Health inspection·October 19, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of the medical record for Resident #29 revealed an admission date of 07/01/21 with diagnoses including vascular dementia with behavioral disturbances, psychotic disorder with delusions, major depression, anxiety disorder and neuralgia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #29 was severely cognitively impaired with inattention and disorganized thinking. Resident #29 required assistance with activities of daily living. Review of the activity assessment dated [DATE] revealed Resident #29 attended and enjoyed group activities. Resident #29 enjoyed watching television, listening to music, bingo, arts and crafts, seek and find objects, her baby doll, and sitting outside. Review of the plan of care for Resident #29 revealed Resident #29 had the potential for activity deficit related to cognitive impairment, decreased mobility and behavior problems. The interventions included to assist Resident #29 to group activities, provide an activity calendar and provide one on one attention. Observations on 10/16/23 at 12:06 P.M. and on 10/17/23 at 9:18 A.M. of Resident #29 revealed Resident #29 was lying in her bed with eyes closed. An interview on 10/19/23 at 2:20 P.M. with the Director of Nursing (DON) confirmed the activity plan of care was not personalized to meet Resident #29's needs. 3. Record review for Resident #32 revealed this resident was admitted to the facility on [DATE] and had diagnoses including acquired absence of the right leg below the knee, nicotine dependence, and viral hepatitis C. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/05/23, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. This resident was assessed to require supervision for bed mobility, transfers, toileting, and eating. Review of the care plan, most recently revised on 05/10/23, revealed this resident was at risk for impaired skin integrity related to a left below the knee amputation and prosthetic leg left extremity. Interventions included to monitor skin to stump for redness, edema, and abrasions and to inspect skin during routine daily care. Interview with Resident #32 on 10/17/23 at 2:30 P.M. revealed the resident had undergone an amputation of the right leg below the knee. Observation on 10/17/23 at 2:30 P.M. revealed Resident #32 had a right below the knee amputation and had a prosthesis for the right lower extremity. Resident #32 did not have a left leg amputation or prosthetic. Interview with the Director of Nursing (DON) on 10/18/23 at 2:05 P.M. verified Resident #32 had a right below the knee amputation and right lower leg prosthetic and the care plan was incorrect as it identified the resident as having a left below the knee amputation and left leg prothesis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366202 If continuation sheet Page 2 of 18 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 366202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal Care of Coal Grove 813 1/2 Marion Pike Coal Grove, OH 45638 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 observations, interviews, and record reviews, the facility failed to ensure monitoring of a resident's skin after post surgical intervention. This affected one resident (#32) of the two residents reviewed for skin conditions during the annual survey. The facility census was 41. Residents Affected - Few Findings include: Record review for Resident #32 revealed this resident was admitted to the facility on [DATE] and had diagnoses including acquired absence of the right leg below the knee, nicotine dependence, and viral hepatitis C. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/05/23, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. This resident was assessed to require supervision for bed mobility, transfers, toileting, and eating. Review of the care plan, most recently revised on 05/10/23, revealed this resident was at risk for impaired skin integrity related to a left below the knee amputation and prosthetic leg left extremity (this was in error as the resident had a right below the knee amputation, not left). Interventions included to monitor skin to stump for redness, edema, and abrasions and to inspect skin during routine daily care. Review of the active physicians order, dated 05/22/23, revealed an order to monitor stump to left leg lower extremity for redness, edema, abrasions, and notify physician. Review of the resident's medical record revealed no documented evidence the resident's skin to the right stump was being monitored for redness, edema, and abrasions. Review of the nurse's progress note, dated 10/18/23, revealed this nurse went to check on the resident. The resident had reddened area to right stump. The Nurse Practitioner was notified and new orders were obtained to change Lidocaine patch to once daily, on for 12 hours then remove, and to change the strength of the Lidocaine patch to four percent. There was no evidence any treatment was ordered and/or provided to the resident's red, irritated skin. Interview with Resident #32 on 10/17/23 at 2:30 P.M. revealed the resident had undergone an amputation of the right leg below the knee and had been asking staff members for cream for the right stump due to irritation. During interview with Resident #32, he stated they were not monitoring the stump at all. Observation on 10/17/23 at 2:30 P.M. revealed Resident #32 had a right below the knee amputation and had a prosthesis for the right lower extremity. The skin to the right stump area was observed to be red and irritated. Interview with the Director of Nursing (DON) on 10/18/23 at 2:05 P.M. verified the order to monitor the skin to the left stump area was incorrect as the resident actually had a right stump and prosthesis following a right below the knee amputation. The DON verified there was no documented evidence the resident's skin at the right stump area was being monitored by staff and the area was red and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366202 If continuation sheet Page 3 of 18 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 366202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal Care of Coal Grove 813 1/2 Marion Pike Coal Grove, OH 45638 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 irritated. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366202 If continuation sheet Page 4 of 18 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 366202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal Care of Coal Grove 813 1/2 Marion Pike Coal Grove, OH 45638 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 - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure adequate care and services were provided to identify residents at risk for elopement and prevent elopement. This affected two residents (#4 and #43) out of the five residents residents reviewed for accidents during the annual survey. The facility census was 41. Findings include: 1. Record review for Resident #4 revealed this resident was admitted to the facility on [DATE] and had diagnoses including anxiety disorder, schizophrenia, mood disorder, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/14/23, revealed this resident was rarely/never understood evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 99. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting and to require supervision for eating. This resident was assessed to use a wander/elopement alarm daily. Review of the care plan, dated 09/15/21, revealed this resident was at risk for elopement. Interventions included wanderguard as ordered and follow facility elopement procedures. Review of the active physician orders for Resident #4 revealed no orders were in place for the monitoring or placement of a wanderguard. Observation on 10/19/23 at 8:30 A.M. revealed Resident #4 was observed lying in bed and had a wanderguard in place to the right ankle. The resident refused to allow observation of the wanderguard for expiration date. Interview with Licensed Practical Nurse (LPN) #84 on 10/19/23 at 8:35 A.M. revealed residents had wanderguard in place as ordered by the physician and the wanderguards were checked for placement and function according to the physicians orders. LPN #84 verified Resident #4 had a wanderguard in place to the right ankle but did not have orders for the wanderguard to be in place or to check the function of the wanderguard. Interview with the Administrator on 10/19/23 at 9:30 A.M. revealed the facility did not have policies or procedures addressing the use and monitoring of wanderguards for residents. Review of the facility policy titled Elopement Prevention, not dated, revealed residents would be assessed for elopement risk and if identified as being at risk, an individualized care plan would be implemented to prevent elopement. The residents care plan would indicate if the resident was at risk for elopement and interventions to promote safety. 2. Record review for Resident #43 revealed this resident was admitted to the facility on [DATE] and had diagnoses including insomnia, dementia, and anxiety disorder. Review of the admission MDS assessment, dated 08/24/23, revealed this resident had severely impaired cognition evidenced by a BIMS assessment score of 00. This resident was assessed to require (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366202 If continuation sheet Page 5 of 18 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 366202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal Care of Coal Grove 813 1/2 Marion Pike Coal Grove, OH 45638 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 extensive assistance from one staff member for bed mobility, transfers, toileting. Level of Harm - Minimal harm or potential for actual harm Review of the care plan, dated 08/28/23, revealed this resident was at risk for elopement related to impaired memory, sits/stands by doors, and exits. Interventions included to apply wanderguard and check per facility policy. Residents Affected - Few Review of the physicians order, dated 08/19/23, revealed an order for a wanderguard to be in place as ordered two times a day for wandering. There were no orders present to check the function or placement of the wanderguard. Observation on 10/18/23 at 10:31 A.M. revealed Resident #43 was observed to have a wanderguard in place to the right ankle with an expiration date of 07/2026. The resident was observed to independently get up from his seat and begin wandering down the hallway. Interview with the DON on 10/18/23 at 2:05 P.M. verified Resident #43 had a wanderguard in place but did not have orders to check the function or placement of the wanderguard. Interview with LPN #84 on 10/19/23 at 8:35 A.M. revealed residents had wanderguards in place as ordered by the physician and the wanderguards were checked for placement and function according to the physicians orders. Interview with the Administrator on 10/19/23 at 9:30 A.M. revealed the facility did not have policies or procedures addressing the use and monitoring of wanderguards for residents. Review of the facility policy titled Elopement Prevention, not dated, revealed residents would be assessed for elopement risk and if identified as being at risk, an individualized care plan would be implemented to prevent elopement. The residents care plan would indicate if the resident was at risk for elopement and interventions to promote safety. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366202 If continuation sheet Page 6 of 18 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 366202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal Care of Coal Grove 813 1/2 Marion Pike Coal Grove, OH 45638 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 observation, interview, record review and facility policy review revealed the facility failed to implement dietary recommendations timely. This affected one resident (#29) of four residents reviewed for nutrition. The facility census was 41. Residents Affected - Few Findings include: Review of the medical record for Resident #29 revealed an admission date of 07/01/21 with diagnoses including vascular dementia with behavioral disturbances, psychotic disorder with delusions, major depression, anxiety disorder, type two diabetes mellitus, and chronic obstructive pulmonary disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #29 was severely cognitively impaired with inattention disorder, disorganized thinking and problems with appetite. Resident #29 required staff assistance with eating. Resident #29 weighed 159 pounds with no weight loss, or dental problems. Review of the physician orders for October 2023 revealed Resident #29 was on a regular diet, puree texture and thin liquids. Resident #29 did not have an order for a dietary supplement. Review of the dietitian documentation dated 09/07/23 at 11:38 A.M. revealed Resident #29 had experienced a moderate weight loss of seven pound in 90 days with a current weight of 159 pound. Resident #29 remained in the obese class with a BMI of 30. Resident #29 was ordered a regular diet, puree texture, thin liquids and an appetite stimulant. The intake record indicated Resident #29 had been eating 50-75% of meals over the past seven days. The Registered Dietitian (RD) recommended offering a magic cup one time daily. The RD will continue to monitor. Review of the dietitian documentation dated 10/09/23 at 2:11 P.M. revealed Resident #29's weight continued to decline with current body weight of 154 pounds. The weight history indicated Resident #29 had experienced moderate weight loss of five and one half pounds (3.4%) in 30 days. Current body mass index (BMI) was 29.0 and resident was within ideal BMI for her age. Resident #29 received a regular diet, puree texture with thin liquids. Resident #29 received an appetite stimulant. The staff reported Resident #29 oral intake was fair to poor, and she required more assistance with eating her meals. The Registered Dietitian (RD) recommended a magic cup (dietary supplement) daily on 09/07/23 but it was not ordered. RD recommended offering magic cup once daily if available or medpass 2.0 of 60 milliliters (ml) by mouth two times daily if magic cup is not available. The RD will continue to monitor. Review of Resident #29 weights revealed on 06/16/23 weighed 167 pounds, refused weight in 07/23 and 08/23, on 09/04/23 weighed 159 pound, and on 10/04/23 weight 154 pounds. Review of the plan of care revised on 12/02/22 for Resident #29 revealed Resident #29 had a potential for a nutritional problem related to a BMI greater than 30, modified texture, diagnosis of dementia and weight fluctuation related to edema, medications and diagnosis. The interventions included administer medications as ordered, allow the resident to make choices or preferences of food as able, dietary consult as needed, observe the resident for coughing, choking, chewing problems or pocketing food, obtain lab work as ordered, obtain weights as ordered, provide diet as ordered, provide (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366202 If continuation sheet Page 7 of 18 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 366202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal Care of Coal Grove 813 1/2 Marion Pike Coal Grove, OH 45638 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 supplements as ordered, and speech therapy screen as needed. Level of Harm - Minimal harm or potential for actual harm Review of the meal intake documentation for October 2023 revealed Resident #29 consumed 75-100% of all meals. Residents Affected - Few Observations on 10/16/23 at 12:50 P.M. and 10/18/23 at 12:40 P.M. of Resident #29 revealed Resident #29 was eating her lunch at bedside. Resident #29 was feeding herself and eating bites from all the food provided. There was not a magic cup provided on the meal tray. An interview on 10/19/23 at 12:53 P.M. with the Director of Nursing (DON) revealed the procedure for the RD recommendations was the DON received the recommendations via email. The DON would then notify the physician for approval, write the order, put the order in the electronic health record, and complete a dietary ticket for the kitchen. The DON confirmed the RD recommendation on 09/07/23 for Resident #29 to receive a magic cup once daily was not confirmed, written or implemented. Review of the facility provided policy titled Dietary: Diet Changes and Reports with no date revealed nursing services was responsible for notifying the dietary department of any changes in the resident's diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366202 If continuation sheet Page 8 of 18 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 366202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal Care of Coal Grove 813 1/2 Marion Pike Coal Grove, OH 