Health inspection·January 24, 2023

F 0567 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #35's resident fund statements dated 01/01/22 to 12/31/22 revealed the resident had an active account and the balances ranged from $3,588.38 to $5,468.71. Review of Resident #35's resident fund management services authorization agreement to handle funds dated 01/10/23 revealed there was an X for the resident's signature. The two witness signatures were staff members. There was no evidence an agreement was obtained prior to 01/10/23. Interview on 01/17/23 at 4:28 P.M., with the BOM #187 revealed there was not a resident fund management service authorization agreement obtained when Resident #35's account when it was open. Last week BOM #187 had the resident place an X on the agreement form, even though the resident had dementia and was not competent to sign the agreement. The two witnesses who signed the agreement on 01/10/23 were staff members of the facility. Review of the facility's policy titled Foundations Health Solution Policy and Procedure dated 12/10/21 revealed the nursing facility shall establish and maintain a system that ensures full, complete, and separate accounting of each resident's Personal Needs Allowance (PNA) account funds. All residents with trust funds must have a trust fund authorization before an account can be established. Authorizations must be kept in an orderly fashion for easy access and auditing purposes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366478 If continuation sheet Page 2 of 22 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 366478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750 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 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident fund review, interview, and policy review the facility failed to ensure residents received spend down notifications timely and reimbursed funds timely after death. This affected one (Resident #35) of five residents reviewed for personal funds and one (Resident #74) of two residents reviewed for closer of account. Residents Affected - Few Findings included: 1. Record review revealed Resident #35 was admitted to the facility on [DATE] with diagnoses of dementia, psychosis, mental disorder, depression, anxiety, and Alzheimer's disease. The resident's primary insurance was Medicaid and secondary was Medicare. Review of Resident #35's resident fund statements dated [DATE] to [DATE] revealed the resident had an active account and the balances ranged from $3,588.38 to $5,468.71. Review of Resident #35's resident fund management services authorization agreement to handle funds dated [DATE] revealed there was an X for the resident's signature. The two witness signatures were staff members. There was no evidence an agreement was obtained prior to [DATE]. Interview on [DATE] at 4:28 P.M., with the Business Office Manager (BOM) #187 reported she has never sent a spend down notification to any of the residents since she had been employed by the facility. She had two residents that have gone over the $2,000.00 in the last year. BOM #187 wasn't informing the representatives prior to reaching the $2,000.00 max until the resident funds accounts had gone over. The BOM #187 reported she would call Resident #35's family when the resident's account was over and she would help the resident spend money on personal items or the family would buy snacks. 2. Record review revealed Resident #74 was admitted to the facility on [DATE] and expired on [DATE]. Review of Resident #74's resident fund management services authorization agreement to handle funds dated [DATE] revealed the resident's power of attorney (POA) had signed the authorization, however the authorization was not witnessed. Review of Resident #74's personal needs allowance account remittance notice undated revealed the resident expired on [DATE] and the remittance amount was $818.93. Review of the facilities check to the attorney general for Resident #74's Medicaid estate recovery revealed the money was not reimbursed back to the state until [DATE]. Interview on [DATE] at 4:35 P.M., with the BOM #187 revealed the Resident #74's had expired on [DATE], however the facilities accounting firm had closed the account before she had printed a reimbursement check to the state. The money was not reimbursed within the 30 days per the regulation. The BOM also confirmed the authorization was not witnessed. Review of the facilities policy titled Foundations Health Solution Policy and Procedure dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366478 If continuation sheet Page 3 of 22 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 366478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750 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 0569 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete [DATE] revealed the nursing facility shall establish and maintain a system that ensures full, complete, and separate accounting of each resident's Personal Needs Allowance (PNA) account funds. A provider shall give written notification to each resident who receives Medicaid benefits and whose funds are managed by the provider, when the amount in the resident's PNA account reached $200.00 less than the resource limit. A copy of the notice would be kept in the record. Upon discharge of a resident, a provider shall release all funds up to and including the maximum resource limit amount. The PNA account must be closed within 30 days of death. Funds must be returned to the Estate Recovery for a Medicaid recipient. The PNA account must be closed within 30 days of discharge. Representatives payee funds must be returned to social security, Private funds may be sent to the resident. All residents with trust funds must have a trust fund authorization before an account can be established. Authorizations must be kept in an orderly fashion for easy access and auditing purposes. Event ID: Facility ID: 366478 If continuation sheet Page 4 of 22 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 366478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750 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 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident medical and financial record review, resident interview, resident family interview, and staff interview, the facility failed to allow residents to receive all mail without it being unopened. This affected one (Resident #33) of one resident reviewed for opened mail. The census was 71. Residents Affected - Few Findings Include: Resident #33 was admitted to the facility on [DATE]. His diagnoses included heart and kidney failure. Review of his Minimum Data Set (MDS) assessment revealed he was cognitively intact. Review of Resident #33 financial records revealed he had an opened personal funds account with the facility. There were multiple entries per month of funds that were being added, via checks that were deposited by the facility into this account. There were between two and four checks per month added to this financial account; the checks