Inspection·November 21, 2019

F 0657 was to be reviewed and revised at least quarterly with the MDS and on an as needed basis as changes occur in the resident's regimen. 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: 366372 If continuation sheet Page 2 of 6 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 366372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Keystone Pointe Health and Rehabilitation 383 Opportunity Way Lagrange, OH 44050 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 0698 Provide safe, appropriate dialysis care/services 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 medical record review, review of facility agreement with the dialysis center, resident and staff interview, the facility failed to ensure there was documented evidence of collaboration of care and communication between the nursing facility and the dialysis provider. This affected one resident (#33) of one reviewed for dialysis. The facility census was 112. Residents Affected - Few Findings include: Medical record review revealed Resident #33 admitted to the facility on [DATE]. Diagnosis included end state renal disease. The resident was receiving dialysis treatments every Tuesday, Thursday and Saturday. Review of Resident #33's most recent plan of care revealed the resident received dialysis treatments every Tuesday, Thursday and Saturday and was at risk for adverse effects of dialysis and/or infection of the dialysis access site. Interventions included to encourage Resident #33 to take the communication form to dialysis and return it to the nurse when she returned and for the facility to maintain communication with the dialysis center staff and physician. Review of the facility's Intra-Facility Communication Form revealed the facility was to provide the dialysis provider residents current mental status, weight history and vital signs, medications given the day of treatment, diet order, fluid limit, meal intakes over the past week, lung sounds, dialysis access dressing condition, assessment of the access site, if signs of infection were present and any pertinent comments or recent and/or impending surgeries for the resident. Review of Resident #33's Intra-Facility Communication Forms, from 10/01/19 through 11/19/19, revealed the facility failed to provide the requested information listed on the form to the dialysis center. Review of the forms dated 10/22/19, 10/31/19, 11/14/19 and 11/19/19 revealed only the resident's vital signs and that her morning medications were given was provided and on 10/26/19 only the resident's vital signs were provided. Further review revealed no documented evidence the facility provided any of the requested information on 10/01/19, 10/05/19, 10/08/19, 10/12/19, 10/15/19, 10/17/19, 10/24/19, 10/29/19, 11/05/19, 11/09/19, 11/12/19 and 11/16/19. Interview on 11/18/19 at 10:23 A.M., with Resident #33 revealed staff sometimes gave her paperwork to take with her to her dialysis appointments. If they did, she was supposed to bring it back with her when she returned to the facility. Interview on 11/19/19 10:22 A.M., Licensed Practical Nurse (LPN) #301 revealed nursing staff were supposed to fill out a new Intra-Facility Communication Form each time a resident went to a dialysis appointment and the form was sent with the resident to their appointment. The Dialysis center was supposed to fill out their required portion of the form, pertaining to the resident's condition during the dialysis treatment, and return the form with the resident at the end of the appointment. If the resident did not return with the form, staff were supposed to call the Dialysis center to obtain the form. If unsuccessful, attempts were to be documented in the residents medical record. Interview on 11/20/19 04:20 P.M., the Director of Nursing (DON) verified Resident #33's Intra-Facility Communication Forms for 10/22/19, 10/26/19, 10/31/19, 11/14/19 and 11/19/19 were not completed with all the requested information. The DON further verified there was no documented evidence the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366372 If continuation sheet Page 3 of 6 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 366372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Keystone Pointe Health and Rehabilitation 383 Opportunity Way Lagrange, OH 44050 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete facility provided any of the requested information on 10/01/19, 10/05/19, 10/08/19, 10/12/19, 10/15/19, 10/17/19, 10/24/19, 10/29/19, 11/05/19, 11/09/19, 11/12/19 and 11/16/19. Review of an agreement between the facility and dialysis center titled, SNF Outpatient Dialysis Services Agreement, dated 09/15/08, revealed the dialysis center would provide to the facility information on aspects of the management of a designated resident's care related to the provision of dialysis services. Further review revealed the facility was to ensure all appropriate medical and administrative