45638 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and review of facility policy, the facility failed to ensure pharmacy recommendations were reviewed and implemented timely. Additionally, the facility failed to ensure the policy for pharmacy recommendations addressed actions to be taken for urgent pharmacy recommendations. This affected three residents (#28, #38, and #43) of the five residents reviewed for unnecessary medications during the annual survey. The facility census was 41. Findings include: 1. Record review for Resident #38 revealed this resident was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia without behavioral disturbances, and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/15/23, revealed this resident was assessed to be rarely/never understood evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 99. This resident was assessed to be dependent upon two staff members for transfers and toileting and to require extensive assistance from two staff members for bed mobility. Review of the pharmacy recommendation, dated 03/09/23, revealed a recommendation to consider adding Take apical pulse before giving, if less than 50 beats per minute (bpm), hold and notify prescriber to the residents order for the administration of Metoprolol (an anti-hypertensive medication). The recommendation did not contain a response or signature by the physician. Review of the active physicians order for the administration of Metoprolol, dated 01/12/23, revealed the order did not contain instructions to take apical pulse before giving, and if less than 50 bpm, hold and notify prescriber. Review of the pharmacy recommendation, dated 08/31/23, revealed a recommendation to evaluate the medication Citalopram (an antidepressant medication) for continued use. The recommendation did not contain a response by the physician and was signed and dated 10/07/23 (37 days after the recommendation was made). Review of the active physicians order, dated 01/12/23, revealed an order for 20 milligrams of Citalopram to be administered once daily for generalized anxiety disorder. The order had not been modified since being implemented on 01/12/23. Interview with the Director of Nursing (DON) on 10/18/23 at 2:05 P.M. verified the pharmacy recommendation dated 03/09/23 did not contain a response or signature from the physician and the order for the administration of Metoprolol did not contain the recommendation from the pharmacy. The DON further verified the pharmacy recommendation dated 08/31/23 did not contain a response from the physician and had been signed as being reviewed by the physician on 10/07/23, 37 days after the recommendation had been made. Interview with the Administrator on 10/19/23 at 10:15 A.M. verified the facility policy for addressing pharmacy recommendations did not contain instructions for actions to be taken for urgent pharmacy recommendations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366202 If continuation sheet Page 9 of 18 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 366202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal Care of Coal Grove 813 1/2 Marion Pike Coal Grove, OH 45638 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility policy titled Pharmacy Recommendations, revised 01/2020, revealed resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented and reported to the Director of Nursing, prescriber, and Medical Director. The Director of Nursing, or Assistant Director of Nursing, will review the recommendations with the Physician and Medical Director as soon as practicable but no later than 30 days. The Director of Nursing will track recommendations and ensure any changes are implemented into the medical record. The policy did not contain instructions for actions to be taken for urgent pharmacy recommendations. 2. Record review for Resident #43 revealed this resident was admitted to the facility on [DATE] and had diagnoses including hypertension, abnormal glucose, anxiety disorder, insomnia, and dementia. Review of the admission MDS assessment, dated 08/24/23, revealed this resident had severely impaired cognition evidenced by a BIMS assessment score of 00. This resident was assessed to require extensive assistance from one staff member for bed mobility, transfers, and toileting. Review of the pharmacy recommendation, dated 09/05/23, revealed a recommendation to provide a diagnosis for the use of Seroquel (an anti-psychotic medication) or consider titrating off the medication. The pharmacy recommendation did not contain a response by the physician and was signed and dated by the physician on 10/13/23 (38 days after the recommendation was made). Review of the active physicians order, dated 08/19/23, revealed an order for 25 mg of Seroquel to be administered three times a day. The order had not been titrated or changed since being implemented on 08/19/23 and continued to not provide a diagnosis as recommended by the pharmacist. Interview with the DON on 10/18/23 at 2:05 P.M. verified the pharmacy recommendation dated 09/05/23 did not contain a response from the physician and had been signed by the physician on 10/13/23, 38 days after the recommendation had been made. Interview with the Administrator on 10/19/23 at 10:15 A.M. verified the facility policy for addressing pharmacy recommendations did not contain instructions for actions to be taken for urgent recommendations. Review of the facility policy titled Pharmacy Recommendations, revised 01/2020, revealed resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented and reported to the Director of Nursing, prescriber, and Medical Director. The Director of Nursing, or Assistant Director of Nursing, will review the recommendations with the Physician and Medical Director as soon as practicable but no later than 30 days. The Director of Nursing will track recommendations and ensure any changes are implemented into the medical record. The policy did not contain instructions for actions to be taken for urgent pharmacy recommendations. 