Health inspection·November 7, 2019

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on record review, policy review and interview the facility failed to ensure their abuse policy and procedure contained screening procedures for all staff to be checked against the nurse aide registry (NAR) for potential abuse prior to beginning employment with the facility. The facility failed to ensure all licensed nursing staff were checked against the NAR prior to employment. This had the potential to affect all 45 residents residing in the facility. Residents Affected - Many Findings include: Review of employee files revealed the following: 1. Registered Nurse (RN) #12 was hired on 04/16/19 and was not checked against the nurse aide registry (NAR) for potential abuse. 2. RN #19 was hired on 06/06/19 and was not checked against the NAR prior to hire. RN #19 was checked against the NAR on 09/23/19 and had no findings. 3. RN #10 was hired on 08/12/19 and was not checked against the NAR for potential abuse. Review of the facility policy titled Abuse, Mistreatment, Neglect, and/or Misappropriation of Resident Property dated 07/18/12 and revised 07/2019 revealed potential employees would be screened for a history of abuse, neglect or mistreating of residents. Nurse aide registry verification would be completed if applicable. On 11/07/19 at 9:23 A.M. interview with Human Resource (HR) #59 verified RN #10, #12 and #19 were not checked against the NAR prior to hire. An additional interview at 1:20 P.M. revealed RN #19 was checked in September 2019, after she had worked over three months in the facility. On 11/07/19 at 1:00 P.M. interview with the Director of Nursing verified the Abuse policy did not indicate all employees should be verified against the NAR prior to employment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366190 If continuation sheet Page 2 of 15 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 366190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belmont Manor 51999 Guirino Drive St Clairsville, OH 43950 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 0641 Ensure each resident receives an accurate assessment. 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 staff interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were accurately completed. This affected three residents (#14, #16 and #34) of 15 residents whose MDS assessments were reviewed. Residents Affected - Few Findings include: 1. Review of Resident #14's medical record revealed a 11/14/18 admission with diagnoses including dementia, depression and anemia. Review of the record revealed there was no evidence of a pressure ulcer in August 2019. Review of the 08/26/19 quarterly MDS 3.0 assessment revealed the resident was severely impaired for daily decision making and had an unhealed Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister). Interview on 11/04/19 at 4:42 P.M. with the Director of Nursing (DON) verified the resident had not had a pressure ulcer in August and the 08/26/19 MDS assessment was incorrectly coded. 2. Review of Resident #16's medical record revealed an admission date of 04/26/15 with diagnoses including psychotic disorder and Alzheimer's. Review of the pressure ulcer skin grids revealed on 04/29/19 the resident had two unstageable pressure ulcers, full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, grey, green or brown) and/or eschar (tan, brown or black) in the wound bed, to bilateral heels and a Stage II pressure ulcer to the right shoulder, all facility acquired. The resident was admitted to the hospital and upon return the 05/16/19 five day MDS assessment indicated there were two unstageable pressure ulcers and one Stage II pressure ulcer present on admission. Review of the 08/23/19 quarterly MDS assessment revealed the resident had an unstageable pressure ulcer present on admission. The MDS was coded the resident received seven days of an anticoagulant. Interview 11/07/19 at 10:40 A.M. with the DON verified the pressure ulcers were incorrectly coded present on admission when they were facility acquired. The DON verified the resident had the pressure ulcers prior to admission to the hospital and they did not worsen. Verification occurred the 05/16/19 and 08/23/19 MDS assessments were incorrectly coded as admitted with when the pressure ulcer were facility acquired. In addition, review of the physician orders revealed a 05/10/19 order for Plavix, a thienopyridine class of drug that inhibits platelet aggregation and thus inhibits aspects of blood clotting, for circulation. Review of the 08/23/19 quarterly MDS assessment revealed it was coded for receiving seven days of an anticoagulant. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366190 If continuation sheet Page 3 of 15 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 366190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belmont Manor 51999 Guirino Drive St Clairsville, OH 43950 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 0641 Level of Harm - Minimal harm or potential for actual harm Interview on 11/05/19 at 10:04 A.M. with the Director of Nursing verified the Plavix was coded as an anticoagulant in error when it was an antiplatelet. 3. Record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including cerebral infarction and long-term use of anticoagulant. Residents Affected - Few Review of Resident #34's orders and Medication Administration Records (MAR) dated 10/2019 revealed no evidence the resident had received an anticoagulant. Review of Resident #34's quarterly MDS 3.0 assessment dated [DATE] revealed the resident received seven days of an anticoagulant. Interview on 11/05/19 at 12:58 P.M. with Licensed Practical Nurse (LPN) #22 verified Resident #34's quarterly MDS assessment dated [DATE] was coded inaccurately for anticoagulant use and the resident did not receive an anticoagulant during the month of October 2019. The LPN reported she had coded Plavix (anti-platelet) as an anticoagulant in error. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366190 If continuation sheet Page 4 of 15 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 366190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belmont Manor 51999 Guirino Drive St Clairsville, OH 43950 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure an accurate Preadmission Screening and Resident Review (PASARR) was completed for Resident #36. This affected one resident (#36) of one resident reviewed for PASARR services. Findings include: Review of Resident #36's medical record revealed an admission date of 10/04/17 with diagnoses including Bipolar disorder and depression. Review of the Preadmission Screening Resident Review revealed it was originally sent prior to admission on [DATE]. The PASARR result revealed the level of care was not an authorization for Medicaid nursing facility payment. The result form indicated to consult with your local county department of human services for the decision on nursing facility payment. Prior to the 10/04/17 admission, on 09/25/17, the 05/21/13 form was faxed with a progress note including the use of Dilaudid, an anticonvulsant, and Metoprolol for hypertension. Section D: indications of serious mental illness indicated yes and had written in depressive disorder. There was no indication of the County Board being made aware of the resident's Bipolar disorder for decision making of services. The diagnosis of Bipolar disorder was not included on the PASARR when the resident was admitted with the diagnosis on 10/04/17. The PASARR was not accurate or corrected on subsequent assessments. Interview on 11/04/19 at 3:23 P.M. with the Director of Nursing (DON) verified the resident's Bipolar disorder diagnosis was not on the PASARR application prior to admission. The DON verified the facility did not identify the inaccurate PASARR assessment that should have included the Bipolar disorder diagnosis to determine if Level II services were needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366190 If continuation sheet Page 5 of 15 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 366190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belmont Manor 51999 Guirino Drive St Clairsville, OH 43950 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 0692 Provide enough food/fluids to maintain a resident's health. 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 the facility failed to ensure Resident #192's food, fluid and intravenous intake were being monitored following an acute change in condition which resulted in the resident being admitted to the hospital for severe dehydration. This affected one resident (#192) of one resident reviewed for hemodialysis. Residents Affected - Few Findings include: Record review revealed Resident #192 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, anemia, dysphagia, vascular dementia, cerebrovascular infarction, hemiplegia and hemiparesis, epilepsy, and metabolic encephalopathy. On 10/31/19 and 11/05/19 diagnoses of end stage renal disease, dehydration, dry mouth, nutritional deficiency, and dependence on renal dialysis were added to the diagnoses list. Review of Resident #192's plan of care for cerebrovascular accident (CVA) with left hemiplegia and frontal/temporal encephaloma dated 04/02/14 revealed to observe the resident's intake to assure adequate fluid intake to