Health inspection·April 18, 2022

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident record review, and staff interview, the facility failed to ensure pressure reduction interventions were utilized as ordered by the physician. This affected one (#8) of three resident reviewed for pressure ulcers. The census was 30. Residents Affected - Few Findings include: Review of the medical record for Resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnoses include Alzheimer's disease, cognitive communication deficit, anxiety, insomnia, contracture of the right hand, affective mood disorder, psychosis, and history of right heel pressure ulcer. Review of an assessment titled, Braden Scale for Predicting Pressure Score Risk, dated 07/16/21, revealed Resident #8 was a high risk for developing pressure ulcers. Review of Resident #8's active physician orders revealed on 07/19/21 the resident was ordered to wear heel protectors to bilateral heels every shift. Continued review of the active orders revealed on 07/20/21 the resident was ordered a hand roll to the right hand, check every shift. Review of a care plan dated 01/19/22, revealed Resident #8 had a pressure ulcer or the potential for pressure ulcer development related to a history of ulcers and impaired mobility. Interventions included, administer treatments as ordered and monitor for effectiveness, check hand roll to right hand every shift, follow facility policies and protocols for prevention/treatment of skin breakdown, and heel protectors to bilateral heels every shift. Observation on 04/11/22 at 9:37 A.M. of Resident #8 revealed the resident was seated in a wheelchair, sleeping, with the television on. Heel protectors were noted to be sitting in the resident's recliner chair and not placed on the resident. The resident was observed with no hand roll in the right hand. Observation on 04/12/22 at 8:00 A.M. and 10:30 A.M. of Resident #8 revealed the heel protectors and hand roll were not in place. Interview on 04/12/22 at 10:44 A.M. State Tested Nurse Aide (STNA) #100 verified Resident #8's heel protectors were to be on at all times and roll should be in place. The STNA reported the resident was provided A.M. care by third shift staff and third shift staff should have put on the heel protectors and placed the hand roll in Resident #8's right hand. STNA #100 further verified the resident was not wearing heel protectors and there was no hand roll in the resident's right hand. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366171 If continuation sheet Page 2 of 8 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 366171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cridersville Nursing and Rehab 603 East Main Street Cridersville, OH 45806 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record reviews, staff interviews, and review of facility policy, the facility failed to conduct thorough root cause analysis to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls and falls with injury, resulting in actual harm when a resident experienced repeated falls resulting in fractures. This affected one resident (#30) of three residents reviewed for falls. The census was 30. Finding include: Review of the medical record for Resident #30 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, Alzheimer's disease, unsteadiness on feet, psychotic disorder, major depression, and cognitive communication deficit. Review of fall risk assessment dated [DATE], revealed Resident #30 was at moderate risk for falls. Review of admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #30 was severely cognitively impaired. The resident required extensive assistance of two people for bed mobility and toilet use and limited assistance of one person for transfers. The assessment revealed Resident #30 had a history of falls prior to admission. Review of care plan revised 01/13/22, revealed Resident #30 was at risk for falls and fall related injuries. Documentation revealed the resident did not realize physical limitations caused by a chronic medical condition and had a history of reoccurring falls. The resident had poor impulse control and poor muscle coordination due to weakness and a fractured right ankle, incontinence, and acute mental status changes which caused poor safety awareness. Interventions included, weight bearing to right foot with boot in place, check on safety during daily care rounds, check room while providing care, keep pathways free of clutter/obstacles, complete fall risk assessment per protocol, anticipate needs, position objects that are frequently used in proximity, encourage use of reacher, nonskid footwear, and mechanical lift for all transfers. Review of a document titled, Incident Audit Report, dated 01/04/22 at 11:42 P.M., revealed Resident #30 was sitting on the floor in his room with his back leaning against the recliner chair, no injury was noted. The resident reported toothpaste was dropped on the floor and he was attempting to pick it up. Resident #30 was assisted to the recliner and education was provided on the importance of using the call light and waiting for staff assistance. Further review revealed the resident was noncompliant with waiting for staff assistance due to cognition. The intervention was to continue to re-educate the resident for the importance of staff assistance. Continued review revealed the resident was alert and oriented to person and ambulatory with assistance. Fall factors were documented as confused, gait imbalance, impaired memory, incontinent, and weakness/fainted. The care plan was documented as reviewed. Review of a document titled, Incident Audit Report, dated 01/04/22 at 2:41 P.M., revealed Resident #30 was noted to be sitting on the bathroom floor with his back resting against the toilet. The resident complained of right ankle pain. Documentation revealed the resident was trying to go to the bathroom and the resident's ankle gave out. Resident #30 had swelling to his right ankle and was non-weight bearing. Two staff assisted Resident #30 to his wheelchair and the physician was called with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366171 