Health inspection·November 25, 2022

F 0677 Review of the Shower/Tub Bath policy, dated 02/2022 revealed the purpose of the procedure was to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. 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: 366309 If continuation sheet Page 2 of 15 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 366309 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards of East Liverpool, The 709 Armstrong Lane East Liverpool, OH 43920 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review and interview the facility failed to ensure routine skin assessments were completed for Resident #28 to timely identify the deterioration of a pressure ulcer. Residents Affected - Few Actual Harm occurred on 09/23/22 after the facility failed to complete routine assessments (from 09/02/22 to 09/23/22) and evaluation of treatments for skin impairment resulting in Resident #28's sustaining a deterioration in skin integrity and subsequent Stage III (full thickness skin loss involving damage or premature death of subcutaneous tissue that may extend down to, but not through, underlying connective tissue. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue) pressure ulcer to the right buttocks. This affected one resident (#28) of two residents reviewed for pressure ulcers. The facility identified four residents with pressure ulcers with the exclusion of Stage I pressure ulcers (non-blanchable redness with unopened skin). Findings include: Review of Resident #28's medical record revealed diagnoses including chronic kidney disease, depression, morbid obesity, type two diabetes mellitus, and moderate protein calorie malnutrition. A Braden scale assessment, dated 06/14/22 revealed Resident #28 was at low risk for pressure ulcer development with risk factors identified as having rarely moist skin, chair fast status, very limited mobility, and a potential problem with friction and shear. A care plan initiated 06/15/22 indicated Resident #28 was at risk for complications such as pressure ulcers related to heart disease, diabetes mellitus, a history of peripheral vascular disease with areas of concern to both lower extremities, anemia and moisture associated skin damage. The care plan indicated Resident #28 also refused to go to bed at times. Interventions included weekly head to toe skin inspections. A nursing skin assessment, dated 08/27/22 revealed the resident had two smaller than dime sized skin tears noted to Resident #28's right gluteal fold (a prominent fold that marks the upper limit of the thigh from the lower limit of the buttock). The physician was contacted with treatment orders received to change dressing every day and as necessary until resolved. A nursing skin assessment, dated 09/01/22 revealed the area to the right gluteal fold was assessed as a Stage II(superficial ulcer that presented as an abrasion, blister or shallow crater) pressure ulcer which measured 1.5 centimeters (cm) in length by 1.5 cm width with 0.3 cm depth. The assessment indicated factors contributing to the ulcer included decreased mobility, decreased activity, decreased sensory perception, poor nutrition, non-compliance and moisture. The assessment indicated Resident #28 frequently declined to reposition, opting to sit in her wheelchair for the duration of day shift despite education being provided. Orders were received to cleanse the open area with normal saline, pat it dry, apply calcium alginate to the wound bed and cover it with a dry sterile dressing every night shift and as necessary. A wound consultation note, dated 09/02/22 revealed Resident #28 had an area which started as shearing to the right buttocks but had gotten larger. There was no assessment of the right buttocks wound (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366309 If continuation sheet Page 3 of 15 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 366309 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards of East Liverpool, The 709 Armstrong Lane East Liverpool, OH 43920 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 documented by the wound consultant at that time and there was no treatment change. Level of Harm - Actual harm A Braden scale assessment dated [DATE] continued to indicate Resident #28 was at low risk for development of pressure ulcers. Residents Affected - Few The next documented assessment of the right buttocks pressure ulcer was completed by the wound consultant on 09/23/22 when the area was assessed to be a Stage III pressure ulcer which measured 1.5 cm in length by 1.9 cm width with 0.2 cm depth with a moderate amount of serosanguineous drainage (thin, possibly pink or red-tinged). At that time, Resident #28 reported wound pain rated as a five on a scale of 0 to 10 (with 10 being the most severe pain). The treatment was changed. On 11/23/22 at 8:40 A.M., Licensed Practical Nurse (LPN) #811 was interviewed regarding the lack of assessments of the right buttock