Health inspection·November 21, 2019

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few needs it. She has discussed this with her about not leaving her personal items in there because she had a roommate up until one week and half ago. The DON said she was not allowed to store her items in the bathroom in case another resident in moved into the room. She said the resident has been deemed independent by therapy and will be going home on Friday. She then said the staff were taking her to the bathroom, and they would take the products in when they went in there and again re-iterated, she just became independent with mobility in the last week. Review of the facility's policy titled Peregrine Health Services, Inc; Residents Rights Policy, dated 02/2015, revealed the standard is to assure that the resident's dignity, well-being, and self-determination is maintained to assure that residents are knowledgeable to their rights and responsibilities in this regard. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366224 If continuation sheet Page 2 of 9 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 366224 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Celina 1301 Myers Road Celina, OH 45822 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on record review, observation, staff interview and policy review, the facility failed to ensure Resident #4 ingested her physician ordered medication in the presence of the administering nurse and failed to ensure medications were secured when not in the presence of a nurse. The facility identified two residents, #22 and #123, as being independently mobile and confused. The facility census was 23. Findings include: 1. Review of the medical record of Resident #4 revealed an admission date of 06/04/12 and re-admission date of 03/26/19. Diagnoses included fracture of neck of right femur, absence of right hip, anxiety disorder, insomnia, hypothyroidism, atherosclerotic heart disease of native coronary artery without angina pectoris, heart failure, elevated blood pressure reading without diagnosis of hypertension, squamous cell carcinoma of right lower leg and anemia. Review of the medication administration record for 11/2019 revealed Resident #4 was scheduled to receive two tablets of acetaminophen (treats minor aches and pains) 500 milligrams (mg.), one capsule of acidophilus (supplement), one tablet of Norvasc (treats high blood pressure) 10 mg., one tablet of Allegra (treats allergies) 180 mg., one tablet of Lasix (diuretic) 20 mg., one tablet of iron 325 mg. (supplement), one tablet of Ocuvite (supplement), one tablet of Lopressor (treats high blood pressure) 100 mg., one tablet of Protonix. (treats gastroesophageal reflux disease) 40 mg., one tablet of potassium chloride (supplement) 20 milliequivalent (mEq.), one tablet of Mirapex (treats Parkinson's disease) 0.5 mg., one tablet of Pravachol (cholesterol lowering medication) 80 mg., one tablet of Requip (treats Parkinson's disease) two mg., one tablet of Senna (stool softener 8.6 mg., one half tablet of Vitamin B-12 (supplement) 100 mcg., and one tablet of Augmentin (antibiotic) 875 mg. by mouth. Observation on 11/20/19 at 7:30 A.M. revealed a small, clear, plastic cup with numerous medications, sitting on the bedside table in the private room of Resident #4. Interview on 11/20/19 at 7:30 A.M. with Licensed Practical Nurse (LPN) #210 verified she had left the medications in the room of Resident #4 that morning. 2. Observation on 11/20/19 at 2:45 P.M. revealed a vial of tuberculin purified protein derivative (a diagnostic antimicrobial) was left, unattended, on top of the medication cart. The medication cart was located at the west end of the nurse's station. Interview on 11/20/19 at 2:45 P.M. with Director of Nursing and Clinical Resource Nurse #247 provided verification of the unattended vial of tuberculin purified protein derivative on the medication cart. The facility identified two residents, #22 and #123, as being independently mobile and confused. Review of the facility's policy titled Medication Storage in the Facility, dated 08/2014, revealed medications and biologicals are to be stored safely, securely, and properly and accessible only to licensed personnel. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366224 If continuation sheet Page 3 of 9 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 366224 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Celina 1301 Myers Road Celina, OH 45822 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 - Few 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. Based on medical record review, staff interview and review of the facility's policy, the facility failed to ensure the as needed anti-anxiety medications were given the required stop date. This affected one (Resident #8) of five residents reviewed for unnecessary medications. This had the potential to affect three residents the facility identified as using as needed anti-anxiety medications. The facility's census was 23. Findings include: Review of the