Health inspection·August 22, 2024

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 medical record review, staff interview, and review of the policy, the facility failed to complete skin assessments and document skin alterations for a resident. This affected one (#81) of three resident reviewed for pressure ulcers. The facility census was 29. Residents Affected - Few Findings include: Review of the medical record of Resident #81 revealed an admission date of 08/13/24. Diagnoses included back pain, hypertension, coronary artery disease, sick sinus syndrome, and hyperlipidemia. No minimum data assessment had been completed. The Brief Interview of Mental Status assessment dated [DATE] revealed him to be cognitively intact. Review of the progress note dated 08/13/24 at 2:39 P.M., revealed Resident #81 arrived to the facility. The note had a entry skin assessed noted to have biopsy on 8/12 to back dressing and skin assessed see Point Click Care (PCC) assessment also noted to have bed sore. Review of the PCC admission assessment revealed a lesion on the upper back of Resident #81, no notation related to a bed sore. Review of the physician orders revealed an order dated 08/13/24 to apply a dry foam dressing to the coccyx and change daily. An order to apply Mupirocin ointment 2% to the lesion on the upper back twice daily and leave open to air. Further review of the medical record revealed no evidence of description of either the wound on the coccyx or the lesion on the upper back until 08/21/24, when the wound nurse arrived and assessed. On 08/21/24, the upper back lesion was assessed as a surgical biopsy site measuring five centimeters (cm) in length, 0.1 cm in width, and 0.1 cm in depth with approximately 100% epithelial tissue, the edges were approximated, and the surrounding tissue was fragile, and no drainage was noted. Six sutures were observed. The description of the coccyx wound was a stage three pressure ulcer measuring one cm in length, 0.5 cm in width, and 0.2 cm in depth surrounded by two cm in length, two cm in width, and 0.1 cm in depth of moisture associated skin disorder. The pressure wound was assessed as 90% epithelial tissue and 10% granulation tissue. Scant amount of serous drainage was noted and a border gauze dressing was applied and a pressure reducing cushion was suggested. Interview on 08/21/24 at 1:30 P.M., with Registered Nurse #158 verified there was no description of the wounds to Resident #81 had been documented until 08/21/24 after surveyor questioned. Review of the policy titled, Pressure Injury Risk Assessment, dated August 2022, revealed all residents will have a visual assessment of their skin. A complete head-to-toe skin check is completed by the licensed nurse upon admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366171 If continuation sheet Page 2 of 7 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 08/22/2024 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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, observations, staff interviews, and resident interview, the faciliy failed to ensure a resident experiencing pain was provided pain management. This affected one (#11) of one residents reviewed for pain management. The faciliy census was 29. Residents Affected - Few Findings included: Record review for Resident #11 revealed the resident admitted to the facility on [DATE]. Diagnoses for Resident #11 included: paraplegia, chronic pain, obesity, pneumonia, bladder disorder, sepsis, heart failure, and neuromuscular dysfunction of bladder. Review of Resident #11 care plans dated [DATE] revealed a focus for alteration in comfort as evidence of verbalizing complaints of pain. Interventions include administer pain medications per order. Review of Resident #11's medication orders revealed on [DATE] the resident was ordered to receive Oxycodone 5 milligrams (mg) every 6 hours as needed for pain. Review of Resident #11's Medication Administration Record (MAR) dated [DATE] revealed the last dose administered of the as needed Oxycodone was on [DATE] at 4:07 A.M. Observation and interview on [DATE] at 9:20 A.M., revealed Resident #11 getting into her bed. Resident #11 stated she was having a lot of pain, rating it a 6 out of 10 on the pain scale. Resident #11 stated she had requested her as need Oxycodone medication last night before bed but was told by the night nurse there was no supply of oxycodone for her in the medication cart. Resident #11 stated the nurse informed her the pharmacy was contacted and they were awaiting the shipment of the oxycodone to the facility. Resident #11 stated she has been in pain ranging from a 5-7 since [DATE] evening when she requested the pain medication. Interview on [DATE] at 9:27 A.M., with Licensed Practical Nurse (LPN) #111 verified Resident #11 had an order for Oxycodone 5 mg every 6 hours as needed for pain. LPN #111 verified there was no supply of Oxycodone in the medication cart for Resident #11. LPN #111 stated she would contact the pharmacy and request an emergency dose for Resident #11's request. LPN #111 stated there was a supply of oxycodone in the emergency supply and the pharmacy could supply a code to the nurse to retrieve the pain medication. LPN #111 stated the pharmacy would then have to supply the medication at the next shipment. Review of Resident #11's pain monitoring revealed on [DATE] at 9:31 A.M., the resident reported to the nurse a pain level of 8 out of 10. Interview on [DATE] at 10:30 A.M., with LPN #111 stated the pharmacy refused to supply a code for the emergency medication due to the hand written prescription being expired. LPN #111 stated there was an active order in Resident #11's medical records for the Oxycodone, however the actual script had expired and the provider was notified of the expired script and a new script was requested to be written so LPN #111 could fax the new prescription to the pharmacy. LPN #111 stated she was waiting for the new prescription and the nurse would then notify pharmacy for the emergency code. Per LPN #111 as soon as the pharmacy responded with the code for the new prescription she would administer the pain medication to Resident #11. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366171 If continuation sheet Page 3 of 7 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 08/22/2024 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 0697 Level of Harm - Minimal harm or potential for actual harm Interview on [DATE] at 11:00 A.M., with the Assistant Director of Nursing (ADON) #146 verified the Oxycodone order on the narcotic sheet was not expired and was available for a refill on [DATE]. ADON #146 verified there was Oxycodone in the emergency supply. During the interview with ADON #146, LPN #111 entered the office and stated she had not contacted the pharmacy or the provider regarding the prescription for the Oxycodone. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366171 If continuation sheet Page 4 of 7 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 08/22/2024 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the infection control logs, resident interview, and staff interview, the facility failed to ensure a resident did not receive unnecessary medications. This affected one (#11) of six residents reviewed for unnecessary medications. The current census is 29. Residents Affected - Few Findings include: Record review for Resident #11 revealed the resident admitted to the facility on [DATE]. Diagnoses for Resident #11 include paraplegia, chronic pain, obesity, pneumonia, bladder disorder, sepsis, heart failure, and neuromuscular dysfunction of bladder. Review of Resident #11's prescribed medications revealed on 05/23/24 the resident was ordered to receive Amoxicillin-Pot Clavulanate Oral Tablet 875-125 milligrams (mg) Give 1 tablet by mouth one time a day related to cellulitis of abdominal wall. No end date of the medications was noted in the orders. Review of the facility's infection control log from June 2024 to August 2024 revealed Resident #11 was not listed as a resident with an active infection receiving an antibiotic for cellulitis of abdominal wall. Interview on 08/20/24 at 10:00 A.M., with Resident #11 revealed the resident has been receiving antibiotics for unknown reasons and unknown length of time. Interview on 08/21/24 at 3:00 P.M., with Registered Nurse (RN) #158 identified as the Infection Control Preventionist, revealed Resident #11 was receiving an antibiotic since 05/23/24 and there was no end date until 08/20/24. Per RN #158, Resident #11 did not have an active infection and was receiving the antibiotics as a preventative medication for a resolved abscess. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366171 If continuation sheet Page 5 of 7 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 08/22/2024 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 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 record review and staff interview, the facility failed to ensure narcotic medication administration was documented in the medical records for residents. This affected one (#11) of five residents reviewed for medication administration documentation. The current census is 29. Findings include: Record review for Resident #11 revealed the resident admitted to the facility on [DATE]. Diagnoses for Resident #11 included: paraplegia, chronic pain, obesity, pneumonia, bladder disorder, sepsis, heart failure, and neuromuscular dysfunction of bladder. Review of Resident #11 care plans dated 02/23/24 revealed a focus for alteration in comfort as evidence of verbalizing complaints of pain. Interventions include administer pain medications per order. Review of Resident #11's medication orders revealed on 07/26/24 the resident was ordered to receive Oxycodone 5 milligrams (mg) every 6 hours as needed for pain. Review of Resident #11's narcotic sign out sheets dated July 2024 revealed on 07/18/24 the nurses signed an Oxycodone tablet at 3:00 P.M. and at 9:32 P.M., on 07/19/24 at 2:00 P.M., on 07/20/24 at 5:00 A.M., on 07/21/24 at 10:00 P.M. Review of Resident #11's Medication Administration Records (MAR)s dated July 2024 revealed no corresponding documentation of the Oxycodone being administered to the resident on 07/18/24 at 3:00 P.M. and at 9:32 P.M., on 07/19/24 at 2:00 P.M., on 07/20/24 at 5:00 A.M., on 07/21/24 at 10:00 P.M. Review of Resident #11's narcotic sign out sheets dated August 2024 revealed the nurses signed out an Oxycodone tablet on 08/11/24 at 8:00 P.M., 08/11/24 at 7:28 P.M., 08/18/24 at 4:30 A.M., and on 08/18/24 at 10:30 P.M. Review of Resident #11's Medication Administration Records (MAR)s dated August 2024 revealed no corresponding documentation of the Oxycodone being administered to the resident on 08/11/24 at 8:00 P.M., 08/11/24 at 7:28 P.M., 08/18/24 at 4:30 A.M., and on 08/18/24 at 10:30 P.M. Observations of a narcotic count for Resident #11's in the medication locked box revealed no concerns. Interview on 08/21/24 at 3:30 P.M., with ADON #146 verified the documentation errors. The ADON #146 stated there has been no discrepancy with narcotic counts and verified if a nurse signs out a narcotic from the locked box they are to document the administration of the medication into the electronic records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366171 If continuation sheet Page 6 of 7 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 08/22/2024 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, staff interview, and policy review, the facility failed to place one resident in Enhanced Barrier Precautions (EBP) to prevent the spread of infection. This affected one (#81) of one resident reviewed for infection control. The facility census was 29. Residents Affected - Few Findings include: Review of the medical record of Resident #81 revealed an admission date of 08/13/24. Diagnoses include back pain, hypertension, coronary artery disease, sick sinus syndrome, and hyperlipidemia. No minimum data assessment had been completed. The Brief Interview of Mental Status assessment dated [DATE] revealed him to be cognitively intact. Review of the admission assessment dated [DATE] revealed Resident #81 had a surgical lesion site on the upper back. Review of the physician orders revealed an order for Mupirocin ointment (an antibiotic) to be applied twice daily and the site left open to air. No documentation as to the reason for the antibiotic ointment or description of the wound was located in the medical record. Interview on 08/21/24 at 10:00 A.M., with Assistant Director of Nursing (ADON) #146 revealed the facility was unaware of the nature or reason of the surgical biopsy site and would obtain additional information. Review of the progress note from the previous facility, received on 08/21/24 at 11:43 A.M., revealed the surgical biopsy site on the upper back of Resident #81 was growing Staphylococcus. Interview on 08/21/24 at 1:00 P.M., with ADON #146 revealed Resident #81 had not been placed in EBP as the facility was unaware of the need until today when the new information was obtained from the previous facility. Review of the policy titled, Enhanced Barrier Precautions, dated 04/01/24 revealed EBP are indicated when for residents with any of the following to include wounds. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366171 If continuation sheet Page 7 of 7