Health inspection·August 9, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Review of the quarterly MDS assessment, dated 07/25/23 revealed the resident had intact cognition and required one person assistance for bed mobility, bathing, transfers, toileting and supervision for eating. Record review for Resident #31's showers from 07/01/23 to present date revealed documentation for showers on 07/14/23, 07/27/23, 08/01/23, 08/02/23, 08/05/23 and 08/06/23. Residents Affected - Few Interview on 08/07/23 at 9:57 A.M., with Resident #31 revealed she did not receive showers or bed baths routinely. Interview on 08/08/23 at 1:43 P.M., with State Tested Nurse Assistant (STNA) #18 revealed there was not always time to ensure residents received their showers timely, especially if there were only two STNAs scheduled which she stated happened weekly. Interview on 08/09/23 at 8:42 A.M., with the Director of Nursing (DON) acknowledged there was no other shower documentation to verify more showers were provided to Residents #19, #25 and #31. This deficiency represents non-compliance investigated under Complaint Number OH00145017. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366171 If continuation sheet Page 2 of 12 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 08/09/2023 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 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 record review, observations, and staff interview, the facility also failed to ensure skin assessments and wound measurement were completed timely. This affected two (#21 and #31) of three residents reviewed for skin impairment. The facility census was 29. Residents Affected - Few Findings include: 1. Review of medical record for Resident #21 revealed admission date of 07/22/23. Medical diagnoses included kidney failure, gastroparesis, Diabetes Mellitus type 2 and anxiety. Review of the admission Minimum Data Set assessment dated [DATE] revealed the resident had intact cognition and was independent or required only limited assistance for his activities of daily living. Review of the electronic medical record for Resident #21 revealed a non-pressure skin assessment and a weekly wound assessment dated [DATE] for a left knee blister. No skin reassessment was completed until 08/08/23 which revealed a decrease in size, area pink with no drainage. No signs or symptoms if infection and the physician was to be updated. Review of the electronic medical record for Resident #21 revealed a non-pressure skin assessment dated and a weekly wound assessment 07/29/23 for right ankle skin tear, no measurements documented. No reassessment was completed until 08/08/23 which revealed the area documented as 2.0 centimeters (cm) by (x) 2.0 cm x 0.0 cm depth. Area healing with scant amount of drainage no signs or symptoms of infection. A treatment of Bactroban (topical antibiotic) and dry dressing was to be applied. 2. Review of medical record for Resident #31 revealed admission date of 03/21/23. Medical diagnoses included: respiratory failure, stage four kidney disease, depression, stroke, and Diabetes Mellitus. Review of the quarterly MDS assessment, dated 07/25/23 revealed the resident had intact cognition and required one person assistance for bed mobility, bathing, transfers, toileting and supervision for eating. Review of the electronic medical record for Resident #31 revealed a non-pressure skin assessment and a weekly assessment form dated 07/18/23 for Moisture Associated Skin Damage (MASD) to left buttock, measuring length 9.5 cm x 5.0 cm x 0.1 cm depth. There were no further weekly skin assessments completed until 08/08/23. The area was assessed as healed. Observation on 08/08/23 at 2:16 P.M. with Licensed Practical Nurse (LPN) #14 of Resident #31 revealed no concern for MASD on her buttocks. Interview on 08/08/23 at 2:33 P.M., with Corporate Regional Nurse (CRN) #19 verified weekly assessment and measurement had not been completed for Resident #21 and #31's skin impairments. This deficiency represents non-compliance investigated under Complaint Number OH00145017. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366171 If continuation sheet Page 3 of 12 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 08/09/2023 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 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 record review, observations, and staff interview, the facility also failed to ensure skin assessments and wound measurement were completed timely. This affected one (#18) of three residents reviewed for skin impairment. The facility census was 29. Residents Affected - Few Findings include: Review of medical record for Resident #18 revealed admission date of 07/07/23. Medical diagnoses included bipolar disease, pulmonary embolism, stage four sacral pressure ulcer and multiple sclerosis. Review of five day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident intact cognition and required extensive