Inspection·November 14, 2022

F 0580 their references. The Discharge AMA form would be placed in the medical record along with narrative documentation that reflected conversations that were relevant to the resident discharging. 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: 366443 If continuation sheet Page 2 of 16 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 366443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belpre Landing Nursing and Rehabilitation 1915 Hill Street Belpre, OH 45714 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure written notification was provided related to bed hold procedures. This affected two residents (#27 and #44) of four residents reviewed for hospitalization. Findings include: 1. Review of Resident #27's medical record revealed an admission date of 11/02/22 with diagnoses including chronic obstructive pulmonary disease, history of lung transplant, chronic kidney disease and rectal cancer. Review of the resident's payer source revealed the resident received Medicare Part A services. Review of the progress note, dated 11/02/22 at 3:52 P.M. revealed the resident was sent to the emergency room due to an abrupt onset of change in mental status. A subsequent progress note revealed the resident was admitted to the hospital with diagnoses including urinary tract infection, renal failure and metabolic encephalopathy. Record review revealed the resident did return from the hospital. Further review of the medical record revealed no evidence the resident received written notification of the facility bed hold policy. On 11/09/22 at 1:45 P.M. interview with Business Office Manager #107 verified no bed hold letter was provided to Resident #27 upon transfer to the hospital. The BOM stated she only provided letters to residents who received Medicaid and not all residents, regardless of payer source. 2. Review of Resident #44's closed medical record revealed the resident was admitted to the facility on [DATE] and transferred to the hospital 10/19/22 for dizziness, hypotension and shaking. The medical record made no mention if the resident was admitted to the hospital, however, the resident did not return to the facility. The resident received services through Medicare Part A. Further review of the medical record revealed no evidence of bed hold notification prior to the resident's transfer to the hospital. On 11/09/22 at 1:45 P.M. interview with BOM #107 verified Resident #44 and/or his responsible party were not provided written bed hold notification prior to the resident's transfer to the hospital. The BOM stated she only provided letters to residents who received Medicaid and not all residents, regardless of payer source. Review of the facility Bed Hold Policy, revised 04/2019 revealed the facility would offer Medicaid residents the opportunity to hold their bed for a maximum of 30 days per calendar year. If the resident's payer source was one other than Medicaid, the resident or their sponsor would contact the facility if they would be holding the bed via telephone and/or in person on the next business day following admission to the hospital. The facility would, at that time, inform them of their financial responsibility in regards to the bed hold option. The charges would be reasonable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366443 If continuation sheet Page 3 of 16 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 366443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belpre Landing Nursing and Rehabilitation 1915 Hill Street Belpre, OH 45714 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #95's plan of care was accurate and updated to reflect the resident's advance directives. This affected one resident (#95) of one resident reviewed for advanced directives. Findings include: Review of the medical record for Resident #95 revealed an admission date of [DATE] with diagnoses including malignant neoplasm of upper lobe of right bronchus or lung, chronic obstructive pulmonary disease, and atherosclerotic heart disease of native coronary artery. Review of Resident #95's physician's orders for [DATE] revealed a Do Not Resuscitate-Comfort Care Arrest (DNRCCA) advanced directive. Continued review of Resident #95's medical record revealed a signed DNR Identification Form, dated [DATE] indicating Resident #95 selected to be a DNRCC-Arrest If this box is checked, the DNR Comfort Care Protocol is implemented in the event of a cardiac arrest or a respiratory arrest. Review of the plan of care, dated [DATE] reflected Resident #95's advance directives included the resident was a Full Code (as per wishes). Interventions included advance directives would be placed on chart, call 911 for emergency help if needed, code status would be reviewed at lease quarterly, annually and as needed, staff would initiate cardiopulmonary resuscitation (CPR) until emergency medical services (EMS) arrived, staff would notify physician of resident wishes and carry out any orders, staff would update family/responsible part of residents wishes. Review of the plan of care, dated [DATE] revealed