Health inspection·March 5, 2024

F 0561 This deficiency represents non-compliance investigated under Master Complaint Number OH00151400. 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: 366352 If continuation sheet Page 2 of 14 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 366352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emerald Pointe Health and Rehab Ctr 100 Michelli Street Barnesville, OH 43713 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on record review, policy review, and interview, the facility failed to ensure resident representatives and physician were notified of changes in treatment and condition. This affected two residents (#59, #61) of three residents reviewed for notification. The census was 58. Findings include: 1. Record review of Residents #61 revealed a 09/09/22 admission with diagnoses including unspecified dementia, proximal atrial fibrillation, atherosclerotic heart disease, sick sinus syndrome, chronic kidney disease stage four, psoriasis, hypertension, hyperlipidemia, aortic aneurysm, peripheral vascular disease, anemia in chronic kidney disease, major depressive disorder, Anxiety, Gastroesophageal reflux disease, hemiplegia, gout, constipation, angina pectoris, overactive bladder, insomnia, Hydronephrosis, chronic pain syndrome, vitamin D deficiency, macular degeneration, cough, puritis, shortness of breath, hyperglycemia, old myocardial infarction, personal history of neoplasm with the breast, personal history of pulmonary embolism and dry eye syndrome. Review of the quarterly 01/15/24 Minimum Data Set Assessment included the resident was independent for daily decision making, had functional impairment of bilateral lower extremities, and needed maximal assist for toileting. Record review revealed on 01/12/24 at 3:47 P.M. Resident #61 reported she did not feel well. The resident reported having a cough that has become increasingly worse. Resident #61 felt warm to touch. Noted forehead temperature of 103.5 degrees Fahrenheit, blood pressure 170/72, pulse 83 beats per minute and respirations 22 breaths per minute and requested to be sent to the emergency room. The resident returned with a diagnosis of Influenza A on supplemental oxygen. Record review revealed on 01/15/24 the nephrologist was notified of a 01/12/24 urinalysis that was positive for escherichia coli. The resident was started on Cipro, an antibiotic, 250 milligrams (mg) twice a day for seven days. Review of physician orders revealed the antibiotic (Cipro) was to be administered until 12:00 P.M. on 01/22/24. Record review revealed on 01/15/24 the dietician note indicated resident may benefit from supplement usage at present (Influenza A) diagnosis. Interventions included a recommendation for the resident to receive 120 milliliters (ml) of House Supplement at bedtime. A physician order was written 01/15/24 for 120 ml of house supplement at bedtime. Record review revealed on 01/21/24 at 6:30 P.M. a physician order was written for Immodium A-D Oral Tablet 2 MG (Loperamide HCl), antidiarrheal, give one tablet by mouth every six hours as needed for diarrhea. No more than four tablets in 24 hour period. Record review revealed at 6:39 P.M. on 01/21/24 Immodium 2 mg was administered for diarrhea. On 01/22/24 at 6:20 A.M. it was documented the Immodium was ineffective. On 01/22/24 at 6:36 A.M. Immodium was administered for diarrhea. At 1:53 P.M. the follow up note said the Immodium was effective. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366352 If continuation sheet Page 3 of 14 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 366352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emerald Pointe Health and Rehab Ctr 100 Michelli Street Barnesville, OH 43713 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review revealed on 01/22/24 at 2:15 P.M. the physician was notified of the resident having multiple episodes of foul smelling diarrhea with mucous, and is currently on oral antibiotics. An order was received to collect specimen and send for testing for Clostridium difficile. Review of an occupational therapy treatment encounter note written on 01/23/24 at 9:02 A.M. included on 01/22/24 the resident was observed with loose stools, nausea and vomiting. Therapist notified nurse of reported symptoms for further assessment. Therapist provided education on use of call light to minimize fall risk and if symptoms worsen. Review of treatment sheets revealed the resident did not ever consume any of the house supplement ordered 01/15/24 for twice a day. Review of the meal percentages revealed there were no meals documented for 01/21/24. The resident consumed 50 percent of breakfast and refused lunch and supper on 01/22/24. On 01/23/24 the resident refused breakfast. The resident was sent to the emergency room at lunch time 01/23/24. Record review revealed on 01/23/24 at 12:04 P.M. there was a progress note for the resident to be sent out. Record review revealed on 01/23/24 at 