Health inspection·June 28, 2022

F 0569 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 05/11/22 paperwork was sent to an attorney. BOM #381 revealed as of 06/23/22 she had not heard anything from the attorney or court and had not called the resident's son for guidance in spending the excess money in the resident personal fund account. BOM #381 verified the account has been over the Medicaid limit for the last eight months. BOM #381 verified there was no evidence in a six month period from [DATE] until April 2022 of contacting family to discuss the need for a spend down of funds or return of funds to protect Medicaid eligibility. 2. Record review revealed Resident #38 had a balance of $3405.16 in his personal funds account as of 06/23/22. Accounting for the year grace period to spend government stimulus checks revealed on 01/31/22 the resident was $377.10 over the limit and currently $1405.16 over the allowed amount on 06/23/22. Review of the quarterly statements revealed they were sent to the residents' son. A letter was sent with the quarterly funds the balance exceeded what was allowed under Medical Assistance, Please contact your Business Office Manager within the next seven days to discuss continuance of Medicaid benefits. Review of the statements revealed $521.49 on 12/31/21 was the only expenditure in the year 2021. Review of the last quarterly statement revealed from January 2022 through March 2022 the resident's balance maintained consistently between $3644.22 and $4042.90. On 06/23/22 at 9:00 P.M. interview with BOM #381 revealed she called the son in October 2021 and left a message without a return call. The son did not respond to the letters. The next documented attempt to reach the son was 06/13/22 when it was decided to give two grandchildren $500.00 each, leaving a $3405.16 balance as of 06/23/22, $1405.16 over the $2000.00 allowance. Family indicated they would get a computer and clothes for the resident. BOM #381 verified the account has been over the Medicaid limit for the last five months. BOM #381 verified there was no evidence in a eight month period [DATE] till June 2022 of contacting family to discuss the need for a spend down of funds or return of funds to protect Medicaid eligibility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 2 of 28 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 366051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Northpointe 3291 Northpointe Drive Zanesville, OH 43701 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on observation, record review, facility policy and procedure review and interview the facility failed to notify Resident #6's representative when the resident experienced a skin tear on the arm requiring treatment. This affected one resident (#6) of 21 sampled residents reviewed for notification. Findings include: Review of the medical record for Resident #6 revealed an admission date of 06/01/21. A Minimum Data Set (MDS) 3.0 assessment, dated 03/10/22 revealed the resident had short and long term memory impairment and received Hospice services. An event note, dated 06/07/22 at 6:42 A.M. revealed the aide alerted the nurse Resident #6 had a skin tear on her right forearm. The resident was unable to state what caused the skin tear. The area was cleansed and a dry clean dressing applied. A physician's order was obtained on 06/07/22 to cleanse the right forearm with normal saline and cover with foam dressing. The dressing was to be changed every three days. The event note documented the resident representative was notified on 06/07/22 at 6:42 A.M. On 06/21/22 at 2:50 P.M. Resident #6 was observed to have a dressing on her right forearm. The dressing was dated 06/19/22. Review of the facility policy titled Guidelines for Responsible Party Notification, dated 08/01/16 revealed the purpose was to ensure the responsible party was aware of all diagnostic testing results or change in condition in a timely manner. The responsible party should be notified of a change in condition immediately. Documentation of notification should be recorded in the electronic health record. On 06/21/22 at 2:52 P.M. interview with Resident 6's responsible party revealed he had not been notified of what happened to the resident's right forearm or the need for a dressing. On 06/23/22 at 2:00 P.M. interview with the Assistant Director of Nursing revealed she had spoken to the nurse who documented the responsible party was notified on 06/07/22 at 6:42 A.M. She stated the nurse confirmed she did not notify the responsible party. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 3 of 28 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 366051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Northpointe 3291 Northpointe Drive Zanesville, OH 43701 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on record review, facility policy and procedure review and interview the facility failed to ensure an allegation of rape, involving Resident #9 was thoroughly investigated and included written details of the total circumstances of the allegation being made. This affected one resident (#9 of three residents reviewed in facility self-reported incidents (SRIs). Residents Affected - Few Findings include: Review of Resident #9's medical record revealed a 09/08/21 admission date with diagnoses including dementia without behavioral disturbance, multiple subsegmental pulmonary emboli without acute cor pulmonale, occlusion and stenosis of left carotid artery, major depressive disorder, single episode, hypertension, constipation, shortness of breath, disorientation, and syncope and collapse. A 03/23/22 quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident was independent for daily decision making, required staff supervision set up assistance for bed mobility and transfers and was independent for ambulation. Review of the resident's plan of care revealed no plan of care had been developed related to the resident making false accusations. Review of SRI tracking number 220842, dated 04/26/22 revealed the Administrator was made aware Resident #9 stated she was raped. The SRI revealed the facility unsubstantiated the allegation. The SRI documentation included it was reported to the Administrator the resident was raped. The resident was interviewed and assessed. The resident then denied the allegation. The resident stated she was not touched inappropriately and she felt very safe, well cared for and liked it at the facility. An entire house audit with head to toe assessment/skin assessments was completed with no concerns noted. Residents with a Brief Interview for Mental Status score of 14 or higher (intact cognition) were interviewed with no concerns noted. Other staff were interviewed with no concerns noted. The SRI revealed out of an abundance of caution, the incident was reported to the police department. However, a review of the investigation revealed there was no statement included in the investigation with details from anyone who took the allegation of rape from Resident #9. There was no information on who was told or what the resident actually reported. The Administrator's summary indicated she was informed of an allegation of rape with no other details. On 06/23/22 at 7:14 P.M. interview with the Administrator revealed she had been notified of the allegation of rape by Former Director of Nursing (DON) #342. Review of a Statement of Witness form by Former Director of Nursing #342 (dated 04/26/22) read I am not aware of any accusations made by Resident #9 nor have I heard anything related to this. On 06/23/22 at 8:12 P.M. interview with the Administrator revealed she did not get a written statement from the Former Director of Nursing stating what the resident said when she told her she was raped. The Administrator was not told and did not obtain written or verbal details of when, by whom or where the rape allegedly took place. The Administrator was unaware if Former DON #342 obtained any details of the rape. The Administrator verified the statement she had from the Former DON was that she had no knowledge of allegations of abuse. The Administrator said that meant she was stating she had not previously heard of these statements being made. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 4 of 28 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 366051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Northpointe 3291 Northpointe Drive Zanesville, OH 43701 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 0610 Level of Harm - Minimal harm or potential for actual harm Review of the facility Abuse and Neglect procedural guidelines, effective 08/29/19 revealed to identify and interview all involved persons including the alleged victim, alleged perpetrator, witnesses and others who might have knowledge of the allegations. Provide complete and thorough documentation of the investigation. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 5 of 28 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 366051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Northpointe 3291 Northpointe Drive Zanesville, OH 43701 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on closed record review, facility policy and procedure review and interview the facility failed to ensure Resident #70 was provided a notice of the facility bed hold policy prior to a hospital transfer. This affected one resident (#70) of one resident reviewed for hospitalization. Findings include: Review of Resident #70's closed medical record revealed an admission date of 05/04/22 with diagnoses including hemiplegia, and hemiparesis following cerebral infarction affecting left non dominant side. facial weakness, hypertensive heart, congestive heart failure, chronic kidney disease stage 3, atherosclerotic heart failure, atrial fibrillation, chronic pulmonary edema and osteoporosis. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 05/10/22 revealed the resident was moderately impaired for daily decision making, was sad two to six days with a poor appetite and had trouble concentrating twelve to fourteen days of the review period. The assessment revealed the resident required limited assistance from one staff for bed mobility, transfers, personal hygiene, toileting and dressing. A discharge, return not anticipated MDS assessment was completed on 05/25/22. Review of a nursing progress note, dated 05/25/22 at 8:59 P.M. revealed the State Tested Nurse Aide (STNA) walked past resident's room and noticed the resident had her call light wrapped around her neck three times. The resident was sitting on the floor when the STNA entered the room. The resident stated she did not want to be there anymore. The nurse called 911 and had resident sent out to the emergency room for evaluation. There were no ligature marks or loss of conciousness. The resident was provided with one on one supervision and was not left alone until she left with in the ambulance. Further review of the closed medical record revealed no written evidence the facility bed hold policy was provided to the resident or family upon transfer to the hospital. The closed medical record revealed no evidence of the resident and/or family stating they did not plan for the resident to return to the facility after the hospitalization. On 06/22/22 at 6:58 P.M. interview with the Administrator verified the resident was not provided information/bed hold letter upon transfer to the hospital. The Administrator revealed this was due to the facility incorrectly marking the resident discharged , so staff did not think a bed hold letter was needed. Review of the Bed hold Notification policy, effective 11/28/16 revealed the resident and responsible party had a right to be notified verbally and in writing on reserve the payment policy for the State plan when someone goes out to the hospital or on a therapeutic leave. Before transferring a resident to the hospital or allowing a resident to go on a therapeutic leave the nursing designee or other designated staff members should provide written information to the resident and/or family or legal representative of the bed hold an omission policies. In case of emergency transfers the notice of the bed hold policy under the state plan and the facility's bed hold policy should be provided to the resident or resident's representative by nursing designee within 24 hours of the transfer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 6 of 28 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 366051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Northpointe 3291 Northpointe Drive Zanesville, OH 43701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on record review and interview the facility failed to develop a comprehensive psychotropic plan of care identifying target behaviors related to the use of antipsychotic, anti-anxiety and antidepressant medications for Resident #50. This affected one resident (#50) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #50's medical record revealed a 04/29/21 admission with diagnoses including dementia without behavioral disturbance, multi-system degeneration of the autonomic nervous system, orthostatic hypotension, major depressive disorder, single episode, Type 2 diabetes mellitus with diabetic neuropathy, psychosis not due to a substance or known physiological condition, severe protein-calorie malnutrition, anxiety disorder, diverticulosis of intestine (part unspecified) without perforation or abscess without bleeding, gastroesophageal reflux disease without esophagitis, allergic rhinitis, dizziness and giddiness and repeated falls. Review of the 05/12/22 annual Minimum Data Set (MDS) 3.0 assessment revealed the resident was moderately impaired for daily decision making, exhibited no moods or behaviors and required extensive assistance from one staff for bed mobility and transfers. The assessment revealed the resident received antipsychotic, anti-anxiety and anti-depressant medication. A review of physician's orders revealed the resident had an order, dated 04/20/22 for the anti-anxiety medication, Ativan. An order, dated 04/29/21 for the anti-depressant medication, Cymbalta for major depressive disorder. An order, dated 06/07/22 for the anti-psychotic medication, Risperdal two milligrams (mg) at bedtime for psychosis not due to a substance or known physiological condition and Risperdal one mg daily. And an order, dated 01/28/22 for the anti-depressant medication, Trazodone at bedtime. Review of the 05/14/21 psychotropic medication care plans revealed the following: An anti-depressant plan of care indicating the resident was at risk for developing adverse effects from the use of anti-depressant medicine medication. The goal was for the resident to be free of adverse effects of antidepressants. The approach was attempt a gradual dose reduction in two separate quarters with at least one month between the attempts during the first year the resident received an anti-depressant medication then yearly unless clinically contradicted. A plan of care indicating the resident was at risk for adverse consequences related to receiving an antipsychotic medication for psychosis. The long-term goal was for the resident to not exhibit signs and drug related side effects or adverse drug reaction. Interventions included attempt a gradual dose reduction within two separate quarters at least one month between attempts during the first year the resident receives an antipsychotic medication then yearly and less contradicted. Aims test per guidelines. A plan of care indicating the resident was at risk for adverse consequences related receiving an anti-anxiety medication for anxiety. The long-term goal was for the resident to not exhibit signs of drug related side effects or adverse drug reaction. Interventions included attempt a gradual dose reduction within two separate quarters at least one month between attempts during the first year the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 7 of 28 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 366051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Northpointe 3291 Northpointe Drive Zanesville, OH 43701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm resident receives an antipsychotic medication then yearly unless contradicted and AIMS testing per guidelines. The care plans did not include identified behaviors, measurable person centered objectives and/or nonpharmacological interventions. Residents Affected - Few On 06/23/22 on 5:31 P.M. interview with Registered Nurse #341 verified the resident care plans had no identified targeted behaviors to monitor or measure and lacked evidence of non-pharmacological interventions for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 8 of 28 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 366051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Northpointe 3291 Northpointe Drive Zanesville, OH 43701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #6 revealed an admission date of 06/01/21. Residents Affected - Few A Minimum Data Set (MDS) 3.0 assessment, dated 03/10/22 revealed the resident had short and long term memory impairment and was on Hospice. An event note on 06/07/22 at 6:42 A.M. revealed the aide alerted the nurse Resident #6 had a skin tear on her right forearm. The resident was unable to state what caused the skin tear. The area was cleansed and a dry clean dressing applied. A physician's order was obtained on 06/07/22 to cleanse the right forearm with normal saline and cover with foam dressing. The dressing was to be changed every three days. Review of the treatment administration record revealed the dressing to Resident #6's right forearm was documented as being changed on 06/22/22. On 06/21/22 at 2:50 P.M. Resident #6 was observed to have a dressing on her right forearm. The dressing was dated 06/19/22. However, observations on 06/23/22 at 9:35 A.M. revealed Resident #6 had a dressing on her right forearm, dated 06/19/22. (As observed on 06/21/22). On 06/23/22 at 9:35 A.M. interview with the Assistant Director of Nursing confirmed the dressing on Resident #6's forearm was dated 06/19/22. On 06/23/22 at 2:00 P.M. the Assistant Director of Nursing confirmed the nurse had documented the dressing was changed on 06/22/22 but it was not. Based on observation, record review and interview the facility failed to ensure non-pressure related wound care was provided for a surgical wound for Resident #168 and a skin tear for Resident #6 as ordered. This affected two residents (#6 and #168) of two residents reviewed for non-pressure skin conditions. Findings include: 1. A review of Resident #168's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including orthopedic aftercare following a surgical amputation, an acquired absence of the left leg above the knee, chronic total occlusion of an artery of the extremities and peripheral vascular disease. A review of Resident #168's physician's orders revealed an order, dated 06/17/22 to cleanse left above knee amputation (LAKA) incision with soap and water, pat dry, and apply a dry clean dressing wrapping it with Kerlix daily and as needed (PRN) until his follow up with the vascular surgeon on 06/30/22. A review of Resident #168's admission/ 5 day Minimum Data Set (MDS) 3.0 assessment, dated 06/08/22 revealed the resident did not have any communication