Health inspection·February 16, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure showers/bed baths were provided to residents requiring assistance with activities of daily living. This affected two residents (#325 and #326) of two residents reviewed for showers. The facility census was 73. Residents Affected - Few Findings include: 1. Resident #325 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, extended spectrum beta lactamase (ESBL) resistance, and diabetes mellitus. Review of Resident #325's Minimum Data Set (MDS) 3.0 assessment revealed it was still in progress. Review of the resident level of function section in Resident #325's baseline care plan dated 02/09/23 revealed the resident preferred a shower and required total care when bathed. The baseline care plan had no documented evidence of behaviors or refusals. Review of the State Tested Nursing Assistance Book revealed Resident #325 was to receive a shower on Wednesdays and Sundays. Review of Resident #325's shower documentation revealed Resident #325 did not receive a shower or bed bath from 02/09/23 to 02/15/23. Interview with Resident #325 on 02/13/22 at 10:31 A.M. revealed he had not received a shower since he was admitted to the facility. 2. Resident #326 was admitted to the facility on [DATE] with diagnoses including enterocolitis due to clostridium difficile (C-Diff), heart failure, and gout. Review of Resident #326's MDS 3.0 assessment revealed it was still in progress. Review of the resident level of function section in Resident #325's baseline care plan dated 02/08/23 revealed the resident preferred a shower and required assistance when bathed. The baseline care plan had no documented evidence of behaviors or refusals. Review of the State Tested Nursing Assistance Book revealed that Resident #326 was to receive a shower on Mondays and Fridays. Review of the resident shower documentation revealed Resident #326 had not received a shower or bed bath from 02/08/23 to 02/14/23. Interview with Resident #326 on 02/13/22 at 10:25 A.M. revealed he had not received a shower since he was admitted to the facility. Interview on 02/15/23 at 10:12 A.M. with Licensed Practical Nurse (LPN) #108 verified that Resident #325 did not receive a shower or bed bath from 02/09/23 to 02/15/23 and Resident #326 did not receive a shower or bed bath from 02/09/23 to 02/14/23. LPN #108 verified that no behaviors or refusal of care were documented for Residents #325 and #326. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366484 If continuation sheet Page 2 of 5 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 366484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Johnstown Pointe Nursing & Rehabilitation Center 383 West Coshocton Street Johnstown, OH 43031 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Review of the undated State Tested Nursing Assistant (STNA) job description revealed STNA's are responsible to successfully assist all residents with activities of daily living including bathing. 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: 366484 If continuation sheet Page 3 of 5 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 366484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Johnstown Pointe Nursing & Rehabilitation Center 383 West Coshocton Street Johnstown, OH 43031 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure behaviors for Resident #55 were monitored before and while adjusting psychotropic medications. This affected one resident (#55) of five residents reviewed for unnecessary medications. The facility census was 73. Findings include: Review of the medical record for Resident #55 revealed an admission date of 05/13/21 with diagnoses including depression, Wernicke's encephalopathy, anxiety disorder, anxiety disorder, dementia, and other schizoaffective disorders. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #55 had moderately impaired cognition. During the seven-day assessment reference period, the resident received antipsychotics, antianxiety, and antidepressants. Review of Resident #55's plan of care dated 02/14/23 revealed the resident was at risk for adverse effects related to psychoactive medication use. Resident #55 took antianxiety and antidepressant medication related to anxiety and depression and antipsychotic medication related to a schizoaffective disorder. Interventions included assessing behaviors for which drugs are being given, monitoring, and recording frequency, assessing for adverse effects, giving medications as ordered, monitoring medications for effectiveness, and treating and relieving adverse effects as ordered. Review of the physician order for Resident #55 dated 01/06/22 to 01/03/23 revealed an order for Seroquel tablet (antipsychotic) 75 milligrams (mg) by mouth two times a day related to schizoaffective disorders. Review of the physician note dated 01/03/23 revealed Resident #55 was seen for medication review. The facility staff and family reported worsening hallucinations and agitation. According to the staff, the resident was calling her sister several times during the day and night and yelling people are in her room when she was by herself. The physician recommended increasing Seroquel to 100 mg twice a day and Xanax three times a day. Review of the physician order for Resident #55 dated 01/14/22 to 01/04/23 revealed an order for Xanax Tablet (antianxiety) 0.5 mg one tablet by mouth two times a day for anxiety. Review of the physician order for Resident #55 dated 01/04/23 revealed an order for Xanax tablet 0.5 mg one tablet was to be given by mouth three times a day for anxiety. Review of the physician orders for Resident #55 dated 01/04/23 revealed orders for Seroquel tablet 100 mg one time a day for behavior, and Seroquel tablet 100 mg one time a day for schizoaffective disorder. Review of the physician notes and progress notes from 12/21/23 to 01/03/23 revealed no evidence of behavior monitoring. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366484 If continuation sheet Page 4 of 5 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 366484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Johnstown Pointe Nursing & Rehabilitation Center 383 West Coshocton Street Johnstown, OH 43031 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 0758 Review of the medical record from 12/21/23 to 01/03/23 revealed no evidence of behavior monitoring. Level of Harm - Minimal harm or potential for actual harm Interview on 02/15/23 at 12:04 P.M. with the Director of Nursing (DON) confirmed the progress and physician's progress notes provided were the only behavior monitoring they had. She confirmed Resident #55 had increased behaviors requiring the increase in her medication; however, these behaviors were not monitored or documented. When asked how they track any outside factors influencing behaviors, she did not know. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366484 If continuation sheet Page 5 of 5