If continuation sheet Page 3 of 8 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 366171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cridersville Nursing and Rehab 603 East Main Street Cridersville, OH 45806 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 - Actual harm Residents Affected - Few orders received for Resident #30 to be sent to the hospital for evaluation and treatment. The resident was assessed as alert and oriented to self and ambulatory with assistance. Fall factors included gait imbalance, impaired memory, and ambulating without assistance. The resident was found to have a fracture of the right ankle. Actions included, non-weight bearing until seen by physician, mechanical lift for transfers, and therapy to work with resident cognitive barriers. Review of fall risk evaluation dated 01/04/22 at 2:47 P.M. revealed Resident #30 had a history of three or more falls in the past three months and was ambulatory/incontinent. The resident was assessed to have balance problems while standing, balance problems while walking, decreased muscular coordination, change in gait pattern when walking through doorway, and required use of assistive devices. The document included clinical suggestions such as rubber-soled shoes or nonskid slippers to be worn for ambulation, utilize toileting program, and utilize personal/pressure sensor alarms. None of the clinical suggestions were selected. The score for the assessment was 19, which indicated Resident #30 was at high risk for falls. Review of document titled, Incident Audit Report, dated 03/12/22 at 12:23 P.M., revealed Resident #30 was found on the bathroom floor. Documentation revealed the resident's bottom was on the floor and legs/feet were pointing south. The resident reported attempting to get on the toilet and slid off and onto the floor. The resident denied pain and denied hitting his head. Resident #30's family and physician were notified. Fall factors included impaired memory, incontinent, ambulating without assist, and improper footwear. Documentation revealed the interdisciplinary team (IDT) reviewed and agreed the resident was currently receiving therapy services, who would assess and make recommendations due to the poor cognition of Resident #30. Review of a fall risk evaluation dated 03/19/22 at 9:09 P.M. revealed Resident #30 had intermittent confusion. The resident had a history of one to two falls in past three months. The resident was noted to be chairbound and required restraints and assistance with elimination. The resident was assessed to have balance problems while standing, balance problems while walking, and required use of assistive devices. The document included clinical suggestions such as rubber-soled shoes or nonskid slippers to be worn for ambulation, utilize toileting program, and utilize personal/pressure sensor alarms. None of the clinical suggestions were selected. The score for the assessment was 15, which Resident #30 was at high risk for falls. Review of a document titled, Incident Audit Report, dated 04/12/22, revealed Resident #30 was sitting on the floor next to the bed. Resident #30 was noted to be incontinent of urine. The resident reported trying to get up to go to the bathroom. Documentation revealed the resident was alert and oriented to person and wheelchair bound. Fall factors included gait imbalance, impaired memory, incontinent, and ambulating without assistance. Further review revealed the IDT reviewed and agreed with physician order for an x-ray to Resident #30's right ankle. Resident #30 was documented as unteachable or redirectable to not ambulate without assistance. Review of radiology interpretation dated 04/13/22, revealed the impression was severe osteopenia, nondisplaced fracture through the bases of the second through fifth metatarsals, and soft tissue swelling. Acute fracture noted through the right distal fibula. Periosteal thickening in the proximal fibula may represent old injury. Review of a progress note dated 04/13/22 at 11:55 A.M. revealed the physician was made aware of the radiology results and a new order was received to send Resident #30 to the hospital for evaluation and treatment. Review of a progress note dated 04/13/22 at 8:55 P.M. revealed the resident returned (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366171 If continuation sheet Page 4 of 8 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 366171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cridersville Nursing and Rehab 603 East Main Street Cridersville, OH 45806 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 to the facility from the hospital. The resident was non-weight bearing. A splint was noted on the right lower extremity and the splint was to remain in place until follow-up with the physician. Level of Harm - Actual harm Residents Affected - Few Interview on 04/13/22 at 8:32 A.M. with Registered Nurse (RN) #105 revealed Resident #30 was not able to use the toilet or urinal. RN #105 revealed the resident was to be monitored for incontinence and provided care as needed. Interview on 04/13/22 at 11:20 A.M. with Therapy Staff (TS) #300 revealed Resident #30 received occupational and physical therapy. TS #300 reported the resident had a long-term goal for toileting. TS #300 revealed the resident required a mechanical lift for transfers and was currently a max assist of three staff for up to 15 seconds. TS #300 reported the resident was not safe to be on the toilet or a bedside commode related to poor trunk control, leaning, recall of less than a minute, and weakness. TS #300 reported therapy was working with the resident on trunk control and strengthening to reduce leaning. TS #300 revealed Resident #30 was able to self-propel in the wheelchair to his room and use the urinal. Interview on 04/13/22 at 4:25 P.M. with the Regional Nurse Consultant (RNC) revealed Resident #30 had a Brief Interview of Mental Status (BIMS) score of five, indicating Resident #30 was severely cognitively impaired. Resident #30 was not teachable, therefore the RNC felt the resident was not appropriate for a toileting