Health inspection·August 24, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure an appropriate copy of a resident's advanced directive was maintained in the resident's medical record. This affected one (Resident #383) of one resident reviewed for advanced directives. The facility census was 124. Findings include: Review of the medical record revealed Resident #383 was admitted on [DATE]. Diagnoses included urinary tract infection, acute kidney failure, hypertensive heart and chronic kidney disease, chronic kidney disease, pressure ulcer sacral region stage II, hyperkalemia, hyperlipidemia, diverticulosis of large intestine without perforation or abscess without bleeding. Review of the physician order dated 08/10/23 revealed Resident #383's advanced directive was Do Not Resuscitate Comfort Care-Arrest (DNRCC-Arrest). Review of the care plan dated 08/13/23 revealed Resident #383 had chosen advanced directive of DNRCC-Arrest. The medical record did not include a signed copy of the advanced directive. Interview on 08/23/23 at approximately 3:00 P.M. with the Director of Nursing (DON) verified Resident #383's medical record did not contain a copy of the advanced directive and provided a previous and current DNRCC document. Review of DNRCC document signed 08/23/23 verified Resident #383 advanced directive was DNRCC-Arrest. Review of DNRCC document signed June 12th with an unknown year, revealed Resident #383 had previously chosen DNRCC. Review of Resident #383's medical record on 08/24/23 revealed Resident #383's prior DNRCC document had been upload to the electronic medical record instead of the most recent DNRCC document. Review of the policy, Do Not Resuscitate Order, reviewed 06/08/22, verified do not resuscitate orders must be obtained by the resident's attending physician and the physician order sheet maintained in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366068 If continuation sheet Page 2 of 18 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 366068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchard Villa 2841 Munding Drive Oregon, OH 43616 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure dependent residents received nail care. This affected one (Resident #47) of four residents reviewed for activities of daily living. The census was 124. Residents Affected - Few Findings included: Review of the medical record revealed Resident #47 was admitted on [DATE]. Diagnoses included Alzheimer's disease, dementia with agitation, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and schizoaffective disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was moderately cognitively impaired. Resident #47 required extensive two person assistance for personal hygiene and was dependent upon staff for bathing. Review of the care plan revised on 04/03/23 revealed Resident #47 required extensive assistance with personal hygiene and for staff to provide nail care as needed. Further review of the medical record revealed no documentation showing the resident received nail care or the resident refused nail care. Observation on 08/21/23 at approximately 2:00 P.M. revealed Resident #47 had long fingernails with dark substance embedded under each nail. Observation on 08/23/23 at 8:45 A.M. revealed Resident #47 had long fingernails with dark substance embedded under each nail. Observation on 08/24/23 at approximately 10:00 A.M. revealed Resident #47 in the common area and her fingernails continued to remain untrimmed with dark substance embedded under each nail. Interview on 08/24/23 at approximately 10:05 A.M. with Registered Nurse (RN) #316 verified Resident #47 had dark substance embedded under the nails and agreed they needed trimmed. Interview on 08/24/23 at 12:03 P.M. with Licensed Practical Nurse (LPN) #255 revealed Resident #47 was not always compliant but she has previously been successful with providing nail care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366068 If continuation sheet Page 3 of 18 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 366068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchard Villa 2841 Munding Drive Oregon, OH 43616 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** Based on medical record review, observation, resident interview, and staff interview, the facility failed to ensure TED hose were applied per physician order. This affected one (Resident #61) of one resident reviewed for edema. The facility census was 124. Residents Affected - Few Findings include: Review of Resident #61's medical record revealed an admission date of 05/19/22 and a readmission date of 07/06/22. Diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), type II diabetes, bipolar disorder, schizoaffective disorder, congestive heart failure (CHF), and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 was cognitively intact and required extensive assistance with