were sent to the facility via mail and addressed to Resident #33. Interview on 01/18/23 at 1:25 PM with Resident #33 revealed he did not give the facility permission to open his mail and deposit the checks into this personal funds account the facility opened. He stated he knew the checks were to be delivered to the facility via mail. He stated he received two checks from two different companies a month. Interview with Resident #33 family on 01/17/23 at approximately 2:00 P.M. confirmed the facility opened Resident #33 mail without his permission. They would get his checks in the mail, and open/deposit them into his personal funds account without asking his permission first or giving the mail to him first. Interview with Business Office Manager (BOM) #187 on 01/17/23 at 3:26 P.M. and 01/18/23 at 8:27 A.M. confirmed she would get the mail for Resident #33, which included his checks that were sent each month, and open them to deposit the checks into his personal funds account. She stated she was afraid he was going to keep throwing them away prior to depositing them, so she decided to get them, open the checks from the mail, and deposit the checks. She confirmed she did not have permission from Resident #33 or his family to open his mail. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366478 If continuation sheet Page 5 of 22 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 366478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital records, interview, and policy review the facility failed to ensure a resident was involved in advance directive decisions. This affected one (Resident #225) of two residents reviewed for advance directives. Findings included: Record review revealed Resident #225 was admitted to the facility on [DATE] with diagnoses including heart and respiratory failure. Review of Resident #225's progress notes dated 01/11/23 to 01/23/23 revealed the resident had no cognition impairment. Review of Resident #225's hospital notes dated 01/06/23 to 01/11/23 revealed the resident was a full code and had changed code status on 01/06/23 to Do Not Resuscitate-Comfort Care Arrest (DNRCC-A). Review of Resident #225's facility physician orders dated 01/11/23 revealed the resident's code status was a full code. Review of Resident #225's paper care conference note dated 01/17/23 revealed the social worker had marked the resident's code status was a full code. Interview on 01/18/23 at 3:45 P.M. and 4:13 P.M., with Resident #225 and his son to clarify discrepancy in the hospital records revealed the resident reported his code status was a DNRCC-A. The resident and the son both reported the staff at the nursing home had never asked the resident or the son about the resident's Advance Directives/code status, however the resident had signed papers at the hospital changing his code status from full code to DNRCC-A. The son reported his two sisters, himself, and his father just had a care conference with the facility yesterday. Both the resident and son reported they don't recall telling anyone at the facility asking the resident if he wished to be a full code. Interview on 01/18/23 at 4:18 P.M., with Registered Nurse (RN) #132 reported she had assisted with part of Resident #225's admission. The RN reported she recalls the resident indicating he wanted to be a full code. RN #132 verified the hospital records had listed the resident as full code and DNRCC-A. The nurse went and spoke to Resident #225 and came back and reported the resident wanted his code status to be a DNRCC-A and not a full code. The surveyor requested a copy of Resident #225's DNRCC-A papers that were completed at the hospital; however they were never provided. Review of the facility's policy titled Social Services Policy/Procedure Manual dated 11/22/16 revealed the resident's right to formulate an Advance Directive, and to accept or refuse medical or surgical treatment. On admission, the facility will determine if the resident had executed an Advance Directive and if not, determine whether the resident would like to formulate an Advance Directive. Up admission should the resident have an Advance Directive, copies will be made and placed on the chart as well as communicated to the staff. During the care planning process, the facility will identify, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366478 If continuation sheet Page 6 of 22 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 366478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750 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 0578 clarify, and review with the resident or legal representee whether they desire to make any changes related to the Advance Directives. 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: 366478 If continuation sheet Page 7 of 22 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 366478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Potential for minimal harm Based on staff personnel record review, staff interview, and facility handbook review, the facility failed to complete reference checks for newly hired staff in a timely manner. This had the potential to affect 71 of 71 residents. Residents Affected - Many Findings Include: Review of Registered Nurse (RN) #109 personnel file revealed she was hired by the facility on 06/13/22. Her reference checks were completed on 06/16/22 and 06/17/22. Review of State Tested Nursing Aide (STNA) #198 personnel file revealed she was hired by the facility on 09/16/22. Her reference checks were completed on 09/13/22 and 09/21/22, which one was after her hire date. Review of Human Resource (HR) Director #110 personnel file revealed she was hired by the facility on 01/24/22. She had three hand written notes on the back of her application in which it appeared that reference checks were completed/attempted. There were no dates as to when these reference checks were completed/attempted. Interview with HR Manager #110 on 01/19/23 at 9:20 A.M. revealed the facility utilizes the 30 days after hire to complete all the background and reference checks. She stated they utilize the same time frame for the Bureau of Criminal Investigation (BCI) checks, which can be returned to the facility within the first 30 days of hire for final determination of employment status. She confirmed the reference checks listed above were not completed by the first day of hire for those new employees. Review of facility Employee Handbook, undated, revealed employment openings will be filled by applicants who, in judgement or the hiring supervisor, best meet the requirements of the job. The selection process is an attempt to match an applicant's education, skills and interests with the requirements of the job. Applicants will be evaluated through written application, careful interviewing and reference checks. When the applicant has been offered a position with the facility, employment will be conditioned upon the successful completion or verification of the following: verification of the applicant's references. Review of facility Abuse, Neglect, Exploitation, and