Health inspection·July 17, 2023

F 0686 Level of Harm - Actual harm Residents Affected - Few lower extremity. The assessment revealed the resident required extensive assistance from two staff for bed mobility and was totally dependent on staff for transfers, dressing, locomotion, toilet use, personal hygiene, and bathing. The assessment reflected the resident had no pressure ulcers noted, however had pressure reducing device for her chair and bed, was receiving a nonsurgical dressing application, and application of ointment/medication to an area other than her feet. The resident was not receiving a treatment to her feet. Record review revealed a right heel assessment dated [DATE] which reflected Resident #66 had a scabbed area on the right heel measuring two centimeters in length by one centimeter (cm) width that was not present on admission. The nurse's description of the area noted it was pressure, statis, and a diabetic wound. An additional note indicated the area didn't have characteristics of a pressure sore; however, the aides reported the resident frequently had her foot in a position that could compromise the skin integrity. There was no evidence the resident was re-evaluated for additional pressure relieving interventions at this time. The next assessment, dated 06/22/23 revealed the resident had a right heel wound that measured three cm by two cm with 2.3 cm depth. The peri wound was described as being moist and macerated. The wound had a moderate amount of serosanguinous drainage, no odor present and the surrounding tissue was pink, and blanchable. Then there was second note, also dated 06/22/23 indicating the right heel was not a pressure ulcer but rather a scabbed area that was healed. Record review revealed no additional assessments or documentation of the resident's heel(s) after 06/22/23. On 07/10/23 at 4:15 P.M. observation of Resident #66's heels with Registered Nurse (RN) #107 revealed the resident's heels were not floated off the bed and there was dark purple non-blanchable area on the resident's left heel. The resident reported the area was very painful. The resident was noted to have her legs folded up under her in bed. The RN reported the resident left leg was contracted making it difficult to float her heels. Record review revealed no evidence this observed pressure ulcer was previously identified. The ulcer was discovered as a DTI. On 07/11/23 at 9:44 A.M. interview with the Director of Nursing (DON) revealed she was not previously aware of a pressure area to Resident #66's left heel but was told by staff the resident's heels were not floated off the bed during the surveyor's observation with RN #107. The DON verified the resident had a physician's order and plan of care with interventions to float the resident's heels. The DON reported the resident's left leg was contracted and it was hard for the resident to straighten out her left leg. The DON indicated possibly the nursing assessment completed on 06/16/23 was inaccurate and should have been for the left heel and not the right heel. The nurse had started an assessment on the right heel but the DON felt that was an error and should have possibly been for the left heel. The DON reported the resident had scabs originally on the left heel, however she did not feel scabs were pressure related. The DON provided no additional explanation as to what the areas of skin impairment would have been caused from if not pressure. The facility did not have a specific pressure ulcer prevention, identification or treatment policy and procedure. The DON only provided a copy of a book she had received during her training related to staging wounds. 2. Record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including unstageable pressure ulcer right buttocks, hemiplegia and hemiparesis affecting left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 2 of 10 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 07/17/2023 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 non-dominated side, type two diabetes mellitus with diabetic neuropathy, heart failure, and neuromuscular dysfunction of bladder. Level of Harm - Actual harm Residents Affected - Few A plan of care, dated 03/10/23 for skin integrity revealed the resident was at risk for skin breakdown related to receiving antiplatelet and diuretic medication, left side hemiplegia, incontinence of bowel/bladder and risk for malnutrition. Interventions included treatment to coccyx as ordered, avoid shearing, conduct weekly skin assessment, encourage to turn and reposition, float heels as needed and pressure reduction cushion in chair and mattress. Review of the plan of care revealed it was not updated to reflect the development of any actual pressure ulcers for Resident #66. Review of Resident #66's medical record revealed the resident was being followed by an outside wound clinic for a pressure ulcer to the right gluteal fold. A visit note, dated 04/26/23 revealed Resident #66 had a Stage III (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss) pressure injury to the right gluteal fold that measured four-centimeter (cm) length by four cm width by four cm depth. The wound bed was full thickness, granulation, red and the peri-wound was excoriated and macerated. There was tunneling noted at the 7 o'clock position that