dressing. Review of a plan of care focus area, revised 12/08/22, revealed Resident #61 was at risk for decreased cardiac output and abnormal lab values related to CHF, hyperlipidemia, use of anticoagulant medication, and use of diuretics. Interventions included knee high TED hose (stockings designed to help prevent blood clots and swelling in legs) as ordered. Review of current physician orders revealed knee high TED hose, apply every morning and remove at bedtime. Observation and concurrent interview on 08/21/23 at 2:57 P.M. of Resident #61 revealed the resident in bed and had bilateral lower extremity edema. Resident #61 stated she was supposed to wear TED hose every day but staff never put them on her. Additional observations of Resident #61 on 08/22/23 at 9:47 A.M., 12:13 P.M., and 1:52 P.M. revealed the resident was not wearing TED hose. Interview on 08/22/23 at 1:52 P.M. of Licensed Practical Nurse (LPN) #351 confirmed Resident #61 was not wearing TED hose. LPN #351 was unaware of Resident #61 refusing to wear them, and State Tested Nurse Aides (STNAs) typically assisted residents with putting on TED hose. Interview on 08/22/23 at 1:55 P.M. of State Tested Nurse Aide (STNA) #207 verified she did not assist Resident #61 with applying her TED hose today. STNA #207 stated she typically put them on the resident if she got out of bed, but since she did not want up, she did not put them on her. Follow-up observation and concurrent interview on 08/22/23 at 1:58 P.M. of Resident #61 revealed the resident in bed. Resident #61 had bilateral lower extremity edema and no TED hose on. Resident #61 stated she had three new pairs of TED hose but she was unable to put them on herself and staff did not assist her with applying the stockings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366068 If continuation sheet Page 4 of 18 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 366068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchard Villa 2841 Munding Drive Oregon, OH 43616 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to follow audiology recommendations to better assist with hearing. This affected one (Resident #14) of one reviewed for hearing. The census was 124. Residents Affected - Few Findings include: Review of Resident #14's medical record revealed an admission date of 10/26/22. Diagnoses included end stage renal failure, congestive heart failure, and diabetes mellitus. Review of Resident #14's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. Review of Resident #14's most recent care plan revealed she had a communication problem related to a hearing deficit and was required to wear hearing aids. Review of the Audiology Group progress note dated 07/12/23 revealed the staff and family had noticed a recent decrease in Resident #14's responsiveness and she complained of newly decreased hearing. Recommendations were for the attending physician or nursing staff to complete wax removal from both ears. The audiologist would re-evaluate after the removal. Further review of Resident #14's medical record revealed no mention of ear wax removal for the resident. Interview with Resident #14 on 08/21/23 at 2:45 P.M. revealed she had been examined by the audiologist in early July 2023 and she was informed she had a wax build up in her left ear and the facility was to irrigate her ears and then she was to return to the audiologist for a follow up appointment. Interview with the Director of Nursing on 08/22/23 at 3:33 P.M. revealed she was unaware if the audiologist recommendations had been followed for Resident #14. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366068 If continuation sheet Page 5 of 18 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 366068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchard Villa 2841 Munding Drive Oregon, OH 43616 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 medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure a hand splint was used to prevent contractures per physician order. This affected one (Resident #68) of one reviewed for contractures. The facility census was 124. Findings include: Review of Resident #68's medical record revealed an admission date of 12/29/22. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, aphasia, type II diabetes, congestive heart failure (CHF), major depressive disorder, asthma, atherosclerosis, and dysphagia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #68 was cognitively intact and required extensive assistance with dressing, personal hygiene, toilet use, locomotion, and bed mobility. Review of the plan of care revised 04/13/23 revealed Resident #68 had potential for alteration in skin integrity related to immobility, incontinence, and splint usage. Interventions included wear left resting hand splint four hours in the morning and four hours in the afternoon to prevent contracture. Additionally, Resident #68 had an activities of daily living (ADLs) self-care performance deficit related to decreased mobility along with diagnoses of hemiplegia and hemiparesis, aphasia, cerebral infarction and atherosclerosis. Interventions included wear left resting hand splint four hours in the morning and four hours in the afternoon to prevent contracture. Review of current physician orders revealed Resident #68 was to wear left resting hand splint four hours in the morning and four hours in the afternoon to prevent contracture. Observation and concurrent interview on 08/21/23 at 3:10 P.M. of Resident #68 had a left hand contracture. A splint was observed on the resident's bedside table. Resident #68 stated she was supposed to wear the splint every day but staff had only put it on her once. Resident #68 stated her left hand sometimes hurt and she was concerned about her fingernails digging into the palm of her hand. Additional observations on 08/22/23 at 9:49 A.M., 12:19 P.M., and 1:32 P.M. revealed Resident #68 was not wearing the splint on her left hand and the splint was laying on her bedside table. Interview on 08/22/23 at 1:50 P.M. of Licensed Practical Nurse (LPN) #351 verified Resident #68 was not wearing the splint on her left hand for contractures. LPN #351 stated therapy usually applied the splint each day and she had not been informed the resident had refused to wear it, noting Resident #68 did not refuse care. Interview on 08/23/23 at 8:45 A.M. of Director of Rehabilitation (DOR) #364 revealed therapy only applied splints during trial periods to ensure proper fit, and during trial periods, splints were not left in resident rooms. DOR #364 stated Resident #68 had already been properly fitted for her left hand splint and nursing staff were responsible to apply it per physician orders. Review of facility policy titled, Contracture Prevention and Management, reviewed 03/23/21, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366068 If continuation sheet Page 6 of 18 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 366068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchard Villa 2841 Munding Drive Oregon, OH 43616 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 revealed contracture prevention and management involves the moving of joints and/or application of orthotic devices according to an individualized plan to prevent or reduce contractures/deformity/atrophy. Additionally, contracture management programs included orthotics, which was identified as the application of a supportive device to maintain an affected limb in a functional position to prevent or reduce contractures. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366068 If continuation sheet Page 7 of 18 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 366068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchard Villa 2841 Munding Drive Oregon, OH 43616 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, resident interview, and staff interview, the facility failed to ensure fall interventions were in place for two (Residents #10 and #90) of three reviewed for falls. The facility census was 124. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 12/01/22 with diagnoses of hemiplegia and hemiparesis, dementia, and repeated falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had impaired cognition and required extensive assistance of two people for bed mobility, transfers, and toileting. Review of Resident #10's current care plan revealed he was at risk for falls with a history of falls. Interventions included using a call sign to remind him to ask for assistance and having the call light accessible when in his room. Observation on 08/23/23 at 9:12 A.M. revealed Resident #10 in bed with his call light wrapped around the bottom of his enabler bar, with the call light button dangling above the floor, out of Resident #10's reach. Further observation revealed a yellow sign on the wall alongside Resident #10's bed stating, Please use your call light for assistance. Interview at that time with Resident #10 confirmed he could not find his call light. Interview on 08/23/23 at 9:15 AM with State Tested Nurse Aide (STNA) #246 confirmed Resident #10's call light was out of his reach, and confirmed he had a paper encouraging him to use the call light when he needed assistance. STNA #246 clipped the call light to Resident #10's shirt before leaving the room. 2. Review of the medical record for Resident #90 revealed an admission date of 01/06/23 with diagnoses of hemiplegia and hemiparesis, dementia, and repeated falls. Review of the quarterly MDS assessment dated [DATE] revealed Resident #90 had impaired cognition and required extensive assistance of two people for bed mobility, toileting, and was totally dependent on two people for transfers. Further review revealed Resident #90 had two or more falls without injury since the previous assessment. Review