prevent dehydration. Review of Resident #192's dietary note dated 09/06/19 and 09/09/19 revealed the resident weighed 200 pounds and was on a mechanical soft diet with nectar thick liquids, pureed meats-no mixed consistencies, no rice, white soft bread only, puree biscuits, and rolls. The notes indicated the resident ate in the assist dining room. The resident received mighty shakes (nutritional supplements) with meals with good intake most of the time. The resident's estimated fluid needs were 2278-2733 milliliters (ml). He had noted coughing episodes while drinking. Speech had treated the resident for dysphagia. Review of Resident #192's nursing progress notes revealed: On 10/11/2019 at 6:28 P.M. the nurse was called into resident's room. The resident had shallow, rapid respirations, lung fields were clear x 4. His skin was cool, had a web like mottling, and nail beds were blue. Oxygen was started at 2.5 liters per minute (LPM) per cannula. Resident was talking and responding appropriately. He was grinding his teeth but stopped when asked to. His blood pressure was 153/69, pulse 139, respirations were 48, temperature was 98.7, and blood sugar was 206. The resident's father was notified, and he did not want him sent out unless the doctor felt he needed to be sent to emergency room. The doctor was notified and ordered a complete blood count (CBC) with diff, complete metabolic panel (CMP), Depakote level, and urine (UA). If there was no improvement from the oxygen within 45 minutes, then send resident to emergency room. On 10/11/19 at 7:14 P.M. the resident was more alert. His nail bed was no longer blue, and skin no longer mottled. His pulse was 118, respirations were 38, blood pressure 121/59, and pulse oxygen level was 94% on 2.5 liters of oxygen. Resident's father notified of orders and improvement of condition. On 10/11/2019 at 7:21 P.M , revealed lab work was obtained and sent for testing as ordered. Review of Resident #192's laboratory results dated [DATE] revealed the resident blood and urine was collected on 10/11/19 at 7:00 P.M. and was faxed to the facility on [DATE] at 6:26 P.M. Further (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366190 If continuation sheet Page 6 of 15 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 366190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belmont Manor 51999 Guirino Drive St Clairsville, OH 43950 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 0692 Level of Harm - Minimal harm or potential for actual harm review revealed the resident sodium level was high 146 (137-145), BUN was high 70 (9-20) and creatine was high 2.3 (0.7-1.3). His white blood count was low 3.55 (4.70-10.8), red blood count low 3.56 (4.7-6.10), hemoglobin was low 11.4 (14-18), hematocrit was low 35.8 (42-52) and plates were low 105 (130-400). His urine was hazy brown with small trace of bilirubin, large amount of blood, positive nitrates, large number of leukocytes, and may bacteria. Residents Affected - Few On 10/12/19 at 6:25 P.M. the resident continued to be lethargic, CMP, CBC and UA back and reviewed by doctor with new orders to start the antibiotic, Macrobid 100 milligrams (MG) and Probiotic twice daily for possible urinary tract infection (UTI), intravenous (IV) Dextrose 5% NACL 0.45% run at 125 milliliter (ML)/hour (HR) for two hours, then decrease rate to 80ML/HR for 22 Hours for the total of 24 Hours of fluid for dehydration. Resident's father notified of all orders and in agreement, family continues wishes for resident to stay at facility and receive treatment and not be sent to hospital at this time. On 10/13/19 at 9:19 A.M. the resident continued to be lethargic, short of breath, and not eating. Resident pulled out IV twice and was not able to be re-started after multiple attempts. Unable to obtain pulse oxygen reading. New orders to discontinue IV fluids and the resident would be sent to the emergency room for evaluation or become comfort care. Resident's mother updated and would call back after discussing with her husband. On 10/13/19 at 1:57 P.M. the resident's parents requested for the resident to be comfort care and not sent to the hospital for treatment. The doctor was notified of resident's decline in condition with new orders to change code status and discontinued current diet due to difficulty with holding in mouth. Initiate regular, puree texture, pudding thick liquid. On 10/14/19 at 9:47 A.M. the resident's mother agreed for speech therapy to evaluate and treat resident due to resident was holding puree food and pudding thicken liquids in mouth. The doctor was notified, and new orders received for speech therapy. On 10/14/19 at 1:17 P.M., the resident