Health inspection·September 14, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a facility investigation, and interview, the facility failed to ensure allegations of abuse were reported to the State Survey Agency. This affected one (Resident #101) of three residents reviewed for abuse. Findings include: Review of Resident #101's closed medical record revealed diagnoses including cerebral infarction with paralysis affecting the left non-dominant side, anxiety disorder, generalized muscle weakness, heart disease, hypertension, osteoarthritis and osteoporosis. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #101 was severely cognitively impaired. No behavioral symptoms or rejection of care was noted. Review of a skin assessment dated [DATE] revealed no documentation of impairment/bruises. A skin assessment dated [DATE] indicated Resident #101 had a group of five bruises measuring 6 centimeters (cm) x 6 cm x 0 cm to the right upper extremity. Review of progress notes for the period between 01/06/23 and 01/09/23 revealed no documentation as to the cause of the bruises. During an interview on 09/12/23 at 11:27 A.M., the Director of Nursing (DON) stated her first day worked was 01/09/23. The DON stated she did not recall any unusual occurrences on 01/09/23 but she had a soft file for an incident that occurred 01/11/23. On 09/12/23 at 12:30 P.M., the DON stated she believed Registered Nurse (RN) #475 had opened the skin assessment the wrong date and it should have been dated 01/11/23 instead of 01/09/23. Review of the soft file from 01/11/23 revealed a written statement by Activity Director (AD) #405 which indicated she was posting daily activity schedules when she heard Resident #101 crying. Resident #101 was crying tears and when asked what was wrong she replied she was attacked. When asked by whom she pointed to the floor and stated they went into her room. AD #405 indicated because she was unable to understand what Resident #101 was upset about she asked the aide what was going on. The aide reported the lab girl was there to draw Resident #101's blood. AD #405 indicated Resident #101 was very upset. AD #405 indicated she reported the incident to Social Service Designee (SSD) #406. The file revealed a body assessment was completed for Resident #101 on 01/11/23. A bruise was noted to the back of the right hand measuring 11 cm x 9.5 cm. A bruise was noted to the back of the right arm between the wrist and elbow measuring 9.5 cm x 7 cm. A set of five individual bruises were noted to the left arm with the entire area measuring 6 cm x 6 cm that had been observed 01/09/23. The back of the left hand was slightly discolored. Bruises measuring 1 cm x 1 cm and 5 cm x 3 cm were observed on the back of the left leg. During an interview on 09/12/23 at 1:10 P.M., AD #405 stated she recalled hearing Resident #101 screaming very loudly. When she went in the room Resident #101 was alone and yelled several times She hurt me. She hurt me. AD #405 stated after she was unable to calm Resident #101 down she spoke to the aide (could not recall who) and was told the phlebotomist had been in to draw blood. Resident #101 was pointing to her arm. AD #405 stated she spoke with SSD #406 and they reported the incident to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 2 of 35 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 09/14/2023 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 0609 the prior DON. Level of Harm - Minimal harm or potential for actual harm During an interview on 09/12/23 at 2:10 P.M., the Administrator stated he recalled speaking to the prior DON about the incident. The prior DON indicated to him that she had spoken to the phlebotomist and the lab company (no interviews documented). He recalled the previous DON stating she believed the bruises were from the tourniquet. The Administrator acknowledged when Resident #101 made accusations of being attacked a report would generally be submitted to the State Survey Agency but it was not in this case. Residents Affected - Few During an interview on 09/13/23 at 11:28 A.M., the Administrator stated based on what he was told at the time of the incident he did not believe the incident needed reported to the State Survey Agency. Looking hindsight with the current interviews and review of the record a report could have potentially been needed. On 09/13/23 at 4:02 P.M., the Administrator stated the facility had submitted a report to the State Survey Agency and began a more thorough investigation of the incident which occurred 01/11/23 and the phlebotomist was suspended from providing services at the facility pending outcome of the investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 3 of 35 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 09/14/2023 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 0610 Respond appropriately to all alleged violations. 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, review of a facility investigation, and interview, the facility failed to ensure allegations of abuse were thoroughly investigated. This affected one (Resident #101) of three residents reviewed for abuse. The census was 44. Residents Affected - Few Findings include: Review of Resident #101's closed medical record revealed diagnoses including cerebral infarction with paralysis affecting the left non-dominant side, anxiety disorder, generalized muscle weakness, heart disease, hypertension, osteoarthritis and osteoporosis. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #101 was severely cognitively impaired. No behavioral symptoms or rejection of care was noted. Review of a skin assessment dated [DATE] revealed no documentation of impairment/bruises. A skin assessment dated [DATE] indicated Resident #101 had a group of five bruises measuring 6 centimeters (cm) x 6 cm x 0 cm to the right upper extremity. Review of progress notes for the period between 01/06/23 and 01/09/23 revealed no documentation as to the cause of the bruises. During an interview on 09/12/23 at 11:27 A.M., the Director of Nursing (DON) stated her first day worked was 01/09/23. The DON stated she did not recall any unusual occurrences on 01/09/23 but she had a soft file for an incident that occurred 01/11/23. On 09/12/23 at 12:30 P.M., the DON stated she believed Registered Nurse (RN) #475 had opened the skin assessment the wrong date and it should have been dated 01/11/23 instead of 01/09/23. The DON had been unable to locate any information regarding a cause for the cluster of five bruises from 01/09/23. Review of the soft file from 01/11/23 revealed a written statement by Activity Director (AD) #405 which indicated she was posting daily activity schedules when she heard Resident #101 crying. Resident #101 was crying tears and when asked what was wrong she replied she was attacked. When asked by whom she pointed to the floor and stated they went into her room. AD #405 indicated because she was unable to understand what Resident #101 was upset about she asked the aide what was going on. The aide reported the lab girl was there to draw Resident #101's blood. AD #405 indicated Resident #101 was very upset. AD #405 indicated she reported the incident to Social Service Designee (SSD) #406. The file did not contain any interviews/statements from SSD #406, phlebotomist or any nursing assistants or nurses. The file indicated other residents who had lab draws on 01/11/23 were assessed and interviewed (as applicable). However, there was no documentation regarding the findings. The file revealed a body assessment was completed for Resident #101 on 01/11/23. A bruise was noted to the back of the right hand measuring 11 cm x 9.5 cm. A bruise was noted to the back of the right arm between the wrist and elbow measuring 9.5 cm x 7 cm. A set of five individual bruises were noted to the left arm with the entire area measuring 6 cm x 6 cm that had been observed 01/09/23. The back of the left hand was slightly discolored. Bruises measuring 1 cm x 1 cm and 5 cm x 3 cm were observed on the back of the left leg. During an interview on 09/12/23 at 1:10 P.M., AD #405 stated she recalled hearing Resident #101 screaming very loudly. When she went in the room Resident #101 was alone and yelled several times She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 4 of 35 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 09/14/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hurt me. She hurt me. AD #405 stated after she was unable to calm Resident #101 down she spoke to the aide (could not recall who) and was told the phlebotomist had been in to draw blood. Resident #101 was pointing to her arm. AD #405 stated she spoke with SSD #406 and they reported the incident to the prior DON. During an interview on 09/12/23 at 1:14 P.M., SSD #406 stated after AD #405 reported the incident to her they spoke with the prior DON but it was indicated to her nursing would take over from there and she was not required to do any follow up. During an interview on 09/12/23 at 1:17 P.M., State Tested Nursing Assistant (STNA) #456 stated she had known Resident #101 to get blood drawn from other phlebotomists and she never screamed and yelled or made accusations as she did on 01/11/23. STNA #456 stated after hearing the yelling (before breakfast) she went to Resident #101's room but did not recall the phlebotomist being in the room at the time. STNA #456 indicated new bruises were observed after the phlebotomist visit. During an interview on 09/12/23 at 2:10 P.M., the Administrator stated he recalled speaking to the prior DON about the incident. The prior DON indicated to him that she had spoken to the phlebotomist and the lab company (no interviews documented). He recalled the previous DON stating she believed the bruises were from the tourniquet. The skin assessment diagram was discussed which indicated a set of bruises going up Resident #101's arm (individual distinctly identified bruises) which would not be consistent with a tourniquet placement. The current DON was present and stated the lab reported they did three attempts when attempting to get labs which could account for some of the bruising but the lab did not document location of attempted draws. The Administrator acknowledged when Resident #101 made accusations of being attacked a report would generally be submitted to the state agency but it was not in this case. It was also addressed the soft file investigation did not indicated the aide was interviewed/gave a statement and although there was a list of