issues and was cognitively intact. The resident was not known to display any behaviors nor was he known to reject care during the seven days of the assessment period. The MDS was coded to reflect the resident had a surgical wound and was receiving (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 9 of 28 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 366051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Northpointe 3291 Northpointe Drive Zanesville, OH 43701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 surgical wound care. Level of Harm - Minimal harm or potential for actual harm A review of Resident #168's active care plans revealed no plan of care was in place to directly address the surgical incision to the LAKA site. The resident did have a non-compliance care plan but it only addressed not keeping his indwelling urinary catheter collection bag covered and did not indicate he was known to refuse surgical wound care or the application of a dressing to the surgical wound on his amputation site. Residents Affected - Few A review of Resident #168's treatment administration record (TAR's) for June 2022 revealed the order to cleanse the incision to the LAKA site with soap and water and to pat dry, apply a dry clean dressing, and wrap with Kerlix securing with tape daily and PRN was included on the TAR. The nurses were initialing it was being completed as ordered daily between 6:00 A.M. and 10:00 A.M. A review of Resident #168's nursing progress notes revealed a nurse's note, dated 06/22/22 at 9:14 A.M. that indicated the resident's LAKA was ordered for a dry clean dressing (DCD) daily but the resident was known to take it off as he stated it pulled when he took his drawers up and down while using the bathroom. The physician had been notified but no return call was received. A prior note on 06/21/11 indicated the DCD would be applied as the resident allowed. On 06/22/22 at 8:35 A.M., an observation of Resident #168 revealed he was lying in bed. A surgical wound was noted to the LAKA site with sutures intact. There was no dressing in place nor was there evidence of an old dressing having been applied and removed. An interview with the resident at the time of the observation revealed staff had not been providing any surgical wound care to his amputation site to include the application of a dressing. Subsequent observations on 06/22/22 through 06/23/22 revealed no evidence of a dressing having been applied to the resident's LAKA site. Multiple observations were made on those two days with no evidence of a dressing having been applied or evidence it had previously been applied and removed by Resident #168. An observation on 06/23/22 at 11:15 A.M. revealed the resident was in bed watching TV. His lower body was covered with a blanket. He was asked if he had a dressing on his LAKA surgical site and denied having one on. He uncovered his stump to reveal no dressing was in place. His sutures remained intact and the surgical incision was well approximated with only slight redness noted along the incision site. There was no drainage noted or signs of any infection. On 06/23/22 at 11:15 A.M., a follow up interview with Resident #168 revealed the staff had not been washing his surgical incision to his LAKA site with soap and water as ordered by the physician. He denied he had been refusing the treatment to his surgical site or had been removing the dressing himself after it had been applied as indicated in the progress notes. He denied his dressing was catching on his pants when he pulled them up and down when using the bathroom as also indicated in the nurses' progress notes. He denied he had a dressing applied to that surgical wound after they stopped using the wound vac on 06/17/22. The resident revealed he would not be opposed to having wound care provided or a dressing applied if the physician wanted it and it was to help prevent infection. He thought it would be good for it to be left open to air but denied anyone had ever provided him education on the benefits/ risks associated with the treatment provided. The resident revealed the only thing that would catch on his pants when he pulled them up and down was his sutures as they were long and would cause discomfort. The resident stated he had since trimmed them down using a pair of scissors so that was not as much as an issue. The resident stated he was not sure if he should have done that or not but did it anyway. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 10 of 28 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 366051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Northpointe 3291 Northpointe Drive Zanesville, OH 43701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 06/23/22 at 11:30 A.M. an interview with LPN #303 revealed she was not aware of what the treatment orders were for Resident #168's surgical wound to his left stump. The LPN had to check the resident's orders and confirmed the incision was supposed to be cleansed with soap and water, pat dry, apply DCD, and wrap with Kerlix securing with tape every day and PRN. She confirmed the order had been in place since 06/17/22 and acknowledged the resident had not been observed to have a dressing in place during observations from 06/21/22 to 06/23/22. She reported the treatment was to be done on day shift between 6:00 A.M. and 10:00 A.M. She denied she had completed the treatment to Resident #168's surgical incision as ordered for 06/23/22 despite it being over an hour and a half past due. She reported this was the first day she had worked with the resident in a while. The LPN revealed the last time she took care of him, the resident still had the use of the wound vac. On 06/23/22 at 2:38 P.M., a phone interview with RN #308 revealed she was the nurse who was assigned to the resident's unit on 06/21/22 and 06/22/22, when he was not noted to have a dressing on to his LAKA surgical site. She reported the resident did not like to have a dressing on to his stump as when he went to the bathroom his pants would catch on the dressing and pulled it off. It would also catch on his suture and cause him discomforts. She reported the resident was temperamental and did not like to be bothered or disturbed while in the bathroom. RN #308 revealed she did not approach the resident on those days to perform his treatment as ordered. RN #308 revealed she assumed the resident washed his stump incision with soap and water when he was washing the rest of his body as part of his personal care. She stated she reached out to the physician on 06/22/22 to let him know the resident was not wanting to keep a dressing on his incision site to see if he would allow it to be left open to air. She denied they had heard back from the physician after she reached out to him. She was going to wait and see what the physician wanted to do before approaching the resident about his treatment or dressing applications. RN #308 revealed she tried to tread lightly around the resident and did not want to upset him. RN #308 revealed the resident had told the staff in the past that he felt they treated him like a baby and she just did not want to upset him. She denied she had provided education to the resident as to why it was important to comply with treatments and to maintain a dressing on his surgical site to prevent infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 11 of 28 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 366051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Northpointe 3291 Northpointe Drive Zanesville, OH 43701 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 observation, record review, facility policy and procedure review and interview the facility failed to adequately assess a pressure ulcer for Resident #67 to identify the proper stage of the ulcer. This affected one resident (#67) of two residents reviewed for pressure ulcers. Residents Affected - Few Findings include: A review of Resident #67's medical record revealed the resident was originally admitted to the facility on [DATE]. He was hospitalized on [DATE] and was readmitted to the facility on [DATE]. Resident #67 had diagnoses including a fracture of the second and third lumbar vertebrae, morbid obesity and adult onset diabetes mellitus. A review of Resident #67's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/30/22 revealed the resident was assessed to be at risk for pressure ulcers and also had an unhealed pressure ulcer. The unhealed pressure ulcer was noted to be a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough that may also present as an intact or open/ ruptured blister) that was present upon admission or reentry into the facility. A review of Resident #67's physician's orders revealed the resident had an order in place to cleanse his left heel with normal saline, pat dry, apply a nickel thick layer or Santyl (an autolytic wound debrider) ointment to the wound bed, cover with a 4 x 4 gauze fluffed and slightly damp with normal saline, cover with an ABD, and wrap with Kerlix. The treatment was to be completed every day and as needed (PRN) and was initiated on 06/01/22. A review of Resident #67's active care plans revealed the resident had a care plan in place for having actual altered skin integrity and was at risk for related complications due to a pressure injury to the left heel. The interventions included assessing and recording the condition of the skin surrounding the pressure ulcer and completing a weekly skin assessment to include measurements and observations of the pressure ulcer and record. Review of the weekly wound assessments revealed the following: A wound assessment, dated 05/17/22 indicated