nursing Assistant #147 stated the resident has a lot of trouble hearing and she was not aware of the resident having any hearing aides. Observations on 07/26/23 at 7:48 A.M. revealed staff to deliver Resident #12's breakfast tray to her room. The staff person was walking in a loud voice so that the resident could hear her. Interview with Resident #12 on 07/26/23 at 8:45 A.M. revealed she felt she had an increase in difficulty hearing since admission to the facility. She stated she felt she needed her hearing tested to see if she needed hearing aides. Interview with Licensed Practical Nurse #196 on 07/26/23 at 8:19 A.M. confirmed Resident #12 was hard of hearing. She stated she would consider her moderately impaired with hearing. She confirmed you have to elevate your level of voice for her to hear you. Interview with Social Service Designee #168 on 07/26/23 at 1:15 P.M. confirmed Resident #12 has difficulty hearing. She confirmed staff have to adjust their voice level to converse with the resident. She stated the company they use for hearing evaluations had not been at the facility since August 2022 and were not coming again until September 2023. She stated the resident's concern with hearing had not been brought up to her. She stated she would need to contact the resident's daughter to have her seen for a hearing evaluation. Based on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure residents received audiology/optometry services timely when needed. This affected two residents (#12 and #50) of two residents reviewed for vision/ hearing. Findings include: 1. Medical record review revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus and vision impairment. A review of Resident #50's ancillary service consent form dated 05/25/23 revealed the resident consented to receive optometry services from the facility's contracted optometrist while residing in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 7 of 30 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 07/31/2023 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 0685 facility. Level of Harm - Minimal harm or potential for actual harm A review of Resident #50's five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed resident's vision was adequate with the use of corrective lenses. Residents Affected - Few A review of Resident #50's active care plans revealed the resident had impaired vision function related to not having her eyes dilated for quite some time and her prescription had changed. A review of Resident #50's current orders dated 07/2023 revealed orders for optometrist consult as needed. A review of Resident #50's social service notes revealed on 05/25/23 the resident had glasses but was in the need of new ones. The resident had a strong support system and access to healthcare. Interview on 07/24/23 at 10:17 A.M., with Resident #50 revealed her son had asked the facility on admission to arrange an appointment for her to see the ophthalmologist because she had some vision changes and has not had new glasses for 15 years. The facility still has not made the arrangements. Interview on 07/25/23 at 2:40 P.M., with Social Service Designee #168 revealed the ophthalmologist was just at the facility on 05/18/23 and would not be back until 08/03/23, however the resident was not on the list to be seen in August, 2023. Interview on 07/25/23 at 3:52 P.M. and 07/26/23 at 9:10 A.M. with Licensed Practical Nurse (LPN) #201 revealed she was not aware Resident #50 had requested to see the ophthalmologist and would go talk to her now and arrange an appointment. The resident had agreed to see an optometrist outside the facility. Review of the facility policy titled Optometry Services (undated) revealed for the convenience of our residents, we had identified an optometrist who was licensed to practice optometry in the State of Ohio, and who was available to provide services to our residents in their attending physician determines they have a need for optometry services. If such services were needed, the resident can elect to receive services from this optometrist or one of your own choosing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 8 of 30 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 07/31/2023 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident #58's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, dementia with agitation, unspecified psychosis, major depressive disorder, restlessness and agitation, peripheral vascular disease, and osteoarthritis. Residents Affected - Few A review of Resident #58's care plan, dated 12/28/21 revealed she had a care plan in place for being at risk for an alteration to skin integrity related to bladder incontinence, impaired cognition, and poor safety awareness. The goal was for her to have no new areas of skin breakdown. The interventions included skin inspections, preventative treatments as ordered, keep bony prominences from direct contact, encouraging/ assisting her with turning and repositioning with routine nursing rounds and as needed (PRN) for comfort as tolerated or as she would allow. Pillows were to be used to maintain positioning. A review of Resident #58's quarterly pressure ulcer risk assessment dated [DATE] revealed the resident was assessed as being a high risk for pressure ulcers. Her risk factors included having a very limited sensory perception, her skin being very moist, being chair fast, having very limited mobility, and a problem with friction and shearing. The comments in the assessment indicated the resident was a two to one maximum assist to transfer. Preventative interventions/treatments were indicated to be in place. There were no additional quarterly pressure ulcer risk assessments completed after the assessment on 01/04/23. A review of Resident #58's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech. She was sometimes able to make herself understood and was sometimes able to understand others. She had short and long term memory impairment and her cognitive skills for daily decision making was moderately impaired. She displayed verbal behaviors directed at others and other behaviors not directed at others. She was not known to reject care during the assessment reference period of the past seven days. The resident required an extensive assist of two for bed mobility, transfers, and toilet use. Ambulation did not occur. She was always incontinent of her bowel and bladder and was at risk for pressure ulcers, but did not have any unhealed pressure ulcers at the time the assessment was completed. A review of Resident #58's weekly skin assessments revealed the skin inspections were being completed as per the plan of care through 07/01/23. There was no skin assessment completed on 07/08/23, as it should have been. The skin assessments skipped from 07/01/23 to 07/15/23. The skin assessments showed the resident was first noted to have a pink area to her right hip/ bony prominence beginning on 05/20/23. That assessment did not include any measurements of the red area noted to her right hip, nor did it indicate if the pink area was blanchable or not. There was no indication what the pink area was classified as as the type indicated on the assessment was other. The skin assessment defined a Stage I pressure ulcer as intact skin with non-blanchable redness of a localized area usually over a bony prominence. The assessment indicated they did not recognize the red area as pressure and an ulcer tracking tool was not initiated. The comments under the assessment indicated the right hip/ bony prominence was noted to be pinkish with skin intact in the area of her previous right hip surgery. A new order was initiated for Mepilex (foam dressing) to be applied to the area as a preventative measure. Weekly skin assessments through 06/10/23 continued to mention the area to the resident's right hip describing it as a slight pink area each week it was assessed. None of those assessments indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 9 of 30 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 07/31/2023 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 0686 whether the slightly pink area blanched or not, nor did they include measurements to see if the pink area was increasing in size. They continued the same treatment initiated on 05/20/23 as a preventative measure. Level of Harm - Actual harm Residents Affected - Few A weekly skin assessment dated [DATE] revealed Resident #58 was noted to have a scabbed area to her right hip. It measured 0.3 centimeters (cm) in length x 0.2 cm in width x 0.1 in depth. The area was described under type as other and was not identified as a pressure ulcer with any staging indicated. Subsequent weekly skin assessments completed through 07/15/23 continued to mention the scabbed area to her right hip classified under type as other with no identification as a pressure ulcer or staging. It