one person assistance for bed mobility, total dependence for toileting and supervision for eating. Record review of the 07/27/23 hospital records for Resident #18 revealed an unstageable sacral wound measuring 6.5 centimeters (cm) x 6.0 cm 2.5 cm. Record review of the 07/28/23 admission assessment for Resident #18 revealed documentation for sacral wound, unstageable with no measurements. There were no other assessments until 08/08/23 with the wound measuring 6.0 cm x 5.0 cm x 2.5 cm with minimum/moderate serosanguinous drainage. Progress of the wound was improving and continue with current plan of care. Observation on 08/07/23 at 2:12 P.M., with Licensed Practical Nurse (LPN) #14 of Resident #18's wound revealed the dressing was dated 08/07/23, no purulent drainage when removed. Wound bed noted to be beefy red, no slough, no odor, surrounding tissue intact and no obvious signs or symptoms of infection and Resident #18 stated she had pain at the site in the past, but had no concern recently. Interview on 08/08/23 at 2:33 P.M., with Corporate Regional Nurse (CRN) #19 verified weekly assessment and measurement had not been completed for Resident #18's skin impairment. This deficiency represents non-compliance investigated under Complaint Number OH00145017. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366171 If continuation sheet Page 4 of 12 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 08/09/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, resident and staff interviews, the facility failed to provide catheter care as ordered. This affected three (#19, #31, #37) of three residents reviewed for the care and treatment of a catheter. The facility census was 29. Findings include: 1. Review of medical record for Resident #19 revealed admission date of 07/27/23. Medical diagnoses included: hemiplegia, hemiparesis non dominant side following a stroke, stroke, Diabetes Mellitus Type two, dementia, and Parkinson's Disease, depression, schizoaffective disorder, bipolar type. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required extensive two person assistance for toileting, one person assistance for bed mobility, bathing, transfers, and supervision for eating. Interview on 08/07/23 at 9:57 A.M., with Resident #19 revealed staff did not always clean around his catheter. Review of the August 2023 physician orders for Resident #19, revealed an order for catheter care every shift. Record review of the August Treatment Administration Record (TAR) for Resident #19 revealed no documentation catheter care was provided day shift on 08/02/23, evening and night shift on 08/05/23 or night shift 08/06/23. 2. Review of medical record for Resident #31 revealed admission date of 03/21/23. Medical diagnoses included: respiratory failure, stage four kidney disease, depression, stroke, and Diabetes Mellitus. Review of the quarterly MDS assessment, dated 07/25/23 revealed the resident had intact cognition and required one person assistance for bed mobility, bathing, transfers, toileting and supervision for eating Record review of the July and August 2023 physician orders for Resident #31 revealed an order for supra pubic catheter care every shift and to change the suprapubic catheter monthly at the facility on the 26 th of every month. Record review of the July and August TAR for Resident #31 revealed no documentation catheter care was provided on evening shift 07/01/21, 07/08/23, 07/18/23, 07/22/23, 07/27/23, and 08/05/23; on the day shift 07/14/23, 07/15/23, 07/26/2; and the night shift 07/08/23, 07/12/23, 07/18/23, 07/22/23 or 07/27/23, 08/05/23 or 08/06/23. Further review revealed no documentation of supra pubic catheter change as ordered on 07/26/23. 3. Review of medical record for Resident #37 revealed admission date of 02/17/23. Medical diagnoses included: chronic obstructive pulmonary disease, bipolar disease and Diabetes Mellitus. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366171 If continuation sheet Page 5 of 12 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 08/09/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Review of quarterly MDS assessment dated [DATE] revealed the resident had intact cognition and required supervision of activities of daily living. Record review of the August 2023 physician orders for Resident #37 revealed an order for suprapubic catheter care every shift. Residents Affected - Few Record review of the August TAR for Resident #37 revealed no documentation catheter care was provided day shift on 08/01/23; on evening shift on 08/02/23, 08/05/23 08/06/23; and the night shift on 08/02/23, 08/05/23 or 08/06/23. Interview on 08/08/23 at 1:43 P.M., with State Tested Nurse Aide (STNA) #18 revealed there was not always time to ensure residents received incontinence/catheter care timely, especially if there were only two STNA's scheduled, which she stated happened weekly. Interview on 08/09/23 at 11:17 A.M. with the Director of Nursing (DON) acknowledged there was no documentation to verify catheter care was provided on the aforementioned dates for catheter care for Residents #19, #31 or #37. Review of the policy titled Catheter Care dated August 2022, indicated documentation-the following information should be recorded in the resident's medical record: Catheter care was given. This deficiency represents non-compliance investigated under Complaint Number OH00145017. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366171 If continuation sheet Page 6 of 12 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 08/09/2023 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Potential for minimal harm Based on record review and staff interview, the facility failed to complete annual evaluations of nursing assistants as required. This had the potential to affect all 29 residents residing in the facility. The facility census was 29. Residents Affected - Many Findings include: Record review of the personnel file for State Tested Nursing Assistants (STNA) #20 revealed STNA #20 had a hire date of 02/10/23. There was no evidence of an annual evaluation being completed. Record review of the personnel files for STNA #21 revealed TNA #21 had a hire date of 02/15/22. There was no evidence of an annual evaluation being completed. Interview on 08/09/23 at 8:37 A.M., with the Administrator verified STNA #20 and #21 did not have an annual performance evaluation completed. He added he had identified this as a concern for all employees shortly after taking his position. This deficiency represents non-compliance investigated under Complaint Number OH00145017. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366171 If continuation sheet Page 7 of 12 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 08/09/2023 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 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 medical record review, observation, policy review and staff interview, the facility failed to ensure medications were available for administration and administered per physician orders. This affected three (#17, #32, #39) of four residents reviewed for medication administration. The facility census was 29. Findings include: 1. Review of medical record for Resident #17 revealed admission date of 02/25/22. Medical diagnosis included Alzheimer's Disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had intact cognition and required extensive one person assistance for bed mobility, transfers, toileting and supervision for eating. Record review of the August 2023 Mediation Administration Record (MAR) for Resident #17 revealed Percocet five milligram (mg)/325 milligram for pain, was unavailable for administration on 08/08/23, 08/09/23. N-Acetyl Cysteine Oral Tablet (amino acids) 600 mg (supplement) was unavailable for administration on 08/05/23, 08/06/23, 08/08/23 and 08/09/23. Interview on 08/09/23 at 11:17 A.M., with the Director of Nursing (DON) verified the medication was documented as not being available for administration. 2. Review of medical record for Resident #32 revealed admission date of 06/15/23. Medical diagnoses included stroke, hemiplegia right dominant side, dementia without behaviors, and chronic obstructive pulmonary disease. Review of the admission MDS assessment dated [DATE], revealed the resident's cognition was not assessed. He required extensive two person assistance for bed mobility, transfers, toileting and one person assistance for eating. Record review of the August 2023 MAR for Resident #32 revealed tricagrelor (antiplatelet) 90 milligram ordered twice daily was unavailable on 08/01/23 at 9:00 P.M. and on 08/07/23 and 08/08/23 at 9:00 A.M. Observation of medication administration on 08/08/23 at 8:24 A.M., of Licensed Practical Nurse (LPN) #14 for Resident #32 revealed LPN #14 stated Sodium Chloride one gram (supplement) and ticagrelor 90 milligrams (antiplatelet) were not located in the medicine cart and not available to administer. LPN #14 was observed to crush Acetaminophen 650 milligrams (pain/fever) extended release prior to adding to applesauce for administration. Interview at the observation revealed LPN #14 acknowledged extended-release medication should not be crushed. Interview on 08/09/23 at 11:17 A.M., with the DON verified the medication was documented as not being available for administration. 