pressure ulcer between 09/01/22 and 09/23/22, although the wound clinic had documented the area had gotten larger on 09/02/22. LPN #811 stated she would look for additional information. On 11/23/22 at 10:05 A.M., LPN #811 provided nursing notes, dated 09/07/22 at 1:04 A.M. which indicated Resident #28 refused to have treatment to her gluteal fold three times, on 09/08/22 at 12:19 A.M. which indicated Resident #28 refused treatment to her gluteal fold three times and on 09/13/22 at 7:04 A.M. indicating Resident #28 did not want her dressings changed at that time. LPN #811 indicated that was all staff could find regarding possible refusal of dressing changes that would not permit observations/assessments. LPN #811 verified even if Resident #28 refused dressing changes/assessments those specific days, there was no reason assessments could not have been completed on other days to ensure ongoing monitoring and assessments were being completed to timely identify the deterioration. As of 11/23/22 the area remained a Stage III pressure ulcer. Attempts to observe the resident's pressure ulcer during the onsite annual survey were unsuccessful. The resident was up out of bed very early each day and refused to lay down for a wound observation. Treatments were scheduled and completed during the night shift and had already been completed when the surveyor entered on night shift during the survey to observe. Review of the facility policy, titled Pressure Ulcers, effective October 2022 indicated the facility would ensure a resident with pressure ulcers received necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing. The Unit Nurse would track the healing progress and alter the plan of care and treatment when needed by filling out a weekly pressure ulcer status report for each resident with skin breakdown that included type of wound, location, shape, measurements, stage, color/redness/warmth/swelling, granulation/surrounding tissue/ulcer edges, odor, treatments/dressing changes/medications, presence of infection or other complications, and pain. The assessment was to be used to evaluate pressure ulcer treatment weekly for effectiveness and inform the physician of pressure ulcer status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366309 If continuation sheet Page 4 of 15 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 366309 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards of East Liverpool, The 709 Armstrong Lane East Liverpool, OH 43920 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** 2. Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including major depressive disorder, severe intellectual disabilities and unspecified mood disorder. Review of the physician's orders revealed an order dated 03/09/22 to transfer (resident) using a mechanical (Hoyer) lift and two staff assist every day and night shift. Review of Resident #33's fall plan of care, dated 08/26/22 revealed an intervention to transfer using a Hoyer mechanical lift and two staff assist. Review of Resident #33's MDS 3.0 assessment, dated 10/21/22 revealed the resident exhibited severe cognitive impairment. On 11/22/22 at 9:00 A.M. State Tested Nursing Assistant (STNA) #805 and STNA #807 were observed providing A.M. (morning) care to Resident #33. The STNA staff were observed to provide incontinence care and then assisted the resident to sit up on the side of the bed. Each STNA then picked Resident #33 up under the arms and lifted her from the bed to the chair. The resident had one foot on the floor, was not observed to be able to fully bear weight and a gait belt was not used during the transfer. On 11/22/22 at 9:10 A.M. interview with STNA #805 revealed she was unaware Resident #33 required a Hoyer mechanical lift to appropriately transfer from the bed to the wheelchair per the physician's order. Review of the facility Transfers and Lifts policy, dated 11/2022 revealed the facility would ensure all staff members were instructed in safe transfer and lifting techniques and how to report suspected injuries. Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure a fall investigation was completed after a resident reported a fall and failed to update the comprehensive care plan for Resident #37. The facility also failed to ensure adequate assistance using a mechanical (Hoyer) lift was provided to Resident #33 during a transfer to prevent a possible fall/injury. This affected two residents (#37 and #33) of three residents reviewed for accidents and hazards. Findings include: 1. Review of the medical record for Resident #37 revealed an admission date of 10/14/22 with diagnoses including metabolic encephalopathy, wedge compression fracture of T11 and T12, and multiple fractures of ribs on the right side. Review of fall risk observation tool completed on admission [DATE] and on 11/14/22 revealed Resident #37 was assessed to be at high risk for falls. Review of the admission Minimum Data Set 3.0 (MDS) assessment, dated 