the resident was readmitted to the facility with a blister area that was noted to have opened. The area measured 4.7 centimeters (cm) in length by 3.5 cm width and had 100% granulation tissue in the wound bed. The wound edges were not attached to the base and was macerated/ soft. A wound assessment, dated 05/31/22 revealed Resident #67's pressure ulcer was assessed to be an an unstageable pressure ulcer (known pressure ulcer but was not stageable due to the coverage of the wound bed by slough and/ or eschar) that measured 8 cm in length by 6 cm width with 0.1 cm depth. The wound bed had 30% granulation, 50% slough and 20% eschar and the wound had indicated to have declined. A wound assessment, dated 06/07/22 revealed Resident #67's pressure ulcer was assessed to be a Stage II pressure ulcer at that time, despite it being identified as an unstageable pressure ulcer the week before. It measured 8.4 cm in length by 4.5 width with 0.1 cm depth and was noted to have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 12 of 28 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 366051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Northpointe 3291 Northpointe Drive Zanesville, OH 43701 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 purulent drainage with a slight odor. There was 60% granulation and 40% slough present in the wound bed, which would not be present, if the pressure ulcer by definition was truly a stage II pressure ulcer. A wound assessment, dated 06/14/22 revealed Resident #67's pressure ulcer continued to be classified as a Stage II pressure ulcer. It measured 8 cm in length by 4 cm width with 0.3 cm depth and had a moderate amount of seropurulent exudate. The wound bed had 70% of granulation was noted and 30% slough. A wound assessment, dated 06/21/22 revealed Resident #67's pressure ulcer remained classified as a Stage II pressure ulcer. It measured 7.8 cm in length by 3.8 cm width with 0.2 cm depth with a moderate amount of seropurulent drainage. The wound bed was indicated to be comprised of 70% epithelialization tissue and 30% slough tissue. On 06/23/22 at 10:15 A.M. a treatment observation was completed for Resident #67's pressure ulcer to the left heel. The treatment was performed by Licensed Practical Nurse (LPN) #303 and she was assisted by the facility's acting Director of Nursing (DON) who was also considered the facility's wound nurse. The treatment was performed in accordance with the physician's orders. The DON assessed the wound and obtained measurements, after the wound had been cleansed. She reported the peri-wound area was macerated and the wound bed had 30% slough and 70% epithelial tissue present. She was hesitant when describing the wound bed as having epithelialization tissue present stating it more in a question than a statement. She stated she classified the wound as a Stage II pressure ulcer despite previously stating there was 30% slough present. On 06/23/22 at 2:10 P.M. an interview with the Director of Nursing (DON) revealed she had just taken over as the facility's acting DON and had been the wound nurse for the past month. She reported she was tossed into that role and had received wound training in May 2022. She stated she took her test and became wound certified on 05/20/22. She confirmed the resident's area on his left heel originated on 05/12/22, when he returned to the facility after a hospitalization between 05/10/22 and 05/12/22. She reported it was a blister that opened and would have been considered a Stage II pressure ulcer at that time. She reported she did not assess it as a Stage II pressure ulcer until the assessment completed on 05/24/22, as that was when she became wound certified and was more familiar with wounds and their assessments. She was not sure why she classified the pressure ulcer as a Stage II pressure ulcer on 06/07/22, after the previous week she had assessed it as an unstageable pressure ulcer. She acknowledged an unstageable pressure ulcer had to be either a Stage III or IV pressure ulcer when the slough or eschar was removed and could not be a Stage II pressure ulcer underneath. She also acknowledged her weekly assessments since 05/31/22 continued to assess the pressure ulcer as a Stage II pressure ulcer even though she indicated slough was present in the wound bed. She acknowledged by definition a Stage II pressure ulcer did not have slough present. She was then asked to clarify her assessment on 06/21/22, when she indicated epithelialization tissue was present in the wound bed when she agreed she should have assessed the wound as a Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon, or muscle was not exposed, slough may be present but did not obscure the depth of tissue loss) at that time. She reported she was informed by the MDS nurse that it could not be epithelialization tissue present in a Stage III pressure ulcer, as the wound healing would occur from the base of the wound up and not from the sides. She knew epithelialization tissue healing occurred when wounds healed by the edges closing together, such as with a Stage II pressure ulcer, skin tear or burn and granulation tissue healing occurred when the wound filled in from the base up until it was healed. She stated she was still learning as she went along and it was a work in progress. She revealed she was becoming more familiar with wounds after she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 13 of 28 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 366051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Northpointe 3291 Northpointe Drive Zanesville, OH 43701 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 had been trained and continued to gather experience in wound management. Level of Harm - Minimal harm or potential for actual harm A review of the facility policy titled Pressure/ Stasis/ Arterial/ Diabetic Wound Guidelines, revised 05/10/17 revealed the purpose of the policy was to provide weekly documentation of wound measurements and condition. Reassessments/ measurements were to be completed weekly or with significant change in wound. It did not provide any directive in staging of the pressure ulcers and the facility did not provide any additional policies that addressed that. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 14 of 28 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 366051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Northpointe 3291 Northpointe Drive Zanesville, OH 43701 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, facility policy and procedure review and interview the facility failed to ensure fall prevention interventions were implemented as planned for Resident #14 and Resident #51 to decrease the residents' risk of falls. This affected two residents (#14 and #51) of four residents reviewed for falls. Findings include: 1. Review of Resident #51's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including myocardial infarction, hypertropic cardiomyopathy, Alzheimer's disease late onset, unspecified dementia with behavioral disturbance, mood disorder due to known physiological condition, mixed receptive-expressive language disorder, unspecified psychosis not due to substance or known psychological condition. Deficiency of B vitamin, hypothyroidism, history of falling, osteoarthritis, hypertension, dry eye syndrome. cognitive communication deficit, difficulty walking, muscle weakness, constipation, dysphasia and altered mental status. A review of Resident #51's care plan, initiated 11/27/18 revealed the resident was at risk for falling related to a history of falls, weakness, cognitive impairment and receiving medication that increases risk of falls. The goal was for the resident to remain free of falls with major injury. Interventions included visual cues to bathroom door to identify bathroom location as resident will allow and staff to offer early morning snack as resident will allow. Review of the resident's falls in the last year revealed the resident sustained falls on 08/28/21, 04/23/22, 05/04/22 and 05/08/22. A review of Resident #51's 05/04/22 fall revealed the resident was found in front of the bathroom doorway. The resident sustained a skin tear to the left elbow as a result of the fall. Upon questioning, the resident thought she was looking for the toilet. A new intervention included visual cue to bathroom door. A review of Resident #51's 05/08/22 fall revealed the resident was noted to have a fall in the morning of 05/08/22 prior to breakfast. The resident was noted to sustain two skin tears (one to right arm, and one to left) as a result of the fall. Upon investigating, the resident was noted to receive breakfast on the memory care unit around 7:00 A.M. A new intervention was for staff to offer an early morning snack prior to breakfast. Review of the 05/16/22 significant change Minimum Data Set (MDS) 3.0 assessment revealed the resident was coded as not having any falls since the last assessment. Review of the 06/03/22 quarterly MDS 3.0 assessment revealed the resident was moderately impaired for daily decision making, exhibited rejection of care and wandering. The resident required set up assist from one staff for bed mobility, staff supervision set up for transfers, toileting walking in room, in corridor and on unit. The assessment revealed the resident had no falls since the last assessment and received anti-psychotic, anti-depressant and diuretic medications. On 06/22/22 at 2:20 P.M. and 3:15 P.M. and on 06/23/22 at 9:55 A.M., 10:03 A.M. and 12:01 P.