Inspection visit

InspectionDecember 18, 2023

HIGHLAND OAKS HEALTH CENTERCMS #36514737 citations on this visit

37 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 37 deficiencies, 3 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, resident funds documentation review, and facility policy review, the facility failed to ensure staff were not witnesses for Resident #32's and #62's account and failed to ensure money was dispersed timely upon the death of Resident #288. This affected three residents (#32, #62, and #288) of five residents reviewed for personal funds. The facility census was 85. Findings include: 1. Review of Resident #32's medical record revealed she was admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain, nonexudative age-related macular degeneration, and mixed hyperlipidemia. Review of Resident #32's admission Minimum Data Set (MDS) 3.0 assessment, dated 08/10/23, revealed she was severely cognitively impaired. Review of Resident #32's Resident Fund Management Services Authorization and Agreement to Handle Resident Funds, dated 08/03/23, revealed the witness for the authorization was Business Office Manager (BOM) #179. Interview on 12/13/32 at 8:35 A.M. with BOM #179 revealed she had been the witness when Resident #32's representative authorized the facility to handle her personal funds on 08/03/23. She revealed she did not know she was not allowed to be the witness. 2. Review of Resident #62's medical record revealed he was admitted to the facility on [DATE] with diagnoses including hypertensive encephalopathy, hypertensive heart disease with heart failure, vascular dementia, and essential hypertension. He was discharged from the facility on 12/02/23. Review of Resident #62's admission MDS 3.0 assessment, dated 07/10/23, revealed he was severely cognitively impaired. Review of Resident #62's Resident Fund Management Services Authorization and Agreement to Handle Resident Funds, dated 06/29/23, revealed the witness for the authorization was BOM #179. Interview on 12/13/32 at 8:35 A.M. with BOM #179 revealed she had been the witness when Resident #62's representative authorized the facility to handle his personal funds on 06/29/23. She revealed she did not know she was not allowed to be the witness. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 72 Event ID: 365147 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. Review of Resident #288's medical record revealed she was admitted to the facility on [DATE] with diagnoses including acute respiratory disease, unspecified heart failure, gastro-esophageal reflux disease, and weakness. Further review revealed she was discharged on 03/02/23. Review of Resident #288's Resident Trust Fund Authorization, dated 02/17/21, revealed the facility managed her funds. Review of Resident #288's Resident Statement Landscape revealed her account was closed on 03/23/23 due to expiring on 03/02/23. However, the remaining funds in her account, $1,964.52, were not dispersed at they should have been. Interview on 12/13/23 at 8:36 A.M. with BOM #179 verified she did close the account but did not send the money back to the State of Ohio and she should have. She could not answer why the money was not sent back to the State of Ohio. She verified it was not acceptable to hold money which should have been returned to the State of Ohio for nine months after a resident has passed away. Review of the facility policy titled, Resident Personal Funds, undated, revealed upon discharge, eviction, or death of a resident with a personal funds deposited with the facility, the facility will convey within 30 days the resident's funds and a final account of those funds to the resident, or in the case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State law. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 2 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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, resident and staff interviews, and policy review the facility failed to ensure the resident's code status/advance directives were consistent in the medical record and failed to include the resident in the decision-making process related to his code status. This affected one resident (#34) of 24 residents reviewed for advanced directive. Findings include: Record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, bipolar, anxiety, heart disease, atrial fibrillation, diabetes, seizures, knee pain, and depression. Review of Resident #34's current orders dated 12/2023 revealed on 07/05/22 the resident's code status was a do-not-resuscitate comfort care (DNRCC). The resident's original order dated 05/27/21 indicated the resident was a full code. Further review of Resident #34's medical record revealed no evidence of a signed advanced directive for DNRCC. Interview on 12/06/23 at 3:21 P.M., with the Administrator confirmed Resident #34's orders indicated the residents code status was DNRCC; however, there was no evidence an advance directive was signed. Interview on 12/07/23 at 8:11 A.M., with the Director of Nursing (DON) confirmed there was no signed consent form for the residents DNRCC advance directive that was ordered on 07/05/22; however, the facility had the physician sign a DNRCC advance directive yesterday (12/06/23). Interview on 12/07/23 at 11:09 A.M., with Resident #34, Social Service Designee (SSD) #178, and the DON revealed the resident reported he never felt so good in his life and had already survived several heart attacks and he wanted to be a full code. The resident verified no one had talked to him about changing his code status to an DNRCC yesterday. The DON confirmed the facility had the physician sign a DNRCC advance directive yesterday due to there being an order written on 07/05/22 for an DNRCC; however, the facility did not discuss with the resident his wishes on his code status. Review of the facility Advance Directives policy, dated 2016, revealed all advance directives shall be displayed prominently in the medical record. An advanced directive included Do-Not-Resuscitate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 3 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to provide adequate supervision and effective/necessary intervention for Resident #68 to prevent potential incidents of resident to resident sexual abuse toward Resident #77. This affected two residents (#68 and #77) of six residents reviewed for abuse. The facility census was 85. Findings included: Record review revealed Resident #68 admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, hypertension, hyperlipidemia, gout, vascular dementia, and insomnia. Review of nursing note dated 08/18/23 at 6:01 P.M. revealed Resident #68 was sitting in the dining room and began to make sexual statements during conversations with female residents. Staff did redirect Resident #68, but he circled back to sexual statements and was speaking of orgies with female residents. Staff were instructed to encourage Resident #68 to sit at tables with