medical record for Resident # 8 revealed an admission date of 06/19/19. Diagnoses included anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 10/01/19, revealed the resident was severely cognitively impaired and he received anti-anxiety medications seven days a week. Review of the plan of care, dated 07/31/19, revealed a plan for use of anti-anxiety medications for the anxiety disorder with an intervention which included to give anti-anxiety medications ordered by the physician. Review of the physician's orders, dated 08/24/19, revealed an order for Ativan (anti-anxiety medication) 0.5 milligrams (mg.) one tablet to be give three times daily as needed (PRN) was discontinued and the new order was for Ativan 0.5 mg. one tablet to be given four times a day PRN without a stop date and continues to be the current order on the physician's orders dated 11/19/19. Review of the pharmacist's monthly report, dated 09/05/19, revealed Resident #8 currently had a PRN order for Ativan. It stated according to the new Centers for Medicare and Medicaid Services (CMS) guidelines regarding as needed psychotropic, the medication can only be written for 14 days initially. The medication may be extended if documentation is provided with reasoning and a time frame is specified. No exceptions are made for hospice patients. Please provide supportive documentation for continued use or consider discontinuing this medication if you feel it appropriate. The doctor responded, on 09/17/19, with the response to continue the use with re-evaluation in two months. The discontinuation of the PRN Lorazepam has the potential to negatively impact functional and cognitive function. Anxiety exacerbations may present themselves as agitation and care refusal. Interview with the Director of Nursing (DON) on 11/20/19 at 9:30 A.M. verified Resident #8's physician order for Ativan 0.5 mg. to be given one tablet four times a day PRN did not have a stop date. The DON verified the doctor did respond to the pharmacist's request and did put a reason with the need to re-evaluate in two months but did not put a stop date on the order for Ativan for Resident #8. Review of the facility's policy titled Psychotropic Medications Policy, dated 11/2017, revealed residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition. When an emergency or acute condition occurs, the previous criteria needs met and all of the following, acute treatment is 14 days or less. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366224 If continuation sheet Page 4 of 9 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 366224 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Celina 1301 Myers Road Celina, OH 45822 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, staff interview and policy review, the facility failed to ensure the medication error rate was less than five percent. There were five medication errors out of 25 opportunities resulting in a 20 percent medication error rate. This affected two (Resident #9 and #20) of two residents observed for medication administration. The facility census was 23. Residents Affected - Few Findings include: 1. Review of the medical record of Resident #9 revealed an admission date of 03/28/17 and a re-admission date of 10/02/19. Diagnoses included vitamin D deficiency, hyperlipidemia, atherosclerotic heart disease of the native coronary artery without angina pectoris, nonrheumatic mitral valve stenosis, longstanding persistent atrial fibrillation, acute on chronic systolic heart failure, venous insufficiency, type two diabetes mellitus without complications, essential hypertension and anemia. Observation on 11/20//19 at 7:40 A.M. of medication administration to Resident #9 revealed Licensed Practical Nurse (LPN) #210 administered one tablet of Protonix (a proton pump inhibitor) 40 milligrams (mg), one tablet of Cardizem (an antiarrhythmic) 120 mg, one tablet of Bumex (a diuretic) one mg., one-half tablet of Lopressor (an antihypertensive) 25 mg. and one capsule of potassium chloride (supplement) 10 milliequivalents (mEq.) by mouth. Subsequent review of the physician orders for Resident #9 revealed an order for iron (a supplement) 65 mg. and Cholecalciferol (a supplement) 25 micrograms (mcg.) by mouth. Review of the medication administration record (MAR) for 11/2019 revealed the iron 65 mg. had not been added to the record after receiving the order on 11/18/19. During the medication administration, LPN #210 picked up the bottle of Cholecalciferol and read the dosage as 1,000 international units (I.U.) LPN #210 stated this one was not the right dosage and did not prepare to administer the medication. 