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 15 of 28 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 366051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Northpointe 3291 Northpointe Drive Zanesville, OH 43701 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 observations of the resident's room revealed there was no signage (cues) visible on the bathroom door or walls. On 06/23/22 at 9:55 A.M. interview with Registered Nurse (RN) #300 revealed the resident was a recent transfer to the unit as she was exit seeking. The RN revealed she did not know anything about falls for the resident. On 06/23/22 at 12:04 P.M. interview with RN #300 verified there was no signage (visual cues) on the bathroom door to alert the resident of location in the of the bathroom. RN #300 revealed the intervention did not carry over to the resident's profile for the State Tested Nursing Assistant (STNA) staff to know a sign was to be there. On 06/23/22 at 12:09 P.M. interview with STNA #304 revealed she did not recall ever seeing a sign in the resident's room to locate the bathroom. She did not know what the resident's fall interventions would be. The STNA was unaware to offer the resident a snack before breakfast. STNA #304 revealed it was not on the resident's profile, information the STNA staff could view in their documentation system to offer a snack in the morning before breakfast. The STNA denied offering the resident a snack this morning. On 06/23/22 at 1:55 P.M. interview with RN #320 verified the resident had falls 05/04/22 and 05/08/22 resulting in skin tears. The RN verified the 05/16/22 significant change (MDS) 3.0 assessment was coded in error and should have coded two falls with minor injury instead of no falls since last assessment. Review of the facility Fall Management Program Guidelines, reviewed 03/16/22 revealed the facility strived to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. The resident care plan shall be updated to reflect any new or change in interventions. Nursing staff would monitor and document continued resident response and effectiveness of interventions for 72 hours. Discuss risk and interventions with resident and/or responsible party and communication interventions during shift report. 2. A review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including a history of falling, unsteadiness on her feet, difficulty in walking, muscle weakness, syncope and collapse and hypertension (HTN). A review of Resident #14's annual Minimum Data Set (MDS) 3.0 assessment, dated 04/04/22 revealed the resident did not have any communication issues and was cognitively intact. The resident required supervision with staff set up help for bed mobility, ambulation in room and corridor, locomotion on and off the unit and dressing, staff supervision with the assist of one was needed for transfers and toilet use. The resident was noted to have had one fall with injury that was not major since her prior assessment. A review of Resident #14's active care plans revealed the resident experienced actual falls and was at risk for falling related to syncope and collapse, HTN, pain, and the use of oxygen and oxygen tubing. The goal was for the resident to remain free of falls with major injury. Interventions included (on 03/23/22) anti-tippers (bars applied to the back of the wheelchair to prevent it from tipping backwards) to her wheelchair. A review of Resident #14's fall events revealed she had a fall that occurred on 03/23/22 in the day (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 16 of 28 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 366051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Northpointe 3291 Northpointe Drive Zanesville, OH 43701 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 room. It was a witnessed fall and she was noted to tip her wheelchair over. The immediate action taken was for the use of anti-tippers to her wheelchair. On 06/23/22 at 5:00 P.M. an observation of the resident's wheelchair in her room revealed it did not include anti-tippers to the back of her wheelchair. The resident confirmed she did have a fall in the activity room in which her wheelchair tipped over. She was not sure if the facility staff ever put anti-tippers on the back of her wheelchair after that fall occurred. Findings were verified by LPN #318. On 06/23/22 at 5:05 P.M., an interview with LPN #318 confirmed Resident #14's fall prevention interventions in her plan of care included the use of anti-tippers to the back of her wheelchair. She confirmed the wheelchair in the resident's room was the wheelchair used by the resident and it did not have anti-tippers on the back of it. She reported she would submit a work order to have them put on the wheelchair by the maintenance department. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 17 of 28 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 366051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Northpointe 3291 Northpointe Drive Zanesville, OH 43701 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 record review, facility policy and procedure review and interview the facility failed to ensure Resident #49's weights were obtained as recommended by the dietician to adequately monitor the resident's nutritional status and to identify a significant weight loss in a timely manner. This affected one resident (#49) of three residents reviewed for nutrition. Residents Affected - Few Findings include: A review of Resident #49's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including adult onset diabetes mellitus, depression, anxiety, anemia, Vitamin D deficiency, hyperlipidemia and rheumatoid arthritis. A review of Resident #49's nutrition admission assessment, dated 05/10/22 revealed the resident's current body weight was 195 pounds upon admission. The weight was stable with the weight obtained in the hospital. The dietician indicated the facility would monitor the resident's weight trends and weekly weights were ordered. Interventions listed as part of the nutrition admission assessment revealed no new recommendations were made but they would continue to monitor her weight trends. A plan of care, dated 05/10/22 revealed Resident #49 was malnourished/ at risk for malnutrition related to her diagnoses, inadequate nutrient/ energy intakes, and/or metabolic demands. The interventions included obtaining the resident's weights as ordered/ needed. A review of a nutrition progress note, dated 06/01/22 revealed the resident was noted to have a current body weight of 166 pounds, which was a 28.4 pound/14.6% weight loss in the past 26 days. A weight loss of 5% in one month was a significant loss and a loss of greater than 5% was a severe loss. The dietician indicated weekly weights for monitoring were ordered. The interventions specified the dietician recommended to continue weekly weights for four weeks as part of her review. She also recommended changing the resident's current supplement order of Ensure twice a day to Med Pass 120 milliliters three times a day. A review of Resident #49's physician's orders revealed the resident was not ordered to have weekly weights obtained until 06/02/22. There was no evidence weekly weights had been ordered following her admission into the facility until 06/02/22. A review of Resident #49's weights recorded in the electronic health record (EHR) confirmed the resident weighed 195 pounds on 05/04/22. There was no documented evidence of the resident being weighed again until 05/30/22 when her weight was down to 166.6 pounds. On 06/23/22 at 4:10 P.M., an interview with Registered Nurse (RN) #341 confirmed there was no evidence of any weights being obtained for Resident #49 between 05/04/22 and 05/30/22. She denied knowledge the resident was a weekly weight after she had been admitted to the facility on [DATE]. She denied it was the facility practice to get weekly weights for four weeks on all new admissions but had seen that done in other facilities. She acknowledged by doing weekly weights after the resident's admission they would have identified her weights were trending down before she ended up having a significant/severe weight loss of 28.4 pounds/14.6% in less than 30 days. She acknowledged the dietician indicated in her nutrition admission assessment, dated 05/10/22 that they would continue to monitor the resident's weight trends and she would be weighed weekly for four weeks. She was not able to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 18 of 28 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 366051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Northpointe 3291 Northpointe Drive Zanesville, OH 43701 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 determine why an order for weekly weights had not been obtained prior to 06/02/22 when the dietician intended for them to be monitored weekly after her initial nutrition assessment was completed. A review of the facility policy titled Guidelines for Weight Tracking, revised 01/16/21 revealed the purpose of the policy was to ensure weights were monitored for weight gain and/or loss to prevent complications arising from compromised nutrition/ hydration. The procedures indicated residents would have their weight taken and recorded upon admission to establish a baseline. Unless otherwise indicated or ordered by the physician the resident would have their weight taken and recorded monthly. Event ID: Facility ID: 366051 If continuation sheet Page 19 of 28 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 366051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Northpointe 3291 Northpointe Drive Zanesville, OH 43701 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to develop and implement a comprehensive and individualized pain management program to provide