Health inspection·October 4, 2021

F 0676 quarterly MDS 3.0 assessment dated [DATE]. Level of Harm - Actual harm Review of the Task List dated 09/04/21 through 10/02/21 revealed Resident #16 was dependent on staff for transfers on six of six opportunities, dependent on staff for dressing 55 of 59 opportunities, dependent on staff for personal hygiene 49 of 59 opportunities and dependent on staff for toileting 51 of 57 opportunities. Residents Affected - Few On 09/28/21 at 12:50 P.M. and 09/29/21 between 9:50 A.M. and 10:06 A.M. Resident #16 was observed laying in bed. Interview with the resident at the time of the observation revealed concerns that the staff did not get her out of bed, she required help from staff now to perform ADL's and she was not receiving any restorative or therapy services. Review of the resident's medical record, including a review of the physician's orders, dated 09/30/21 revealed no evidence of a restorative nursing program or therapy services to restore the resident to her previous ADL functional levels. Review of the [NAME] dated 09/30/21 revealed no evidence Resident #16 was receiving restorative or therapy services to restore previous transfer, toileting, dressing and personal hygiene functional levels. The resident was to use a bedside commode with a back for toileting; however, no bedside commode was observed in her room. On 09/30/21 at 2:38 P.M. interview with Registered Nurse #123 verified therapy did not screen Resident #16 after her decline in ADL's and no therapy or restorative nursing programs had been implemented to prevent the identified decline or promote increased function/independence for the resident. On 09/30/21 at 3:13 P.M., interview with Occupational Therapist Assistant (OTA) #900 revealed facility staff update the therapy director about changes in resident ADL status either by writing it up but mostly by catching him in the hallway and asking therapy to screen a resident who has had a decline. OTA #900 revealed if he thought a resident didn't need therapy after a therapy screen, they would not do evaluation for therapy. OTA #900 revealed she also believed the physician was involved in the process as well. OTA #900 revealed OT works with residents who decline in continence including recommendations for a toileting program with exercising strengthening for female residents. OTA #900 was not aware of a decline for Resident #16. On 09/30/21 at 3:57 P.M. interview with State Tested Nursing Assistant (STNA) #144 revealed she routinely worked with Resident #16 and had noticed the resident's decline in ADL's over the last several months. Since the decline, the STNA staff no longer try to get the resident up with the sit-to-stand lift because Resident #16 tended to lean to the side, her knees drop and they do not feel safe using it so now all transfers were with a Hoyer lift. STNA #144 also revealed the resident had become dependent on staff for most of her ADL's, she was not receiving restorative that she was aware of and thought therapy had picked the resident up after she had first declined. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 2 of 17 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #30's medical record revealed an admission date of 10/09/20 with diagnoses including depression and hypertension. Residents Affected - Few Review of the nursing admission assessment dated [DATE] revealed the resident had a hearing impairment and wore a hearing aid to the left ear. Review of the physician's orders, dated 10/30/20 revealed to check the function of bilateral hearing aids every day shift on Friday and change the batteries as needed. Review of the consults offered as needed for vision, dental, podiatry and audiology plan of care initiated 03/24/21 revealed interventions including social services would work with the resident and staff offering consults per need to meet his needs. On 04/19/21 the resident's ears were cleaned by visiting audiology and referred to audiologist for hearing and hearing aid check. On 09/23/21 the resident was seen by audiology, the resident refused hearing aids per discussion with the audiologist at that time. No other care plans related to the resident's hearing were contained in the medical record. Review of the Audiology Visit Note dated 04/19/21 revealed the patient plan would be for a recommendation for an audiology referral if the patient, family, physician and/or facility wished to pursue audiology services. Review of the social service progress note dated 04/19/21 revealed the resident was seen by the visiting audiology this date to have his ears cleaned. The resident would be referred to have the audiologist follow-up with a consult for the resident's hearing and to check his hearing aid. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/30/21 revealed the resident had moderate cognitive impairment and was independent with bed mobility, transfers, eating and toilet use. The resident required extensive assistance of one staff member with dressing and limited assistance of one staff member with personal hygiene. The resident had moderate hearing difficulty with or without hearing aids. Review of the Treatment Administration Record (TAR) for September 2021 revealed the resident's bilateral hearing aids were checked for function every day shift on Fridays. Review of the Audiology Visit note, dated 09/02/21 revealed moderate to profound mixed hearing loss. The benefits and limitations of hearing aids were discussed but the patient decided not to pursue hearing aids at this time. A recommendation to follow up with an ENT was recommended due to the resident's hearing loss. Review of the nurse progress note, dated 09/03/21 revealed the visiting audiologist performed a hearing test on 09/02/21 and the resident continued to wear his existing hearing aids. Further review of the medical record revealed no mention of an ENT appointment was scheduled. On 09/27/21 at 11:25 A.M. an interview with Resident #30 was attempted however, due to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 3 of 17 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 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 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's hearing loss, not wearing his hearing aids and the surveyor wearing a mask, the resident was unable to have a conversation with the surveyor. On 09/30/21 at 10:00 A.M. interview with Licensed Practical Nurse (LPN) #151 revealed the resident wore bilateral hearing aids kept in his room, in a drawer. The LPN indicated the resident does have hearing loss but he was able to understand the staff with verbal communication. On 09/30/21 at 10:08 A.M. a follow-up interview was attempted with the resident. He verified he was not wearing the hearing aid to his right ear and stated it needed a new battery which he had not yet installed. The surveyor attempted to communicate with the resident through note writing but, but due to the resident's recent eye surgery, he was unable to see the notes on the notebook. The resident stated he currently only had one hearing aid which he stated was for his right ear. The resident denied the surveyor permission to see his hearing aid(s). On 09/30/21 at 10:10 A.M. interview with State Tested Nursing Assistant (STNA) #144 revealed the resident was a night shift assist with dressing and bathing and staff were to assist him with wearing his hearing aids and putting the hearing aids in. Further interview revealed she wasn't sure if the resident had one or two hearing aids but if he doesn't have them (the hearing aid(s)) in, she offers for him to wear them as it sometimes helps him to hear better. On 09/30/21 at 2:50 P.M. interview with Social Services Designee (SSD) #138 verified the resident had hearing aids but the audiologist recommendation made during the September 2021 visit to follow with an ears, nose and throat (ENT) physician was not addressed and had not been scheduled until the issue was identified on 09/30/21. The SSD verified she was responsible to follow-up with consultation notes from visiting vendors for services rendered in the facility. The SSD stated an appointment with an ENT was scheduled for 10/15/21. On 09/30/21 at 2:54 P.M. interview with LPN #126 verified the resident did not have documentation in the care plan or STNA task/[NAME] regarding if the resident had one or two hearing aides. Further interview revealed the resident was admitted with two hearing aides and staff providing care to the resident should be able to state the amount of adaptive equipment the resident used or be able to look at the care plan and determine the amount and type of adaptive equipment the resident uses. Lastly, the LPN stated it should be clear in the medical record if the resident had one or two hearing aids. On 09/30/21 at 5:00 P.M. interview with Registered Nurse #123 verified the resident had a need for a hearing/hearing aid care plan but one was not created for the resident even though the need was identified through the comprehensive assessment when the resident was admitted to the facility on [DATE]. Based on observation, record review and interview the facility failed to ensure the adequate use of hearing aid devices and/or ensure assistive devices (communication devices) were available for resident use to promote optimal hearing. The facility also failed to complete comprehensive assessments and/or develop a comprehensive and individualized care plans related to hearing deficit and ensure an ear nose throat (ENT) referral was completed timely for Resident #30. This affected two residents (#12 and #30) of two residents reviewed for communication-sensory. Findings include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 4 of 17 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 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 0685 Level of Harm - Minimal harm or potential for actual harm 1. Medical record