Inspection·March 9, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and staff interview, the facility failed to ensure residents had access to a clean bathroom. This affected two (Residents #02 and #12) of three residents reviewed for physical environment. The facility census was 19. Findings include: Observation on 03/06/23 at 9:43 A.M. of the bathroom shared by Resident #02 and #12, revealed three large light green stains to the bathroom floor around the toilet. The bathroom was noted to have a strong odor of urine. Interview on 03/07/23 at 7:35 A.M. with Housekeeper #108 stated the facility was aware of the stains to the floor and the strong urine odor to Resident #02 and #12's bathroom. Housekeeper #108 stated housekeeping had been cleaning the floor frequently and the stains had improved but they were unable to get rid of the urine odor or stains to the floor. Interview on 03/07/23 at 8:45 A.M. with Maintenance #128 confirmed the floor to Residents #02 and #12's bathroom had large green stains and the bathroom had a strong urine odor. Maintenance #128 stated the housekeeping staff have been working to remove the stains but were unable to remove the green stains. Maintenance #128 stated the facility planned to replace the tiles in the bathroom floor to Resident #02 and #12's room but a date had not been set to replace the tiles. This deficiency represents non-compliance for Complaint Number OH00137461. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 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 366234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Nursing Center of Rockford 201 Buckeye Street Rockford, OH 45882 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the medical record of Resident #08 revealed an admission date of 07/30/21. Diagnoses included major depressive disorder, anxiety disorder, psychotic disorder with hallucinations due to known physiological condition, other hallucinations, schizoaffective disorder, and psychotic disorder with delusions due to known physiological condition. Residents Affected - Some Review of the MDS assessment dated [DATE] revealed Resident #08 had severe cognitive impairment. Review of the PASRR Identification Screen dated 08/02/21, signed by Social Service #115, revealed the form lacked documentation of Resident #08's mental health diagnoses. Further review of the medical record revealed no documentation to support the facility received the PASRR Review Results prior to Resident #08 admitting on 07/30/21. 5. Review of the medical record of Resident #10 revealed an admission date of 06/29/22. Diagnoses included anxiety disorder, major depressive disorder, and bipolar type schizoaffective disorder. Review of the MDS assessment dated [DATE] revealed Resident #10 was cognitively intact. Review of the PASRR Identification Screen dated 06/28/22 revealed the form lacked documentation of Resident #10's mental health diagnoses. Further review of the medical record revealed no documentation to support the facility received the PASRR Review Results prior to Resident #10 admitting to the facility on [DATE]. Interview on 03/08/23 at 4:13 P.M. with Social Service #115 verified the lack of accuracy of the PASRR Identification Screen forms for Residents #01, #05, #08, #10, and #20. She further confirmed no PASRR review results had been received for Residents #05, #08, #10, and #20 prior to their admission to the facility. Review of the policy titled, Resident Assessment-Coordination with PASRR Program, revised 10/01/22, stated all applicants to the facility would be screened with the PASARR program under Medicaid to ensure the individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Based on record review, staff interview, and policy review, the facility failed to ensure an accurate Preadmission Screen and Resident Review (PASRR) was completed and failed to ensure the PASRR Review Results were obtained timely. This affected five (Residents #01, #05, #20, #08, and #10) of five residents reviewed for PASRRs. The facility census was 19. Findings include: 1. Review of the medical record for Resident #01 revealed an admission date of 07/02/21 with diagnoses of residual schizophrenia, major depression, and unspecified psychosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #01 was cognitively intact. Resident #1 required supervision with bed mobility, transfers, locomotion, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 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 366234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Nursing Center of Rockford 201 Buckeye Street Rockford, OH 45882 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 0645 eating. Resident #01 required limited assistance with toileting and extensive staff assistance with bathing. Level of Harm - Minimal harm or potential for actual harm Further review of the medical record revealed a PASRR screen was completed on 05/11/18. The Review Results indicated Resident #01 had no indications of serious mental illness nor a developmental disability. Continued review of the PASRR screen revealed the form did not indicate the mental health diagnoses of psychosis and did not state that due to the mental disorder the individual experienced a limitation in maintaining personal hygiene. Residents Affected - Some 2. Review of the medical record for Resident #05 revealed an admission date of 04/29/21 with diagnoses of schizophrenia, bipolar disorder, and major depression. Review of the MDS assessment dated [DATE], indicated Resident #05 had moderate cognitive impairment. Resident #05 required extensive assist with bed mobility, dressing, toileting, and personal hygiene. Resident #05 was dependent upon staff for transfers and bathing and was non-ambulatory. Further review of the medical record revealed a PASRR screen completed on 05/10/19 revealed the form did not include the mental health diagnoses of schizophrenia or major depression. Further review of the medical record revealed no documentation to support the facility received the PASRR Review Results prior to Resident #05 admitting to the facility on [DATE]. 