of the Fall Review dated 08/20/23 revealed Resident #90 was high risk for falls. Review of the current care plan revealed Resident #90 was at risk for falls due to a history of falls and impaired mobility. Interventions included keeping the bed against the wall with a mat to the floor, an accessible call light, a defined perimeter mattress (a mattress with high or firm edges to deter rolling off the edge), and a low bed. Observation on 08/23/23 at 7:56 A.M. revealed Resident #90 in bed, in a dark room. Resident #90's bed was in the high position, away from the wall, and no floor mat was on either side of the bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366068 If continuation sheet Page 8 of 18 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 366068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchard Villa 2841 Munding Drive Oregon, OH 43616 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 Interview at that time with Resident #90 stated he preferred his bed in a lower position, and further stated staff always leave his bed too high. Interview on 08/23/23 at 8:01 A.M. with Admissions Coordinator #282 revealed she was also an STNA and was helping residents get up that morning. Admissions Coordinator #282 confirmed Resident #90's bed was away from the wall, was not in the low position, and no floor mat was next to the bed. Interview and observation on 08/24/23 at 7:06 A.M. with Unit Manager (UM) #300 revealed Resident #90 lying in bed. UM #300 stated Resident #90's mattress did not have stiff edges as would be expected on a perimeter mattress. Interview on 08/24/23 at 10:34 A.M. with the Director of Nursing (DON) confirmed fall interventions were developed for Resident #90 after each of his falls, including providing a perimeter mattress. Further interview confirmed Resident #90's care plan included fall interventions of keeping the bed against the wall, in the low position, and keeping a fall mat next to the bed. This deficiency represents non-compliance investigated under Complaint Number OH00145696. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366068 If continuation sheet Page 9 of 18 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 366068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchard Villa 2841 Munding Drive Oregon, OH 43616 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to implement tube feeding recommendations in a timely manner. This affected one (Resident #62) of one reviewed for tube feedings. The facility identified three residents who received tube feedings. The facility census was 124. Findings include: Review of Resident #62's medical record revealed an admission date of 11/15/22 and a readmission date of 01/15/23. Diagnoses included unspecified severe protein calorie malnutrition, dysphagia, type II diabetes, spinal stenosis, hypertension, osteoarthritis, and personal history of pulmonary embolism. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was cognitively intact, had a feeding tube, and received 51% or more of total calories through tube feeding. Review of a plan of care focus area, revised 08/09/23, revealed Resident #62 required a feeding tube to assist in maintaining or improving nutritional status related to dysphagia. Interventions included tube feeding per dietitian recommendations and physician order. Review of a Nutritional assessment dated [DATE] revealed Resident #62 had an unintentional weight loss of 17.4% over 180 days. Will increase tube feed Diabetasource AC at 100 mls/hr for 16 hours. Review of a physician order dated 05/03/23 and discontinued on 07/16/23 revealed enteral feed one time a day for nutritional supplement Diabetasource AC to run at 100 milliliters/hour (ml/hr) from 4:00 P.M. to 6:00 A.M. Review of a physician order dated 07/16/23 (six days after the nutritional assessment) revealed enteral feed one time a day for nutritional supplement Diabetasource AC to run at 100 ml/hr from 4:00 P.M. to 8:00 A.M. Review of Resident #62's weight on 07/10/23 revealed the resident weighed 116.6 pounds (lbs.) and on 08/01/23, Resident #62 weighed 121.2, indicating no additional weight loss. Interview on 08/23/23 at 9:26 A.M. of Diet Tech (DT) #273 revealed any recommendations to adjust a tube feeding were provided to nursing to obtain a physician order. DT #273 confirmed on 07/10/23, she recommended an increase in Resident #62's tube feeding due to a significant weight loss and the physician order was not obtained until 07/16/23 (six days later) to implement the recommendation. DT #273 stated she would expect recommendations to be processed and a physician order obtained within 24 to 72 hours of the recommendation, and verified six days between her recommendation and the physician order being obtained and implemented was excessive. DT #273 stated she was glad Resident #62 had not experienced any additional weight loss. Review of facility