mostly male residents. Record review revealed Resident #77 admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia without behaviors, hypertensive heart disease without heart failure, hypertension, hyperlipidemia, polyarthritis, and vascular dementia. Review of care plan revealed no behaviors were documented. Review of a nursing note from 09/15/23 at 11:19 A.M. revealed Resident #68 was making inappropriate sexual comments to female peers while sitting in the common room, and was redirected to sit with men. Review of a provider note on 09/19/23 at 5:02 P.M. by Certified Nurse Practitioner (CNP) #225 revealed Resident #68 was evaluated after having inappropriate behaviors with female residents and getting into bed with a female resident without his pants on. Resident #68 had been speaking about sex a lot with another male residents. Review of a nursing note from 09/20/23 at 9:12 P.M. by Licensed Practical Nurse (LPN) #256 revealed another resident was found in Resident #77's bed, and residents were separated. At the time of the incident, the resident's representative was notified and declined to send Resident #77 to the hospital for further evaluation. Record review revealed the facility submitted a self-reported incident, tracking number 239417, involving an incident of sexual abuse occurring on 09/20/23 at 9:05 P.M. involving Resident #68 and Resident #77. A narrative summary of the incident and investigation revealed Resident #68 was found in Resident #77's room in her bed unclothed. Resident #77 was fully clothed and under her sheets. The residents were separated immediately and increased supervision was initiated. Notification to the physician and family occurred and head to toe assessments completed on both residents revealed no were issues noted. Resident #68 was seen by a psychiatrist on 09/21/23 with medication changes noted. The facility investigation revealed both residents remained at psychosocial baseline with no additional concerns at this time. The incident noted Resident #68 was disoriented and got into the wrong bed and was easily redirected. No sexual allegations were made throughout the investigation. Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 4 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #77's family declined to send the resident to the hospital for further evaluation. As a result of the investigation, the facility unsubstantiated the incident of sexual abuse. Review of both Resident #68 and Resident #77's care plans revealed no comprehensive and individualized plan of care were developed following this incident related to sexual activity and/or inappropriate sexual behavior for either resident. A witness statement, dated 09/20/23 by Resident Care Assistant (RCA) #163 revealed RCA #163 had started rounds at approximately 8:30 P.M. when he noticed Resident #77 was not in her bed. RCA #163 walked into Resident #68's room and witnessed both residents in bed, with Resident #68's arm wrapped around Resident #77. Resident #68 was naked and Resident #77 was fully dressed. After being separated and taken to her room, Resident #77 was completely silent. By the time RCA #163 left the room, Resident #77 had laid down in her bed in the fetal position and was holding her stomach. RCA #163 did report this to the nurse and the resident was placed on 15-minute checks. Review of this witness statement revealed it differed from the content of the location where the residents were found in the above SRI and nursing note. The discrepancy was not explained during the investigation. Review of a provider note from 09/21/23 at 5:01 P.M. by CNP #225 revealed nursing staff notified her Resident #68 had been found in bed with a female resident naked. He had been noted to be more sexual lately with other residents. Psychiatric consult requested. Review of a provider note on 10/08/23 at 10:48 P.M. by CNP #225 revealed Resident #68 had been displaying increased behavioral issues with female residents, crawling into their beds at times naked, and believed they were his wife. Follow-up psychiatric notes for Resident #68 dated 10/19/23 revealed there had been some improvement with the sexual acting out behaviors. No frank aggression, no frank agitation, dementia does appear to be progressing. A note, dated 11/02/23 for Resident #68 revealed the resident's sexual acting out had been resolved. A note, dated 11/16/23 revealed no mention of behaviors; the resident was seen for determining (mental) capacity. Review of a provider note from 11/18/23 at 8:57 P.M. by CNP #225 revealed Resident #68 was seen and evaluated due to thinking he was going to marry a female resident. Resident #68 was having behaviors towards two female residents specifically, psych started the resident on the anti-depressant medication, Paxil in hopes to help behaviors and indicated the medication, Tagament might also be necessary. Review of nursing note from 12/03/23 at 9:21 P.M. revealed Resident #68 was in Resident #77's bed with her. Resident #68 had no shirt on and his pants were inside out, and the bedroom door was shut. During dinner, STNA staff had reported Resident #68 asked Resident #77 to go to his room with him but was redirected. Record review revealed no assessment or interventions were initiated following this incident on 12/03/23. Interview on 12/07/23 at 10:58 A.M. with STNA #132 revealed Resident #68 climbed into bed with women he thought were his wife, but was redirectable. Interview on 12/07/23 at 4:30 P.M. with RCA #163 revealed Resident #68 was usually able to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 5 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few redirected from inappropriate behaviors. During the interview, RCA #163 recalled an incident (date not provided) when Resident #68 was completely nude in bed with Resident #77, but Resident #77 was clothed wearing Resident #68's shirt. RCA #163 also reported Resident #68 was once in a female residents bed sleeping and wearing a pull up, but the other resident was sitting in a chair watching him. RCA #163 reported an additional incident with Resident #68 and Resident #77 where both resident's were in Resident #77's bed but fully clothed. No additional investigations or documentation of additional incidents were provided by the facility to review as part of the annual survey process. Interview on 12/11/23 at 2:37 P.M. with STNA #198 revealed Resident #68 had behaviors with a female resident and you had to keep an eye on him, including an incident where Resident #68 was naked in bed with Resident #77 who was clothed. STNA #198 stated even on this date she received report to keep an eye on the residents. Interview on 12/11/23 at 2:44 P.M. with LPN #133 revealed Resident #68 was in a room with a female resident on the day of the interview and were separated rather quickly. Interview on 12/11/23 at 5:52 P.M. with Registered Nurse (RN) #202 confirmed Resident #68 and Resident #77 did not have care plan for sexually inappropriate behaviors