review revealed Resident #12 was admitted on [DATE] with diagnoses including heart disease and hard of hearing (HOH). Review of admission 5-day Minimum Data Set (MDS) 3.0 assessment, dated 07/08/21 revealed Resident #12 had minimal hearing difficulty with hearing aids. Residents Affected - Few Review of the care plan titled Communication Problem related to hearing deficit, dated 07/14/21 revealed a goal to make basic needs known on a daily basis through 10/19/2021. Interventions included to use bilateral hearing aids, check function/placement, use alternative communication tools as needed and monitor effectiveness of communication strategies and assistive devices. Review of the physician's orders, dated September 2021 revealed Resident #12 wore bilateral hearing aids and functioning/placement was to be checked every shift. Review of the record revealed no documented evidence of a comprehensive ear or hearing assessment. Review of the [NAME] dated 09/27/21 revealed no evidence of hearing aids, communication strategies or other assistive devices. On 09/27/21 at 2:28 P.M. during an observation, an attempted interview with the resident revealed the resident was very HOH. Resident #12 stated she had a hearing aid in the left ear but was unable to hear the question and unable to state if the hearing aid was functional. No hearing aid was observed in the right ear. On 09/28/21 at 12:50 P.M. Resident #12 stated staff had replaced her hearing aid battery and she was able to hear. On 09/28/21 at 2:41 P.M. interview with Registered Nurse #123 verified there was no hearing assistive devices or communication strategies listed on the resident's [NAME] for staff to utilize. On 09/29/21 between 9:50 A.M. and 10:06 A.M. Resident #12 was observed in her room and stated it was difficult to hear what the surveyor was asking her. Resident #12 was observed wearing bilateral hearing aids and stated the right hearing aid needed the battery changed. No paper, pen or other communication tools were observed in the resident's room. On 09/29/21 at 12:15 P.M. interview with Licensed Practical Nurse (LPN) #151 revealed nursing staff were responsible for the care of resident hearing aids (HA), ensuring the hearing aids were functioning properly and in place. LPN #151 revealed she had replaced Resident #12's batteries three days earlier and her hearing aids should be functioning. At 12:19 P.M., LPN #151 entered Resident #12's room, wearing a face mask, and began speaking to the resident. Resident #12 looked at the nurse and said I cannot hear you. LPN #151 asked if she could look at the resident's hearing aid and the resident again stated that she could not hear the nurse. Resident #12 revealed she was unable to tell what the nurse was saying without seeing her lips. Without using an alternative communication device, LPN #151 then removed the resident's hearing aid and the resident stated the battery needed changed. At that time, LPN #151 stated no, it just needs the volume increased and replaced the hearing aid. When asked if she could hear now, the resident did not respond. Resident #12 asked if the surveyor was a facility nurse and LPN #151 told the resident the surveyor was from the Department of Health. The resident stated again that she was still unable to hear the nurse. The surveyor at that time looked and no communication device, paper or pen were available for use. The surveyor wrote on a surveyor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 5 of 17 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 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 0685 Level of Harm - Minimal harm or potential for actual harm note who she worked for and showed the resident who stated oh, the health department. LPN #151 then left the room. On 09/29/21 between 12:42 P.M. and 12:50 P.M. interview with Registered Nurse (RN) #123 verified the resident was HOH with no communication devices specified and none available for use. Residents Affected - Few On 09/29/21 at 2:41 P.M. interview with RN #123 verified the resident had not had an audiologist or ear canal assessment and there were no hearing or communication interventions in place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 6 of 17 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure a timely smoking assessment and smoking care plan were completed for Resident #31. This affected one resident (#31) of three residents reviewed for accidents. The facility identified one resident who smoked. The facility census was 34. Findings include: Medical record review revealed Resident #31 was admitted on [DATE] with diagnoses including metastatic breast cancer. Review of the admission Evaluation with Baseline care plan, dated 05/31/21 revealed resident did not smoke. Review of the physician's order, dated 06/01/21 revealed to apply a Nicotine Patch 24 Hour 7 MG/24 HR transdermal one time a day for smoking cessation. The transdermal patch was discontinued on 