policy titled, Enteral Nutrition Policy, undated, revealed the dietitian/diet tech will make recommendations on enteral feed type, rate, and flush order based on resident's specific needs. Upon physician approval, orders will be entered/adjusted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366068 If continuation sheet Page 10 of 18 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 366068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchard Villa 2841 Munding Drive Oregon, OH 43616 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to provide physician ordered medication. This affected one (Resident #382) of one reviewed for availability of medications. The census was 124. Findings include: Review of Resident #382's medical record revealed an admission date of 07/28/23. The resident was discharged home on [DATE]. Diagnoses included Parkinson's disease, dementia, congestive heart failure, diabetes mellitus type II, and auditory hallucinations. Review of Resident #382's entrance Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired. Review of Resident #382's progress note dated 07/28/23 revealed the resident was admitted from home for respite care via family. The medication list provided by the family was sent to the medical doctor for review. Review of Resident #382's admission records revealed an order for magnesium citrate 1,000 milligrams (mg), which was to be taken by mouth daily. Review of Resident #382's Medication Administration Record (MAR) dated July 2023 revealed magnesium citrate was missing from the MAR and was failed to be administered. Interview with the Director of Nursing (DON) on 08/22/23 at 3:00 P.M. revealed a medication list was provided by the family when Resident #382 was admitted . The list included magnesium citrate 1,000 mg. The DON verified the medication failed to be administered while the resident was in the facility. Review of the facility policy titled, Physician Services, reviewed 11/13/22 revealed staff were to follow physician orders as written. This violation represents non-compliance investigated under Complaint Number OH00145696. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366068 If continuation sheet Page 11 of 18 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 366068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchard Villa 2841 Munding Drive Oregon, OH 43616 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, resident interview, and policy review, the facility failed to ensure medications were stored properly. This affected one (Resident #7) of four reviewed for medication storage. The facility census was 124. Findings Included: Review of Resident #7's medical record revealed an admission date of 01/01/20. Diagnoses included chronic obstructive pulmonary disease, schizophrenia, heart failure, and atrial fibrillation. Review of Resident #7's quarterly Minimum Data Set (MDS) dated [DATE] revealed he had an intact cognition. The resident required one person limited assistance for activities of daily living and supervision/set up help for eating. Review of Resident #7's most recent care plan revealed he had impaired cognition function/impaired thought process related to impaired decision making, short term memory loss, and mild confusion. The resident suffered from ineffective breathing patterns as evidenced by shortness of breath on exertion and lying flat at times, labored respirations due to COPD, and sleep apnea. Interventions included to administer medications and respiratory treatments as ordered and monitor the effectiveness and adverse reactions of the medications and treatment. Review of Resident #7's physician orders revealed an order dated 03/02/23 for Ipratropium-Albuterol (relaxes and opens air passages) 0.5-2.5 (3) milligrams per 3 milliliters solution to be inhaled orally three times a day for cough and sneezing. Observation of medication administration on 08/23/23 at 1:12 P.M. with Licensed Practical Nurse (LPN) #344 revealed she attempted to administer a breathing treatment of Ipatropium-Albuterol solution to Resident #7, but he revealed she could take the ampoule away because he had some in his chair side drawer. The resident was noted to have an unlabeled, clear plastic ampoule of liquid medication in his bedside table which appeared to be an ampoule of Ipatropium-Albuterol solution. LPN #344 verified Resident #7 had medications left at his bedside and nurses failed to observe or assist with the aerosol treatments. Interview with Resident #7 on 08/23/23 at 1:14 P.M. revealed if he was sleeping in his recliner, the nurses failed to wake him for his breathing treatments and would lay the ampoule on his chair side table for him to complete on his own. He stated at times he would have three ampoules in his drawer and just pull one out when he felt he needed a breathing treatment. Review of the undated policy titled, Storage of Medications, revealed medications and biologicals are stored safely, securely, and properly, following the manufacturer's recommendations or those of the supplier. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366068 If continuation sheet Page 12 of 18 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 366068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchard Villa 2841 Munding Drive Oregon, OH 43616 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of facility policies, the facility failed to ensure food was prepared in a sanitary manner. This affected one (Resident #54) directly, and had the potential to affect all residents in the facility. All residents residing in the facility received food from the kitchen. The facility census was 124. Findings include: 1. Review of the medical record for Resident #54 revealed an admission date of 07/09/19 with a diagnosis of Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #54's cognition was not assessed. Further review revealed Resident #54 required supervision with setup help only for eating. Review of the current physician order for Resident #54 revealed he received a regular diet with regular textures and thin liquids. Observation on 08/21/23 at 12:30 P.M. revealed Registered Nurse (RN) #283 preparing a peanut butter and jelly sandwich. RN #283 held the bread in her left hand while spreading peanut butter and jelly on it with her right hand. RN #283 then washed her hands, picked up the sandwich and provided it to Resident #54 in the dining room. RN #283 did not wear gloves while in contact with the resident's food. Interview on 08/21/23 at 12:41 P.M. with RN #283 confirmed she held the bread in her hand while preparing a sandwich for Resident #54. RN #283 stated she washed and dried her hands before preparing the sandwich, but did not wear gloves. RN #283 was unaware whether she should wear gloves when preparing ready-to-eat foods for residents. Review of the undated policy, Food Preparation and Handling revealed bare hands should never touch read to eat raw food directly. 2. Observation on 08/23/23 at 11:58 A.M. revealed [NAME] #203 wearing a hairnet with hair sticking outside the hairnet on both sides of her face, in front of and covering her ears, hanging above her chinline. [NAME] #203 was covering pre-poured beverages with plastic lids. Observations on 08/23/23 beginning at approximately 3:35 P.M. revealed [NAME] #203 wearing a hairnet with hair sticking outside the hairnet on both sides of her face. [NAME] #203 was placing slices of bread on a baking sheet. Continued observation revealed [NAME] #203 preparing pureed food. Interview on 08/23/23 at 3:51 P.M. with [NAME] #203 confirmed her hair was outside the hair net while she prepared food for residents. Further interview confirmed all hair should be covered during food preparation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366068 If continuation sheet Page 13 of 18 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 366068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchard Villa 2841 Munding Drive Oregon, OH 43616 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of physician orders, review of treatment administration records (TAR), and staff interview, the facility failed to ensure treatment administration was accurately documented in the medical record. This affected two (#61 and #68) of two residents reviewed for treatments. The facility census was 124. Findings include: 1. Review of Resident #61's medical record revealed an admission date of 05/19/22 and a readmission date of 07/06/22. Diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), type II diabetes, bipolar disorder, schizoaffective disorder, congestive heart failure (CHF), and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 was cognitively intact and required extensive assistance with dressing. Review of a plan of care focus area revised 12/08/22 revealed Resident #61 was at risk for decreased cardiac output and abnormal lab values related to CHF, hyperlipidemia, use of anticoagulant medication, and use of diuretics. Interventions included knee high TED hose (stockings designed to help prevent blood clots and swelling in legs) as ordered. Review of current physician orders revealed knee high TED hose apply every morning and remove at bedtime. Review of the TAR dated 08/21/23 and 08/22/23 revealed nursing documented Resident #61's TED hose had been applied as ordered. Observation and concurrent interview on 08/21/23 at 2:57 P.M. of Resident #61 revealed the resident in bed. Resident #61 had bilateral lower extremity edema. Resident #61 stated she was supposed to wear TED hose every day but staff never put them on her. Additional observations of Resident #61 on 08/22/23 at 9:47 A.M., 12:13 P.M., and 1:52 P.M. revealed the resident was not wearing TED hose as physician ordered. Interview on 08/22/23 at 1:52 