program or scheduled toileting. The RNC verified the resident had three falls while attempting to take self to the toilet, two of which resulted in fractures. The RNC verified the intervention for the fall dated 01/04/22 at 11:42 was educating the resident to wait for staff assistance, the intervention for the fall dated 01/04/22 at 2:41 P.M. was hospital evaluation/treatment and mechanical lift for transfers, intervention for the fall dated 03/12/22 was therapy services, and the intervention for the fall dated 04/12/22 was x-ray of the right ankle. The RNC verified the interventions did not address toileting needs of Resident #30. Interview on 04/13/22 at 4:47 P.M. with the Director of Nursing (DON) revealed Resident #30 was not able to use a urinal because the resident was shaky and would spill the urine. Interview on 04/14/22 at 11:40 A.M. with the DON revealed the facility's incident audit report was their root cause investigation form. Interview on 04/14/22 at 1:21 P.M. with the DON revealed there was no policy for root cause analysis, they just followed the form. Review of undated facility policy titled, Falls Policy and Procedure, revealed, based upon assessment, the IDT would develop interventions based upon the resident risk factors and individual needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366171 If continuation sheet Page 5 of 8 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 366171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cridersville Nursing and Rehab 603 East Main Street Cridersville, OH 45806 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, the facility failed to ensure food was prepared and stored in a safe and sanitary manner. This had the potential to affect all 31 residents residing in the facility. The census was 30. Findings include: Observation of the kitchen on 04/11/22 at 10:30 A.M. revealed Dietary Manager (DM) #410 without a hairnet while preparing breakfast. Further observations revealed a refrigerator with a temperature of 42 degrees Fahrenheit. Additionally, chemicals of rinse agent, sanitizer, and dish detergent were stored on the floor next to bottled water, sports drinks, and open boxes of Styrofoam cups. The label on the rinse agent stated, Harmful if swallowed. The label on the sanitizer stated, Danger, keep out of reach of children. Lastly, the label on the dish detergent stated, Danger, harmful to eyes. Interview with DM #410 at 10:42 A.M. verified he was not wearing a hairnet while preparing breakfast. DM #410 also verified the containers of chemicals stored on the floor next to beverages. Observations of lunch service on 04/11/22 at 11:20 A.M. revealed the same refrigerator observed at 10:30 A.M. continued to be 42 degrees Fahrenheit. Cottage cheese prepared for lunch was 51 degrees Fahrenheit (10 degrees higher than the required temperature). Interview on 04/11/22 at 11:29 A.M. DM #410 verified the temperatures of the refrigerator and cottage cheese did not meet required temperatures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366171 If continuation sheet Page 6 of 8 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 366171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cridersville Nursing and Rehab 603 East Main Street Cridersville, OH 45806 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on review of facility records, staff interview, and review of facility policy, the facility failed to hold Quality Assessment and Assurance meetings at least quarterly. This had the potential to affect all 31 residents in the facility. The facility census was 30. Residents Affected - Many Findings Include: Review of the Quality Assurance (QA) sign in sheets revealed a QA meeting was held on 01/27/22. No other meetings were documented as being completed. There were no meetings documented taking place from March 2021 to October 2021. Interview on 04/14/22 at 1:42 P.M. the Administrator verified there were no QA meetings held from March 2021 through October 2021. Review of the undated facility policy titled, Quality Assurance Committee, revealed the QA committee shall meet at least quarterly and as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366171 If continuation sheet Page 7 of 8 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 366171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cridersville Nursing and Rehab 603 East Main Street Cridersville, OH 45806 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with the Director of Nursing, the facility failed to offer vaccination for pneumonia to residents. This affected four residents (#1, #8, #19, and #24) of five residents reviewed for pneumonia vaccination. The census was 30. Residents Affected - Some Findings include: Review of Resident #1's record revealed the resident was admitted on [DATE]. No declination or consent for a pneumonia vaccination was noted in Resident #1's paper chart or electronic chart. Review of Resident #8's record revealed the resident was admitted on [DATE]. No declination or consent for a pneumonia vaccination was noted in Resident #8's paper chart or electronic chart. Review of Resident #19's record revealed the resident was admitted on [DATE]. No declination or consent for a pneumonia vaccination was noted in Resident #19's paper chart or electronic chart. Review of Resident #24's record revealed the resident was admitted on [DATE]. No declination or consent for a pneumonia vaccination was noted in Resident #24's paper chart or electronic chart. Interview on 04/13/22 at 11:40 A.M. the Director of Nursing (DON) verified there was no documentation stating Residents #1, #8, #19, and #24 were offered pneumonia vaccinations. Review of facility policy titled, Influenza and Pneumococcal Vaccine Policy, revised 07/25/07 revealed all newly admitted residents would be assessed for pneumococcal vaccine status upon admission. Residents without proof of previous pneumococcal vaccination should receive one dose of pneumonia vaccine per Center for Disease Control (CDC) guidance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366171 If continuation sheet Page 8 of 8