was four cm. The wound had moderate amount of serosanguineous drainage. The wound clinic note revealed the ulcer had been present since 10/29/22. During this visit, a new dressing/treatment order was implemented to pack the wound with lightly moist Dakin's conform followed by gauze, abdominal dressing, and secure with tape daily and as needed if it becomes soiled was ordered. The resident was to return in three weeks on 05/15/23. The resident was seen by the physician assistant (PA) on 05/12/23. The PA reflected the resident had a Stage III pressure injury of buttock. New orders to follow-up with wound center as scheduled and obtain repeat wound culture of area due to history of pseudomonas. However, the wound culture was not collected until 05/18/23 (six days after being ordered by the PA). Review of Resident #66's wound clinic note dated 05/15/23 revealed the pressure ulcer to the right gluteal fold wound had deteriorated. The wound bed had bone exposure and slough. The peri wound was now non-blanchable, erythema, moist, and purple. The pressure ulcer measured 5.5 cm in length by 6.5 cm width with 2.7 cm depth. The wound was assessed to have stool in it and large amount of serosanguineous drainage. New treatment orders included to stop the Dakin's due to maceration of the wound and to cleanse the wound daily (normal saline/soap and water), pack wound with conform followed by gauze, abdominal dressing, and secure with tape. The dressing was to be changed daily and as needed if it becomes soiled. The resident was to return on 05/29/23. Review of the wound clinic note and facility documentation revealed no evidence of an investigation or determination as to why the ulcer had deteriorated at this time. There was no evidence the resident's skin needs were re-assessed at this time to ensure adequate and effective interventions were in place to promote healing and to prevent additional decline. In addition, review of the administration records revealed no evidence the facility implemented this new wound care order following the wound clinic visit on 05/15/23. The administration records from 05/15/23 to 07/10/23 revealed staff continued to cleanse the wound with wound cleaner/normal saline, lightly pack with Dakin's moist gauze, and apply abdominal dressing once daily. Review of Resident #66's wound culture results, dated 05/25/23 revealed the aerobic culture was positive for pseudomonas aeruginosa. The organism was susceptible to the antibiotics listed except for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 3 of 10 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 07/17/2023 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 - Actual harm Residents Affected - Few Ticarcillin (which it was resistant to). Record review revealed no evidence the PA or physician were notified of the wound culture results or evidence the resident was assessed for the need for an antibiotic based on the wound culture results. Review of Resident #66's wound clinic note dated 05/31/23 revealed the pressure ulcer to the right gluteal fold measured four cm in length by three cm width with 2.3 cm depth and had moderate serosanguineous drainage. The wound bed assessment was not legible. The treatment orders were to cleanse the wound daily with soap and water, pack wound with conform followed by gauze, abdominal dressing, and secure with tape. Change the dressing daily and as needed if it becomes soiled. The resident was to return on 06/28/23. Review of Resident #66's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #66 had range of motion impairment to one side on the upper extremity and both sides of the lower extremity. The assessment revealed the resident required extensive assistance from two staff for bed mobility and was totally dependent on staff for transfers, dressing, locomotion, toilet use, personal hygiene, and bathing. The assessment, which was inaccurate based on wound clinic and PA documentation, reflected the resident had no pressure ulcers noted, however had pressure reducing device for her chair and bed, was receiving a nonsurgical dressing application, and application of ointment/medication to an area other than her feet. The resident was not receiving a treatment to her feet. Review of Resident #66's wound clinic note dated 06/28/23 revealed the pressure ulcer to the right gluteal fold measured two cm in length by four cm width by 2.5 cm depth. The wound bed had slough and peri-wound was noted to have erythematous and moisture. The wound was draining moderate amount of serosanguineous drainage. There was no change in wound orders. Although the resident was being following for wound care by the outside wound clinic (approximately monthly), review of the facility wound assessments/documentation revealed no evidence facility staff assessed (including a description or staging of the pressure ulcer) weekly on 04/26/23, 05/04/23, 05/11/23, 05/18/23, 05/25/23, 06/01/23, 06/08/23 or 06/22/23. Further review revealed an order dated from 02/15/23 to 07/10/23 for staff to cleanse right buttocks with wound with cleanser or normal saline, apply Medi-honey, and cover with a foam dressing as needed. However, review of the administration records revealed there was no evidence the Medi-honey was applied from 05/01/23 to 07/10/23. Review of