P.M. of Licensed Practical Nurse (LPN) #351 confirmed Resident #61 was not wearing TED hose and State Tested Nurse Aides (STNAs) typically assisted residents with putting on TED hose. LPN #351 verified she documented TED hose were applied per physician order on the TAR and had not confirmed they had actually been applied. LPN #351 stated she documented the treatment as completed unless she was informed by the STNA the resident had refused to wear them. Interview on 08/22/23 at 1:55 P.M. of State Tested Nurse Aide (STNA) #207 verified she did not assist Resident #61 with applying her TED hose today. STNA #207 stated she typically put them on the resident if she got out of bed, but since she did not want up, she did not put them on her. Follow-up observation and concurrent interview on 08/22/23 at 1:58 P.M. of Resident #61 confirmed the resident did not have TED hose on as documented as completed on the TAR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366068 If continuation sheet Page 14 of 18 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 366068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchard Villa 2841 Munding Drive Oregon, OH 43616 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of Resident #68's medical record revealed an admission date of 12/29/22. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, aphasia, type II diabetes, congestive heart failure (CHF), major depressive disorder, asthma, atherosclerosis, and dysphagia. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #68 was cognitively intact and required extensive assistance with dressing, personal hygiene, toilet use, locomotion, and bed mobility. Review of the plan of care revised 04/13/23 revealed Resident #68 had potential for alteration in skin integrity related to immobility, incontinence, and splint usage. Interventions included wear left resting hand splint four hours in the morning and four hours in the afternoon to prevent contracture. Additionally, Resident #68 had an activities of daily living (ADLs) self-care performance deficit related to decreased mobility along with diagnoses of hemiplegia and hemiparesis, aphasia, cerebral infarction and atherosclerosis. Interventions included wear left resting hand splint four hours in the morning and four hours in the afternoon to prevent contracture. Review of current physician orders revealed Resident #68 to wear left resting hand splint four hours in the morning and four hours in the afternoon to prevent contracture. Review of the TAR dated 08/21/23 and 08/22/23 revealed nursing documented Resident #68's splint had been applied as ordered. Observation and concurrent interview on 08/21/23 at 3:10 P.M. of Resident #68 revealed the resident in bed. Resident #68 had a left hand contracture. A splint was observed on the resident's bedside table. Resident #68 stated she was supposed to wear the splint every day but staff had only put it on her once. Resident #68 stated her left hand sometimes hurt and she was concerned about her fingernails digging into the palm of her hand. Additional observations on 08/22/23 at 9:49 A.M., 12:19 P.M., and 1:32 P.M. revealed Resident #68 was not wearing the splint on her left hand and the splint was laying on her bedside table. Interview on 08/22/23 at 1:50 P.M. of Licensed Practical Nurse (LPN) #351 verified Resident #68 was not wearing the splint on her left hand for contractures and she documented on the TAR the splint had been applied per physician order without confirming the splint was on. LPN #351 stated therapy usually applied the splint each day and she had not been informed the resident refused to wear it so she assumed it was on. Interview on 08/23/23 at 8:45 A.M. of Director of Rehabilitation (DOR) #364 revealed therapy only applied splints during trial periods to ensure proper fit and, during trial periods, splints were not left in resident rooms. DOR #364 stated Resident #68 had already been properly fitted for her left hand splint and nursing staff were responsible to apply it per physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366068 If continuation sheet Page 15 of 18 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 366068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchard Villa 2841 Munding Drive Oregon, OH 43616 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record, resident and staff interviews and review of facility policy, the facility failed to ensure carpet was in good repair. This affected one (Resident #45) and had the potential to affect 23 (Residents 3, #9, #17, #18, #27, #28, #38, #39, #45, #46, #47, #53, #55, #73, #79, #81, #83, #84, #86, #89, #107, #118, and #121) who were indecently mobile and residing on the Bayshore hall. Additionally, the facility failed to ensure a resident's bathroom was kept in a clean and sanitary manner. This affected one (Resident #64) of one resident observed for bathroom cleanliness. The facility census was 124. Findings include: 1. Interview on 08/22/23 at approximately 9:30 A.M. with Resident #45 revealed the hallway carpet on Bayshore has a large snag and the resident was concerned she could trip and fall. Observation on 08/23/23 at 11:47 A.M. revealed in the walkway of the Bayshore hallway carpet, there was an indent of missing carpet and an area approximately one inch to one and a half inches high and approximately six to ten inches long that had bubbled up. Interview on 08/23/23 at 11:48 A.M. with Registered Nurse (RN) #316 verified the walkway of the hall carpet had a large bubble-like appearance. 