Inspection visit

Health inspectionOctober 12, 2023

CENTERBURG POINTECMS #36629914 citations on this visit

14 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 14 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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** Based on record review and resident and staff interviews, the facility did not ensure Resident #105 participated in and received a copy of her baseline care plan within 48 hours of admission. This affected one resident (Resident #105) of two residents reviewed for baseline care plans. The facility census was 59. Findings Include: Review of Resident #105's medical record revealed the resident admitted on [DATE] with diagnoses including diabetes, atrial fibrillation, hypertension and displaced intertrochanteric fracture of left femur. The resident discharged on 10/11/23. Resident #105 was listed as her own guarantor, and no other responsible parties were listed. Further review of the medical record revealed there was no baseline care plan, nor comprehensive plan of care in lieu of the baseline care plan, signed by Resident #105 to serve as evidence Resident #105 agreed to initial care goals and services and treatments that would be provided by the facility and personnel acting on behalf of the facility. There was one document regarding resident centered care all about me information and revealed the form was dated 10/09/23 at 9:40 A.M. The form documented Resident #105's preferred name, care preferences including showering and bathing preference and time of day preferred, wake and bedtime preferences, and therapy service time preference. The form was signed by the activity director and there was no resident signature. Interview with Resident #105 on 10/10/23 at 1:10 P.M. revealed she did not know if a care plan meeting had been held on her behalf, and she had not received a copy of any care plan. Interview with Social Service Director (SSD) #500 on 10/11/23 at 4:15 P.M. confirmed an initial care plan meeting with Resident #105 to discuss care goals, services and treatments was not completed within 48 hours of admission having just had the initial care plan meeting on 10/09/23. SSD #500 stated the initial resident care path was completed five to seven days after admission and then a resident care conference occurred in the first month at the facility. Review of the Policy titled Interim/Baseline Care Planning Policy, dated 11/28/16 with a revision date of 08/11/20, revealed within 48 hours of admission, the facility will develop and implement an interim/baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident until a comprehensive assessment can be completed, leading to a comprehensive care plan. The baseline care plan will be used until the comprehensive assessment and care plan is developed by the interdisciplinary team. The procedure to implement will include involving the interdisciplinary team and the resident and/or residents family and/or resident's (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 26 Event ID: 366299 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 366299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011 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 responsible party. 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: 366299 If continuation sheet Page 2 of 26 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 366299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on record review, observation and interview, the facility failed to ensure physician orders were obtained to provide treatment to an area of skin impairment for Resident #40. The affected one (#40) resident of seven residents reviewed for wounds. The facility census was 59. Review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cellulitis and chronic venous hypertension with ulcer and inflammation to lower left leg. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no hallucinations, required supervision for activities of daily living, was occasionally incontinent of bladder and always continent of bowel. The resident was coded as being at risk for pressure ulcers but as not having any pressure ulcers. Review of a progress note dated 10/09/23 at 1:25 P.M. revealed Resident #40 had dry skin caught in her sock and a skin tear occurred when the podiatrist removed the sock for a nail assessment. The wound was cleansed, and dressing applied. Review of Resident #40's treatment administration record and physician orders revealed there was no treatment ordered or documented wound care for the Resident's skin tear which occurred on 10/09/23. Interview with Resident #40 on 10/10/23 at 11:05 A.M. revealed the resident had an area to her left ankle the facility was treating. Observation of wound care on 10/11/23 at 11:14 A.M. performed by Registered Nurse (RN) #143 revealed the wound was wrapped with Kerlix (gauze), had an ABD pad (absorbent dressing) over the Xeroform (wound cover) which was placed on the wound. The wound dressing removed was not dated with the day the dressing was applied. The wound was observed to be cleansed with normal saline, and redressed with Xeroform, an ABD pad and wrapped with Kerlix. The dressing was dated 10/11/23, and initialed by the nurse. Interview with RN #143 on 10/11/23 at 11:16 A.M. confirmed she was the RN who provided wound care to the residents. RN #143 verified she had been employed at the facility about two months. RN #143 stated Resident #40 had very dry skin and often refused to have her lotion applied. Interview with RN #143 on 10/11/23 at 11:47 A.M. confirmed she was the nurse who initiated the wound care for resident #40 after the skin tear occurred on 10/09/23. RN #143 verified the wound treatment was not ordered, and she was just putting the wound care orders in place stating after she had dressed the wound on 10/09/23 all craziness broke out and she had just gotten to put the orders in the computer. RN #143 revealed she was having the nurse practitioner see the resident's wound on 10/13/23 when rounds are made. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366299 If continuation sheet Page 3 of 26 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 366299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policies, the facility failed to ensure pressure reducing interventions were in place for Resident #9, #10, and #305. This affected three residents (#9, #10, and #305) of seven residents reviewed for skin impairment or pressure ulcers. The facility census was 59. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 12/01/10 with diagnoses including major depressive disorder, type two diabetes mellitus, sleep disorder, dissociative and conversion disorders, Alzheimer's disease, and mild cognitive impairment. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was rarely or never understood. Review of the plan of care dated 12/02/20 revealed Resident #9 was at risk for impaired skin integrity related to incontinence, fragile skin, impaired mobility, impaired cognition, and diagnoses. Interventions biweekly skin checks, barrier cream after incontinence, cushion to wheelchair, encourage fluids, encourage and assist to elevate heels off mattress, pillows for positioning, pressure reducing mattress, treatments as ordered, and turning and repositioning as tolerated. Review of the physician order dated 10/01/21 revealed Resident #9 was to lay down between meals to take pressure off of her coccyx. Review of the meal times revealed breakfast was at 7:30 A.M., lunch was at 11:30 A.M., and dinner was at 5:00 P.M. Observation on 10/10/23 at 10:22 A.M. and on 10/11/23 at 8:37 A.M., 9:31 A.M., 9:57 A.M., 11:24 A.M., 12:30 P.M., and 1:33 P.M. revealed Resident #9 was in her wheelchair in the common area or in her room sitting in her wheelchair. Interview on 10/11/23 at 2:35 P.M. with Registered Nurse (RN) #117 revealed Resident #9 had been recently put to bed. RN #117 verfied she had been otherwise up in her chair and revealed being unaware of any time schedule for Resident #9 to be in bed. Interview on 10/11/23 at 4:41 P.M. with the Director of Nursing (DON) verified Resident #9 had a physician order to lay down after meals to reduce pressure. Interview and observation on 10/12/23 at 10:01 A.M. with State Tested Nursing Aide (STNA) #154 verified Resident #9 was up in her chair instead of being put back to bed after breakfast. Review of the policy Skin and Wound Care Pest Practices revised 06/10/22, revealed pressure reduction and redistribution should be provided for those at risk. They should be provided according to interdisciplinary assessment and recommendation. 3. Review of the medical record for Resident #10 revealed an admission date of 07/08/23 with readmission on [DATE]. Diagnoses included chronic kidney disease, bipolar disorder, depression, vascular (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366299 If continuation sheet Page 4 of 26 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 366299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011 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 0686 disease, muscle weakness and heart failure. Level of Harm - Minimal harm or potential for actual harm Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact with a BIMS of 13 and required extensive assistance of two staff members for bed mobility and was totally dependent for transfers. Residents Affected - Few Review of care plan dated 07/10/23 revealed Resident #10 was at risk of skin impairments with interventions including administer medications and treatments as ordered, assess and document the status of the area (healing or declining), monitor document and report to physician any changes in wounds, turn and reposition as indicated. Resident had potential for skin breakdown related to decreased mobility with interventions to turn and reposition, use pressure reducing devices as indicated and complete skin assessments. Review of Physician order dated 07/08/23 revealed order to elevate heels off bed as tolerated for preventative care. Physician order dated 08/08/23 for Prevlon boots on while in bed for wound care prevention. Review of orders dated 07/08/23 revealed order to turn and reposition as tolerated and while in bed. Review of progress notes revealed no noted documentation of residents refusal to wear the prevalon boots or offload heels. Observation on 10/10/23 at 9:40 A.M., 11:10 A.M., 2:05 P.M., 4:20 P.M. revealed observations of Resident #10 laying in bed flat on his back with no off loading support and prevlon boots sitting in the chair next to Resident's bed. Interview and observation dated 10/11/23 at 11:59 A.M. with Resident #10 revealed he was laying in bed with his heels pressed upon the bed matress. Resident #10 had prevlon boots sitting on the chair next to his bed. Resident 10 said he had boots to wear on his legs/feet and confirmed they were sitting on his chair and he was not wearing boot while in bed. Interview and observation on 10/12/23 at 9:03 A.M. with Registered Nurse (RN) #149 confirmed Resident #10 had his feet placed with heels pressed against the matress. RN #149 confirmed Resident #10 should be wearing Prevlon boots for off loading support. RN #149 confirmed orders were in place for off loading, repositioning and to wear the prevlon boots while in bed. Observation on 10/12/23 at 11:00 A.M. revealed resident was in the same position flat on his back with heels pressed into matress and prevlon boots were sitting on dresser in the same spot as two hours prior. Review of facility policy titled Skin and Wound care Best Practices, dated 06/10/22 revealed facility shall provide evidence based prevenative based skin care and treatment to prevent skin complications. This deficiency represents noncompliance investigated under complaint OH00146954. 2) Review of Resident # 305's medical record revealed Resident #305 was admitted to the facility on [DATE] with the diagnoses including congestive heart failure, cardiomyopathy, high blood pressure, diabetes mellitus type two, weakness, and alcohol dependency. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366299 If continuation sheet Page 5 of 26 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 366299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #305's admission assessments revealed Resident #305 had impaired cognition and required extensive assistance from staff to complete activities of daily living (ADL) tasks including dressing, personal hygiene, bed mobility, and transfers. Review of Resident #305 physician orders revealed an order dated 10/01/23 for the application of Prevalon boots (pressure relieving devices) to bilateral lower legs and feet to be worn at all times and may be removed for bathing and hygiene. Review of Resident #305's baseline care plan dated 10/05/23 revealed Resident #305 had potential for skin breakdown with the goal of Resident #305's skin to remain intact with the implementation of interventions including the use of pressure relieving devices as indicated. Observations on 10/10/23 at 12:06 P.M. revealed Resident #305 sitting in a wheelchair, there were no pressure relieving devices in place to bilateral lower legs and feet. Further observation on 10/10/23 at 2:47 P.M. revealed a set of green colored pressure relieving devices laying on the top of the clothes armoire located in Resident #305's room. Observations on 10/11/23 at 6:38 A.M. and at 1:00 P.M. and again on 10/12/23 at 8:15 A.M. revealed Resident #305 did not have the pressure relieving devices in place to bilateral lower legs and feet. The green colored pressure relieving devices remained on the top of the clothes armoire in Resident #305's room. Interview on 10/12/23 at 8:15 A.M. with the Director of Nursing (DON) confirmed Resident #305 was laying in bed without the pressure relieving devices in place to bilateral lower legs and feet. Further confirmation by the DON revealed the pressure relieving devices were laying on top of the clothes armoire in Resident #305's room. Review of the facility's policy titled, :Skin and Wound Care Best Practices revised date 06/10/22 revealed, Provide pressure redistribution/relief devices according to interdisciplinary assessment and recommendation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366299 If continuation sheet Page 6 of 26 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 366299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policies, the facility failed to ensure fall interventions were in place for Resident #1 and #38 and failed to ensure Resident #29 had smoking assessment upon admission and quarterly This affected three residents (#1, #38, and #29) of six residents reviewed for accidents/hazards. The facility census was 59. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 09/02/16 with diagnoses including schizophrenia, dysphagia, dementia, depression, anxiety, type two diabetes mellitus, heart failure, and cerebral palsy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 had severely impaired cognition. She'd had one fall since the previous assessment. Review of the plan of care dated 10/01/16 revealed Resident #1 was at risk for falls characterized by history of falls, injury, and or multiple risk factors related to impaired balance, non-ambulatory, receives diuretic, antianxiety, antidepressant, and antipsychotic medications, and diagnoses. Interventions included assisting with mobility, keeping the bed in the lowest position, applying dycem to grab bar in bathroom, nonskid strips to exit side of bed, in front of commode, and in the room's doorway, and wheelchair at bedside when resident was in bed. Review of the physician order dated 09/22/18 revealed Resident #1 was to have nonskid strips in front of her toilet. Observation on 10/10/23 at 12:05 P.M., 10/11/23 at 11:00 A.M., and 10/12/23 at 8:00 A.M. revealed there were no nonskid strips in Resident #1's room or bathroom. Interview on 10/11/23 at 10:36 A.M. with State Tested Nursing Aide (STNA) #154 verified there were no nonskid strips in the resident's room. 2. Review of the medical record for Resident #38 revealed an admission date of 06/29/21 with diagnoses including bipolar disorder, anxiety disorder, Alzheimer's disease, and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition. Review of the plan of care dated 05/05/23 revealed Resident #38 was at risk for falls. On 10/18/22 she had a fall without injury and on 05/04/23 she had an unwitnessed fall without injury. Interventions included keeping the bed in the lowest position, maintaining needed items within reach, nonskid strips to the doorway and exit side of bed, offering to lay down between meals, and tilt and space wheelchair for mobility. Observation on 10/10/23 at 12:30 P.M.,10/11/23 at 11:00 A.M., and 10/12/23 at 8:00 A.M. revealed there were no nonskid strips in Resident #38's room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366299 If continuation sheet Page 7 of 26 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 366299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011 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 Interview on 10/11/23 at 10:36 A.M. with State Tested Nursing Aide (STNA) #154 verified there were no nonskid strips in the resident's room. 3) Review of Resident #29's medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including brain cancer, lung cancer, depression, alcohol dependence and nicotine dependence. Review of Resident #29's physician orders revealed the order dated 05/15/23 as Resident #29 being an independent smoker. Review of Resident #29's quarterly [NAME] Data Set (MDS) dated [DATE] revealed Resident #29 had intact cognition and required supervision by staff for activities of daily living (ADL) tasks. Review of Resident #29's care plan dated 04/06/22 revealed Resident #29 was an independent smoker with the goal for Resident #29 to maintain a safe smoking environment with the implementation of interventions including staff to complete smoking assessments to ensure continued safety while smoking. Review of Resident #29 admission assessments revealed there were no smoking assessments or smoking evaluations completed upon admission to the facility on [DATE]. Further review of Resident #29's assessments revealed a quarterly smoking assessment completed on 05/15/23. Observation on 10/11/23 at 1:30 P.M. revealed Resident #29 independently smoking with other residents. Interview on 10/12/23 at 9:09 A.M. with Licensed Practical Nurse (LPN) #118 revealed the initial smoking evaluation and assessment should be completed upon admission to the facility and then quarterly smoking assessments should be completed each quarter to coincide with the scheduled quarterly MDS. LPN #118 confirmed Resident #29 did not have an admission smoking evaluation or assessment completed and the only quarterly smoking assessment was completed on 05/15/23. Review of the facility's policy titled, Resident Smoking Policy revised date 10/20/22 revealed, During the admission process, nursing will ask resident if they smoke or if they have the intent to smoke while in the facility. Anyone answering yes is further assessed for smoking safety awareness and the need for reasonable physical or safety accommodations. The assessment is completed thereafter on readmission, quarterly, and with any significant change in the resident's condition. This deficiency represents noncompliance investigated under complaint OH00146954. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366299 If continuation sheet Page 8 of 26 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 366299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy and interviews, the facility failed to ensure weights were completed as ordered and the physician was notified of weight changes for Resident #22 and Resident #305. This affected two residents (#22 and #305) out of five residents reviewed for nutrition. The facility census was 59. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 08/25/23 with diagnoses including chronic pulmonary edema, anxiety disorder, acute and chronic respiratory failure, cognitive communication deficit, and acute on chronic diastolic heart failure. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 had intact cognition. Review of the physician order dated 08/26/23 to 08/29/23 revealed Resident #22 was to be weighed every day shift at the same time each morning. The heart failure center and primary care physician were to be notified of weight gain or loss of more than two pounds overnight or five pounds in one week. Review of the physician order dated 08/30/23 revealed Resident #22 was to be weighed daily at 6:00 A.M., she was to be weighed at the same time each morning. The heart failure center and primary care physician were to be notified of weight gain or loss of more than two pounds overnight or five pounds in one week. Review of Resident #22's weights revealed she experienced a two pound (lbs.) or more weight change from 09/03/23 (216.0 lbs.) to 09/04/23 (214.0 lbs.), from 09/05/23 (213.4 lbs) to 09/06/23 (215.4 lbs.), from 09/10/23 (217.0 lbs.) to 09/11/23 (214.4 lbs.), from 09/16/23 (216.8 lbs.) to 09/17/23 (224.0 lbs.), from 09/22/23 (222.8 lbs.) to 09/23/23 (218.2 lbs.), from 10/02/23 (219.0 lbs.) to 10/03/23 (215.0 lbs.), from 10/08/23 (214.6 lbs.) to 10/09/23 (218.8 lbs.), and from 10/09/23 (218.8 lbs.) to 10/10/23 (214.8 lbs.). Review of Resident #22's weights revealed she experienced a five-pound weight change in a week from 08/27/23 (223.2 lbs.) to 09/04/23 (214.0 lbs.), from 09/10/23 (217.0 lbs.) to 09/17/23 (224.0 lbs.), and from 09/17/23 (224.0 lbs.) to 09/24/23 (217.0 lbs.). Review of the progress notes from 08/27/23 to 10/10/23 revealed no evidence the physician or heart failure center was notified of weight changes. Interview on 10/12/23 at 11:00 A.M. with the Director of Nursing (DON) verified there was no evidence the physician was notified of weight changes. 