2. Review of the medical record of Resident #20 revealed an admission date of 10/23/19. Diagnoses included acute cystitis with hematuria, benign paroxysmal vertigo, hypothyroidism, anxiety, anemia, type two Diabetes Mellitus without complications, hyperlipidemia, major depressive disorder, essential hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, old myocardial infarction, unspecified atrial fibrillation, and acute on chronic diastolic (congestive) heart failure. Observation on 11/20/19 at 7:45 A.M. revealed LPN #210 prepared and administered one tablet of aspirin (antiplatelet) 81 mg., one tablet of calcium 600 mg. with 400 I.U. of vitamin D3 (a supplement), one tablet of Aricept (for dementia)10 mg., one capsule of Prozac (an antidepressant) 10 mg., one tablet of Lasix (a diuretic) 40 mg., one tablet of iron (a supplement) 65 mg., one tablet of Imdur (for angina) 60 mg., one tablet of Lopressor (an antihypertensive) 50 mg., one tablet of Protonix (a proton pump inhibitor) 40 mg., one tablet of potassium chloride (a supplement) 10 mEq., two capsules of Preservision (a supplement), one tablet of Senna plus (a stool softener) 8.6-50 mg., one tablet multivitamin (a supplement), one tablet vitamin B12 (a supplement) 1000 mcg, one tablet Atorvastatin (lipid lowering agent) 20 mg., one tablet cranberry (supplement), one chewable tablet of vitamin D (supplement) 500 mg and one chewable tablet vitamin C (supplement) 240 mg to Resident #20. Review of the resident's physician order, dated 11/2019, revealed an order for one tablet calcium 500 mg. with vitamin D3 400 I.U. and two tablets of vitamin B12 1000 mg. to be administered orally. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366224 If continuation sheet Page 5 of 9 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 366224 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Celina 1301 Myers Road Celina, OH 45822 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 0759 The physician orders were silent for an order for calcium 500 mg. Level of Harm - Minimal harm or potential for actual harm Interview on 11/20/19 at 8:06 A.M. with LPN #210 provided verification of Resident #9 not receiving iron 65 milligrams (mg.) and one tablet of Cholecalciferol 25 mcg. LPN #210 stated she was unaware 25 mcg. was equivalent to 1000 I.U. LPN #210 further verified Resident #20 did not receive the two tablets of Vitamin B12 1000 mg. as ordered. LPN #210 further verified the calcium 600 mg. with vitamin D3 400 I.U. was not the ordered dose of calcium 500 mg. with vitamin D3 400 I.U. LPN #210 verified there was no order for calcium 500 mg. Residents Affected - Few Review of the facility's policy titled Preparation and General Guidelines; Medication Administration-General Guidelines, dated 08/2014, revealed the five rights (right resident, right drug, right dose, right route, and right time) are to be applied prior to medication being administered. The MAR was to be employed during medication administration. The MAR should be compared to the medication label. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366224 If continuation sheet Page 6 of 9 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 366224 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Celina 1301 Myers Road Celina, OH 45822 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 - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview and review of the facility's policy, the facility failed to ensure proper sanitary measures were being used during the making of pureed meals by removing soiled gloves before touching food. This had the potential to affect three residents (#1, #10 and #124) who eat pureed diets. Furthermore, the facility failed to ensure foods were transported throughout the facility in a sanitary manner. This had the potential to affect six residents who were being served a room tray (#1, #12, #13, #16, #20 and #123). The facility census was 23. Findings included: 1. Observation of [NAME] #1 preparing pureed diets on 11/20/19 at 10:54 A.M. revealed she had washed her hands and donned gloves. She took the meat and gravy out of the oven and used the tongs to get the meat out of the container, put the pureed meats in a container then placed the container back into the oven. She then took the mashed potatoes out of the oven, took the temperature, then placed it back into the oven. The cook did not change her gloves. She then opened the bag which contained angel food cake, and with her contaminated gloves pulled out two large pieces and broke it up into the blender. The cook verified she should have changed her gloves after every time she touched something different. The facility identified three residents (#1, #10 and #124) who receive a pureed diet from the kitchen. Review of the facility's undated policy Disposable Gloves revealed disposable gloves shall be worn to prevent cross-contamination. Gloved hands are considered a food contact surface that can become contaminated. Disposable gloves shall be changed between tasks and as often as hands need to be washed. 