Inspection·April 21, 2021

F 0604 Level of Harm - Minimal harm or potential for actual harm Practical Nurse (LPN) #21 confirmed this observation and reported she would have to check the resident's orders and care plan to verify if the resident was to have the alarm while in the recliner. LPN #21 and Assistant Director of Nursing (ADON) #18 confirmed the tab alarm was only ordered and care planned for when the resident was in bed. The ADON reported she would remove alarm and educate staff. Residents Affected - Few Interview on 04/14/21 at 1:15 P.M. with the Director of Nursing (DON) verified there was no restraint assessment completed for the resident's tab alarm. The DON reported she felt the pull tab alarm was appropriate at the time of the fall for the resident's safety, however not all interventions were exhausted prior to using the tab alarm. On 04/14/21 at 2:40 P.M., Resident #16 was sitting in a wheelchair in the common area near the nurse's station. The resident had a pull tab alarm fastened to the back of her shirt. The resident asked the surveyor if she could take her to the bathroom because she could not stand up alone with that thing, referring to the pull tab alarm. ADON #18 was observed in the hallway and the surveyor reported the resident's needs to the ADON. The ADON assisted the resident back to her room. Interview on 04/15/21 at 10:10 A.M., with the DON and ADON #18 revealed Resident #16 did not have an order, plan of care, or assessment for the tab alarm to the chair. The order and care plan were only to have a tab alarm in place in bed. The ADON confirmed Resident #16 had the tab alarm on while she was up in her wheelchair yesterday even after it was identified earlier in the day as a concern. The DON reported she did not realize the staff were still utilizing the tab alarm in the chair after it was addressed earlier in the day yesterday. The DON was not aware the tab alarm was preventing the resident was standing while she was in a chair, however the tab alarm was never ordered or assessed to be used while the resident was in a chair. Review of the facility policy, Restraint use, dated 06/20/15, revealed the facility creates and maintains an environment that fosters minimal use of restraints. Alternatives to restraints to be used may include scheduled ambulation, diversional activities, scheduled exercise, use of a lounge chair, or positioning devices. No restraint would be used without a physician's order unless it was an extreme emergency to protect the resident from injury. The least restrictive restraint device would be used. A restraint assessment shall be used for the initial and ongoing assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366260 If continuation sheet Page 2 of 8 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 366260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claymont Health and Rehabilitation 5166 Spanson Drive SE Uhrichsville, OH 44683 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on interview and record review the facility failed to ensure all residents with decreased range of motion received appropriate services and equipment to improve mobility. This affected one (Resident #23) of two residents reviewed for special equipment. The census was 38. Findings included: Review of the medical record for Resident #23 revealed an admission date of 02/16/21. Diagnoses included cerebral infarction (stroke) due to venous thrombosis, left side hemiplegia (paralysis on one side of the body), obesity and anxiety. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 02/23/21, revealed the resident was alert, oriented and had intact cognition and used a wheelchair for locomotion. The Occupational Therapy (OT) evaluation and Plan of Treatment dated 03/05/21 indicated Resident #23 would demonstrate good postural and joint alignment and would not have signs and symptoms of decreased skin integrity or discomfort. Under the assessment summary, it indicated there was a functional limitation as result of posture related to left side hemiplegia. Under the wheelchair and equipment section it indicated the resident used a power wheelchair. Review of the therapy note dated 03/10/21 revealed they spoke with the wheelchair representative and he would be in tomorrow to assess Resident #23. Interview on 04/13/21 at 8:22 A.M. with Resident #23 revealed she wanted the facility to help assist her in getting an electric (power) wheelchair. Resident #23 stated therapy was going to have a wheelchair representative come in and fit her for a wheelchair but then was told she did not qualify for an electric wheelchair and she would have to wait until she went home. Resident #23 stated she did not understand