Misappropriation of Resident Property policy, dated 11/21/16, revealed no procedures listed on reference checks for newly hired staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366478 If continuation sheet Page 8 of 22 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 366478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750 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, medical record review, and staff interview, the facility failed to ensure a resident's back brace (ordered to be in place at all times when out of bed) was implemented. This affected one (Resident #19) of the 24 residents reviewed for orders being implemented. The facility census was 71. Residents Affected - Few Findings include: Review of the medical record for Resident #19 revealed an admission date of 11/14/22. Diagnoses included dementia without behavioral disturbance, muscle wasting and atrophy, symbolic dysfunction, dysphagia, difficulty walking, L 2 fracture, and osteoarthritis. Review of Resident #19's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 09 indicating a moderately impaired cognition for daily decision making abilities. No behaviors were noted with this assessment review including rejection of care. Resident #19 required extensive assistance from two staff members for bed mobility, transfers, toilet use, and extensive assistance from one staff for dressing and eating. Resident #19 was noted to be free of impairment to the bilateral upper or lower extremities and noted to requires a walker for mobility assistance. Review of the plan of care dated 11/22/22 revealed Resident #19 was at risk for alteration in comfort due to back fracture impaired mobility. Interventions include to encourage and assist resident to maintain proper body alignment, encourage and assist resident to turn and reposition every 2 hours as needed, notify Medical Director for review of or changes, offer backrub or warm blankets, offer non-pharmaceutical interventions, pain assessment per facility policy, rest periods as needed, Review of Resident #19's physician orders for January 2023 revealed a order for resident to wear a back brace, on at all times when out of bed; may remove when laying in bed. Review of Resident #19's treatment administration record (TAR) for January 2023 revealed this order had been implemented as ordered and the back brace was on and in proper position while Resident #19 was out of bed. Observation on 01/17/23 at 9:52 A.M., on 01/17/23 at 3:21 P.M., on 01/18/23 at 8:42 A.M. and on 01/18/23 at 1:34 P.M. of Resident #19 revealed the resident up out of bed sitting in a reclining Broda chair in the dining room. Resident #19 was not wearing a back brace during these observations. Interview on 01/18/23 at 1:25 P.M. with Licensed Practical Nurse (LPN) #150 confirmed the order for Resident #19 to have a back brace on at all times while out of bed and to be removed when laying in bed. LPN #150 revealed she spoke with the resident's family who agreed with changing the order to as tolerated due to the resident not tolerating the brace very well. LPN #150 has been meaning to change it but has not yet. LPN #150 also confirmed this order had been marked as completed in the resident's TAR for 01/17/23 day shift and night shift and on 01/18/23 day shift and night shift. LPN #150 revealed that if Resident #150 refused to wear the back brace, the TAR should have been marked with a 9 indicating to review the progress note and then a progress note should have been completed, which it was not. Review of facility policies revealed the facility did not provide a policy regarding back braces or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366478 If continuation sheet Page 9 of 22 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 366478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750 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 implementing physician orders. 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: 366478 If continuation sheet Page 10 of 22 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 366478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including palliative care, diabetes, end stage renal disease, hypothyroidism, chronic obstructive pulmonary disorder, and disorder of lipoprotein metabolism. Residents Affected - Some Interview on 01/17/23 at 9:25 A.M., with Resident #59 reported her weight loss was due to she doesn't like a lot of the food the facility serves. She doesn't like the smell of broccoli and cauliflower; however, the staff keeps putting it on her plate. Resident #59 reported she has told staff several times she did not like those items and they keep sending them on her meal tray. Review of Resident #59's diet history/food preference dated 09/24/22 revealed the resident was 63 inches tall, usual body weight was 165, weight was steady, and no issues with chewing or swallowing. She drank one Glucerna daily at home and disliked peas. The residents' likes were beef, chicken, and vegetables. The resident's breakfast preference were biscuits and gravy, scrambled eggs, toast, French toast, pancakes, bacon, potatoes, and orange juice. The information was provided by the resident. Review of Resident #59's meal tickets dated 01/19/23 revealed the resident's diet was regular, dislikes peas, likes were chicken, turkey, beef, and 2% of milk. For breakfast she likes fried eggs and gets a mighty shake for all three meals. Review of Resident #59's weights revealed on admission the resident weighed 166 pounds. On 10/02/22 Resident #59's weight was 148.4, which indicated a 17.6-pound weight loss. There was no evidence the resident was re-weighed to check the accuracy of the weight loss. On 11/08/22 Resident #59's weight was 149.3. There was no evidence the resident was weighed in December 2022. On 01/01/23 the resident weighed 138.8, which indicated a 10.5-pound weight loss from November. There was no evidence the resident was re-weighed to check the accuracy of the weight loss. The resident had a 27.2-pound weight loss from 09/24/22 to 01/01/23. Review of Resident #59's admission minimum date set (MDS) dated [DATE] and quarterly MDS dated [DATE] revealed the resident was set up for meals and ate independently, no swallowing disorders, and no significant weight loss noted. The 01/01/23 quarterly MDS indicated the resident was on a therapeutic diet. Review of Resident #59's dietary notes dated 10/13/22 revealed the resident's current weight was 148.4 pounds with a body mass index (BMI) of 26.4 indicating she was overweight. The resident had a 10.6 percent weight loss since 09/24/22. Her meal intakes ranging 0-100%. Recommend changing house supplements to 120 milliliter (ml) three times daily between meals to encourage better meal acceptance. Review of Resident #59's dietary note dated 01/02/23 revealed the resident's current weight was 138.8 and her BIM was 24.6. The resident had 16.4% weight loss in four months. Meal intakes are usually 25-50%. The resident was independent with meals. The resident was on a regular diet. Her diet