in their care plans. Interview on 12/12/23 at 11:05 A.M. with Director of Nursing (DON) revealed staff were unable to locate documentation of 15 minute checks for Resident #68's incidents of being found in bed with Resident #77. Interview on 12/12/23 at 2:18 P.M. with STNA #148 revealed Resident #68 does have sexual behaviors towards two female residents, and when he goes in their rooms he always takes off all his clothes except for his underwear at times. STNA #148 stated this happens often and she stated she did not believe any of the residents had the ability to consent to this type of interaction. The STNA was not aware the residents' families had been notified of the continued interactions, since it was not a big deal the first time it happened. Review of witness statement received on 12/12/23 from LPN #158 revealed aides were walking down the hall and saw Resident #68 and #77 trying to get into the wrong bed together, they were both assisted to their own beds, and families were not notified because there was no change of condition regarding charting from 12/03/23. Interview on 12/13/23 at 12:19 P.M. with DON revealed she believed at times Resident #68 and Resident #77 could consent to intimate activities; however she stated she did not believe there was a way to assess when they were or were not. Attempts to reach Resident #77's family during the onsite investigation were unsuccessful. Review of the facility Abuse Policy defined sexual abuse as non-consensual sexual contact of any type with a resident. Incidents of resident to resident sexual abuse would be referred to the facility interdisciplinary team (IDT) for determination of appropriate interventions. Record review revealed no evidence the facility IDT team determined any appropriate interventions to prevent Resident #77 or other residents from being sexually abused by Resident #68. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 6 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to report and/or investigate an injury of unknown origin for Resident #29. This affected one resident (#29) of one resident reviewed for reporting requirements. The facility census was 85. Findings include: Record review revealed Resident #29 admitted to the facility on [DATE] with diagnoses including dementia, atherosclerotic heart disease without angina, atrial fibrillation, psychosis not due to a substance or known condition, hyperlipidemia, ischemic cardiomyopathy, congestive heart failure, anxiety disorder, other depression episodes, mood (affective) disorder, and insomnia. Review of orders revealed Resident #29 had an order for a mat to the floor by the bed on 10/23/21. Review of nursing note from 01/12/23 at 3:36 A.M. by Licensed Practical Nurse (LPN) #194 revealed a nursing aide summoned her to Resident #29's room while resident was in bed to observe new discoloration to the right eye and redness under the left eye, with no complaints of pain. Review of nursing note from 01/12/23 at 6:13 A.M. by LPN #194 revealed when Resident #29 entered the dining room, bruising was noted to the inner corner of the right eye and redness across the bridge of the nose and under the left eye with slight swelling. Resident #29 denied pain. LPN #194 concluded the note by stating Resident #29 was frequently up at night in her room with lights off and in her closet. Review of an interdisciplinary team note on 01/13/23 at 8:26 A.M. by Registered Nurse (RN) #245 revealed bruising was consistent with accidentally bumping into an object. Interview on 12/06/23 at 8:52 A.M. with the Director of Nursing (DON) revealed she spoke with staff regarding Resident #29's bruising and thought maybe Resident #29 rolled over in her sleep and hit her face on the dresser by her bed. The DON confirmed no interviews were completed to investigate the bruising. Interview on 12/07/23 at 3:21 P.M. with the DON revealed she did not think facial bruising would be considered suspicious and the nurse had done a good investigation by stating Resident #29 had probably hit her face off something in her closet. The DON stated Resident #29 does not often exit her closet with bruising on her face, but she does rummage in her closet a lot, so it was plausible. Review of a policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property revealed an injury of unknown source occurs when the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident and the injury is suspicious because of the location, extent, or number of injuries observed. The policy further stated the facility will have procedures in place to identify events such as suspicious bruising of residents, the administrator should be notified immediately, and the facility will notify the state agency as soon as possible but no later than 24 hours from the time the incident was made known to staff. The investigation should be completed in five working days unless there are special circumstances, the resident and all witnesses should be interviewed including staff on duty when injury was discovered and prior shifts as well, and evidence of an investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 7 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Many Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to ensure Resident #84 who was being transferred to the local emergency department received a notice of transfer/discharge. This affected one resident (#84) of one resident reviewed for hospitalization and had the potential to affect all 85 residents residing in the facility. Findings included: Review of Resident #84's medical record revealed she was admitted to the facility on [DATE] with diagnoses including tubulo-interstitial nephritis, morbid (severe) obesity, type two diabetes, chronic obstructive pulmonary disease (COPD), essential hypertension, and hypertensive heart disease without heart failure. Review of Resident #84's quarterly [NAME] Data Set (MDS) 3.0 assessment, dated 10/06/23, revealed she was cognitively intact. Review of Resident #84's progress note, dated 10/31/23 and timed 9:02 P.M., revealed the ambulance and emergency personnel arrived and the resident left the building appearing in stable condition. She was alert and oriented times four (person, place, time, and situation). The family left separately with all of the resident's personal belongings with the resident's permission. The resident stated this was done in case she stayed at the hospital longer and her room was not able to be held in the facility. Interview on 12/12/23 at 1:00 P.M. with Registered Nurse (RN) #202 revealed notification of transfer/discharge were documented in observations in the electronic health record. Review of Resident #84's observations revealed no documentation to support she received a transfer/discharge notice. Interview on 12/12/23 at 2:01 P.M. with the Director of Nursing (DON) verified there was no documentation to support Resident #84 received a transfer/discharge notice prior to her transfer out to the emergency department