06/05/21. Review of the care plan titled Smoker Cessation, dated 06/04/21 revealed Resident #31 was a heavy smoker now under going smoker cessation. The goal was the resident would have no desire to smoke through the next review. Interventions included a nicotine patch transdermally one time a day. Review of the electronic Medication Administration Record (MAR) dated June 2021 revealed the Nicotine patch was applied on 06/02/21, refused on 06/03/21 and 06/04/21 and discontinued on 06/05/21. Review of the medical record revealed no evidence the resident was a smoker between 06/05/21 and 08/12/21. Review of the Smoking-Safety Screen, dated 08/12/21 revealed Resident #31 was assessed to be alert and oriented with no dexterity issues, was able to light cigarette with no difficulty and had safety awareness. Resident #31 was determined to be independent for smoking. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #31 was cognitively intact for daily decision-making. On 09/28/21 at 5:30 P.M., observation revealed Resident #31 was smoking outside in a designated area, staff were present and no concerns were identified. On 09/29/21 at 12:50 P.M. interview with Registered Nurse (RN) #123 verified Resident #31's smoking care plan was inaccurate. RN #123 revealed she was unaware the resident had started smoking again. RN #123 verified the resident's MAR indicated the nicotine patch was discontinued on 06/05/21. The resident stated she started smoking again after the patch was discontinued in June 2021. RN #123 verified the facility did not assess Resident #31 for smoking safety until 08/12/21 and the care plan was inaccurate. RN #123 also indicated Resident #31 was the only resident who smoked in the facility at this time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 7 of 17 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 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 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to provide care and services to maintain and/or restore bladder continence for Resident #16. Actual Harm occurred when Resident #16 was assessed to be a candidate for a scheduled toileting program that was not implemented and the resident declined from frequently to always incontinent of urine. This affected one resident (#16) of one resident reviewed for bladder incontinence. The facility identified 20 residents occasionally or frequently incontinent of bladder with five residents on urinary toileting programs. The facility census was 34. Findings include: Medical record review revealed Resident #16 was admitted on [DATE] with diagnoses including a malignant temporal lobe tumor (main functions of the temporal lobe in the brain includes understanding language, memory acquisition, face recognition, object recognition, perception and processing auditory information) and weakness. Review of the care plan titled Neurogenic bladder, dated 02/12/21 revealed the resident had timed voids. The resident must attempt to void every four hours and straight cath (catherization) as needed. Review of the care plan titled Functional Bladder Incontinence related to confusion and physical limitations, revised 03/08/21 revealed goals for the resident to be continent at all times through the review date and remain free from skin breakdown. Interventions included to monitor, document, report possible causes of incontinence and toilet the resident upon waking, before meals and at bedtime. Review of the Bowel and Bladder Program Screener, dated 04/25/21 revealed Resident #16 was a candidate for a scheduled toileting program. Review of the record revealed no evidence of a comprehensive bowel or bladder assessment after 04/25/21. Review of the progress note, dated 04/27/21 revealed Physician #500 was in to visit the resident and stated ok to start occupational and physical therapy mobility as tolerated. Resident #16 complained of frequent urination, burning with urination and incontinence at times. Review of the quarterly Interdisciplinary Historical Screen/Data Collection, dated 07/09/21 revealed the resident required max/dependent assistance (from staff) for toileting. No change in toileting or continence was noted and no referral for a therapy evaluation was completed. Review of the Bladder Task List dated 09/01/21 through 09/30/21 revealed Resident #16 was incontinent of bladder the entire month. There was no evidence the toileting program was completed per plan of care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 8 of 17 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 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 0690 Level of Harm - Actual harm On 09/30/21 at 1:55 P.M. interview with Registered Nurse #123 verified there was no comprehensive assessment of Resident #16's bowel and bladder after 04/25/21, a toileting program was not implemented as care planned and no interventions were implemented to restore bladder function for the resident who was identified to