Health inspection·April 26, 2021

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** Based on observation, interview and record review the facility failed to ensure fingernails of four dependent residents, Resident #2, #5, #14, and #15, were cleaned/trimmed. This affected four of four residents reviewed for activities of daily living (ADLs). Residents Affected - Some Findings include: 1. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with the diagnoses of non-pressure ulcer of the lower leg, diabetes, chronic kidney disease, benign neoplasm of the penis, morbid obesity, cellulitis, depression, schizophrenia, and chronic obstructive pulmonary disease. Review of the current plan of care dated 06/11/20 (re-used from a previous admission) revealed Resident #2 was at risk for a decline in ADL function related to weakness, obesity, and wounds on his legs. Interventions included: allow time for rest breaks, break tasks down so ADL's are easier for the resident to perform, encourage resident participation, provide necessary adaptive equipment to meet daily needs, and staff to anticipate needs and assist as needed. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderately impaired cognition and required extensive assistance from staff for ADLs. Review of the shower sheets dated 03/29/21 to 04/21/21 revealed no documentation Resident #2's fingernails were cleaned/trimmed. Observations on 04/19/21 at 10:05 A.M., 04/21/21 at 7:48 A.M. and 11:43 A.M. revealed Resident #2 had long, dirty fingernails. Interview on 04/21/21 at 11:30 A.M. with the Director of Nursing (DON) revealed resident fingernails were to be cleaned/trimmed on shower days. Interview on 04/21/21 at 11:43 A.M. with Management #300 verified the fingernails of Resident #2 were long and dirty. Review of the the facility policy, Resident Care Showers, dated 10/20, revealed the facility would provide resident care to promote the highest physical, mental and emotional well-being. Nails and skin would be observed during routine care and showering for care needs including shaving, nail trimming, and skin integrity. The resident should receive two showers a week. 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with the diagnoses of chronic obstructive pulmonary disease, hemiplegia (paralysis on one side of the body), vascular dementia with behavior disturbance, tremor, diabetes, cerebral infarction (stroke), epilepsy, pulmonary fibrosis, peripheral vascular disease, major depressive disorder, and anxiety disorder. Review of the plan of care dated 09/04/19 revealed Resident #5 required staff assistance with ADL performance. Interventions included staff to assist with bathing, dressing, toileting and personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366037 If continuation sheet Page 2 of 7 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 366037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bowerston Hills Nursing & Rehabilitation 9076 Cumberland Road Bowerston, OH 44695 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 Review of the quarterly MDS assessment dated [DATE] revealed Resident #5 had intact cognition and required extensive assistant from staff for ADLs. Review of the shower sheets dated 03/04/21 to 04/21/21 revealed no documentation Resident #5's fingernails were cleaned/trimmed. Residents Affected - Some Observations on 04/19/21 at 10:10 A.M. and 04/21/21 at 11:44 A.M. revealed Resident #5 had long dirty fingernails. Interview on 04/19/21 at 10:10 A.M. with Resident #5 revealed his fingernails had not been trimmed and he did not like them long. Interview on 04/21/21 at 11:30 A.M. with the DON verified resident's fingernails were to be cleaned/trimmed on shower days. Interview on 04/21/21 at 11:44 A.M. with Management #300 verified the fingernails of Resident #5 were long and dirty. Review of the the facility policy, Resident Care Showers, dated 10/20, revealed the facility would provide resident care to promote the highest physical, mental and emotional well-being. Nails and skin would be observed during routine care and showering for care needs including shaving, nail trimming, and skin integrity. The resident should receive two showers a week. 3. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease, diabetes, COVID-19, disorientation, depression, cerebral infarction (stroke), dementia, need for assistance with personal care, cerebrovascular disease, and bipolar disorder. Review of the plan of care dated 03/25/20 revealed Resident #14 was at risk for ADL functional decline related to right knee pain and his knee giving out at times, wearing a brace, weakness, Alzheimer's disease, hypertension, diabetes and cardiovascular accident. Interventions included: allow time for rest breaks, break tasks down so ADL's are easier for the resident to perform, encourage resident participation, provide necessary adaptive equipment to meet daily needs, and staff to anticipate and assist as needed. Review of the annual MDS assessment dated [DATE] revealed Resident #14 had severely impaired cognition and required staff supervision for personal hygiene. Review of the shower sheets dated 03/04/21 to 04/21/21 revealed no documentation Resident #14's fingernails were cleaned/trimmed. Observation on 04/19/21 at 10:00 A.M. revealed the fingernails of Resident #14 were long and dirty. Interview at that time revealed staff had not trimmed his fingernails in a while. Interview on 04/21/21 at 11:30 A.M. with the DON indicated resident fingernails were to be cleaned/trimmed on shower days. Interview on 04/21/21 at 11:46 A.M. with Management #300 verified the fingernails of Resident #14 were long and dirty. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366037 If continuation sheet Page 3 of 7 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 366037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bowerston Hills Nursing & Rehabilitation 9076 Cumberland Road Bowerston, OH 44695 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 - Some Review of the the facility policy, Resident Care Showers, dated 10/20, revealed the facility would provide resident care to promote the highest physical, mental and emotional well-being. Nails and skin would be observed during routine care and showering for care needs including shaving, nail trimming, and skin integrity. The resident should receive two showers a week. 4. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with the diagnoses of diabetes, vascular dementia, cerebral infarction (stroke), chronic obstructive pulmonary disease, schizophrenia, hypertension, depression, chronic respiratory failure, and right hemiplegia (paralysis on one side of the body). Review of the plan of care dated 11/29/17 revealed Resident #15 was at risk for a decline in ADL function related and alteration in ADL performance related to respiratory failure, hemiplegia, cerebrovascular accident, hypertension, and diabetes. Interventions included: allow time for rest breaks, break tasks down so ADL's are easier for the resident to perform, encourage resident participation, provide necessary adaptive equipment to meet daily needs, and staff to anticipate and assist as needed. Review of the quarterly MDS assessment dated [DATE] revealed Resident #15 had severely impaired cognition and required total assistance from staff for all ADL's. Review of the shower sheets dated 03/04/21 to 04/21/21 revealed no documentation Resident #15's fingernails were cleaned/trimmed. Observation on 04/19/21 at 10:05 A.M. revealed the fingernails of Resident #15 were long and dirty. Interview on 04/21/21 at 11:30 A.M. with the DON indicated resident fingernails were to be cleaned/trimmed on shower days. Interview on 04/21/21 at 11:43 A.M. with Management #300 verified the fingernails of Resident #15 were long and dirty Review of the the facility policy, Resident Care Showers, dated 10/20, revealed the facility would provide resident care to promote the highest physical, mental and emotional well-being. Nails and skin would be observed during routine care and showering for care needs including shaving, nail trimming, and skin integrity. The resident should receive two showers a week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366037 If continuation sheet Page 4 of 7 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 366037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bowerston Hills Nursing & Rehabilitation 9076 Cumberland Road Bowerston, OH 44695 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 - 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 pressure ulcer assessments were completed at least weekly and individualized pressure relieving interventions were initiated in a timely manner for Resident #2. This affected one of one resident reviewed for pressure ulcers. Residents Affected - Few Findings include: Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including non-pressure ulcer of the lower leg, diabetes, chronic kidney disease, benign neoplasm of the penis, morbid obesity, cellulitis, depression, schizophrenia, and chronic obstructive pulmonary disease. The facesheet indicated his original admission date was 05/01/20 and the initial admission date was 01/22/21. Review of the current plan of care dated 06/11/20 (date on this plan of care was listed as being from 2020) revealed Resident #2 was a risk for impaired skin integrity related to impaired circulation, impaired mobility, wound ulcers, obesity, diabetes, and peripheral vascular disease. Interventions included barrier cream after each incontinent episode as needed, encourage fluids, pad and protect the skin as needed, pillows for repositioning, and pressure reduction devices (no specific devices were listed). All of the interventions listed had an implementation date of 06/11/20 and were not specific and individualized to Resident #2's current physical condition, including his actual pressure ulcer. Review of the admission physician's orders dated 01/22/21 revealed Resident #2 was admitted to the facility with treatment orders to cleanse open areas on his right and left buttocks with normal saline, pat dry and apply a border foam dressing until healed. Review of the admission Skin Grid Pressure form dated 01/22/21 revealed Resident #2 was admitted with an unstageable pressure ulcer to the left buttock which measured 2.6 centimeters (cm) in length by 0.8 cm in width by 0.0 cm in depth. This document indicated the area was pressure related, had a scab over it and was unstageable. Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #2 had moderately impaired cognition, required extensive assistance from staff for bed mobility, and had one unstageable pressure ulcer with slough. According to the National Pressure Ulcer Advisory Panel (NPUAP), unstageable pressure ulcers are ulcers with a full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, greenish or brown tissue) and/or eschar (tan, brown or black tissue). The base of the ulcer is used to denote the inability to determine the depth and stage of the ulcer since visualization of the wound bed is not possible due to slough/eschar. Review of the Skin Grid Pressure form dated 02/01/21, 10 days after the initial assessment, revealed Resident #2's pressure ulcer was now identified as a stage three sacral wound. The NPUAP defines a stage three pressure ulcer as a full-thickness tissue loss in which subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure depth of tissue loss and undermining and tunneling may be present. This assessment indicated the pressure ulcer had deteriorated and measured 5.0 cm in length by 5.0 cm in width by 1.0 cm in depth. There was 20 percent slough covering the wound, with a moderate amount of serosanguinous drainage. The peri-wound was discolored and macerated. The physician was notified but no new treatment orders were given. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366037 If continuation sheet Page 5 of 7 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 366037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bowerston Hills Nursing & Rehabilitation 9076 Cumberland Road Bowerston, OH 44695 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 - Minimal harm or potential for actual harm Residents Affected - Few Review of the Skin Grid Pressure form dated 02/08/21 revealed Resident #2's sacral pressure ulcer declined again and now measured 8.0 cm in length by 8.0 cm in width by 0.2 in depth. This assessment indicated the pressure ulcer areas to the left and right buttock combined into one pressure ulcer at the sacral area with soft, yellowish-brown slough covering most of the wound, a foul odor was present, and a moderate amount of serosanguinous drainage. The treatment order was changed this date and directed nurses to cleanse the open area to the sacrum with normal saline, apply calcium alginate silver (a highly absorbent gel-like covering with silver which promotes wound healing and assists in killing bacteria), cover with a border foam to be changed two times a week and as needed. Review of the Skin Grid Pressure form dated 03/01/21 revealed the open areas to the right and left buttocks had combined into one pressure ulcer which measured 6.0 cm in length by 5.0 cm in width by 3.0 cm in depth. The ulcer edges were dark brown in color and there was a very foul odor. The pressure ulcer was wound was now a Stage 3 pressure ulcer. The assessment indicated the pressure ulcer had declined. Review of the Skin Grid Pressure form dated 03/08/21 revealed Resident #2's sacral pressure ulcer had declined and measured 6.0 cm in length by 5.0 cm in width by 4.0 cm in depth with tunneling present at 12 o'clock which was 5.0 cm deep. The treatment was changed this date for nursing staff to apply a negative pressure wound vacuum to the sacral pressure ulcer with continuous pressure at 125 millimeters of mercury (mmHg). They were to cleanse the wound with normal saline, apply foam to the wound bed, cover with clear transparent dressing, change the dressing twice weekly and indicated the foam should never touch the intact surrounding skin. Review of physician orders dated 03/18/21 revealed new orders for Resident #2 to have an alternating air mattress to his bed and for him to be referred to Union Hospital Wound Clinic. Review of the Skin Grid Pressure form dated 04/19/21 revealed the sacral wound of Resident #2 was a Stage 3 pressure wound which measured 5.0 cm in length by 3.0 cm in width by 4.1 cm in depth with tunneling at 12 o'clock which was 2.7 cm deep. There was a large amount of bloody drainage with no odor. Observation of the wound could not be completed as Resident #2 continued to be treated with the wound vacuum and it was only changed three times a week. The resident left the faciity on [DATE] at 1:45 P.M. to go to a physician's appointment and the wound vacuum was reapplied there. Interview on 04/22/21 at 10:15 A.M. with the DON verified Resident #2 had no specific, individualized pressure relieving interventions in place until 03/18/21 when the alternating air mattress was ordered, weekly pressure ulcer assessments were not completed from 01/22/21 to 02/01/21 (10 days) and there were declines noted in the pressure ulcer. The DON stated Resident #2 was supposed to be started on collagen on 02/01/21 but she could not find a physician order written for this supplement. Interview on 04/26/21 at 4:45 P.M. with the Director of Nursing (DON) verified the plan of care for Resident #2 had not been updated since his last admission to the facility and was dated 06/11/20. The DON verified no resident specific interventions, including pressure relieving interventions, were implemented until the alternating air mattress was ordered on 03/18/21, after the pressure ulcer declined. Review the facility policy, Skin Assessment Monitoring or Healing Process Policy and Procedure, dated 01/01/16, revealed a nurse would assess ulcers and wounds at the time of admission, re-admission, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366037 If continuation sheet Page 6 of 7 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 366037 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bowerston Hills Nursing & Rehabilitation 9076 Cumberland Road Bowerston, OH 44695 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 a significant change and weekly thereafter until healed. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy, Skin Assessment and Documentation Policy and Procedure, dated 01/01/16, revealed pressure ulcers were to be measured once a week and as needed for any changes in the wound. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366037 If continuation sheet Page 7 of 7