12:08 A.M. a note that included resident noted with increased lethargy. No oral intake this shift. Dry mucous membranes. Skin turgor poor. Opens eyes slightly to verbal stimuli. Asked resident if she would like to go to the emergency room, shakes her head yes. Resident has had one incontinent episode of liquid stool this shift. Unable to obtain specimen for C-Diff due to brief absorbed all of the liquid. Will not drink fluids. The physician was updated. Record review revealed there was no evidence of the resident's emergency contact being notified of the urinary tract infection, start of antibiotics, diarrhea and medication order, order for laboratory test for stool, refusing meals, order for house supplement, refusing house supplement, and nausea and vomiting. There was no evidence of the physician being notified of refusal of house supplement, meal refusal or nausea and vomiting. Interview on 02/27/24 at 11:42 A.M. with the Director of Nursing verified there was no evidence of family notification related to the change in condition, urinary tract infection, start of antibiotics, diarrhea and medication order for diarrhea, order for laboratory test for stool, refusing meals, order for house supplement, refusing house supplement, and nausea and vomiting. Further, there was no evidence of the physician being notified of refusal of house supplement, meal refusal or nausea and vomiting. Review of the facility Change of Condition policy (revised 04/2013), which the facility indicated was also the physician notification policy, included a change in condition is defined as deterioration in the health, mental, or psychosocial status of a resident related to a life threatening condition, a significant alteration in treatment or a significant change in the resident's clinical condition or status. The unit supervisor or charge nurse will notify the resident, physician, guardian/interested family members of all changes as stated above and of any other situations requiring notification. The person doing the notification may document all notification. A competent resident may request that their family not be notified if they choose to exercise their right to privacy. If they do not choose the right to privacy the family must be notified. 2. Record review for Resident #59 revealed a 11/09/23 admission with diagnoses including pneumonia, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366352 If continuation sheet Page 4 of 14 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 366352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emerald Pointe Health and Rehab Ctr 100 Michelli Street Barnesville, OH 43713 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few acute respiratory failure with hypoxia, partial intestinal obstruction, diverticulosis, muscle wasting and atrophy, dysphasia, anxiety disorder, neuropathy, hypertension, protein calorie malnutrition, hyperlipidemia, depressed mood, chronic obstructive pulmonary disease, atrial fibrillation, hypocalcemia, osteoarthritis, retention of urine, myocardial infarction, anemia, dementia, constipation, and vitamin D deficiency. Review of a 11/16/23 admission MDS revealed the resident was moderately impaired for daily decision making. Review revealed on 01/31/24 the resident returned from the pulmonologist with orders for nebulizer treatments, albuterol 2.5 milligrams (mg) four times a day and as needed. There was no evidence of the family representative being notified of the new order. The surveyor was provided an undated handwritten note from Transport #80 noting the resident's son would not be able to go with the resident to the doctor appointment. The surveyor was provided an undated handwritten note from Registered Nurse #93 that he informed the son about choosing a nephrologist because the resident had been refusing appointments. During the conversation he indicated he updated the son on the resident's current condition and new orders received for breathing treatments. Interview on 02/27/24 at 11:42 A.M. with the Director of Nursing verified there was no evidence of family notification related to the new breathing treatment being added to the resident's plan of care. This deficiency represents non-compliance investigated under Complaint Number OH00150989. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366352 If continuation sheet Page 5 of 14 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 366352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emerald Pointe Health and Rehab Ctr 100 Michelli Street Barnesville, OH 43713 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on record review and interview, the facility failed to ensure a plan of care was in place related to a blister from spilled coffee. This affected one resident (#15) of three residents reviewed for skin conditions. The census was 58. Findings include: Review of Resident #15's medical record revealed a 07/01/18 admission with diagnoses including type two diabetes mellitus without complications, chronic obstructive pulmonary disease, unspecified, diastolic congestive heart failure, atherosclerotic heart disease, essential primary hypertension, rheumatoid arthritis, hyperlipidemia, arthritis, iron deficiency anemia, morbid severe obesity, hypokalemia, Gastroesophageal reflux disease without esophagitis,allergic rhinitis, adjustment disorders with depressed mood, vitamin D deficiency, encounter for orthopedic aftercare following a surgical amputation, muscle weakness, and a personal history of Covid. Review of a quarterly 01/09/24 Minimum Data Set Assessment indicated the resident was independent for daily decision making, with lower extremity impairment on one side, Interview on 02/26/24 at 11:22 A.M. with Resident #15 revealed she spilled coffee on herself twice and had red areas and a blister. She stated the kitchen ran out of lids for the coffee. One day her coffee cup was covered with saran wrap. When she took the saran wrap off the coffee cup she spilled the coffee on her stomach. Another day her coffee was covered with aluminum foil. She also spilled her coffee on her stomach. Both times she burned herself. Resident #15 indicated after she has her breakfast she gets a bath. She included she told the aides both times when they came in to give her a bath. She lifted her shirt to reveal several red areas nickel to quarter size remaining from the spills. Review of a 01/09/24 Skin Grid Non -Pressure included a new skin problem, a left upper quadrant blister 1.0 centimeter (cm) by 3.0 cm unable to determine depth, with a red dry periwound. Resident states she spilled coffee on herself. Order received to cleanse with normal saline and leave open to air until healed. Review of a 01/09/24 Skin Grid Non -Pressure included a right upper quadrant burn. It was 1.5 cm length by 2.5 cm width unable to determine depth. No drainage. No odor, no tunneling, no undermining and had no prior assessment. It was red and dry. Review of a Health Status Note dated 01/09/24 included resident has a reddened, dry area on right and left upper quadrants. Right area is 1.5 cm X 2.5 cm and left area is 1.0 cm X 3.0 cm. Resident said I spilled coffee on myself a couple weeks ago. Area assessed and cleansed with normal saline. Interview on 02/26/24 at 3:41 P.M. with Dietary Manager #79 revealed the coffee comes out of the kitchen between 140-150 degrees Fahrenheit. Review of the temperature logs revealed the coffee temperatures ranged from 135-161 degrees Fahrenheit. Record review revealed on 01/29/24 an Occupational Therapy referral was made to assess self (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366352 If continuation sheet Page 6 of 14 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 366352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emerald Pointe Health and Rehab Ctr 100 Michelli Street Barnesville, OH 43713 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm feeding. On 02/16/24 restorative nursing assessment included active range of motion exercises and bilateral hand/wrist splints. Review of the current comprehensive plans of care revealed none of the plans identified the resident had a history of burning herself with spilled coffee to alert the staff of the potential for reoccurrence. Residents Affected - Few Interview on 03/04/24 at 3:12 P.M. with the Director of Nursing revealed she found a discontinues plan of care for the blister. There was not an active plan of care to remind staff the resident had a blister from spilling coffee on herself. This deficiency represents an incidental finding of non-compliance investigated under Master Complaint Number OH00151400. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366352 If continuation sheet Page 7 of 14 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 366352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emerald Pointe Health and Rehab Ctr 100 Michelli Street Barnesville, OH 43713 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure timely intervention for a resident with nausea and vomiting. This affected one resident (#61) of three residents reviewed for change in condition. The census was 58. Residents Affected - Few Findings include: Record review of Residents #61 revealed a 09/09/22 admission with diagnoses including unspecified dementia, proximal atrial fibrillation, atherosclerotic heart disease, sick sinus syndrome, chronic kidney disease stage four, psoriasis, hypertension, hyperlipidemia, aortic aneurysm, peripheral vascular disease, anemia in chronic kidney disease, major depressive disorder, Anxiety, Gastroesophageal reflux disease, hemiplegia, gout, constipation, angina pectoris, overactive bladder, insomnia, Hydronephrosis, chronic pain syndrome, vitamin D deficiency, macular degeneration, cough, puritis, shortness of breath, hyperglycemia, old myocardial infarction, personal history of neoplasm with the breast, personal history of pulmonary embolism and dry eye