on 10/31/23 and she should have. Review of the facility policy titled, Transfer and Discharge Documentation, revised 12/2016, revealed when a resident was transferred or discharged from the facility, the following information would be documented in the medication record: an appropriate notice was provided to the resident and/or legal representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 8 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0625 Level of Harm - Potential for minimal harm Residents Affected - Many Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to ensure a resident who was being transferred to the local emergency department received a notice of bed hold. This affected one resident (#84) of one resident reviewed for hospitalization and had the potential to affect all 85 residents residing in the facility. Findings included: Review of Resident #84's medical record revealed she was admitted to the facility on [DATE] with diagnoses including tubulo-interstitial nephritis, morbid (severe) obesity, type two diabetes, chronic obstructive pulmonary disease (COPD), essential hypertension, and hypertensive heart disease without heart failure. Review of Resident #84's quarterly [NAME] Data Set (MDS) 3.0 assessment, dated 10/06/23, revealed she was cognitively intact. Review of Resident #84's progress note, dated 10/31/23 and timed 9:02 P.M., revealed the ambulance and emergency personnel arrived and the resident left the building appearing in stable condition. She was alert and oriented times four (person, place, time, and situation). The family left separately with all of the resident's personal belongings with the resident's permission. The resident stated this was done in case she stayed at the hospital longer and her room was not able to be held in the facility. Interview on 12/12/23 at 1:00 P.M. with Registered Nurse (RN) #202 revealed notification of bed hold was documented in observations in the electronic health record. Review of Resident #84's observations revealed no documentation to support she received a bed hold notice. Interview on 12/12/23 at 2:01 P.M. with the Director of Nursing (DON) verified there was no documentation to support Resident #84 received a bed hold notice prior to her transfer out to the emergency department on 10/31/23 and she should have. Review of the facility policy titled, Bed Hold Policy, revised 1/2020, revealed before transferring a resident from the facility, the resident would be provided in writing information on the resident's rights and limitations regarding bed holds. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 9 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, resident record review, and facility policy review, the facility failed to ensure Preadmission Screening and Resident Reviews (PASARRs) were updated appropriately. This affected four residents (#13, #16, #26, #63) of nine residents reviewed for PASARR. The facility census was 85. Findings include: 1. Review of Resident #16's medical record revealed she was admitted to the facility on [DATE] with diagnoses including schizophrenia (entered 10/31/18), anxiety disorder (entered 10/31/18), and other specified depressive episodes (entered 06/20/19). Review of Resident #16's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/05/23, revealed she was severely cognitively impaired, had active diagnoses of anxiety, depression, and schizophrenia, and had verbal and physical behavioral symptoms directed toward others one to three days of the seven-day assessment reference period. Review of Resident #16's physician order, dated 06/26/23, identified she was to receive Haldol decanoate (a long acting antipsychotic medication) 50 milligram/milliliter (mg/ml) intramuscular one day a month on the 27th of the month; physician order, dated 03/31/23, identified Lorazepam Intensol concentrate (an antianxiety medication) two mg/ml amount of 0.5 ml oral every four hours as needed for anxiety, agitation and shortness of breath; and physician order, dated 12/05/23, identified she was to receive ADR Cream (Ativan, Diphenhydramine, and Reglan) topically 2 ml topically (discontinue oral schedule Ativan when cream is started) every two hours as needed for restless, anxiety, and aggressive behavior not to exceed 12 ml daily total. Review of Resident #16's most recent PASARR, dated 10/23/18, revealed under Section D: Indications of Serious Mental Illness, the box beside schizophrenia was marked with an X and the review results revealed she was not applicable for services. The box beside anxiety disorder had not been marked with an X. Review of Resident #16's PASARR, dated 12/05/23, revealed under Section E: Indications of Serious Mental Illness, subsection 1), the boxes beside schizophrenia, mood disorder, and panic or other severe anxiety disorder were marked with and X. Further review under Section E: indications of Serious Mental Illness, subsection 6), the boxes beside anti-psychotics, anti-depressants, anti-anxiety, and mood stabilizer were marked with an X. Interview on 12/05/23 at 8:35 A.M. with the Social Services Director (SSD) #178 verified Resident #16 did not have an up-to-date PASARR. She reported the most recent PASARR Resident #16 had was dated 10/23/18 and she completed a new one the A.M. of 12/05/23 after this surveyor asked for a copy of the most recent PASARR. Interview on 12/05/23 at 3:21 P.M. with SSD #178 verified Resident #16's PASARR, dated 12/05/23, was still not accurate because she was not on an antidepressant or mood stabilizer. She verified the PASARR needed to be accurate. 2. Review of Resident #26's medical record revealed she was admitted to the facility on [DATE] with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 10 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some diagnoses including opioid use, unspecified with opioid induced psychotic disorder (entered 02/01/23), bipolar disorder (entered 02/01/23), major depressive disorder, single episode, mild (entered 01/02/23), and generalized anxiety disorder (entered 07/24/23). Review of Resident #26's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/30/23, revealed she was mildly cognitively impaired, had active psychiatric/mood disorders of anxiety, depression, and bipolar, and did not exhibit verbal or physical behaviors towards others. Review of Resident #26's physician order, dated 07/22/23, identified she was to receive Buspirone (an antianxiety medication) 5 mg twice a day for anxiety; and a physician order, dated 07/03/23, identified Trintellix (an antidepressant medication) 20 mg once a day. Review of Resident #26's most recent PASARR, dated 01/31/23, revealed under section E: Indications of Serious Mental Illness subsection 6), the boxes beside of anti-depressant and anti-anxiety were not marked with an X. Interview 12/05/23 at 3:01 P.M. with SSD #178 verified Resident #26's PASARR, dated 01/31/23 was the most recent, and was not up to date since she was taking antianxiety and antidepressant medications. She verified the current PASARR was not up-to-date and should be. 3. Record review revealed Resident #13 admitted to the facility on [DATE] with diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, anxiety disorder, major depressive disorder, hallucinations, and osteoarthritis. Review of orders revealed Resident #13 had an order to add a diagnosis of schizophrenia on 03/30/23. Review of a quarterly MDS completed on 11/09/23 revealed Resident #13 had behaviors of hallucinations. Record review revealed Resident #13 did not receive a new PASARR to identify the new diagnosis of schizophrenia. Interview on 12/05/23 at 5:01 P.M. with SSD #178 confirmed a new PASARR had not been completed since Resident #13 received a diagnosis of schizophrenia and she had not been notified of the schizophrenia diagnosis. 