why the facility could not assist in getting her an electric wheelchair prior to her going home to improve and assist with her mobility in the facility. Interview on 04/14/21 at 10:37 A.M. with Certified Occupational Therapy Assistant (COTA) #42 stated Resident #23 had requested an electric wheelchair on 03/05/21. COTA #42 stated she had started the process for Resident #23 to be fitted and receive an electric wheelchair. COTA #42 stated the paperwork was started and an appointment to see the wheelchair representative was scheduled for 03/11/21. COTA #42 stated after talking with the administration, Resident #23 was unable to get a electric wheelchair due to being respite and not going to be in the facility long term, she would have to wait to get a wheelchair until she was back out in the community. COTA #42 stated she had to tell Resident #23 that she did not qualify for an electric wheelchair and cancel the wheelchair representative. COTA #42 stated Resident #42 was upset with not being able to get an electric wheelchair. Interview on 04/14/21 at 11:01 A.M. with the Administrator stated it was not their policy to assist residents with motorize wheelchairs if they were leaving the facility after a short stay. Later at 12:36 P.M. the Administrator stated she did not realize Resident #23 was so upset about not getting assistance with getting a motorized wheelchair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366260 If continuation sheet Page 3 of 8 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 366260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claymont Health and Rehabilitation 5166 Spanson Drive SE Uhrichsville, OH 44683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to ensure meals were offered per orders. This affected two (Resident #14 and #15) of three reviewed for nutrition. The census was 38. Residents Affected - Few Findings include: 1. Resident #15 was originally admitted on [DATE] and re-admitted to the facility on [DATE] with diagnoses including end stage renal (kidney) disease, type two diabetes mellitus, and anemia. Review of Resident #15's current nutritional plan of care revealed on 03/26/20 double portion entrees were added and a sack lunch was to be sent with Resident #15 on dialysis days. Interventions included to provide his diet per orders. Review of Resident #15's current physician orders dated 04/2021 revealed the resident was ordered a regular, no added salt diet with double portions for all meals. Review of Resident #15's dietary note dated 04/07/21 revealed the resident was recently readmitted to the facility after a hospital admission. The note said the resident continued with hemodialysis three times a week at 5:30 A.M. and a sack lunch was sent by dietary. Resident #15 was ordered a regular, no salt added diet with double portions. The note said Resident #15 had a 12.5 pound weight loss in 30 days, however suspected the weight loss was related to fluid volume changes and decreased caloric intakes during previous inpatient hospital stay. This dietary note indicated dialysis staff agreed with these diet orders. Observation on 04/15/21 at 12:15 P.M. of Resident #15 revealed the resident did not receive double portions. Assisted Director of Nursing (ADON) #18 confirmed this observation and reported the kitchen usually sends two meal trays. ADON #18 checked the meal cart and verified there was no second meal tray for Resident #15. Interview on 04/19/21 at 10:46 A.M. with Resident #15 revealed he doesn't always get double portions with each meal. He reported on dialysis days he usually asks for two trays because when he returns, he was usually hungry. He said the facility forgets to send his sack lunch to dialysis or the lunch was not palatable. He said the water and pudding were usually warm, and the peanut butter and jelly sandwiches were soggy. He had requested a ham sandwich because he was tired of eating cheese sandwiches, however they never sent him ham. He had also requested the facility not to send crackers because he can't open the crackers, however they continue to send crackers in his packed lunch. Interview on 04/20/21 at 9:35 A.M., with the Director of Nursing (DON) revealed she was aware of Resident #15's concerns with staff not sending his packed lunch to dialysis and the issue with the crackers, however she thought those issues had been resolved. She said she was not aware of the soggy sandwiches and him not receiving double portions for all meals. 