3. Review of medical record for Resident #39 revealed admission date of 05/15/22. Medical diagnoses included non-traumatic brain dysfunction, Diabetes Mellitus and dementia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366171 If continuation sheet Page 8 of 12 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 08/09/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the quarterly MDS assessment dated [DATE], revealed the cognition interview was unable to be completed and required supervision to limited assistance with all activities of daily living. Observation of medication administration on 08/07/23 of Registered Nurse (RN) #13 at 11:14 A.M., revealed she crushed the extended-release Potassium (supplement) prior to adding it to applesauce and administering to Resident #17. Interview at the time of the observation, RN #13 acknowledged extended-release medication should not be crushed. Record review of the August [DATE] for Resident #39 revealed Ativan (anxiety) 0.5 milligrams ordered three times daily was unavailable on 08/05/23 for the 6:00 P.M. dose and on 08/06/23 for the 12:00 P.M. and 6:00 P.M. dose. Interview on 08/09/23 at 11:17 A.M., with the DON verified the medication was documented as not being available for administration. Interview and observation on 08/09/23 at 11:17 A.M., with the Director of Nursing (DON) of the medication cart revealed the medication ticagrelor was dispensed under the brand name of Brilinta. The DON updated the MAR to include this information to avoid omission. Review of the policy titled Administering Medications dated December 2012, revealed medications must be administered in accordance with orders. This deficiency represents non-compliance investigated under Complaint Number OH00145017. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366171 If continuation sheet Page 9 of 12 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 08/09/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record, policy review and staff interviews, the facility failed to ensure residents were free of medication errors five percent or greater. There was a total of four medication observed of 25 opportunities, which resulted in a 16 percent (%) error rate. This affected two (#17 and #32) of four residents observed for medication administration. The facility census was 29. Residents Affected - Few Findings include: 1. Review of medical record for Resident #17 revealed admission date of 02/25/22. Medical diagnosis included Alzheimer's Disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had intact cognition and required extensive one person assistance for bed mobility, transfers, toileting and supervision for eating. Observation of medication administration on 08/07/23 at 11:14 A.M., of Registered Nurse (RN) #13 revealed she crushed the extended-release Potassium (supplement) prior to adding it to applesauce and administering to Resident #17. Interview at the time of the observation, RN #13 acknowledged extended-release medication should not be crushed. 2. Review of medical record for Resident #32 revealed admission date of 06/15/23. Medical diagnoses included stroke, hemiplegia right dominant side, dementia without behaviors, and chronic obstructive pulmonary disease. Review of the admission MDS assessment dated [DATE], revealed the resident's cognition was not assessed. He required extensive two person assistance for bed mobility, transfers, toileting and one person assistance for eating. Observation of medication administration on 08/08/23 at 8:24 A.M. of Licensed Practical Nurse (LPN) #14 for Resident #32 revealed LPN #14 stated Sodium Chloride one gram (supplement) and Ticagrelor 90 milligrams (antiplatelet) were not located in the medicine cart. LPN #14 was observed to crush Acetaminophen 650 milligrams (pain/fever) extended release prior to adding to applesauce for administration. Interview at the observation revealed LPN #14 acknowledged extended-release medication should not be crushed. Interview and observation on 08/09/23 at 11:17 A.M., with the Director of Nursing (DON) of the medication cart revealed the medication ticagrelor was dispensed under the brand name of Brilinta. The DON updated the MAR to include this information to avoid omission. Review of the policy titled Administering Medications dated December 2012, revealed medications must be administered in accordance with orders. This deficiency represents non-compliance investigated under Complaint Number OH00145017. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366171 If continuation sheet Page 10 of 12 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 08/09/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review, staff and resident interview, the facility failed to ensure proper infection control measures were followed for residents. This affected two (#18 and #21) of four residents observed for infection control. The facility census was 29. Residents Affected - Few Findings include: 1. Review of medical record for Resident #18 revealed admission date of 07/07/23. Medical diagnoses included bipolar disease, pulmonary embolism, stage four sacral pressure ulcer and multiple sclerosis. Review of five day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident intact cognition and required extensive one person assistance for bed mobility, total dependence for toileting and supervision for eating. Observation on 08/08/23 at 2:12 P.M., of Licensed Practical Nurse (LPN) #14 providing wound care for Resident #18 revealed the resident was assisted to the right side. The