measured 0.9 cm x 0.5 cm with no depth recorded when measured on 07/15/23. It was not until a skin assessment was done on 07/22/23 that the resident's area to her right hip was assessed as an Unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer was covered by slough (yellow, tan, gray, green, or brown) and/ or eschar (tan, brown, or black) in the wound bed. A review of Resident #58's nurses' progress notes dated 06/29/23 revealed a nurse's note at 3:33 A.M. that indicated the resident was noted to have a scabbed area to her right hip that measured 1 cm in circumference with a dark scab in the center and yellow slough surrounding. The surrounding tissue was pink to extend the total area to about a 3 cm circle. Scant dark exudate (drainage) was noted on the existing dressing. The nurse cleansed it with in house wound cleanser, patted it dry, and placed a Mepilex dressing on it (as was previously ordered as a preventative treatment. The nurses' progress notes did not provide any documented evidence of the physician or hospice being notified of the deteriorating area to her right hip, that met the definition of an Unstageable pressure ulcer. A review of an interdisciplinary team (IDT) note dated 07/13/23 at 2:41 P.M. revealed the IDT met to discuss Resident #58's fall preventions due to changes in her condition, but did not discuss anything about the deteriorating wound she had on her right hip that was then an Unstageable pressure ulcer. The nurses' progress notes were absent for any further documentation pertaining to the area on Resident #58's right hip until a nurse's note dated 07/22/23 at 8:58 P.M. that indicated during a routine skin assessment the Mepilex dressing was removed from her right hip. The previous scabbed area was then noted to be open with slough to wound bed. A treatment was completed as ordered (same treatment initiated on 05/20/23 as a preventative treatment). A message was left for the hospice nurse to return a call and, when the call was returned, the hospice nurse was notified. New orders were received at that time for the resident to avoid lying on her right side. They were to turn her every two hours from her back to her left side due to the pressure ulcer on her right hip. A new treatment order was given for the pressure ulcer to her right hip to include the use of a wet to dry dressing daily and PRN until healed. The physician was not notified of the resident's Unstageable pressure ulcer to her right hip until 07/24/23 at 11:41 A.M. The progress notes indicated they were awaiting a response, but the response was not documented as having been received. A review of Resident #58's ulcer tracking tool for a pressure ulcers revealed an ulcer tracking tool was not initiated for the resident for any pressure ulcers until 07/22/23. The ulcer tracking tool identified the resident as having an Unstageable pressure ulcer to the right hip/ trochanter that measured 4 cm by 4 cm. The date of origin was indicated to be 07/22/23, despite the resident having documentation in her nurses' progress notes as having a wound to her right hip on 06/29/23 that met the definition of an Unstageable pressure ulcer. The assessment indicated the resident had a moderate amount of serosanguinous drainage and the wound bed was covered with white slough. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 10 of 30 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 07/31/2023 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 0686 Level of Harm - Actual harm Residents Affected - Few On 07/24/23 the resident's care plan was updated to reflect she had impaired skin integrity as evidenced by a pressure ulcer to her right hip. The goal was for her to exhibit slow healing of the pressure ulcer as exhibited by development of healthy tissue. The interventions included changing the dressing according to the physician's orders, evaluating the wound daily and monitor it for an intact dressing, signs and symptoms of infection, progress and/or changes, initiate a skin grid to document the size, color, odor, drainage and monitor progress weekly and as needed, protein supplementation as per the physician's orders, provide pressure relief for the affected area, avoid lying on her right side while in bed, and reposition her every two hours from her back to her left side, while lying in bed. On 07/27/23 at 10:55 A.M., an interview with STNA #161 revealed Resident #58 had an area to her right hip that had been there for a month or two. She indicated the resident had a hip replacement and had a bony prominence that stuck out on her right hip. The right hip had a red area and normally had a dressing on it. The area was now open and had a different type of dressing on it. She was not sure why the resident had skin breakdown when preventative measures had been in place. On 07/27/23 at 11:00 A.M., an interview with LPN #105 revealed the resident had an area to her right hip. She believed it was classified as a pressure ulcer, but would have to check the medical record to make sure. She too indicated the resident had a bony prominence on her right hip. When she first started working there it had a foam padding over it. She did not think the area was classified or staged as a pressure ulcer when it was first documented as a red area. She was the nurse working on 07/22/23, when the wound to the right hip was found to have the wound bed covered in white slough. She stated she was the one that documented that in the nurses' progress notes. She asked the nurse manager to come and look at it because she was not sure how to document it. It was a 4 cm by 4 cm area at that time. She notified hospice, but was not present when the hospice nurse called back in. Another nurse that came in at 9:00 P.M. would have been the one to speak with hospice and get the new order for treatment. She was not aware of there being a wound on the resident's right hip that had a dark scabbed area in the centered with yellow slough surrounding it as was documented on 06/29/23 in the progress notes. It was not until she discovered the wound on 07/22/23 that she looked back through the nurses' progress notes and seen that was documented on 06/29/23. She confirmed it was not until 07/22/23 that they got new orders for the resident that included an appropriate treatment for an Unstageable pressure ulcer and to turn the resident every two hours from her back to her left side. She was not sure why breakdown occurred with her previous skin prevention interventions in place. She was surprised to find the resident's right hip to have that kind of breakdown in it. She agreed hospice and/ or the resident's physician should have been notified on 06/29/23, when the resident was documented as having a deteriorating skin issue that met the definition of an Unstageable pressure ulcer. She indicated they would have wanted to get a new treatment order that was appropriate for that stage of a pressure ulcer and not continue the same treatment that was initially ordered as a preventative treatment. On 07/27/23 at 2:15 P.M., an interview with the DON revealed she was not able to find any additional information pertaining to the resident's pressure ulcer assessments. She did not see evidence of a more recent pressure ulcer risk assessment being completed after 01/04/23, nor did she find evidence of a weekly skin assessment being completed on 07/15/23. She confirmed the resident's area to her right hip was not assessed as a pressure ulcer, until 07/22/23, when it was identified as an Unstageable pressure ulcer covered with white slough. She did not provide any documented evidence of the redness that was noted to Resident #58's right hip beginning on 05/20/23 being assessed by a nurse for blanching to rule out it being a Stage I pressure ulcer at that time. She also confirmed the nurse that documented the area to the right hip as having had a scabbed center (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 11 of 30 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 07/31/2023 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 0686 Level of Harm - Actual harm Residents Affected - Few with yellow slough surrounding it should have contacted the physician for a new treatment instead of continuing the same preventative treatment that had been previously ordered. She stated the nurse that documented that was an LPN and was not qualified to assess the staging of pressure ulcers. She acknowledged there was no evidence of another nurse assessing the area or a new treatment being initiated until 07/22/23, when the area was again documented in the progress notes and finally being classified as an Unstageable pressure ulcer. She confirmed the area went from a 1 cm by 1 cm scabbed area with dark scabbing in the center and yellow slough surrounding it to a 4 cm by 4 cm Unstageable pressure ulcer with the wound bed being covered with white