experience a decline in bladder function. Residents Affected - Few On 09/30/21 at 2:38 P.M. interview with Registered Nurse (RN) #123 verified when the (scheduled toileting) intervention was added it did not include the staff discipline: therefore, the order for a scheduled toileting program did not flow over to the [NAME] or administration records (MAR/TAR) to implement. Also, RN #123 verified therapy did not screen the resident after the identified decline in ADL care for transfers and toileting. On 09/30/21 at 3:03 P.M. interview with State Tested Nursing Assistant (STNA) #142 and at 3:07 P.M. interview with STNA #100 revealed both STNAs indicated they were made aware of a residents' level of assist needed by verbal report and referencing the [NAME]. Both STNAs indicated Resident #16 was checked every two hours for incontinence. The STNAs denied knowledge of any type of scheduled toileting program for the resident. On 09/30/21 at 3:13 P.M. interview with Occupational Therapist (OT) Assistant #900 revealed staff update the therapy director about changes in resident ADL status either by writing it up but mostly by catching him in the hallway and asking therapy to screen a resident who has had a decline. She stated if the therapist thought a resident didn't need therapy after the screen, they would not do an evaluation for therapy. She also believed the physician was involved in the process as well. She stated OT worked with residents for toileting if they go from being continent to incontinent. She stated they would do a bowel and bladder toileting program and they would do exercises to help with strengthening for females. On 09/30/21 at 3:57 P.M. interview with STNA #144 revealed she routinely works with Resident #16 and had noticed the resident was more incontinent of bladder, was not on an individualized toileting program but was checked every two hours for incontinence. Resident #16 was now unable to use the sit to stand lift and had to use the Hoyer lift for transfers. STNA #144 revealed it had been several months since the resident's decline was noted and had told the nurse. Since the decline the STNA staff no longer tried to get the resident up with the sit to stand lift because the resident tended to lean to the side, her knees drop and was not safe; therefore, the resident was now transferred with a Hoyer lift (mechanical lift). Review of the undated policy and procedure titled Bowel and Bladder Incontinence Management revealed the purpose was to identify, assess and provide appropriate treatment and services to achieve or maintain as much normal urinary function as possible to each incontinent resident without the use of an indwelling catheter unless there was a valid medical justification. The restorative nurse or designee was to complete a bowel and bladder incontinence assessment, determine appropriate interventions based on outcome of the assessment to enhance the resident's quality of life and functional status. Each resident would have an individualized care plan based on the goals, notify resident and responsible party would be involved in the development of the toileting program per the assessment. Staff were to implement care plan interventions. A bowel and bladder toileting program was to be individualized to each resident needs to promote or regain functional ability of bowel and bladder. Nursing and therapy as indicated would follow care plan interventions for toileting needs for overall improvement of urine and or bowel elimination. Evaluation of effectiveness of program was to be reviewed on a regular basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 9 of 17 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 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 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review revealed Resident #12 was admitted on [DATE] with diagnoses including heart disease, vitamin D deficiency, pain in the hip unspecified and weakness. Review of the physician admission History and Physical, dated 07/09/21 revealed the progress note was not transcribed until 09/29/21. Review of the Telemedicine Progress Note, dated 08/25/21 revealed the progress note was not transcribed to 09/30/21. Both the admission History and Physical and Telemedicine Progress Note were not available for review until requested by the surveyor. On 09/30/21 at 11:11 A.M., interview with LPN #150 verified the physician progress notes were not timely transcribed or available for review until requested by the surveyor. 