syndrome. Review of the quarterly 01/15/24 Minimum Data Set Assessment included the resident was independent for daily decision making, had functional impairment of bilateral lower extremities, and needed maximal assist for toileting. Record review revealed on 01/12/24 at 3:47 P.M. Resident #61 reported she did not feel well. The resident reported having a cough that has become increasingly worse. Resident #61 felt warm to touch. Noted forehead temperature of 103.5 degrees Fahrenheit, blood pressure 170/72, pulse 83 beats per minute and respirations 22 breaths per minute and requested to be sent to the emergency room. The resident returned with a diagnosis of Influenza A on supplemental oxygen. Record review revealed on 01/15/24 the dietician note indicated resident may benefit from supplement usage at present (Influenza A) diagnosis. Interventions included a recommendation for the resident to receive 120 milliliters (ml) of House Supplement at bedtime. A physician order was written 01/15/24 for 120 ml of house supplement at bedtime. Record review revealed on 01/21/24 at 6:30 P.M. a physician order was written for Immodium A-D Oral Tablet 2 MG (Loperamide HCl), antidiarrheal, give one tablet by mouth every six hours as needed for diarrhea. No more than four tablets in 24 hour period. Record review revealed at 6:39 P.M. on 01/21/24 Immodium 2 mg was administered for diarrhea. On 01/22/24 at 6:20 A.M. it was documented the Immodium was ineffective. On 01/22/24 at 6:36 A.M. Immodium was administered for diarrhea. At 1:53 P.M. the follow up note said the Immodium was effective. Record review revealed on 01/22/24 at 2:15 P.M. the physician was notified of the resident having multiple episodes of foul smelling diarrhea with mucous, and is currently on oral antibiotics. An order was received to collect specimen and send for testing for Clostridium difficile. Review of an occupational therapy treatment encounter note written on 01/23/24 at 9:02 A.M. included on 01/22/24 the resident was observed with loose stools, nausea and vomiting. Therapist notified nurse of reported symptoms for further assessment. Therapist provided education on use of call light to minimize fall risk and if symptoms worsen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366352 If continuation sheet Page 8 of 14 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 366352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emerald Pointe Health and Rehab Ctr 100 Michelli Street Barnesville, OH 43713 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of treatment sheets revealed the resident did not consume any of the house supplement ordered 01/15/24 for twice a day. Review of the meal percentages revealed there were no meals documented for 01/21/24. The resident consumed 50 percent of breakfast and refused lunch and supper on 01/22/24. On 01/23/24 the resident refused breakfast. The resident was sent to the emergency room at lunch time 01/23/24. Record review revealed on 01/23/24 at 12:04 P.M. there was a progress note for the resident to be sent out. Record review revealed on 01/23/24 at 12:08 P.M. a note that included resident noted with increased lethargy. No oral intake this shift. Dry mucous membranes. Skin turgor poor. Opens eyes slightly to verbal stimuli. Asked resident if she would like to go to the emergency room, shakes her head yes. Resident has had one incontinent episode of liquid stool this shift. Unable to obtain specimen for C-Diff due to brief absorbed all of the liquid. Will not drink fluids. The physician was updated. Record review revealed a 01/23/24 note the facility received a call from the hospital stating the resident passed away at 10:26 P.M. The facility conducted an investigation after the death and determined on 01/21/24 no meal percentages were documented. An undated handwritten interview of State Tested Nurse Aide (STNA) #83 included she ate better Sunday than on Saturday. For breakfast she ate 25%, lunch 60% and supper she did not eat. A statement included on 01/20/24 the resident was tired. On 01/21/24 she was doing a lot better. Her mood improved and she had more pep. She had a bedbath 01/21/24. She did not want a shower. She was drinking and her bowels moved once. A statement written and dated 01/25/24 by Licensed Practical Nurse (LPN) #96 who worked 7:00 A.M.-7:00 P.M. on 01/20/24 and 01/21/24 included the resident was not her usual self. She was recovering from the flu but said she was feeling better. She was having diarrhea, she got an order for Immodium which seemed to help. The resident said they told her she had diarrhea. She said she was eating and drinking fluids. The resident said she was not coughing as bad. A written statement dated 01/24/24 by Registered Nurse (RN)#93 who worked 7:00 A.M. to 7:00 P.M. on 01/22/24 included the resident was feeling better. He sat her up and she took her medicine. The STNA reported diarrhea, mucous and foul smelling. He received an order for a stool for c-diff and told the aide to get him the next time she went. RN #93 told staff to push fluids. The resident's lips were moist and she drank two cups of water with each medication pass. A written statement dated 01/24/24 by LPN #105 who worked 7:00 P.M.