remained lethargic and continued to have web like mottling all over. He frequently mouth breaths and was not eating. He was letting food and liquids run out of his mouth. Oxygen continued at 2.5 LPM and oxygen level was 93%. On 10/14/19 at 2:41 P.M. the nurse spoke to the resident's father and he would like another IV started due to he felt the resident needed more fluids because he was not taking fluids by mouth. The physician was notified and new orders were received for D5 1/2 normal saline at 89 ml/hr. for 24 hours. On 10/14/19 at 3:09 P.M. the nurse attempted several times to start and IV without success. New orders were received to discontinue IV. Resident's father notified. On 10/14/19 at 4:37 P.M. the resident's father called the facility and wanted his son to be sent to the hospital for IV's for rehydration. Resident transported to the emergency room via squad. On 10/14/19 at 11:21 P.M. revealed the resident was admitted to the hospital with dehydration. Review of Resident #192's hospital notes, dated 10/15/19 revealed the resident was diagnosed with severe dehydration, acute on chronic renal failure likely due to severe dehydration requiring dialysis, hypotension due to her hypovolemia and dehydration, leukocytosis, anemia, and thrombocytopenia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366190 If continuation sheet Page 7 of 15 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 366190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belmont Manor 51999 Guirino Drive St Clairsville, OH 43950 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 0692 The treatment plan included dialysis and placement of gastrostomy (PEG) tube for tube feeding. Level of Harm - Minimal harm or potential for actual harm Further review of Resident #192's medical record revealed no evidence of the tracking of oral intake or IV intake for the resident from 10/01/19 to 10/15/19. Further review of meal intakes revealed on 10/11/19 the resident's meal intake for breakfast was 51-75%, lunch was 0-25%, and dinner 51-75%. On 10/12/19 he ate 76-100% and he refused lunch and dinner. On 10/13/19 he ate 0-25% for breakfast and 76-100% for lunch. There was no evidence of meal intake for dinner on 10/13/19. On 10/14/19 he ate 76-100% for breakfast and 0-25% for lunch. Residents Affected - Few Review of Resident #192's discharge Minimum Data Set (MDS) 3.0 assessment, dated 10/15/19 revealed the resident required extensive assistance from staff for eating and total dependence from staff for toilet use and transfers. Record review revealed Resident #192 was readmitted to the facility on [DATE] at 4:35 P.M. with a temporary dialysis port to right upper chest and PEG tube to the mid abdomen. Review of Resident #192's weights revealed on 09/19/19 the resident weighed 202 pounds. The next documented weight was not until after the resident's return from the hospital on [DATE] which he weighed 183.3. Interview on 11/06/19 at 1:40 P.M. with Dietician #65 verified there was no evidence from 10/01/19 to 10/15/19 the resident's intakes were monitored. The dietician reported her general rule was if the resident was eating well, they were probably drinking well even though there was no supporting documentation of intake. Interview on 11/06/19 at 2:24 P.M., with State Tested Nursing Assistant (STNA) #30 revealed she had provided care to the resident between 10/11/19 and 10/14/19. The STNA reported the resident was not acting like himself and had complaints of muscle pains in his left arm. She reported the concerns to his nurse. The nurse told the STNA he could not have pain in his left arm because he had a stroke and could not feel anything. The resident continued to complain of arm pain, had decrease fluid intakes, and his urine was dark, so she went to another nurse to get a second opinion. The nurse verified the resident could have pain in his arm even though he had a stroke. The nurse then called the doctor and received orders for IV therapy. The STNA reported on night shift on 10/12/19 into 10/13/19 during care she had pulled out the IV when she was turning him. During the interview, the STNA revealed she only recorded the meal intakes for Resident #192 and the percentage of might shake he drank with meals. Interview on 11/06/19 at 3:26 P.M. with Laboratory Technician (LT) #73 verified Resident #192's urine and blood sample were collected on 10/11/19. The results were available on 10/12/19 at 9:54 A.M. The LT reported the results should have been automatically sent to the facility on [DATE] at 9:54 A.M. She was not able to provide explanation why the results were not faxed to the facility until 6:26 P.M. on 10/12/19. Interview on 11/07/19 at 