Inspection·February 23, 2023

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on observations, interviews, and record review, the facility failed to ensure information was available for residents and their representatives on how to file a grievance and who the facility designated as a Grievance Official. This had the potential to affect 21 of the 21 residents in the facility. Facility census was 21. Findings include: Observation of the facility during the survey on the days of 02/21/23, 02/22/23, and 02/23/23 revealed there were no postings of how to file a grievance available for the residents, in the facility. On 02/22/23 at 10:39 A.M. interview with Residents #7, #13, #14, and #15 at the Resident Council interview revealed the residents did not know how to file a grievance. All residents present stated they would just tell someone they had a concern and it usually was addressed. Most of the time they are happy with the resolution but not always. Resident #14 stated he had not received his glasses that were ordered last year. The resident stated he had asked multiple staff but no one informed him of the situation with his glasses. On 02/23/23 at 11:35 A.M. interview with Licensed Practical Nurse (LPN) #104 revealed the grievance forms are not at the nurse's station as stated in the admission packet and the Resident Handbook. LPN#104 stated if a resident asked to file a complaint or grievance, she would refer the resident to the Director of Nursing (DON) or the Administrator. On 02/23/23 at 11:37 A.M. interview with the DON revealed if the residents have a concern someone from administration or the activities director, who coordinates Resident Council, works with the resident to address the concern or fill out the grievance form. On 02/23/23 at 1:05 P.M. phone interview Activities Director #116 revealed she schedules the Resident Council meetings, reminds the residents of the meeting day and time, and review the minutes for the previous month (including outcomes of the concerns). She does not fill out the grievance forms but refers the residents to the Administrator or DON if concerns are not resolved. On 02/23/23 at 2:25 P.M. interview with Administrator #117 revealed the grievance process instructions were not posted in the facility. The forms are at the nurse's station and in the administration office. Most of the residents would need help filling out the form so the grievance process is addressed as concerns are raised by the residents. Review of the current resident handbook revealed a resident with a concern may complete a concern form which should be available at the Nursing Stations, Business office or Administrative office. There is also a Grievance Committee comprised of the Facility's staff, Residents, sponsors, or outside representatives in a ratio of not more than one staff member to every two Residents, sponsors, or outside representatives. Procedures are reviewed at least annually by the Facility with the advice of Residents, their sponsors, or both. Record review of resident council meeting minutes from 01/22 to 02/23 revealed no information provided to residents on how to file a grievance, no information that confidentiality will be maintained if a grievance is filed, and no information that the procedures have been reviewed with Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366037 If continuation sheet Page 2 of 14 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 02/23/2023 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 0585 input. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366037 If continuation sheet Page 3 of 14 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 02/23/2023 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 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to initiate a significant change Minimum Data Set (MDS) assessment, within 14 days, following a hospice admission. This affected one (#18) of one resident reviewed for hospice services. The facility census was 21. Residents Affected - Few Findings include: Review of the medical record for Resident #18 revealed an admission date of 01/25/23 with diagnoses including dementia, atherosclerotic heart disease, history of cerebral vascular infarction, and history of urinary tract infection. Review of the 5-Day Minimum Data Set (MDS) assessment, dated 01/31/23, indicated Resident #18's Brief Interview for Mental Status (BIMS) score was 04, which indicated severely impaired cognition. The resident did not have any hallucinations, delusions, physical or verbal behaviors, or rejection of care. This was the most current MDS assessment completed. Review of a physician order, dated 02/06/23, revealed the order to admit the resident to hospice services. Review of the Care Plan, dated 02/21/23, revealed Resident #18 received hospice services related to cerebral atherosclerosis. During interview on 02/22/23 at 2:45 P.M., the Director of Nursing (DON) confirmed the significant change MDS assessment was not timely initiated, within 14 days, following Resident #18's hospice admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366037 If continuation sheet Page 4 of 14 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 02/23/2023 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 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** 3. Review of Resident #10's medical record revealed diagnoses including convulsions and hypertension. Residents Affected - Some Review of the January 2023 Medication Administration Record (MAR) revealed Resident #10 received Furosemide (diuretic) 20 milligrams (mg) every morning for congestive heart failure between 01/06/23 and 01/12/23. A quarterly MDS dated [DATE] did not reflect the use of a diuretic over the seven day assessment period. On 02/22/23 at 9:43 A.M., during interview, the Director of Nursing (DON) verified the MDS was coded incorrectly, verifying Resident #10 had received a diuretic. 