adequate pain control for Resident #35. Residents Affected - Few Actual harm occurred on 06/21/22 when Resident #35, who received Hospice services for terminal Parkinson's Disease, complained of continued, unrelieved pain despite scheduled and as needed narcotic pain medication doses, exhibited by verbal complaints of pain and moaning. The facility failed to comprehensively assess the resident's pain and notify Hospice services and/or the primary care physician regarding the resident's increased pain resulting in the resident being very restless and unable to get adequate rest due to increased pain despite additional dosages of as needed pain medication. This affected one resident (#35) of one resident reviewed for pain. The facility identified 12 residents receiving Hospice services and 50 residents on a pain management program. The census was 71. Findings include: Review of Resident #35's medical record revealed an admission date of 02/25/22 with diagnoses including metabolic encephalopathy, Parkinson's Disease, chronic kidney disease, kidney and ureter stones. The resident was also admitted with a pressure ulcer that was determined to be a [NAME] (terminal) ulcer by Hospice staff. Review of the admission Observation and Data Collection form, dated 02/25/22 revealed the resident did not report pain on admission to the facility. Review of the plan of care, dated 03/04/22 revealed the resident was at risk for pain related to acute pain, pressure ulcer and treatments, cervical disc degeneration and history of femur and pubis fracture. Interventions including notify physician of increased pain, observe for and record verbal and non-verbal signs of pain. Review of the Hospice team care plan (provided by the Hospice provider), dated 04/13/22 revealed the Hospice team was responsible for professional management of care in all settings as care related to the (resident's) terminal diagnosis and related conditions. The Hospice team was responsible for plan of care coordination with all contracted providers. Nursing, psych/social/pastoral care and volunteer visits as needed 24 hours per day for symptom management, emotional and spiritual support. Patient/caregiver informed of 24/7 access to all services and phone numbers provided. Review of the significant change Minimum Data Set (MDS) 3.0 assessment, dated 04/25/22 revealed the resident had moderate cognitive impairment and required extensive assistance of two staff to total dependence of one staff for activities of daily living. Further review revealed the resident occasionally had pain during the assessment and rated his pain an eight on a 1-10 pain scale, which indicated a moderate pain level and staff relied on non-verbal indicators such as protective body movements and vocal complaints of pain. The assessment revealed the resident received opiate pain medications seven days during the assessment period. Review of the physician's orders revealed the resident had an order, dated 04/13/22 for the pain medication, Oxycodone 7.5 milligrams (mg) every two hours as needed for pain and an order, dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 20 of 28 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 366051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Northpointe 3291 Northpointe Drive Zanesville, OH 43701 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 0697 05/04/22 for Oxycodone 10 mg one tablet orally every four hours. The Oxycodone 10 mg was scheduled at 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M. and 8:00 P.M. Level of Harm - Actual harm Residents Affected - Few A plan of care, dated 05/09/22 revealed the resident was receiving Hospice services for terminal diagnosis of Parkinson's disease. Interventions included to administer drugs as needed for palliation per physician orders, administer pain medication as ordered and as needed, communicate with Hospice when any changes were indicated to the plan of care, coordinate care with the Hospice provider with the contact number and address of Hospice provided. On 06/21/22 at 5:15 P.M. interview with Resident #35's son revealed he wanted to ensure the resident's pain was controlled and he was comfortable. The son stated there were recent issues with the resident's pain control and the resident having extreme pain. Review of a progress note, authored by Registered Nurse (RN) #385, dated 06/21/22 at 10:03 P.M. revealed the resident was moaning out in pain. Scheduled pain medications given with negative results noted. As needed pain medications given twice with negative results noted. One on one and repositioning negative. The resident complained of pain in his kidneys, back and all over. The resident refused dinner, offered and accepted fluids. The note indicated this nurse would continue to monitor. Review of a progress note, authored by RN #385, dated 06/22/22 at 12:00 A.M. revealed the resident continued to complain of pain. This nurse administered scheduled pain medications with an additional dose of as needed (PRN) pain medications after one on one, toileting and repositioning were ineffective. The resident stated his hips felt like they were breaking through his skin. The resident stated he was miserable. The note revealed the nurse provided fluids to the resident. The resident continued to have no urine output at this time. Further review of the progress note, dated 06/22/22 at 4:07 A. M. revealed the resident continued to moan in discomfort while laying in bed. The resident continued to have zero urine output at this time. The nurse completed a bladder scan with results of greater than 400 milliliters of urine in the bladder. A urinary catheter was inserted per order due to urinary retention. The resident tolerated the procedure with greater than 400 milliliters of milky yellow urine obtained. The urine was noted to have a large amount of sediment upon return. The note revealed the nurse medicated the resident with scheduled pain medication as well as a dose of the PRN pain medication. The resident stated the pain was still terrible. The resident remained alert and able to make his needs known during the night. The resident was very restless and unable to get adequate rest due to increased pain despite additional dosages of PRN pain medication. On 06/22/22 at 5:25 A.M. Hospice was notified of the change in resident condition as well as increased pain. The nurse asked for a possible re-assessment for the need of Morphine pain medication. Awaiting a return call from the hospice nurse. Further review of the progress notes revealed no additional documentation regarding the Hospice notification or the resident's pain until 06/22/22 at 2:25 P.M. when RN #309 documented the Hospice nurse visited and a new order was received to change the resident's scheduled pain medication and increase the dosage of the PRN Oxycodone. Review of the PRN Oxycodone doses revealed staff documented the resident received additional Oxycodone on 06/21/22 at 5:31 P.M. (effective), 10:03 P.M. (effective); 06/22/22 1:14 A.M. (effective) and 3:35 A.M. (effective). However, the effectiveness documented on the PRN medication sheets were not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 21 of 28 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 366051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Northpointe 3291 Northpointe Drive Zanesville, OH 43701 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 0697 reflective of the narrative nurse progress notes documented in the medical record. Level of Harm - Actual harm On 06/23/22 at 12:40 P.M. interview with Hospice Registered Nurse (RN) #401 revealed she visited Resident #35 from Hospice and revealed Hospice staff were unaware of the resident's continued complaints of unrelieved pain until 06/22/22 during the 5:00 A.M. hour when the Hospice triage nurse was notified. RN #401 verified Hospice was not updated on the intensity of the resident's pain or his inability to rest during the night and the message relayed was not as stated in the facility nurse's progress notes. RN #401 indicated had this been described to the triage nurse, Hospice would have visited the resident sooner for his pain management. RN #401 revealed the Hospice goal for Resident #35 was to achieve the best level of pain control for the resident as possible. RN #401 revealed the resident would never be pain free due to his chronic pain but Hospice wanted the resident as comfortable as possible. RN #401 revealed the resident received scheduled Oxycodone (narcotic pain medication) every four hours and Oxycodone every two hours as needed. RN #401 revealed the facility staff were told hospice could be called any time, day or night, if they need to report something or the resident needed anything and the expectation would be the same for uncontrolled pain. Further interview revealed, for a Hospice resident with uncontrolled pain, offering food and fluids would be an ineffective intervention to attempt and if he was having issues with pain control as indicated in the progress notes, a call should have been placed to the triage nurse to evaluate the resident and hopefully get new orders and something different for pain control started sooner. The RN also revealed there were always options for Hospice patients for pain control and if the resident was not achieving comfort, he should not have been left in that amount of pain for the night, affecting his ability for rest. Lastly, the RN stated residents with Hospice services needed to have the best pain control possible and verbalizations of unrelieved pain and/or moaning indicated the resident did not have the best pain control for him. RN #401 revealed the