2. Review of the medical record for Resident #14 revealed an admission date of 03/27/13. Diagnoses included pyloric stenosis (a narrowing of esophagus) and dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/09/21, revealed the resident had impaired cognition and was on a mechanically altered diet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366260 If continuation sheet Page 4 of 8 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 366260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claymont Health and Rehabilitation 5166 Spanson Drive SE Uhrichsville, OH 44683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the quarterly dietary assessment note dated 02/09/21 revealed Resident #14 received a pureed diet and per the gastrointestinal (GI) doctor orders. Resident #14 was to have six small meals due to Resident #14 having a history of intermittent emesis at times and requiring frequent dilation procedures of the espohagus. Review of physician's orders for April 2021 revealed Resident #14 was ordered a regular diet, pureed texture, thin consistency liquids and six small meals per day (hot foods at breakfast, lunch and dinner and cold foods at 10:00 A.M., 2:00 P.M. and at bedtime). Observation on 04/12/21 at 11:45 A.M. of Resident #14's meal ticket revealed the resident was to have six small meals with hot foods at breakfast, lunch and dinner and cold foods at 10:00 A.M., 2:00 P.M. and at bedtime. Her lunch meal tray was observed with a bowl of puree chicken dumplings, a bowl of puree peas and a bowl of puree peaches. Resident #14 stated she did not receive meals between the regular meals and verified she did not get six small meals a day. Observation on 04/14/21 at 10:10 A.M. revealed Resident #14 sitting in her room. She was not eating and had no meal or food served to her. Observations on 04/14/21 at 1:39 P.M. and 2:43 P.M. revealed Resident #14 in her room without a small meal or evidence a meal had been served. Interview on 04/14/21 at 2:44 P.M. with State Tested Nurses Assistant (STNA) #22 stated the kitchen was to bring the extra meal trays to the nurse's station between regular meals for Resident #14. STNA #22 stated the kitchen does not always bring out a meal tray for Resident #14 and she would get her a pudding off the snack cart. STNA #22 verified the kitchen did not bring a meal tray to Resident #14 at 10:00 A.M. or 2:00 P.M. this day. Interview on 04/14/21 at 2:53 P.M. with Registered Dietitian (RD) #43 verified Resident #14's hot items should be given at meals and at 10:00 A.M., 2:00 P.M. and 6:00 P.M. Resident #14 should be served her cold items and she should receive two to three items. RD #43 verified a pudding cup is not enough for an extra meal. RD #43 said the extra meal tray were to be brought out to the nurses, so they can alert the aides the meal had arrived. Interview on 04/14/21 at 4:00 P.M. with Dietary Manager #7 verified she was the cook for the week and said she had not sent out any extra meals for Resident #14. Dietary Manager #7 verified Resident #14 was to have six small meals a day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366260 If continuation sheet Page 5 of 8 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 366260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claymont Health and Rehabilitation 5166 Spanson Drive SE Uhrichsville, OH 44683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure blood pressure medications were administered per physician ordered parameters. This affected two (Resident #10 and Resident #15) of five residents reviewed for unnecessary medication. The census was 38. Residents Affected - Few Findings included: 1. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, heart failure, hypertension (high blood pressure), and coronary artery disease. Review of medication administration records (MAR) and physician orders dated 03/01/21 to 04/15/21 revealed Resident #10 was ordered hydralazine 25 milligrams (mg) twice daily for hypertension. There was an additional order directing nursing staff to hold the medication if the systolic blood pressure (SBP) was less than 140. The MAR revealed Resident #10 received hydralazine in error 12 times when her SBP was less than 140. On 03/04/21 the SBP was 132, on 04/06/21 the SBP was 135, on 03/08/21 the SBP was 131, on 03/12/21 the SBP was 130, on 03/17/21 the SBP was 126, on 03/26/21 the SBP 131, on 03/30/21 the SBP was written incompletely as 12, on 04/10/21 the morning SBP was 112, on 04/10/21 the evening SBP was 118, on 04/11/21 the morning SBP was 122, on 04/11/21 the evening SBP was 122, and on 04/15/21 the SBP was 138. Interview on 04/20/21 at 9:35 A.M. with the Director of Nursing (DON) verified the above findings. The DON reported she could not find any documentation to verify the hydralazine was held on the dates noted above when the SBP was less than 140. 