liberalized at this time to offer more variety of food in diet. The resident is a high nutritional risk. Her needs are not being met as related to inadequate by mouth intakes. The resident was at risk for continued unavoidable significant weight loss and decline in nutritional status related to inadequate protein-energy intakes and limited food acceptance as evidence by poor to fair meal intakes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366478 If continuation sheet Page 11 of 22 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 366478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Recommend six ounces might shakes with meals to offer 600 calories and 18 grams of protein. Monitor weights, labs, by mouth intakes. The goal will remain comfortable and tolerate least restrictive diet consistency. Review of Resident #59's current orders dated 01/2023 revealed on 10/13/22 the physician ordered house supplements 120 ml three times daily between meals and on 01/03/23 mighty shakes with meal. There was no evidence of an order for weights. The resident was ordered a regular diet. Review of Resident #59's meal intakes dated 12/26/22 to 01/23/23 revealed the resident had refused 17 meals and the majority of the intakes were 1-50%. There was no evidence the resident was offered a substitute when she refused the meal. Review of Resident #59's potential for alternation in nutrition and hydration plan of care related to BMI (25-29.9 overweight status), hypertensive heart and chronic kidney disease without heart failure, stage five chronic kidney disease, type two diabetes, osteoarthritis, depression, gout, anxiety, depression, chronic obstructive pulmonary disease, and hospice palliative care. Intervention included the resident would remain comfortable and tolerate least restrictive diet consistency, coordinate care with hospice, honor food preferences as able, invite resident to foods related activities, monitor labs as ordered, offer meal substitutes when food are refused, provide meals and supplements as ordered, and weights as ordered. Review of Risk Assessment form titled Provider Services Nutrition Recommendation Physician Notification of Significant Weight Changes dated 10/19/22 revealed on 10/18/23 (future date that has not occurred yet) Resident #59's family was notified of weight change. The physician signed the notification form on 10/19/22 indicating the resident had a decrease of 10.6% since 09/24/22. Review of Risk Assessment form titled Provider Services Nutrition Recommendation Physician Notification of Significant Weight Changes dated 01/06/23 revealed on 01/06/23 the physician signed the notification form indicating the resident had a decrease of 16.4% since 09/24/22. Interview on 01/19/23 at 11:49 A.M. with Dietary Technician (DT) #200 , Dietician #201, and Dietary Manager (DM)#160 revealed the DM reported he had spoken to the resident two weeks ago and reviewed her preferences, however he did not document the interview because there was no changes. The DT #200 reported she had not spoken to the resident, however felt her assessment was sufficient without speaking to the resident to ask her input on her weight loss. The DT #200 reported she doesn't know if staff had re-weighed the resident with noted weight loss on 10/02/22 and 01/01/23 or if the resident was weighed in December. She only reviews the weights that are documented in the electronic medical record. The Dietician reported she believes the admission weight was inaccurate due to it was hard to believe the resident had lost that much weight in that short period of time. The Dietician reported the DT should speak to residents as part of her assessment. Interview on 01/19/23 at 11:58 A.M., with Hospice Aide #202 revealed the Resident #59 had voiced complaints of food all the time to her. She had reported the residents' concerns to the staff; however, food concerns were not addressed. Interview on 01/19/23 at 3:13 P.M., with DT #200 and the Director of Nursing (DON) revealed the resident weight was correct on admission. There was no evidence the resident was re-weighed within 24 hours for accuracy of weight loss on 10/02/22 or 01/01/23. There was no evidence the facility weighed the resident in December 2022. The DON reported hospice residents were weighed monthly. There was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366478 If continuation sheet Page 12 of 22 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 366478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some no evidence the physician or hospice was notified in the medical record, however the DON reported she may have evidence the physician was notified on her risk assessment documentation (not part of the medical record). The facility doesn't have a policy on weighing residents and the facility just follows best practice. Interview on 01/23/23 at 9:37 A.M., with DT #200 reported the physician should have been notified of Resident #59's weight loss in 24-48 hours. DT #200 reviewed the risk assessment forms, which are not part of the medical record, indicated the physician was not notified of the 17.6-pound weight loss on 10/02/22 until 10/19/22 and the additional 10.5-pound weight loss on 01/01/23 the physician was not notified until 01/06/23, which was not timely. There was no evidence the Resident was weighed in December 2022. DT #200 reported she had went and spoke to the Resident on 01/19/23 to update her preferences and the resident had told her she did not like broccoli, cauliflower, rice, green beans, and soups. The DT confirmed the new intervention for both noted weight loss was supplements (house and might shakes). The resident was receiving six supplements a day and when she spoke to the resident the resident wanted to continue the supplements due to, she liked them. The DT reported she was working remotely from another facility on 01/02/23 when she had completed the resident's assessment, however she was in the building on the 5th but did not interview the resident. The floor staff/DON should notify hospice of weight loss, however there was no documented evidence that hospice was notified, but hospice should be reviewing the residents record at least monthly. The facility called hospice to see if they had obtained weights, however it appears the weight information was obtained from the facilities records on 11/28/22. Review of the best practice for weight loss undated revealed significant weight loss or trending insidious with loss should be documented timely, within 7 days. Assess resident's ability to eat independently and adequacy of nutrient intake. Notify the physician for significant unplanned weight changes. Consider risk factors that may contribute to weight loss. Intervention was to utilize food first. Liberalized diet, fortified foods, choice of meals/snack, increase portion size of favorite food or consider small portions, restorative dining, increased assistance at meal, therapy and pharmacy consults, appetite stimulants, and nutritional supplementation between meals. Based on medical record