2. Review of Resident #64's medical record revealed an admission date of 06/26/23. Diagnoses included encounter for orthopedic aftercare following surgical amputation, other complications of amputation stump, type II diabetes, end stage renal disease, dependence on renal dialysis, morbid obesity, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, acquired absence of right leg below knee, and acquired absence of left leg below knee. Further review of Medicare 5-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was cognitively intact and required total dependence for transfers and extensive assistance with bed mobility, toilet use, and personal hygiene. Observation on 08/21/23 at 10:36 A.M. revealed Resident #64 in the bathroom. Staff entered the room, proceeded into the bathroom, and assisted Resident #64 into the room. Staff pulled the privacy curtain and continued to assist the resident with care. Observation of the bathroom revealed a brown substance on the toilet seat, down the right side of the toilet, and three nickel size brown, wet spots on the floor next to the right of the toilet. Continued observations on 08/21/23 at 11:56 A.M. and 1:20 P.M. revealed the brown substance remained on the toilet seat, down the side of the toilet, and on the floor next to the toilet, with the spots on the floor now dry. Interview on 08/21/23 at 3:00 P.M. of State Tested Nurse Aide (STNA) #343 confirmed the substance on the toilet seat, down the right side of the toilet, and on the floor to the right of the toilet. STNA #343 stated she believed it to be feces, verified Resident #343 needed assistance in the bathroom, and stated it should have been cleaned up. STNA #343 proceeded to get housekeeping to assist with cleaning Resident #64's bathroom. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366068 If continuation sheet Page 16 of 18 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 366068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchard Villa 2841 Munding Drive Oregon, OH 43616 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 0921 Level of Harm - Minimal harm or potential for actual harm Review of facility policy titled Routine Cleaning, reviewed 06/08/22, revealed to clean hard surfaces as needed (when spills or soiling occur). This deficiency represents non-compliance investigated under Complaint Number OH00145696. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366068 If continuation sheet Page 17 of 18 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 366068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchard Villa 2841 Munding Drive Oregon, OH 43616 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure an effective pest control program. This had the potential to affect 11 (#1, #9, #17, #40, #46, #53, #83, #86, #89, #107, and #121) residents residing on the Bayshore unit. The facility census was 124. Residents Affected - Some Findings include: Observation on 08/21/23 at 4:36 P.M. of the Bayshore unit dining area revealed multiple gnats flying around the refrigerator. A gnat trap on top of the refrigerator had approximately 15 gnats sitting on the trap. Interview on 08/22/23 at 7:30 A.M. of Resident #86 revealed there were gnats everywhere, including in the halls, resident rooms, and in the dining area. Resident #86 stated she believed they were coming from the drains. Observation on 08/22/23 at 2:18 P.M. with Maintenance Supervisor (MS) #276 verified the gnats in the dining area on the Bayshore unit. MS #276 stated they tried to keep up with the gnats and housekeeping put out the gnat traps. MS #276 stated the gnat trap must be full and needed emptied. While the facility had an exterminator at the facility monthly, MS #276 stated she had not had them address the gnats. MS #276 placed the gnat concern on the log for the exterminator and stated they would be out sometime this month but she did not know exactly when. Review of facility policy titled, Pest Control, undated, revealed the facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. In addition, maintenance services assist, when appropriate and necessary, in providing pest control services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366068 If continuation sheet Page 18 of 18