3. Review of the medical record for Resident #20 revealed an admission date of 12/13/22 with diagnoses of post-traumatic stress disorder (PTSD), anxiety, hallucinations, major depression, schizoaffective disorder, and insomnia. Review of the MDS assessment dated [DATE], indicated Resident #20 was cognitively intact. Resident #20 required supervision with bed mobility, transfers, eating, and toileting. Resident #20 required extensive assistance with bathing. Further review of the medical record revealed a PASRR screen, dated 12/02/22, which did not indicate Resident #20 had schizoaffective disorder or post-traumatic stress disorder (PTSD). Further review of the medical record revealed no documentation to support the facility received the PASRR Review Results form prior to Resident #20's admission date of 12/13/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 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 366234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Nursing Center of Rockford 201 Buckeye Street Rockford, OH 45882 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record of Resident #10 revealed an admission date of 06/29/22. Diagnoses include heart failure, anxiety disorder, major depressive disorder, bipolar type schizoaffective disorder, and type II diabetes mellitus. Review of the MDS assessment dated [DATE] revealed Resident #10 was cognitively intact. Interview on 03/06/23 at 12:43 P.M. with Resident #10 revealed she had never been included in a care conference. Further review of the medical record revealed no indication a care conference for Resident #10 had been held since admission. Interview on 03/09/23 at 9:30 A.M. with Social Services #115 revealed no care conference had been held with Resident #10. Review of the facility policy, Care Planning- Resident Participation, undated, verified the facility will discuss the plan of care with the residents and/or representatives at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will make an effort to schedule the conference at the best time of the day for the resident/resident's representative. The facility will obtain a signature from the resident and/or resident representative after discussion or viewing of the care plan. Based on medical record review, staff and resident interviews, and policy review, the facility failed to conduct quarterly care conferences. This affected three (Residents #10, #11, and #18) of three residents reviewed for care conferences. The census was 19. Findings include: 1. Review of the medical record revealed Resident #11 was admitted on [DATE]. Diagnoses included heart failure, high blood pressure, and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of the social service progress notes dated 06/30/22 revealed a care conference was held for the resident. Further review of the medical record, including progress notes, revealed no other care conferences taking place, indicating care conferences were not completed quarterly. Interview on 03/08/23 at 11:37 A.M. with Social Services #115 verified Resident #11 had not had any care conferences since 06/30/22. 2. Review of the medical record revealed Resident #18 was initially admitted on [DATE]. Diagnoses included gastrointestinal hemorrhage, anemia, severe protein-calorie malnutrition, acute respiratory failure with hypoxia, anxiety disorder, and high blood pressure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 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 366234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Nursing Center of Rockford 201 Buckeye Street Rockford, OH 45882 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 0657 Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact. Level of Harm - Minimal harm or potential for actual harm Interview on 03/06/23 at 12:10 P.M. with Resident #18 revealed she did not recall having care conferences. Residents Affected - Few Review of social service progress notes dated 08/24/22 and 02/07/23 care conferences were held for the resident on those dates. Further review of the medical record revealed there were no other care conferences held, including one for November, three months after the 08/24/22 care conference, indicating care conferences were not completed quarterly. Interview on 03/08/23 at 10:55 A.M. with Social Services #115 verified care conferences for Resident #18 were only completed in August 2022 and February 2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 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 366234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Nursing Center of Rockford 201 Buckeye Street Rockford, OH 45882 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 - Many 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 observation, staff interview, and review of facility smoking contract, the facility failed to ensure cigarettes were lit outside the facility. Furthermore, the facility failed to ensure the resident smoking area was free from cigarette butts. This had the potential to affect all 19 residents residing in the facility. Additionally, the facility failed to ensure alcohol was stored properly. This affected one (Resident #11) of one resident reviewed for alcohol storage. The facility census was 19. Findings include: 1. Observation on 03/06/23 at 3:43 P.M. revealed State Tested Nursing Assistant (STNA) #117 lighting the cigarettes of two male residents while they were inside the building, prior to them exiting to the courtyard patio. Observations of the courtyard revealed the presence of a large