residents who received lab work the same day with stars beside some of the names indicating those residents were interviewed there was no information about what the residents stated during the interviews. During an interview on 09/13/23 at 11:12 A.M., STNA #413 stated she heard Resident #101 screaming and yelling no and stop. When she entered Resident #101's room she saw that the phlebotomist continued to attempt the blood draw even after the resident told her to stop. STNA #413 stated Licensed Practical Nurse (LPN) #478 intervened and told the phlebotomist she had to stop. STNA #413 stated the phlebotomist continued to provide services at the facility and had heard she did the same thing to one other resident (would not identify). STNA #413 stated after the incident Resident #101's hand had become swollen and the entire back of her hand and going up her arm had bruising. STNA #413 was unable to state how far up the arm the bruise went. STNA #413 stated Resident #101 just said to her it hurt but did not state what happened. During an interview on 09/13/23 at 11:28 A.M., the Administrator stated based on what he was told at the time of the incident he did not believe the incident needed reported to the State Survey Agency. Looking hindsight with the current interviews and review of the record a report could have potentially been needed. An attempt to contact the previous DON (RN #476) on 09/13/23 11:52 A.M. was unsuccessful and she did not return a phone call as requested. During an interview on 09/13/23 at 11:59 A.M., Phlebotomist #477 was interviewed via phone and stated she would not force a resident to have their blood drawn. Phlebotomist #477 denied any knowledge (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 5 of 35 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 09/14/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of a resident being injured during a blood draw although one time one of the residents on the dementia unit became combative mid-draw. (Resident #101 did not reside on the dementia unit.) During an interview on 09/13/23 at 2:36 P.M., Clinical Consultant #458 verified the investigation was not comprehensive. Clinical Consultant #458 verified there was nothing documented in Resident #101's medical record revealing an explanation for the bruises on the upper arm. Clinical Consultant #458 stated RN #476 no longer worked at the facility. On 09/13/23 at 4:02 P.M., the Administrator stated the facility had submitted a report to the State Survey Agency and began a more thorough investigation of the incident which occurred 01/11/23 and the phlebotomist was suspended from providing services at the facility pending outcome of the investigation. During a phone interview on 09/13/23 at 4:26 P.M., LPN #478 stated she did not know if she felt comfortable talking about the incident. That bringing it up had sent a wave through her whole body and the facility staff had to keep working and nothing more than a fine would be given by the Department of Health. LPN #478 stated she had to think about sharing information and was encouraged to call with any information she could share. No additional information was provided. Review of the facility's policy, Abuse Prevention, Identification, Investigation and Reporting Policy, revised 08/15/22, revealed all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The charge nurse was responsible for immediately reporting the allegations of abuse to the Administrator or designated representative. Should an incident or suspected incident of Resident abuse be reported or observed, the Administrator or his designee would designate a member of management to investigate the alleged incident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 6 of 35 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 09/14/2023 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to provide written transfer notification to the resident and/or representative when a resident was transferred to the hospital. This affected two (Resident #49 and #4) of three residents reviewed for hospitalization. The facility census was 44. Findings include: 1. Review of Resident #49's medical record revealed an admission date of 07/12/23 with diagnoses that included congestive heart failure, atrial fibrillation and atherosclerotic heart disease. Further review of the medical record revealed on 07/22/23 Resident #49 was transferred to the local hospital and admitted on [DATE] for exacerbation of chronic obstructive pulmonary disease. Further review of the medical record found no evidence of written notification of transfer provided to the resident or resident representative following admission to the hospital. Interview on 09/13/23 at 10:45 A.M., with social services designee (SSD #406) revealed no written transfer notification was provided to the resident or representative when the resident was transferred to a hospital. 2. Review of Resident #4's medical record revealed she was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, chronic atrial fibrillation, hypothyroidism, unspecified dementia and essential hypertension. Review of Resident #4's admission Minimum Data Set (MDS), dated [DATE], revealed she was severely cognitively impaired. Review of Resident #4's progress note, dated and timed 08/02/23 at 11:45 A.M., revealed the local emergency medical system was at the facility for transport her to the emergency room for evaluation. Further review revealed a note dated and timed, 08/02/23 at 5:41 P.M. that Resident #4 had been admitted to the local hospital and on 08/07/22 at 10:22 P.M. she returned to the facility for readmission. Interview on 09/14/23 at 11:50 A.M. with Social Services Designee #406 revealed the facility did not complete written transfer/discharge notices when a resident was transferred to a hospital. The facility did not have a policy related to Notice Requirements Before Transfer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 7 of 35 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 09/14/2023 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review and staff interview the facility failed to ensure residents and/or resident representatives admitted to the hospital were provided bed hold notification. This affected one (Resident #49) of three residents reviewed for hospitalization. The facility census was 44. Findings include: Review of Resident #49's medical record revealed an admission date of 07/12/23 with diagnoses that included congestive heart failure, atrial fibrillation and atherosclerotic heart disease. Further review of the medical record revealed on 07/22/23 Resident #49 was transferred to the local hospital and admitted on [DATE] for exacerbation of chronic obstructive pulmonary disease. Further review of the medical record found no evidence of written notification of bed hold days remaining provided to the resident or resident representative following admission to the hospital. Interview on 09/13/23 at 10:45 A.M., with social services designee (SSD #406) revealed no notification of bed hold days remaining were provided to the resident or representative after admission to the hospital. Review of the facility policy Bed-Holds and Return with a revision date of March 2022 indicated all residents/representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents are provided written information about these polices at least twice: well in advance of any transfer and at the time of transfer (or, if the transfer was an emergency, within 24 hours). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 8 of 35 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 09/14/2023 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 0641 Ensure each resident receives an accurate assessment. 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, MedScape online drug reference app review and staff interview, the facility failed to ensure resident assessments were completed accurately. This affected five (Resident #4, #5, #13, #26 and #27) of 15 residents reviewed for assessments. The facility census was 44. Residents Affected - Some Findings include: 1. Review of Resident #5's medical record revealed an admission of 07/24/20 with diagnoses that include congestive heart failure, mitral valve prolapse, atherosclerotic heart disease, atrial fibrillation and peripheral vascular disease. Review of the quarterly minimum data set (MDS) 3.0 assessment with a reference date of 08/11/23 revealed bed rails used as a restraint. No other restraint use was indicated on the MDS assessment. Further review of the medical record including physician's orders and care plans revealed no evidence of any restraint use including bed side rails. Review of the physician's orders revealed no evidence of any type of current restraint use. Observation of Resident #5 on 09/11/13 at 10:02 A.M. revealed no evidence of any type of restraint use. On 09/11/23 at 12:14 P.M., interview with State Tested Nurse Aide (STNA) #422 indicated no use of restraints for Resident #5. On 09/11/23 at 12:14 P.M. interview with Licensed Practical Nurse (LPN) #472 indicated no use of restraints for Resident #5. On 09/11/23 at 12:37 P.M. interview with the Director of Nursing (DON) verified no current use of restraint for Resident #5 and also verified a MDS coding error related to the use of restraints. 2. Review of Resident #13's medical record revealed an admission date of 03/11/14 with diagnoses that included congestive heart failure, atrial fibrillation, osteoporosis and difficulty walking. Nursing notes on 06/24/23 indicated Resident #13 sustained a fall and a laceration to the head was found. Resident #13 was transferred to the local emergency room and found with no additional injuries including fractures. Review of the quarterly MDS 3.0 assessment with a reference date of 07/06/23 indicated Resident #13 sustained a fall with a major injury. Further review of the medical record found no evidence of any fall with a major injury sustained by Resident #13. On 09/13/23 at 9:35 A.M. interview with the DON and Registered Nurse (RN) #410 verified the MDS coding error for Resident #13. They indicated the resident did not have a fall with major injury. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 9 of 35 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 09/14/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm 3. Review of Resident #26's medical record revealed an admission date of 03/03/22 with diagnoses that included Alzheimer's disease, Parkinson's disease and atherosclerotic heart disease. Further review of the medical record including physician's orders revealed on 03/03/22 the resident was placed on hospice services. Residents Affected - Some Review of the quarterly MDS 3.0 assessment with a reference date of 06/02/23 found no evidence of Resident #26 currently receiving hospice services while in the facility. On 09/13/23 at 9:35 A.M. interview with the DON and RN #410 verified the MDS coding error for Resident #26. They indicated the MDS should indicate the resident is currently receiving hospice services. 4. Review of Resident #27's medical record revealed an admission date of 12/04/19 with diagnoses that included atherosclerotic heart disease, cerebrovascular accident and hypertension. Further review of the medical record including physician's orders revealed the use of clopidogrel (anti-platelet medication) 75 milligrams (mg) every day for atherosclerotic heart disease. No physician's orders were found for any anti-coagulant medication. Review of the quarterly MDS 3.0 assessment with a reference date of 08/01/23 revealed the current use of an anticoagulant for seven days during the seven day look back period. Review of the MedScape online drug reference app revealed clopidogrel is an anti-platelet medication, not an anti-coagulant medication. On 09/13/23 at 9:35 A.M. interview with the DON and RN #410 verified the MDS coding error for Resident #27 related to anti-coagulant use. 5. Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE]. She was readmitted to the facility on [DATE] following a hospitalization for a urinary tract infection (UTI). Her diagnoses also included dementia, heart failure, and hypertension. A review of Resident #4's admission/ 5 day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was coded on the MDS as having received a diuretic (a medication that helps with the production of urine). She was marked as having received a diuretic all seven days of the seven day assessment period. She was not coded on the MDS assessment as having received any injections or an antibiotic. A review of Resident #4's medication administration record (MAR) for August 2023 revealed the resident was given Ceftriaxone (Rocephin) 250 milligrams (mg) intramuscularly once daily for a UTI between 08/08/23 and 08/13/23. Five doses of the Ceftriaxone had been given during the admission/ 5 day MDS assessment reference period (08/08/23 through 08/14/23). There was no evidence on the MAR of the resident being given a diuretic during the seven days of the MDS' assessment period. On 09/14/23 at 9:45 A.M., an interview with the Director of Nursing revealed she was the one who was doing MDS assessments at the time Resident #4's admission/ 5 day MDS assessment was completed on 08/14/23. She acknowledged the MDS assessment was not coded accurately to reflect the correct medication classifications the resident received during the MDS assessment's seven day look back period. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 10 of 35 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 09/14/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm She confirmed the resident did not receive a diuretic during that seven day period and had received an antibiotic five days during that same seven day assessment period. She also confirmed the antibiotic that was received was given as an intramuscular injection and the resident should have been marked as receiving injections five days of the seven day assessment period. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 11 of 35 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 09/14/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on medical record review and interview, the facility failed to ensure a Preadmission Screening/Resident Review (PAS/RR) assessment was accurate upon admission and failed to ensure an updated PAS/RR was submitted to determine if a resident would benefit from specialized services. This affected one (Resident #3) of one resident reviewed for PAS/RR. 16 residents were screened for need for PAS/RR reviews. The census was 44. Findings include: Review of Resident #3's medical record revealed an initial admission date of 01/21/13. Review of the medical diagnoses record revealed diagnoses relevant on admission included dysthymic disorder (mood disorder), dementia, and post traumatic stress disorder (PTSD). On 02/07/17 a diagnosis of psychotic disorder was added. On 01/13/18 a diagnosis of recurrent major depressive disorder was added. Review of the PAS/RR dated 01/18/13 indicated Resident #3 did not have a documented diagnosis of dementia, had no diagnosis of any mental disorders including mood disorders or other psychotic disorders. The assessment indicated Resident #3 had a severe, chronic disability that was attributable to a seizure disorder but was closely related to an intellectual development disorder because the condition resulted in impairment of general intellectual functioning or adaptive behavior similar to that of persons with intellectual disabilities and required treatment or services similar to those required for persons with intellectual disabilities. The disability was likely to continue indefinitely. On 09/13/23 at 9:45 A.M., Social Service Designee (SSD) #406 indicated the most recent screening information for PAS/RR was provided. On 09/13/23 at 9:48 A.M., Licensed Practical Nurse (LPN) #467 verified Resident #3 had diagnoses which were not indicated on the PAS/RR screen provided and appeared to be new onset diagnoses. On 09/12/23 at 12:45 P.M., the Director of Nursing (DON) verified the discrepancies between the PAS/RR screen available and Resident #3's diagnoses. The DON verified the screen from 2013 did not indicate Resident #3 had dementia or mood disorders and Resident #3 was not re-evaluated with new diagnoses of psychotic disorder and major depression. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 12 of 35 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 09/14/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #11's medical record revealed diagnoses including bipolar disorder, hypertension, chest pain, type two diabetes mellitus, heart disease, obesity, psychosis, depression, adult failure to thrive, and congestive heart failure. An admission Evaluation with baseline care plan dated 03/09/23 revealed as needs were identified a baseline care plan was developed. However, there was no evidence Resident #11 and/or her representative had the baseline care plan reviewed with them or that they were provided a written summary of the baseline care plan. On 09/13/23 at 2:03 P.M., the Director of Nursing (DON) verified the baseline care plan was not reviewed with residents and their representatives and copies were not provided. The interdisciplinary team generally met with residents and their representatives within 21 days of admission. Review of the facility policy titled, Care Plans - Baseline, revised 03/2022, revealed the resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following: the stated goals and objectives of the resident; a summary of the resident's medications and dietary instructions; any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and any updated information based on the details of the comprehensive care plan, as necessary. Based on interview, resident record review, and facility policy review, the facility failed to ensure residents received a written summary of their baseline care plan. This affected four Resident (#4, #11, #38 and #42) of four residents reviewed for baseline care plans. The facility census was 44. Findings included: 1. Review of Resident #4's medical record revealed she was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, chronic atrial fibrillation, hypothyroidism, unspecified dementia and essential hypertension. Review of Resident #4's admission Minimum Data Set (MDS), dated [DATE], revealed she was severely cognitively impaired. Review of Resident #4's Baseline Care Plan, dated 06/01/23, revealed it was developed to care for the immediate needs of the resident within 48 hours of admission. However, there was no documentation to support the resident/resident representative was educated on the baseline plan of care or provided a written summary. Interview on 09/13/23 at 2:03 P.M. with the DON revealed the process in the facility was for the interdisciplinary team to meet with the resident/representative within 21 days of admission. The DON verified the baseline care plans were completed in the computer. However, they were not reviewed with the resident/representative, signed to confirm reviewing, nor was a copy given to the resident/representative. 2. Review of Resident #38's medical record revealed she was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus without complications, dysphagia, encounter for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 13 of 35 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 09/14/2023 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 0655 palliative care, cerebral infarction, and chronic obstructive pulmonary disease. Level of Harm - Minimal harm or potential for actual harm Review of Resident #38's admission MDS 3.0 assessment, dated 05/23/22, revealed she was cognitively impaired. Residents Affected - Some Review of Resident #38's Baseline Care Plan, dated 05/16/22, revealed it was developed to care for the immediate needs of the resident within 48 hours of admission. However, there was no documentation to support the resident/resident representative was educated on the baseline plan of care or provided a written summary. Interview on 09/13/23 at 2:03 P.M. with the DON revealed the process in the facility was for the interdisciplinary team to meet with the resident/representative within 21 days of admission. The DON verified the baseline care plans were completed in the computer. However, they were not reviewed with the resident/representative, signed to confirm reviewing, nor was a copy given to the resident/representative. 