2. Resident #15 was originally admitted on [DATE] and re-admitted to the facility on [DATE] with diagnoses including end stage renal (kidney) disease, hypertension, chronic combined systolic and diastolic heart failure, and coronary artery disease. Review of Resident #15's MAR's, blood pressure readings, and physician orders dated 03/15/21 to 04/15/21 with Registered Nurse (RN) #26 on 04/20/21 at 12:14 P.M. revealed the following: A. Resident #15 was ordered hydralazine 50 mg one tablet three times daily for hypertension. The medication was to be held if the BP was less than 120/80. On 03/15/21 the BP was less than 120/80 for the upon rising dose (145/78), lunch dose (140/59), and bedtime (128/68) and the medication was administered. On 03/16/21, Resident #15's blood pressure was less than 120/80 for the lunch dose (155/73) and bedtime dose (120/59) and the medication was documented as administered. On 03/17/21 the bedtime medication was administered and there was no evidence the blood pressure was checked. On 03/18/21 the bedtime blood pressure (130/75) was less than 120/80 and the medication was documented as administered. On 03/19/21 the resident's upon rising blood pressure (121/61) was less than 120/80 and the medication was documented as administered. On 04/07/21 the parameters were changed to hold the hydralazine medication if the SBP (top number of blood pressure reading) was less than 100. There was no evidence the resident's blood pressure was checked prior to administration of the hydralazine medication on 04/08/21, 04/09/21, and 04/11/21 for the lunch dose and on 04/10/21 for the bedtime dose. B. On 04/07/21, Resident #15 was ordered clonidine 0.2 mg one tablet twice daily for hypertension and nurses were directed to hold the medication if the SBP was less than 140. The MAR indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366260 If continuation sheet Page 6 of 8 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 366260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claymont Health and Rehabilitation 5166 Spanson Drive SE Uhrichsville, OH 44683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #15 received the clonidine at bedtime on 04/10/21 when his SBP was 128, the upon rising dose was administered on 04/11/21 when the SBP was 134 and the betimes dose was administered on 04/11/21 when the SBP was 124. C. Resident #15 was ordered Norvasc 10 mg one tablet daily for hypertension and it was to be held if the BP was less than 120/80. Resident #15 received the Norvasc on 03/15/21 when the blood pressure was 140/59 and on 03/18/21 when the blood pressure was 130/75. RN #26 confirmed the blood pressure medications were given at times when it should have been held according to the parameters ordered by the physician and medications were administered with checking the BP first to ensure the BP met the parameters prior to the medication administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366260 If continuation sheet Page 7 of 8 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 366260 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Claymont Health and Rehabilitation 5166 Spanson Drive SE Uhrichsville, OH 44683 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #16 received the pneumococcal immunization per request. This affected one of four residents reviewed for immunizations. The census was 38. Residents Affected - Few Findings included: Medical record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, anxiety, major depression disorder, arthritis, chronic kidney disease, and heart disease. Review of Resident #16 pneumococcal immunization consent dated 03/27/20 revealed Resident #16's daughter had signed consents for both the pneumococcal 13 and 23 vaccines to be administered. Review of Resident #16's immunization records revealed on 08/21/20 the resident's daughter had called and stated the resident had received the Prevnar 13 vaccine at her doctor's office on 01/16/17. Further review revealed no evidence the pneumococcal 23 was administered. Interview on 04/20/21 at 9:35 A.M., Assistant Director of Nursing (ADON) #18 reported Resident #18's pneumococcal 23 vaccine was missed. She verified the daughter had originally signed both consents and then contacted the doctor's office to make sure her mother had not already had the vaccines. ADON #18 said the daughter called back and spoke to another nurse; however, the message was not forwarded to her. The ADON reported she called Resident #16's daughter last night (04/19/21) and the physician and they both wanted the resident to have the pneumococcal 23. The vaccine was ordered and would be administered as soon as it arrived. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366260 If continuation sheet Page 8 of 8