4. Record review revealed Resident #63 admitted to the facility on [DATE] with diagnoses including major depressive disorder, dementia, anxiety disorder, post-traumatic stress disorder (PTSD), pseudobulbar affect, anemia, hypothyroidism, hyperlipidemia, and adult failure to thrive. Record review revealed Resident #63 had PASARR completed on 08/29/22 which did not have the diagnosis of PTSD listed. Interview on 12/05/23 at 5:01 P.M. SSD #178 confirmed Resident #63's PASARR should reflect the diagnosis of PTSD. SSD #178 stated she completes PASARRs when residents admit from the community, if they admit from another referral source she will print and keep a copy, and if a new diagnosis is added she should complete a significant change PASARR to reflect the change. SSD #178 stated the facility cancelled the behavior monitoring meeting so the process in tracking new diagnoses was disrupted. Review of the undated facility policy titled, Resident Assessment - Coordination with PASARR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 11 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0644 Level of Harm - Minimal harm or potential for actual harm Program revealed the facility coordinates assessments with the PASARR program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 12 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident #4's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included unspecified dementia without behavioral disturbances and bipolar disorder. Residents Affected - Few A review of Resident #4's PASARR Identification Screen dated 07/07/23 revealed the PASARR was completed for a Preadmission Screening (PAS) from the community. Section (E.) of the PASARR was to document all the diagnoses the resident had of any mental disorders that were listed below. The diagnoses listed below included mood disorder, but mood disorder was not marked despite the resident's diagnoses including bipolar disorder (which was a mood disorder). The PASARR result notice indicated the resident did not have any indications of a serious mental illness and/ or developmental disability based on the PASARR Identification Screen that was submitted. On 12/12/23 at 4:23 P.M., an interview with SSD #178 revealed she was the one who was responsible for PASARR's. She confirmed Resident #4's PASARR Identification Screen completed on 07/07/23 did not accurately reflect the resident's mental illness diagnoses as a mood disorder or any other mental illness diagnosis was marked on the identification screen. She acknowledged he had bipolar disorder, and the identification screen should have been marked to reflect he had a mood disorder, since bipolar disorder was a type of mood disorder. She stated she should have completed a significant change PASARR when noting the PASARR Identification Screen previously completed was not completed accurately to reflect his mental illness diagnoses. Based on interview, resident record review, and facility policy review, the facility failed to ensure the Preadmission Screening and Resident Reviews (PASARRs) were completed accurately upon admission. This affected three residents (#4, #16, and #47) of nine residents reviewed for PASARR. The facility census was 85. Findings include: 1. Review of Resident #16's medical record revealed she was admitted to the facility on [DATE] with diagnoses including schizophrenia (entered 10/31/18), anxiety disorder (entered 10/31/18), and other specified depressive episodes (entered 06/20/19). Review of Resident #16's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/05/23, revealed she was severely cognitively impaired, had active diagnoses of anxiety, depression, and schizophrenia, and had verbal and physical behavioral symptoms directed toward others one to three days of the seven day assessment reference period. Review of Resident #16's physician order, dated 06/26/23, identified she was to receive Haldol decanoate (a long acting antipsychotic medication) 50 milligram/milliliter (mg/ml) intramuscular one day a month on the 27th of the month; physician order, dated 03/31/23, identified Lorazepam Intensol concentrate (an antianxiety medication) two mg/ml amount of 0.5 ml oral every four hours as needed for anxiety, agitation and shortness of breath; and physician order, dated 12/05/23, identified she was to receive ADR Cream (Ativan, Diphenhydramine, and Reglan) topically 2 ml topically (discontinue oral schedule Ativan when cream is started) every two hours as needed for restless, anxiety, and aggressive behavior not to exceed 12 ml daily total. Review of Resident #16's most recent PASARR, dated 10/23/18, revealed under Section D: Indications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 13 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of Serious Mental Illness, the box beside schizophrenia was marked with an X and the review results revealed she was not applicable for services. Interview on 12/05/23 at 8:35 A.M. with Social Services Director (SSD) #178 verified Resident #16's PASARR was not accurate upon admission. She verified anxiety disorder should have also been marked with an X. 3. Record review revealed Resident #47 admitted to the facility on [DATE] with diagnoses including heart failure, schizoaffective disorder, schizophrenia, conduct disorder, dementia with behaviors, disorientation, obsessive compulsive disorder, intellectual disabilities, anxiety disorder, depressive disorder, hyperlipidemia, hypertension, altered mental status, and hypoxia. Record review revealed a hospital exemption was completed for Resident #47 prior to admission, but the facility did not complete a PASARR once it was determined Resident #47 would be staying in the facility longer than 30 days. Interview on 12/05/23 at 5:01 P.M. with SSD #178 confirmed a PASARR was never completed for Resident #47. Review of the undated facility policy titled, Resident Assessment - Coordination with PASARR Program revealed the facility coordinates assessments with the PASARR program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 14 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and facility policy review, the facility