2. Review of Resident #305's medical record revealed Resident #305 was admitted to the facility on [DATE] with the diagnoses including congestive heart failure, cardiomyopathy, high blood pressure, diabetes mellitus type two, and alcohol dependency. Review of Resident #305's admission assessments revealed Resident #305 had impaired cognition and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366299 If continuation sheet Page 9 of 26 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 366299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm required extensive assistance from staff to complete activities of daily living (ADL) tasks including dressing and transfers. Review of Resident #305 physician orders revealed an order dated 10/05/23 for the completion of daily weights related to the diagnosis of congestive heart failure. Residents Affected - Few Review of Resident #305's weight record revealed entries for completed weights on 09/28/23 at 223 pounds (lbs.), 10/01/23 at 234 lbs., 10/6/23 at 235.1 lbs., and 10/8/23 at 236.2 lbs. indicating from 09/28/23 to 10/08/23 Resident #305's weight had increased significantly by 13.2 lbs. or 5.58 percent in 10 days. Review of Resident #305's baseline care plan dated 10/05/23 revealed Resident #305's weight is to be monitored due to potential weight fluctuations related to fluid retention caused by congestive heart failure. Review of Resident #305's Point of Care (POC) task documentation revealed weight entries for 09/28/23 to 10/11/23 with only one entry dated 10/09/23 at 2:22 A.M. marked not applicable to obtain Resident #305's weight. Interview on 10/12/23 at 8:14 A.M. with the Director of Nursing (DON) confirmed Resident #305 was not being monitored for fluid retention related to congestive heart failure by the lack of daily weights being obtained per the physician's order. Review of the facility's policy titled, Weight Policy revised date of 02/01/20 stated obtaining accurate weights is vital for the nutritional assessment of each resident and can be used as a basis for medical and nutritional intervention. Nursing is responsible for the determination of each individual's weight. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366299 If continuation sheet Page 10 of 26 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 366299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure pain was addressed timely and appropriately for Resident #258. This affected one (Resident #258) of four residents reviewed for pain. Facility census was 59. Residents Affected - Few Findings include: Review of the medical record for Resident #258 revealed an admission date of 10/09/23 and discharge date on 10/11/23. Diagnoses included fracture of fibula, fracture of tibia, osteoarthritis, depression, anxiety, and osteoporosis. Review the admission assessment dated [DATE] revealed Resident #258 arrived to the facility at 6:00 P.M. from the hospital. Review of the care plan dated 10/09/23 revealed Resident #258 had potential for pain with interventions to administer pharmacological interventions as ordered and assess residents pain for verbal and non verbal indicators. Review of physician orders dated 10/09/23 revealed an order for oxycodone-acetaminophen (pain medication containing narcotics) oral tablet 10-325 mg to be given every six hours as needed. Review of EBOX (a secured, electronic prescription containment and dispensing system) contents list revealed oxycodone-acetaminophen 10-325 mg was available in the facility upon order from a physician. Review of the Medication Administration Record (MAR) dated 10/2023 revealed Resident #258 received one dose of oxycodone-acetaminophen medication late afternoon on 10/10/23 and one dose in the morning 10/11/23. Review of progress notes dated 10/09/23 to 10/11/23 revealed no mention of pain assessments after the initial admission. Interview on 10/10/23 at 1:45 P.M. with Resident #258 revealed she was not provided with pain medication upon request in a timely manner. She revealed she requested pain medication and had to wait about two hours before staff brought in pain meds. She revealed she told the State Tested Nursing Aide (STNA) #111 that she was in pain and the STNA informed the nurse. After a while she told the STNA she never received pain medication as requested and the STNA got the Director of Nursing (DON) involved. Resident #258 revealed the DON came and spoke with her and that was the only reason she was given the pain medication around the two hour mark after asking for it. Resident #258 revealed she had admitted the previous day and not received any pain medications since before she left the hospital to come to the facility. Interview on 10/10/23 at 1:51 P.M. with STNA #111 revealed Resident #258 had informed her she was in pain and asked for a pain medication. STNA #111 revealed she informed the bedside nurse right away. STNA #111 revealed resident reported to her she was still waiting on her pain medication so STNA reported the delay in pain treatment to the DON who went and spoke with Resident #258 and was able to get her pain medication. Interview on 10/11/23 at 4:45 P.M. with DON confirmed resident had complained about not getting the pain medication timely and revealed she was asked by staff to speak with her after she had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366299 If continuation sheet Page 11 of 26 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 366299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few requested a pain medication that was not provided timely. The DON revealed after looking into her medications, DON found resident was changed from getting pain medication every four hours at the hospital to every six hours at the facility and the DON believed Resident #258 did not understand the change in timing. The DON revealed she had no explanation as to why Resident #258 was only given one pain medication dose on 10/10/23 and one on 10/11/23. The DON confirmed Resident #258 should have been able to receive pain medication every six hours as ordered and verified the lack of pain assessments. Review of policy titled Physician/Provider Orders dated 12/14/21 revealed the charge nurse shall review all physician orders upon admission. The facility did not have a policy related to following Physician orders or providing medications as ordered. Review of policy titled Pain Management Protocol, dated 10/24/22, revealed facility shall ensure residents are assessed for pain. Residents pain shall be addressed by pharmalogical and nonpharmalogical interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366299 If continuation sheet Page 12 of 26 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 366299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011 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. Based on record review, observation, interview and review of facility policy, the facility did not ensure an assessment for the appropriateness of use of bed rails versus alternatives was completed for Resident #259. This affected one resident (#259) of four residents reviewed for accidents/hazards. The facility census was 59. Findings include: Review of the medical record for Resident #259 revealed an admission date of 10/09/23. Diagnoses included fracture of humerus, diabetes, anxiety, fatigue, and dementia. Review of the Minimum Data Set (MDS) 3.0 assessment revealed the MDS had not yet been completed due to new admission. Review of physician orders revealed no evidence of order for bed rails of any kind. Review of assessments revealed no evidence of a bed rail or safety assessment being completed prior to Resident #259 