Inspection·August 24, 2021

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observations and staff interview, the facility failed to post the daily staffing in the facility. This had the potential to affect all residents residing in the facility. The census was 36. Residents Affected - Many Findings include: Observation on 08/18/21 at 10:45 A.M. of the daily staffing posting for the Coast and Prairie units revealed the staffing posting was dated 08/16/21. Interview on 08/18/21 at 10:45 A.M. with Registered Nurse (RN) #50 confirmed the daily staffing posting for the Coast and Prairie unit did not reflect the correct date. Observation on 08/18/21 at 10:50 A.M. of the daily staffing posting for the Mountain and Forest units revealed there was no daily staffing posting for that side of the facility. Interview on 08/18/21 at 10:50 A.M. with State Tested Nursing Assistant (STNA) #7 confirmed there was no daily staffing posting in the holder where the posting should be displayed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366450 If continuation sheet Page 2 of 8 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 366450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestowne Rehabilitation 1371 Main Street Hamilton, OH 45013 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of facility policy, the facility failed to implement a pharmacy recommendation by ensuring an antidepressant was decreased timely when approved by the physician. This affected one resident (#118) of three residents reviewed for unnecessary medication. The facility census was 36. Findings include: Medical record review for Resident #118 revealed an admission date on 08/04/21. Diagnoses include hemiplegia and hemiparesis following a stroke, aphasia, pneumonia, wedge compression fracture, anxiety, major depressive disorder, abdominal pain, hypertension, benign prostatic hyperplasia (BPH), fibromyalgia, kidney failure, urine retention, depression and contracture of right thigh. Review of admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #118 revealed an impaired cognition. Resident required supervision for bed mobility, limited assist for transfers and toileting and supervision for eating. Resident is always continent for bowel an bladder. Resident was coded as having a diagnosis of depression and received antidepressant daily during the assessment period. Review of the plan of care for Resident #118 dated 08/06/21 revealed resident was at risk for alteration in mood and psychosocial wellbeing related to restrictions to the facility due to Coronavirus Disease 2019 (COVID-19) pandemic. Interventions included observe for any mood or behavioral changes and notify physician as indicated, provide for expression of feelings related to situational stressor and provide psychologist consults as needed. Review of the care area assessment (CAA) completed for Resident #118 and dated 08/19/21 revealed resident was receiving antidepressant for depression and anxiety. CAA refers to gradual dose reduction in chart. Further stated resident is being closely monitored for adverse reactions and ill effects of medication. Review of pharmacy recommendations for Resident #118 dated 08/06/21 revealed a recommendation for the reduction of Celexa 40 milligrams (mg) one time a day to Celexa 20 mg one time a day. Review of physician recommendations for Resident #118 dated 08/06/21 revealed the physician agreed with the pharmacy recommendations to decrease Celexa 40 mg daily to Celexa 20 mg daily. The physician signed the document 08/10/21. Review of physician orders for Resident #118 revealed an order dated 08/05/21 Celexa oral tablet 40 mg one time a day related to major depressive disorder Review of the medication Administration record for August 2021 for Resident #118 revealed the resident received Celexa 40 mg daily since 08/05/21. Interview on 08/19/21 11:24 A.M. with Registered Nurse (RN) #4 verified Resident #118's Celexa should have been decreased when the physician order was returned on 08/10/21 on the pharmacy recommendation was received (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366450 If continuation sheet Page 3 of 8 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 366450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestowne Rehabilitation 1371 Main Street Hamilton, OH 45013 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 0756 Level of Harm - Minimal harm or potential for actual harm Review of facility policy titled Pharmacy Formulary, dated 09/04/16, revealed medication orders will be transmitted to the pharmacy by a facsimile copy of the practitioner orders as soon as possible after it is written. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366450 If continuation sheet Page 4 of 8 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 366450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestowne Rehabilitation 1371 Main Street Hamilton, OH 45013 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and hospital staff interview, observations and facility policy review, the facility failed to ensure a resident was free from unnecessary medications when the staff failed to monitor lab levels as ordered. This affected two (#118 and #125) of five residents reviewed for medication monitoring. The facility census was 36. Residents Affected - Few Findings included: 1. Medical record review for Resident #118 revealed an admission date on 08/04/21. Diagnoses include hemiplegia and hemiparesis following a stroke, aphasia, pneumonia, wedge compression fracture, anxiety, major depressive disorder, abdominal pain, hypertension, fibromyalgia, kidney failure, urine retention, and contracture of right thigh. Review of admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #118 revealed an impaired cognition. Resident required supervision for bed