Health inspection·August 8, 2022

F 0569 Level of Harm - Minimal harm or potential for actual harm despite the resident being private pay. She could not specify a time frame for when the refund would be issued. Review of the Review of Ohio 2019 admission Agreement revealed if an over payment has occurred, the amount of overpayment would be refunded within 30 days. Residents Affected - Few Interview with the Administrator on 08/03/22 at 11:45 A.M. verified the refund should have been processed within 30 days, per the facility policy. 2. Review of medical record for Resident #261 revealed an admission date of 01/15/21 and a discharge date of 11/02/21. Diagnoses included psychotic disorder, unspecified dementia, type two diabetes mellitus, and atrial fibrillation. Review of the facility business records for Resident #261 revealed Resident #261 had $1,459.55 in his facility account. A check numbered 1940 for $1459.55 was written to Resident #261's son on 02/09/22. Interview on 08/08/22 at 10:55 A.M. with the Administrator and Regional Director of Operations #671 verified Resident #261 was discharged on 11/02/21 and Resident #261's funds were conveyed outside of the required timeframe of 30 days. This deficiency substantiates Master Complaint Number OH00133633. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366378 If continuation sheet Page 2 of 13 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 366378 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covington Skilled Nursing & Rehab Center 100 Covington Drive East Palestine, OH 44413 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed substantiate self-reported incident (SRI) tracking number (#)223300 dated 06/27/22 after resident personal checks written to the facility were compromised. This affected six (Residents #5, #19, #22, #27, #29, and #44) of six residents reviewed for misappropriation. The facility census was 44. Residents Affected - Some Findings include: Review of the medical record for Resident #5 revealed an admission date of 03/20/22. Diagnoses included major depressive disorder, dysphagia following cerebral infarction, and type two diabetes mellitus. Review of the medical record for Resident #19 revealed an admission date of 11/19/21. Diagnoses included chronic systolic heart failure, type two diabetes mellitus, and dementia with Lewy bodies. Review of the medical record for Resident #22 revealed an admission date of 01/14/22. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, neuromuscular dysfunction of the bladder, and type two diabetes mellitus. Review of the medical record for Resident #27 revealed an admission date of 09/30/20. Diagnoses included hypertension, dementia, and Alzheimer's disease. Review of the medical record for Resident #29 revealed an admission date of 12/16/21. Diagnoses included osteoarthritis, peripheral vascular disease, type two diabetes mellitus. Review of the closed medical record for Resident #44 revealed an admission date of 02/01/22 and a discharge date of 07/03/22. Diagnoses included chronic kidney disease, paranoid schizophrenia, and psychosis. Review of the facility SRI tracking #223300 dated 06/27/22 revealed the investigation of misappropriation the incident was unsubstantiated due to Resident's #5, #19, #22, #27, #29, and #44 not losing any money. Interview on 08/01/22 at 10:29 A.M. with Resident #22 revealed he did remember his checking account being compromised. He was unsure of the details but reported he did not lose any money because the bank refunded it all. Interview on 08/03/22 at 1:30 P.M. with the Administrator revealed Resident #5's family member came forward on 06/27/22 and reported a personal check that was written to the facility was compromised after it cleared the bank. The check information was altered to only leave the signature and banking information. That check was then rewritten to a new payee and made out for a larger amount of money. The family member reported the bank caught the fraud and stopped payment on the check. He also had to open a new checking account. The Administrator revealed they then learned of five other residents affected. She reported all family members filed police reports and all opened new checking accounts with their own personal banks. The Administrator reported since the bank stopped all payments on the fraudulent checks and no residents lost money the allegation was unsubstantiated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366378 If continuation sheet Page 3 of 13 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 366378 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covington Skilled Nursing & Rehab Center 100 Covington Drive East Palestine, OH 44413 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 08/02/22 at 2:40 P.M. with Resident #19's Power of Attorney (POA) reported she did make a payment to the facility from her sister's joint account on 05/27/22. She reported in June 2022 she heard from the bank that 14 checks had been attempted to be cashed from the one check written to the facility on [DATE]. She revealed each check was written over 1,000 dollars. She