slough. A review of the facility's policy on pressure ulcers (revised 04/27/22) revealed a resident who entered the facility without a pressure ulcers should not develop pressure ulcers, unless the resident's clinical condition demonstrated that they were unavoidable. The facility was to provide care and services to promote the prevention of pressure ulcer development and promote healing of pressure ulcers that were present. They were to identify residents at risk for development of pressure ulcers by utilizing pressure ulcer risk assessments per the EHR. Those risk assessments were to be completed quarterly. A licensed nurse was to do a visual head to toe assessment of each resident weekly and document the findings in the EHR. 4. A review of Resident #129's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included chronic neck/ back pain, chronic kidney disease, and neuropathy. A review of Resident #129's skin assessment completed upon his admission [DATE] revealed the resident had a Stage two pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red/ pink wound bed, without slough; may also present as an intact or open/ ruptured serum-filled blister) to the left inner buttock that measured 2.3 cm x 3 cm x 0.01 cm. The skin assessment indicated he was not reviewed for a turning and repositioning program. A review of Resident #129's Minimum Data Set (MDS) assessments revealed his Medicare 5-day MDS assessment and admission MDS assessment was still in progress. A review of Resident #129's care plans revealed he had a care plan in place, dated 07/20/23 for being at risk for an alteration in skin integrity. The goal was for him to not have any new areas of skin breakdown. The interventions included the need to turn and reposition him every two hours. His care plans also indicated he had a Stage II pressure ulcer to his left buttock related to immobility, weakness, and deconditioning. This care plan was also initiated on 07/20/23. The goal was for his pressure ulcer to show signs of healing. The interventions included administering treatments as ordered and assisting him to turn/reposition at least every two hours, more often as needed, or requested. The care plan interventions were reflected on the Kardex (information made available to the aides to identify the resident's care needs/ requirements). A review of Resident #129's physician's orders (dated 07/19/23) revealed the resident had a treatment order in place to cleanse the Stage II pressure ulcer to the left inner buttock with soap and water, rinse, pat dry, and apply an Optifoam dressing. Staff were to complete the dressing change one time a day every three days and as needed (PRN). A review of Resident #129's treatment administration record (TAR's) for July 2023 revealed there was no documented evidence of the resident having his treatment provided to the Stage II pressure ulcer on his left inner buttocks on 07/23/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 12 of 30 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 07/31/2023 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 0686 Level of Harm - Actual harm Residents Affected - Few A review of Resident #129's nurses' progress notes revealed there was no evidence of the resident refusing any treatments to his pressure ulcer on the left inner buttock or to support why his treatment was not signed off as having been completed on 07/23/23. Observations of Resident #129 on multiple occasions between 07/25/23 at 10:09 A.M. and 07/26/23 at 7:05 A.M. noted him to always be in bed in a supine position lying on his back with direct pressure to the Stage II pressure ulcer to his left inner buttocks. No pillows were being used for positioning and the resident always had his head of the bed raised and the knee [NAME] on the bed raised putting direct pressure on his buttocks. He was not observed to be placed in a side lying position during any of the observations made. On 07/25/23 at 8:22 A.M., an interview with Resident #129 revealed his treatment had only been completed once by the facility in the seven days he had been at the facility. He reported the treatment that was signed off on the TAR as having been completed on 07/25/23 was the only treatment he received to the pressure ulcer he had on his left buttock. He did not recall them doing a treatment on 07/23/23, when no documentation had been made in the TAR showing it had been. He had denied any of the staff were coming in and assisting him with turning and repositioning every two hours as per his plan of care. He denied he had the strength to physically turn himself in bed and would not oppose them coming in and assisting him with that. On 07/26/23 at 8:30 A.M., an interview with STNA #203 revealed she had only worked at the facility for about a month now. She worked on the rehabilitation unit, where Resident #129 resided, and worked there last Sunday. She was familiar with the resident and thought he would be at risk for pressure ulcers as he did not get up much or walked around. She only knew of him having a mark on his buttocks that was the result of sitting on his bedpan on 07/24/23, but denied it was open. She was not aware of him having any other skin issues, but did not work with him all that often. The resident required an extensive assist with rolling/ turning/ dressing etc. She claimed they did rounds every couple of hours and would ask him if he needed anything. They pulled him up in bed and repositioned him when in there. When she worked last Sunday, they placed a pillow behind his back to help shift the weight off his buttocks. She worked Monday, but was assigned to a different section of the rehabilitation unit. She said she would have helped in his section as well, but could not explain why he was observed in the same position all day on Monday (07/24/23). On 07/26/23 at 8:41 A.M., an interview with RN #183 revealed Resident #129 was at risk for pressure ulcers. She was not sure if he had any existing pressure ulcers and had to check the computer to see if he had any areas. She initially denied he had any pressure ulcers reporting he only had yeast on his scrotum, bruising, and blanchable areas to his bilateral buttocks. She was referring to the skin assessment that was completed on 07/24/23. She then noted that he had a Stage II pressure ulcer to his left inner buttocks. She was asked what they were doing to treat that area and to promote healing. She indicated they were performing a treatment to his left inner buttock according to what was included in his physician's orders. The aides were also turning and repositioning him regularly. She claimed she would check the residents regularly to ensure they were being turned. She would also remind the aides regularly that the residents needed turned. She was not sure why a treatment had not been signed off as having been completed on 07/23/23, when due, or why the resident was observed not to have been turned and repositioned the past couple of days when observations were made. On 07/26/23 at 8:50 A.M., the DON was informed of concerns with Resident #129 not being turned and repositioned every two hours as per his plan of care. She was also informed there was no documentation to support his treatment to the pressure ulcer on his left inner buttocks being completed on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 13 of 30 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 07/31/2023 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 0686 Level of Harm - Actual harm Residents Affected - Few 07/23/23 as ordered. She was not able to provide any additional information to explain why the treatment had not been signed off as having been completed on 07/23/23. She stated she spoke with the RN #183, who was the nurse that worked on 07/23/23, and the nurse was not able to explain why the treatment was not documented as having been completed. The nurse did not provide her any indication that it was completed as ordered. She stated she would also remind the nursing assistants on the need to ensure the resident was being turned and repositioned. She confirmed he had weakness and needed assistance with turning and repositioning. On 07/26/23 at 1:30 P.M., a follow up interview with RN #183 revealed she had been racking her brain to figure out why she did not document the treatment to the resident's left inner buttock being done on 07/23/23. She reported she was the nurse assigned that day. She recalled she went to do the treatment and did not note any open area at that time. She stated it would have been difficult to get a dressing in that area so she just applied moisture barrier cream instead, which was not the ordered treatment. She denied she had documented such or had updated the physician to get a new treatment order, when she decided not to provide the treatment as ordered. She acknowledged the TAR showed the treatment was provided to the resident as ordered on 07/25/23 and there was no evidence it had been healed. Based on observations, medical record review, staff interview, resident interview, and policy review, the facility failed to prevent the development of pressure ulcers and failed to provide the necessary treatment and services to promote healing. Actual harm occurred to Resident #12, who had impaired mobility and required staff assistance for activities of daily living, on 06/02/23 when the resident's in-house pressure ulcer deteriorated to a Stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed) due to a lack of proper interventions ( including repositioning and monitoring of wound vac treatment) being implemented by the facility. Actual harm occurred to Resident #58 on 06/29/23 when the facility failed to identify, assess, and implement the appropriate treatment for a pressure ulcer that started as a Stage I (intact skin with a localized area of non-blanchable erythema (redness) resulting in the ulcer deteriorating to an Unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar). This affected four residents (#3, #12, #58, and #129) of four residents reviewed for pressure ulcers. The facility identified 13 residents with pressure ulcers, six of which were facility acquired. The facility census was 75. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 10/31/22 and diagnoses including dementia, diabetes, peripheral vascular disease, and chronic obstructive pulmonary disease. The plan of care dated 11/01/22 stated the resident was at risk for alterations in skin integrity related to generalized weakness, impaired mobility, and requiring assistance with activities of daily (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 14 of 30 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 07/31/2023 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 0686 Level of Harm - Actual harm Residents Affected - Few living. Interventions included encourage/assist to turn and reposition every two hours as tolerated, or will allow. Use pillow to maintain positioning. A plan of care dated 11/28/22 stated the resident had a current pressure ulcer to the coccyx. It stated to assess/record/monitor wound healing. An admission Minimum Data Set (MDS) 3.0 assessment completed 11/07/22 documented a Brief Interview for Mental Status score (BIMS) of 15, indicating intact cognition. It indicated no pressure ulcers were present. An ulcer tracking tool on 02/21/23 identified the resident as having a Stage II (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister) pressure ulcer on the coccyx measuring 1.2 centimeters (cm) by 0.4 cm by 0.1 cm deep. The resident began being seen by the wound center on 02/24/23. On 02/24/23 the wound center described the wound as a Stage III (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) pressure ulcer of the coccyx measuring 2.1 x 1 x 0.3 cm. The date acquired was listed at 12/24/22. The area was debrided. The wound center recommended turning the resident every two hours and keep turned on her left and on her right as much as possible. On 05/04/23 the pressure ulcer continued as Stage III measuring 0.3 by 0.3 by 0.5 cm. At that time, a PICO Single use negative pressure wound therapy system was ordered with dressing to be changed weekly. It stated a PICO education sheet was sent on 05/04/23. A quarterly MDS 3.0 assessment on 06/02/23 documented a BIMS of 11, indicating moderately impaired cognition. It indicated the resident required extensive assistance from two staff for bed mobility and toilet use. It indicated the resident was totally dependent upon staff for transfers and hygiene and was always incontinent. It indicated the resident had a Stage III pressure ulcer which was not present upon admission. On 06/02/23 the wound center now described the pressure ulcer as a Stage IV measuring 0.3 by 0.2 by 0.4 cm. and the treatment was changed with the PICO wound therapy system being discontinued. On 06/23/23 the wound center described the pressure ulcer as a Stage IV measuring 0.3 by 0.4 by 0.2 cm. The PICO wound therapy system was re-ordered with dressing to be changed weekly. On 07/18/23 the Stage IV pressure ulcer measured 0.5 by 0.2 by 0.4 cm. with bone visible per the wound center. The PICO wound therapy system continued with changing weekly and there were continued recommendations to turn every two hours and keep turned on left and right as much as possible. However, review of facility ulcer tracking tools revealed on 07/18/23 the facility was still categorizing the pressure ulcer as a Stage III and had measurements of 0.5 by 0.3 by 0.2 (which did not match the wound center measurements). Observations on 07/24/23 at 8:58 A.M. and 10:45 A.M. revealed Resident #12 to be in bed on her back. On 07/25/23 at 10:12 A.M., 10:58 A.M., 12:16 P.M., 1:48 P.M., and 3:30 P.M. the resident was in bed on her back. Interview with Resident #12 on 07/26/23 at 8:45 A.M. revealed she stated she was not always turned (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 15 of 30 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 07/31/2023 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 0686 and repositioned as she should be. She stated she was not turned/repositioned the day before. At that time, she was positioned on her right side. Level of Harm - Actual harm Residents Affected - Few Interview with Nursing Assistant #115 on 07/26/23 at 10:35 A.M. revealed Resident #12 needed staff assistance with repositioning. She stated the resident was cooperative with turning on 07/25/23 but they had only used one pillow under her side instead of two, as they were using on 07/26/23. She stated the resident had asked for two pillows to be used for positioning on 07/26/23. Interview with Licensed Practical Nurse (LPN) #196 on 07/26/23 at 10:40 A.M. revealed she did not know why the resident was not being positioned on her sides instead of just putting a pillow under her with the resident still appearing to be laying on her back. She stated the resident needed to be turned onto her sides every two hours. Observations of Resident #12's PICO wound therapy system on the coccyx on 07/26/23 at 10:20 A.M. revealed the PICO power pump had no lights on to indicate it was functioning properly and the tubing was going under the resident with a potential for pressure to be blocked or to cause pressure to the resident's skin. This was confirmed by LPN #196. She stated that she had not received any training on the PICO wound therapy system and thought there was an audible alarm to alert staff if it was not working properly. She stated she did not know how to check for the proper function of the system. She confirmed there was nothing in place to monitor for the proper functioning of the system. Resident #12 stated, at that time, that the batteries were probably dead. Review of instructions for the PICO single use negative pressure wound therapy system revealed it is used for patients who would benefit from a suction device (negative pressure wound therapy) as it may promote wound healing via removal of low to moderate levels of exudate and infectious materials. The instructions stated the system does not contain any audible alerts and has visual indicators to let you know when there is an issue. It stated dressings should be checked frequently. Instructions stated that a green ok light flashes if the pump is working correctly. (Green light was not on during observation above). The instructions stated that if all lights were off, problems could be dead batteries, pump has completed its course of therapy (contact healthcare professional right away), or the pump is in standby mode (has been paused). Interview with LPN #196 on 07/26/23 at 10:20 A.M. confirmed that the instructions verified no audible alarm and not working properly if no lights are on. Review of the facility policy titled Pressure Ulcer Prevention (dated 06/08/11 and revised 04/27/22) revealed a resident who enters the facility without pressure ulcers should not develop pressure ulcers unless the resident's clinical condition demonstrates that they were unavoidable. A licensed nurse will do a visual head to toe assessment of each resident weekly and document findings. Implement individualized interventions to attempt to stabilize, reduce, or remove underlying risk factors such as but not limited to: reposition frequently according to physician order or at resident request. Interview with the Director of Nursing on 07/26/23 at 11:00 A.M. revealed that since the PICO dressing is changed weekly at the wound clinic, the measurements on the facility weekly ulcer tracking tools were obtained from the wound clinic notes. She stated the facility was not routinely observing the wound but this was not noted on the weekly ulcer tracking tools. She confirmed the facility measurements did not match the wound clinic measurements on 