2. Observation on 11/18/19 at 11:26 A.M. revealed State Tested Nursing Assistant (STNA) #212 pushing a metal, open cart down the hallway. The cart contained six trays with covered plates and bowls, and the trays also held uncovered glasses and cups, filled with liquids. The trays were intended for Residents #1, #12, #13, #16, #20 and #123. Interview on 11/18/19 at 12:50 A.M. with STNA #212 verified the uncovered glasses and cups on the tray in the hallway. Review of the facility's undated policy titled Food Transport Safety revealed food shall always be covered when in transit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366224 If continuation sheet Page 7 of 9 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 366224 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Celina 1301 Myers Road Celina, OH 45822 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, observation, staff interview, family interview, review of Centers for Disease Control and Infection guidelines and facility policy review, the facility failed to decrease the risk of the spread of an infection when staff and family members failed to wear personal protective equipment when entering the room and providing care to Resident #13. This affected one (#13) of one resident reviewed for transmission based precautions and had the potential to affect all the residents residing in the facility. The facility census was 23. Residents Affected - Many Findings include: 1. Review of the medical record of Resident #13 revealed an admission date of 07/02/19. Diagnoses included cerebral infarction, essential hypertension, anxiety disorder, rheumatoid arthritis with rheumatoid factor, major depressive disorder, peripheral vascular disease, repeated falls and altered mental status. A diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) was documented on a physician order dated 11/07/19. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/12/19, revealed Resident #13 was cognitively intact, required limited assistance of one staff for bed mobility, transfers, toileting and personal hygiene. Review of the medical revealed Resident #13 was in contact isolation related to MRSA infection to the right gluteal fold. Observation on 11/18/19 at 11:45 A.M. revealed Registered Nurse (RN) #201, State Tested Nursing Assistant (STNA) #212 and Physical Therapy Assistant (PTA) #248 went into the room of Resident #13 and no one had on personal protective equipment (PPE), gloves or gown. PTA #248 was seated on the unmade bed of Resident #13 atop of the used incontinence protective pad. RN #201 used an automatic blood pressure cuff to obtain the blood pressure. After obtaining the reading, RN #201 placed the device in the pocket of her uniform top. STNA #212 was assisting Resident #13 with getting seated in the recliner for lunch. None of the staff members had on disposable gloves or protective gowns. A family member was also in the room and was not utilizing PPE. Interview on 11/18/19 at 11:55 A.M. with Director of Nursing (DON), Clinical Resource Nurse (CRN) #247 and RN #201 provided verification of the staff and family member not utilizing PPE when in the room of Resident #13. RN #201 verified she had not cleaned the blood pressure cuff prior to placing the device in her pocket, contaminating her pocket. RN #201 was under the assumption that as long as the wound was covered, PPE was not required. Interview on 11/18/19 at 1:20 P.M. with two of Resident #13's daughters revealed they were informed no PPE was required as the wound was covered. Review of the Centers for Disease Control and Infection (CDC), dated 01/07/16, revealed contact precautions included to wear PPE, including gloves and gown, when in contact with the resident and/or the resident's environment. It also stated to clean and disinfect dedicated resident equipment, including a blood pressure cuff. 2. Observation on 11/19/19 at 9:55 A.M. of the dressing change completed on Resident #13 by Licensed Practical Nurse (LPN) #226 revealed LPN #226 and CRN #247 donned gown and gloves and entered the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366224 If continuation sheet Page 8 of 9 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 366224 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Celina 1301 Myers Road Celina, OH 45822 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 room of Resident #13. CRN #247 was only assisting Resident #13 with positioning. LPN #226 removed the soiled dressing from the right gluteal fold of Resident #13 and placed the dressing in the clear trash bag-lined bin beside the recliner. LPN #226 proceeded to cleanse the wound using sterile water, patted the wound dry and placed the gauze into a red-biohazard lined trash bin. LPN #226 then applied the ordered ointment to the wound and placed a clean dressing on the wound. LPN #226 removed the red biohazard trash bag from the room, leaving the soiled dressing in the clear bag beside Resident #13's recliner. Interview on 11/19/19 at 10:15 A.M. with CRN #247 and LPN #226 provided verification of the soiled dressing having been placed into a clear trash bag and not into the biohazard bag. The soiled dressing remained in the room. Review of the facility's Nursing Skills Checklist, dated 07/2018, revealed dressings will be discarded of appropriately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366224 If continuation sheet Page 9 of 9