being given bed rails. Review of the care plan revealed no evidence of bed rails being included in the care plan. Interview and observation on 10/10/23 at 11:54 A.M. with Resident #259 revealed she had bilateral bed rails on her bed, resident was lying in bed with a right arm fracture with her arm in a sling. The resident revealed she was not sure why the bed had bed rails on it and revealed she did not have much strength and did not use them to get adjusted in bed. Observation on 10/11/23 at 11:57 A.M. of Resident #259 revealed her bed had bilateral bed rails. Interview and observation on 10/11/23 at 12:20 P.M. with Registered Nurse (RN) #136 confirmed Resident #259 had bilateral bed rails and revealed she did not know why. RN #136 confirmed Resident #259 did not have physician order for bed rails and did not have any assessments for bed rails or safety with bed rails. RN #136 confirmed resident had a broken arm in a sling and revealed a bedrail on that side of the bed would not be appropriate as it could not be used to pull herself up. RN #136 also confirmed the admission checklist in Resident #259's paper chart included a check off for bed rails including assessment and physician order and revealed this section was left blank. Interview on 10/11/23 at 12:45 P.M. with the Administrator and Director of Nursing (DON) at 12:55 P.M. revealed the admission checklist was an internal document and although it was a part of the paper medical record, the facility would not provide a copy for the survey and survey team to review and removed it from the chart. Interview on 10/11/23 at 12:55 P.M. with the DON acknowledged a resident should be assessed for the need and safety of bed rails and they should be ordered by a physician prior to use and should also be part of the care plan. DON reviewed the care plan and confirmed it did not have bed rails included. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366299 If continuation sheet Page 13 of 26 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 366299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011 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 Review of the policy titled, Bed Rail Policy, dated 04/25/23. revealed facility would use bed rails only in limited circumstances to treat a medical condition and enhance functional abilities. The facility would attempt to use appropriate alternatives prior to use of bed rails. If a bed rail would be used, first the facility would assess for potential risks, assess for risk verse benefit and review with resident and or representative, obtain consent prior to installation, ensure proper dimensions based on residents' size and weight, and install them based on the manufacturer's guidelines. This deficiency represents non-compliance identified during the investigation of Complaint Number OH00146954. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366299 If continuation sheet Page 14 of 26 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 366299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Many Based on record review and staff interview the facility failed to have eight consecutive hours daily of Registered Nurse (RN) coverage in the facility. This had the potential to affect the 59 residents who resided at the facility. Findings include: Review of the payroll based journal information revealed the facility failed to have eight consecutive hours of Registered Nurse (RN) coverage in the facility on 01/01/23, 01/07/23, 01/21/23, 02/04/23 and 02/05/23. Interview with Assistant Administrator (AA) #131 on 10/10/23 at 4:40 P.M. confirmed there was no RN in the facility on 01/01/23, 01/07/23, 01/21/23, 02/04/23 and 02/05/23. AA #131 stated the Director of Nursing (DON) during that time stated she was available and on call on those days. AA #131 stated the DON did not realize having a RN available and on call did not meet the requirement. AA #131 stated the facility had prioritized the hire of RN's even for Licensed Practical Nurse (LPN) positions and the facility utilized RN agency staff and this had not continued to be a problem. The deficient practice was corrected on 02/28/23 when the facility implemented the following corrective actions: • Education was provided on 02/28/23 to the DON and the Assistant Director of Nursing by the Administrator/designee regarding of the staffing requirement and the need for the RN to be present in the facility and if the RN scheduled called off the DON or another RN designated by the DON would be required to come to the facility. • Monitoring of the nursing schedule completed by the Assistant Administrator was completed weekly for four weeks then monthly times two months. Review of the the monitoring revealed the weekly monitoring was performed in March 2023 and the monthly monitoring was performed in April 2023 and May of 2023. There was no current non-compliance identified at the time of the annual survey completed on 10/12/23. Review of the staffing tool completed for 09/24/23 through 09/30/23, the daily staffing posting for 09/23/23 through 09/29/23 and the daily staffing for 10/10/23 through 10/12/23 confirmed there was an RN in the facility for eight consecutive hours daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366299 If continuation sheet Page 15 of 26 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 366299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011 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 interview and record review the facility failed to monitor blood pressure according to medication parameters and failed to ensure parameters were in place for pain medication for Resident #35. This affected one resident (#35) of six residents reviewed for medications. The facility census was 59. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #35 revealed an admission date of 09/10/21 with diagnoses including depression, anxiety, Parkinson's disease, hypertension, and chronic atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had intact cognition. Review of the plan of care dated 08/24/22 revealed Resident #35 was at risk for altered cardiac status, atrial fibrillation, and hypertension. Interventions included providing medications as ordered, monitoring for signs of decreased cardiac output, notifying the physician as needed with any changes, and vital signs as ordered. Review of the physician order dated 10/11/22 revealed Resident #35 had an order for Norvasc Tablet 10 milligrams (mg) one tablet by mouth one time a day. The medication was to be held for systolic blood pressure below 110 milligrams per deciliter (mg/dl). Review of the Medication Administration Record (MAR) for September 2023 and 10/01/23 through 10/10/23 revealed Norvasc was administered daily, however, there was no daily monitoring of blood pressure. Review of the blood pressure documentation revealed for September 2023 and 10/01/23 through 10/10/23 Resident #35's blood pressure was assessed on 09/08/23, 09/15/23, 10/03/23, and 10/10/23. Interview on 10/12/23 at 9:10 A.M. with the Director of Nursing (DON) verified blood pressure was not being documented daily and should have been according to the orders to determine whether or not the Norvasc should be given or put on hold. 2. Review of the medical record for Resident #35 revealed an admission date of 09/10/21 with diagnoses including depression, anxiety, Parkinson's disease, hypertension, and