Resident #95 wished her advanced directive to be Do Not Recusant, Comfort Care Arrest (DNRCCA). Interventions included advance directives would be on chart, hospitalize as needed for all routine test and treatments, if resident choked, provide abdominal thrust but do not proceed with CPR, send a copy of my DNR orders to any hospital visits. On [DATE] at 2:26 P.M. interview with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #112 confirmed Resident #95 had a care plan indicating an advanced directive for full Code and a care plan for a DNR-CCA. LPN #112 claimed when Resident #95 was first admitted to the facility, there was not a signed code status form in her medical record, so until this was obtained, Resident #95 would be treated as a Full Code. When the official code status form was obtained and signed by the physician, Resident #95's plan of care should have been updated to reflect the proper code status and the old care plan should have been deleted. LPN #53 verified a signed, updated DNR Identification Form was located in Resident #95's medical record. Review of facility undated policy titled Advanced Care Planning Policy revealed Advanced Directive: A written document that stated what medical treatment a resident wanted in the event he/she was unable to make his/her own health care decisions. Cardiac Arrest: The absence of a palpable pulse. Comfort Care: Any of the following: a. nutrition when administered to diminish the pain or discomfort of a resident, not to postpone his/her death. b. hydration when administered to diminish the pain or discomfort of a resident, not to postpone his/her death. c. any other medical or nursing procedure, treatment, intervention, or other measure that is taken to diminish the pain or discomfort of a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366443 If continuation sheet Page 4 of 16 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 366443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belpre Landing Nursing and Rehabilitation 1915 Hill Street Belpre, OH 45714 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 0657 resident, no to postpone his/her death. 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: 366443 If continuation sheet Page 5 of 16 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 366443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belpre Landing Nursing and Rehabilitation 1915 Hill Street Belpre, OH 45714 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #246, who required staff assistance for activities of daily living received adequate and timely assistance with nail care to maintain proper hygiene. This affected one resident (#246) of four residents reviewed for activities of daily living (ADL) care. Residents Affected - Few Findings include: Review of Resident #246's medical record revealed an 10/20/22 admission date with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting left non dominant side, severe protein calorie malnutrition, hyperlipidemia, failure to thrive and anemia. Review of the 10/21/22 activities of daily living plan of care revealed the resident had a self care deficit related to debility, hemiplegia, shortness of breath and weakness. The goal was for the resident's needs to be met through the review date. Review of the 10/26/22 five-day Minimum Data Set (MDS) 3.0 assessment revealed the resident was moderately impaired for daily decision making, required extensive assistance from two staff for bed mobility and transfers and and extensive assistance from one staff for personal hygiene. On 11/07/22 at 11:20 A.M. Resident #246 was observed in bed with dark debris under the fingernail beds. On 11/07/22 at 4:38 P.M. the resident's fingernails remained dirty. On 11/08/22 at 10:52 A.M. the resident's fingernails on the right hand and left thumb were observed to have dark debris in the nail beds. On 11/08/22 at 11:12 A.M. interview and observation with State Tested Nursing Assistant (STNA) #85 verified the resident's nails needed cleaned. STNA #85 indicated staff were to do nail care when baths and showers were given. Review of the Fingernail Care policy, revised 10/2018 revealed fingernail care was completed to provide cleanliness and prevent the spread of infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366443 If continuation sheet Page 6 of 16 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 366443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belpre Landing Nursing and Rehabilitation 1915 Hill Street Belpre, OH 45714 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure physician ordered anti-embolism stockings/(TED) hose were in place for Resident #2. This affected one resident (#2) of one resident reviewed for hemodialysis. Residents Affected - Few Findings include: Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, protein calorie malnutrition, anxiety, congestive heart failure (CHF), end stage renal disease, osteoarthritis. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 09/26/22 revealed the resident's cognition was moderately impaired, he required extensive assistance from one staff member for bed mobility, dressing, and personal hygiene, and required extensive assistance from two or more staff members for transfers and toilet use. Review of the physician's orders for 11/2022 revealed an order for TED hose (anti-embolism stockings) to be on in the morning and off at bedtime. On 11/08/22 at 12:02 P.M., 2:53 P.M. and 3:45 P.M. Resident #2 was observed without the ordered TED hose in place. On 11/08/22 at 3:45 P.M. interview with State Tested Nursing Assistant (STNA) #64 verified the resident's TED hose were no in place as ordered. There was no evidence the resident had refused the TED hose on this date provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366443 If continuation sheet Page 7 of 16 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 366443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belpre Landing Nursing and Rehabilitation 1915 Hill Street Belpre, OH 45714 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure wound care was provided using proper and adequate infection control techniques to decrease the risk of infection for Resident #349. This affected one resident (#349) of two residents reviewed for pressure ulcers. Residents Affected - Few Findings include: Review of Resident #349's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including pneumonia, diabetes mellitus, severe protein calorie malnutrition, pacemaker, epilepsy, dementia, high blood pressure and anemia. Review of the plan of care , dated 11/04/22 revealed the resident had actual impaired skin integrity/pressure ulcer related to Stage I (non-blanchable erythema of intact skin) pressure ulcer to right buttock and left rear hip and unstageable (obscured full-thickness skin and tissue loss) pressure ulcer to coccyx (as documented on admission). Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 11/08/22 revealed the resident was totally dependent on one staff for toilet use. Review of the physician's order revealed an order to cleanse coccyx with in house wound cleanser, pat dry, apply skin prep to peri wound, apply Medihoney, then pack wound with calcium alginate and cover with border foam dressing, change daily and as needed if soiled or dislodged, change every shift and as needed and monitor coccyx for signs and symptoms of infection and dressing placement. On 11/09/22 at 9:35 A.M. observation of the dressing change to the coccyx wound revealed Licensed Practical Nurse (LPN) #112 washed her hands and applied gloves and removed the old dressing. The LPN removed her gloves and washed her hands, put on new gloves and cleansed the wound with dermal wound cleanser and 4 x 4 gauze. Wearing the same gloves, the LPN applied skin prep around the wound, then opened q-tips and applied Medi-honey into the wound. Still wearing the same gloves she opened the calcium alginate and tore off a piece and place it into the wound bed and placed a boarder foam dressing over it, removed her gloves and washed her hands. On 11/09/22 at 9:45 A.M. interview with LPN #112 verified she failed to complete proper hand hygiene and glove use during the pressure ulcer dressing change for Resident #349. Review of the facility undated Pressure Ulcer Prevention and Risk Identification policy revealed if a new skin area was identified on the skin assessment or during any other type of care or service, the licensed nurse would initiate a skin grid/measurement flow record. The skin grid would be updated every seven days until the area was resolved. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366443 If continuation sheet Page 8 of 16 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 366443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belpre Landing Nursing and Rehabilitation 1915 Hill Street Belpre, OH 45714 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. Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure fall safety measures were in place for Resident #19 as planned. This affected one resident (#19) of three residents reviewed for accidents. Findings include: Review of Resident #19's medical record revealed a 09/27/22 admission and re-admission date of 10/13/22 with diagnoses including dementia without behavioral disturbance, psychotic disturbance and mood disturbance, and anxiety, difficulty walking, muscle wasting and atrophy, muscle weakness, cognitive communication deficit, muscle wasting and atrophy, insomnia, osteoporosis and anxiety disorder. Review of the new admission assessment revealed the resident was at risk for falls due to impaired decision making, delusions, vision impaired, wandering, restlessness/agitation, needing assistance in activity of daily living self performance, unsteady gait, use of assistive device for mobility, bladder incontinence and involuntary of bowel, osteoporosis and vertigo. Interventions included bed stabilizers, lock bed, have commonly used articles within easy reach: water, call light, remote control, telephone and maintain a clear pathway. Review of the 10/20/22 admission Minimum Data Set (MDS) 3.0 assessment revealed the resident was severely impaired for daily