Health inspection·September 25, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete admitted to the facility in July 2025. 4. Record review for Resident #33 revealed the resident was admitted to the facility on [DATE]. Diagnoses included hemiplegia, malnutrition, difficulty walking, and cerebral infarction. Review of the MDS comprehensive assessment dated [DATE] revealed Resident #33 had mildly impaired cognition and was a set-up only for daily hygiene. Interview on 09/23/25 at 10:15 A.M. with Resident #33 revealed she had fallen in the bathroom due to the sink being in disrepair in August 2025. Per Resident #33, the sink had been leaking in the past and was wobbly. Resident #33 stated she reported the sink to staff before in July 2025 and was told the sink was on back order and would be replaced but at the time of survey it still had not been fixed. Resident #33 stated it was inconvenient to walk all the way to the other shower room or visitor bathrooms to wash her hands or complete simple daily hygiene tasks. Observation on 09/23/25 at 10:40 A.M. of the shower room on the South unit revealed the room was accessible from the hallway and the room shared by Resident #9, Resident #16, Resident #33, and Resident #35. In the shower room there was a toilet and a shower with a shower curtain. Located next to the toilet there were water lines connected to a faucet and there was no porcelain basin connected to the wall. Interview on 09/23/25 at 1:35 P.M. with Certified Nurse Aide (CNA) #118 revealed the sink in the room shared by Resident #9, Resident #16, Resident #33, and Resident #35 on the South unit had been in disrepair for a long time. Per CNA #118 the staff and residents reported the need to repair the sink to the maintenance department and was told the sink was on a list of repairs and was ordered to be replaced. CNA #118 stated all personal care requiring a sink required the residents in the room to go to the other shared shower room or the visitor bathrooms. CNA #118 stated when staff care for Resident #9 the obtain water from the shower stall. Review of the undated list of projects in the facility for repairs revealed there were no repairs for any shower rooms or bathroom sink listed on the document. Review of the invoice dated 09/06/25 revealed a new porcelain sink basin had been ordered by the facility. Review of the receipt invoice dated 09/10/25 revealed the new porcelain sink basin had been received and shipped to the facility. Interview on 09/23/25 at 10:41 A.M. with the Corporate Maintenance Director (CMD) verified the sink in the shower room was non-functional since 08/10/25 when the sink fell off the wall. Per the CMD, the sink was being repaired and was on the scheduled list to be repaired soon. The CMD did not give any actual date for the completion of the repair. Interview on 09/23/25 at 11:25 A.M. with the Administrator revealed there was a list of projects to be completed. The Administrator verified the sink in the room shared by Resident #9, Resident #16, Resident #33, and Resident #35 had fallen off the wall on 08/10/25 and had been non-functional since. The Administrator verified there were no repairs to the shower rooms or bathrooms noted on the list of work-orders and projects to be completed. Per the Administrator all repairs were in progress but had no dates listed on the form provided. Interview on 09/23/25 at 4:22 P.M. with Maintenance Director (MD) #116 revealed on 08/10/25 the sink in the shared shower room adjacent to Resident #9, Resident #16, Resident #33, and Resident #35's room fell to the floor causing a break in the water lines. Per MD #116, the nurse was able to turn off the water to the sink, but MD #116 came to the facility the night of the incident and had to shut off water supply to the sink to prevent further flooding. MD #116 stated on 08/11/25 he reported to his supervisors and the Administrator on 08/11/25 the sink would need to be replaced, and a new basin would have to be ordered. MD #116 verified the projects list had no dates and no shower room or sink repairs noted on the list of work orders to be completed. MD #116 verified the new sink arrived at the facility on 09/10/25 and had been in storage until 09/23/25 when the surveyor observed the bathroom missing the sink and the he had been instructed to start the repair to replace the sink. This deficiency represents non-compliance investigated under Complaint Number OH00167414 (1261183). Event ID: Facility ID: 366171 If continuation sheet Page 2 of 5 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 09/25/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on medical record review and staff interview, the facility failed to initiate a care plan related to anticoagulation medication use. This affected one (#24) of three residents reviewed for care plans. The census was 41. Findings include: Review of medical record for Resident #24 revealed admission date of 06/24/25. The resident was admitted with diagnoses including end stage renal disease, diabetes mellitus, hyperkalemia, dependence on renal dialysis, heart failure, and intellectual disabilities. Review of Resident #24's physician orders dated 01/17/25 for revealed orders for the anticoagulant warfarin sodium Tablet eight (8) milligram (mg) and one (1) mg; to give 0.5 tablet of 1 mg with 8 mg to equal 8.5 mg by mouth one time a day for treating and preventing blood clots. Review of Resident #24's care plan dated 07/20/25 revealed the plan was absent for anticoagulants. Interview with the Director of Nursing (DON) on 09/24/25 at 2:34 P.M. verified Resident #24 did not have a plan of care for anticoagulant medication use. This deficiency represents an incidental finding discovered during the complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366171 If continuation sheet Page 3 of 5 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 09/25/2025 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 medical record review, review of hospital documents, and resident and staff interview, the facility failed to prevent an avoidable fall. Actual harm occurred on 08/10/25 when Resident #33 was in the bathroom leaning on the sink. The sink broke loose from the wall, fell to the floor, and broke into pieces. Resident #33 subsequently fell on top of a sharp piece of the sink and sustained a five millimeter (mm) laceration which hemorrhaged blood and required hospitalization with sutures needed to close the wound. This affected one (Resident #33) of three residents reviewed for accidents. The census was 41. Findings include: Record review for Resident #33 revealed the resident was admitted to the facility on [DATE]. Diagnoses included hemiplegia, malnutrition, difficulty walking, and cerebral infarction. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #33 had mildly impaired cognition and required set-up only for daily hygiene. Review of Resident #33's care plans dated 06/10/25 revealed a focus for falls. Interventions include keeping the bedside table within reach, keeping the call light within reach, keeping the room free of clutter, and therapy as ordered. Review of Resident #33's weight records recorded on 08/02/25 revealed the resident weighed 115 pounds. Review of Resident #33's progress notes dated 08/10/25 at 7:30 P.M. revealed the nurse was alerted by staff and other residents that the resident had an unwitnessed fall. The nurse noted a trail of blood from the outer hallway to the bathroom and bedroom door. Resident #33 was found groaning in pain. There was a moderate amount of blood hemorrhaging from Resident #33's lower back side. The resident was assessed by the nurse, attempts to stop the bleeding were applied, and emergency medical services were contacted. The nurse documented Resident #33 said she was leaning against the sink momentarily to finish hygiene when the sink detached from the wall. She fell and the sink fell to the floor. Resident #33 said she landed on a sharp piece of the sink causing a laceration to the lower lumbar area. Resident #33 was transported to the hospital for evaluation and treatment, and the nurse contacted the maintenance director due to not being able to completely turn off the water flooding into the bathroom and hallway. Review of Resident #33's hospital documents, dated 08/10/25, revealed the resident was admitted to the hospital for treatment to a laceration obtained after a fall onto a sink at the nursing home. Resident #33 suffered a 5 mm laceration on her back and required six sutures for closure. The resident was treated for pain at the hospital and sent back to the facility on [DATE] with instructions on wound care. During an interview on 09/23/25 at 10:02 A.M., Resident #35 and Resident #16, both residents stated they did not see the actual fall Resident #33 sustained on 08/10/25 in the bathroom. Resident #35 and Resident #16 stated they heard Resident #33 fall and then cry out for help. Resident #16 stated she went to get staff help, and Resident #35 stated she activated her call light and went to see if she could help Resident #33. Both residents stated the staff responded quickly to help Resident #33 and emergency medical services took the resident quickly to the hospital. Resident #16 stated she and other residents reported their concerns with the broken sink to other staff including the maintenance department prior to 08/10/25. During an interview on 09/23/25 at 10:41 A.M., Corporate Maintenance Director (CMD) #1 verified the sink in the shower room was non-functional since 08/10/25 when the sink fell off the wall. During an interview on 09/23/25 at 1:12 P.M., Resident #33 stated the bathroom sink had been in disrepair since July 2025 but was totally broken after her fall in August 2025. Resident #33 did not provide any details regarding the fall at the time of the original interview but stated since the sink was still broken at the time of the survey and she was unable to do her daily hygiene regularly in her own bathroom. Resident #33 stated she was upset she had to walk down the hall to the other shower room on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366171 If continuation sheet Page 4 of 5 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 09/25/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete other side of building in order to do simple tasks such as washing her face and brushing her teeth. During an interview on 09/23/25 at 5:00 P.M. Resident #33 stated she was showering and had her clothes on the sink. Resident #33 stated she was alone in the bathroom getting dressed after her shower when she felt she felt unstable. Resident #33 stated she leaned on the sink to steady herself and the sink then wobbled off the wall onto the ground causing her to fall on top of the sink and it cut her back. Resident #33 stated she was not using the water sink for hygiene at the time of the fall and stated the sink was wobbly prior to the day of her fall. Resident #33 stated she received sutures for the laceration and the staff acted quickly and got her to the hospital fast. Resident #33 stated she did have pain in her back from the laceration immediately after the fall; however, the resident stated she had no continued pain with the injury and the wound had since healed. During an interview on 09/23/25 at 4:22 P.M., Maintenance Director (MD) #116 stated on 08/10/25 the sink in the shared shower room adjacent to room [ROOM NUMBER] fell to the floor causing a break in the water lines. MD #116 stated the nurse was able to turn off the water to the sink, but MD #116 came to the facility the night of the incident and had to shut off water supply to the sink to prevent further flooding. MD #116 stated he was informed Resident #33 fell while she was using the sink. MD #116 stated the sink was old and only mounted to the wall by the studs and did not have any support legs. MD #116 stated he did not know the condition of the sink prior to 08/10/25 as he did not perform any routine maintenance checks on sinks in the facility. MD #116 stated he had conducted a sink audit on 08/11/25 and found three other wall mounted sinks in the facility similar to the sink in the shared shower room. MD #116 stated he could not recall any reports of the other sinks being in disrepair prior to the sink audit. MD #116 verified the new sink arrived at the facility on 09/10/25, was put in storage, and was currently being installed as of 09/23/25 during the survey. MD #116 stated the new sink would be installed with a support structure. During an interview on 09/23/25 at 5:30 P.M., the Administrator verified Resident #33 fell on [DATE] while she was using the sink in the resident's room which also was the shared shower room for the South unit. Resident #33 leaned her whole weight on the sink causing it to come loose from the wall and fall to the floor. The Administrator verified Resident #33 only weighed 115 pounds at the time of the fall. The Administrator stated, due to the age of the building, there was no way to determine the age of the wall mounted sink in the bathroom but stated she believed the sink to be in working order at the time of the fall. The Administrator denied Resident #33 suffered any pain from the injury and stated if the resident had not leaned on the sink, it would not have fallen causing her to fall to the ground. The Administrator verified there had been no witnesses to the fall and stated Resident #33 stated she was changing her clothes in the room when she grabbed the sink. The Administrator stated she believed the resident had to have applied greater force than 115 pounds in order for the sink to have come loose and fallen to the floor. The Administrator verified there were no routine maintenance checks on the sinks in the facility prior to the fall on 08/10/25.This deficiency represents an incidental finding discovered during the complaint investigation. Event ID: Facility ID: 366171 If continuation sheet Page 5 of 5