9:59 A.M. with the Director of Nursing (DON) verified there was an almost 24 hour delay in receiving laboratory testing results for Resident #192 which delayed the resident's IV treatment for dehydration. She reported the lab company was new in the last 30 days and they had not had any other concerns with delay in results, however this was the first-time labs were done on the weekend. The DON reported she could not justify why the nurse determined the resident had improved with oxygen in 45 minutes when he was still symptomatic (elevated respiration and pulse) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366190 If continuation sheet Page 8 of 15 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 366190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belmont Manor 51999 Guirino Drive St Clairsville, OH 43950 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resulting in the nurse not sending the resident to the hospital and he continued to decline in condition. There was no evidence the nurse had notified or updated the physician after the 45 minutes to determine the resident did not need sent to the hospital on [DATE]. The DON confirmed there was no assessment of the resident for almost 24 hours from 10/11/19 at 7:14 P.M. until 10/12/19 at 6:25 P.M., and 10/13/19 at 9:19 A.M., until 10/14/19 at 1:17 P.M., when the resident was sent to the hospital. She confirmed there was no documentation regarding the residents' complaints of muscle pain, color of urine, or evidence the resident's IV came out on night shift on 10/12/19 into 10/13/19 per the STNA's statement. She confirmed staff did not document information regarding IV location, size, assessments, etc. The DON verified staff were not monitoring intakes even when the resident was receiving IV therapy to ensure he was receiving adequate hydration per dietary recommendations. The DON reported the facility did not have a policy or procedure on dehydration or hydration, however she stated resident intakes should be monitored when residents were receiving IV fluids for dehydration. During the onsite survey, a request for evidence of intake for the might shakes for 10/2019 was made. However the facility only provided one day, 10/04/19 which indicated the resident took 120 ml of the supplement for all three meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366190 If continuation sheet Page 9 of 15 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 366190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belmont Manor 51999 Guirino Drive St Clairsville, OH 43950 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 0791 Provide or obtain dental services for each resident. 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 the facility failed to ensure Resident #34 received timely dental services. This affected one resident (#34) of three residents reviewed for dental services. Residents Affected - Few Findings include: Record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus type two, dysphagia, dementia, bipolar, schizophrenia, and anemia. The resident was noted to be edentulous upon admission. She had Medicaid and Medicare insurance. Review of Resident #34's dental plan of care revealed the resident had oral/dental problems related to being edentulous. The facility would coordinate/arrange dental care and transportation as needed or ordered. Interview on 11/04/19 at 11:01 A.M., with Resident #34 revealed she was supposed to get new dentures. However, she stated it had been awhile and she had never received them. Review of Resident #34's dental note dated 05/09/19 revealed the resident's paper work was completed for full set of dentures. The resident would be fitted with wax at the next visit. There was no evidence the resident had seen a dentist after 05/09/19. Review of the dental schedule, dated 10/15/19 revealed no evidence Resident #34 was seen by the dentist during this onsite visit. Interview on 11/05/19 at 5:00 P.M., with Registered Nurse (RN) #72 revealed the dentist was to come quarterly. The facility had terminated service with the previous dental company as of 08/31/19. The previous company was to return in August 2019, however they never came. The facility had signed a new contract with a new dental company, and they were to start on 09/01/19, however they did not start seeing residents until 10/15/19. RN #72 confirmed Resident #34 was not seen on 10/15/19 by the dentist and the last dental note dated 05/09/19 indicated the resident would be seen at the next visit for a wax fitting. The RN reported the resident had a really old pair of dentures in her room, however she was not able to wear them. Interview on 11/06/19 at 4:00 P.M. with the Director of Nursing (DON) revealed there was no evidence the resident was sent to an outside dentist for dentures or was seen by the dentist when he had visited on 10/15/19. She stated the resident would be seen on 11/29/19 by the new dental company. Review of undated ancillary services policy and procedure revealed the facility would offer ancillary services. Dental would make scheduled visits every six months or by treatment plan as written. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366190 If continuation sheet Page 10 of 15 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 366190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belmont Manor 51999 Guirino Drive St Clairsville, OH 43950 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure dishes were washed, food was served, and hall trays were passed under sanitary conditions to prevent contamination and/or food borne illness. This had the potential to affect 43 of 43 residents who received meal trays. Two residents (#92 and #192) were identified to receive nothing by mouth. Findings include: 1. Initial observation of the kitchen on 11/04/19 at 8:20 A.M. revealed an observation of the dishwasher. The dishwasher was a low temperature dishwasher. The wash and rinse temperatures were observed to be 120 degrees Fahrenheit. Dishwasher Employee #69 ran three trays of dishes through the dishwasher. Two loads were on the drying rack. Observation of the fourth cycle revealed a wash temperature of 108 degrees Fahrenheit and a rinse of 120 degrees Fahrenheit. On 11/04/19 at 8:40 A.M. Dietary Manager #64 told the dishwasher employee to run it through again since it did not reach 120 degrees Fahrenheit. Dietary Manager #67 stated a red light was on meaning the breaker had flipped and she put the breaker back on for the hot water booster. The fifth cycle had a wash temperature of 108 degrees Fahrenheit and a rinse of 122 degrees Fahrenheit. The sixth cycle reached 120 degrees for the wash temperature. Observation of the drying rack where the first two cycles of dishes were placed revealed the dishes were not clean. A pitcher had white and off-white debris on the sides. A pot lid, skillet and large pot were on the drying rack with food on the inside of the pot, edges of the lid and inside the skillet. Review of the undated Dishwashing policy revealed the dishwasher temperature would be maintained at 120 degrees Fahrenheit or greater. The procedure included to drain and refill the dish machine without running through the cycle until the 120 degree temperature was obtained. If dish machine remained idle for an extended period of time, the above procedure may need to be repeated prior to dishwashing. Interview on 11/04/19 at 8:43 A.M. with Dietary Manager #64, Dishwasher Employee #69 and Dietary Staff #67 verified the dishwasher employee was running dishes through the dishwasher before it reached 120 degrees Fahrenheit. Dishes were placed on the drying rack when they had food on them and had not come clean in the dishwasher. Interview on 11/05/19 at 2:45 P.M. with the Director of Nursing (DON) verified the dishwashing policy was not followed. 2. Observation on 11/05/19 at 4:32 P.M. of the dinner meal tray line revealed [NAME] #67 applied hand mitts, opened the oven and took stacks of warmed plates out placing them on a cart. She removed the hand mitts and then threw them in a basket with others. [NAME] #67 did not wash her hands after removing the oven mitts. She took the lids, plastic and foil off the tins on the tray line and served the food without first washing her hands. At the time of the observation, the rectangular fluorescent lights above the tray line were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366190 If continuation sheet Page 11 of 15 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 366190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belmont Manor 51999 Guirino Drive St Clairsville, OH 43950 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 observed to have visible brown dust. There were three lights down the tray line and prep surface, and above the four carts of trays prepped for the supper meal with visible brown dust. Some dust balls were hanging on by a thread blowing. The three lights most soiled were next to the heating/air conditioning vents which were in the ceiling next to them. Interview on 11/05/19 at 5:07 P.M. with Dietician #65 and [NAME] #67 verified the inside of the oven mitts would be dirty. Verification occurred [NAME] #67 should of washed her hands after removing the oven mitts before uncovering the tins on the tray line and serving. The staff interviewed further verified the vents were dusty above the tray line, prep counter and serving carts. 