decision making, required limited assistance from two staff for bed mobility and transfers, extensive assistance from one staff for toilet use, personal hygiene, walking in room and dressing and (staff) supervision set up for eating. The assessment revealed the resident had no upper or lower extremity impairment, no hallucinations, delusions or behaviors and no falls. The resident utilized antipsychotic, antianxiety, antidepressant, and antibiotic medications during the assessment reference period. Record review revealed a 11/05/22 11:29 A.M. incident note which included the nurse was called into the resident's room due to the resident being on the floor. Found resident laying on the floor between the bed and recliner. Resident alert. Assessment of resident completed. Noted bruising to the right side of forehead, temple and above right eyebrow. Noted bruising to left hip and back of neck. Resident stated she was standing up, reaching for something and fell to the floor. Vital signs as follows: temperature 97.4 degreess Fahrenheit, pulse 88 beats per minute, oxygen 98%, blood pressure 149/97 and respirations 18 breaths per minute. Review of a 11/07/2022 9:35 A.M. interdisciplinary team follow-up note included the resident was alert and oriented to person, confused, baseline for resident. No neurological deficits noted. Resident propelling self in wheelchair, no signs/symptoms of pain or discomfort. Bed in low position at time of fall. Perimeter mattress was placed to resident's bed along with bilateral floor mats. On 11/07/22 at 3:41 P.M. Resident #19's room was observed. There were no floor mats in the room and no perimeter mattress on the resident's bed. On 11/08/22 at 11:40 A.M. the resident was observed without a perimeter mattress on her bed as per the new fall intervention following the 11/05/22 fall. On 11/08/22 at 11:42 A.M. interview with Licensed Practical Nurse (LPN) #111 verified the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366443 If continuation sheet Page 9 of 16 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 366443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belpre Landing Nursing and Rehabilitation 1915 Hill Street Belpre, OH 45714 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 did not have a perimeter mattress in place as care planned. Level of Harm - Minimal harm or potential for actual harm On 11/09/22 at 10:47 A.M. the resident was observed in bed without a fall mat to the left of her bed as care planned. The resident was observed with a black and blue right eye and forehead. Residents Affected - Few On 11/09/22 at 10:49 A.M. interview with LPN #53 verified the resident was in bed without bilateral floor mats as ordered. Review of the undated facility Falls Program revealed the interdisciplinary team would review occurrences and the implemented immediate interventions daily and implement additional interventions, as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366443 If continuation sheet Page 10 of 16 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 366443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belpre Landing Nursing and Rehabilitation 1915 Hill Street Belpre, OH 45714 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #349's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including pneumonia, diabetes, severe protein calorie malnutrition, pacemaker, epilepsy, dementia, high blood pressure and anemia. Residents Affected - Some Review of the admission MDS 3.0 assessment, dated 11/08/22 revealed the resident required staff assistance for activities of daily living. Review of the physician's orders for 11/2022 revealed an order to change aerosol nebulizer set-up every seven days and as needed (PRN) on night shift every Sunday. The resident also had an order for Ipratropium Bromide Solution 0.02 % 2.5 ml inhalation three times a day for COPD. On 11/07/22 at 12:30 P.M., 3:03 P.M. and 4:02 P.M. observation revealed the resident's nebulizer with tubing and mask were not dated or covered and laying on the resident's bed side stand uncovered. On 11/08/22 at 10:43 A.M. the nebulizer with tubing and mask were observed not dated or covered. On 11/08/22 at 10:57 P.M. interview with Licensed Practical Nurse (LPN) #111 verified the resident's oxygen nebulizer tubing and mask were not properly dated or stored. 