confirmed the bank did stop all payments on those checks, and a new account was opened. She also confirmed she did file a police report. Resident #19's POA reported she now purchases cashier's checks for eight dollars apiece to pay for her sister's room and board because she does not want the facility knowing her sister's new checking account number. Interview on 08/03/22 at 2:52 P.M. with Resident #44's guardian reported her bank notified her in June of 2022 that Resident #44's personal checking account had insufficient funds. When she reached out to the bank, she was told three checks each written over 2,500 dollars had been attempted to be withdrawn from his account. Resident #44's guardian reported the bank pinpointed the check as being copied from the original check written to the facility in May 2022. She confirmed the bank did refund all the money and a new account was opened. She did file a police report. Interview on 08/03/22 at 3:35 P.M. with Resident #27's daughter and POA revealed she checks Resident #27's bank account daily. She reported one morning she went on to check and found it was overdrawn 800 dollars. She immediately called the bank, and they reported multiple checks had been attempted to be withdrawn for over 2,700 dollars. The bank confirmed the checks were copied from the original check written to the facility. She also confirmed the bank did stop all payments and a new account was opened. Resident #27's daughter reported she did file a police report. She also reported she does not want her mother to know that her checking account was compromised because it would cause her too much anxiety. Interview on 08/03/22 at 3:49 P.M. with Resident #29's son-in-law and POA revealed scammers got a copy of the check written to the facility and copied it 11 times in the amount of 29,400 dollars total. He reported the bank caught it immediately and reversed all the charges. The bank confirmed the 11 copied checks were from a check written to the facility. He also confirmed a new account was opened and a police report was filed. Resident #29's son-in-law also reported he now makes all payments electronically to the facility to protect his banking account information. Interview on 08/04/22 at 10:19 A.M. with Chief of Police #670 confirmed all six families of residents affected did file police reports and an investigation was ongoing. Interview on 08/04/22 at 10:30 A.M. with Resident #5's son confirmed he did hear his father tell him something about his checking account being compromised and a new account was opened but his father had since passed away. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366378 If continuation sheet Page 4 of 13 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 366378 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covington Skilled Nursing & Rehab Center 100 Covington Drive East Palestine, OH 44413 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a representative of the Office of the State Long-Term Care Ombudsman was notified of facility initiated discharges. This affected 19 residents (Residents #35, #46, #244, #245, #246, #247, #248, #249, #250, #251, #252, #253, #254, #255, #256, #257, #258, #259 and #260). The facility census was 44. Findings include: 1. Review of the medical record for Resident #46 revealed an admission date of 05/23/22 and discharge date of 06/13/22. Diagnoses included traumatic subdural hemorrhage without loss of consciousness, fall, dementia with behavioral disturbance, essential primary hypertension, and closed fracture of unspecified part of neck of right femur. Review of the Discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 was discharged with return not anticipated. Review of nursing progress notes dated 06/13/22 revealed Resident #46 was transported to the hospital for a change in condition, and then admitted . Interview on 08/03/22 at 8:44 A.M. with Administrator verified the facility did not timely notify a representative of the Office of the State Long-Term Care Ombudsman of the facility initiated discharge of Resident #46 on 06/13/22. The Administrator provided a folder and a facility admission/discharge report dated 08/03/22 for review. 2. Review of the facility admission/discharge report, dated 08/03/22, for residents discharged from 02/01/22 to 08/03/22 revealed the following residents received a facility-initiated discharge to a hospital: • Resident #36 was discharged on 07/26/22 • Resident #255 was discharged on 04/24/22 • Resident #256 was discharged on 04/29/22 • Resident #257 was discharged on 06/19/22 • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366378 If continuation sheet Page 5 of 13 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 366378 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covington Skilled Nursing & Rehab Center 100 Covington Drive East Palestine, OH 44413 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Resident #258 was discharged on 06/20/22 Level of Harm - Minimal harm or potential for actual harm • Resident #259 was discharged on 07/01/22 Residents Affected - Some • Resident #260 was discharged on 07/05/22 Attached