chronic atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had intact cognition. Review of the plan of care revised 06/20/23 revealed Resident #35 had pain related to pre-admission fall, history of falls, Parkinson's disease, decreased mobility, and disease process. Interventions included administering medications as ordered, assessing and recording pain per routine, and non-pharmacological pain interventions as allowed. Review of the physician order dated 10/01/22 revealed an order for Tylenol 325 mg two tablets by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366299 If continuation sheet Page 16 of 26 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 366299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011 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 mouth every six hours as needed for pain. There were no parameters for administration. Level of Harm - Minimal harm or potential for actual harm Review of the MAR for September 2023 revealed Tylenol was not administered. Review of the MAR for October 2023 revealed Tylenol was not administered. Residents Affected - Few Review of the physician order dated 03/21/23 revealed Resident #35 was to receive morphine Sulfate 20 milligrams (mg) per milliliter (ml) 0.25 ml by mouth every three hours as needed for pain or shortness of breath. There were no parameters for administration. Review of the MAR for September 2023 revealed morphine was given on 09/03/23 for a pain of seven, on 09/08/23 for a pain of eight, on 09/11/23 for a pain of five, on 09/17/23 for a pain of ten, on 09/23/23 for a pain of ten, on 09/25/23 for a pain of ten, and on 09/27/23 for a pain of six. Review of the MAR for October 2023 revealed it was given on 10/02/23 twice for a pain of three and pain of six, on 10/07/23 for a pain of six, and on 10/10/23 for a pain five. Interview on 10/12/23 at 9:10 A.M. with the Director of Nursing (DON) verified there were no parameters for the 'as needed' pain medication. She reported the resident was alert and oriented and would often request which medication she wanted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366299 If continuation sheet Page 17 of 26 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 366299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility did not ensure Resident #258 was administered medications in accordance with physician orders and therefore free of significant medication errors. This affected one resident (#258) of six residents reviewed for medication administration. The facility census was 59. Residents Affected - Few Findings include: Review of the medical record for Resident #258 revealed an admission date of 10/09/23 and discharge date on 10/11/23. Diagnoses included fracture of fibula, fracture of tibia, osteoarthritis, depression, anxiety, surgical wound infection, and osteoporosis. Review of the nursing admission assessment dated [DATE] revealed Resident #258 arrived to the facility at 6:00 P.M. from the hospital. Resident #258 had an elevated,. above normal blood pressure of 147/90. Review of the Hospital Discharge summary dated [DATE] revealed instructions to take these meds which included Carvedilol (cardiac medication used to treat high blood pressure and heart conditions) 12.5 milligrams (mg) by mouth twice daily, Cephalexin ( an antibiotic used to treat infection) 500 mg capsule by mouth three times daily and Venlafaxine (antidepressant) 75 mg by mouth daily in evenings. Review of the care plan dated 10/09/23 revealed Resident #258 was on antibiotic therapy with interventions to administer full course of antibiotic as prescribed. Review of physician orders revealed orders dated 10/10/23 for Carvedilol oral tablet 12.5 mg to be given twice daily, an order dated 10/09/23 and again 10/10/23 for Cephalexin 500 mg oral tablet to be given three times daily, and an order dated 10/10/23 for Venlafaxine HCl Oral tablet 75 mg to be given once daily. Review of EBOX ( an electronic prescription containment and dispensing system ) contents list included Carvedilol 12.5 mg and Cephalexin 500 mg indicating these prescription were available upon Resident #258 admitting to the facility. Review of the Medication Administration Record (MAR) dated 10/2023 revealed Carvedilol oral tablet 12.5 mg was not given on 10/09/23 evening dose, Cephalexin 500 mg oral tablet was not received on 10/10/23 morning dose and Venlafaxine HCl Oral tablet 75 mg was not received on 10/09/23 evening dose. Review of progress notes dated 10/09/23 to 10/11/23 revealed no mention of resident missing doses or delays from pharmacy and staff informing the physician of these concerns or delays. Interview on 10/10/23 at 1:45 P.M. with Resident #258 revealed she was not provided her antibiotic medication, her blood pressure medication or her antidepressant medication as her doctor prescribed. Interview on 10/11/23 at 2:53 P.M. with Licensed Practical Nurse (LPN) #156 revealed she worked night shift 10/09/23 and revealed she had two admissions and was told by the previous nurse everything was done for Resident #258 except the aides needed to complete the inventory sheet of belongings. She revealed Resident #258's medications had been submitted to pharmacy and they did not arrive until about 3:00-4:00 A.M. the next morning on 10/10/23. LPN #156 revealed she did not provide any medications to Resident #258 and revealed it was her first day working at this facility and was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366299 If continuation sheet Page 18 of 26 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 366299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few familiar with their EBox procedures. LPN #156 confirmed Resident #258 missed several medications after admitting to the facility on [DATE]. Interview on 10/11/23 at 3:17 P.M. with LPN #133 revealed she was working day shift on 10/09/23 and revealed she was not assigned to Resident #258, but helped the assigned nurse with imputing orders and medications into the computer and sending scripts to pharmacy. She revealed she was unaware of what medications Resident #258 received after admission to the facility. Interview on 10/11/23 at 3:26 P.M. with LPN #165 revealed she worked day shift on 10/09/23 and was assigned to Resident #258 and revealed she could not remember if she provided any medications to Resident #258. LPN #165 revealed another nurse assisted in putting orders in the chart and sent to pharmacy. Interview on 10/11/23 at 4:45 P.M. with the Director of Nursing (DON) confirmed Resident #258 missed doses of medication and revealed she was not aware of any details. The DON revealed she was not aware several of the missed medications were in the Ebox and said Resident #258 decided to leave the facility after just under two days of admission. Review of policy titled Physician/Provider Orders, dated 12/14/21, revealed the charge nurse shall review all physician orders upon admission. The facility did not have a policy related to following Physician orders or providing medications as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366299 If continuation sheet Page 19 of 26 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 366299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011 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 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Based on record review, review of