amount of cigarette butts on the ground, in the mulch, in the grass, and on the cement. STNA #117 verified the large amounts of cigarette butts throughout the courtyard. Interview on 03/06/23 at 3:45 P.M. with STNA #117 verified she lit cigarettes for residents inside the facility, prior to the resident exiting the facility. She added, all staff do this. Interview on 03/09/23 at 10:11 A.M. with the Administrator revealed he conducted walking observations numerous times throughout the day when at the facility, twice a week. The Administrator stated he was unaware staff were lighting cigarettes inside the building. He stated a resident knocked over a receptacle and spilled the cigarette butts and indicated staff cleaned the area yesterday. Observation on 03/09/23 at 10:20 A.M. of the patio courtyard area where the residents smoke, revealed cigarette butts lying in the mulch, in the grass, and on the cement area. Some of the butts appeared to be falling apart and discolored from excess moisture. Review of the, Tranquility of [NAME] Smoking Contract, revealed smoking was not permitted inside the facility. 2. Review of the medical record revealed Resident #11 was admitted on [DATE]. Diagnoses included heart failure, high blood pressure, and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of the physician order dated 11/17/22, revealed Resident #11 may have one alcoholic beverage, daily every 24 hours as needed. Review of the care plan updated 11/17/22 revealed Resident #11 was care planned to have one alcoholic beverage per day. Observation on 03/06/23 at 11:17 A.M. revealed a liquor bottle of Kahlua on the floor by the resident's bedside. Interview on 03/07/23 at 1:25 P.M. with Licensed Practical Nurse (LPN) #110 verified a 750 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 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 366234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Nursing Center of Rockford 201 Buckeye Street Rockford, OH 45882 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 milliliter (ml) bottle of Kahlua on the floor by Resident #11's bedside. The liquor bottle was open but mostly full with about 2.5 to 3 inches missing from the top. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 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 366234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Nursing Center of Rockford 201 Buckeye Street Rockford, OH 45882 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 0741 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. Based on medical record review, employee file review, and staff interview, the facility failed to complete Behavioral Health training upon hire for new employees. This affected two State Tested Nurse Aides (STNAs #106 and #117) of four STNAs review for Behavioral Health training. Additionally, this affected four (Residents #2, #5, #20, and #1) of four residents reviewed for mental health diagnoses. The facility identified 16 residents with mental health diagnoses (Residents #1, #6, #2, #5, #12, #123, #18, #15, #7, #174, #3, #11, #20, #175, #8, and #10). The facility's census was 19. Findings include: Review of the medical record for Resident #2 revealed an admission date of 03/11/2020 with medical diagnoses of schizoaffective disorder and paranoid schizophrenia. Review of the medical record for Resident #5 revealed an admission date of 04/29/21 with medical diagnoses of schizophrenia, bipolar disorder, and depression. Review of the medical record for Resident #20 revealed an admission date of 12/13/22 with medical diagnoses of post traumatic stress disorder (PTSD), anxiety, hallucinations, depression, schizoaffective disorder, and insomnia. Review of the medical record for Resident #1 revealed an admission date of 07/02/21 with medication diagnoses of schizophrenia, depression, and psychosis. Review of the employee file for STNA #106 revealed a hire date of 11/23/22. Further review revealed no did not documentation to support STNA #106 received specialty care training for residents with mental health. Review of the employee file for STNA #117 revealed a hire date of 12/07/22. Further review revealed no did not documentation to support STNA #117 received specialty care training for residents with mental health. Interview on 03/09/23 at 11:30 A.M. with Business Office Assistant #146 confirmed STNAs #106 and #117) did not receive specialty care training for residents with mental health. Interview on 03/09/23 at 3:30 P.M. with the Director of Nursing (DON) confirmed all but three (Residents #4, #14, and #19) out of the 19 residents in the facility had psychiatric diagnoses. Review of the policy titled, Behavioral Health Services, stated all facility staff, including contracted staff and volunteers, shall receive education to ensure appropriate competencies and skill sets for meeting the behavioral health needs of the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 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 366234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Nursing Center of Rockford 201 Buckeye Street Rockford, OH 45882 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** 3. Review of the medical record of Resident #10 revealed an admission date of 06/29/22. Diagnoses included heart failure, anxiety disorder, major depressive disorder, bipolar type schizoaffective disorder, and type II diabetes mellitus. Review of the MDS assessment dated [DATE] revealed Resident #10 was cognitively intact. Further review of the medical record revealed no documentation to support the pharmacy completed a monthly medication regimen review for July 2022 and August 2022. Interview on 03/07/23 at 2:37 P.M. with the DON revealed the facility had no pharmacy reviews for the months of July 2022 and August 2022. Review of the facility policy titled, Medication