10/20/22 revealed Resident #37 had mild cognitive impairment. The assessment revealed Resident #37 was independent with bed mobility, required supervision with one-person physical assistance for transfers and toilet use and required extensive one-person physical assistance for dressing. A plan of care, dated 11/14/22 revealed Resident #37 would be at reduced risk of falls/injury through the next review date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366309 If continuation sheet Page 5 of 15 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 366309 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards of East Liverpool, The 709 Armstrong Lane East Liverpool, OH 43920 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 Review of the nursing progress note, dated 11/19/22 at 6:15 A.M. revealed Resident #37 reported she fell in her room, (the fall was unwitnessed). The resident was assessed to have an open area on her right leg and reported she hit her heard. The resident was assessed, the physician and family were notified, and the resident was sent to the emergency room for evaluation and treatment. The resident returned to the facility on the same day. Residents Affected - Few Record review revealed following the fall/incident on 11/19/22, the resident's plan of care was not updated or revised to ensure individualized and comprehensive fall/safety interventions were in place to prevent additional falls for the resident. On 11/21/22 at 10:30 A.M. interview with the Assistant Director of Nursing (ADON)/Registered Nurse (RN) #804 revealed following the fall, the facility did not complete a comprehensive fall investigation and indicated no new interventions were initiated following the fall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366309 If continuation sheet Page 6 of 15 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 366309 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards of East Liverpool, The 709 Armstrong Lane East Liverpool, OH 43920 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure Resident #41 had a medical necessity for a urinary catheter. This affected one resident (#41) of two residents reviewed for urinary catheters. The facility identified two residents with indwelling urinary catheters. Findings include: Review of Resident #41's medical record revealed diagnoses included acute nephritic syndrome (a syndrome comprising signs of nephritis, which is kidney disease involving inflammation), infection and inflammatory reaction due to internal right knee prosthesis and type two diabetes mellitus. An admission assessment, dated 10/22/22 indicated Resident #41 had a urinary catheter (reason for use was not indicated) and was scheduled for dialysis on Tuesdays, Thursdays and Saturdays. An incision on the right knee was intact with 17 steri strips present. admission orders included use of an indwelling catheter, monitoring output, and providing catheter care twice a day. A care plan initiated 10/22/22 indicated Resident #41 had an indwelling urinary catheter which put her at risk for complications. The care plan did not indicate the rationale for the catheter use. A nursing note dated 10/23/22 at 9:36 P.M. indicated Resident #41 had a second knee surgery performed on 09/12/22. An admission Minimum Data Set (MDS) 3.0 assessment, dated 10/28/22 revealed Resident #41 was able to understand others, able to make herself understood and was cognitively intact. The MDS assessment noted the use of an indwelling urinary catheter. A skin assessment dated [DATE] indicated Resident #41's right knee incision was healed, well approximated and with no drainage. A nursing note dated 11/11/22 at 10:55 P.M. indicated Resident #41 was non-compliant with placement of the urinary catheter bag. The note indicated Resident #41 would lay it on floor even after education. A physician progress note, dated 11/16/22 at 9:04 A.M. indicated the nephrologist would be contacted for evaluation of removal of the urinary catheter. On 11/21/22 at 12:22 P.M. Resident #41 was observed to have a urinary catheter. Resident #41 stated she had the urinary catheter for a couple months but nobody was able to tell her why she had it. Resident #41 stated she did not think she should have the catheter. The resident indicated she was having no trouble voiding prior to the catheter being inserted. A nursing note, dated 11/22/22 at 7:48 A.M. revealed Resident #41 was requesting the urinary catheter be removed. The physician on call was notified and deferred to the nephrologist. The dialysis clinic was contacted and indicated they would speak with the nephrologist and inform the facility of his decision. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366309 If continuation sheet Page 7 of 15 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 366309 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards of East Liverpool, The 709 Armstrong Lane East Liverpool, OH 43920 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 No documentation was located indicating the rationale for the urinary catheter use. Level of Harm - Minimal harm or potential for actual harm On 11/22/22 at 8:15 A.M. Registered Nurse (RN) #803 was seen/overheard on the phone informing an unidentified caller Resident #41 wanted the urinary catheter removed and stating she could see no diagnosis for use. Residents Affected - Few On 11/22/22 at 8:19 A.M. RN #803 revealed Resident #41 had the urinary catheter when she was admitted . The catheter was in place because Resident #41 was having incontinence and it put her at risk for infecting her knee incision. Since the knee incision was healed and Resident #41 wanted the catheter out, the attending physician had her contact the dialysis center to ensure there would be no problem with removing it. On 11/22/22 at 11:18 A.M. interview with RN #810 revealed hospital records reflected the urinary catheter was placed on 10/07/22 when Resident #41 was having kidney issues and edema. The facility did not specifically do urinary catheter assessments. RN #810 revealed if the urinary catheter was placed to prevent infection of the knee incision, there would have been no further reason for the catheter once the skin was healed on 11/06/22. RN #810 verified she did not see any follow up on the physician progress note from 11/16/22 which indicated follow up with the nephrologist about catheter removal until 11/22/22. On 11/22/22 at 3:02 P.M. RN #803 revealed she received an order it was okay to discontinue the resident's urinary catheter on this date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366309 If continuation sheet Page 8 of 15 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 366309 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards of East Liverpool, The 709 Armstrong Lane East Liverpool, OH 43920 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview the facility failed to ensure Resident #4's oxygen tubing and humidification bottle were maintained in a clean and sanitary manner and changed weekly as ordered by the physician. This affected one resident (#4) of two residents reviewed for oxygen use. Residents Affected - Few Findings include: Review of the medical record for Resident #4 revealed an initial admission date of 09/11/22 a readmission date of 09/27/22 with diagnoses including acute and chronic respiratory failure, atrial flutter and anxiety disorder. Review of the physician's orders revealed an order, dated 09/11/22 to change oxygen tubing and humidifier bottle weekly every Sunday. Review of admission Minimum Data Set (MDS) 3.0 assessment, dated 10/03/22 revealed Resident #4 had intact cognition. The assessment revealed Resident #4 required extensive one-person physical assistance for bed mobility, transfers, and dressing, was independent with set up help only for eating and required staff supervision with one-person physical assistance for personal hygiene. The assessment also noted Resident #4 was occasionally incontinent of urine and always continent of bowel. Review of Resident #4's Treatment Administration Record for November 2022 revealed Resident #4 was to have oxygen tubing and bottle changed on 11/20/22. The administration record revealed these tasks were documented/signed off as being completed by the nurse. On 11/21/22 at 9:00 A.M. observation of Resident #4's oxygen tubing and humidifier bottle revealed they were dated 11/13/22. On 11/21/22 at 9:10 A.M. interview with Registered Nurse #505 verified Resident #4's oxygen tubing and bottle were dated 11/13/22 and had not been changed on 11/20/22 as per order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366309 If continuation sheet Page 9 of 15 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 366309 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards of East Liverpool, The 709 Armstrong Lane East Liverpool, OH 43920 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 Based on observation, record review and interview the facility failed to ensure Resident #11 received medication/treatment only while necessary by failing to discontinue an antibiotic medication cream after an area to the resident's back was healed. This affected one resident (#11) of five residents reviewed for unnecessary medication use. Residents Affected - Few Findings include: Review of the medical record for Resident #11 revealed an admission date of 05/25/21 with diagnoses including Parkinson's disease, dysphagia and scoliosis. Review of the physician's orders revealed an order, dated 05/18/22 for Silvadene cream 1% silver (antibiotic cream) to affected areas topically every shift for purpura with drainage. Review of the Medication Administration Record and Treatment Administration Record from 05/18/22 to 11/22/22 revealed Resident #11 received this cream twice daily. Review of quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/01/22 revealed Resident #11 