mobility, limited assist for transfers and toileting and supervision for eating. Resident was coded as receiving anticoagulant medication all seven days of the look back period. Review of the plan of care for Resident #118 dated 08/06/21 revealed resident was at risk for adverse effects of medication due to anticoagulants usage. Interventions included avoid massaging legs, handle resident carefully to avoid bruising, monitor for deep vein thromboses, localized heat redness and pain, obtained laboratory tests as ordered. Review of active physician's orders dated 08/16/21 for Resident #118 revealed an order to hold Coumadin collect an international normalized ratio (measurement of blood coagulation in the circulatory system) test (INR), repeat INR daily until patient is therapeutic between 2.0 and 3.0 and report changes to medical doctor or nurse practitioner. Review of laboratory results for Resident #118 contained no documentation for laboratory tests conducted on 08/17/21 as ordered. Observation on 08/18/21 at 9:51 A.M. of Resident #118 revealed multiple small areas of varying degree of blue and black discolorations on right arm. Interview on 08/18/21 at 2:42 P.M. with hospital laboratory staff #70 stated the facility staff input the laboratory tests to be collected into an electronic web-based system. Laboratory Staff #70 verified no laboratory tests were placed into the system for Resident #118 for 08/17/21, further stated the laboratory did not miss the test as it was not ordered for us to draw the blood sample. Interview on 08/19/21 10:53 A.M. with Registered Nurse (RN) #4 verified the INR was not collected on the 08/17/21 as it should was ordered. Interview with Director of Nursing on 08/19/21 at 3:30 P.M. stated the laboratory test for Resident #118's INR was missed on 08/17/21 when the lab came to draw the samples that morning. 2. Medical record review for Resident #125 revealed an admission date on 08/05/21 with diagnoses including osteoarthritis, assistance with personal care, severe obesity, urinary tract infection, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366450 If continuation sheet Page 5 of 8 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 366450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestowne Rehabilitation 1371 Main Street Hamilton, OH 45013 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few lymphedema, major depressive disorder, kidney failure, cardiomyopathy, hypertension, atrial fibrillation and chronic pain. Review of the admission MDS assessment dated [DATE] revealed the resident had intact cognition. Resident #125 required extensive assist of two staff members for bed mobility, transfers, and toileting. Resident requires supervision for eating. Resident was coded as receiving anticoagulants for three days during the look back period. Review of the plan of care for Resident #125 dated 08/06/21 revealed resident was at risk for adverse effects of medication due to anticoagulants usage. Intervention included avoid massaging legs, handle resident carefully to avoid bruising, monitor for deep vein thromboses, localized heat redness and pain, obtained laboratory tests as ordered. Review of the physician orders for Resident #125 revealed an order dated 08/05/21 for INR one time a day every Monday and Thursday for long term use of warfarin. Review of laboratory results for Monday 08/09/21 for Resident #125 contained no documentation for completion of ordered laboratory tests as ordered. Review of nursing progress notes' dated 08/10/21 at 6:11 P.M. for Resident #125 revealed an order to hold warfarin, INR 3.3 today, repeat daily INR until resident is Therapeutic between 2.0 and 3.0 and report changes to physician or nurse practitioner. Review of Coumadin Flow sheet for Resident #125 revealed an entry dated 08/06/21 indicating the next INR was scheduled on 08/09/21. Handwritten in the edge of the document near the date 08/09/21 with the initials belonging to RN #17 stated unavailable. The next line on the document was dated 08/10/19 indicating an INR was collected and continued to be abnormal. Review of hospital laboratory documents dated 08/09/21 revealed Resident #125 was not listed on the schedule for blood collection for an INR on 08/09/21. Interview with 08/18/21 at 2:42 P.M. with hospital laboratory staff #70 stated the facility staff input the laboratory that we draw into an electronic web-based system. Laboratory Staff #70 verified no laboratory tests were placed into the system for Resident #125 for 08/09/21, further stated the laboratory did not miss the test as it was not ordered for us to draw the blood sample. Interview on 08/19/21 at 3:19 P.M. with Registered Nurse (RN) #17 stated she called the nurse schedule on 08/17/21 and was told the laboratory did not have enough blood to complete the INR on 08/09/21. Interview on 08/19/21 at 4:04 P.M. with RN #75 (working on 08/17/21) stated she was not able to confirm an INR was collected for Resident #125 or if it was for another resident on 08/09/21. RN #75 was not able to recall the laboratory staff notifying RN of the lack of blood needed to complete the INR as ordered. Review of facility policy titled Laboratory, Radiology and other Diagnostic, dated 11/28/16, revealed the facility failed to implement the policy in regards to the allegation. Letter A states the facility is responsible for the quality and timeliness of the services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366450 If continuation sheet Page 6 of 8 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 366450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestowne Rehabilitation 1371 Main Street Hamilton, OH 45013 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, staff and resident interview, and review of facility policy, the facility failed to administer insulin as