2. Review of Resident #9's medical record revealed a 02/09/22 admission and re-admission date of 05/27/22 with a diagnoses including chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, asthma and heart failure. Review of the 10/01/22 quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident was severely impaired for daily decision making, required extensive assist from two staff for bed mobility, extensive assistance from one staff for transfers and dressing and staff supervision set up for eating. The MDS 3.0 assessment revealed the resident was at risk for developing pressure ulcers, utilized a pressure reducing device for bed, had no unhealed pressure ulcers and used oxygen. On 11/07/22 at 11:50 A.M. Resident #9 was observed using oxygen being delivered per nasal cannula at 2 liters per minute. The cannula and bag were dated 10/02/22. There was a nebulizer machine and mouth piece on the resident's bedside table. The mouthpiece was not in its holder. The mouthpiece was observe laying on the over bed table with the mouthpiece touching the table. On 11/07/22 at 4:30 P.M. observation revealed the resident had a nasal cannula on delivering oxygen. The nasal cannula remained dated 10/02/22. There was a clear storage bag hanging on the oxygen condenser. The bag was dated 10/02/22. The nebulizer mouthpiece remained touching the bedside table. Review of the physician's orders revealed the resident had no physician order for the use of oxygen. There was an order, dated 05/27/22 for an Albuterol Sulfate HFA aerosol medication 108 (90 Base) micrograms (MCG)/ACT two puffs orally every four hours as needed for shortness of breath/wheezing and an order for Ipratropium-Albuterol Solution 0.5-2.5 milligrams (MG)/3 milliliters (ML) three ml inhalation orally every six hours as needed for shortness of breath/wheezing. Review of the resident's care plan revealed there was not a comprehensive plan of care developed for the use of oxygen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366443 If continuation sheet Page 11 of 16 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 366443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belpre Landing Nursing and Rehabilitation 1915 Hill Street Belpre, OH 45714 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 11/08/22 at 10:59 A.M. Licensed Practical Nurse (LPN) #111 verified the resident had oxygen tubing and bag which were both dated 10/02/22. LPN #111 verified the nebulizer was laying on the over bed table with the mouthpiece touching the table. On 11/09/22 at 11:11 A.M. interview with the DON verified the resident had no physician order or care plan related to the use of oxygen in place until 11/08/22. Review of facility undated policy titled Oxygen Per Concentrator revealed under procedure- check physician's orders and adjust liter flow to prescribed flow. Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure orders were in place for oxygen use and/or failed to ensure oxygen supplies were maintained in a clean and sanitary manner for Resident #9, #13 and #349. The facility also failed to ensure hospital discharge instructions were implemented for Resident #44 to prevent potential re-hospitalization and failed to ensure the resident's respiratory needs were met. This affected one resident (#44) of four residents reviewed for hospitalization and three residents (#9, #13 and #349) of four residents reviewed for respiratory care. Findings include: 1. Review of the closed medical record for Resident #44 revealed the resident was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea, chronic respiratory failure, atrial fibrillation, chronic obstructive pulmonary disease (COPD) and congestive heart failure. Review of the hospital Discharge summary, dated [DATE] revealed the resident had presented to the emergency room after several weeks of progressively worsening shortness of breath. He had been non-compliant with his Trilogy (an all-in-one ventilation device capable of delivering invasive and non-invasive ventilation modes) machine. Resident #44 received non-invasive ventilation for obstructive sleep apnea. The resident had been intubated during his hospital stay and now required nocturnal BiPAP (non-invasive ventilation used to provide breathing support administered through a face mask, nasal mask or helmet. Air, usually with added oxygen, is given through the mask under positive pressure; generally the amount of pressure is alternated depending on whether someone is breathing in and out) and nasal cannula during the day. For the obstructive sleep apnea the hospital encouraged compliance with Trilogy machine every bedtime. Further review of the discharge summary revealed the resident had obstructive sleep apnea and wore Trilogy nightly. The orders indicated what medications to stop and which to continue. The discharge summary made no mention of discontinuing the resident's Trilogy and oxygen, however there was not a specific order for either in the summary. Review of the resident's admission orders to the facility revealed the orders did not indicate to continue the Trilogy. However, per the admission assessment, the resident received oxygen delivered via a BiPAP. Review of the admission Communication form, dated 10/16/22, however not part of the medical record, indicated the resident received oxygen and per the hospital social worker, the physician discontinued the Trilogy due to non-use. However, there was no clarification on the discharge summary or in the facility medical record regarding the discontinuation of the Trilogy due to non-use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366443 If continuation sheet Page 12 of 16 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 366443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belpre Landing Nursing and Rehabilitation 1915 Hill Street Belpre, OH 45714 