to the admission/discharge report was a fax confirmation report of pages received, dated 08/03/22 at 7:73 A.M. to the ombudsman office regarding discharge notices. Review of the folder contained a facility admission/discharge report, dated 02/17/22, for residents discharged from 01/01/21 to 12/31/21 revealed the following residents received a facility-initiated discharge to a hospital: • Resident #254 was discharged on 05/01/21 • Resident #244 was discharged on 05/22/21 and again on 06/12/21 • Resident #245 was discharged on 06/19/21 • Resident #246 was discharged on 04/06/21 • Resident #247 was discharged on 05/10/21 • Resident #248 was discharged on 01/01/21 • Resident #249 was discharged on 01/14/21 • Resident #250 was discharged on 01/30/21 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366378 If continuation sheet Page 6 of 13 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 366378 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covington Skilled Nursing & Rehab Center 100 Covington Drive East Palestine, OH 44413 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 • Level of Harm - Minimal harm or potential for actual harm Resident #251 was discharged on 01/31/21 • Residents Affected - Some Resident #252 was discharged on 07/25/21 • Resident #253 was discharged on 01/09/22 Attached to the admission/discharge report was a fax confirmation report of pages received, dated 02/22/22 at 1:17 P.M. to a representative of the Office of the State Long-Term Care Ombudsman regarding discharges. Interview on 08/03/22 at 8:52 A.M. with Administrator verified the above reports were sent to the representative of the Office of the State Long-Term Care Ombudsman for the facility initiated discharges for the year 2021 on 02/22/22 and for discharges from 02/01/22 through the current date on 08/03/22. Administrator confirmed it was not timely notification as required. This deficiency substantiates Complaint Number OH00131608. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366378 If continuation sheet Page 7 of 13 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 366378 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covington Skilled Nursing & Rehab Center 100 Covington Drive East Palestine, OH 44413 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #9's annual assessment was submitted within 14 days after completion. This affected one (Resident #9) of one resident reviewed for assessments. The facility census was 44. Residents Affected - Few Findings include: Review of the medical record for Resident #9 revealed an admission date of 12/16/18. Medical diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, generalized muscle weakness, difficulty walking, and COVID-19. An Annual Minimum Data Set (MDS) 3.0 assessment was completed with an assessment reference date of 06/05/22. Review of the facility batch status report dated 08/04/22 revealed the Annual assessment dated [DATE] was submitted and accepted on 08/04/22. Interview on 08/04/22 at 11:22 A.M. with Licensed Practical Nurse (LPN) #669 verified Resident #9's Annual MDS 3.0 assessment dated [DATE] was not submitted until 08/04/22, which was not within the required timeframe. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366378 If continuation sheet Page 8 of 13 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 366378 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covington Skilled Nursing & Rehab Center 100 Covington Drive East Palestine, OH 44413 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure Resident #28's hearing aid was replaced in a timely manner. This affected one (Resident #28) of one resident reviewed for hearing. The facility census was 44. Residents Affected - Few Findings include: Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnoses including muscle weakness, osteoarthritis, spinal stenosis, major depressive disorder, and a history of COVID-19. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 had moderate difficulty hearing and wore hearing aids, required extensive assist of two staff for activities of daily living (ADL), use of a wheelchair for mobility and was on hospice. Review of Resident #28's care plan of 08/03/22 revealed care areas included communication deficit related to a hearing deficit as evidenced by highly impaired hearing and requiring two hearing aids. Interventions included audiology consult as needed, monitoring effectiveness of communication strategies and hearing aids and monitoring/documenting/reporting hearing impairment. Review of the nursing progress note of 06/03/22 at 10:03 A.M. revealed per midnight report- residents hearing aid shattered last evening. Called son to inquire about who Resident #28 sees for audiology. Resident #28's son stated he hasn't seen anyone in Ohio since he got the hearing aids in Tennessee. This nurse then asked if residents son had a preference as to whom his father sees for hearing aid replacementhe stated he does not have a preference. Information communicated to scheduling to have resident set up with an audiologist. Observations on 08/02/22 at 8:45 A.M., 08/03/22 at 8:59 A.M. and 