failed to ensure residents had comprehensive care plans in place to address pressure ulcers, schizophrenia, anxiety, and insomnia. This affected four resident's (#4, #13, #30, and #188) of 26 residents reviewed for care plans. Findings include: 1. A review of Resident #4's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included insomnia. A review of Resident #4's physician's orders revealed he had an order to receive Melatonin (a supplemental sleep aid) 10 milligrams (mg) by mouth every night at bedtime. The order had been in place since 09/20/23. A review of Resident #4's active care plans revealed he did not have a care plan in place to address his diagnosis of insomnia or the use of Melatonin as a sleep aid. Findings were verified by the Director of Nursing (DON). On 12/12/23 at 2:50 P.M., an interview with the DON confirmed she was not able to find a care plan for the resident to address his diagnosis of insomnia and use of a sleep aid. She stated they initiated a care plan for insomnia, after it was brought to her attention. A review of the facility's policy on Comprehensive Assessments and the Care Delivery Process, revised December 2016, revealed comprehensive assessments would be conducted to assist in developing person-centered care plans. Comprehensive assessments, care planning and the care delivery process involved collecting and analyzing information, choosing, and initiating interventions, and then monitoring results and adjusting interventions. 4. Record review revealed Resident #188 was admitted to the facility on [DATE] with diagnoses including unspecified cirrhosis of liver, ascites, unspecified protein-calorie malnutrition, essential (primary) hypertension, hypertensive heart disease without heart failure, acute kidney failure, unspecified, solitary pulmonary nodule, hypo-osmolality, and hyponatremia, thrombocytopenia, unspecified. There was no evidence the resident had diagnoses of pressure ulcers on the diagnoses list. Review of Resident #188's admission MDS assessment dated [DATE] revealed Resident #188 had a stage II pressure (partial-thickness skin loss with exposed dermis) on admission. Review of Resident #188' Braden score dated 11/06/23 revealed the resident was at risk for pressure ulcer development. Review of Resident #188's admission skin event note for pressure dated 11/06/23 revealed the resident had area on the right buttocks that measured 0.5 centimeters (cm) by 0.5 cm. There was no documented depth or stage of the pressure ulcer. Review of Resident #188's wound management note revealed on 11/10/23 the resident had a pressure ulcer on right buttocks; however, there was no staging of the pressure ulcer. The first wound (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 15 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0656 Level of Harm - Minimal harm or potential for actual harm management note was on 11/10/23 at 2:16 P.M., indicated the wound measured 1.4 cm by 1.9 cm by 0.1 cm no exudate, granulation tissue, and to apply Zinc topically. The next wound management note was for 11/17/23 that indicated the wound was 0.9 cm by 1.4 cm by 0.1 cm with granulation tissue and was improving. The last wound management note was 11/21/23 0.9 cm by 0.9 cm by 0.1 cm granulation tissue no exudate. There were no more measurements in the electronic medical record (EMR) after 11/21/23. Residents Affected - Some Review of Resident #188's wound consult notes dated 11/10/23 to 12/01/23 revealed the resident had a stage II pressure ulcer on her buttocks since admission to the facility. The area measured 1.4 cm by 1.9 cm by 0.1 cm. The wound base was shallow and composed of 100 percent (%) clean tissue, no drainage, and peri wound area appeared normal. Apply [NAME] or equivalent to area every shift and as needed. On 11/17/23 the area measured 0.9 cm by 1.4 cm by 0.1 cm assessment of wound bed same continue with Desitin. On 11/21/23 the area was 0.9 cm by 0.9 cm by 0.1 cm, continue treatment and assessment, there was no change. On 12/01/23 the area measured 0.7 cm by 0.9 cm by 0.1 cm, same assessment and treatment. Review of the undated facilities pressure injury staging guide revealed a stage II pressure ulcer was partial-thickness skin loss with exposed dermis. Unstageable was obscured full-thickness skin and tissue loss. Review of Resident #188's plan of care revealed no evidence of a plan of care for pressure ulcers. Review of Resident #188's skin integrity related to decreased mobility and ascites dated 11/27/23 revealed weekly skin assessment, pressure reduction cushion to chair, and moisture barrier protectant to perineal area as needed. Review of Resident #188 base line plan of care dated 11/06/23 revealed the resident had a venous/stasis ulcer. Interventions include notifying physician of any adverse finding with skin integrity and to inspect the skin when repositioning, toileting, assisting with activities of daily living, and notify the nurse of any adverse findings. There was no documented evidence of a pressure ulcer base line plan of care. Observation on 12/06/23 at 7:36 A.M., with Assistant Director of Nursing (ADON) #150 and the DON of Resident #188 revealed the resident was sitting in a recliner with feet on the floor. The staff member stood the resident up and there was no pressure relieving cushion under the resident. The resident had an open area on her buttocks the size of a pea. The area had yellow stringy tissue in the wound bed and the depth appeared to measure 0.3 cm deep. Interview on 12/06/23 at 8:37 A.M., 10:20 A.M., and 10:44 A.M., with ADON #150 and the DON revealed they had gone back and measured the pressure ulcer. The area measured 0.7 cm by 0.9 cm by 0.3 cm, which was a decline from 12/01/23. The DON confirmed the resident did not have a comprehensive plan of care for the pressure ulcer, nor did the resident have a pressure relieving cushion on the chair. 2. Review of Resident #30's medical record revealed she was admitted to the facility on [DATE] with diagnoses including major depressive disorder, single episode, adjustment disorder, suicide attempt, suicidal ideations, generalized anxiety disorder, unspecified atrial fibrillation, and essential hypertension. Review of Resident #30's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/10/23, revealed she was cognitively intact and had active diagnoses of anxiety and depression. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 16 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0656 Review of Resident #30's comprehensive plan of care revealed no care plan for anxiety. Level of Harm - Minimal harm or potential for actual harm Interview on 12/11/23 at 10:28 A.M. with Registered Nurse (RN) #202 verified there was no anxiety plan of care for Resident #30, and there should be. She reported she initiated an anxiety care plan for Resident #30 on 12/11/23. Residents Affected - Some Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised 12/18, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Further review revealed the comprehensive, person-centered care plan will incorporate identified problem areas. 