Health inspection·November 18, 2021

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Minimum Data Set (MDS) assessments for Resident #3 were accurately completed. This affected one resident (#3) of three residents reviewed for hospice services and/or pressure ulcers. Residents Affected - Few Findings include: Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbances, hypertension, atherosclerotic heart disease, Alzheimer's disease, type two diabetes mellitus and malignant neoplasm of the prostate. a. Review of the Hospice level of care, dated 07/06/21 revealed Resident #3 elected to receive Hospice services effective 07/16/21. Review of Section O of the significant change MDS 3.0 assessment, dated 08/11/21 revealed Resident #3 was not identified to have received Hospice services. Review of Section O of the quarterly MDS 3.0 assessment, dated 11/11/21 revealed Resident #3 was not identified to have received hospice services. b. Review of the weekly skin assessments, physician's orders, and progress notes, dated 06/01/21 through 11/11/21 revealed no evidence Resident #3 had any type of pressure ulcer during this time. Review of Section M of the significant change MDS 3.0 assessment, dated 08/11/21 revealed Resident #3 was assessed to have an unhealed Stage II pressure ulcer. Interview with MDS Coordinator #905 on 11/16/21 at 1:25 P.M. verified the MDS 3.0 assessments for Resident #3, dated 08/11/21 and 11/11/21, had not been completed accurately as the resident had been receiving Hospice services at the time of the assessments. MDS Coordinator #905 revealed she would immediately complete a modification for both assessments to correct the errors. Interview with Licensed Practical Nurse (LPN) #311 on 11/16/21 at 1:40 P.M. revealed Resident #3 had treatment orders in place for self inflicted scratches to his buttocks but had never had any areas of pressure. Interview with Chief Clinical Officer (CCO) #921 on 11/16/21 at 2:55 P.M. verified Section M of the significant change MDS 3.0 assessment, dated 08/11/21, contained inaccurate documentation of an unhealed Stage II pressure ulcer for Resident #3. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366003 If continuation sheet Page 2 of 4 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 366003 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal Care Center of Franklin Furnace 4734 Gallia Pike Franklin Furnace, OH 45629 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure fall safety interventions were in place as care planned for Resident #14, who was at risk for falls and had a history of falls. This affected one resident (#14) of nine residents reviewed for falls. Findings include: Record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including bipolar disease, paranoid schizophrenia, hearing loss, malignant neoplasm of brain, history of cerebrovascular accident (CVA), muscle weakness and need for assistance with personal care. Review of the plan of care, initiated 03/02/20 revealed Resident #14 was at risk for falls and potential injury due to impaired balance, unsteady gait and history of falls. Interventions included ensure resident wearing footwear properly, or non-skid socks, non-skid strips to floor at bedside, encourage to stand from seated position using arms of the chair, apply shoes before ambulating and therapy ordered as needed. Record review revealed Resident #14 sustained a fall of 08/08/21 in his room at the bedside resulting in a right knee abrasion. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/01/21 revealed Resident #14 had moderately impaired cognition and required limited assistance from staff for bed mobility, transfers, walking, toileting, eating and hygiene. Review of the fall risk assessment, dated 11/06/21 revealed Resident #14 was at moderate risk for falls and had multiple falls in the past six months. Symptoms included jerking when turning and noted the resident was unbalanced when standing. Review of a physician's order, dated 11/15/21 revealed to ensure proper footwear when ambulating, ensure resident wore threaded footwear when up , must sit in chair when smoking not at picnic table, non-skid socks, occupational therapy to evaluate and treat three to five times weekly for neuro- muscular reeducation and the anti-psychotic medication, Haldol 0.5 milligrams one time a day and 5 milligrams at bedtime for behaviors. On 11/15/21 at 3:43 P.M. Resident #14 was observed ambulating and was noted to be unsteady on his feet when exiting from his room. On 11/15/21 at 3:45 P.M. observation of Resident #14's room revealed no non-skid floor strips near the resident's bed. On 11/16/21 at 3:30 P.M. interview with Regional Operations Nurse (RN) #845 verified Resident #14 did not have non-skid floor strips in place. RN #845 revealed the non-skid floor strip intervention, initiated on 03/02/20, was discontinued on 11/16/21 because the resident didn't need it any longer. During the interview, RN #845 revealed new flooring had been installed last week in Resident #14's room and the non-skid floor strips were not replaced on the floor at that time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366003 If continuation sheet Page 3 of 4 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 366003 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal Care Center of Franklin Furnace 4734 Gallia Pike Franklin Furnace, OH 45629 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm On 11/17/21 at 9:03 A.M. interview with Maintenance Director #156 revealed the non-skid floor strips in Resident #14's room had not been replaced since the new flooring had been installed. Review of the facility policy titled Fall Policy, dated 10/01/18 revealed the facility was to complete a review of resident falls and implement interventions to attempt to prevent or reduce falls and injuries related to falls. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366003 If continuation sheet Page 4 of 4