Inspection·June 20, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 4. Review of the medical record for Resident #08 revealed an admission date of 12/08/17 with diagnoses including COPD, osteoporosis, COVID-19, adult failure to thrive, dysphagia, encephalopathy, colitis, chronic kidney disease, depression, congestive heart failure, hypertension, and Alzheimer's disease. Review of the care plan for Resident #08 initiated 12/08/17 revealed there was no care plan for hospice services. Review of the MDS assessment for Resident #08 dated 02/09/24 revealed the resident had severe cognitive impairment. Review of physician's orders for Resident #08 revealed an order dated 03/26/24 for the resident to admit to hospice services. There was no terminal diagnosis included in the order. Interview on 06/18/24 at 11:17 A.M. with the DON confirmed Resident #08 received hospice services, but there was no care plan in place for the resident regarding hospice services. Based on record review and staff interview the facility failed to develop comprehensive resident care plans. This affected four (Residents #01 #08, #11, and #118) of eight residents reviewed for care plans. The facility census was 19 residents. Findings include: 1.Review of the medical record for Resident #118 revealed an admission date of 04/25/24 with diagnosis including chronic obstructive pulmonary disorder (COPD), atherosclerotic heart disease, anxiety, vascular dementia with anxiety, diabetes mellitus type two, major depressive disorder, and panic disorder. Review of the admission Minimum Data Set (MDS) for Resident #118 for dated 05/02/24 the resident was cognitively impaired with verbal behaviors. Resident #118 was dependent on the staff with toileting hygiene, and showers or bathing, and required substantial to maximum assistance with bed mobility, transfers and mobility in her wheelchair. Resident #118 received antipsychotic and antidepressant medications. Review of the physician's orders for Resident #118 dated June 2024 revealed the resident had orders for Seroquel, an antipsychotic medication and Trazodone, an antidepressant medication. Review of the facility fall investigation for Resident #118 dated 05/10/24 revealed the resident had a fall without injuries while ambulating. Review of the physician's orders for Resident #118 dated June 2024 revealed the resident had orders for Seroquel, an antipsychotic medication and Trazodone, an antidepressant medication. Review of the nurse progress note for Resident #118 dated 06/17/24 timed at 5:11 A.M. revealed the resident began to yell out during morning care, was using profanity and was striking the staff and hitting, kicking and pulling the staff's hair. Staff were unable to redirect the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366107 If continuation sheet Page 2 of 4 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 366107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven Nursing Home 2274 McDermott Pond Creek Road McDermott, OH 45652 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 Review of the care plan for Resident #118 dated 05/16/24 revealed the resident was at risk for falls, but the care plan did not include goals or interventions. Review of the care plan for Resident #118 dated 05/16/24 revealed the resident had behaviors. but the care plan did not include target behaviors or interventions. Residents Affected - Some Review of the care plan for Resident #118 dated 05/16/24 revealed the resident had the potential to be verbally aggressive, but the care plan did not include goals or interventions. Review of the care plan for Resident #118 dated 05/16/24 revealed the resident had impaired function/dementia and impaired thought processes, but the care plan did not include goals or interventions. Review of the care plan for Resident #118 dated 05/16/24 revealed the resident used psychotropic medications and antidepressant medications, but the plan of care had no goals or interventions. Interview on 06/20/24 at 9:11 A.M. with State Tested Nursing Assistant (STNA) #250 confirmed target behaviors, interventions for target behaviors, and fall precautions should be listed on the resident's plan of care. Interview on 06/20/24 at 9:17 A.M. with Registered Nurse (RN) #80 confirmed target behaviors with redirection interventions and fall precautions and interventions should be found on the plan of care. Interview on 06/18/24 at 2:58 P.M. with the Director of Nursing (DON) confirmed the care plans for Resident #118 were not complete in the areas of falls, dementia care, and psychotropic medications to include goals, interventions, and target behaviors. 2. Review of the medical record for Resident #01 revealed an admission date of 04/03/24 with diagnoses including adult failure to thrive, major depressive disorder, and COPD. Review of the admission MDS assessment for Resident #01 dated 04/10/24, revealed the resident was cognitively intact and received antipsychotic medications. Review of the care plan for Resident #01 dated 04/23/24 revealed the resident used psychotropic medications, but the care plan did not include target behaviors or interventions related to the use of the medications. Review of the physician's order for Resident #01 revealed an order dated 05/01/24 for Risperdal 0.5 mg once daily and order dated 05/02/24 for Risperdal 1.0 mg once daily. Interview on 06/20/24 at 9:49 A.M. with the DON confirmed Resident #01 received antipsychotic medication but the care plan did not include target behaviors or interventions related to the use of the medication. 3. Review of the medical record for Resident #11 revealed an admission date of 12/07/22 with diagnoses including major depressive disorder, COPD, and dementia with other behavioral disturbances. Review of the care plan for Resident #11 initiated 12/07/22 revealed it did not include a care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366107 If continuation sheet Page 3 of 4 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 366107 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven Nursing Home 2274 McDermott Pond Creek Road McDermott, OH 45652 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 addressing the use of antipsychotic medications to include target behaviors and interventions. Level of Harm - Minimal harm or potential for actual harm Review of the physician's orders for Resident #11 revealed an order dated 02/25/24 for Risperdal 0.5 twice daily. Residents Affected - Some Review of the quarterly MDS assessment for Resident #11 dated 04/03/24 revealed the resident was cognitively impaired and received antipsychotic medication. Interview on 06/20/24 at 9:49 A.M. with the DON confirmed Resident #11 received antipsychotic medication but the care plan did not include use of the medication, target behaviors or interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366107 If continuation sheet Page 4 of 4