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The progress notes were silent to encouraging the use of the BiPAP, education of the risks and benefits of not wearing/wearing the BiPAP, why the resident was not wearing his BiPAP or clarification regarding the use of the BiPAP. Review of the facility History and Physical (H&P), dated 10/17/22 and completed by Physician #119 revealed the resident was admitted to the hospital from [DATE] to 10/16/22. The H&P reflected the resident was a gentleman with multiple medical problems including COPD and obstructive sleep apnea. The H&P noted the resident used a Trilogy machine, but was apparently non-compliant with it. He reported he could not wear his CPAP, BiPAP or Trilogy due to sore throat. He had acute-on-chronic hypoxic hypercapnic respiratory failure requiring intubation. He certainly had oral thrush and the physician noted a concern with yeast esophagitis based on symptoms. The note indicated the resident would be empirically treat. Overall prognosis for this gentleman is extremely poor. It sounds like he is noncompliant to start with. He does not wear his Trilogy or CPAP or BiPAP here and I am sure he is not going to wear it in the future, which is what got him into this trouble to start with. Review of the physician orders revealed an order, dated 10/17/22 for Nystatin four times a day and Diflucan daily for 14 days to treat oral and esophageal thrush. Review of the progress note, dated 10/19/22 at 10:45 A.M. revealed the resident was with decreased alertness, increase in lethargy, shaking, complaining of dizziness and feeling unwell. Vitals were taken and the resident's blood pressure was 76/45, oxygen 100% and respirations 16. The nurse practitioner was notified and suggested to send the resident to the hospital. 911 was activated and the resident was transported via stretcher out of the facility. Review of the hospital records dated 10/19/22 revealed the resident was discharged from the hospital three days ago after he was admitted for acute on chronic hypercapnic respiratory failure requiring intensive care unit and mechanical ventilation. He was sent from the skilled facility for evaluation of lethargy. It was not clear whether the patient had been compliant with non-invasive mechanical ventilation. On 11/09/22 at 3:30 P.M. interview with the Director of Nursing (DON) verified the hospital documentation reflected the resident wore a Trilogy at bedtime and the social worker from the hospital notified the facility the resident's trilogy had been discontinued due to non-use. However, the hospital documents discussed the resident using the Trilogy at bedtime and there was no order to discontinue the Trilogy. The DON also verified the admission assessment noted the resident received oxygen via BiPAP and he was re-admitted to the hospital on [DATE] for respiratory failure and was intubated receiving mechanical ventilation. The DON verified the facility should have clarified the use of the Trilogy through orders to continue or discontinue and education should have been provided if the resident was refusing and the reason for his refusal should have been documented as well. 4. Review of the medical record for Resident #13 revealed an admission date of 10/28/22 with diagnoses including pneumonia, cognitive communication deficit and dementia without behavioral disturbances. Review of a hospital visit summary, dated 10/28/22 revealed while at the hospital Resident #13 was on room air for respiratory status and no equipment was needed upon discharge to the skilled nursing facility. The resident was to remain room air for respiratory needs. Review of Resident #13's admission Packet, dated 10/28/22 (with a lock date of 10/31/22) revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366443 If continuation sheet Page 13 of 16 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 366443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belpre Landing Nursing and Rehabilitation 1915 Hill Street Belpre, OH 45714 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 Level of Harm - Minimal harm or potential for actual harm the resident's lungs were clear throughout bilaterally, no noted difficulty breathing. No supplemental oxygen was noted to be ordered or required for respiratory status. Review of Resident #13's plan of care revealed the resident did not have any type of care plan related to the use or need of supplemental oxygen. Residents Affected - Some Review of Resident #13's physician orders for November 2022 revealed no physician order for the use of supplemental oxygen. Review of the progress notes for Resident #13 from 10/28/22 through 11/10/22 revealed no information regarding staff receiving any orders for oxygen use, or the resident's need for supplemental oxygen. Review of Resident #13's Physical History and Physicals/Consult Evaluation, dated 10/31/22 and 11/04/22 indicated no need or use of supplemental oxygen was in place. On 11/07/22 at 9:30 A.M. Resident #13 was observed to have an oxygen concentrator machine sitting next to the bed. The oxygen concentrator was not in