ordered by the physician resulting in a significant medication error. This affected one (#175) of three residents reviewed for medication administration. The census was 36. Residents Affected - Few Findings include: Review of record for Resident #175 revealed an admission date of 08/09/21 with a diagnosis of diabetes mellitus (DM.) Review of the mental status evaluation for Resident #175 dated 08/10/21 revealed resident was cognitively intact. Review of the care plan for Resident #175 dated 08/12/21 revealed resident had unstable blood glucose levels. Intervention included: administer medications as prescribed, educate resident/representative on preparation and administration of insulin injection, educate resident/representative regarding fluid & dietary restrictions, educate resident/ representative regarding prescribed treatment plan to manage blood sugars, evaluate blood glucose level per ordered frequency, monitor for signs/symptoms of hypoglycemia, hyperglycemia, monitor medication effectiveness for management of blood glucose level. Review of the August 2021 physician orders for Resident #175 revealed an order for insulin to be injected per sliding scale based before meals based upon blood sugar: if blood sugar is 151 to 200 = three units; 201 to 250 = four units; 251 to 300 = six units; 301 to 350 = 12 units; 351 to 400 = 15 units; 401 to 450 = 18 units, subcutaneously before meals related to DM. Review of the breakfast tray ticket for Resident #175 dated 08/18/21 revealed resident was served a tray in her room, a low fat/low cholesterol regular texture diet. Observation on 08/18/21 at 8:15 A.M. revealed Licensed Practical Nurse (LPN) #55 obtained Resident #175's blood sugar and it was 496. LPN #55 administered 18 units of insulin per sliding scale to resident. Interview on 08/18/21 at 8:15 A.M. with Resident #175 confirmed she was served breakfast at approximately 7:45 A.M. and was supposed to have her blood sugar taken and insulin administered before breakfast. Interview on 08/18/21 at 8:20 A.M. with LPN #55 confirmed Resident #175's blood sugar was 496 on 08/18/21 at approximately 8:15 A.M. LPN #55 further confirmed the resident's physician had ordered for insulin to be administered per sliding scale before meals and blood sugar was obtained and insulin administered after resident had already consumed breakfast. Review of the facility policy titled Administration of Medications dated 02/01/21 revealed medications were to be given at the time ordered and as directed by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366450 If continuation sheet Page 7 of 8 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 366450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jamestowne Rehabilitation 1371 Main Street Hamilton, OH 45013 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 Based on record review, observation, staff interview, review of facility policy, and review of online resources per the Centers for Disease Control (CDC) and the Center for Medicare and Medicaid Services (CMS), the facility failed to ensure staff wore appropriate eye protection to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). Additionally, the facility failed to ensure staff used proper infection control practices during medication administration. This affected one (#175) of three residents observed for medication administration. The census was 36. Residents Affected - Few Findings include: Review of the medical record for Resident #175 revealed an admission date of 08/09/21 with a diagnosis of diabetes mellitus. Review of the physician orders for Resident #175 revealed an order dated 08/10/21 for diltiazem hydrochloride extended release 120 milligram (mg) capsule by mouth. Observation on 08/18/21 at 7:50 A.M. revealed Licensed Practical Nurse (LPN) #55 prepared and administered medications to Resident #175. LPN #55 was not wearing eye protection. LPN #55 opened resident's diltiazem capsule and it dropped on the top of the medication cart. LPN #55 picked up diltiazem capsule with her bare hands and dropped it in the cup for administration to the resident. Interview on 08/18/21 at 8:20 A.M. with LPN #55 confirmed she was not wearing eye protection during medication administration to Resident #175 and further confirmed she touched Resident #175's medication with her bare hand prior to preparing for administration. Interview on 08/18/21 at 2:59 P.M. with Registered Nurse (RN) #60, the facility's Infection Preventionist (IP) confirmed based on the current positivity rate of COVID-19 for the county in which the facility is situated, all staff should wear eye protection at all times in resident areas. Review of facility policy titled Administration of Medications dated 02/01/21 revealed tablets and capsules should be handled so that the fingers do not touch the medication. Review of the facility policy titled COVID-19 Preparedness Response and Plan dated 07/23/20 revealed in times of sustained community transmission (county positivity rate is over five percent), face shield or lab style goggles must be worn in all resident care areas. Review of an online resource from CMS titled COVID-19 Nursing Home data at https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data-Test-Positivity-Rates/q5r5-gjyu/ revealed the county in which the facility was situated was experiencing a moderate spread of COVID 19 with a positivity rate of 8.7 percent and was identified as a color of yellow for the week ending in 08/10/21. Review of an online resource per the CDC at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html revealed the use of eye protection in healthcare facilities is recommended in areas with moderate to substantial community transmission and staff should don eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366450 If continuation sheet Page 8 of 8