3. Review of Resident #42's medical record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's disease, essential hypertension, type two diabetes mellitus, hyperlipidemia, and depression. Review of Resident #42's admission MDS, 3.0 assessment, dated 03/27/23, revealed she was severely cognitively impaired. Review of Resident #42's Baseline Care Plan, dated 03/20/23, revealed it was developed to care for the immediate needs of the resident within 48 hours of admission. However, there was no documentation to support the resident/resident representative was educated on the baseline plan of care or provided a written summary. Interview on 09/13/23 at 2:03 P.M. with the DON revealed the process in the facility was for the interdisciplinary team to meet with the resident/representative within 21 days of admission. The DON verified the baseline care plans were completed in the computer. However, they were not reviewed with the resident/representative, signed to confirm reviewing, nor was a copy given to the resident/representative. Interview on 09/13/23 at 2:03 P.M. with the DON revealed the process in the facility was for the interdisciplinary team to meet with the resident/representative within 21 days of admission. The DON verified the baseline care plans were completed in the computer. However, they were not reviewed with the resident/representative, signed to confirm reviewing, nor was a copy given to the resident/representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 14 of 35 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 09/14/2023 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 record review, observation, staff interview, and policy review, the facility failed to ensure fall prevention interventions were implemented as per the resident's plan of care. This affected one (Resident #27) of two residents reviewed for accidents. The census was 44. Findings include: A review of Resident #27's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a fracture of an unspecified part of the neck of the left femur (07/24/23), history of repeated falls, difficulty in walking, muscle weakness, unspecified intracapsular fracture of the right femur (02/21/22), presence of an artificial right hip joint, aphasia following CVA, HTN, and dizziness and giddiness. A review of Resident #27's quarterly fall risk assessment dated [DATE] revealed the resident was assessed as a moderate risk for falls. Her risk factors included cognitive impairment, the use of medications that increased her risk for falls, and diagnoses that predisposed her to falls. A review of Resident #27's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had unclear speech and moderate difficulty in hearing. She was usually able to make herself understood and was usually able to understand others. She had poor short term memory and her cognitive skills for daily decision making was moderately impaired. No behaviors or rejection of care was noted. She was independent with set up help for bed mobility, transfers, walking in the hall, locomotion and toilet use. Supervision with set up help was needed with ambulation in her room. A review of Resident #27's care plans revealed the resident was at risk for further falls. The care plan reflected the resident had a fall on 02/13/22 that resulted in a right hip fracture. She was known to be noncompliant with waiting for assistance and with the use of her call light. The care plan was last revised on 02/24/22. Her interventions included the use of a low bed. On 09/12/23 at 8:50 A.M.,, observations of Resident #27 noted the resident to be lying in bed with her eyes open. She responded when spoken to but her speech was difficult to understand. Her bed was found not to be in its lowest position. On 09/12/23 at 2:07 P.M., further observation of Resident #27 noted her to be lying in bed on her left side facing her window. Her bed was not in its lowest position as the bed frame was approximately 18 inches off the floor. On 09/12/23 at 9:09 P.M., an interview with LPN #419 revealed Resident #27 was considered a fall risk and had fallen in the past with fractures. She confirmed the resident was supposed to be in a low bed. She verified the resident's bed was not in its lowest position and used the bed controls to lower the bed. She lowered it approximately eight inches so the bed frame was only 10 inches off the floor. On 09/12/23 at 2:25 P.M., the facility's Director of Nursing (DON) was informed Resident #27's bed was found to be in a raised position on two separate occasions. She acknowledged the resident had the use of a low bed as one of her fall prevention interventions and, with the bed in a raised (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 15 of 35 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 09/14/2023 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 position, her fall prevention interventions were not being implemented as per her plan of care. Level of Harm - Minimal harm or potential for actual harm A review of the facility's fall policy revised March 2018 revealed, based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. The staff would implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. In conjunction with the attending physician, staff would identify and implement relevant interventions to try to minimize serious consequences of falling. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00136459. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 16 of 35 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 09/14/2023 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, inter-department email communication review and staff interview, the facility failed to ensure dietary recommendations were communicated effectively. This affected one (Resident #31) of four residents reviewed for nutrition. The facility census was 44. Residents Affected - Few Findings include: Review of Resident #31's medical record revealed an admission date of 08/25/20 with diagnoses that included diabetes mellitus, chronic kidney disease, dementia and hypertension. Review of Resident #31's weights revealed a 6.6% weight loss in the last 30 days that was identified on 09/04/23. Review of the dietary progress revealed a progress note on 09/10/23 which indicated a significant weight loss that was identified on 09/04/23. The dietician recommended to increase Resident #31's nutritional supplement. Review of Resident #31's nutritional supplements revealed on 08/02/23 the resident was ordered the use of 8 ounce sugar free house supplement daily. No evidence was found of any increase as recommended by the dietician on 09/10/23 as indicated in dietary notes. Interview with the Director of Nursing (DON) on 09/13/23 at 2:25 P.M. revealed the dietician will email her recommendations made for any resident, including those identified with a significant weight loss. Review of the email dated 09/11/23 at 4:53 P.M. from the dietician to the DON revealed no evidence of recommendation to increase nutritional supplements for Resident #31. The email only indicated triggers for malnutrition. Additional interview with DON on 09/13/23 at 2:35 P.M. verified the email communication from the dietician did not indicate any recommendation to increase nutritional supplements as indicated in the dietary notes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 17 of 35 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 09/14/2023 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and resident record review, the facility failed to ensure a resident was assessed prior to the use of bed side rails and she was properly care planned for bed side rails. This affected one Resident (#38) of one resident reviewed for accidents. The facility census was 44. Findings included: Review of Resident #38's medical record revealed she was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus without complications, dysphagia, encounter for palliative care, cerebral infarction, and chronic obstructive pulmonary disease. Review of Resident #38's admission Minimum Date Set (MDS) 3.0 assessment, dated 05/23/22, revealed she was cognitively impaired and was totally dependent on the help of two persons to physically assist with bed mobility. Review of Resident #38's significant change MDS 3.0 assessment, dated 07/20/23, revealed she was rarely or never understood, was totally dependent on the help of one person to physically assist with bed mobility and was receiving hospice services. Review of Resident 38's physician order, dated 07/01/22, identified her side rails on her bed were to be padded. There was no order specifically for the side rails. Review of Resident #38's side rail assessment revealed she was assessed for side rails on 08/18/22, over six weeks after the order for the padded side rails. Further review revealed the most recent side rail assessment was on 05/13/23 Review of Resident #38's baseline care plan, dated 05/16/22, revealed consent was received for bilateral side rails. Review of Resident #38's comprehensive plan of care, dated 05/27/22, revealed she was to have bilateral grab bars to her bed and on 01/30/23 it was changed to bilateral rails to her bed. Observation on 09/11/23 at 9:56 A.M. of Resident #38 lying in bed with her bilateral, upper padded ½ side rails engaged. Observation on 09/11/23 at 2:58 P.M. of Resident #38 lying in bed with her bilateral, upper padded ½ side rails engaged. Observation on 09/12/23 at 7:58 A.M. of Resident #38 lying in bed with the bilateral, upper padded ½ side rails engaged. Interview on 09/12/23 at 8:05 A.M. with the DON verified Resident #38 did not have a side rail assessment until almost six weeks after the order for padding of her side rails and did not have a side rail assessment 08/23 as she should have due to side rail assessments are to be done quarterly. She also verified Resident 38's comprehensive care plan was not accurate until 01/30/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 18 of 35 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 09/14/2023 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 0700 This deficiency represents non-compliance investigated under Complaint Number OH00136459. 