07/18/23. She stated she completed the ulcer tracking tool on 07/18/23 but copied the measurements from the previous assessment, which were not accurate. She confirmed the facility was not documenting the wound as a Stage four, even though the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 16 of 30 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 07/31/2023 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 0686 wound center was. She confirmed the wound had started in house as a Stage II then progressed to a Stage III and was now being classified as a Stage IV by the wound clinic. Level of Harm - Actual harm Residents Affected - Few 2. Review of the medical record for Resident #3 revealed an admission date of 10/23/18 and diagnoses including dementia and cerebral vascular accident with left sided weakness. A Minimum Data Set assessment completed 05/28/23 documented a Brief Interview for Mental Status score of 2, indicating severe cognitive impairment. The resident had upper extremity impairment on one side and required extensive assistance from two staff with bed mobility and toileting. It indicated the resident had no pressure ulcers. Pressure ulcer risk assessments completed on 03/29/23 and 07/22/23 indicated the resident was at moderate risk for the development of pressure ulcers. A weekly skin assessment on 07/17/23 indicated the resident's skin was clear and without pressure ulcers. On 07/22/23 a pressure ulcer tracking tool documented the resident developed a one centimeter by one centimeter (no depth documented) Stage II pressure ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister) on the sacrum. It stated it was a ruptured blister noted during morning care. Review of physician's orders revealed a treatm[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 17 of 30 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 07/31/2023 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 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, staff interview, and policy review, the facility failed to ensure Resident #3, who had limited range of motion received the appropriate treatment and services to prevent further decrease in range of motion. Actual harm occurred on 06/13/22 when Licensed Practical Nurse (LPN) #196 identified Resident #3's left dominant hand had a decline in range of motion, the hand was more contracted and the nurse was unable to use an existing carrot splint as it caused the resident increased pain. The splint was subsequently discontinued. Prior to the decline there was no evidence staff were routinely providing passive range of motion for the resident. Following the identified decline, there was no evidence of a timely referral to therapy and no evidence any other interventions were implemented to attempt to prevent further decline of the left hand contracture. This affected one resident (#3) of one resident reviewed for range of motion. The facility census was 75. Findings include: Review of the medical record for Resident #3 revealed an admission date of 10/23/18 and diagnoses including dementia and cerebral vascular accident with left sided weakness. Review of an occupational therapy evaluation dated 12/21/21 revealed Resident #3 was referred for evaluation of left hand contracture due to poor staff carryover of passive range of motion and applying splint. Per staff, resident no longer fits in palmar guard splint and is experiencing decreased skin integrity of palm due to flexion contracture/rubbing of nails into palm. The plan was for therapy to provide passive range of motion to the left hand to decrease the contracture and to identify the most appropriate type of hand splint with a trial of a carrot splint. The goal was improved range of motion in the left hand and to tolerate a splint for greater than eight hours. Review of an occupational therapy Discharge summary dated [DATE] revealed the resident had good participation with passive range of motion, was utilizing the carrot splint with good success and comfort, and was able to tolerate the splint for greater than eight hours. It was recommended for the splint to continue with staff applying. However, review of range of motion restorative program documentation revealed range of motion services were discontinued on 01/06/22 (two days prior to occupational therapy being discontinued) due to resident not participating in programs on a routine basis, even though occupational therapy documented the resident had good participation in passive range of motion on 01/08/22. There was no evidence of any further range of motion services provided. A physician's order was obtained on 02/09/22 to encourage the resident to utilize the carrot splint to left hand daily (one month after occupational therapy was discontinued with recommendation for splint use). Review of the treatment administration records and nurses notes for May and June 2022 revealed no evidence of refusal of the carrot splint with it being documented as applied daily. However, review (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 18 of 30 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 07/31/2023 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 0688 Level of Harm - Actual harm Residents Affected - Few of a nurses progress note on 06/13/22 at 2:58 P.M. by Licensed Practical Nurse (LPN) #196 revealed resident's left hand is more contracted and trying to use the carrot splint causes the resident more pain. Splint will be discontinued at this time. There was no evidence of a referral to therapy due to the decline and no evidence that any other interventions were put in place to attempt to prevent further decline of the left hand contracture. The plan of care was silent to any range of motion services. A Minimum Data Set (MDS) 3.0 assessment completed 05/28/23 documented a Brief Interview for Mental Status score of 2, indicating severe cognitive impairment. The assessment identified the resident had upper extremity impairment on one side and required extensive assistance from two staff with bed mobility and toileting. Review of an occupational therapy evaluation dated 07/25/23 revealed Resident #3 was noted with a significant left hand contracture currently not appropriate for splint option due to severity, will require intensive passive range of motion prior to splinting. Resident was at risk for losing ability to feed self (left hand dominant). The strength of the left hand was unable to be determined due to severe pain. Occupational therapy was to begin 07/25/23 five times per week for four weeks. Observations on 07/25/23 at 10:10 A.M. revealed Resident #3 to be in bed. Her left hand was contracted with all of her fingers bent inward towards the palm in a fist. No padding or splinting of the hand was observed. Observations on 07/26/23 at 7:13 A.M. revealed Resident #3 (who was left hand dominant) to be feeding herself in bed with her right hand. Her left hand remained contracted with all of her fingers bent inward towards the palm in a fist. No padding or splinting of the hand was observed. Interview with Rehab Director #205 on 07/26/23 at 1:25 P.M. confirmed Resident #3 was re-evaluated by occupational therapy on 07/25/23 due to her left hand contracture. She confirmed Resident #3 was last seen by occupational therapy 01/08/22 after being provided with therapy due to poor staff carry over of passive range of motion and splint use from the last time she had received therapy. She confirmed Resident #3 was discharged [DATE] with good participation in passive range of motion and use of carrot splint. She stated after the resident was discharged from occupational therapy, she would have expected the nursing staff to continue with passive range of motion and use of the carrot splint as she was able to tolerate it for eight hours. She stated she did not know why the restorative program was discontinued 01/06/22 when therapy documented good participation on 01/08/22. She confirmed a referral was not made to therapy after the splint was discontinued in June 2022. She confirmed the resident's left hand contracture had declined and staff would have to start out with a rolled towel until passive range of motion was provided and the resident was able to utilize a splint again. Interview with LPN #196 on 07/26/23 at 2:00 P.M. confirmed she discontinued the carrot splint on 06/13/22. She stated that she felt like she was told by someone to discontinue it as she would not have done it on her own but does not remember the details of why it was discontinued. She stated she did not know why the resident was not referred back to therapy when the splint was discontinued since the resident's hand was more contracted, at that time. Observations on 07/26/23 at 2:15 P.M. revealed LPN #196 to attempt to put a wash cloth, which was folded over once, into Resident #3's left hand. LPN #196 tried to open the resident's fingers