use at the time of observation. The oxygen tubing was noted to be laying on the floor with no date noted on the tubing. On 11/08/22 at 10:58 A.M. Resident #13 was observe to have an oxygen concentrator machine remain in her room, not in use, next to her bed. The oxygen tubing was noted to be laying on the floor, with the date of 11/07/22 noted on it. On 11/08/22 at 11:05 A.M. interview with Licensed Practical Nurse (LPN) #68 confirmed Resident #13 had a supplemental oxygen concentrator in her room. LPN #68 revealed she was not sure why it was in there since the resident did not have an order for it. At the time of the interview, LPN #68 confirmed Resident #13's oxygen tubing was not in a protective bag and the nasal cannula part of the tubing was touching the floor. LPN #68 claimed Resident #13's family had been known to come in and take the resident's oxygen off and place the tubing on the oxygen concentrator where it would then fall to the floor, but also confirmed a bag for the oxygen tubing to be placed in when not in use was not available. On 11/10/22 at 1:30 P.M. interview with the Director of Nursing (DON) revealed the oxygen concentrator was removed from Resident #13's room since there was no real reason for the resident to have it and there was no order for its use. The DON verified she was not really sure why the oxygen concentrator was in Resident #13's room to begin with. Review of facility undated policy titled Oxygen Per Concentrator revealed under procedure- check physician's orders. If oxygen was not in use, place cannula in a plastic bag. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366443 If continuation sheet Page 14 of 16 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 366443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belpre Landing Nursing and Rehabilitation 1915 Hill Street Belpre, OH 45714 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure pureed food was prepared by the recipe to ensure it was served at the proper consistency. This affected two resident (#39 and #349) two residents who received pureed diets from the kitchen. Findings include: On 11/09/22 at 9:30 A.M. observation of the pureed food process revealed Dietary [NAME] (DC) #99 first obtained the temperature of the chicken (204.5 degrees Fahrenheit) and cauliflower (200 degrees Fahrenheit). DC #99 then placed the chicken in the food processor and added an unmeasured amount of hot water and broth. DC #99 pureed four ounces of chicken for both Resident #39 and Resident #349. Dietary [NAME] #99 then placed the cauliflower in the food processor and pureed two ounces of cauliflower without adding any additional liquids or items. DC #99 then placed the food items in bowls once completed. Review of the recipe, dated 10/13/22 for the pureed vegetable revealed when processing to gradually add food thickener and melted margarine to the vegetables while processing. Review of the undated facility policy and procedure for mechanical soft diets revealed it shall be the responsibility of the Dietary Manager to assure recipes for pureed diets were available and followed by staff. On 11/09/22 at 9:45 A.M. interview with Dietary Manager #59 verified DC #99 had not used a recipe during the pureed food process for the chicken and cauliflower observed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366443 If continuation sheet Page 15 of 16 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 366443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belpre Landing Nursing and Rehabilitation 1915 Hill Street Belpre, OH 45714 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. Based on observation, record review and interview the facility failed to ensure Resident #21's medical record was maintained in an accurate manner related to wound care. This affected one resident (#21) of two residents reviewed for pressure ulcers. Findings include: Review of Resident #21's medical record revealed a 04/09/22 admission with diagnoses including orthopedic aftercare following surgical amputation, absence of right leg below knee, respiratory failure, peripheral vascular disease and anxiety. On 11/09/22 at 11:23 A.M. Resident #21 was observed sitting on the side of the bed dressed in street clothes. The resident's prosthetic leg was off and she had no dressing in place to the right stump. The resident had a dressing in place to her left heel. Review of the November 2022 treatment administration record revealed to monitor dressing to right medial amputation. The treatment order was signed off/documented as being completed twice a day. However, record review revealed a physician's order, dated 09/21/22 to discontinue the dressing to the resident's right stump. On 11/09/22 at 4:28 P.M. interview with Licensed Practical Nurse (LPN) #53 verified the resident did not have a dressing on her right stump. LPN #53 verified staff were documenting twice a day they were monitoring a dressing to the right medial leg when a dressing had not been ordered since 09/21/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366443 If continuation sheet Page 16 of 16