Regimen Review, undated, revealed the drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart. Based on record review, staff interview, and policy review, the facility failed to complete monthly medication regimen reviews. This affected three (Residents #02 #05, and #10) of five residents reviewed for medication regimen reviews. The facility census was 19. Findings include: 1. Review of the medical record for Resident #02 revealed an admission date of 03/11/20 with medical diagnoses of schizoaffective disorder, paranoid schizophrenia, and extrapyramidal and movement disorder. Review of the Minimum Data Set (MDS) dated [DATE] indicated Resident #02 was cognitively intact. Resident #02 required supervision with bed mobility, transfers, eating, and ambulation. Resident #02 required limited assistance with toileting and extensive assistance with bathing. Further review of the medical record revealed no documentation to support the pharmacy completed a monthly medication regimen review for 05/2022, 06/2022, 07/2022, and 08/2022. 2. Review of the medical record for Resident #05 revealed an admission date of 04/29/21 with medical diagnoses of left sided hemiplegia, schizophrenia, unspecified, history of cerebral infarction due to thrombosis, bipolar disorder, major Depression, diabetes mellitus (DM), and morbid obesity. Review of the Minimum Data Set (MDS) dated [DATE] indicated Resident #05 had moderate cognitive impairment. Resident #05 required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. Resident #05 was dependent upon staff for transfers and bathing and was non-ambulatory. Further review of the medical record revealed no documentation to support the pharmacy completed a monthly medication regimen review for 05/2022, 06/2022, and 07/2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 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 366234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Nursing Center of Rockford 201 Buckeye Street Rockford, OH 45882 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 Interview on 03/08//21 at 3:31 P.M. with the Director of Nursing (DON) confirmed the facility did not have documentation to support pharmacy medication regimen reviews were completed for Residents #02 and #05 monthly. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 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 366234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Nursing Center of Rockford 201 Buckeye Street Rockford, OH 45882 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure medications were stored properly. This affected one (Resident #19) of one resident reviewed for medications left at bedside. The facility's census was 19. Findings include: Review of the medical record for Resident #19 revealed an admission date of 12/12/22 with medication diagnoses of chronic obstructive pulmonary disease (COPD), pneumonia, anemia, and hypertension. Review of the Minimum Data Set (MDS) dated [DATE] indicated Resident #19 was cognitively intact. Resident #19 required supervision with bed mobility, transfers, ambulation, and toileting. Review of Resident #19's physician orders revealed an order dated 12/30/22 for guaifensin (Mucinex) extended release 600 milligram (mg) tablet one tablet daily by mouth and an order dated 01/07/23 for acetaminophen (Tylenol) 500 mg two tablets by mouth three times per day. Review of the medication self-administration safety screen dated 12/12/22 revealed Resident #19 was not safe to self-administer medications. Observation and interview on 03/06/23 at 9:00 A.M. with Resident #19 revealed three medications sitting on his bedside table, with no nurse present in the room. Resident #19 stated the medications on the table was his Mucinex, that the nurse left for him to take after he goes out to smoke, and he believed the other two medications was his Tylenol, but he was not sure. Interview on 03/06/23 at 9:19 A.M. with Licensed Practical Nurse (LPN) #124 confirmed Resident #19 had one guaifenesin medication and two acetaminophen pills sitting on his bedside table. LPN #124 stated Resident #19 preferred to take the guaifenesin medication after he smoked, so LPN #124 left the medication with Resident #19. LPN #124 stated she did not leave the acetaminophen with Resident #19 during the morning medication pass and was not sure how long the acetaminophen was on the bedside table. Review of the policy titled, Medication Administration, stated medications are to be administered by licensed nursing, or other staff who are legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy stated the licensed nurse is to observe the consumption of medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 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 366234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Nursing Center of Rockford 201 Buckeye Street Rockford, OH 45882 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a facility list of residents identified as smokers, review of the facility assessment, staff interview, and review of facility policy, the facility failed to identify smoking residents. Additionally, the facility assessment failed to address the facility's smoking population's needs. This had the potential to affect eight (Residents #2, #3, #6, #10, #11, #12, #14, and #19) identified by the facility as smoking residents. The facility's census was 19. Findings include: Review of a facility provided list of residents identified as smokers, revealed eight residents (#2, #3, #6, #10, #11, #12, #14, and #19) smoked out of the 19 residents residing in the facility, equaling 42 percent (%) of the facility population. Review of the facility assessment dated [DATE] revealed the assessment did not identify the facility's resident smoking population, nor did it identify needed services and care