enough to put the folded washcloth in between her fingers and the palm of her hand. The resident verbalized oh, as if in pain. LPN #196 stated she did not feel any type of range of motion was provided after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 19 of 30 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 07/31/2023 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 0688 the splint was discontinued in June 2022. Level of Harm - Actual harm Interview with the Director of Nursing on 07/27/23 at 9:40 A.M. confirmed the plan of care was silent to range of motion services and there was no evidence of any range of motion services provided once the splint was discontinued in June 2022. Residents Affected - Few Review of the facility policy titled Functional Range of Motion, dated 11/2011 revealed the functional range of motion assessment would be used to identify the residents active or passive range of motion and/or limitations of each body part, allowing for intervention when appropriate to maintain or improve present level of functioning and to prevent decline in functional status. Referrals would be made to therapy or restorative nursing when clinically indicated and based upon physician order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 20 of 30 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 07/31/2023 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of fall investigations, interview, and policy review, the facility failed to ensure Resident #48 was properly positioned in bed when unattended resulting in an avoidable fall with major injury (hip fracture). Actual Harm occurred on 04/04/23 following a fall at 10:40 P.M. when the facility failed to ensure the resident was properly positioned in bed and left unattended resulting in the resident rolling out of bed and sustaining a hip fracture. This affected one resident (#48) of two residents reviewed for accidents. Findings include: Record review revealed Resident #48 was admitted to the facility on [DATE] with hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, tremors, left foot drop, bilateral hearing loss, diabetes, Foley catheter due to neuromuscular dysfunction of the bladder and chronic kidney disease. Review of Resident #48's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/22/23 revealed the resident required extensive assistance of two person for bed mobility and toileting, and total dependence for transfers. The resident had limited range of motion on one side of the upper and lower extremity. Review of Resident #48's plan of care revealed the resident was at risk for falls related to cerebrovascular accident (CVA). There was no evidence to place something in front of the resident or stand in front of her when providing peri care and two assists if needed per the interdisciplinary team (IDT) note dated 04/21/23. Review of Resident #48's nursing note dated 04/04/23 revealed an aide reported to the nurse while changing the resident she rolled out of bed. The resident stated she just kept right on rolling that she couldn't stop herself. The resident complained of right hip pain and stated she did hit her head. The resident was transported to a local hospital; however, it was full, and she was being moved to another local hospital due to a right hip fracture. The note indicated she would more than likely not need surgery and the fracture would heal on its own. Review of Resident #48's hospital note dated 04/04/23 revealed the resident had non-displaced right femoral neck fracture. Review of the facility fall investigation dated 04/04/23 revealed State Tested Nursing Assistant (STNA) #169's statement indicted she had rolled Resident #48 to her side and hit the call light to get the nurse to apply Zinc on the resident. The statement revealed the STNA waited five to ten minutes and then asked if she could go get her really quick. When the STNA returned the resident was on the floor. The STNA did not see or hear the resident hit the floor. The STNA reported the root cause of the fall was she should have had the resident roll back on to the bed fully. There was no evidence of a second staff member assisting in the resident's care at the time of the incident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 21 of 30 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 07/31/2023 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 - Actual harm Residents Affected - Few Review of a late entry IDT note dated 04/21/23 revealed IDT review of 04/04/23 incident: State Tested Nursing Assistant (STNA) had just completed peri care while the resident was lying on her left side holding to grab bar with right hand to steady herself in position. The STNA stepped to door to summon nurse for treatment and when she turned the resident was lying on floor on her back. The resident stated she rolled forward and couldn't stop and that she bumped her head and right hip hurt. Nurse was summoned, resident stabilized in place, assessed and physician was notified with orders to send to emergency room (ER) for evaluation. X-ray showed non-displaced right femur fracture, however, ortho felt surgery was not needed and to treat conservatively. At present the resident was weight bearing as tolerated. The resident has not been able to ambulate for a very long time as she is afraid, she may fall, is transferred in Hoyer and uses wheelchair for mobility with staff assist. Resident has diagnoses of left hemiplegia from CVA/muscle spasms and uses right arm and hand for activities of daily living (ADL's) and holding herself over on side for peri care. Air mattress to bed for comfort with bolsters for her comfort and states she feels secure with the bolsters. Staff educated to place something in front of her or stand in front of her when providing peri care and two assists if needed. Review of Resident #48's care guide revealed no evidence to place something in front of her or stand in front of her when providing peri care and two assists if needed per the IDT note dated 04/21/23. The care guide indicated the resident required extensive assist to total assist with bed mobility and toileting. Bilateral grab bars on bed to assist with bed mobility. Position with pillows if needed due to tendency to lean to the left. Use two assists with all transfers with floor staff. Interview on 07/24/23 at 10:26 A.M. and 07/27/23 at 2:10 P.M., with Resident #48 confirmed she doesn't have much control of her left side due to a stroke and was not able to control her body and rolled out of bed fracturing her hip. The resident could not recall many details of the incident, but staff was providing care and left her on her side, and she rolled out of bed and could not stop herself. Interview on 07/27/23 at 2:16 P.M. with the Director of Nursing (DON) confirmed the STNA had left Resident #48 on her side in the bed, which was not a safe position, resulting in the resident rolling out of bed and fracturing her hip. The STNA should have waited for staff to answer the call light or rolled the resident back on her back in bed. The plan of care was not updated to reflect the new intervention to have place something in front of her or stand in front of her when providing peri care and two staff assist if needed per the IDT note dated 04/21/23. Review of the facility policy titled Fall Management (dated 01/14/14 and revised 08/18/22) revealed safety was a priority. The facility's effort was to focus on minimizing fall risk and fall related injuries. New intervention would be implemented by the unit staff as soon as possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 22 of 30 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 07/31/2023 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 medical record review, staff interview, and policy review, the facility failed to ensure a resident with significant weight loss received timely interventions as recommended by the dietetic technician. This affected one of five residents reviewed for nutrition (#31). The facility census was 75. Residents Affected - Few Findings include: Review of the medical record for Resident #31 revealed an admission date of 12/14/22 and diagnoses including dementia, dysphagia (difficulty swallowing), Parkinson's disease, and diabetes. The resident weighed 90.4 pounds upon admission on [DATE]. A Minimum Data Set assessment completed 04/28/23 documented a Brief Interview for Mental Status score of 9, indicating moderately impaired cognition. It stated the resident was 62 inches tall, weighed 92 pounds, had no weight loss, and required extensive assistance from staff with eating. The resident had a plan of care in place, revised 07/13/23, which stated the resident had a nutritional problem or potential nutritional problem related to advanced age, chronic diagnosis, receiving a restrictive/mechanically altered diet, variable meal intakes, psychoactive