-7:00 A.M. 01/22/24 included the resident was her usual talkative self and coughing. She did not have diarrhea that shift. A written statement dated 01/25/24 by LPN #97 who worked 7:00 A.M. to 7:00 P.M. on 01/23/24 included night shift staff gave the medication. The resident was sleeping when she peeked in. No reports from anyone of any problems. There was nothing in report about a change of condition. The STNA reported she was not acting right. She (LPN #97) assessed and asked the resident if she wanted to go to the emergency room and she shook her head yes. The STNA reported diarrhea times one. She told the STNA she needed a stool specimen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366352 If continuation sheet Page 9 of 14 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 366352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emerald Pointe Health and Rehab Ctr 100 Michelli Street Barnesville, OH 43713 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 The facility did not interview the STNA's who worked 01/22/24 or 01/23/24. Level of Harm - Minimal harm or potential for actual harm Interview on 02/27/24 at 11:03 A.M. with STNA #81 revealed Resident #61 wanted to stay at the hospital when she was diagnosed with Influenza A but they told her there was nothing they could do for her that was not being done at the nursing home. Resident #61 told her she had a urinary tract infection and was on antibiotics. She was short of breath from the flu. The resident was a very picky eater. They knew she would eat a bacon cheeseburger, hot dog, grilled cheese. For breakfast the resident ate toast, little Debbie's, cereals, and juice. She was eating less when she had the flu, just the cereal,and half her juice. We were constantly filling up her water glass. We would fill up the four ounce water glasses, and she was drinking tons of water and apple juice. She was saying her tongue was dry from oxygen. She noted when passing trays the resident had diarrhea. A few days before she was sent out she was coughing. On 01/20/24 she seemed like she was feeling better. She was coughing up mucus on 01/21/24 and spitting into tissues. Residents Affected - Few Interview on 02/27/24 at 11:42 A.M. with the Director of Nursing revealed she did not know there was a therapy note indicating the therapist reported Resident #61 had nausea and vomiting. She indicated she interviewed the nurses and no one reported nausea but acknowledged the therapist wrote she notified the nurse of nausea, vomiting and diarrhea. She verified if the nurse was aware of vomiting he/she should have requested medication for nausea. Interview on 02/27/24 at 1:06 P.M. with Occupational Therapist #146 included when she went into the resident's room on 01/22/24 for therapy the resident had a basin in front of her and was vomiting. She told the nurse the resident was vomiting as she had documented. Interview on 02/27/24 at 1:41 P.M. with STNA #84 revealed on 01/23/24 Resident #61 was still having diarrhea, weak, fatigued and vomited once. She told LPN #97 the resident was not acting right. LPN #97 did not go back to assess the resident. This deficiency represents non-compliance investigated under Complaint Number OH00150989. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366352 If continuation sheet Page 10 of 14 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 366352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emerald Pointe Health and Rehab Ctr 100 Michelli Street Barnesville, OH 43713 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interview, the facility failed to ensure pressure reduction measures were in place as ordered. This affected two residents (#4, #15) of three residents reviewed for skin impairment. Residents Affected - Few Findings include: 1. Record review of Resident #4 revealed a 01/24/24 admission with diagnoses including hemiplegia,hemiparesis following cerebral infarct affecting left non dominate side, protein calorie malnutrition, muscle weakness, dysphasia, muscle wasting and atrophy, proximal atrial fibrillation, tremor, hypercalcemia, gastrointestinal hemorrhage, pulmonary hypertension, major depressive disorder, hypertension, iron deficiency, anemia, hyperlipidemia, heart failure, pain, nausea and vomiting, urine retention, and benign prosthetic hyperplasia. Review of a 01/31/24 admission Minimum Data Set Assessment (MDS) revealed the resident was independent for daily decision making, had upper extremity impairment on one side, and required maximum assist for turning and rolling in bed. Review of a 02/15/24 Pressure Skin Grid revealed a right heel unstageable (full thickness tissue loss where the depth of the wound or bed sore is completely