review, resident interview, staff interview, and facility policy review, the facility failed to adequately monitor resident nutritional status and health. This affected four (Residents #7, #39, #41, and #59) of five residents reviewed for nutrition. The census was 71. Findings Include: 1. Record review revealed Resident #7 was admitted to the facility on [DATE]. Her diagnoses were acute of chronic right heart failure, atrial fibrillation, generalized edema, low back pain, disorder of bone density, constipation, enterococcus as the cause of diseases, urinary tract infection, and hypertension. Review of her Minimum Data Set (MDS) assessment, dated 10/02/22, revealed she was cognitively intact. Review of Resident #7 weights revealed the following weights and dates in which significant change occurred: 08/08/22 (139.1 pounds), 09/01/22 (115.4 pounds), 10/02/22 (112.2 pounds), and 11/01/22 (121 pounds). Review of Resident #7 progress notes, dated 09/01/22 to 11/01/22, revealed no documentation to support the resident, resident's representative, not resident's physician were notified of the significant weight changes. Also, there was no documentation in the progress notes to support re-weights were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366478 If continuation sheet Page 13 of 22 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 366478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750 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 0692 taken to confirmed the significant weight change. Level of Harm - Minimal harm or potential for actual harm Review of Resident #7 care plan, dated 09/01/22, revealed an intervention that meal substitutes are to be offered if the resident refuses her meal. Residents Affected - Some Review of Resident #7 meal intake documentation, dated August 2022, September 2022, November 2022, December 2022, and January 2023, revealed a total of 66 meals that were either refused or not documented as being refused or consumed. There was no documentation to support these substitutes were offered as well. Interview with Licensed Practical Nurse (LPN) #178, LPN #203, and State Tested Nurse Aide (STNA) #124 on 01/19/23 at 8:20 A.M., 8:27 A.M., and 8:40 A.M. stated the aides typically take the resident weights; but the nurses will help as well. They are to be done at least once a month. STNA #124 stated she is told by the nurses if there is a weight that is to be done daily or weekly, the morning of when it should be completed. They take a piece of paper around with them to get the weights, document on that paper, and then give the paper to the nurse to enter the weights into the electronic medical record (EMR). LPN #178 and LPN #203 confirmed the EMR will alert them if there is a significant weight change entered into the medical record. They will either tell the aide to retake the weight because of the significant change (on the same day the significant weight change is noted), or contact the dietitian/diet tech to inform them, and then take directive from them about the next steps. New weights will be added to the EMR when a re-weight is completed. If not in the medical records, no evidence it was completed. Interview with Dietary Tech (DT) #200 on 01/19/23 at 10:15 A.M. stated she will visit the facility once a week to review all significant weight changes and dietary concerns. She also confirmed she will review the EMR a few times a week to see if there are any significant changes that need addressed. She will also expect the nursing staff to call her with any significant changes, including significant weight changes. If they don't inform her (which she admitted the notifications to her from nursing staff could be better), she looks at the weights a couple times per week to determine if there are any concerns. She would expect to have a re-weight done within 24 hours, and then report back to her with that re-weight to verify it was accurate. She stated Resident #7 has congestive heart failure, so her weights can significantly change. She confirmed she would want to be notified of significant changes to her weight, due to her congestive heart failure. She confirmed there were no documented re-weights and should have been. 2. Record review revealed Resident #39 was admitted to the facility on [DATE]. Her diagnoses were atrial fibrillation, type II diabetes, obstructive and reflux uropathy, hypothyroidism, hyperlipidemia, osteoporosis, major depressive disorder, squamous cell carcinoma of skin, difficulty walking, osteoarthritis, and anxiety. Review of her MDS assessment, dated 10/05/22, revealed she had a mild cognitive impairment. Review of Resident #39 weights revealed the following weights and dates in which significant change occurred: 06/07/22 (149 pounds), 07/01/22 (136.6 pounds), and 08/02/22 (129 pounds). Review of Resident #39 progress notes, dated 07/01/22 to 08/04/22, revealed no documentation to support the resident, resident's representative, not resident's physician were notified of the significant weight changes. Also, there was no documentation in the progress notes to support re-weights were taken to confirm the significant weight change. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366478 If continuation sheet Page 14 of 22 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 366478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #39 care plan, undated, revealed an intervention that meal substitutes are to be offered if the resident refuses her meal. Review of Resident #39 meal intake documentation, dated July 2022, September 2022, October 2022, November 2022, and December 2022, revealed a total of 69 meals that were either refused or not documented as being refused or consumed. There was no documentation to support these substitutes were offered as well. Interview with Dietary Tech (DT) #200 on 01/19/23 at 10:15 A.M. confirmed Resident #39 lost significant amounts of weight and no reweighs completed. She confirmed Resident #39 should have been re-weighed timely, and the significant changes should have been reported to her. 3. Record review revealed Resident #41 was admitted to the facility on [DATE]. His diagnoses were hemiplegia and hemiparesis, aphasia, chronic respiratory failure, pneumoconiosis, unspecified severe protein-calorie malnutrition, chronic embolism and thrombosis, epilepsy, atherosclerotic heart disease, peripheral vascular disease, contracture of right hand, squamous cell carcinoma, anxiety disorder, major depressive disorder, hyperlipidemia, and other chest pain. Review of his MDS assessment, dated 10/21/22, revealed he had a significant cognitive impairment. Review of Resident #41 weights revealed the following weights and dates in which significant change occurred: 07/01/22 (199 pounds), 08/02/22 (178.2 [pounds), 09/01/22 (188.6 pounds), 10/02/22 (188 pounds), 10/18/22 (200.4 pounds), 10/23/22 (191.3 pounds), 11/04/22 (177.8 pounds), and 11/10/22 (173 pounds). Review of Resident #41 progress notes, dated 07/01/22 to 11/30/22, revealed no documentation to support the resident, resident's