for smoking residents. Further review revealed the assessment indicated the facility would provide person-centered, directed care for psycho, social or spiritual support. The specific care or practices listed included to support helpful coping mechanisms. Interview on 03/08/23 at 3:00 P.M. the Administrator and Director of Nursing (DON) claimed the facility assessment covered smokers under the, Support helpful coping mechanisms, section. However, further review of the assessment revealed the smoking population was not addressed anywhere in the assessment. Interview on 03/09/23 at 3:30 P.M. with the DON revealed 42% of the facility's population were identified as smoking residents, which was a high amount. Review of the facility policy titled, Facility Assessment, reviewed 10/21/22 revealed the facility would conduct a facility-wide assessment to determine what resources are necessary to care for residents. The facility assessment will include the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity and other pertinent facts that are present within the population. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 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 366234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Nursing Center of Rockford 201 Buckeye Street Rockford, OH 45882 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 the facility's water management program information, staff interview, review of the Centers for Disease Control (CDC) guidance, and review of facility policy, the facility failed to have an appropriate Legionella water management program in place. This had the potential to affect all 19 residents in the facility. Residents Affected - Many Findings include: Review of the facility's Legionella environmental assessment form dated 05/26/22 revealed the assessment was not fully completed and did not include all the required components. Further review revealed the facility did not complete a map/flow diagram of the facility and/or water temperature monitoring. Interview on 03/09/23 at approximately 1:50 P.M. with Maintenance Staff #128 revealed she had been working in the maintenance position since the end of November 2022. Maintenance Staff #128 admitted she was unaware what the requirements were for the water management program and verified she had yet to do anything regarding water management related to Legionella, including monitoring of water temperatures. Review of the undated CDC guidance titled, Overview of Water Management Programs, revealed water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. Seven key elements of a Legionella water management program are to: • Establish a water management program team • Describe the building water systems using text and flow diagrams • Burden of Waterborne Disease • Read about various illnesses, including Legionnaires' disease, in CDC's first estimates of the impact of waterborne disease in the United States. • Identify areas where Legionella could grow and spread • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 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 366234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Nursing Center of Rockford 201 Buckeye Street Rockford, OH 45882 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 Decide where control measures should be applied and how to monitor them Level of Harm - Minimal harm or potential for actual harm • Establish ways to intervene when control limits are not met Residents Affected - Many • Make sure the program is running as designed (verification) and is effective (validation) • Document and communicate all the activities Review of the facility's policy, Legionella Surveillance, undated, verified Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 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 366234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Nursing Center of Rockford 201 Buckeye Street Rockford, OH 45882 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the Centers for Disease Control and Prevention (CDC) guidance for Coronavirus 2019 (COVID-19) vaccination and boosters, the facility failed to ensure residents were offered COVID-19 vaccines in a timely manner. This affected five (Residents #3, #6, #5, #8, and #11) of five residents reviewed for COVID-19 vaccination. This also had the potential to affect all residents residing in the facility. The facility census was 19. Findings include: 1. Review of the medical record revealed Resident #3 was admitted on [DATE]. Diagnoses included type two diabetes mellitus, borderline personality disorder, schizophrenia, hyperlipidemia, essential (primary) hypertension, nicotine dependence, major depressive disorder, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of COVID-19 vaccine documentation dated 11/04/21 revealed Resident #3's responsible party declined the COVID-19 vaccine on 11/04/21. Further review of the medical record revealed there was no additional documentation showing the resident was offered the COVID-19 vaccine since 11/03/21. 2. Review of the medical record revealed Resident #6 was admitted on [DATE] and readmitted on [DATE]. Diagnoses included unspecified convulsions, nicotine dependence, schizophrenia, cerebral cysts, benign neoplasm of brain, dementia, bipolar, and epilepsy. Review of the MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired. Review of COVID-19 vaccine documentation, dated 11/04/21, revealed Resident #6's responsible party declined the COVID-19 vaccine on 11/04/21. Further review of the medical record revealed there was no additional documentation showing the resident was offered the COVID-19 vaccine since 11/04/21. 