08/03/22 at 2:40 P.M. revealed Resident #28 was very hard to engage in conversation and was not wearing hearing aids. He had difficulty hearing accurately, and understanding simple phrases and commands, even at a loud volume. The facility provided an appointment sheet dated 06/06/22 appointment as soon as possible (ASAP) with audiologist for broken hearing aide, spoke with resident's son; states he is waiting for audiology apt visit with 360. Interview on 08/04/22 at 10:05 A.M. with Resident #28' son reported it was reported to him when his father's hearing aid was crushed, over eight weeks ago, and it seemed to be taking a pretty long period of time to get it replaced. Not having the hearing aid makes it difficult to communicate when he and his family visit, which is about three times a week. He tried to put the other hearing aid in, but his father's hearing loss required both hearing aids for effective communication. The son reported the care was good, but some of the appointments, like for a replacement hearing aid, could have been handled better. He was told the facility would schedule an audiology appointment to replace the hearing aid. He verified no other options were discussed with him and his father had not received a replacement hearing aid. Interview on 08/04/22 at 10:43 A.M. with State Tested Nursing Assistant (STNA) #626 revealed as he was getting Resident #28 up on 06/03/22, he found the hearing aid in pieces on the floor, next to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366378 If continuation sheet Page 9 of 13 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 366378 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covington Skilled Nursing & Rehab Center 100 Covington Drive East Palestine, OH 44413 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 0685 Level of Harm - Minimal harm or potential for actual harm the bed. It appeared that it was either crushed by the mechanical lift or stepped on. The STNA immediately reported it to the nurse and called the resident's son who said he would like to get the hearing aid replaced. Review of the February 2018 policy Hearing Impaired Resident, Care of revealed staff will help residents who have lost or damaged hearing devices in obtaining services to replace a hearing aid. Residents Affected - Few Review of the audiologist list for 08/16/22 revealed Resident #28 was on the list to be seen on that date. This deficiency substantiates Complaint Number OH00131608. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366378 If continuation sheet Page 10 of 13 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 366378 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covington Skilled Nursing & Rehab Center 100 Covington Drive East Palestine, OH 44413 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 - Some 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, interview, drug manufacture review, and facility policy review the facility failed to ensure drugs in the medication storage room refrigerator were stored at the proper temperatures and dated when opened. This affected eight (Resident's #1, #4, #10, #23, #36, #40, #41, #194) and had the potential to affect all 44 residents residing in the facility. Findings include: Observation during the tour of the facility's medication storage room on 08/04/22 at 8:30 A.M. with Licensed Practical Nurse (LPN) #605 and Director of Clinical Services #668 revealed the medication room refrigerator's internal thermometer read 31 degrees Fahrenheit (F). Stored inside the refrigerator was one Glargine (Lantus) insulin pen for Resident #1, one Glargine (Lantus) insulin pen for Resident #4, one Humalog insulin pen for Resident #10, one Glargine (Lantus) insulin pen for Resident #23, one unopened vial of Lispro insulin for Resident #36, three boxes of house stock Acetaminophen suppositories, one opened and undated vial of Tubersol (used to test for tuberculosis), and one unopened vial of Tubersol. Interview at the time of observation of the medication storage refrigerator with LPN #605 confirmed the vial of Tubersol was undated and opened, and the Acetaminophen suppositories were inadvertently put in the refrigerator. Record review revealed Resident #1 was admitted on [DATE]. Diagnoses included type two diabetes mellitus, hypertension, and Alzheimer's disease. Physician order dated 05/04/22 revealed an order for a Lantus Solostar (insulin) 100 unit/milliliter (ml) pen injector. Record review revealed Resident #4 was admitted on [DATE]. Diagnoses included type two diabetes mellitus, anxiety, essential HTN, and schizophrenia. Physician order dated 07/14/22 revealed an order for Glargine (insulin) 100 unit/ml solution pen-injector. Record review revealed Resident #10 was admitted on [DATE]. Diagnoses included type two diabetes mellitus, acute and chronic respiratory failure with hypoxia, and chronic kidney failure. Physician order dated 07/13/22 revealed an order for Humalog Kwikpen (insulin) solution pen injector 100 unit/ml. Record review revealed Resident #23 was admitted on [DATE]. Diagnoses included type two diabetes mellitus, major depressive