4. Medical record review revealed Resident #16 was admitted on [DATE] with diagnoses including a temporal lobe tumor and weakness. Review of the Physician Progress Notes revealed the note dated 05/27/21 was not transcribed until 07/24/21, and the note dated 06/24/21 was not transcribed until 08/17/21. On 09/30/21 at 4:30 P.M. interview with LPN #126 verified the resident's physician progress notes were not trasncribed in a timely manner which resulted in important documentation being left of the resident's medical record to ensure a comprehensive approach to resident care and accurate/complete medical record was maintained. Review of the policy titled Nursing Communication for Continued Plan of Care of Resident dated January 2020 revealed the physician round sheet was placed in the 24-hour book on the day of visit with all orders and pertinent information. A copy of the Physician Rounds Sheet also shall be placed in the front of the 24-hour Communication Book. The facility did not have a policy regarding timeliness of transcription of physician progress as of 09/30/21 per Licensed Practical Nurse #126. Based on record review, facility policy and procedure review and interview the facility failed to ensure physician progress notes were timely transcribed and placed on the medical record to ensure a comprehensive approach to resident care and accurate/complete medical record was maintained. This affected four residents (#12, #16, #18 and #30) of 16 residents reviewed for comprehensive medical records. Findings include: 1. Review of Resident #18's medical record revealed an admisison date of 10/28/14 with diagnoses including dementia with Lewy Bodies and sarcoidosis of the lungs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 10 of 17 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 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 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/04/21 revealed the resident had severe cognitive impairment for daily decision making and required staff assistance with activities of daily living. Review of the physician progress notes revealed the resident was seen by the physician and a note was dictated on 04/28/21 but not transcribed until 05/27/21, 05/27/21 but not transcribed until 07/08/21 and 06/24/21 but not transcribed until 08/19/21. On 09/30/21 at 4:30 P.M. interview with Licensed Practical Nurse (LPN) #126 verified the resident's physician progress notes were not trasncribed in a timely manner which resulted in important documentation being left of the resident's medical record to ensure a comprehensive approach to resident care and accurate/complete medical record was maintained. 2. Review of Resident #30's medical record revealed an admission date of 10/09/20 with diagnoses including depression and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/30/21 revealed the resident had moderate cognitive impairment and was independent with bed mobility, transfers, eating and toilet use. The resident required extensive assistance of one staff member with dressing and limited assistance of one staff member with personal hygiene. The resident had moderate hearing difficulty with or without hearing aides. Review of the physician progress notes revealed the resident was seen on 04/28/21 with a note dictated but not transcribed until 05/31/21, 05/27/21 but the note was not transcribed until 07/12/21 and 06/24/21 but not transcribed until 08/19/21. On 09/30/21 at 4:30 P.M. interview with LPN #126 verified the resident's physician progress notes were not trasncribed in a timely manner which resulted in important documentation being left of the resident's medical record to ensure a comprehensive approach to resident care and accurate/complete medical record was maintained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 11 of 17 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 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. Based on record review, facility policy and procedure review and interview the facility failed to ensure resident specific rationale was provided for pharmacy reviews when the physician disagreed. This affected one resident (#10) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #10's medical record revealed an admission date of 03/11/14 with diagnoses including anxiety, depression and angina. Review of the physician orders revealed the resident had an order for Ativan (anti-anxiety medication) every 24 hours as needed for anxiety from 09/23/20 through 04/22/21. Review of the Note to Attending Physician/Prescriber, dated 11/26/20 revealed the resident was currently receiving Ativan 0.5 milligram (mg) daily as needed (prn). State and federal guidelines have been updated and include 14 day limits on prn psychotropics. The 14 day limitation may be extended beyond 14 days if the attending physician or prescriber documents the following upon initiation of the prn psychotropic order: believe it is appropriate to extend the order and documents clinical rationale for the extension and provided specific duration of use. Please consider the following at this time: discontinue prn Ativan or add stop date to Ativan and clinical rationale for therapy greater than 14 days. The physician disagreed with the recommendation but did not provide resident specific rationale to support the physician's response. Review of the Note to Attending Physician/Prescriber dated 