3. Observation on 11/04/19 at 12:10 P.M. of the delivery of hall lunch trays revealed the staff did not wash or sanitize their hands during the process. State Tested Nursing Assistant (STNA) #27 and #28 passed the Hall A and B lunch trays. STNA #28 delivered one lunch tray to Resident #40 on Hall A. STNAs #27 and #28 then delivered trays to the residents on the B hall which included Resident #11, #17, #19, #24, #36, #94 and #95 without washing their hands or using hand sanitizer between tray delivery. The STNAs were observed to touch the door handles to resident rooms while entering to deliver the meal trays for some of the rooms. STNA #27 touched the lid of the cup for Resident #36, opened two straws and placed them in the cups after touching door knobs and overbed tables without first washing or sanitizing her hands. STNA #28 picked up a cup by the rim after touching the door handle to room [ROOM NUMBER]. Interview on 11/04/19 at 12:24 P.M. with STNA #28 and #29 verified they did not wash their hands or use hand sanitizer during the lunch hall tray pass. STNA #28 indicated she understood how touching door handles and furniture in the rooms could not ensure her hands sanitary. Review of the Handling of Meal Trays policy, revised 11/01/19 revealed distribution of trays was done without touching anything but the tray itself. If hands become soiled, they must be washed before proceeding. Otherwise must use hand sanitizer between each tray. Interview on 11/05/19 at 2:45 P.M. with the DON verified the the Handling of Meal Trays policy was not followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366190 If continuation sheet Page 12 of 15 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 366190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belmont Manor 51999 Guirino Drive St Clairsville, OH 43950 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 Based on record review and interview the facility failed to ensure the Legionella assessment was reviewed annually, failed to implement their Legionella policy and failed to ensure the policy and assessment contained all of the required components. This had the potential to affect all 45 residents residing in the facility. Residents Affected - Many Findings include: Review of the facility Legionella policy, dated 07/26/17 revealed the policy was to reduce the possible growth of Legionella and other contaminants. The following measures were to be instituted in order to further minimize the risk: - Identify and check dead plumbing legs for standing water -Inspect pipes/plumbing for any leaks that could lead to standing water -Inspect shower heads for scaling or sediments or blockage (where Legionella can grow) -Inspect sinks/toilets for leaks or blockage (where Legionella can grow) -Inspect eye stations for scaling or sediments -Inspect respiratory equipment for scaling or sediments -Inspect ice machines for scaling and sediments -Inspect HVAC systems for standing water -Inspect hot pack/heating units in therapy room -Ensure water heaters operate at a temperature of 110 or greater -If an outbreak occurs, the water transport company will provide the facility with clean, contaminant free water for drinking, cooking, and flushing of toilets. Laundry would be taken to the laundromat. Maintenance would inspect and record the inspections of the aforementioned areas every three months and address, clean, correct, and replace or provide maintenance as needed. Further review revealed no evidence of who to contact in case of an outbreak or evidence who was on the water management team. Review of the facility Legionella environmental assessment revealed the assessment was last updated 08/01/17. In addition, review of the Maintenance Legionella Water Management Cleaning Schedule, dated 07/24/2019 and 10/14/2019 revealed maintenance was to check every three months (Jan, April, July, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366190 If continuation sheet Page 13 of 15 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 366190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belmont Manor 51999 Guirino Drive St Clairsville, OH 43950 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many October) all rooms for HVAC, plumbing (sinks, toilets, pipes to ensure they were free from scaling, corrosion, standing/lying water), check the shower heads and spigots for blockage and check respiratory equipment. The scheduled indicated maintenance would inspect and record the inspection of the aforementioned areas every three months and address, clean and replace or provide maintenance as needed. There were no