the staffing tool and resident and staff interviews, the facility administration failed to ensure there was sufficient direct care staff at all times in the facility to meet the minimum staffing requirement of two point five (2.5) hours of direct care per resident per day. This had the potential to affect all 59 residents living in the facility. Findings include: Review of the staffing tool completed for 09/24/23 through 09/30/23 revealed on 09/24/23 the facility only provided two point two seven (2.27) hours of direct care per resident per day. Interview with Resident #106 on 10/10/23 at 10:14 A.M. revealed staff are all nice, but when the facility was short staffed it takes a long time to answer the call light. The resident stated she needed assistance to complete her daily care needs and one time staff attempted to weigh her at 12:00 A.M. and she refused to be weighed at that time and was weighed the next day. Interview with Resident #107 on 10/10/23 at 10:25 A.M. revealed the facility was short in nurse aides which affected the call light response time. Resident #107 stated call lights usually take 20-25 minutes to be answered by the staff. Interview with Resident #45 on 10/10/23 at 3:33 P.M. revealed he thought the facility needed more staff. He stated he does not always get put to bed at 8:30 P.M. as he desires. Interview with Assistant Administrator (AA) # 131 included record review of the staffing tool completed 09/24/23 through 09/30/23. AA #131 confirmed the facility did not meet the two point five (2.5) hours of direct care per resident per day on 09/24/23. AA #131 stated the facility had agency staff scheduled on that day and they did not show up to work. This deficiency represents noncompliance investigated under complaint OH00146954. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366299 If continuation sheet Page 20 of 26 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 366299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility did not keep an accurate record of skin impairment and wound status in the medical record for Resident #10. This affected one (Resident #10) of seven residents reviewed for skin impairments. The facility census was 59. Findings include: Review of the medical record for Resident #10 revealed an admission date of 07/08/23 with readmission on [DATE]. Diagnoses included chronic kidney disease, bipolar disorder, depression, vascular disease, muscle weakness and heart failure. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 was cognitively intact and required extensive assistance of two staff members for bed mobility and was totally dependent for transfers. Review of the care plan dated 07/10/23 revealed Resident #10 was at risk of skin impairments with interventions including administer medications and treatments as ordered, assess and document the status of the area (healing or declining), monitor document and report to physician any changes in wounds, turn and reposition as indicated. Resident had potential for skin breakdown related to decreased mobility with interventions to turn and reposition, use pressure reducing devices as indicated and complete skin assessments. Review of wound assessments dated 08/01/23, 08/08/23, 08/16/23 and 08/22/23 revealed Resident #10 had a right great toe wound noted to be an abrasion. These assessments lacked consistency regarding date of onset of the right great toe wound. The wound assessment dated [DATE] indicated wound onset was 08/01/23. The wound assessment dated [DATE] indicated the wound was identified as new on 07/08/23 and the wound assessment dated [DATE] indicated the wound was identified as new on 08/16/23. The wound assessment dated [DATE] indicated the wound was identified as new on 07/08/23. Review of a physician order dated 08/17/23 revealed an order to monitor scabs to toes every shift until healed, monitor scabs to bilateral knees every shift, and for the right great toe, cleanse with normal saline, pat dry and cover with a clean dry dressing daily and as needed. Review of weekly skin assessments dated 10/02/23 revealed Resident #10 had skin issues including right great toe and small, scabbed areas on the right shin. Review of weekly skin assessments dated 10/09/23 revealed Resident #10 had no current skin issues. Review of the Treatment Administration Record (TAR) dated 09/2023 and 10/2023 revealed the physician ordered treatment and dressing to the right great toe was being marked off as completed daily. Interview on 10/11/23 at 11:59 A.M. with Resident #10 revealed he had wounds on his legs, shins and feet areas. Interview and observation on 10/12/23 at 9:03 A.M. with Registered Nurse (RN) #149 confirmed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366299 If continuation sheet Page 21 of 26 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 366299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #10 had scabbed areas to shins/legs. RN #149 revealed Resident #10 did not have any wounds on his feet. Observation of Resident #10's legs and feet revealed he had over 10 scabbed areas on his bilateral shins and no sores visible on his feet or toes. RN #149 reviewed Resident #10's physician orders and revealed the treatment dressing change to the right toe as indicted on the TAR was actually not being done as marked on the TAR because it was not needed and should have been discontinued once it had healed. RN #149 verified it was incorrect documentation that did not reflect Resident #10's current skin status. Interview on 10/12/23 at 10:40 A.M. with RN #149 revealed the wound and skin assessments did not accurately reflect the dates a wound was first found, status of wounds and skin impairments. RN #149 confirmed it was not documented when the wound on Resident #10's right toe was healed. RN #149 verified the skin assessments in the medical record did not show all details of treatments and stages of wound care through healing of the wounds. RN #149 verified the facility should have documentation of when each wound had healed and verified the weekly skin assessment dated [DATE] was not accurate, as Resident #10 had scabs on his shins at that time. Review of facility policy titled Skin and Wound care Best Practices, dated 06/10/22, revealed facility shall complete weekly skin assessments and shall be reviewed by the interdisciplinary team. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366299 If continuation sheet Page 22 of 26 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 366299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure residents or their responsible parties received education and signed consent for influenza and pneumococcal immunizations. This affected four residents (#17, #6, #106, and #16) of five residents reviewed for immunizations. The facility census was 59. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #17 revealed an admission date of 02/05/21 with diagnoses including depression, type two diabetes, hypertension, chronic obstructive pulmonary disease, and anemia. Review of the immunization report for Resident #17 revealed they received the Influenza vaccine on 10/25/22. Review of the medical record revealed no evidence Resident #17 received education or signed consent to receive the immunization. Interview on 10/12/23 at 11:00 A.M. with the Director of Nursing (DON) verified she could not locate education and a signed consent form for the immunization. 