resident's pain management regimen was changed to longer acting medications and a higher dose of Oxycodone every two hours, as needed, to prevent additional issues with pain management. Residents Affected - Few On 06/23/22 at 3:28 P.M. interview with the Assistant Director of Nursing verified the progress notes indicated the resident had uncontrolled pain and the nurse working should have contacted Hospice for the resident before the end of her shift to ensure the resident had effective pain management. The ADON revealed the nurse should have called the primary care physician if Hospice wasn't available but indicated Hospice was available with an on-call nurse after hours seven days a week. The ADON also verified there was no comprehensive pain assessment completed with the resident's uncontrolled pain on 06/21/22 into 06/22/22. The ADON verified the facility pain management policy required a comprehensive pain assessment be completed with changes in pain and the plan of care indicated the physician or hospice should be contacted with changes in pain. Lastly, the ADON verified the nursing progress notes indicated the resident had severe, uncontrolled pain affecting his quality of life and his ability to sleep and/or rest with a terminal diagnosis. The ADON also verified there was no evidence the primary care physician was notified. On 06/23/22 at 5:06 P.M. interview with RN #309 revealed she was the nurse who relieved night shift on 06/22/22. The night shift nurse reported the resident had excruciating pain throughout the night. The Hospice nurse came that day and ordered medication changes. The RN verified Resident #35's pain was usually controlled and it was unusual for him to have uncontrolled pain like he had during the shift. Attempts to reach RN #385 during the survey process were unsuccessful. Review of the Guidelines for Pain Observation and Management Policy, dated 05/11/16 and revised (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 22 of 28 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 366051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Northpointe 3291 Northpointe Drive Zanesville, OH 43701 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 0697 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 05/23/17 revealed the purpose of the policy was to ensure each resident's pain including it's origin, location, severity, alleviating and exacerbating factors, current treatment and response to treatment was observed and documented according to the needs of each individual. If there was a change in pain indicators or verbalizations from resident, a pain event form would be completed to indicate changes and care plan update. Educate the resident/family/care givers on the pain management interventions and importance of notifying staff of changes in pain status. Implement the care plan approaches to assist with pain management. Evaluate the effectiveness of pain management interventions and modify as indicated. Event ID: Facility ID: 366051 If continuation sheet Page 23 of 28 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 366051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Northpointe 3291 Northpointe Drive Zanesville, OH 43701 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 observation, record review, facility policy and procedure review and interview the facility failed to identify and/or monitor and measure specific targeted behaviors, perform Abnormal Involuntary Movement Scale (AIMS) testing and/or complete gradual dose reductions as required for the use of psychotropic medication to ensure psychotropic medications were justified and administered at the lowest effective dose for each resident. This affected three residents (#41, #50 and #51) of five residents reviewed for unnecessary medication use. The facility identified 55 residents who received psychoactive medications. The facility census was 71. Findings include: 1. Review of Resident #50's medical record revealed a 04/29/21 admission with diagnoses including dementia without behavioral disturbance, multi-system degeneration of the autonomic nervous system, orthostatic hypotension, major depressive disorder, single episode, Type 2 diabetes mellitus with diabetic neuropathy, psychosis not due to a substance or known physiological condition, severe protein-calorie malnutrition, anxiety disorder, diverticulosis of intestine (part unspecified) without perforation or abscess without bleeding, gastroesophageal reflux disease without esophagitis, allergic rhinitis, dizziness and giddiness and repeated falls. A review of physician's medication orders revealed the resident had an order (dated 04/20/22) for the anti-anxiety medication Ativan one milligram (mg) twice a day and Ativan 0.5 mg once a day for anxiety. An order (dated 04/29/21) for the anti-depressant medication, Cymbalta 90 mg daily for major depressive disorder. An order (changed 06/07/22) for the anti-psychotic medication, Risperdal two mg at bedtime for psychosis not due to a substance or known physiological condition and Risperdal one mg daily. An order (dated 01/28/22) for the anti-depressant medication, Trazodone 300 mg at bedtime for depressive disorder. Review of the plan of care, dated 05/14/21 for psychotropic medication use revealed the following: A plan of care indicating the resident was at risk for developing adverse effects from the use of anti-depressant medicine medication. The goal was for the resident to be free of adverse effects of anti-depressants. The approach included to attempt a gradual dose reduction in two separate quarters with at least one month between the attempts during the first year the resident received an anti-depressant medication then yearly unless clinically contradicted. A plan of care indicating the resident was at risk for adverse consequences related to receiving an anti-psychotic medication for psychosis. The long-term goal was the resident would not exhibit signs and drug related side effects or adverse drug reaction. Interventions included attempt a gradual dose reduction within two separate quarters at least one month between attempts during the first year the resident receives an antipsychotic medication then yearly and less contradicted. AIMS testing per guidelines. A plan of care indicating the resident was at risk for adverse consequences related to receiving an anti-anxiety medication for anxiety. The long-term goal was the resident would not exhibit signs of drug related side effects or adverse drug reaction. Interventions included attempt a gradual dose reduction within two separate quarters at least one month between attempts during the first year the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 24 of 28 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 366051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Northpointe 3291 Northpointe Drive Zanesville, OH 43701 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 resident receives an antipsychotic medication then yearly and less contradicted. AIMS testing per guidelines. Review of the 05/12/22 annual Minimum Data Set (MDS) 3.0 assessment revealed the resident was moderately impaired for daily decision making, exhibited no moods or behaviors and required extensive assist from one staff for bed mobility and transfers. The assessment revealed the resident received anti-psychotic, anti-anxiety and anti-depressant medication. Record review revealed no evidence of two gradual dose reductions for the resident's Risperdal from admission 04/2021 through 04/2022. Record review revealed no evidence of a GDR for the use of Cymbalta. On 06/25/22 (following surveyor intervention) the pharmacy made a recommendation for a GDR. Record review revealed no evidence of a GDR attempt for the use of Ativan. Review of the Medication Administration Record (MAR) revealed staff were to document from set target behavior/psych at the end of each shift; mark frequency (how often behavior occurred and intensity) and how resident responded to redirection. The intensity code zero revealed the behavior did not occur, one reflected the behavior was easily altered and two was difficult to redirect. The findings were to be documented twice a day. The same wording was repeated for the target set behavior for anxiety and for depression. There were 10 days between 06/01/22 and 06/22/21 where a numerical number of one or two was entered for psychological behaviors, 16 days for depression and 17 days for anxiety. There was no indication of what the psychological, depression and anxiety behaviors were. There was no evidence of baseline or continued Abnormal Involuntary Movement (AIMS) testing for the resident. Review of a Behavior Analysis Report, documented by STNA staff revealed there were no behaviors documented for the resident from May or June of 2022. Review of the May and June 2022 progress notes revealed no documented behaviors exhibited by the resident. On 06/22/22 at 2:13 P.M. the resident was observed at a music activity. On 06/23/22 at 09:08 A.M. the resident was at an exercise activity. No behaviors were observed. On 06/23/22 on 5:31 P.M. interview with Registered Nurse #341 verified the resident had no identified targeted behaviors being monitored and measured for the use of psychotropic medications. There was no required AIMS testing completed and attempts to complete GDR's of the medications (Ativan, Cymbalta, and Risperdal) had not occurred as care planned/required. Review of the facility 10/09/17 Psychotropic Medication Usage and Gradual Dose Reductions policy revealed the policy was to ensure every effort was made for residents receiving psychoactive medications to obtain