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 19 of 35 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 09/14/2023 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 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, review of hospital records, and staff interview, the facility failed to ensure medications were only used when there was an adequate indication for use and a resident did not receive antibiotics administered via an intramuscular (IM) injection unless warranted for the treatment of an infection. This affected one (Resident #4) of five residents reviewed for unnecessary medications. The census was 44. Residents Affected - Few Findings include: A review of Resident #4's medical record revealed she was admitted to the facility on [DATE] with the diagnoses of dementia with behavioral disturbances, chronic pain syndrome, adult onset diabetes mellitus, and congestive heart failure. She was hospitalized on [DATE] and re-admitted to the facility on [DATE]. A review of Resident #4's physician's orders revealed there was an order for the resident to be sent to the hospital for an evaluation on 08/02/23. There was another physician's order dated 08/07/23 for the resident to receive ceftriaxone (Rocephin) 250 milligrams (mg) IM every day until 08/13/23 for a diagnosis of a UTI and Diflucan (anti-fungal medication) 100 mg by mouth one time a day until 08/17/23 related to a UTI. A review of Resident #4's medication administration record (MAR) for August 2023 revealed five doses of the IM Rocephin was administered to the resident between 08/08/23 and 08/13/23. The dose that was due on 08/09/23 was not administered to the resident as a 5 was added to the box in which the nurse was to initial to show the medication was administered as ordered. The legend indicated a 5 meant to hold/ see nurses' notes. The MAR also showed the resident received Diflucan 100 mg by mouth every day as ordered through 08/17/23. A review of Resident #4's hospital records for her hospitalization between 08/02/23 and 08/07/23 noted a history and physical report that indicated the resident was sent to the hospital for a change in her mental status with agitation. Her work up in the emergency room showed a slightly elevated ammonia level and a UTI. She was afebrile with a temperature of 97.4 degrees Fahrenheit (F.). Her assessment and plan indicated she had acute cystitis (inflammation of the urinary bladder) with hematuria (blood in the urine) present. Her urine was growing yeast and Diflucan was to be added. Her unusual change in behavior was thought to possibly be caused by an infection. A review of Resident #4's laboratory tests completed in the hospital revealed a urinalysis was collected on 08/02/23. The preliminary report identified Urogenital Flora (normal bacteria that live in the urogenital tract that helps maintain a healthy balance in the tract to prevent infections and other health problems) being present in her urine. The final report on 08/05/23 revealed urogenital flora and Candida Glabrata (species of yeast that lived naturally in and on the body most commonly in the GI tract, the mouth, and the genital area, and can be found as a part of your natural microflora). Both colony counts were only between 1,000 to 5,000 CFU's/ milliliter (ml). A repeat urinalysis collected on 08/06/23 showed a preliminary report with no growth of any organisms after 24 hours. The final report verified on 08/09/23 revealed Candida Glabrata was the only organism identified and had a colony count of 10,000 to 20,000 CFU/ml. Further review of Resident #4's medical record revealed a re-admission history and physical (H&P) was completed on 08/08/23 at 9:00 A.M. The H&P indicated the resident was recently admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 20 of 35 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 09/14/2023 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 0757 Level of Harm - Minimal harm or potential for actual harm hospital with the diagnosis of a UTI or cystitis. She was on IM Rocephin at the time the H&P was completed. Her assessment on the H&P revealed she had no constitutional symptoms like fever, chills, body aches, or fatigue. She denied any dysuria or hematuria. She was afebrile with a temperature of 98 degrees F. The impression on the H&P indicated she had a UTI with fungal infection. The plan was to continue all her medications with no change in the treatment plan being made. Residents Affected - Few On 09/13/23 at 10:50 A.M., an interview with LPN #467 verified Resident #4 received IM Rocephin for a UTI following her hospitalization between 08/02/23 and 08/07/23. She confirmed the laboratory testing done at the hospital, to include a urinalysis, did not support the resident having a UTI that warranted the use of IM Rocephin to treat it. She acknowledged the resident was given five doses of IM Rocephin between 08/08/23 and 08/13/23 when the hospital's urinalysis only showing evidence the resident had a yeast infection. She further acknowledged the Diflucan that was ordered concurrently with the IM Rocephin should have been adequate in treating her yeast infection, without the resident requiring IM Rocephin. She claimed she reviewed residents for antibiotic use when they returned from the hospital, but she was not sure what Candida Glabrata was. She also did not know urogenital flora was normal flora found in the bladder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 21 of 35 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 09/14/2023 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. Based on medical record review, policy review, and interview, the facility failed to ensure anti-psychotic medications were utilized only when medically necessary. This affected one (Resident #3) of five residents reviewed for medication use. The census was 44. Findings include: Review of Resident #3's medical record revealed diagnoses including post traumatic stress disorder (PTSD), dementia, major depressive disorder, psychotic disorder, dysthmic disorder, and mood disorder with depressive features. Review of a psychiatrist note dated 03/14/23 indicated risperdal (antipsychotic) (order for 0.5 milligram at bedtime for repetitive behavior and delusions related to dementia) would be decreased 0.25 milligrams (mg). An order was written for risperdal 0.25 mg every day for delusions. A psychiatrist note dated 04/11/23 revealed the risperdal would be discontinued. A psychiatrist note dated 05/09/23 indicated Resident #3 was doing well with the discontinuation of the risperdal. A nursing note dated 05/14/23 at 9:41 A.M. indicated Resident #3 was yelling out all hell was breaking loose and get to the kitchen and various other comments. Non-pharmacological interventions were ineffective. Acetaminophen was administered. A subsequent note at 10:45 A.M. indicated the acetaminophen was effective and Resident #3 was resting in bed without further signs or symptoms of discomfort and anxiety. A nursing note dated 05/15/23 at 5:44 A.M. indicated Resident #3 became combative with staff during morning care by swinging his arms at staff, yelling and holding on to the side rails to prevent care. There was no evidence of non-pharmacological interventions being attempted. A nursing note dated 05/15/23 at 10:16 A.M. indicated the psychiatrist was updated on increased behaviors. New orders were received to start risperdal 0.25 mg at bedtime for delusions related to psychotic disorder. A nursing note dated 05/18/23 at 6:44 A.M. indicated Resident #3 was loud and yelling during most of the night. He would spell his last name then he was going to [NAME] Virginia to see how his mother was doing. On 09/13/23 at 10:50 A.M., Licensed Practical Nurse (LPN) #467 was interviewed regarding rationale for re-initiation of the risperdal. It was discussed since the psychiatrist visit on 05/09/23 Resident #3 had exhibited behaviors on 05/14/23 in which the administration of acetaminophen was effective. Due to that information it was asked if there was an effort to determine if pain/discomfort played a role in the behaviors exhibited 05/15/23 prior to the psychiatrist being contacted and risperdal being re-initiated. LPN #467 indicated multiple behaviors were recorded. Medication Administration Records (MARs) for April and May 2023 were provided for behavior tracking as supportive information regarding documentation. Since the psychiatrist visit on 05/09/23, only behaviors on 05/14/23 were documented. On 09/13/23 at 12:15 P.M., Psychiatrist #450 was interviewed via phone. Psychiatrist #450 stated he did not recall what staff told him regarding Resident #3's behaviors prior to re-initiation of risperdal. Findings from the behavior tracking were discussed. Psychiatrist #450 indicated he could not answer as to why staff would not attempt Tylenol administration to rule out pain or other non-pharmacological interventions prior to contacting him if it had been effective previously. Psychiatrist #450 stated if the behaviors were only occurring once or twice he might have ordered a one time or prn (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 22 of 35 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 09/14/2023 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 psychotropic verses a routinely scheduled medication. Psychiatrist #450 requested LPN #467 contact him as he wanted to attempt to reduce the risperdal again. On 09/13/23 at 1:35 P.M., Activity Director #405 stated she had discovered music helped to calm Resident #3 when he was exhibiting behaviors. Residents Affected - Few Review of the facility's Antipsychotic Medication Use policy, revised December 2016, revealed antipsychotic medications might be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms had been identified ad addressed. Residents would only receive antipsychotic medications when necessary to treat specific conditions for which they were indicated and effective. Diagnoses of a specific condition for which antipsychotic medications were necessary to treat would be based on a comprehensive assessment of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 23 of 35 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 09/14/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, spread sheet review, and facility policy review, the facility failed to ensure the spread sheet was followed and residents received the correct portion of food. This affected the 23 residents receiving the regular line meal (#1, #2, #5, #6, #7, #8, #9, #10, #15, #19, #23, #24, #25, #29, #31, #32, #35, #37, #39, #41, #43, #44, and #301) and the 11 residents receiving the mechanical soft meal (#4, #12, #17, #20, #26, #27, #28, #33, #34, #42, and #45) for the lunch meal observation. The facility census was 44. Findings included: Review of the documentation titled, Daily Production dated Tuesday 09/12/23, revealed for lunch, residents receiving the regular line meal were to receive four ounces of saffron rice, six ounces of pork and mushroom stir fry, and four ounces of oriental blend vegetables and residents receiving a mechanical soft diet meal were to receive four ounces of saffron rice with four ounces of mechanical soft pork and four ounces of green beans. Observation on 09/12/23 at 11:32 A.M. of [NAME] #483 plating food for lunch. During the plating of a regular line meal, it was noted she was plating six ounces of saffron rice and four ounces of pork and mushroom stir fry and oriental blend vegetables which had been mixed together instead of keeping them separated. It was also noted she was plating six ounces of saffron rice for residents who were to receive a mechanical soft diet. At 11:50 A.M. the dietary staff realized they were not providing the proper ounces of food items on the plate. At that time, [NAME] #483 switched the scoops in the rice and the pork/vegetables resulting in residents receiving four ounces of saffron rice and six ounces of pork and vegetables combined. Interview on 09/12/23 at 11:45 A.M. with Regional Dietary Manager #465 verified there was no way to confirm the residents getting the regular tray line were receiving six ounces of pork and four ounces of vegetables per the spreadsheet because they were mixed together. She verified she should not have mixed the pork and vegetables together to ensure the correct amount of pork and vegetables was provided to the resident. She also verified that combined the total ounces of pork and vegetables would be 10 ounces and [NAME] #483 was plating four ounces resulting in the resident being slighted six ounces of pork and vegetables and later was plating six ounces resulting in the resident being slighted four ounces or pork and vegetables. During the plating of the entire lunch meal, the residents receiving the regular tray line received less pork and mushroom stir fry and oriental blend vegetables than they should have. Interview on 09/12/23 at 11:50 A.M. with the Regional Dietary Manager #465 verified [NAME] #483 was also not providing the correct amount of saffron rice since she was initially putting six ounces on the plate, and it should have been four ounces. Review of the facility policy titled, Menu Spreadsheets and Spreadsheet Approval, undated, revealed there shall be a spread sheet of the regular menu that shows food items and portion size of food items for all diets served. This deficiency represents non-compliance investigated under Complaint Number OH00136459. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 24 of 35 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 09/14/2023 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation and interview, the facility failed to prepare pureed food in the proper form. This had the potential to affect all seven residents (#3, #13, #16, #21 #22, #36, and #38) who were receiving pureed meals. The facility census was 44. Findings included: Observation on 09/12/23 at 10:04 A.M. of [NAME] #483 placing one cup of chicken broth in the Robot Coup bowl followed by seven servings of pork. [NAME] #483 started to Robot Coup and let it run for approximately two minutes. She looked at the pureed pork and reported it was ready to be served. This surveyor asked [NAME] #483 to taste the pureed pork to confirm the pork was the correct consistency and she did. [NAME] #483 reported it was the correct puree consistency to serve to residents. This surveyor then tasted the pork puree and had to chew the pork. Regional Dietary Manager #465 tasted the puree after this surveyor and confirmed the pork was not the correct consistency and needed to be chewed. [NAME] #483 then continued to puree the pork stopping two more times when Regional Dietary Manager #465 tasted the pureed pork and reported it was not the correct consistency. [NAME] #483 pureed the pork for an additional six to seven minutes to get the correct consistency. Observation on 08/12/23 at 10:26 A.M. of [NAME] #483 placing one half a cup of chicken broth in the Robot Coup bowl followed by seven servings of green beans. [NAME] #483 started the Robot Coup and let it run for approximately one minute. She then tasted the pureed green beans and reported they were the correct consistency to serve to residents. Upon placing a plastic spook in the pureed green beans, and upon tipping the spoon, the green beans ran quickly off the spoon. This surveyor tasted the green beans, and they were noted to be too thin in texture. Regional Dietary Manager #465 tasted the green beans after this surveyor and confirmed they were too thin. [NAME] #483 then added 1/4 cup of thickener to the green bean puree, continued to puree the green beans and then tasted them again. The green beans were the correct consistency. Interview on 09/12/23 at 10:38 with [NAME] #483 verified the pork and green bean purees were not the correct consistency when she felt they were ready to be served. She verified the pork was not pureed enough and needed to be chewed when she first thought it was ready to serve and the green beans were too thin when she first thought they were ready to be served. [NAME] #483 also verified she had initially thinned the green beans by putting half a cup of chicken broth in the Robot Coup bowl and then had to add thickener. Interview on 09/12/23 at 10: 40 A.M. with Regional Dietary Manger #465 verified pureed food should not be thinned and then thickened. She verified the original item should be pureed and then thinners or thickeners should be added gradually to maintain the nutritional value of the food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 25 of 35 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 09/14/2023 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 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, tray card review, menu review and facility policy review, the facility failed to ensure preferences were honored when providing beverages. This affected three Residents (#2, #15, and #23) of three residents reviewed for beverage of choice. The facility census was 44. Findings included: Observation on [DATE] at 8:42 A.M. of three and one half gallons of 2% white milk in the milk cooler. There were no other types of milk (whole or chocolate) noted in the cooler. An interview at the time with [NAME] #483 verified there was only one type of milk, 2%. Observation on [DATE] at 7:10 A.M. of one and one half gallons of 2% white milk in the milk cooler. There were no other types of milk (whole or chocolate) noted in the cooler. An interview at the time with Cook/Dietary Aide #479 revealed the chocolate milk had expired and the facility discarded it. She verified there was no chocolate milk for all three meals on [DATE] or breakfast on [DATE]. She reported the facility order was to be delivered on [DATE]. Review of the tray cards revealed two Residents, (#15 and #23) wanted chocolate milk for breakfast and review of the tray card for Resident #2 did not reveal any drink preference. Review of the facility menu revealed choice of milk for each meal. An interview on [DATE] at 7:40 A.M. with Resident #2 revealed he was not happy regarding not having chocolate milk. He reported he would not drink regular milk and reported this was not the first time he didn't have the chocolate milk he wanted. An interview on [DATE] at 7:20 A.M. with Cook/Dietary Aide #479 revealed even though Resident #2 did not have chocolate milk on his tray card and he asked for it daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 26 of 35 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 09/14/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, the facility failed to ensure food was stored properly, kitchen equipment was clean, the kitchen environment was clean, kitchen staff's hair was properly restrained, kitchen staff washed hands after touching trash can lids and prior to donning (putting on) gloves, and the Robot Coup was sanitized and dried between uses. This had the potential to affect all 44 residents receiving food from the kitchen. The facility census was 44. Findings included: 1. Observation on 09/11/23 at 8:32 A.M. of bread on the bread rack revealed the following: three full loaves which were sealed but had no date on them, three partial loaves which were not sealed (the end of the bag was open) and did not have a date on them, one pack (eight count) of hotdog buns which were sealed but had no date on them, three packs (12 count) of hamburger buns which were sealed but had no date on them, one pack (nine count) of hamburger buns which were not sealed (the end of the [NAME] was open)and did not have a date on them, and one pack (five count) of hamburger buns which were sealed and did not have a date on them. An interview at the time with Cook/Dietary Aide #479 verified the bread comes to the facility frozen and when it is removed from the freezer, it should be dated. Cook/Dietary Aide #479 verified the bread should have been closed and not left open to air. Review of the facility policy titled, Food Storage (Dry, Refrigerated and Frozen), reviewed 08/12/23, revealed all open products (as able) will be sealed (rolled closed, wrapped closed, with lid closed, etc.) to ensure quality and prevent contamination against pests and rodents. Further review revealed goods that have been opened with no date, left on the floor, or not properly sealed will be discarded and all open dry good products are sealed, labeled, and dated. 2. Observation on 09/11/23 at 8:35 A.M. of the walk-in refrigerator revealed the following: 1/2 of a large bag of cheddar cheese cubes which was opened and sealed, the cheese appeared dried and was dated for 08/19/23; an almost full large bag of shredded carrots which was open and sealed, the carrots appeared watery and was dated for 08/14/23; 1/2 of a large bag of shredded mozzarella cheese which was open, sealed and not dated; one-half of a raw onion which was partially wrapped in cling wrap, dated 08/24, and watery; one large bag of shredded lettuce which not open but brown and watery; 3/4 of a gallon of scrambled eggs dated 09/11/23 which had a piece of aluminum foil on top which had a whole in it; and a pan of approximately 20 waffles dated 09/11/23 which had a piece of aluminum foil on top which had a whole in it and didn't completely cover the pan. An interview at the time with Cook/Dietary Aide #479 verified there were food items in the refrigerator which were not properly covered and protected from air, not dated when it was opened to know when to discard them and decaying but maintained in the refrigerator for use. Review of the facility policy titled, Food Storage (Dry, Refrigerated and Frozen), reviewed 08/12/23, revealed all open products (as able) will be sealed (rolled closed, wrapped closed, with lid closed, etc.) to ensure quality and prevent contamination against pests and rodents. Further review revealed goods that have been opened with no date, left on the floor, or not properly sealed will be discarded and all open refrigerated food products are sealed, labeled, and dated. 