2. Review of the medical record for Resident #6 revealed an admission date of 04/14/22 with diagnoses including fibromyalgia, unspecified mood disorder, chronic obstructive pulmonary disease, and psychosis. Review of the immunization report for Resident #6 revealed they received the influenza vaccine on 10/25/22. Review of the medical record revealed no evidence Resident #6 or their responsible party received education or signed consent to receive the immunization. Interview on 10/12/23 at 11:00 A.M. with the DON verified she could not locate education and a signed consent form for the immunization. 3. Review of the medical record for Resident #106 revealed an admission date of 09/06/23 with diagnoses including chronic pulmonary embolism, hypertension, metabolic acidosis, and hyperlipidemia. Review of the immunization report for Resident #106 revealed the refused the pneumococcal vaccine on 09/07/23. Review of the medical record revealed no evidence Resident #106 received education related to the immunization. Interview on 10/12/23 at 11:00 A.M. with the DON verified she could not locate evidence of education for the immunization. 4. Review of the medical record for Resident #16 revealed an admission date of 09/25/19 with diagnoses including hypertension, anxiety disorder, bipolar disorder, and unspecified psychosis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366299 If continuation sheet Page 23 of 26 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 366299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the immunization report for Resident #16 revealed they refused the pneumococcal vaccine on 05/15/23 and consented to the influenza vaccine on 10/25/22. Review of the medical record revealed no evidence Resident #16 or their responsible party received education related to the pneumococcal vaccine or received education and signed consent for the influenza vaccine. Interview on 10/12/23 at 11:00 A.M. with the DON verified she could not locate education or a signed consent form for the immunization. Review of the policy Resident Vaccination Policy dated 05/18/22 revealed when a vaccination was ordered, the staff were to review the Center for Disease Control (CDC) vaccine information statement or Emergency Use Authorization with any resident or resident representative before obtaining consent. Education was to be provided before administration. Consent, refusals, and medical ineligibility was to be documented in the immunization portal in the electronic health record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366299 If continuation sheet Page 24 of 26 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 366299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on interview and record review the facility failed to ensure residents or their responsible parties received education and signed consent for COVID-19 immunization. This affected three residents (#17, #6, and #16) of five residents reviewed for immunizations. The facility census was 59. Findings include: 1. Review of the medical record for Resident #17 revealed an admission date of 02/05/21 with diagnoses including depression, type two diabetes, hypertension, chronic obstructive pulmonary disease, and anemia. Review of the immunization report for Resident #17 revealed they received the Moderna Bivalent Booster on 09/22/22. Review of the medical record revealed no evidence Resident #17 received education or signed consent to receive the immunization. Interview on 10/12/23 at 11:00 A.M. with the Director of Nursing verified she could not locate evidence of education for the immunization. 2. Review of the medical record for Resident #6 revealed an admission date of 04/14/22 with diagnoses including fibromyalgia, unspecified mood disorder, chronic obstructive pulmonary disease, and psychosis. Review of the immunization report for Resident #6 revealed they received the Pfizer bivalent booster on 09/22/22. Review of the medical record revealed no evidence Resident #6 or their responsible party received education or signed consent to receive the immunization. Interview on 10/12/23 at 11:00 A.M. with the DON verified she could not locate evidence of education for the immunization. 3. Review of the medical record for Resident #16 revealed an admission date of 09/25/19 with diagnoses including hypertension, anxiety disorder, bipolar disorder, and unspecified psychosis. Review of the immunization report for Resident #16 revealed they received the Pfizer Bivalent Booster on 09/22/22. Review of the medical record revealed no evidence Resident #16 or their responsible party received education or signed consent for the immunization. Interview on 10/12/23 at 11:00 A.M. with the DON verified she could not locate evidence of education for the immunization. Review of the policy Resident Vaccination Policy dated 05/18/22 revealed when a vaccination order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366299 If continuation sheet Page 25 of 26 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 366299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerburg Pointe 4531 Columbus Road Centerburg, OH 43011 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 Level of Harm - Minimal harm or potential for actual harm revealed the staff were to review the Center for Disease Control (CDC) vaccine information statement or Emergency Use Authorization with any resident or resident representative before obtaining consent. Education was to be provided before administration. Consent, refusals, and medical ineligibility was to be documented in the immunization portal in the electronic health record. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366299 If continuation sheet Page 26 of 26

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Citations

14 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0692GeneralS&S Dpotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0757GeneralS&S Dpotential for harm
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
0883GeneralS&S Epotential for harm
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
0700GeneralS&S Dpotential for harm
F700 - Bed Rails
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.
0760GeneralS&S Dpotential for harm
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
0836GeneralS&S Fpotential for harm
F836 - Licensure
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
0655GeneralS&S Dpotential for harm
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0686GeneralS&S Dpotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0697GeneralS&S Dpotential for harm
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
0727GeneralS&S Fpotential for harm
F727 - Except when waived under paragraph (f) or (g) of this section, the
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
0842GeneralS&S Dpotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0887GeneralS&S Dpotential for harm
F887 - Infection control
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

FAQ · About this visit

Common questions about this visit

What happened during the October 12, 2023 survey of CENTERBURG POINTE?

This was a inspection survey of CENTERBURG POINTE on October 12, 2023. The surveyor cited 14 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at CENTERBURG POINTE on October 12, 2023?

Yes, 14 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·October 12, 2023