3. Review of the medical record revealed Resident #5 was admitted on [DATE]. Diagnoses included schizophrenia, cerebral infarction, cerebrovascular disease, bipolar disorder, hyperlipidemia, type two diabetes mellitus, and essential primary hypertension. Review of the MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired. Review of the immunization record revealed Resident #5 last received the COVID-19 vaccine booster Moderna 07/14/22. Further review of the medical record revealed no additional documentation showing the resident was offered an updated COVID-19 booster from 07/14/22 to March 2023. 4. Review of the medical record revealed Resident #8 was initially admitted on [DATE] with re-entry on 10/21/21. Diagnoses included Parkinson's, major depressive disorder, essential primary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 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 366234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Nursing Center of Rockford 201 Buckeye Street Rockford, OH 45882 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 0887 hypertension, restless leg syndrome, psychotic disorder with hallucinations, and schizoaffective disorder. Level of Harm - Minimal harm or potential for actual harm Review of the MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired. Residents Affected - Some Review of the immunization record revealed Resident #5 last received the COVID-19 vaccine booster Moderna 07/14/22. Further review of the medical record revealed no additional documentation showing the resident was offered an updated COVID-19 booster from 07/14/22 to March 2023. 5. Review of the medical record revealed Resident #11 was admitted on [DATE]. Diagnoses included heart failure, high blood pressure, and chronic kidney disease. Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact. Review of the immunization record revealed Resident #5 last received the COVID-19 vaccine booster Moderna 07/14/22. Further review of the medical record revealed no additional documentation showing the resident was offered an updated COVID-19 booster from 07/14/22 to March 2023. Interview on 03/08/23 at 1:50 P.M. with the Director of Nursing (DON) verified the facility had not offered COVID-19 booster vaccines to current residents. Interview on 03/09/23 at 9:05 A.M. with the DON verified Resident #3 and #6 had not been re-offered the COVID-19 vaccine since 11/04/21. Review of the CDC guidance titled, Stay Up to Date with COVID-19 Vaccines Including Boosters, dated 03/02/23 revealed the CDC recommended people stay up to date with the COVID-19 vaccine for their age group. The CDC recommends one updated vaccine for everyone 5 years and older. Updated boosters are called updated because they protect against both the original virus that causes COVID-19 and the Omicron variant. Two COVID-19 vaccine manufacturers, Pfizer and Moderna, have developed updated COVID-19 boosters. Updated COVID-19 boosters became available on 09/22/22 for people aged 12 years and older. Review of the facility policy, COVID-19 Vaccination, dated 09/28/22 verified it is the policy of the facility, in collaboration with the medical director, to have an immunization program against COVID-19 disease in accordance with national standards of practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 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 366234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Nursing Center of Rockford 201 Buckeye Street Rockford, OH 45882 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, and policy review, the facility failed to provide a resident with a functioning call light. This affected one (Resident #05) resident of 19 residents reviewed for functioning call lights. The facility census was 19. Residents Affected - Few Findings include: Review of the medical record for Resident #05 revealed an admission date of 04/29/21 with medical diagnoses of left sided hemiplegia, schizophrenia, unspecified, history of cerebral infarction due to thrombosis, bipolar disorder, major Depression, diabetes mellitus (DM), and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #05 had moderate cognitive impairment. Resident #05 required extensive assistance with bed mobility, dressing, toileting, and personal hygiene, and was dependent upon staff for transfers and bathing and was non-ambulatory. Observation on 03/06/23 at 9:00 A.M. revealed Resident #05 lying in bed with no call light within reach. Further observation revealed the call light box, located on the wall in the center of the room behind of resident's bed, did not have a call light cord or string attached to the call light box for the resident to use to turn on the call light system. Interview on 03/06/23 at 9:05 A.M. with Resident #05 confirmed she did not have access to a call light. Resident #05 stated she would have to yell out from her bed if she needed assistance or her roommate would get a staff member for her. Resident #05 stated she was unsure of how long she had gone without access to a call light when she was in bed or in her wheelchair. Interview on 03/06/23 at 9:45 A.M. with State Tested Nursing Assistant (STNA) #136 confirmed Resident #05 did not have a string or cord attached to the call light box to allow Resident #05 to call for assistance when in bed or in her wheelchair. Interview on 03/07/23 at 8:45 A.M. with Maintenance Staff #128 confirmed Resident #05 did not have access to the call light system in her room. Maintenance Staff #128 confirmed there was no cord or string attached to the call light box for the resident to use in order to turn on the call light system. Review of the policy titled, Call Lights: Accessibility and Timely Response, stated the facility is to adequately be equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. The policy continued to state the staff would ensure the call light was within reach of resident and secured, as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366234 If continuation sheet Page 18 of 18