had severe cognitive impairment with memory problems. The assessment revealed the resident required extensive two-person physical assistance for bed mobility, transfers, dressing, and personal hygiene. The assessment noted the resident was always incontinent of urine and bowel. On 11/22/22 at 1:41 P.M. Licensed Practical Nurse (LPN) #506 was observed performing the treatment to Resident #11. At the time of the observation, there were no areas draining on Resident #11. Interview with LPN #506 at the time of the observation revealed Resident #11 was being treated for purpura on his back, but they had been healed for over a month. LPN #506 was unsure why the Silvadene cream was still being applied to his back as of this date. On 11/22/22 at 2:53 P.M. interview with Registered Nurse (RN) #808 confirmed Resident #11 had been receiving Silvadene cream to his back twice a day since it was originally ordered on 05/18/22. RN #808 verified the resident did not currently have any draining purpura and the areas of concern were not reddened. The RN was unable to provide justification for the continued use of the medicated treatment for the resident as of this date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366309 If continuation sheet Page 10 of 15 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 366309 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards of East Liverpool, The 709 Armstrong Lane East Liverpool, OH 43920 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #26's medical record revealed an initial admission date of [DATE] with diagnoses including depression and anxiety disorder. A progress note by psychiatric Nurse Practitioner (NP) #812 on [DATE] indicated nursing requested Resident #26 be evaluated for severe depression. Resident #26 was in isolation for persistent Clostridium difficile (C-Diff). NP #812 indicated Resident #26 reported improved sleep with the use of Melatonin (treats insomnia) and Vistaril (anti-anxiety). Orders were given to discontinue Melatonin ordered on an as necessary basis, start Melatonin 5 milligrams (mg) every day at bedtime, discontinue Vistaril ordered on an as necessary basis, start Vistaril 25 mg every day at bedtime, and start Cymbalta (anti-depressant) 20 mg every day. A nursing note dated [DATE] at 5:35 A.M. indicated Resident #26 appeared frantic when staff went to her room to provide incontinence care. Resident #26 stated there was a man in the corner by her curtain then spoke of two cats in the register. A nursing note, dated [DATE] at 12:48 P.M. indicated Resident #26 had a change in mental status, experiencing hallucinations concerning people being in her room and fearing they would harm her. Resident #26 was transferred to the hospital for evaluation. Upon return from the hospital on [DATE], Resident #26 had an order for the anti-psychotic medication, Seroquel 25 mg at bedtime for anxiety disorder. A nursing note, dated [DATE] at 1:49 P.M. indicated a physician visited and addressed the use of Seroquel for anxiety. The physician referred Resident #26 to psychiatric services to address changes. On [DATE] psychiatric NP #812 documented nursing requested re-evaluation for Resident #26 since she returned from the hospital. The note indicated Resident #26 had a new order for Seroquel. Resident #26 was oriented with short term memory gaps. Resident #26 appeared to be in better spirits. Resident #26 indicated she had some trouble sleeping and worried a lot at night. Resident #26 denied depression. Mood had trended upwards. No delusions, hallucinations, or paranoia were noted. Orders were given to discontinue the Seroquel with a note to avoid anti-psychotic. Orders were given to administer Vistaril 25 mg every day at bedtime for anxiety/sleeplessness. Review of the [DATE] Medication Administration Record (MAR) revealed no Seroquel was administered on [DATE]. On [DATE] a physician order was written for Seroquel 25 mg every day at bedtime for schizoaffective disorder. The diagnosis was added to the diagnosis list. However, there was no documentation as to why the Seroquel was restarted. On [DATE] a note from psychiatric NP #812 revealed Resident #26 denied depression/anxiety. The note indicated Resident #26 was psychiatrically stable. Instructions included maintaining Cymbalta for anxiety, mood and pain. A gradual dose reduction would likely exacerbate target signs/symptoms thus decrease quality of life. The note did not address why the Seroquel was re-started or address how/why (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366309 If continuation sheet Page 11 of 15 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 366309 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards of East Liverpool, The 709 Armstrong Lane East Liverpool, OH 43920 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 the resident had a schizoaffective disorder diagnosis. Level of Harm - Minimal harm or potential for actual harm On [DATE] at 