representative, not resident's physician were notified of the significant weight changes. Also, there was no documentation in the progress notes to support re-weights were taken to confirm the significant weight change. Interview with Dietary Tech (DT) #200 on 01/19/23 at 10:15 A.M. confirmed Resident #41 lost significant amounts of weight and no reweighs completed in a timely manner. She confirmed Resident #41 should have been re-weighed timely, and the significant changes should have been reported to her. Interview on 01/19/23 at 3:13 P.M., with DT #200 and the Director of Nursing (DON) confirmed that re-weights should be taken within 24 hours of the significant weight being identified in the medical records. They both confirmed they do not have a significant weight change policy, including when to take re-weights. They both confirmed that meal substitutions and snack offerings should be documented in the medical records. They confirmed they could not find any for the above residents. Interview with DT #200 on 01/23/23 at 9:38 A.M. confirmed they do not have any re-weights for the residents. She also confirmed that the physician should be notified of significant weight change within 24 to 48 hours. All documentation should have a date as to when notifications were made, either on the weight log (hand written) or in the EMR. Review of facility Change of Condition policy, dated April 2013, revealed the unit supervisor or charge nurse will notify the resident, physician, and guardian/interested family member of all changes and of any other situations requiring notification. The person doing the notification may document all notification. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366478 If continuation sheet Page 15 of 22 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 366478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750 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** Based on record review, observation, interviews, and policy review the facility failed to ensure respiratory equipment was maintained to prevent infection. This affected two (Resident #1 and #59) of two reviewed for respiratory. Residents Affected - Few Findings included: 1. Record review revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease and heart disease. Observation on 01/17/23 at 9:29 A.M., of Resident #59 revealed the resident's oxygen tubing was dated 10/15/22. The resident's oxygen concentrator was running and set at four liters. The resident's oxygen tubing was wrapped around the bedrail. The resident reported she had removed the oxygen because she needed a break. The resident reported she had no idea when the last time staff changed the oxygen tubing. Observation on 01/18/23 at 7:57 A.M., of Resident #59's oxygen tubing revealed the tubing was still dated 10/15/22. Observation on 01/18/23 at 5:04 P.M., of Resident #59 with Licensed Practical Nurse (LPN) #185 revealed the resident oxygen tubing was dated 10/15/22. LPN #185 confirmed findings and reported staff should change the tubing weekly and staff were told not to date the tubing. Review of Resident #59's orders and treatment administration records (TAR) revealed orders to change the oxygen tubing/cannula/mask once a week on Wednesday and to clean filter on oxygen concentrators weekly since 09/28/22. On 09/24/22 the resident's oxygen orders were oxygen continuous per nasal cannula to maintain saturation above 90% at two liters per minute. Further review of 01/2023 TAR revealed staff signed off the oxygen equipment had been changed on 01/04/23, 01/11/23, and 01/18/23. Review of Resident #59's respiratory plan of care revealed to administer oxygen per orders. There was no evidence of maintaining respiratory equipment. 2. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, respiratory failure, COVID-19, and heart failure. Observation on 01/17/23 at 10:56 A.M., of Resident #1 revealed the oxygen bag was dated 12/22/22. The resident was on isolation precautions for COVID-19. Observation on 01/18/23 at 5:20 P.M., of Resident #1 with Licensed Practical Nurse (LPN) #185 verified Resident #1's oxygen tubing was dated 12/22/22. LPN #185 reported the oxygen tubing should be changed weekly. The resident confirmed the oxygen tubing had not been changed for some time. Review of Resident #1's current orders dated 01/2023 revealed the resident was ordered two liters of oxygen continuously via nasal cannula and to change the oxygen tubing/cannula/mask weekly on night shift every Wednesday. There was no evidence to clean or maintain the oxygen concentrator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366478 If continuation sheet Page 16 of 22 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 366478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750 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 - Few Review of Resident #1's medication and treatment administration records dated 12/22/22 to 01/18/23 revealed the resident was started on antibiotics (Cefdinir)on 01/08/23 for an upper respiratory infection. Staff had signed off they changed the oxygen tubing on 12/28/22 and 01/04/23. Review of Resident #1's progress notes dated 01/08/23 revealed the resident had a productive cough noted with clear mucous, lungs had expiratory wheezes noted to left upper lobe. The resident was hospitalized from [DATE] to 01/13/23. The resident had tested positive on 01/12/23 in the hospital for COVID-19. Review of Resident #1's respiratory plan of care dated 12/28/22 and revised 01/13/23 revealed the resident had respiratory deficiencies or abnormalities of pulmonary function related to heart failure and chronic obstructive pulmonary disease. The resident goal was to reduce the risk of respiratory complications. Further review of Resident #1's plan of care revealed no evidence of maintaining respiratory equipment. Interview on 01/19/23 at 10:19 AM with LPN #185 confirmed staff were signing off they were changing Resident #1's and #59's mask/cannula/tubing when it had not been changed. The LPN #185 reported she had reported the concern to the Director of Nursing (DON) so the issue could be addressed. The facility did not have a contract with the oxygen company to service the oxygen machines. Review of the facility's policy titled Foundation Health Solutions Policy and Procedure dated 09/14/18 revealed to change tubing weekly or as needed. The oxygen concentrators external surfaces are to be cleaned as needed and filters cleaned weekly or as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366478 If continuation sheet Page 17 of 22 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 366478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #46 revealed an initial admission date of 06/29/20 and re-admission [DATE]. Diagnoses included dementia without behavioral disturbances, carcinoma in situ of prostate, squamous cell carcinoma of skin of right ear and external auricular canal, acquired absence of part of head and neck, and psoriasis. Residents Affected - Few Review of the plan of care dated 09/15/22 