Resident #66's care plans revealed no evidence of an actual pressure ulcer plan of care. On 07/10/23 at 4:15 P.M. observation of Resident #66's buttocks with Registered Nurse (RN) #107 revealed the resident had an undated dressing on the right gluteal fold. RN #107 reported the DON called the wound clinic yesterday to update the physician due to the not receiving the correct treatment that was ordered. The RN reported she could not assess or describe the wound to the surveyor because she was not properly trained nor had she taken a wound certification class. The wound was difficult to observe due to poor lighting and the location of the wound. The wound appeared deep and tunneled. There was no drainage noted on the old dressing or signs of infection noted. Interview on 07/10/23 at 12:20 P.M. with the DON revealed she was also the facility wound nurse and had just taken a class on wound care but felt she had not been provided proper training on wound assessment, staging, or appropriate treatments. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 4 of 10 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 07/17/2023 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 - Actual harm Residents Affected - Few On 07/11/23 at 9:44 A.M. interview with the DON revealed she had not been completing wound assessments for Resident #66's right gluteal fold wound because she had been told by the corporate nurse the area was not pressure due to the location of the wound not being on a pressure point area, even though the PA and wound clinic had indicated the wound was a Stage III pressure injury. The corporate nurse was no longer employed by the facility. The DON reported she had called the wound clinic to inform them the resident Dakin's was not discontinued on 05/15/23 per the wound clinics orders and the facility had still been administering the Dakin's soaks in error. The DON also indicated the order for the use of Medi-honey as needed should have been discontinued months ago when the order was changed to Dakins'. On 07/11/23 at 12:10 P.M. interview with the DON confirmed Resident #66's wound culture was ordered on 05/12/23 and not obtained until 05/18/23, which was not timely obtained. The DON reported she had no evidence the wound culture had been addressed (as of this date) and she had since called the ordering PA who reported she did not recall reviewing the wound culture results or ordering antibiotics to treat the organism the culture was positive for. The PA reported she would probably have forwarded the wound culture to the wound clinic to let them treat the organism but could not state for certain. The DON then indicated there was no evidence the wound culture had been sent to the wound clinic for review/follow up. 3. Record review revealed Resident #61 was admitted to the facility on [DATE] with diagnoses including pressure ulcer, chronic kidney disease, anemia, heart failure. Review of Resident #61's skin integrity plan of care dated 09/22/21 and revised 05/11/23 revealed the resident was at risk for skin breakdown and pressure ulcer development related to weakness, requiring assist with her bed mobility, peripheral vascular disease, and incontinence of bowel and bladder. Intervention included to conduct weekly skin assessments. The care plan wasn't updated to reflect the resident's pressure ulcer to the sacrum. Review of Resident #61's quarterly MDS dated [DATE] revealed Resident #61 was at risk for developing pressure ulcers, totally dependent for bathing and required limited assist times one with eating, required extensive assist of two for bed mobility, transfers, and hygiene. Review of Resident #61's progress note dated 05/16/23 revealed the hospice aide informed the nurse about an open area on the resident's bottom. An area was noted in the mid/left upper coccyx. Hospice nurse gave orders to clean area with normal saline or wound cleanser, pat dry and cover with a dry clean dressing three times a week. Review of Resident #61's wound assessments revealed no evidence an initial comprehensive assessment of the pressure ulcer was completed on 05/16/23. Further review of Resident #61's wound progress notes dated 05/18/23 revealed the resident had a Stage II (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister) pressure ulcer to the sacrum that measured 2 cm by 2.5 cm by 0.2 cm. Hospice in agreement to cleanse area with wound cleanser, pat dry, then apply Medi- honey and cover with adhesive foam dressing and change every third day and as needed. Further review of Resident #61's wound management notes revealed on 05/30/23 the sacrum wound measured 1.0 cm by 1.5 cm by 0.01 cm and was a Stage II pressure ulcer. The wound bed was covered with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 5 of 10 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 07/17/2023 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 - Actual harm Residents Affected - Few 30% of slough. On 06/06/23 the wound remained a Stage II pressure ulcer that measured 1.0 cm by 1.3 cm by 0.1 cm with 10% of slough in the wound bed. On 07/06/23 the wound measured 1.0 cm by 1.0 cm and no depth was noted. Review of Resident #61's MAR/TAR revealed from 05/18/23 to 06/22/23 the order was to cleanse the sacrum wound with wound cleanser or normal saline, apply