3. Review of the medical record for Resident #28 revealed an admission date of 03/12/22 with diagnoses of dementia with behavioral disturbances, type two diabetes mellitus, metabolic encephalopathy, major depressive disorder, anxiety disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #28 was severely cognitively impaired with inattention, verbal behaviors directed towards others and rejection of care. Resident #28 required extensive assistance of one for activities of daily living. Resident #28 received an antipsychotic, antianxiety and antidepressant medication seven of the seven days in the look back period. Antipsychotic medications were reviewed, however no Gradual Dose Reduction (GDR) had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366202 If continuation sheet Page 10 of 18 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 366202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal Care of Coal Grove 813 1/2 Marion Pike Coal Grove, OH 45638 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 0756 been attempted. On 07/14/23 the physician had documented a GDR was contraindicated. Level of Harm - Minimal harm or potential for actual harm Review of the monthly pharmacy recommendations from 10/01/22 through 09/30/23 for Resident #28 revealed the pharmacist recommendation dated 10/09/22 to evaluate the antipsychotic medication Quetiapine for continued use and the recommendation dated 03/09/23 to reviewed the antidepressant medication Trazadone for reduction were not addressed or implemented timely. Residents Affected - Few Review of the plan of care for Resident #28 revised on 08/14/23 revealed Resident #28 received antipsychotic and antidepressant medications related to dementia with behaviors, anxiety and depression. The interventions included administer medications as ordered, observe for side effects of antianxiety, antidepressant and antipsychotic medications, review medications as needed, notify the physician as needed, labs as needed and psychiatric counseling services as needed. An interview on 10/18/23 at 2:25 P.M. with the Director of Nursing (DON) confirmed the pharmacy recommendations were not reviewed in a timely manner or implemented. Review of the facility policy titled Pharmacy Recommendations, revised 01/2020, revealed resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented and reported to the Director of Nursing, prescriber, and Medical Director. The Director of Nursing, or Assistant Director of Nursing, will review the recommendations with the Physician and Medical Director as soon as practicable but no later than 30 days. The Director of Nursing will track recommendations and ensure any changes are implemented into the medical record. The policy did not contain instructions for actions to be taken for urgent pharmacy recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366202 If continuation sheet Page 11 of 18 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 366202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal Care of Coal Grove 813 1/2 Marion Pike Coal Grove, OH 45638 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 and staff interview, the facility failed to ensure adequate instructions and indications for the use of topical medications. This affected one resident (#43) out of the five residents reviewed for unnecessary medications during the annual survey. The facility census was 41. Residents Affected - Few Findings include: Record review for Resident #43 revealed this resident was admitted to the facility on [DATE] and had diagnoses including hypertension, abnormal glucose, anxiety disorder, insomnia, and dementia. Review of the admission Minimum Data Set (MDS) assessment, dated 08/24/23, revealed this resident had severely impaired cognition evidenced by a BIMS assessment score of 00. This resident was assessed to require extensive assistance from one staff member for bed mobility, transfers, and toileting. Review of the active physicians order, dated 08/18/23, revealed an order to apply Nystatin External Cream 100,000 units per gram topically to affected areas every eight hours as needed. The order did not contain instructions on where to apply the topical medication, how much of the topical medication to apply, or an indication for the application of the medication. Review of the active physicians order, dated 08/18/23, revealed an order to apply one percent strength Hydrocortisone External Cream topically to affected areas every eight hours as needed. The order did not contain instructions on where to apply the topical medication, how much of the topical medication to apply, or an indication for the application of the medication. Review of the active physicians order, dated 08/18/23, revealed an order to apply 0.44 - 20.6 percent strength Calmoseptine External Ointment topically to affected area two times a day for irritation. The order did not contain instructions on where to apply the topical medication or how much of the topical medication to apply. Interview with the Director of Nursing (DON) on 10/18/23 at 2:05 P.M. verified the orders for the topical application of Calmoseptine External Ointment, Hydrocortisone External Cream, and