revealed Resident #46 had an alteration in skin integrity as evidenced by open lesion present at right ear with a cancer lesion 2nd squamous cell carcinoma. Resident picks at skin at times. Interventions included to assess area for size, color, drainage as needed, and complete skin care. Review of the plan of care, (no date noted) revealed Resident #46 was at risk for infection related to cancer lesion to right ear and resident has a habit of picking at area. Interventions include to administer antibiotics as ordered, assess for signs and symptoms of infection, culture areas if it is clinically suspicious, labs as ordered, and cleanse area as ordered. Review of Resident #46's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating a severely impaired cognition for daily decision making abilities. Resident #46 was noted to display disorganized thinking and inattention. Resident #46 was noted to receive an antibiotic 7 days a week. Review of Resident #46's physician orders for January 2023 revealed an order for Bacitracin Ointment (antibiotic) 500 units/gram, apply to right ear topically every day shift for right ear cancer. Ordered on start on 11/25/21 with no stop date noted. Review of Resident #46's medication administration record (MAR) for January 2023 confirmed the medication Bacitracin Ointment was being applied to the right ear twice a day as ordered. Interview on 01/19/23 at 2:15 P.M. with Director of Nursing (DON) revealed the physician was in the facility today and after speaking with the physician, the antibiotic ointment order was discontinued. The DON stated the continued use of the antibiotic ointment had not been discussed with the physician regarding a discontinue date. Review of facility policy titled Antibiotic Stewardship Program, dated 11/28/17 revealed, It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. (a.) The program includes antibiotic use protocols and a system to monitor antibiotic use. (iv.) Prescriptions for antibiotics shall specify the dose, duration, and indication for use. (b.) Monitoring antibiotic use: (i.) Antibiotic orders obtained upon admission or readmission to the facility shall be reviewed for appropriateness, as well as those obtained from consulting, speciality, or emergency providers. Based on medical record review, staff interview, and facility policy review, the facility failed to provide adequate justification and monitoring for the use of an antibiotic. This affected two (Residents #15 and #46) of four residents reviewed for antibiotic usage. The census was 71. Findings Include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366478 If continuation sheet Page 18 of 22 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 366478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1. Record review revealed Resident #15 was admitted to the facility on [DATE]. Her diagnoses were type II diabetes, osteonecrosis, morbid obesity, MRSA, cellulitis of right lower limb, nontoxic single thyroid nodule, rheumatoid arthritis, osteoarthritis, hypertension, fibromyalgia, major depressive disorder, and psoriasis. Review of her Minimum Data Set (MDS) assessment, dated 11/01/22, revealed she was cognitively intact. Review of Resident #15 physician orders revealed she was ordered Doxycycline 100 milligrams (mg) twice daily for infection for 30 days. This order was written on 03/30/22. Then, on 04/20/22, the order from 03/30/22 for Doxycycline 100 mg was discontinued, and replaced with an order for Doxycycline 100 mg twice daily for infection. The order had no stop date; was written as an indefinite order. But the order was revised on 08/23/22, which gave an order for the Doxycycline to continue for four to six months. Review of Resident #15 progress note, dated 04/20/22, confirmed a new order for Doxycycline 100 mg twice daily. It also confirmed there was no justification or end/review date given for the use of this antibiotic. Review of Resident #15 progress notes, dated 08/19/22, revealed the facility noted that they called the physician to determine how long they are to continue the use of Doxycycline. Review of Resident #15 progress note, dated 08/23/22, revealed Resident #15 went to the physician to be assessed for the use of Doxycycline. The progress note stated the Doxycycline was to continue by mouth, twice daily. Review of Resident #15 McGeer's Criteria, dated 03/29/22, revealed the form was not completed to determine if the use of Doxycycline was needed or justified. Review of facility Infection Control log, dated April 2022, revealed no indication that Resident #15 Doxycycline was documented and captured for review and monitoring. Review of the facility McGeer's Criteria documentation confirmed the facility did not perform an assessment/review of the Doxycycline order on 04/20/22. Interview with Assistant Director of Nursing (ADON) #185 on 01/19/23 at 2:15 P.M. confirmed there was no documented justification for the extension of Doxycycline on 04/20/22. She also confirmed there was no documentation until 08/23/22 regarding an end/review date for Doxycycline. Even on 08/23/22, she confirmed there was no documented justification on the physician orders as to why the Doxycycline was ordered. Interview with Director of Nursing (DON) on 01/19/23 at 2:37 P.M. confirmed the dates of the Doxycycline orders and the lack of justification for the use of this antibiotic. But, she also stated, the doctor wanted and ordered it; who are we to challenge a doctor's orders. Review of the facility Antibiotic Stewardship Program policy, dated 11/28/17, revealed the program includes antibiotic use protocols and a system to monitor antibiotic use. Antibiotic use protocols include: laboratory testing shall be in accordance with current standards of practice. McGeer Criteria are used to define the infections and the Loeb Minimum Criteria are used to determine whether or not to treat an infection with antibiotics. Prescription for all antibiotics shall specify the dose, duration and indication of use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366478 If continuation sheet Page 19 of 22 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 366478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750 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 0886 Perform COVID19 testing on residents and staff. Level of Harm - Minimal harm or potential for actual harm Based on review of COVID-19 testing records, staff interview, and facility policy review, the facility failed to ensure employees who tested positive for COVID-19 had a negative COVID test within 48 hours of returning to work when returning in seven days. This affected three of three employees who tested positive for COVID-19 in the past 50 days and had the potential to affect 71 of 71 residents residing in the facility. Residents Affected - Few Findings include: The facility provided a list of employees who had tested positive for COVID-19 since 12/01/22. The list indicated there were three employees that had tested positive: State Tested Nursing Assistant (STNA) #181 