4. Review of Resident #21's medical record revealed an admission date of 09/19/22 with diagnoses including anxiety, major depressive disorder and insomnia. Review of the physician orders revealed medications including ambien (hypnotic) 10 milligrams (mg) daily at bedtime, venlafexine (antidepressant) extended release 75 mg twice a day; buspar (antianxiety) 10 mg twice a day. Review of the Quarterly MDS dated [DATE] revealed the resident was cognitively intact but did not receive antianxiety, antidepressants or hypnotics during the assessment period. Review of the December 2022 Medication Administration Record (MAR) revealed the resident did receive the ordered medications during the assessment period, 12/21/22 through 12/27/22. On 02/23/23 at 11:34 A.M. interview with the DON verified the resident's MDS did not accurately reflect the medications the resident received. Based on medical record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected diuretic medication use and psychotropic medication use. This affected four residents (#5, #7, #10 and #21) of 15 residents reviewed for assessments. Findings include: 1. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE]. Diagnoses included coronavirus (COVID-19), anemia, major depressive disorder, psychoactive substance abuse, opioid addiction, protein-calorie malnutrition, and chronic viral hepatitis. Review of the Minimum Data Set (MDS) quarterly assessment, dated 10/27/22, inaccurately revealed that Resident #7 received diuretics for zero days during the look-back period. Review of a physician order, dated 10/15/21, revealed the order for Furosemide 20 milligrams (mg) one tablet, two times per day. Review of the Medication Administration Record (MAR) revealed that Resident #7 received Furosemide 20 mg, one tablet, two times per day, from 10/21/22 through 10/27/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366037 If continuation sheet Page 5 of 14 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 02/23/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 02/22/23 at 9:45 A.M. with the Director of Nursing (DON) verified the MDS quarterly assessment, dated 10/27/22, contained an inaccurate assessment of Resident #7's diuretic use. 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included dementia, diabetes mellitus, psychotic disorder with delusions, major depressive disorder, chronic obstructive pulmonary disease, and hypertension. Review of the MDS annual assessment, dated 12/12/22, inaccurately revealed that Resident #5 received diuretics for zero days during the look-back period. Review of a physician order, dated 10/21/22, revealed the order for Bumex one milligram (mg), one tablet, two times per day. Review of the MAR revealed that Resident #5 received Bumex one mg, one tablet, two times per day, from 12/06/22 through 12/12/22. Interview on 02/22/23 at 9:45 A.M. with the DON verified the MDS quarterly assessment, dated 10/27/22, contained an inaccurate assessment of Resident #5's diuretic use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366037 If continuation sheet Page 6 of 14 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 02/23/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to refer a resident with newly diagnosed serious mental disorder, for a Pre-admission Screening and Resident Review (PASARR) re-evaluation. This affected one (#5) of 15 residents reviewed for PASARR. Findings include: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included dementia, diabetes mellitus, major depressive disorder, chronic obstructive pulmonary disease, and hypertension. Review revealed on 12/15/19, the resident was diagnosed with psychotic disorder with delusions. Review revealed a PASARR review, dated 12/28/15, which indicated there was no serious mental illness or developmental disability. Review of a psychiatric progress note, dated 04/19/22, revealed the resident had behaviors including delusions. Interview on 02/23/23 at 1:45 P.M., the Director of Nursing (DON) confirmed the last PASARR evaluation was completed on 2015 and there was not a re-evaluation completed following the resident's new diagnosis of psychotic disorder with delusions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366037 If continuation sheet Page 7 of 14 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 02/23/2023 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 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** Based on medical record review and interview, the facility failed to ensure there was follow up to an optometrist visit recommending eye glasses for one (#14) of 14 residents interviewed regarding vision. The census was 21. Residents Affected - Few Findings include: During an interview of Resident #14 on 02/21/23 at 12:40 P.M. he stated he had eye glasses ordered and he had not received them. Other residents who saw the eye doctor on the same day had received their eye glasses. Review of Resident #14's medical record revealed diagnoses including disorientation and type 2 diabetes mellitus. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #14 had adequate vision with corrective lenses. The assessment indicated Resident #14 was moderately cognitively impaired. Documentation from the facility's eye care provider revealed Resident #14 had an eye exam 09/22/22 which indicated he had a cataract of the right eye, pseudophakia (implant of an intraocular lens to replace a natural lens) of the left eye, hyperopia (nearby objects look blurred) and presbyopia (progressive loss of near focusing ability) of both eyes with no current prescription. The form indicated glasses were required and to encourage full time use for distance and reading. Glasses were recommended and were to be delivered upon approval. A care plan initiated 01/07/23 indicated Resident #14 was at risk for impaired vision related to use of magnifier/magnifier glass. Goals were for Resident #14 to be free of acute eye problems and maintain optimal quality of life within visual limits. Interventions included arranging consultation of an eye care practitioner as needed. On 02/22/23 at 11:13 A.M., during interview, the Director of Nursing (DON) stated Resident #14 never received eye glasses due to issues with his insurance. On 02/22/23 at 12:15 P.M., during interview, the DON stated she spoke to the eye doctor provider and was told insurance would send a denial letter. After the facility got the denial letter they would appeal. Resident #14 could choose to pay out of pocket for the eye glasses. On 02/22/23 at 1:08 P.M., during interview, the Vision Provider Representative #200 stated the information regarding the cost of the eye glasses was submitted to Resident #14's primary insurance provider and was informed they did not cover the cost of glasses. A letter was sent to the resident at the facility on 09/23/22. No other person was listed as the responsible party. On 02/22/23 at 1:22 P.M., during interview, Business Office Manager (BOM) #112 verified the census view of the medical record revealed Resident #14 had Medicaid coverage as of 09/16/22. On 02/22/23 at 1:54 P.M., during interview, the Ohio Medicaid Representative #205 indicated he could see Resident #14 had Medicaid which had back dated benefits as of 09/01/22. The case was not updated in the system until 11/25/22 so he would not have been in the system as covered until then. The DON indicated she would have the vision provider submit the bill for eye glasses to Medicaid. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366037 If continuation sheet Page 8 of 14 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 02/23/2023 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 0685 Level of Harm - Minimal harm or potential for actual harm On 02/22/23 at 2:00 P.M., during interview, the DON stated she usually tracked when residents got glasses and who had not received them. The DON stated she thought because Resident #14 had a hospitalization, it slipped her mind. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366037 If continuation sheet Page 9 of 14 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 02/23/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and interview, the facility failed to ensure a resident's oxygen flow rate was set as ordered and failed to ensure the oxygen tubing and humidifier bottle were changed weekly as ordered. This affected one (#7) of three residents reviewed for respiratory care. The facility identified seven residents receiving oxygen therapy. The facility census was 21. Residents Affected - Few Findings include: Review of the medical record revealed Resident #7 was admitted to the facility on [DATE]. Diagnoses included coronavirus (COVID-19), anemia, major depressive disorder, psychoactive substance abuse, opioid addiction, protein-calorie malnutrition, and chronic viral hepatitis. Review of the Minimum Data Set (MDS) quarterly assessment, dated 10/27/22, revealed Resident #7's Brief Interview for Mental Status (BIMS) score was 15, which indicated intact cognition. There were no behaviors or rejection of care. The resident received oxygen therapy. Review of the Care Plan, dated 01/07/23, revealed Resident #7 is at risk for altered respiratory status with the intervention to administer oxygen as ordered. Review of physician order, dated 12/19/19, revealed the order for oxygen at four liters per minute to be infused via nasal cannula as needed. Further review revealed the physician order, dated 06/19/21, to change the oxygen humidifier bottle and oxygen tubing weekly. Observations on 02/21/23 at 10:28 A.M. and at 12:05 P.M. revealed Resident #7's oxygen flow rate was set at 3.5 liters per minute via nasal cannula and the oxygen humidifier bottle and oxygen tubing were dated 02/12/23. During interview on 02/21/23 at 12:09 P.M., Licensed Practical Nurse (LPN) #104 confirmed Resident #7's oxygen flow rate was incorrectly infusing at 3.5 liters per minute and should be infusing at 4 liters per minute. LPN #104 further confirmed the oxygen humidifier bottle and oxygen tubing had not been changed weekly as ordered. Review of the facility's policy, Oxygen Administration, dated January 2020, revealed to review the physician's order for oxygen administration. Change tubing weekly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366037 If continuation sheet