medication use, and underweight status. The goal was to maintain adequate nutritional status as evidenced by meal/supplement intakes greater than 50 percent and maintaining weight with no significant weight changes. An intervention included the dietician evaluating and making diet change recommendations. Record review revealed the resident was receiving a liquid nutritional supplement (Glucerna), eight ounces, three times daily with good intakes documented. On 06/10/23 Resident #31 weighed 90.6 pounds. On 07/13/23 Resident #31 weighed 84.8 pounds. This represents a 5.8 pound, 6.4% significant weight loss in one month. A dietary progress note on 07/13/23 stated the resident weighed 84.8 pounds and had experienced a significant weight change. The note stated meal intakes were variable with 0-50% consumed at most meals which remains consistent for the resident. Receives Glucerna 8 ounces three times daily with good intakes reported. Underweight with Body Mass Index of 15.5. Usual body weight 86-94 pounds. Super cereal with breakfast was recommended by the Dietetic technician on 07/13/23. Review of an Individual Nutrition Recommendation form revealed on 07/13/23 Super Cereal daily was recommended for Resident #31. However, the physician had not signed the form until 07/25/23 and a physician's order was not written for the super cereal daily until 07/25/23 (to start on 07/26/23) (13 days after it was recommended by the Dietetic Technician). Interview with Licensed Practical Nurse #196 on 07/25/23 at 1:40 P.M. confirmed the recommendation for super cereal for Resident #31 on 07/13/23 did not get signed by the physician or ordered to be given until 07/25/23. Interview with the Director of Nursing on 07/26/23 at 9:30 A.M. confirmed there were 12 days between the recommendation for super cereal and when the physician's order was obtained to start it. She stated the orders were typically obtained within 3-4 days but she would expect the recommendations to be put in place within one week. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 23 of 30 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 07/31/2023 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Interview with Dining Services Manager #153 on 07/26/23 at 9:35 A.M. revealed the kitchen did not receive the recommendation for super cereal for Resident #31 until 07/25/23. Review of the facility Weight Change Policy (dated 04/07 and last revised 03/18), revealed the following procedure would be followed to ensure consistent monitoring and documentation of resident weight and implementation of dietary plan of correction with significant changes. A significant weight loss is identified as 5% in one month, 7.5% in three months, or 10% in six months. Monthly weights are obtained by the 10 th of each month. A three pound gain or loss on a resident weighing less than 100 pounds will be reported to the dietician and the physician. The Dietician or the Registered Dietetic Technician will review the weight changes and make recommendations to the nurse for follow up with the physician as needed. The nurse will notify the physician. Event ID: Facility ID: 366001 If continuation sheet Page 24 of 30 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 07/31/2023 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review the facility failed to ensure residents received timely dental services. This affected one resident (#50) of two reviewed for dental. Residents Affected - Few Findings included: Medical record review revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus and vision impairment. A review of Resident #50's census revealed the resident primary insurance was Medicare until 06/16/23 she was switched to Medicaid. A review of Resident #50's ancillary service consent form dated 05/25/23 revealed the resident consented to receive dental services from the facility's contracted dentist while residing in the facility. A review of Resident #50's five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was edentulous. The resident was not assessed to have broken or loosely fitting full or partial dentures. A review of Resident #50's active care plans revealed the resident had upper and lower dentures. A review of Resident #50's current orders dated 07/2023 revealed orders for a dental consult as needed. A review of Resident #50's oral assessment dated [DATE] revealed the resident reported her bottom dentures rub her gums if she wears them very long and she cannot wear them for that reason and needs them adjusted. A review of Resident #50's initial admission assessment dated [DATE] revealed the resident's bottom dentures don't fit. Review of Resident #50's social service notes revealed on 05/25/23 the resident reported her bottom dentures bother her and she would like to get them adjusted. On 06/06/23 social service had spoken to the resident's son to let him know that the facility could make the appointment for bottom dentures, however the Medicare would not cover dentures and he would have to pay out of pocket. On 06/07/23 the son called back and would like the facility to make the appointment to get the resident bottom dentures. Social service would let transportation know so they could make the appointment. Interview on 07/24/23 at 10:17 A.M., with Resident #50 revealed her son had asked the facility on admission to arrange an appointment for her to see the dentist because her dentures did not fit properly on the bottom. The facility still has not made the arrangements. Interview on 07/25/23 11:00 A.M., with Resident #50 revealed she has had lost weight over the last year because she was not able to eat lots of different foods due to not having proper fitting lower dentures. She was 250 pounds now she is around 179 pounds this morning. Her son visits every morning and brings her breakfast. Resident 50 confirmed the dentures were new and she didn't need new lower (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 25 of 30 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 07/31/2023 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 0791 dentures they just needed adjusted so they would not rub her gums. Level of Harm - Minimal harm or potential for actual harm Interview on 07/25/23 2:40 P.M. withe Social Service Designee (SSD) #168 revealed the dentist only comes once a year and was last there 05/17/23. Residents Affected - Few Interview on 07/25/23 3:51 P.M. with Licensed Practical Nurse (LPN) #201 verified an appointment was never made for Resident #50 to see the dentist. Interview on 07/26/23 at 8:30 A.M. with the Director of Nursing (DON) confirmed Resident #50's dental appointment was missed on her list. The DON reported she kept notes on a list, and she reviews them every morning and then removes it from the list once the issue was resolved. Review of the facility policy titled Dental Services (dated 2002) revealed dental services were provided to residents on routine and emergency basis, on premise and off premise. Residents would be visited every month and as needed. Appointments should be forwarded to the SSD, who was responsible for scheduling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 26 of 30 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 07/31/2023 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and policy review, the facility failed to implement the antibiotic stewardship policy and procedure for antibiotic use. This affected two of five residents reviewed for unnecessary medications (#18 and #30). The facility census was 75. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of 10/14/20 and a diagnosis of dementia. A Minimum Data Set assessment completed 05/24/23 documented a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. Review of nurses progress notes on 04/12/23 at 3:15 P.M. revealed Resident #18 returned to the facility in stable condition. New medication orders received following procedure and hospital to call facility to schedule follow up appointment within the next few days (procedure not specified in nurses notes). Record review revealed a physician's order on 04/12/23 for an antibiotic (Keflex) 250 milligrams twice daily for post op prophylaxis. There was no stop date for the antibiotic. Review of a fax cover sheet addressed to the urologist on 04/26/23 revealed it stated Resident #18 had a cysto, lithotripsy, and stent placement on 04/12/23. Discharge instructions said to call your office for a follow up appointment if you have not called us. Could you please call us to schedule follow up appointment. Also, should there be a stop date for the Keflex 250 milligrams twice daily? Please advise. Review of a nurses progress note on 05/02/23 at 10:51 A.M. revealed the facility received fax back from the urologist stating the resident will be taken to the operating room in two months and they will notify us when surgery is scheduled and resident to be on Keflex long term with no stop date. However, record review did not reveal any additional procedures had occurred or any follow up appointments with the urologist. Resident #18 continued on the antibiotic Keflex 250 milligrams twice daily. There was no documentation to indicate why the continued use of the antibiotic was necessary. Review of the facility policy titled Antibiotic Stewardship (dated 09/08/17 and revised 2/17/22) revealed all antibiotic orders will come with a dose, duration, and progress note explaining the reason for the antibiotic. Interview with the Director of Nursing on 07/27/23 at 3:00 P.M. confirmed Resident #18 had not seen a urologist since 04/12/23 and had no documentation to address the continued need for an antibiotic without a stop date or symptoms. 