on 12/08/22, Occupational Therapy Assistant (OTA) #155 on 12/27/22, and Physical Therapy Assistant (PTA) #113 on 01/11/23. Review of employee COVID-19 testing logs revealed it indicated STNA #181 tested positive on 12/01/22, not 12/08/22. The log indicated OTA #155 tested positive on 12/27/22, and PTA #113 on 01/11/23. Review of the facility policy titled Return to Work Criteria-Interim Policy for COVID-19 revised 09/26/22 revealed healthcare personnel who tested positive for COVID-19 with mild to moderate illness and are not severely immuno-compromised may return to work if at least 7 days have passed and a negative antigen or NAAT is obtained within 48 hours prior to returning to work (if testing is not performed, or a positive test is obtained on day 5-7, the employee may return to work once 10 days have passed since symptoms first appeared) and at least 24 hours have passed since last fever without use of fever-reducing medications and symptoms have improved. Healthcare personnel who were asymptomatic throughout their infection and are not moderately to severely immuno-compromised may return to work if at least seven days have passed and a negative antigen or NAAT is obtained within 48 hours prior to returning to work. If testing is not performed, or a positive test is obtained on day 5-7, the employee may return to work once 10 days have passed since the date of their first positive viral test. 1. Review of a timecard report for STNA #181 revealed on 11/29/22 she clocked in at 7:10 A.M. and left at 8:05 A.M. She was then off work until 12/04/22 and worked from 7:00 A.M. to 7:17 P.M. that day. She also worked 11.75 hours on 12/08/22, 12/09/22, 12/12/22, 12/13/22, and 12/17/22. (COVID-19 testing log indicated she tested positive on 12/01/22 and list provided from facility indicated she tested positive on 12/08/22). There was no documentation to indicate if the employee was symptomatic or not and what criteria was followed for allowing her to return to work. There were no test results available for the testing prior to returning to work. Interview with STNA #181 on 01/19/23 at 3:10 P.M. revealed she tested positive for COVID-19 on 11/29/22 (not 12/01/22 or 12/08/22) and was off work until 12/04/22. She stated she only had mild symptoms of coughing and testing on 12/02/22 and 12/04/22 were negative. Interview with Registered Nurse #109 on 01/19/23 at 3:15 P.M. revealed the list provided to the surveyors of COVID-19 positive staff and the testing result log were inaccurate for STNA #181. She stated STNA #181 actually tested positive for COVID-19 on 11/29/22. She further stated there were no test results available for the testing done on 12/02 and 12/04/22 for STNA #181. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366478 If continuation sheet Page 20 of 22 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 366478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750 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 0886 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the Director of Nursing on 01/19/23 at 4:00 P.M. confirmed STNA #181 tested positive for COVID-19 on 11/29/22, not 12/01/22 or 12/08/22. She stated the facility followed the policy for staff to return to work after seven days with a negative test 48 hours prior. She confirmed there was no documentation of protocol followed to allow staff to return to work. She confirmed there were no test results available for STNA #181 for 12/02 or 12/04/22. She confirmed STNA #181 returned to work on the fifth day after testing positive, not the seventh. 2. Review of the timecard report for PTA #113 revealed she clocked in at 8:38 A.M. on 01/11/23 and clocked out at 8:51 A.M. She did not return to work until 01/17/23. (off 6 days). There was no evidence of any testing results for PTA #113 prior to returning to work. There was no documentation to indicate if the employee was symptomatic or not and what criteria was followed for allowing her to return to work. Interview with the Director of Nursing on 01/19/23 at 4:00 P.M. confirmed there was no documentation of protocol followed to allow staff to return to work and no evidence of a negative test prior to returning to work. She confirmed PTA #113 returned to work on the sixth day after testing positive, not the seventh. She stated she thought PTA #113's symptoms had started on 01/10/23 and so it was considered day 1 of the seven days. 3. Review of the timecard report for OTA #155 revealed she did not work from 12/26/22 to 01/03/23. (Tested positive on 12/27/22). There was no evidence of any testing results for OTA #155 prior to returning to work. There was no documentation to indicate if the employee was symptomatic or not and what criteria was followed for allowing her to return to work. Interview with the Director of Nursing on 01/19/23 at 4:00 P.M. confirmed there was no documentation of protocol followed to allow staff to return to work and no evidence of a negative test prior to returning to work CDC guidance at cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assessment-hcp.html (updated 09/23/22): HCP with mild to moderate illness who are not moderately to severely immuno-compromised could return to work after the following criteria have been met: • At least 7 days have passed since symptoms first appeared if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and • At least 24 hours have passed since last fever without the use of fever-reducing medications, and • Symptoms (e.g., cough, shortness of breath) have improved. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366478 If continuation sheet Page 21 of 22 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 366478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterview Pointe Nursing & Rehabilitation 117 Bartlett Street Marietta, OH 45750 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 0886 • Level of Harm - Minimal harm or potential for actual harm Either a NAAT (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later Residents Affected - Few • HCP who were asymptomatic throughout their infection and are not moderately to severely immuno-compromised could return to work after the following criteria have been met: • At least 7 days have passed since the date of their first positive viral test if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7). • Either a NAAT (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later • HCP with severe to critical illness who are not moderately to severely immuno-compromised could return to work after the following criteria have been met: • At least 10 days and up to 20 days have passed since symptoms first appeared, and • At least 24 hours have passed since last fever without the use of fever-reducing medications, and • Symptoms (e.g., cough, shortness of breath) have improved. • The test-based strategy as described below for moderately to severely immuno-compromised HCP can be used to inform the duration of work restriction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366478 If continuation sheet Page 22 of 22