the maximum benefit with minimal unwanted side effects through appropriate use, evaluation and monitoring by the interdisciplinary team. The policy included the following procedures: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 25 of 28 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 366051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Northpointe 3291 Northpointe Drive Zanesville, OH 43701 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 Residents shall receive psychotropic medications only if designated medically necessary by the prescriber, with appropriate diagnosis or documentation to support its usage. The medical necessity will be documented in the resident's medical record and in the care planning process. Regular monthly review of antipsychotic's for continued need, appropriate dosage, side effects, risks and/or benefits will be conducted, to ensure the use of psychopharmacological medications are therapeutic and remain beneficial to the resident. Efforts to reduce dosage or discontinue psychotropic medications will be ongoing, as appropriate. A gradual dose reduction (GDR) would be attempted for two (2) separate quarters (with at least one month between attempts) per the physician's recommendation. Gradual dose reduction must be attempted annually thereafter, unless medically contraindicated. Sedative/hypnotics would be reviewed quarterly for gradual dose reduction per the physician's recommendation. GDR shall be attempted quarterly unless clinically contraindicated. Gradual dose reductions would be documented on the appropriate event in the Electronic Health Record. 2. Review of Resident #51's medical record revealed a 10/17/18 admission with diagnoses including myocardial infarction, hypertropic cardiomyopathy, Alzheimer's disease late onset, unspecified dementia with behavioral disturbance, mood disorder due to known physiological condition, mixed receptive-expressive language disorder, unspecified psychosis not due to substance or known psychological condition, Deficiency of B vitamin, hypothyroidism, history of falling, osteoarthritis, hypertension, dry eye syndrome. cognitive communication deficit, difficulty walking, muscle weakness, constipation, dysphasia, and altered mental status. An 08/26/21 behavior plan of care revealed the resident demonstrated physically abusive and resistive behaviors toward staff during hands on care. The resident was known to swing, spit and throw things at staff. Interventions included to offer choices in all hands on care and contacts. Observe for signs of sensory over stimulation and encourage resident to move into less stimulating environments as needed. Explain care process prior to delivery of care as needed. A review of physician's orders revealed an order, dated 04/26/22 for the anti-psychotic medication, Seroquel (quetiapine) 25 mg daily for dementia with psychotic behaviors and 50 mg at bedtime. The resident also had an order for the anti-depressant medication, Trazodone 50 mg at bedtime for depression. Review of the 05/09/22 plan of care for psychotropic drug use included the resident was at risk for adverse consequences related to receiving an anti-psychotic medication for mood disorder due to known physiological condition, unspecified psychosis not due to substance or known physiological condition and antidepressant use for depression. The long-term goal was the resident would not exhibit signs and drug related side effects or adverse drug reaction. Interventions included attempt a gradual dose reduction within two separate quarters at least one month between attempts during the first year the resident receives an antipsychotic medication then yearly and less contradicted. AIMS testing per guidelines. Review of the 05/09/22 plan of care for psychotropic drug use included the resident was at risk for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 26 of 28 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 366051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Northpointe 3291 Northpointe Drive Zanesville, OH 43701 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 adverse consequences related to receiving an anti-depressant medication for depression. The long-term goal was the resident will not exhibit signs and drug related side effects or adverse drug reaction. Interventions included attempt a gradual dose reduction within two separate quarters at least one month between attempts during the first year the resident receives an antipsychotic medication then yearly and less contradicted. AIMS testing per guidelines. Residents Affected - Few Review of the 06/03/22 quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident was moderately impaired for daily decision making, exhibited rejection of care and wandering. The resident required one staff set up assist for bed mobility, staff supervision set up for transfers, toileting walking in room, in corridor and on unit. The assessment revealed the resident had no falls since the last assessment and received anti-psychotic, anti-depressant and diuretic medications. Review of the Medication Administration Record (MAR) revealed documentation of set target behaviors of psychosis: delirium, hallucinations and false belief. At the end of each shift mark frequency how often behavior occurred and intensity and how resident responded to redirection. The intensity code zero revealed the behavior did not occur, one reflected the behavior was easily altered and two the behavior was difficult to redirect. The findings were to be documented twice a day. The same wording was repeated for the target set behavior for moods or behaviors (none specified). There were 18 days between 05/23/22 and 06/22/21 where a numerical number of one or two was entered for psychosis and 20 days for moods or behavior. There was no indication of what the psychotic, mood or behaviors were. There was no evidence of baseline or continued AIMS testing for the resident. Review of the Behavior Analysis Report for May and June of 2022 documented by the STNAs staff revealed on 05/07/22 grabbing and hitting redirection. A second entry for 05/07/22 revealed the resident was redirected and 1:1 provided for rejection of care with effect. On 05/21/22 rejection of care was documented with redirection and not effective. A 06/18/22 rejection of care notation indicated the resident was redirected and 1:1 attention was not effective. The resident was not allowing staff to wash her post incontinence. On 06/22/22 at 3:15 P.M. the resident was observed sitting at a music program then in the lobby at a table with three other residents. On 06/23/22 at 9:03 A.M., 10:03 A.M. and 12:01 P.M. the resident was observed in bed with her eyes closed. No behaviors were observed. On 06/23/22 at 9:55 A.M. interview with Registered Nurse (RN) #300 revealed the resident was a recent transfer to the unit and was exit seeking. The RN revealed the resident would cycle and go from social (being up all day) to wanting to be alone. On 06/23/22 at 2:33 P.M. interview with RN #341 verified there was no evidence of a baseline AIMS test. On 06/23/22 at 3:21 P. M. interview with the Assistant Director of Nursing (ADON) verified the target behaviors on the care plans of delirium, hallucinations and false belief and swinging, spitting and throwing things at staff did not match the behaviors on the MAR. The ADON further verified the behaviors on the MAR were not measurable when scored due to not identifying what behavior was observed. 2. Review of Resident #41's medical record revealed an admission date of 09/08/21 with diagnoses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 27 of 28 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 366051 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oaks at Northpointe 3291 Northpointe Drive Zanesville, OH 43701 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 including malignant neoplasm of the right breast, heart failure, schizoaffective disorder, vascular dementia without behavioral disturbance, cognitive communication deficit, restlessness and agitation. Review of the physician's orders revealed an order (dated 09/08/21) for the anti-psychotic medication, Seroquel 50 milligrams (mg) at bedtime. Residents Affected - Few Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/27/22 revealed the resident had severe cognitive impairment and received an anti-psychotic medication seven days during the assessment period, on a routine basis. A gradual dose reduction had not been attempted. Review of the resident was at risk for adverse consequences related to receiving antipsychotic medications for schizoaffective disorder, initiated 05/11/22 revealed interventions including administer medication per physician order, attempt gradual dose reduction (GDR) in two separate quarters (with at least one month between the attempts) during the first year the resident received an antipsychotic medication, then yearly, unless clinically contraindicated; attempt to give the lowest dose possible, pharmacy consult review as needed and review for continued need at least quarterly. Review of the medical record revealed no recommendation or attempt for a GDR or evidence of clinical contraindication was documented related to the use of the Seroquel for the resident. On 06/23/22 at 7:00 P.M. interview with the Assistant Director of Nursing (ADON) verified there was no attempt for a GDR as planned. The ADON revealed the pharmacist had made recommendations for the resident's other psychotropic medications for reduction but no recommendation for the anti-psychotic Seroquel medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 28 of 28