evidence ice machines were checked or evidence the hot packs/heating unit in therapy were checked ensure the water heaters operated at temperatures of 110. Review of the water temperature check log, dated 10/04/19 to 10/31/19 revealed A-Hall water temperatures were 108 on 10/04/19, 10/10/19, 10/24/19 and 10/31/19. The H-Hall tub temperature was only 99 all five weeks. B-Hall water temperature was 109 on 10/10/19. C-Hall water temperature was 108 on 10/10/19. D-Hall water temperatures were 108 on 10/04/19, 10/10/19, 10/24/19 and 10/31/19. E- hall water temperatures were between 105-108 all five weeks. There was no evidence interventions were implemented when the water temperatures were below 110. Further review revealed no evidence the ice machine, water dispensers, whirlpool bath, or hot pack/heating unit in the therapy room were inspected per policy. There was no evidence for rooms not occupied the water would be flushed to decrease the risk of standing water. Interview on 11/06/19 at 8:18 A.M., with the Director of Nursing (DON) verified the most current Legionella assessment was completed on 08/01/17 and should have been completed yearly. She confirmed the policy did not include a water management team or who needed to be contacted (local/state agency, anyone affected, the expertise, or water management team) in case of the suspected case of a Legionella outbreak. The DON verified not all items (ice machine, water dispensers, whirlpool bath, or hot pack/heating unit in the therapy room) noted on the policy were inspected on the maintenance inspection report. She confirmed the water temperatures did not reach 110 degrees several times in October 2019 and there was no evidence an intervention was implemented to ensure water temperatures were greater than 110. She had the maintenance director check water temperatures today (11/06/19) and A-Hall was only 105, A-Hall tub temperature was only 105, B-Hall was 107 and E-Hall was 110 degrees. She had him adjust the hall temperatures and put an out of service signed on the A-Hall tub. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366190 If continuation sheet Page 14 of 15 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 366190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belmont Manor 51999 Guirino Drive St Clairsville, OH 43950 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview the facility failed to implement an effective antibiotic stewardship program to ensure the appropriate use of antibiotics for Resident #16. This affected one resident (#16) of five residents reviewed for unnecessary medication use. Residents Affected - Few Findings include: Review of Resident #16's medical record revealed an admission date of 04/26/15 with diagnoses including psychotic disorder and Alzheimer's disease. Review of the physician's orders revealed an order dated, 07/25/19 order for a urinalysis with culture and sensitivity for increased behaviors and change in mental status. There was an order, dated 07/26/19 for Bactrim DS, an antibiotic, 800/160 milligrams one tablet by mouth two times a day for urinary infection until 08/03/19. On 07/28/19 the Bactrim was discontinued and on 07/29/19 Macrodantin 100 mg one by mouth twice a day for seven days was ordered. Review of urinalysis faxed to the facility 07/26/19 at 3:01 P.M. revealed the urinalysis was loaded with white blood cells and bacteria, indicating an infection. There was a notation on the laboratory report to await for culture and sensitivity. The culture report was faxed to the facility 07/28/19 at 2:02 P.M. The report indicated the bacteria was resistant to Sulfa, contained in Bactrim DS. The notation on the laboratory report indicated to discontinue the Bactrim DS and start Macrodantin, an antibiotic, and a Probiotic for seven days. Review of the Medication Administration Record revealed the resident received two doses of Bactrim DS on 07/27/19 and 07/28/19. Review of the Infection Report and Suspected Infection report revealed no evidence of the administration of Bactrim DS on the report. The reports indicated Macrodantin was administered. Interview on 11/07/19 at 2:34 P.M. with Registered Nurse #10 verified the Bactrim DS was started without the results of the urine culture. The culture determined the Bactrim DS was not appropriate for the bacteria in the urine. Four doses of Bactrim DS were administered unnecessarily. The administration of Bactrim prior to the culture did not promote antibiotic stewardship. Verification occurred the administration of Bactrim was not reflected on the infection control reports. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366190 If continuation sheet Page 15 of 15