4:10 P.M. Registered Nurse (RN)/Clinical Director of Operations #808 was interviewed regarding the Seroquel use, why it was re-started, and who gave the diagnosis of schizoaffective disorder. No additional information was provided by RN #808 Residents Affected - Few On [DATE] at 7:33 A.M. Licensed Practical Nurse (LPN) #811 was interviewed regarding the new diagnosis of schizoaffective disorder when the Seroquel was re-started when Resident #26 had no history of the diagnosis and prior to that diagnosis the physician had been indicating the Seroquel was used to treat anxiety. LPN #811 indicated the facility had been unable to locate additional information. On [DATE] at 11:13 A.M. psychiatric NP #812 was interviewed regarding the order to restart Seroquel for schizoaffective disorder. When asked how Resident #26 met the Diagnostic and Statistical Manual (DSM) of Mental Disorders criteria for schizoaffective disorder, psychiatric NP #812 stated if she added the diagnosis she would have indicated how Resident #26 met criteria. Psychiatric NP #812 stated she doubted she would have given such a diagnosis based on Resident #26's age as the symptoms for a schizoaffective or schizophrenia diagnosis generally were exhibited when a person was in their 20's or 30's. Psychiatric NP #812 revealed she did not document any notes when the facility called to indicate if a dose reduction was ineffective as the facility should be documenting why the medication was restarted. Psychiatric NP #812 stated the Seroquel was probably related to anxiety or breakthrough hallucinations although she had no way of knowing due to lack of documentation. Psychiatric NP #812 indicated the DSM revealed the symptoms of hallucinations had to last longer than what Resident #26 was experiencing for a diagnosis of schizoaffective disorder. Psychiatric NP #812 stated she did not know to what extent or if Resident #26 was having hallucinations when the Seroquel was restarted or if Resident #26 was experiencing distress. Psychiatric NP #812 voiced she hated that Seroquel was even classified as an anti-psychotic because at a lower dose of 25 or 50 mg there was no dopamine blockage and it acted more like an antihistamine. The NP revealed the Seroquel was likely ordered for the resident's anxiety. On [DATE] at 1:38 P.M. interview with Clinical Director of Operations #813 revealed the staff person who wrote the Seroquel order on [DATE] was an agency nurse. On [DATE] at 2:24 P.M. interview with Physician #814 revealed Resident #26 was sent to a local hospital on [DATE] then was sent to another hospital [DATE] due to seizures. Physician #814 stated he could not access records from the second hospital and it was notoriously hard to get information from that hospital. Physician #814 stated Resident #26 had a rough time as she was diagnosed with colon cancer, her son died, and she had been on isolation for C-Diff for a long time. Review of the facility Medications-Anti-psychotic policy, effective [DATE] revealed each resident was to receive only those medications, in doses and for the duration clinically indicated to treat a resident's assessed conditions. An antipsychotic medication was used only for the following conditions/diagnoses as documented in the record and as it met the definitions in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Training Revision (DSM-IV-TR) or subsequent editions: the conditions included schizophrenia, schizoaffective disorder, delusional disorder, mood disorders, schizophreniform disorder, psychosis, atypical psychosis, brief psychotic disorder, dementing illness with associated behavioral symptoms, medical illnesses or delirium with manic or psychotic symptoms and/or treatment-related psychosis or mania. The policy indicated the clinical condition also had to meet at least one of the following criteria: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366309 If continuation sheet Page 12 of 15 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 366309 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards of East Liverpool, The 709 Armstrong Lane East Liverpool, OH 43920 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 1. The symptoms were identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations, delusions or 2. The behavioral symptoms presented a danger to the resident or to others or 3. The symptoms were significant enough that the resident was experiencing one or more of the following: inconsolable or persistent distress, significant decline in function, and/or substantial difficulty receiving needed care. The behavioral symptoms were: 1. Not due to a medical condition or problem that could be expected to improve or resolve as the underlying condition was treated AND 2. Persistent or likely to reoccur without continued treatment AND 3. Not sufficiently relieved by non-pharmacological interventions AND 4. Not due to environmental stressors that could be addressed to improve