information accompanied all residents at the time of transfer or referral to the dialysis unit. Appropriate information was supposed to include the resident's name, address, date of birth , social security number, name and telephone number of the resident's next of kin, insurance information, appropriate medical records including a history of the resident's illness and any laboratory and/or x-ray findings, treatment's presently being provided to the resident including medications. Further review revealed the nursing facility was to ensure that there was documented evidence of collaboration of care and communication between the nursing facility and the dialysis unit. Event ID: Facility ID: 366372 If continuation sheet Page 4 of 6 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 366372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Keystone Pointe Health and Rehabilitation 383 Opportunity Way Lagrange, OH 44050 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on personnel file review, observation, staff interview, and review of facility policy, the facility failed to ensure food was served in a sanitary manner when staff was observed not wearing appropriate hair coverings. This had the potential to affect the 24 residents (#3, #9, #10, #14, #17, #22,#28, #39, #43 #48, #50, #52, #63, #66, #69, #70, #85, #87, #90, #105, #410, #411, #412 and #413) who received food from the [NAME] 100/200 unit servery. The facility census was 112. Findings include: Review of the personnel file for Dietary Aide (DA) #995 revealed the DA signed a document during his orientation on 10/30/19 entitled Hand washing/Infection Control Guidelines indicating acknowledgement of a directive for staff to use hairnets and/or facial nets when handling food. Observation of the [NAME] 100/200 servery on 11/20/19 at 12:07 P.M., with Dietary Aide (DA) #995 revealed the DA was serving food with uncovered and noticeable facial hair. DA #995 verified his facility hair was not covered during the observation. Review of the facilities policy entitled Infection Control-Dietary/Food Handling dated 03/01/16 revealed hairnets or caps must be worn to effectively keep hair from contacting exposed food, clean equipment, utensils and linens. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366372 If continuation sheet Page 5 of 6 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 366372 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Keystone Pointe Health and Rehabilitation 383 Opportunity Way Lagrange, OH 44050 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to ensure staff were informed of a resident who was diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA) infection so precautions could be implemented. This affected one resident (#35) of four reviewed for infection. The facility census was 112. Residents Affected - Few Findings include: Review of Resident #35's medical record revealed an admission date of 06/02/16. Diagnoses included MRSA of the left lower leg, delusional disorders, cerebrospinal fluid drainage, dementia, diabetes mellitus and fibromyalgia. Review of Resident #35's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a low cognitive function. Review of Resident #35's wound care note dated 11/07/19 revealed the resident acquired a laceration to the left lower extremity while on an outing with family. Resident #35 acquired a skin tear measuring 3.5 centimeters (cm) x 2.6 cm x 0.1 cm on a running board of a pick up truck. Review of Resident #35's physician's order dated 11/15/19 revealed an order for Sulfamethoxazole-Trimethoprim (antibiotic) 800-160 milligram tablet by mouth, every 12 hours, for MRSA to left lower leg wound for eight days. Review of Resident #35's most recent care plan revealed no evidence the care plan was updated regarding the recent diagnosis of MRSA, nor were any interventions/precautions put in place. Interview with Resident #35's State Tested Nursing Aide (STNA) #400 on 11/20/19 at 2:58 P.M. confirmed she was unaware Resident #35 had MRSA and did not use any extra infection control precautions while caring for the resident. Interview with Resident #35's Licensed Practical Nurse (LPN) #300 on 11/20/19 at 3:01 P.M. confirmed she was unaware Resident #35 had been diagnosed with MRSA of the lower left leg. Interview with the Director of Nursing (DON) on 11/21/19 at 10:35 A.M. confirmed STNA #400 should have been informed during shift reports Resident #35 had MRSA in the left lower leg. Review of the facility policy titled Infection Prevention and Control Program (IPCP) dated 08/18/10 revealed the RN's (registered nurses) and LPN's supervise direct care staff in daily activities to assure appropriate precautions and techniques are observed, assess the resident's isolation needs, initiate appropriate precautions and consult with Medical Director and/or the resident's attending physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366372 If continuation sheet Page 6 of 6