Nystatin External Cream did not contain information as to where the affected areas were or how much of the medication to apply. The DON further verified the orders for the topical application of Nystatin External Ointment and Hydrocortisone External Cream did not contain an indication for the use of the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366202 If continuation sheet Page 12 of 18 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 366202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal Care of Coal Grove 813 1/2 Marion Pike Coal Grove, OH 45638 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy review the facility failed to ensure target behaviors were identified and appropriate indications for use of antipsychotic medications. This affected six residents (#16, #28, #30, #36, #38 and #43) of seven reviewed for unnecessary medications. The facility census was 41. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 12/21/18 with diagnoses including hypertension, psychosis and major depressive disorder. Review of the physician orders for October 2023 revealed Resident #16 was ordered clonazepam (antianxiety medications) 0.5 milligrams (mg) by mouth three times a day for unspecified psychosis, risperidone (antipsychotic medications) four mg by mouth two times daily for unspecified psychosis and citalopram hydrobromide (antidepressant medication) 40 mg by mouth daily for inappropriate sexual behaviors. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #16 was severely cognitively impaired with physical and verbal behaviors directed towards others that interfered with care, rejected care and wandered. Resident #16 received an antipsychotic, antidepressant and antianxiety medications seven of seven days during the look back period. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated August, September, and October 2023 revealed no identified target behaviors were identified for monitoring for the indication of use of the antipsychotic, antidepressant and antianxiety medications. Review of Activities of Daily Living (ADL) documentation for August, September, and October 2023 revealed no identified target behaviors or documentation. Interview on 10/17/23 at 3:17 P.M. with Registered Nurse (RN) #77 revealed behaviors were not identified and monitored each shift. Interview on 10/18/23 at 2:25 P.M. with the Director of Nursing (DON) confirmed target behaviors were not identified for staff to monitor and or document each shift in the electronic medical record. The DON also confirmed the diagnosis for the use of the antianxiety medication clonazepam was not appropriate for Resident #16. 2. Review of the medical record for Resident #28 revealed an admission date of 03/12/22 with diagnoses including dementia with behavioral disturbances, metabolic encephalopathy, anxiety disorder and major depressive disorder. Review of the physician orders dated October 2023 for Resident #28 revealed Resident #28 was ordered quetiapine fumarate 50 milligrams (mg) by mouth two times daily for vascular dementia with behavioral disturbances, and mirtazapine 15 mg by mouth at bedtime for insomnia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366202 If continuation sheet Page 13 of 18 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 366202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal Care of Coal Grove 813 1/2 Marion Pike Coal Grove, OH 45638 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 0758 Level of Harm - Minimal harm or potential for actual harm Review of the quarterly MDS dated [DATE] for Resident #28 revealed Resident #28 was severely cognitively impaired with inattention, verbal behaviors towards others, rejection of care and wandered. Resident #28 received the antipsychotic and antidepressant medications seven of seven days of the look back period. The antipsychotic medications were reviewed with no Gradual Dose Reduction (GDR) attempted. The physician documented on 07/14/23 a GDR was contraindicated. Residents Affected - Some Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated August, September, October 2023 revealed no identified target behaviors were identified for monitoring for the indication of use of the antipsychotic and antidepressant medications. Review of Activities of Daily Living (ADL) documentation for August, September, and October 2023 revealed no target behaviors or documentation. Interview on 10/17/23 at 3:17 P.M. with Registered Nurse (RN) #77 revealed behaviors were not identified and monitored each shift. Interview on 10/18/23 at 2:25 P.M. with the Director of Nursing (DON) confirmed target behaviors were not identified for staff to monitor and or document each shift in the electronic medical record. The DON also confirmed the diagnosis for the use of the antipsychotic medication quetiapine fumarate and antidepressant medication mirtazapine was not appropriate for Resident #28. 3. Review of the medical record for Resident #30 revealed an admission date of 08/03/23 with diagnoses including bipolar disorder, schizophrenia, schizoaffective disorder, dementia and intellectual disability. Review of the physician orders dated October 2023 for Resident #30 revealed Resident #30 was ordered haloperidol (antipsychotic medication) 1 mg by mouth two times daily for agitation and lorazapam (antianxiety medication) 1 mg by mouth three times daily for agitation. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated August, September, and October 2023 for Resident #30 revealed no identified target behaviors were identified for monitoring for the indication of use of the antipsychotic and antianxiety medications. Review of the significant change MDS dated [DATE] revealed Resident #30 was moderately impaired cognitively impairment. with physical and verbal behaviors directed towards others. Resident #30 required assistance with ADLs. Resident received antipsychotic and antianxiety medication and no GDR attempted. Review of the plan of care for Resident #30 revealed Resident #30 took psychotropic medications and antianxiety medications for anxiety, bipolar disorder and depression. Interventions included medications as ordered, observe for side effects of the the medication, review medications as needed, labs as ordered and psychiatric/counseling services as needed. Review of Activities of Daily Living (ADL) documentation for August, September, and October 2023 revealed no identified target behaviors or documentation. Interview on 10/17/23 at 3:17 P.M. with Registered Nurse (RN) #77 revealed behaviors were not identified and monitored each shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366202 If continuation sheet Page 14 of 18 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 366202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal Care of Coal Grove 813 1/2 Marion Pike Coal Grove, OH 45638 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 10/18/23 at 2:25 P.M. with the Director of Nursing (DON) confirmed target behaviors were not identified for staff to monitor and or document each shift in the electronic medical record. The DON also confirmed the diagnosis for the use of the antipsychotic and antianxiety medication was not appropriate for Resident #30. 4. Review of the medical record for Resident #36 revealed an admission date of 12/14/22 with diagnoses including alcohol abuse with psychotic disorder, psychoactive substance abuse, type two diabetes mellitus and chronic kidney disease. Review of the physician orders dated October 2023 revealed Resident #36 received risperdal 1 mg by mouth two times daily for polysubstance abuse. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated August, September, October 2023 for Resident #36 revealed no identified target behaviors were identified for monitoring for the indication of use of the antipsychotic medication. Review of the quarterly MDS dated [DATE] revealed Resident #36 was moderately cognitively impaired with rejection of care and wandering. Resident #36 required supervision with activities of daily living. Resident #36 received antipsychotic medication with no GDR attempted. Review of the plan of care dated 12/29/22 revalued Resident #36 received psychotropic medication related to behaviors and history of substance abuse. Interventions included medications as ordered, observe for side effects of antipsychotic medication, medication review as needed, labs as ordered and psychiatric/counseling services as needed. Review of Activities of Daily Living (ADL) documentation for August, September, and October 2023 revealed no identified target behaviors or documentation. Interview on 10/17/23 at 3:17 P.M. with Registered Nurse (RN) #77 revealed behaviors were not identified and monitored each shift. Interview on 10/18/23 at 2:25 P.M. with the Director of Nursing (DON) confirmed target behaviors were not identified for staff to monitor and or document each shift in the electronic medical record. The DON also confirmed the diagnosis for the use of the antipsychotic was not appropriate for Resident #36. 5. Record review for Resident #38 revealed this resident was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia without behavioral disturbances, and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/15/23, revealed this resident was assessed to be rarely/never understood evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 99. This resident was assessed to be dependent upon two staff members for transfers and toileting and to require extensive assistance from two staff members for bed mobility. Review of the active physicians order, dated 09/07/23, revealed an order for the administration of 50 milligrams (mg) of Seroquel (an anti-psychotic medication) at bedtime for delirium due to known physiological condition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366202 If continuation sheet Page 15 of 18 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 366202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal Care of Coal Grove 813 1/2 Marion Pike Coal Grove, OH 45638 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the pharmacy recommendation, dated 09/29/23, revealed the resident was currently on the drug Quetiapine (the generic name for Seroquel) with the diagnosis of delirium due to known physiological condition. According to new guidelines, appropriate diagnosis for antipsychotic medications in the long term care setting include: Schizophrenia, Psychosis, Bipolar Disorder with Mania, or Dementia with Delusions or Psychosis. Please consider changing to an appropriate diagnosis or titrating off this medication. The recommendation was signed by the physician on 10/07/23 but did not contain a response to the recommendation. Interview with the Director of Nursing (DON) on 10/18/23 at 2:05 P.M. verified Resident #38 continued to be prescribed the medication Seroquel with a diagnosis of delirium due to known physiological condition and that the resident did not have any of the diagnoses listed on the pharmacy recommendation. 