soiled dressing was removed and placed on the incontinent product. LPN #14 did not remove gloves and wash hands prior to proceeding with dressing change. A 4.0 inch by 4.0 inch gauze moistened with five percent (%) Dakins solution (wound care), was packed loosely into the wound, and covered with dated Mepilex (foam dressing) with no concern. The old dressing was gathered, and LPN #14 removed her gloves, disposed of them at no time during the observation, did LPN #14 perform hand hygiene. Interview with LPN #14, after she left the room and entered the hall, verified she did complete hand hygiene or change her gloves. Observation on 08/09/23 at 8:54 A.M., of incontinence care revealed after cleansing and drying Resident #18, State Tested Nursing Assistant (STNA) #16 placed the soiled washcloth and towel on the floor at the head of the bed. STNA #16 proceeded to apply a new incontinence product and pad, pulled down Resident #18's gown, covered and repositioned her without removing her soiled gloves. STNA #16 then removed her gloves and went behind the curtain and returned with a pair of compression stockings, at no time did STNA #16 perform hand hygiene. Interview with STNA #16, after the observation, acknowledged she usually placed soiled linens on the floor during incontinence care, and verified she did not change her gloves after providing incontinence care or wash her hands after she did remove her gloves. 2. Review of medical record for Resident #21 revealed admission date of 07/22/23. Medical diagnoses included kidney failure, gastroparesis, Diabetes Mellitus type 2 and anxiety. Review of the admission MDS assessment dated [DATE] revealed the resident had intact cognition and was independent or required only limited assistance for his activities of daily living. Record review of the 07/21/23 hospital admission documentation of Resident #21 revealed an admission with Clostridium Difficile (C. Diff). Review of the progress note dated 07/26/23 revealed Resident #21 was found in his room having a seizure, glucose was 28. Glucagon (given emergently for hypoglycemia) was given and Emergency Medical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366171 If continuation sheet Page 11 of 12 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 08/09/2023 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 0880 Services (EMS) were called. Level of Harm - Minimal harm or potential for actual harm Review of the emergency room notes dated 07/26/23 revealed Resident #21 presented with hypoglycemia, hypothermia and covered in feces. Addendum to the note revealed the emergency medical squad (EMS) reported Resident #21 had C. Diff, arrived with stool coming out of his depends (incontinence product), and bed pads were soiled. A large amount of stool was noted. Residents Affected - Few Record review of the physician orders dated 07/26/23 for Resident #21 revealed an order for Dificid (C. Diff) 200 milligrams two times daily for positive C. Diff culture until 08/01/23. Record review of the electronic medical for Resident #21 revealed loose stool/diarrhea was documented at least once a day 07/27/23 through 08/04/23, 08/05/23 revealed no documentation of stool, loose stool/diarrhea was again documented on 08/06/23 and 08/07/23. Interview on 08/07/23 at 10:50 A.M., with Resident #21 revealed he continued to have loose bowel movements. Interview on 08/08/23 at 2:01 P.M., with the Director of Nursing (DON) revealed Resident #21 was admitted with C. diff and placed in isolation. Resident #21 was not confined to his room during isolation. Resident #21 was removed from isolation upon return from the hospital on [DATE], because there was no order for isolation on the discharge orders. The DON stated Resident #21 denied having loose stools upon return to the facility. The DON verified he did not look at the bowel charting for Resident #21, and the reason for the emergency room visit was emergent for hypoglycemia and acknowledged isolation may not be addressed. DON stated in retrospect the physician should have been notified for clarification. Review of the policy titled Wound Care Policy dated August 2022, revealed after the dressing was removed, hands should be washed and dried. After discarding of soiled items, hands should be washed and dried thoroughly. Review of the policy Incontinence Care dated August 2022 revealed to remove the soiled linen, place in a plastic a bag, remove gloves, and wash hands prior to repositioning resident. Review of the policy titled Transmission-Based (isolation) Precautions implement date of 10/24/22, revealed C. Diff required contact precautions for the duration of the illness. Residents on transmission-based precautions should remain in their rooms except for medically necessary care. This deficiency represents non-compliance investigated under Complaint Number OH00145017. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366171 If continuation sheet Page 12 of 12