Health inspection·March 4, 2024

F 0684 in condition. Level of Harm - Immediate jeopardy to resident health or safety • On [DATE], the DON educated all 16 licensed nurses on how to correctly enter laboratory tests into the e-med lab system. The licensed nurses were educated in-person or by telephone. Residents Affected - Few • On [DATE], the DON and LNHA educated all 70 staff members on abuse and neglect. All staff were educated in-person or by telephone. • On [DATE], the DON completed an audit of all 54 residents currently residing in the facility to ensure all laboratory orders were entered into the e-med lab system correctly. The audit revealed there were no incorrect laboratory tests entered into e-med lab system. • On [DATE], the DON completed an audit of all 54 residents to ensure no other residents had changes in condition that were not being addressed by the facility. There were two residents (Residents #1 and #2) observed to have a change in condition during the audit process. Residents #1 and #2 were assessed, the physician was notified, and new physician orders were obtained to treat the changes in conditions. Residents #1 and #2 will be closely monitored and any additional changes will be reported to the physician or NP. • On [DATE], RDCO #600 educated the DON on the morning meeting process to ensure all treatments and physician's orders are being covered during the meeting, specifically related to the monitoring of physician's orders and the entering of laboratory tests. • On [DATE], an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was completed with the Administrator, DON, and Medical Director #700 to discuss the self-inducted plan of correction (SIPOC) and all the steps taken toward an abatement plan. • On [DATE], RDCO #600 educated the LNHA and DON, and Assistant Director of Nursing (ADON) #800 on the process for identifying a change in condition and the timely reporting of a change in condition to the physician. • On [DATE], the LNHA and DON educated all 70 staff members to report any residents showing signs and symptoms of a change in condition. All staff were educated in-person or by telephone. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366202 If continuation sheet Page 2 of 6 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 03/04/2024 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 • Level of Harm - Immediate jeopardy to resident health or safety On [DATE], the DON educated all 16 licenses nurses on how to address a resident's change in condition and the timely reporting of a change in condition to the physician. All nurses were educated in-person or by telephone. Residents Affected - Few • Beginning on [DATE], the DON or designee will complete audits for changes in condition and physician notification. These audits will be completed five times weekly for four weeks. The DON or designee will audit laboratory tests indefinitely. If any concerns are identified, the staff member will be educated at that time. • On [DATE], Regional [NAME] President #888 reviewed and modified the facility's policy titled Lab and Diagnostic Test Result to address the procedure to be followed when ordered labs are not drawn, ensuring labs orders are drawn, and how nursing is to monitor the lab draw status and results. • On [DATE], RDCO #600 educated the DON on the revised Lab and Diagnostic Test Result policy and change in condition and physician notification policy. On [DATE] at 10:07 A.M., the DON educated all 16 nurses by telephone or in-person on the revised Lab and Diagnostic Test Result policy and all 70 staff members were educated on the responsibility of all staff to report any residents showing signs or symptoms of a change in condition. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #60 revealed the resident was admitted to the facility on [DATE]. Resident #60 had diagnoses including atrial fibrillation, muscle weakness, epilepsy, and multiple sclerosis. Review of the hospital records dated [DATE] revealed Resident #60 was under hospice care services for a stroke prior to the hospitalization. Resident #60 improved under hospice care and wanted to receive rehabilitation care so was discharged from hospice services. Resident #60 was discharged from the hospital on [DATE] and admitted to the skilled nursing facility with orders to treat a urinary tract infection with intravenous antibiotics. Review of the nursing progress note, dated [DATE], revealed Resident #60 vomited large amounts of green bile, was diaphoretic (sweating), exhibited increased confusion, had liquid stool in colostomy bag, was lethargic, and slow to respond. The NP was notified with new orders to send Resident #60 to the emergency department for evaluation and treatment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366202 If continuation sheet Page 3 of 6 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 03/04/2024 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the hospital progress notes, dated [DATE] through [DATE], revealed Resident #60 was admitted to the hospital on [DATE] with a life-threatening potassium level of 9.8 mEq/L requiring admission to the intensive care unit and urgent hemodialysis treatments (ICU) on [DATE]. The resident was stabilized while in the hospital and was transferred back to the facility on [DATE]. Resident #60 exhibited high levels of motivation to participate in rehabilitation and expressed she wanted to walk again. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #60 was assessed to have mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 11 (out of 15). Resident #60 was assessed to be dependent upon staff for bed mobility and toileting. Review of the nursing progress notes dated [DATE] through [DATE] revealed no documented evidence staff identified any changes in condition for the resident during this time period. The nursing progress note, dated [DATE] at 10:29 A.M., revealed Resident #60 had a slight increase in confusion, a decrease in appetite, and weight loss. The NP was notified, and new orders were obtained for STAT laboratory testing to be completed. Review of the physician's order, dated [DATE], revealed an order for a Comprehensive Metabolic Panel (CMP), renal panel including Glomerular Filtration Rate (GFR), Complete Blood Count (CBC) with differential, and a B-Natriuretic Peptide (BNP) to be completed STAT due to increased confusion. Review of the requisition for laboratory testing, dated [DATE], revealed orders for a CMP, renal panel including GFR, CBC with differential, and a BNP were entered as routine rather than STAT as ordered by the NP. There were no results of the ordered laboratory tests available for review. There was no evidence the physician or NP were notified the laboratory tests were not completed and no reason was noted in the medical record as to why the laboratory tests were not completed. Record review revealed there were no nursing progress notes completed for Resident #60 between the note on [DATE] at 10:29 A.M. and a note on [DATE] at 8:40 A.M. There was no evidence the resident's overall health status was being monitored or assessed during this time period. The nursing progress note, dated [DATE] at 8:40 A.M., revealed Resident #60 had pale, cool, clammy skin to touch. The resident's breath sounds were diminished in the lower lobes bilaterally. There was no evidence the NP or physician were updated on Resident #60's change in condition at this time. There were no evidence additional assessments or monitoring of the resident completed until 1:30 P.M. The nursing progress note, dated [DATE] at 1:30 P.M., revealed ADON #800 and RN #300 verified Resident #60 had no respirations and no heart rate noted. The physician was notified Resident #60 was deceased . Review of the death certificate revealed Resident #60's immediate cause of death was atrial fibrillation. Interview with the DON on [DATE] at 12:15 P.M. confirmed NP #500 ordered laboratory testing to be completed STAT on [DATE] for Resident #60. The DON verified the STAT laboratory tests were not drawn and therefore there were no results available for review. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366202 If continuation sheet Page 4 of 6 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 03/04/2024 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Telephone interview with NP #500 on [DATE] at 12:53 P.M. confirmed she had ordered STAT laboratory testing to be completed for Resident #60 on [DATE] due to reports of increased confusion and a recent history of critically high potassium levels, which had required hospitalization and were life-threatening. NP #500 stated she would expect STAT laboratory tests to be completed within two to three hours of the physician's order. NP #500 additionally confirmed she had not been notified by the facility the laboratory testing had not been completed for Resident #60 as ordered and had not been notified of the assessment of the resident having diminished breath sounds and cool, clammy, pale skin on [DATE]. NP #500 stated if she had been notified of either situation, she would have ordered the resident be sent to the hospital for evaluation and treatment. Interview with the LNHA and DON on [DATE] at 1:55 P.M. revealed facility management was not aware the STAT laboratory tests had not been obtained for Resident #60 until the morning of [DATE]. The Administrator and DON confirmed the facility did not notify the NP or physician of the ordered laboratory tests not being obtained or of the resident being assessed to have diminished breath sounds and cool, clammy, pale skin on [DATE]. The LNHA and DON stated they were notified during the clinical morning meeting, which was held between 9:00 A.M. and 10:00 A.M. on [DATE], that the laboratory tests were not drawn for Resident #60 because the laboratory company who the facility had a contract with did not have enough staff to come draw the physician ordered laboratory tests. The DON and LNHA stated they did not update the physician or NP of the resident's current condition and the fact the laboratory tests were not drawn because Resident #60 had another change in condition that morning. The Administrator and DON confirmed the facility did not complete an investigation related to the laboratory tests not being drawn for Resident #60 when they were ordered STAT and did not investigate Resident #60's change in condition until [DATE]. Interview with RN #250 on [DATE] at 8:50 A.M. confirmed she had received the order from NP #500 to obtain STAT laboratory tests and had entered the order with the laboratory company the facility contracted with. RN #250 stated she could not recall if she entered the order as STAT or routine. Telephone interview with RN #300 on [DATE] at 9:00 A.M. confirmed Resident #60 did not appear to be well on the morning of [DATE] and had diminished breath sounds and cool, clammy, pale skin. RN #300 stated she did not report the resident's condition to the NP or physician, as she was not familiar with Resident #60 and was told by State Tested Nursing Assistants (STNAs) who worked more frequently with the resident she was not acting far from her baseline. RN #300 stated the DON was questioning whether laboratory testing had been ordered for Resident #60 the day before ([DATE]) as the results could not be located. Interview with STNA #133 on [DATE] at 11:40 A.M. confirmed Resident #60 appeared sick on [DATE]. STNA #133 stated she entered the room around lunch time to check on the resident and the resident did not appear to be breathing. STNA #133 stated she informed the nurse who confirmed the resident had expired. STNA #133 stated the resident's death was unexpected. Interview with the DON on [DATE] at 1:28 P.M. confirmed the orders for STAT laboratory testing to be completed for Resident #60 had been entered as routine instead of STAT as ordered. Telephone interview with NP #500 on [DATE] at 1:52 P.M. confirmed the nurse practitioner would have typically expected follow up laboratory tests to be conducted for a resident admitted to the hospital with a potassium level of 9.8 within one week following the resident's return to the facility. NP #500 stated she could not recall the exact discussion she had with facility staff following Resident #60's return or whether she provided orders for the laboratory tests to be drawn. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366202 If continuation sheet Page 5 of 6 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 03/04/2024 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the facility's contract with Laboratory Company #99 dated [DATE] revealed the laboratory company provided 24 hours per day, 365 days per year STAT (life-threatening situation) services. The STAT testing was to be reported within five hours. The facility agreed to provide completed requisitions that reflect a physician or other practitioner's order for the services. The facility shall ensure that all requisitions are completed accurately with all the information needed for the laboratory company. Review of the facility policy titled Lab and Diagnostic Test Results - Clinical Protocol, revised 11/2018, revealed the physician would identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff would process test requisitions and arrange for tests. Staff would use daily logs to ensure lab orders were in place for each shift. The laboratory, diagnostic radiology provider, and or other testing source would report test results to the facility. If a STAT order had not been drawn within four to six hours, physician notification should take place and further direction given. Review of the facility's undated policy titled Change in Condition and Physician Notification Policy revealed the facility was to promptly identify, respond to, and report changes in resident condition to the resident's physician/NP/physician assistant (PA) and resident/resident's representative. A significant change was a major decline or improvement of the resident's status. The nurse would document timely regarding the change in resident's condition, interventions, and notifications. This deficiency represents non-compliance investigated under Complaint Number OH00150811. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366202 If continuation sheet Page 6 of 6