3. Record review revealed Resident #13 admitted to the facility on [DATE] with diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, anxiety disorder, major depressive disorder, hallucinations, and osteoarthritis. Review of a quarterly MDS assessment completed on 11/09/23 revealed Resident #13 had behaviors of hallucinations. Review of orders revealed Resident #13 was ordered dated 02/22/23 for buspirone 15 mg (antianxiety medication) three times a day by mouth for anxiety, an order dated 04/27/23 for olanzapine 10 mg (an antipsychotic medication) by mouth for delusions and hallucinations, an order dated 03/29/23 for Zoloft 100 mg (antidepressant medication) by mouth, and an order to add a diagnosis of schizophrenia on 03/30/23. Review of the care plan last revised on 11/22/23 revealed no comprehensive care plan was initiated related to new diagnosis of schizophrenia. Interview on 12/13/23 at 12:04 P.M. with RN #202 confirmed there was not a comprehensive care plan in relation to schizophrenia for Resident #13. Review of a policy titled Care Plan, Person-Centered Comprehensive revealed care planning is ongoing and care plans should be revised as information about the residents and the residents' conditions change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 17 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #8's medical record revealed she was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), chronic diastolic (congestive) heart failure, type two diabetes mellitus without complications, anxiety disorder, and major depressive disorder. Review of Resident #8's quarterly MDS 3.0 assessment, dated 10/01/23, revealed she was cognitively intact. Interview on 12/04/23 at 11:23 A.M. with Resident #8 revealed she did not recall having care conferences every quarter. Review of Resident #8's medical record revealed she had care conferences, which are entered into the electronic medical record as Resident First Meetings, on 02/26/22, 06/03/22, 10/10/22, 01/02/23, 04/06/23, and 08/08/23. Interview on 12/11/23 at 2:37 P.M. with SSD #178 verified she was a month late regarding the conferences on 10/10/22, 08/08/23, and the one which was due 11/08/23 and not completed as of the interview. SSD #178 reported she liked to do the care conferences following the completion of the MDS, but she tended to have more care conferences than there were MDS evaluations. Based on record review and interview the facility failed to ensure residents and representatives were invited to participate in care conferences and care plans were updated to reflect residents' current conditions. This affected four residents (#8, #29, #47, and #68) of five residents reviewed for care planning. The facility census was 85. Findings include: 1. Record review revealed Resident #29 admitted to the facility on [DATE] with diagnoses including dementia, contusion of the head, atherosclerotic heart disease without angina, atrial fibrillation, psychosis not due to a substance or known condition, hyperlipidemia, ischemic cardiomyopathy, encephalopathy, cognitive communication deficit, insomnia, and dysphagia. Review of the care conferences revealed Resident #29 had a care conference on 10/10/22 and did not have another care conference until 04/19/23. Interview on 12/05/23 at 5:01 P.M. with Social Services Director (SSD) #178 revealed care conference invitation cards were sent out monthly based on the Minimum Data Set (MDS) assessment calendar to ensure they are completed quarterly. Interview on 12/11/23 at 10:07 A.M. with SSD #178 confirmed Resident #29 did not have a care conference between 10/10/22 and 04/19/23, and they should be completed approximately every three months. 2. Record review revealed Resident #47 admitted to the facility on [DATE] with diagnoses including heart failure, schizoaffective disorder, schizophrenia, conduct disorder, dementia with behaviors, disorientation, obsessive compulsive disorder, intellectual disabilities, anxiety disorder, depressive disorder, hyperlipidemia, hypertension, altered mental status, and hypoxia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 18 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Review of a resident-to-resident Event assessment completed on 09/03/23 at 6:49 P.M. by Licensed Practical Nurse (LPN) #255 revealed Resident #47 made contact with another resident with an event description of resident pushed another resident. The assessment indicated Resident #47 was angry and anxious prior to incident, and the immediate intervention put in place included staff to allow privacy of his room as resident allows. Residents Affected - Some Review of a nursing note on 09/03/23 at 6:50 P.M. by LPN #255 revealed resident made contact with another resident, staff intervened an redirection given. Review of a Behavior and Mood Event assessment completed on 11/23/23 at 6:59 P.M. by Registered Nurse (RN) #137 revealed Resident #47 shoved another resident because she was attempting to take his papers. Immediate interventions included redirection and relocated to a quiet location. Review of an interdisciplinary team note completed on 11/27/23 at 7:30 A.M. by the Director of Nursing (DON) revealed resident became slightly aggressive when another resident attempted to move personal belonging from dining room table. Both residents were redirected easily and continued to participate in normal routines. Review of the care plan last reviewed on 09/29/23 revealed Resident #47 had inappropriate behaviors including placing inappropriate objects in personal orifices. There were no mentions of resident-to-resident incidents or aggressive behaviors. Interview on 12/13/23 at 12:04 PM with RN #202 confirmed there was not a care plan or interventions in place for Resident #47 regarding aggressive behaviors toward other residents. 3. Record review revealed Resident #68 admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, hypertension, hyperlipidemia, gout, vascular dementia, and insomnia. Review of the nursing note on 09/20/23 at 9:12 A.M. by LPN #256 revealed Resident #68 was found in another resident's bed. Residents were separated, and one on one was provided. Review of the nursing note on 12/03/23 at 9:21 P.M. by LPN #158 revealed Resident #68 was found in a female resident's room in bed with her with no shirt on and his pants inside out. Review of the care plan revealed no interventions in place to address sexually inappropriate behaviors. Interview on 12/13/23 at 12:04 P.M. with RN #202 confirmed there was no care plan in place to address Resident #68's sexually inappropriate behaviors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 19 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review revealed Resident #188 was admitted to the facility on [DATE] with diagnoses including unspecified cirrhosis of liver, ascites, unspecified protein-calorie