Page 10 of 14 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 02/23/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on record review, policy review, and interview, the facility failed to provide an appropriate diagnosis for a resident receiving an antipsychotic medication and failed to indicate the duration (stop date) of a psychotropic medication ordered as needed (prn). This affected one (#18) of five residents reviewed for unnecessary medications. Findings include: Review of the medical record for Resident #18 revealed an admission date of 01/25/23 with diagnoses including dementia, atherosclerotic heart disease, history of cerebral vascular infarction, and history of urinary tract infection. Review of the Minimum Data Set (MDS) assessment, dated 01/31/23, indicated Resident #18's Brief Interview for Mental Status (BIMS) score was 04, which indicated severely impaired cognition. The resident did not have any hallucinations, delusions, physical or verbal behaviors, or rejection of care. Review of the Care Plan, dated 01/31/23, revealed Resident #18 received antipsychotic medication related to dementia. Review of a physician order, dated 02/02/23, revealed the order for Lorazepam (Ativan) 0.5 milligrams (mg) by mouth or intramuscularly (IM), every four hours, as needed for anxiety, restlessness, or agitation. The order did not indicate a duration of time or stop date. Review of a physician order, dated 02/07/23, revealed the order for Quetiapine Fumarate (Seroquel) 25 milligrams (mg) by mouth at bedtime for restlessness/anxiety. Review of the Medication Administration Record (MAR), dated February 2023, indicated the resident received Quetiapine Fumarate 25 milligrams (mg) every night. During interview on 02/22/23 at 3:41 P.M., the Director of Nursing (DON) verified the resident is receiving Seroquel, which is an antipsychotic, without an appropriate diagnosis. The DON confirmed the physician order, dated 02/07/23, stated the indication for use was due to restlessness/anxiety. The DON further confirmed there was no stop date indicated on the physician order, dated 02/02/23 for Lorazepam 0.5 mg, every four hours, prn. Review of the facility's policy, Antipsychotic Medication Use, dated December 2016, revealed the residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The need to continue prn orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the prn order will be indicated in the order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366037 If continuation sheet Page 11 of 14 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 02/23/2023 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 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 observations, record review, and interview, the facility failed to make timely referrals for dental services for two (#11 and #14) of 16 residents whose dental status was observed. The facility census was 21. Residents Affected - Few Findings include: 1. Observations of Resident #11 on 02/21/23 at 10:58 A.M. revealed he had no natural teeth and no dentures in. On 02/21/23 at 3:47 P.M., during interview, Resident #11's son indicated Resident #11 had new dentures that had been missing. The facility had reported they were looking for them. Review of Resident #11's medical record reviewed diagnoses including Alzheimer's disease, type 2 diabetes mellitus, dysphagia (difficulty swallowing) and cerebrovascular disease. Between 06/07/21 and 11/07/22, Resident #11 had an order for a regular diet with regular texture. A nursing note dated 11/07/22 at 9:14 A.M. indicated the power of attorney and physician were updated that Resident #11's diet was changed to mechanical soft due to decreased appetite and difficulty chewing. An admission nursing assessment dated [DATE] indicated Resident #11 had full upper and full lower dentures that fit but did not wear them. There was no documentation indicating Resident #11's dentures were missing. Review of a Resident/Family/Staff concern form dated 07/21/22 indicated Resident #11's dentures were missing. Staff were unable to find the dentures in his room, the laundry, day room, dining room or in the chairs. Resident #11 was unable to state what he did with them. Resident #11 was known to take them out and leave them in random places. Resident #11 was added to a list to be seen at the next dental visit. It was unknown if the cost of the dentures would be covered. On 02/22/23 at 4:20 P.M., during interview, the Director of Nursing (DON) stated the facility assessed a resident with lost dentures to see if it affected their intake and if it did they reached out for emergency dental services. If not, the residents were seen with the next visit. The DON stated she would look for documentation regarding any referral for dental services after the dentures were lost. The DON stated the facility was still waiting on the next dental visit to be scheduled. On 02/22/23 at 4:42 P.M., during interview, the Administrator provided a list that was provided to the dental service on 12/20/22 indicating Resident #11's name was on the list to be seen. On 02/23/23 at 7:00 A.M., during interview, the DON verified there was no documentation revealing there was a referral for dental services within three days of the dentures being lost nor was there documentation of extenuating circumstances that led to the delay of dental services being provided. On 02/23/23 at 10:31 A.M., interview of