01/30/21 revealed the resident was currently receiving Ativan 0.5 milligram (mg) daily as needed (prn). State and federal guidelines have been updated and include 14 day limits on prn psychotropics. The 14 day limitation may be extended beyond 14 days if the attending physician or prescriber documents the following upon initiation of the prn psychotropic order: believe it is appropriate to extend the order and documents clinical rationale for the extension and provided specific duration of use. Please consider the following at this time: discontinue prn Ativan or add stop date to Ativan and clinical rationale for therapy greater than 14 days. The physician disagreed with the recommendation but did not provide resident specific rationale to support the physician's response. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/09/21 revealed the resident had moderate cognitive impairment and a diagnosis of anxiety. The resident did not receive antianxiety medication during the assessment period. On 09/29/21 at 4:00 P.M. interview with Licensed Practical Nurse (LPN) #150 verified the physician did not provide rationale as to why he disagreed with the pharmacy recommendations for the prn use of Ativan and the duration of treatment. Review of the Monthly Drug Regimen Review Policy and Procedure implemented 11/20/16 and revised 10/19/17 revealed the pharmacist would review the resident's medical record for any psychotropic drugs including antianxiety medications. The pharmacist would document in a written report any irregularities noted during the drug regimen review and any irregularities identified would be sent to the physician and Director of Nursing. The attending physician or medical director would document he/she had reviewed the identified irregularity and what, if any action they had taken. If there was no change (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 12 of 17 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 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 the attending physician would document his or her rationale in the resident's medical record. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 13 of 17 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure as needed psychotropic medication orders included a duration for use unless rationale to extend use was provided by the ordering practitioner. This affected one resident (#10) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #10's medical record revealed an admission date of 03/11/14 with diagnoses including anxiety, depression and angina. Review of the physician orders revealed the resident had an order for Ativan (anti-anxiety medication) every 24 hours as needed (prn) for anxiety from 09/23/20 through 04/22/21. Review of the Medication Administration Records from 09/23/20 through 04/22/21 revealed the resident received prn Ativan on 10/02/20, 10/17/20, 11/04/20, 12/01/20, 12/02/20, 12/06/20, 12/26/20, 01/03/21, 01/09/21, 02/21/21 and 03/05/21. Review of the Note to Attending Physician/Prescriber, dated 11/26/20 revealed the resident was currently receiving Ativan 0.5 milligram (mg) daily as needed (prn). State and federal guidelines have been updated and include 14 day limits on prn psychotropics. The 14 day limitation may be extended beyond 14 days if the attending physician or prescriber documents the following upon initiation of the prn psychotropic order: believe it is appropriate to extend the order and documents clinical rationale for the extension and provided specific duration of use. Please consider the following at this time: discontinue prn Ativan or add stop date to Ativan and clinical rationale for therapy greater than 14 days. The physician disagreed with the recommendation. Review of the Note to Attending Physician/Prescriber, dated 01/30/21 revealed the resident was currently receiving Ativan 0.5 milligram (mg) daily as needed (prn). State and federal guidelines have been updated and include 14 day limits on prn psychotropics. The 14 day limitation may be extended beyond 14 days if the attending physician or prescriber documents the following upon initiation of the prn psychotropic order: believe it is appropriate to extend the order and documents clinical rationale for the extension and provided specific duration of use. Please consider the following at this time: discontinue prn Ativan or add stop date to Ativan and clinical rationale for therapy greater than 14 days. The physician disagreed with the recommendation. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate cognitive impairment and a diagnosis of anxiety. The resident did not receive antianxiety medication during the assessment period. On 09/29/21 at 4:00 P.M. interview with Licensed Practical Nurse (LPN) #150 verified the physician did not provide a duration for the resident's Ativan despite identification by pharmacy and the resident used the prn Ativan from 09/23/20 through 04/22/21 when it was discontinued. The LPN verified orders for prn psychotropic medications were to have a duration for the order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 14 of 17 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 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, record review and interview the facility failed to ensure Resident #27's eye drops were discarded upon expiration. This affected one resident (#27) of five residents observed for medication administration. Findings include: Review of Resident #27's medical record revealed the resident was admitted on [DATE] with diagnoses including major depressive disorder, Alzheimer's disease and anxiety disorder. Review of Resident #27's physician's orders revealed an order, dated 05/20/21 for Systane Ultra Solution 0.4-0.3% (percent) eye drops, instill one drop in both eyes three times a day related to dry eyes. On 09/28/21 at 11:19 A.M. Licensed Practical Nurse (LPN) #801 was observed administering medication to Resident #27. LPN #801 administered the Systane eye drop medication to the resident's right and left eye. The date of expiration on the side of the eye drop bottle and the bottom of the eye drop package indicated the medication expired 08/2021. On 09/28/21 at 11:24 A.M. interview with LPN #801 confirmed Resident #27's eye drops were expired and should have been discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 15 of 17 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on record review, facility infection control log review, McGeer's Criteria review, facility policy and procedure review and interview the facility failed to ensure antibiotic stewardship protocols were followed regarding the use of antibiotics appropriate to treat infections. This affected two residents (#9 and #186) of four residents reviewed for antibiotic stewardship. Residents Affected - Few Findings include: Review of the June 2021 Infection Control Log revealed Resident #9 and Resident #186 received antibiotics for urinary tract infections (UTI) but did not meet McGeer's Criteria. 1. Review of Resident #9's medical record revealed an admission date of 12/04/19 with diagnosis including heart disease and muscle weakness. Review of the nurse progress note, dated 06/20/21 at 11:50 A.M. revealed the resident was found slumped over the foot of her bed. The resident was diaphoretic, with skin pale and cool, face flushed. The resident was having dry heaves. The resident's physician was notified and ordered to send to the emergency room. The resident was transferred to the emergency room and returned to the facility the same day with antibiotic orders to treat a UTI. Review of the physician's orders revealed an order for Macrobid (antibiotic) 100 milligrams every 12 hours for seven days for a urinary tract infection written 06/20/21. Review of the McGeer's Criteria dated 06/20/21 revealed the resident did not present with any criteria for a UTI without a catheter. Review of the urinalysis dated 06/20/21 revealed no bacterial growth. Review of the June 2021 Medication Administration record revealed the Macrobid was initiated the evening of 06/20/21 and the resident received two doses on the antibiotic before the nurse contacted the physician due to the resident not meeting criteria and the antibiotic was continued. On 09/30/21 at 5:00 P.M. interview with Licensed Practical Nurse (LPN) #150 verified the resident received an oral antibiotic without meeting McGeer's Criteria and the facility administered oral antibiotics without appropriate justification. 2. Review of Resident #186's medical record revealed an admission date of 05/26/21 with diagnosis including diabetes and chronic kidney disease. Review of the nurse progress note, dated 06/16/21 revealed the resident complained of mild discomfort with urination. The resident was afebrile and encouraged to increase fluids. Further review of the nurse progress notes dated 06/17/21 revealed a urinalysis was completed per orders. Review of the urine culture dated 06/17/21 revealed mixed urogenital flora. No bacteria was identified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 16 of 17 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the McGeer's Criteria revealed the resident only met one criteria for UTI, new or marked increase in urinary frequency. Review of the physician's orders, dated 06/17/21 revealed Bactrim DS (antibiotic) 800/160 one tablet twice a day for UTI with the first dose administered on 06/17/21 and continued through 06/22/21 with the morning dose. On 09/30/21 at 5:00 P.M. interview with LPN #150 verified the resident received an oral antibiotic without meeting McGeer's Criteria and the facility administered oral antibiotics without appropriate justification. Review of the Antibiotic Stewardship Policy, dated 12/2016 revealed the purpose of the antibiotic stewardship program was to monitor the use of antibiotics in the facility residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 17 of 17