3. Observation on 09/11/23 at 8:50 A.M. of the large bench can opener revealed it was dirty with a dried black substance on the blade. [NAME] #483 took her fingernail and scraped a black, hard (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 27 of 35 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 09/14/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many substance off the can opener blade. An interview at the time with Cook/Dietary Aide #479 revealed the can opener had not been used for breakfast. She verified she had run the can opener through the dishwasher on 09/10/23 but did not wipe it off or inspect it. She reported she had never been trained to scrub or inspect the can opener for cleanliness. Review of the weekly cleaning schedules of all staff, A.M. cook and P.M. cook revealed no guidance for the cleaning of the large bench can opener. Interview on 09/12/23 at 3:33 P.M. with Regional Dietary Manger #465 verified the can opener was not on any cleaning schedule and should be. Review of the State of Ohio Food Inspection Report, dated 01/05/23, revealed equipment food-contact surfaces were unclean - the can opener was dirty. Review of the facility policy titled, Basic Cleaning Equipment, undated, revealed equipment will be maintained in a clean and sanitary condition after every use to ensure food safety. Further review revealed employees who use equipment will be responsible for washing and sanitizing removable parts after each use. 4. Observation on 09/11/23 at 8:52 A.M. of the walls, ceilings and floor in the food preparation area revealed a splattering of possibly food substances on the walls, ceilings, and floors. An interview at the time with [NAME] #483 verified the kitchen was dirty and since she had been an employee there had been no time to clean it. Observation on 09/11/23 at 8:55 A.M. of the hood vents revealed there was a grease like substance on the vents. An interview at the time with Cook/Dietary Aide #479 and [NAME] #483 verified the hood vents were dirty and they were not sure who was responsible for cleaning them. Review of the facility policy titled, Sanitation of Dietary Department, undated, revealed the dietary staff shall maintain the sanitation of the dietary department through compliance with written, comprehensive cleaning schedule. 5. Observation on 09/11/23 at 4:23 P.M. of Cook/Dietary Aide #480 walking through the kitchen and specifically the food preparation area wearing a ball cap. His hair came out the bottom of the cap and over the collar of his shirt. He also had a full beard. Neither his hair nor his beard was covered to protect the food preparation area. Interview on 09/11/23 at 4:24 P.M. with the DON verified Cook/ Dietary Aide #480 did walk through the kitchen and specially the food preparation area with his hair and beard not covered to protect the area. Review of the facility policy titled, Hair Restraints/Jewelry/Nail Polish, undated, revealed food and nutrition services employees shall wear hair restraints and beard guards. Further review revealed hairnets, hats or hair restraints will be worn at all times in the kitchen and beard guards or masks will be worn as indicated. 6. Observation on 09/12/23 at 10:07 A.M. of [NAME] #483 doffing (removing) her gloves while pureeing pork, using her left hand to lift the trash can lid and then donning (putting on) new gloves without washing her hands. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 28 of 35 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 09/14/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Observation on 09/12/23 at 10:12 A.M. of [NAME] #483 doffing her gloves while still pureeing pork, using her left hand to lift the trash can lid and then donning new gloves without washing her hands. Interview on 09/12/23 at 10:20 A.M. with [NAME] #483 verified she doffed (removed) her gloves, touched the trash can lid and donned (put on) new gloves without watching her hands. Residents Affected - Many Interview on 09/12/23 at 10:21 A.M. with Regional Dietary Manager #465 verified staff should wash their hands after doffing gloves and donning new gloves. Review of the facility policy titled, Hand Washing, reviewed 07/07/23, revealed hands should be washed after engaging in any activity that contaminates the hands and before putting on single-use durable non-absorbent gloves for working with food or clean dishes. 7. Observation on 09/12/23 at 10:16 A.M. of Regional Dietary Manger #465 washing the Robot Coup bowl after the completion of the pork puree. She took the bowl, lid, blade, and spatula to the three compartment sink and washed the four items in the sink using soap. Regional Dietary Manager #465 did not sanitize the four items and then took a towel and dried the outside of the Robot Coup bowl. The Robot Coup bowl was placed on the base and [NAME] #483 continued with the pureeing of green beans. The inside of the bowl, the lid and the blade were not dry. Interview on 09/12/23 at 10:26 A.M. with Regional Dietary Manager #465 verified she did not sanitize the four items she washed and she should have. She also verified the Robot Coup bowl, lid and blade were not dry prior to being used to puree the green beans. Review of the facility policy titled, Blender/Food Processor - Cleaning and Use, undated, revealed using a wiping cloth, wash canister and blade with hot detergent solution, rinse with clean, warm water, sanitize with sanitizing solution and allow to air dry. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 29 of 35 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 09/14/2023 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility policy review, the facility failed to ensure garbage and refuse was disposed of properly. This had the potential to affect all 44 residents residing in the facility. Residents Affected - Many Findings included: Observation on 09/11/23 at 5:45 P.M. of the two dumpsters behind the facility revealed multiple pieces of trash (multiple straws, plastic spoons, rubber gloves, and container caps) on the ground. Observation on 09/12/23 at 4:24 P.M. of the two dumpsters behind the facility revealed multiple pieces of trash (multiple straws, plastic spoons, rubber gloves, and container caps) on the ground. Interview on 09/12/23 at 4:25 P.M. with the Regional Dietary Manager #465 verified there were multiple pieces of trash outside the two dumpsters behind the facility and trash around a dumpster wound tend to draw in pests and vermin. Review of the facility policy titled, Trash Handling, undated, revealed outside dumpsters and the surrounding area are to be kept clean and free of debris. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 30 of 35 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 09/14/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and policy review, the facility failed to follow appropriate infection control practices by not ensuring a resident's indwelling urinary catheter bag was kept off the floor. This affected one (Resident #13) of one residents reviewed for catheters. Residents Affected - Few Findings include: A review of Resident #13's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included chronic pain syndrome, heart failure, chronic kidney disease, urinary retention, and difficulty walking. A review of Resident #13's physician's orders revealed she had the use of an indwelling urinary catheter to continuous drain. The order originated on 09/10/23. A review of Resident #13's care plans revealed she had a care plan in place for the potential for complications related to the use of an indwelling urinary catheter for urinary retention. The care plan was initiated on 09/11/23. The goal was for the resident to be free from catheter-related trauma through the review date. The interventions included the need to position the catheter bag and tubing below the level of the bladder and ensure the tubing is not under the resident's legs. On 09/12/23 at 8:45 A.M., an observation of Resident #13 noted her to be lying in a low bed on her left side facing the door. Her indwelling urinary catheter bag was noted to be resting on the floor. A subsequent observation of the resident on 09/13/23 at 8:48 A.M. noted her to be lying in her low bed on her right side facing the window. Her indwelling urinary catheter bag was hanging on the bed frame on the right side of the bed and was in direct contact with the floor. On 09/13/23 at 9:18 A.M., an interview with State Tested Nursing Assistant (STNA) #404 revealed the aides were responsible for catheter care and did it every shift. They were also responsible for emptying the catheter bags and to make sure it was maintained off the floor and below the level of the resident's bladder. She confirmed Resident #13 had the use of a indwelling urinary catheter and was also in a low bed as a fall prevention intervention. She was asked how they ensured the catheter bag was being maintained off the floor when a resident was in a low bed. She stated it was not easy, if the resident was in a low bed. She indicated, if the indwelling urinary catheter's collection bag was in contact with the floor, it could contaminate it. She was asked to go to Resident #13's room to see if her catheter bag was being maintained off the floor to prevent possible contamination. She verified the catheter bag was in direct contact with the floor. She moved the catheter bag from the middle of the bed and secured it to the bed frame at the foot end of the bed. In doing so, the catheter bag was raised off the floor. A review of the facility's policy on Urinary Catheter Care revised September 2014 revealed the purpose of the procedure was to prevent catheter- associated urinary tract infections. Under the infection control section of the policy, the staff were directed to be sure the catheter tubing and drainage bag were kept off the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 31 of 35 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 09/14/2023 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's infection control log, review of infection reports, staff interview, and policy review, the facility failed to maintain an effective antibiotic stewardship program to ensure antibiotics were not used unnecessarily. This affected two (Resident #4 