the psychotic symptoms or maintain safety AND 5. Not due to psychological stressors or anxiety or fear stemming from misunderstanding related to his or her cognitive impairment that could be expected to improve or resolve as the situation was addressed. Based on record review, facility policy review and interview the facility failed to ensure as needed (PRN) anti-anxiety medication (Xanax) ordered for Resident #33 was not ordered longer than 14 days, had a specific duration for use and stop date. The facility also failed to ensure an appropriate indication for use of the anti-psychotic medication (Seroquel) for Resident #26. This affected two residents (#26 and #33) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including major depressive disorder, severe intellectual disabilities and unspecified mood disorder. Review of Resident #33's physician's orders revealed an order, dated [DATE] for the anti-anxiety medication, Xanax 0.5 mg (milligrams) by mouth every twelve hours as needed for behaviors. Record review revealed the medication was discontinued on [DATE] Review of Resident #33's physician progress note, dated [DATE] indicated to continue Xanax for three months for breakthrough anxiety (from [DATE] to [DATE]). Review of Resident #33's physician's orders revealed an order, dated [DATE] for Xanax 0.5 mg one tablet every eight hours as needed for behaviors related to restlessness and agitation. Record review revealed no stop date or discontinuation date for the medication. Review of Resident #33's physician's progress note, dated [DATE] and psychiatric progress note, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366309 If continuation sheet Page 13 of 15 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 366309 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards of East Liverpool, The 709 Armstrong Lane East Liverpool, OH 43920 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 dated [DATE] revealed no information related to the use of the Xanax. The notes did not include a specific duration for use or stop date. Review of Resident #33's Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed the resident exhibited severe cognitive impairment. Residents Affected - Few Review of Resident #33's medication administration records (MAR) from [DATE] to [DATE] revealed staff administered the Xanax on [DATE] at 1:15 P.M., [DATE] at 8:38 P.M., [DATE] at 1:31 P.M., [DATE] at 10:35 A.M., [DATE] at 12:52 P.M., [DATE] at 8:03 A.M., [DATE] at 7:42 A.M., [DATE] at 10:51 A.M., [DATE] at 12:33 P.M., [DATE] at 12:20 P.M. and [DATE] at 10:28 A.M. On [DATE] at 10:55 A.M. interview with Registered Nurse (RN)/Clinical Director of Operations #812 confirmed Resident #33's Xanax anti-anxiety medication did not have a specific duration for use or stop date and was continued greater than 14 days after being ordered on [DATE]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366309 If continuation sheet Page 14 of 15 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 366309 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards of East Liverpool, The 709 Armstrong Lane East Liverpool, OH 43920 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review and interview the facility failed to ensure Resident #32's Levemir long-acting insulin was discarded once expired. This affected one resident (#32) of one resident identified during the medication storage review who had insulin stored in the medication storage cart on the East Wing. Findings include: Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including type one diabetes, muscle weakness and need for assistance with personal care. Review of Resident #32's Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #32's physician's orders revealed an order, dated [DATE] and discontinued [DATE] for Levemir (long acting insulin) inject 20 units subcutaneously at bedtime related to diabetes. Review of Resident #32's physician's orders revealed an order, dated [DATE] to inject Levemir 18 units subcutaneously at bedtime related to diabetes. Review of Resident #32's Medication Administration Records (MAR) from [DATE] to [DATE] revealed staff administered the Levemir insulin daily as ordered. On [DATE] at 12:10 P.M. observation with Registered Nurse (RN) #809 of the East Wing medication administration cart revealed Resident #32's Levemir long acting insulin was stored in the top drawer. A date on the insulin was noted to be [DATE]. On [DATE] at 12:12 P.M. interview with RN #809 revealed Resident #32's Levemir long acting insulin was only good for 42 days once opened. RN #809 confirmed the insulin was opened on [DATE], had expired on [DATE] and should have been discarded at that time. Review of the facility Medication Storage policy, dated 10/2022 revealed medications would be monitored to assure they were not expired, contaminated or unusable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366309 If continuation sheet Page 15 of 15