obscured by eschar in the wound bed) pressure ulcer measuring 1.5 centimeters (cm) by 2 cm with a red eschar/wound bed. The resident required (dependent) of one staff for bed mobility. Physician orders included a 02/15/24 order to wear heel protectors while in bed as tolerated every shift for pressure wound and cleanse right heel with normal saline, apply betadine, cover with a ABD and cover with Kerlix. Review of a 02/20/24 Pressure Skin Grid revealed a right heel deep tissue injury (persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters )pressure ulcer measuring 1.8 centimeters (cm) by 1.9 cm with a 100% purple wound bed and fleshtone periwound. Observation on 02/26/24 at 1:35 P.M. revealed Resident #4 was in bed without heel bows. There was a pillow under his calves but his heels were resting on the bed. Observation on 02/26/24 at 3:06 P.M. of a dressing change to the right heel revealed the resident did not have heel bows on. After the dressing change, Registered Nurse (RN) #95 and Licensed Practical Nurse (LPN) #96 did not apply heel bows. Interview on 02/26/24 at 6:05 P.M. with State Tested Nurse Aide (STNA) #84 revealed she never had seen heel bows on Resident #4. She looked in his room and could not find any heel bows. Review of the February 2024 treatment administration record (TAR) revealed Resident #4 was to wear heel protectors while in bed as tolerated every shift for pressure wound. This treatment was signed daily as completed. The TAR was signed 02/26/24 as being applied when they were not. Interview on 02/26/24 at 6:10 P.M. with Licensed Practical Nurse (LPN) #96 verified the resident did not have heel bows in place as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366352 If continuation sheet Page 11 of 14 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 366352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emerald Pointe Health and Rehab Ctr 100 Michelli Street Barnesville, OH 43713 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Record review of Resident #15 revealed a 07/01/18 admission with diagnoses including type two diabetes mellitus without complications, chronic obstructive pulmonary disease, unspecified, diastolic congestive heart failure, atherosclerotic heart disease, essential primary hypertension, rheumatoid arthritis, hyperlipidemia, arthritis, iron deficiency anemia, morbid severe obesity, hypokalemia, Gastroesophageal reflux disease without esophagitis,allergic rhinitis, adjustment disorders with depressed mood, vitamin D deficiency, encounter for orthopedic aftercare following a surgical amputation, muscle weakness, and a personal history of Covid. Review of a 01/09/24 quarterly MDS revealed the resident was independent for daily decision making, had lower extremity impairment on one side, and required touch assist for turning and rolling in bed. Review revealed a pressure skin grid dated 09/08/23 revealed 3.5 cm by 3.0 cm deep tissue injury (persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues with a dark purple wound bed) to left heel. Record review revealed a 09/08/23 order for a heel boot to left foot when up in wheelchair and in bed every shift for protection. Review of a pressure ulcer skin grid revealed the left heel on 02/20/24 was unstageable, 0.8 cm by 0.5 cm with 100% thin dry scab. Observation on 02/26/24 at 11:22 A.M. revealed the resident was sitting up in her wheelchair without a boot on as ordered. Interview on 02/26/24 at 11:25 A.M. with STNA #82 revealed she did not know the resident was to wear a boot. She indicated she had not seen the boot for months. Review of the February 2024 TAR revealed the boot was signed off as applied for 02/26/24 and signed off for all the days of February 2024 up to this point. Interview on 02/26/24 at 3:26 P.M. with Registered Nurse (RN) #72 verified the boot was ordered and should be on and not marked as on when it is not. Interview on 02/26/24 at 3:32 P.M. with LPN #97 revealed she doesn't know when the last time was she saw the boot on the resident. She verified the boot was not on as ordered. This deficiency represents non-compliance investigated under Master Complaint Number OH00151400. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366352 If continuation sheet Page 12 of 14 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 366352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emerald Pointe Health and Rehab Ctr 100 Michelli Street Barnesville, OH 43713 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, record review, and interview, the facility failed to ensure accurate medical records. This affected two residents (#4, #15) of three residents reviewed for skin impairment. Residents Affected - Few Findings include: 1. Record review of Resident #4 revealed a 01/24/24 admission with diagnoses including hemiplegia,hemiparesis following cerebral infarct affecting left non dominate side, protein calorie malnutrition, muscle weakness, dysphasia, muscle wasting