6. Record review for Resident #43 revealed this resident was admitted to the facility on [DATE] and had diagnoses including hypertension, abnormal glucose, anxiety disorder, insomnia, and dementia. Review of the admission MDS assessment, dated 08/24/23, revealed this resident had severely impaired cognition evidenced by a BIMS assessment score of 00. This resident was assessed to require extensive assistance from one staff member for bed mobility, transfers, and toileting. Review of the active physicians order, dated 08/19/23, revealed an order for 25 mg of Seroquel to be administered three times a day. The order did not contain a diagnosis or indication for the use of the medication. Review of the pharmacy recommendation, dated 09/05/23, revealed a recommendation to provide a diagnosis for the use of Seroquel (an anti-psychotic medication) or consider titrating off the medication. The pharmacy recommendation did not contain a response by the physician. Interview with the DON on 10/18/23 at 2:05 P.M. verified Resident #43 continued to be prescribed the medication Seroquel without a diagnosis or indication for the use of the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366202 If continuation sheet Page 16 of 18 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 366202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal Care of Coal Grove 813 1/2 Marion Pike Coal Grove, OH 45638 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 review of the infection/antibiotic stewardship log, interview, and policy review the facility failed to ensure all prescribed antibiotics were appropriate. This had the potential to affect all 41 residents residing in the facility. Residents Affected - Some Findings include: Review of the infection control log dated 01/2023 to 09/2023 revealed there was no evidence in February, March, April, May, June and September 2023 the facility identified the organism of the infection and ensured the antibiotic met the criteria for treatment. Further review of the log revealed in February 2023 there was six urinary tract infections (UTI), two gastrointestinal (GI), one skin, and three lower respiratory infections identified. All the infections were treated with antibiotics and did not meet the criteria for antibiotic treatment. Further review of the log revealed in March 2023 there was two upper respiratory infections (URI), two lower respiratory infection, two GI infections, three skin infections, and five UTI's identified. All the infections were treated with antibiotics and did not meet the criteria for antibiotic treatment. Further review of the log revealed in April 2023 there was two respiratory infections, one UTI and one wound infection identified. All the infections were treated with antibiotics and did not meet the criteria for antibiotic treatment. Further review of the log revealed in May 2023 there was two wound infections, two upper respiratory infections and two UTI's identified. All the infections were treated with antibiotics and did not meet the criteria for antibiotic treatment. Further review of the log revealed in June 2023 there was two upper respiratory infections, two UTI's, two lower respiratory infections and one skin infection denitrified. All the infections were treated with antibiotics and did not meet the criteria for antibiotic treatment. Further review of the log revealed in September 2023 there was five UTI's, one lower respiratory infection, one wound and one skin infection identified. All the infections were treated with antibiotics and did not meet the criteria for antibiotic treatment. Interview on 09/19/23 at 3:45 P.M. with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the infection and antibiotic stewardship log was not comprehensive to include all the organism, and ensuring the antibiotics met the criteria for treatment of the infection. The ADON (the infection preventionist) stated she was not checking the correct criteria for infections. The ADON stated she used the McGreer form provided by the facility and was not aware she needed to have a culture for urine and skin. Review of the facility policy title Antibiotic Stewardship, with no date, revealed it was the policy of the facility to maintain an antibiotic stewardship program with the mission of promoting the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366202 If continuation sheet Page 17 of 18 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 366202 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal Care of Coal Grove 813 1/2 Marion Pike Coal Grove, OH 45638 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview, record review, and review of the facility policy revealed the facility failed to ensure adequate monitoring, screening and offering of pneumonia vaccine. This affected four residents (#28, #29, #30 and #36) of five reviewed for immunizations. The facility census was 41. Residents Affected - Some Findings include: Review of the medical record for Resident #28, #29, #30 and #36 revealed the residents did not receive the appropriate pneumonia vaccination based on the Centers of Disease Control and Prevention (CDC) guidelines. Interview on 10/19/23 at 3:40 P.M. with the Director of Nursing and the Assistant Director of Nursing confirmed Resident #28, #29 #30 and #36 did not receive the appropriate pneumonia vaccination as recommended by the CDC. Review of the facility policy titled Pneumococcal Vaccine, with no date, indicated prior to admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series and when indicated, will be offered the vaccine series within thirty days of the admission to the facility unless medically contraindicated or the resident has already been vaccinated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366202 If continuation sheet Page 18 of 18