Dental Services Representative #210 revealed dental services provided in the facility included x-rays, exams, cleanings, fillings, most extractions and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366037 If continuation sheet Page 12 of 14 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 02/23/2023 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 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dentures. The dental service automatically saw residents who had Medicaid services. Notices would be sent out for any private pay residents. The dental service would generally visit when residents were due to be seen. However there were only a few residents who were eligible to be seen at present so they would wait until most residents were due to be seen unless there was an emergency. Dental Services Representative #210 stated if a facility notified them of missing dentures they would seek approval for payment by Medicaid first or give the residents the option to pay privately. In that case, they would coordinate to visit the specific resident. Dental Services Representative #210 stated the facility called the dental service provider on 02/22/23 to schedule a visit. After reviewing the records for Resident #11, Dental Services Representative #210 stated the facility had not notified them that his dentures were missing. Dental Services Representative #210 stated Resident #11 had received dentures in 2022. Medicaid would only pay for dentures every eight years so new dentures would have to be paid for privately. 2. During an interview of Resident #14 on 02/21/23 at 12:40 P.M., Resident #14 was observed to have natural lower teeth but no upper teeth were observed. Review of Resident #14's medical record revealed diagnoses including disorientation, type 2 DM, and adult failure to thrive. An admission assessment dated [DATE] indicated Resident #14 had his own teeth but also indicated dentures fit. The assessment was silent as to the type of dentures Resident #14 had. A dietary note dated 12/16/22 at 10:29 A.M. indicated Resident #14 had lost dentures. Review of a Resident/Family/Staff concern form dated 12/09/22 indicated Resident #14's dentures were missing. Resident #14 stated he took them out in bed and did not know what happened to them. Staff searched the bedroom, laundry, and visible trash and were unable to find the dentures. Resident #14's name was placed on a list to be seen by the dentist. The facility was waiting on a date. On 02/22/23 at 11:11 A.M., during interview, Licensed Practical Nurse (LPN) #104 stated Resident #14 had upper dentures when he was admitted but they were unable to be located about 1-1.5 months prior to the survey. Staff had removed everything from the room in attempts to locate the dentures without success. Resident #14 had no difficulty eating. Resident #14 would be seen when the dentist visited next. On 02/22/23 at 4:20 P.M., during interview, the Director of Nursing (DON) stated the facility assessed a resident with lost dentures to see if it affected their intake and if it did they reached out for emergency dental services. If not, the residents were seen with the next visit. The DON stated she would look for documentation regarding any referral for dental services after the dentures were lost. The DON stated the facility was still waiting on the next dental visit to be scheduled. On 02/22/23 at 4:42 P.M., during interview, the Administrator provided a list that was provided to the dental service on 12/20/22 indicating Resident #14's name was on the list to be seen. On 02/23/23 at 7:00 A.M., during interview, the DON verified there was no documentation revealing there was a referral for dental services within three days of the dentures being lost nor was there documentation of extenuating circumstances that led to the delay of dental services being provided. On 02/23/23 at 10:31 A.M., interview of Dental Services Representative #210 revealed dental services provided in the facility included x-rays, exams, cleanings, fillings, most extractions and dentures. The dental service automatically saw residents who had Medicaid services. Notices would be sent out for any private pay residents. The dental service would generally visit when residents were due (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366037 If continuation sheet Page 13 of 14 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 02/23/2023 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 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete to be seen. However there were only a few residents who were eligible to be seen at present so they would wait until most residents were due to be seen unless there was an emergency. Dental Services Representative #210 stated if a facility notified them of missing dentures they would seek approval for payment by Medicaid first or give the residents the option to pay privately. In that case, they would coordinate to visit the specific resident. Dental Services Representative #210 stated the facility called the dental service provider on 02/22/23 to schedule a visit. After reviewing the records, Dental Services Representative #210 stated Resident #14 had not been seen by dental services yet and his initial visit would be with the next dental visit to the facility. The facility had not reported Resident #14's dentures were missing. Event ID: Facility ID: 366037 If continuation sheet Page 14 of 14