and atrophy, proximal atrial fibrillation, tremor, hypercalcemia, gastrointestinal hemorrhage, pulmonary hypertension, major depressive disorder, hypertension, iron deficiency, anemia, hyperlipidemia, heart failure, pain, nausea and vomiting, urine retention, and benign prosthetic hyperplasia. Review of a 01/31/24 admission Minimum Data Set Assessment (MDS) revealed the resident was independent for daily decision making, had upper extremity impairment on one side, and required maximum assist for turning and rolling in bed. Review of a 02/15/24 Pressure Skin Grid revealed a right heel unstageable (full thickness tissue loss where the depth of the wound or bed sore is completely obscured by eschar in the wound bed) pressure ulcer measuring 1.5 centimeters (cm) by 2 cm with a red eschar/wound bed. The resident required (dependent) of one staff for bed mobility. Physician orders included a 02/15/24 order to wear heel protectors while in bed as tolerated every shift for pressure wound and cleanse right heel with normal saline, apply betadine, cover with a ABD and cover with Kerlix. Review of a 02/20/24 Pressure Skin Grid revealed a right heel deep tissue injury (persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters )pressure ulcer measuring 1.8 centimeters (cm) by 1.9 cm with a 100% purple wound bed and fleshtone periwound. Observation on 02/26/24 at 1:35 P.M. revealed Resident #4 was in bed without heel bows. There was a pillow under his calves but his heels were resting on the bed. Observation on 02/26/24 at 3:06 P.M. of a dressing change to the right heel revealed the resident did not have heel bows on. After the dressing change, Registered Nurse (RN) #95 and Licensed Practical Nurse (LPN) #96 did not apply heel bows. Interview on 02/26/24 at 6:05 P.M. with State Tested Nurse Aide (STNA) #84 revealed she never had seen heel bows on Resident #4. She looked in his room and could not find any heel bows. Review of the February 2024 treatment administration record (TAR) revealed Resident #4 was to wear heel protectors while in bed as tolerated every shift for pressure wound. This treatment was signed daily as completed. The TAR was signed 02/26/24 as being applied when they were not. Interview on 02/26/24 at 6:10 P.M. with Licensed Practical Nurse (LPN) #96 verified the resident did not have heel bows in place as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366352 If continuation sheet Page 13 of 14 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 366352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emerald Pointe Health and Rehab Ctr 100 Michelli Street Barnesville, OH 43713 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Record review of Resident #15 revealed a 07/01/18 admission with diagnoses including type two diabetes mellitus without complications, chronic obstructive pulmonary disease, unspecified, diastolic congestive heart failure, atherosclerotic heart disease, essential primary hypertension, rheumatoid arthritis, hyperlipidemia, arthritis, iron deficiency anemia, morbid severe obesity, hypokalemia, Gastroesophageal reflux disease without esophagitis,allergic rhinitis, adjustment disorders with depressed mood, vitamin D deficiency, encounter for orthopedic aftercare following a surgical amputation, muscle weakness, and a personal history of Covid. Review of a 01/09/24 quarterly MDS revealed the resident was independent for daily decision making, had lower extremity impairment on one side, and required touch assist for turning and rolling in bed. Review revealed a pressure skin grid dated 09/08/23 revealed 3.5 cm by 3.0 cm deep tissue injury (persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues with a dark purple wound bed) to left heel. Record review revealed a 09/08/23 order for a heel boot to left foot when up in wheelchair and in bed every shift for protection. Review of a pressure ulcer skin grid revealed the left heel on 02/20/24 was unstageable, 0.8 cm by 0.5 cm with 100% thin dry scab. Observation on 02/26/24 at 11:22 A.M. revealed the resident was sitting up in her wheelchair without a boot on as ordered. Interview on 02/26/24 at 11:25 A.M. with STNA #82 revealed she did not know the resident was to wear a boot. She indicated she had not seen the boot for months. Review of the February 2024 TAR revealed the boot was signed off as applied for 02/26/24 and signed off for all the days of February 2024 up to this point. Interview on 02/26/24 at 3:26 P.M. with Registered Nurse (RN) #72 verified the boot was ordered and should be on and not marked as on when it is not. Interview on 02/26/24 at 3:32 P.M. with LPN #97 revealed she doesn't know when the last time was she saw the boot on the resident. She verified the boot was not on as ordered. This deficiency represents incidental findings of non-compliance investigated under Master Complaint Number OH00151400. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366352 If continuation sheet Page 14 of 14