Medi-honey, and cover with foam dressing every three days and as needed. However, the frequency was entered every five days instead of every three days therefore during this time frame, the dressing was only changed every five days. On 06/22/23 the order was changed to cleanse the pressure ulcer with wound cleanser or normal saline, apply skin prep around the wound then apply bacitracin with zinc ointment, and cover with foam dressing every five days. Review of Resident #61's hospice notes dated 06/06/23 to 07/10/23 revealed hospice only measured the resident's sacrum pressure ulcer twice. On 06/27/23 the note indicated the resident had a Stage II sacrum pressure ulcer that measured 2.2 cm by 2.7 cm by 0.3. The wound bed was noted to have 20% slough. On 07/10/23 the wound measured 2.2 cm by 2.7 cm by 0.4 cm. Observation on 07/10/23 at 2:32 P.M., of Resident #61 with RN #107 and the DON revealed the resident had an open area the size of pea with depth on sacrum. The DON confirmed the wound had depth. Interview on 07/10/23 at 2:34 P.M., with the DON confirmed there was no comprehensive assessment completed on 05/16/23 when the area was discovered. The DON confirmed there were discrepancies in the depth of the wound due to sometimes she charted 0.1 and 0.01 or no depth. The DON confirmed the staging of the wound was inaccurate as well due to the wound had slough and according to staging recommendation a Stage II has no slough. The DON confirmed the dressing was not changed per orders because she had entered the frequency of Medi-honey as every five days, and it should have been changed every three days and the bacitracin should have been changed daily not every five days. The DON confirmed the care plan was not updated to reflect new sacrum pressure ulcer. 4. Record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including Stage IV pressure ulcers, diabetes, heart failure, anemia, and necrotizing fasciitis. Review of Resident #49's wound clinic notes dated 05/24/23 revealed the resident was noted to have a Stage IV pressure ulcer on the sacrum that measured 1.5 cm by 1.5 cm by 4 cm that had moderate amount of foul-smelling serosanguineous drainage. Discharge instruction included to apply zinc to peri wound, lightly pack wound with aquacel rope followed by dry gauze and mepilex daily and as needed if it becomes soiled. Return in one week. Review of Resident #49's MAR/TAR dated May 2023 revealed no evidence treatment orders to apply zinc to the peri wound, lightly pack wound with aquacel rope followed by dry gauze and mepilex daily and as needed was completed. Review of Resident #49's wound clinic note dated 05/31/23 revealed the sacrum pressure ulcer measured 2.2 cm by 2.3 cm by 2.5 cm with undermining at 12 and 4 o'clock with a depth of 2.3 cm. The wound bed was red with slough and granulation. The resident required an Actigraft procedure. Discharge instruction included to leave mepitel and steri-strips in place for one week. Do not get wet. Change gauze and abdominal dressing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 6 of 10 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 07/17/2023 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 - Actual harm Residents Affected - Few Review of Resident #49's progress note dated 06/01/23 revealed the wound center returned call at this time and stated the Actigraft was placed yesterday, and outer dressing is to be changed daily or as needed. Once dissolved continue to cover with dry clean dressing only until next appointment. Review of Resident #49's MAR/TAR dated June 2023 revealed no evidence the treatment order to leave mepitel and steri-strips in place for one week; do not get wet; change gauze and abdominal dressing was ordered was completed. Review of Resident #49's wound clinic note dated 06/13/23 revealed the sacrum pressure ulcer measured 2.4 cm by 2.0 cm by 3.5 cm with 3.0 cm undermining at 12 o'clock. Interview on 07/11/23 at 12:42 P.M., with the DON confirmed the wound clinic orders on 05/24/23 and 05/31/23 were not documented as being completed as ordered. 5. Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including pressure ulcer chronic kidney disease, heart failure, and left femur fracture. Review of Resident #53's hospital discharge orders dated 06/16/23 revealed to irrigate wound with Dakin's daily. The resident had a Stage IV pressure ulcer on the sacrum. Review of Resident #53's orders and TAR revealed to cleanse coccyx/sacrum pressure ulcer with wound cleanser or normal saline, soak gauze with Dakin's solution and lightly pack wound, cover with abdominal dressing, and change daily as needed. The resident's TAR for June 2023 and July 2023 revealed the wrong order was transcribed on the TAR and the resident's pressure ulcer was being treated by soaking gauze with Dakin's solution and lightly packing the wound instead of the correct order to irrigate the wound with Dakin's daily. Review of Resident #53's wound management report dated 06/22/23 to 07/06/23 revealed no evidence the stage of the sacrum pressure ulcer was assessed. Interview on 07/12/23 at 12:35 P.M., with the DON verified the wound orders were incorrectly transcribed on the TAR and the resident was not receiving the correct treatment to her sacrum pressure ulcer. The DON also confirmed the