2. Review of facility infection tracking records for June 2023 revealed Resident #30 was listed as having a urinary tract infection 06/14/23. Notes on the tracking record stated a urinalysis was ordered by the urologist to be obtained when the resident's catheter was changed (suprapubic catheter). The resident was placed on an antibiotic (Doxycycline 100 milligrams). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 27 of 30 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 07/31/2023 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the medical record for Resident #30 revealed an admission date of 05/18/21. Review of nurse's progress notes on 06/10/23 at 2:59 A.M. revealed supra pubic catheter was changed and urine sample obtained as ordered. Catheter patent and draining yellow urine. No complaints voiced. On 06/13/23 at 11:45 A.M. it was noted the urine culture results were faxed to the urologist. On 06/14/23 at 11:05 A.M. it was noted the facility received call from urology office regarding urine culture. Resident positive for Citrobacter koseri (a gram negative bacteria). Antibiotics were ordered twice daily for seven days. Review of the medication administration record for Resident #30 revealed Doxycycline 100 milligrams twice daily was administered from 06/14/23 to 06/21/23 for a total of 14 doses. Interview with the Director of Nursing on 07/27/23 at 3:00 P.M. confirmed the facility had received an order from the urologist on 06/09/23 to obtain a urine specimen when the catheter was changed for Resident #30. The catheter was changed on 06/10/23 and the urine specimen was sent in. She stated they received a call from the urologist on 06/14/23 with orders for an antibiotic. She stated the facility did not have a copy of the urine culture result. She confirmed the resident did not have any symptoms of a urinary tract infection but was treated with antibiotics anyway. She confirmed this did not meet the criteria for antibiotic use. She stated she had discussed it with the resident's primary care physician but he declined to discontinue the antibiotic use. She stated she did not document the discussion. Review of the facility policy titled Antibiotic Stewardship (dated 09/08/17 and revised 2/17/22) revealed the procedure was to promote best practices reflecting CMS quality improvement recommendations and CDC guidelines regarding use of appropriate antibiotics. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 28 of 30 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 07/31/2023 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on review of immunization records, policy review, and staff interview, the facility failed to ensure a resident or resident's representative was provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunizations for a resident who refused both. This affected one of one residents who refused the influenza and pneumococcal immunizations in a sample of five (#18). The facility census was 75. Residents Affected - Few Findings include: Review of the medical record for Resident #18 revealed an admission date of 10/14/20. A Minimum Data Set assessment completed 05/24/23 documented a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. Review of the immunization records for Resident #18 revealed both the influenza and pneumococcal immunizations had been refused (no dates). Record review revealed the resident/responsible party had been offered the influenza vaccine with education on 10/28/20 with it being declined at that time. There was no evidence the flu vaccine was offered with education annually. There was no evidence when the pneumococcal immunization had been offered or refused or that education was provided regarding benefits and potential side effects. Interview with the Director of Nursing on 07/27/23 at 1:50 P.M. confirmed there was no evidence Resident #18/responsible party was offered/provided with education for the influenza vaccination since 10/28/20 and no evidence of education on refusal of pneumococcal immunization. Review of the facility policy titled Pneumococcal Immunizations (dated 07/21/16 and revised 09/26/22) revealed it is the policy of the facility to minimize the risk of residents acquiring or experiencing complications from pneumococcal pneumonia by ensuring each resident receive the pneumococcal vaccination unless the vaccine is medically contraindicated or the resident refuses the vaccine. The Director of Nursing or designee will coordinate and implement all activities related to the immunization program. Prior to making an informed consent to receive the pneumococcal vaccine, each resident or resident's legal representative will be given the opportunity to read current educational handout material explaining the benefits and potential side effects of the vaccine. After reading the educational handouts, the resident/legal representative will sign an informed consent form to reflect their understanding of the risks and benefits associated with the vaccines. Review of the facility undated policy titled Immunization of Residents revealed all residents must receive a flu vaccination during the fall of each year, unless otherwise ordered by the resident's attending physician or the resident/guardian refuses. The policy did not include providing education for benefits/side effects. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 29 of 30 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 07/31/2023 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on review of immunization records, personnel records, staff interview, and policy review, the facility failed to ensure residents and staff were provided with education regarding the benefits and potential risks associated with the COVID-19 vaccine and failed to have policies/procedures in place regarding COVID-19 vaccines for residents. This affected one of five sampled residents (#18) and one of one staff reviewed. The facility census was 75. Findings include: 1. Five residents were reviewed for COVID-19 vaccines. Four had received the initial doses and had received a recent annual booster. Resident #18, however, had refused the COVID-19 vaccines. Review of the medical record for Resident #18 revealed an admission date of 10/14/20. A Minimum Data Set assessment completed 05/24/23 documented a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. Review of the immunization records for Resident #18 revealed the COVID-19 vaccine had been refused by the resident on 12/23/20 and 04/20/22. There was no evidence education had been provided to the resident/responsible party on the benefits and potential risks associated with the COVID-19 vaccine. Interview with the Director of Nursing on 07/27/23 at 1:50 P.M. confirmed there was no evidence education had been provided to the resident/responsible party on the benefits and potential risks associated with the COVID-19 vaccine upon refusal. Multiple requests were made to the Director of Nursing for the facility policy/procedure for COVID-19 vaccines for residents but it was never provided. 2. Review of the personnel records for Nursing Assistant #171 revealed a hire date of 07/20/23. Nursing Assistant #171 was not vaccinated for COVID-19. Employee training records revealed Nursing Assistant #171 had reviewed the facility policy on COVID-19 vaccines for staff but there was no evidence education had been provided on the benefits and potential risks associated with the COVID-19 vaccine. Review of the facility policy titled COVID-19 Staff Vaccine Policy (dated 11/16/21 and revised 6/08/23) revealed the facility would provide education on the benefit of the up to date COVID-19 vaccination status and vaccine receipt availability on a regular routine basis. Interview with Human Resources Manager #149 on 07/27/23 at 1:11 P.M. confirmed there was no evidence Nursing Assistant #171 had been provided with the actual education on the benefits and potential risks associated with the COVID-19 vaccine. She had only reviewed the policy that stated it would be provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366001 If continuation sheet Page 30 of 30