and #42) of five residents reviewed for antibiotic use. Residents Affected - Few Findings include: 1. A review of Resident #4's medical record revealed she was admitted to the facility on [DATE] with the diagnoses of dementia with behavioral disturbances, chronic pain syndrome, adult onset diabetes mellitus, and congestive heart failure. She was hospitalized on [DATE] and re-admitted to the facility on [DATE]. A review of Resident #4's physician's orders revealed there was an order for the resident to be sent to the hospital for an evaluation on 08/02/23. There was another physician's order dated 08/07/23 for the resident to receive Ceftriaxone (Rocephin) 250 milligrams (mg) IM every day until 08/13/23 for a diagnosis of a UTI and Diflucan (anti-fungal medication) 100 mg by mouth one time a day until 08/17/23 related to a UTI. A review of Resident #4's medication administration record (MAR) for August 2023 revealed five doses of the IM Rocephin was administered to the resident between 08/08/23 and 08/13/23. The dose that was due on 08/09/23 was not administered to the resident as a 5 was added to the box in which the nurse was to initial to show the medication was administered as ordered. The legend indicated a 5 meant to hold/ see nurses' notes. The resident received the Diflucan 100 mg by mouth once daily as ordered through 08/17/23. A review of Resident #4's hospital records for her hospitalization between 08/02/23 and 08/07/23 noted a history and physical report that indicated the resident was sent to the hospital for a change in her mental status with agitation. Her work up in the emergency room showed a slightly elevated ammonia level and a UTI. She was afebrile with a temperature of 97.4 degrees Fahrenheit (F.). Her assessment and plan indicated she had acute cystitis (inflammation of the urinary bladder) with hematuria (blood in the urine) present. Her urine was growing yeast and Diflucan was to be added. Her unusual change in behavior was thought to possibly be caused by an infection. A review of Resident #4's laboratory tests completed in the hospital revealed a urinalysis was collected on 08/02/23. The preliminary report identified Urogenital Flora (normal bacteria that live in the urogenital tract that helps maintain a healthy balance in the tract to prevent infections and other health problems) being present in her urine. The final report on 08/05/23 revealed urogenital flora and Candida Glabrata (species of yeast that lived naturally in and on the body most commonly in the GI tract, the mouth, and the genital area, and can be found as a part of your natural microflora). Both colony counts were only between 1,000 to 5,000 CFU's/ milliliter (ml). A repeat urinalysis collected on 08/06/23 showed a preliminary report with no growth of any organisms after 24 hours. The final report verified on 08/09/23 revealed Candida Glabrata was the only organism identified and had a colony count of 10,000 to 20,000 CFU/ml. Further review of Resident #4's medical record revealed a re-admission history and physical (H&P) was completed on 08/08/23 at 9:00 A.M. The H&P indicated the resident was recently admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 32 of 35 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 09/14/2023 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 hospital with the diagnosis of a UTI or cystitis. She was indicated to be on IM Rocephin at the time the H&P was completed. Her assessment on the H&P revealed she had no constitutional symptoms like fever, chills, body aches, or fatigue. She denied any dysuria or hematuria. She was afebrile with a temperature of 98 degrees F. The impression on the H&P indicated she had a UTI with fungal infection. The plan was to continue all her medications and no change in her treatment plan was made at that time. Residents Affected - Few A review of the facility's infection control log for August 2023 revealed Resident #4 was added to the log to show she had a UTI with an onset date of 08/08/23. The organism cultures was identified as Candida Glabrata. The antibiotic ordered to treat the infection was identified as Rocephin 250 mg IM every day with a completion date of 08/13/23. The infection control log indicated the resident met criteria for treatment of a UTI. A review of Resident #4's infection report (antibiotic criteria sheet) revealed the resident did not have the use of an indwelling urinary catheter at the time of the event onset. The date of the even was indicated to be 08/08/23. The infection report indicated the resident had a clean catch voided urine specimen collected with greater than 100,000 CFU/ml of no more than two species of microorganisms. The date of the culture was indicated to be 08/09/23. The organism cultures was identified as Candida Glabrata. A note under the laboratory testing section indicated yeast and other microorganisms, which were not bacteria were not acceptable UTI pathogens. Mixed flora was not considered an organism. On 09/13/23 at 10:50 A.M., an interview with LPN #467 revealed she reviewed residents upon their readmission to the facility following a hospitalization to see if an antibiotic had been ordered while out of the facility. She confirmed Resident #4 was placed on IM Rocephin for the treatment of a UTI while hospitalized between 08/02/23 and 08/07/23. She confirmed the laboratory testing done at the hospital (to include a urinalysis) did not support the resident having a UTI. She acknowledged the resident was given five doses of IM Rocephin between 08/08/23 and 08/13/23 when the hospital's urinalysis only showed evidence of the resident having a yeast infection. She further acknowledged the Diflucan ordered along with the IM Rocephin would have been an appropriate treatment for her yeast infection, without the resident requiring IM Rocephin. She claimed she reviewed the hospital's diagnostic tests that were obtained while the resident was hospitalized , but she was not sure what kind of organism Candida Glabrata was. She was not aware that organism was yeast and it would rule out the resident as having a UTI that met criteria for treatment. A review of the facility's Antibiotic Stewardship policy revised in December 2016 revealed antibiotics would be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The purpose of the antibiotic stewardship program was to monitor the use of antibiotics in their residents. When a resident was admitted from an emergency department, the admitting nurse would review discharge and transfer paperwork for antibiotic orders. When a culture and sensitivity was ordered, lab results would be communicated to the prescriber as soon as available to determine if the antibiotic therapy should be continued, modified or discontinued. 2. Review of Resident #42's medical record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's disease, essential hypertension, type two diabetes mellitus, hyperlipidemia, and depression. Review of Resident #42's quarterly Minimum Data Set (MDS), dated [DATE], revealed a staff assessment for mental status should be conducted and she had short-term and long-term memory problems. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 33 of 35 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 09/14/2023 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 Resident #42's progress note, dated 08/06/23 at 8:00 A.M., revealed she had increased episodes of incontinence with little output. She was also walking holding the area of her lower back and lower pelvic region. The physician obtained an urinalysis and culture and sensitivity. There was no documentation of any staff requesting to not start an antibiotic until the culture results were obtained. Review of Resident #42's physician order, dated 08/06/23, identified she was to receive Bactrim DS oral tablet 800-160 mg one tablet by mouth two times a day for a urinary tract infection for seven days. Further review of the physician orders revealed it was discontinued on 08/07/23. Review of Resident #42's physician order, dated 08/07/23, identified she was to receive Clindamycin HCL oral capsule 300 mg by mouth three times a day for a urinary tract infection until 08/14/23. Review of Resident #42's medication administration record (MAR), dated 08/23, revealed she received one dose of the Bactrim DS 800-160 mg the evening of 08/06/23, two doses on 08/07/23 and then it was discontinued. Further review revealed the Clindamycin 300 mg was administered three doses each day from 08/08/23 to 08/14/23. Review of Resident #42's urine culture results, dated 08/07/23, revealed she had greater than 100,000 CFU/ml of Lactobacillus species (A) which is normal flora. No susceptibility was obtained due to it being normal flora. Further review revealed the physician was notified and directives were given to start Clindamycin. Interview on 09/13/23 at 2:00 P.M. with Licensed Practical Nurse (LPN) #467, the facility infection preventionist, revealed the physician ordered the Bactrim at the same time as the urinalysis with culture and sensitivity was ordered on 08/06/23. She verified Resident #42's culture results, dated 08/07/23, revealed she needed to be on a different antibiotic and on 08/07/23 Clindamycin was ordered. LPN #467 verified antibiotic stewardship was not followed because an antibiotic was started prior to obtaining the urine culture results and based on the results Resident #42 was not on the correct antibiotic. Review of the facility policy titled, Antibiotic Stewardship, revised 12/16, revealed orientation, training, and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 34 of 35 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 09/14/2023 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure the ice machine drain had an air gap to prevent potential backflow of drain contents into the ice machine. This had the potential to affect all 44 residents residing in the facility. Residents Affected - Many Findings included: Observation on 09/12/23 at 7:23 A.M. of the facility ice machine, which was located in the hallway outside of the kitchen, revealed there was no air gap between the ice machine and the drain. Interview on 09/12/23 at 7:25 A.M. with the Maintenance Director #432 verified there was no air gap between the ice machine and the drain. He verified that microorganisms could backflow into the ice machine since there was no air gap which could lead to contaminated ice and illness for the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 35 of 35