disorder, schizophrenia, and unspecified dementia. Physician order dated 10/19/20 revealed an order for Lantus Solostar (insulin) solution pen injector 100 unit/ml. Record review revealed Resident #36 was admitted on [DATE]. Diagnoses included type two diabetes, rib fracture, and malignant neoplasm of pyloric [NAME] (opening between the stomach and the small intestine). Physician order dated 08/01/22 revealed an order for Lispro (insulin) solution. Record review revealed Resident #40 was admitted on [DATE]. Diagnoses included dysarthria (unclear speech), hemiplegia and hemiparesis following cerebral infarction, and unspecified atrial fibrillation. Physician order dated 07/01/22 revealed an order to administer step one Mantoux (test for tuberculosis). Physician order dated 07/08/22 revealed an order to administer step two Mantoux. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366378 If continuation sheet Page 11 of 13 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 366378 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covington Skilled Nursing & Rehab Center 100 Covington Drive East Palestine, OH 44413 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 - Some Record review revealed Resident #41 was admitted on [DATE]. Diagnoses included pneumonia, congestive heart failure, and hypertension. Physician order dated 07/21/22 revealed an order to administer step one Mantoux. Physician order dated 07/28/22 revealed an order to administer step two Mantoux. Record review revealed Resident #194 was readmitted on [DATE]. Diagnoses included multiple fractures of ribs, wedge compression fracture of vertebra, and pneumothorax. Physician order dated 07/19/22 revealed an order to administer step one Mantoux on 07/19/22. Review of facility document titled Refrigerator Temp Log revealed the refrigerator in the medication room from 07/01/22 through 07/31/22 had temperature readings between 30 degrees (F) and 34 degrees (F) and from 08/01/22 through 08/04/22 had temperature readings between 30 degrees (F) and 32 degrees (F). Review of the drug manufacturing packaging for Tubersol indicated to store between 35 degrees (F) and 46 degrees (F). Review of the drug manufacturing packaging for Acetaminophen suppositories indicated to store between 68 degrees (F) and 78 degrees (F). Review of the drug manufacturing packaging for insulin Lispro solution indicated to store between 36 degrees (F) and 46 degrees (F) until first use. Interview on 08/04/22 at 9:28 A.M. with Director of Clinical Services #660 confirmed the medications stored in the medication room refrigerator were not stored under the proper temperature range of 36 degrees (F) and 45 degrees (F). Review of the facility policy titled Storage of Medications, revised April 2019, revealed drugs are to be stored under proper temperatures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366378 If continuation sheet Page 12 of 13 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 366378 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Covington Skilled Nursing & Rehab Center 100 Covington Drive East Palestine, OH 44413 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide documented evidence indwelling urinary catheter care was provided to Resident #22. This affected one (Resident #22) of two (Resident's #5 and #22) the facility identified as having an indwelling urinary catheter. The facility census was 44. Findings include: Review of the medical record for Resident #22 revealed an admission date of 01/14/22 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, neuromuscular dysfunction of the bladder, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 had moderate cognitive impairment. Resident #22 required extensive one-staff physical assistance for bed mobility, transfers, dressing, toileting, and personal hygiene; and supervision with set-up help only for eating. Resident #22 had an indwelling urinary catheter (a flexible tube that passes through the urethra and into the bladder to drain urine) was always incontinent of bowel. Review of the physician's orders for Resident #22 dated 06/03/22 revealed an order to maintain a 16 French 10 milliliter urinary catheter every shift. Another order dated 06/03/22 stated to provide indwelling urinary catheter care every day at bedtime for infection prevention. Review of the treatment administration record (TAR) for Resident #22 for June 2022 revealed no documented evidence indwelling urinary catheter care was provided on 06/03/22, 06/04/22, 06/05/22, 06/06/22, 06/07/22, 06/08/22, 06/09/22, 06/10/22, 06/11/22, and 06/12/22. Interview on 08/02/22 at 2:00 P.M. with Corporate Nurse #668 confirmed there was no documented evidence of indwelling urinary catheter care from 06/03/22 to 06/12/22. Corporate Nurse #668 also confirmed Resident #22 was sent to the hospital on [DATE] and was admitted on [DATE] with a diagnosis of urinary tract infection with sepsis. Interview on 08/01/22 at 10:29 A.M. with Resident #22 revealed he was unsure if any care was done to his catheter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366378 If continuation sheet Page 13 of 13