facility had not completed staging of the pressure ulcer. Observation on 07/12/23 at 12:42 P.M., with the DON revealed Resident #53 had dried and fresh drainage noted on a pillow placed under her feet while she was in bed. The DON reported the resident had an area on her right heel, but it had resolved. The surveyor asked to look at the resident's left heel. The resident had an open area noted on the left heel that was draining. The resident reported the area on the left heel had been there since the beginning of summer. The DON verified she was not aware of the pressure ulcer on the left heel. Review of Resident #53's medical record revealed no evidence of a pressure ulcer to the left heel. Review of the facility pressure ulcer staging guidelines (dated 2020) from the Wound Care Education Institute revealed a Stage II pressure ulcer was partial-thickness loss of skin with exposed dermis. Granulation tissue, slough, and eschar are not present. A Stage III pressure ulcer was full-thickness loss of skin in which fat is visible in the ulcer and granulation tissue and rolled wound edges are often present. Bone is not exposed. A Stage IV pressure ulcer was full thickness skin and tissue (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 7 of 10 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 07/17/2023 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 - Actual harm loss with exposed or directly palpable fascia, muscle tendon, ligament, cartilage, or bone in the ulcer. A deep tissue pressure injury was intact or non-intact skin with localized area of persistent, non-blanchable, deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00144145. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 8 of 10 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 07/17/2023 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews the facility failed to implement intervention to prevent contractions. This affected one resident (#66) of three residents reviewed for range of motion. Findings included: Record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including unstageable pressure ulcer right buttocks, hemiplegia and hemiparesis affecting left non-dominated side, type two diabetes mellitus with diabetic neuropathy, heart failure, and neuromuscular dysfunction of bladder. Review of Resident #66's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 had range of motion impairment to one side on the upper extremity and both sides of the lower extremity. The resident required extensive assistance of two with bed mobility and was totally dependent for transfers, dressing, locomotion, toilet use, personal hygiene, and bathing. Review of Resident #66's physical therapy notes dated 11/08/22 to 12/19/22 revealed discharge recommendation included to encourage left knee extension and neutral left hip position when resident is in bed for contraction management. The resident would benefit from knee extension brace when she is not limited from the wounds on the back of the thighs. Review of Resident #66's occupational notes dated 02/22/23 to 04/19/23 revealed education was provided for elbow extension splint to left upper extremity. Nursing and the Director of Nursing (DON) was provided education regarding the importance of having the resident to get up in wheelchair every day for improved tolerance for out of bed task, social participation, passive bilateral lower extremity stretching, and for improved overall quality of life. Further review of Resident #66's medical record revealed no evidence the resident was receiving range of motion, splints, or braces. Observation on 07/12/23 at 7:44 A.M. of Resident #66 revealed the resident's left leg was contracted up towards her buttocks. The resident demonstrated and voiced pain when staff attempted to extend her left leg. Observation and interview on 07/12/23 at 10:45 A.M. and 12:13 P.M., of Resident #66 with Physical Therapy Assistant (PTA) #200 confirmed Resident #66's left leg was contracted more than it was in December 2022. PTA #200 verified occupational or physical therapy did not write orders for the elbow or knee extension brace or range of motion. PTA #200 reported the resident would have benefited from a range of motion program because she thought the resident was not able to tolerate the knee brace. The PTA reported she could not find documentation that the resident could not tolerate the knee brace. The PTA reported she did not know where the knee brace was since it was not in the resident's room, but she would look in the storage room for it. The PTA reported the therapist usually doesn't refer a resident to a restorative program, however they will give recommendation to the staff and provide education to the staff. However, there was documented evidence what recommendation were made and who was educated. PTA #200 reported she was going to have occupational and physical therapy evaluate and treat the resident tomorrow. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 9 of 10 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 07/17/2023 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 0688 This deficiency represents non-compliance investigated under Complaint Number OH00144145. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366051 If continuation sheet Page 10 of 10