malnutrition, essential (primary) hypertension, hypertensive heart disease without heart failure, acute kidney failure, unspecified, solitary pulmonary nodule, hypo-osmolality and hyponatremia, thrombocytopenia, unspecified. Residents Affected - Few Review of Resident #188's hospital note dated 10/31/23 revealed the resident had bilateral lower extremity swelling. Review of Resident #188's current orders and medication administration records dated 11/06/23 to 12/06/23 revealed the resident was receiving Lasix (diuretic) 20 mg once daily between 7:00 A.M. to 11:00 A.M. and Spironolactone (diuretic) 20 mg once daily between 7:00 A.M. to 11:00 A.M. The resident an as needed order for Oxycodone 5 mg one every six hours for pain and which she had received 12 doses. There was no evidence non-pharmacological intervention were attempted or pain was assessed prior to administration of the Oxycodone. Review of Resident #188 base line plan of care dated 11/06/23 revealed the resident had a venous/stasis ulcer. Interventions include notifying physician of any adverse finding with skin integrity and to inspect the skin when repositioning, toileting, assisting with ADL's and notifying the nurse of any adverse findings. The resident had no pain. The resident was receiving analgesics/opioids and diuretics and to administer medication as order and notify the physician if any side effects. There was no evidence the resident had edema. Review of Resident #188's skin integrity plan of care related to decreased mobility and ascites dated 11/27/23 revealed weekly skin assessment, pressure reduction cushion to chair, and moisture barrier protectant to perineal area as needed. Review of Residents #188's care plan for high-risk medication dated 11/27/23 revealed the resident received diuretic medication related to hypertension. The intervention included to observe for cardiovascular system and fluid status to determine the effectiveness of diuretic therapy (e.g., edema, jugular vein distention, mental confusion, shortness of breath, abnormal breath sounds, abnormal heart sounds). Review of Resident #188's care plan for pain dated 11/27/23 revealed the resident had pain related to cirrhosis of the liver and decreased bed mobility. The intervention included administering medication as ordered and notifying the physician if any side effects observed or lack of effectiveness and notifying the physician of increased pain. Observe for and record for verbal and non-verbal signs of pain. Attempt non-pharmacological interventions. Observation on 12/04/23 at 3:06 P.M., of Resident #188 revealed the resident was sitting in a recliner with her feet on the floor and no compression stockings were noted. The resident had severe swelling in her bilateral lower extremities (BLE) and verbalized complaints of pain. The resident reported her current pain management program was not effective due to staff does not administer pain medication timely upon request or not at all upon request. The resident reported her pain was so bad at night it was affecting her sleep. Review of Resident #188's skilled charting notes dated 12/03/23 12/04/23, and 12/05/23 revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 20 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 resident had no lower extremity edema. Level of Harm - Actual harm Further review of Resident #188's medical record dated 11/06/23 to 12/05/23 revealed there was only one documentation regarding lower extremity edema on 12/01/23 that indicated the resident had bilateral lower extremity edema. Residents Affected - Few Observation on 12/06/23 at 7:36 A.M., with Assistant Director of Nursing (ADON) #150 and the Director of Nursing (DON) revealed the resident was sitting in the recliner and her legs were not elevated nor did she have compression stocking in-place. The resident's socks were so tight around the top of her legs that it left indentation around her legs when they were pushed down by staff. The ADON continued to remove the resident's socks and the resident had severe pitting edema in bilateral lower legs. The left leg had blister like areas forming on the lower leg. The ADON had assessed the edema by pushing down on the tops of the residents' feet and the front of the legs. The area did not return to normal, and the indentation stayed where the nurse had pushed down. The ADON reported she would classify the edema as four plus pitting edema. The resident reported again to the staff the pain was so bad at night in her legs and feet that she couldn't sleep. She confirmed she had requested pain medication and sometimes she doesn't get it all or she must wait a long time to get it. The resident reported she has a high tolerance for pain but the pain at night was rated a 10 out of 10. The DON reported she would have the physician assess the resident today. Interview on 12/06/23 10:00 A.M., with the DON confirmed staff had been charting no edema except the one progress note on 12/01/23 that indicated the resident continued to have edema and there was no documented evidence the physician was notified of the edema or pain. The DON confirmed there was no documented evidence the pain was assessed prior to administration of the Oxycodone or non-pharmacological attempted prior. The DON reported the nursing staff were new to the facility and were new graduates with not much nursing experience. The facility did not have a policy regarding edema, however staff should utilize the change of condition policy. Review of Resident #188's progress note dated 12/06/28 at 5:28 P.M. revealed the resident continued with increased edema to BLE. The left lower extremity (LLE) was noted with redness and increased warmth. The in-house physician visited and wrote new orders for an antibiotic, Keflex 250 milligrams (mg) twice daily for seven days, laboratory testing including a complete blood count (CBC) and comprehensive metabolic profile (CMP) in one week and to schedule Oxycodone 5 mg every night as the resident stated the pain was at night and requested pain medication to be given every night. Review of the facility policy titled Change in Condition and physician notification policy dated 09/2020 revealed the facilities policy was to promptly identify, respond to, and report changes in the resident condition to the resident's physician. When a change of condition was discovered, the nurse would evaluate the resident and notify the resident's physician with pertinent information and document the findings timely. Review of the facility policy titled Skin Care dated 08/2019 revealed to notify the wound nurse, physician, dietician, and resident representative upon observation of a skin change in condition or new skin area. Review of the facility policy titled Wound Care dated 12/2020 revealed wounds would be evaluated when they are observed and weekly until resolved. Wounds would be monitored for location, size (length, width, depth), undermining, tunneling, exudate, necrotic tissue, and the presence or absence of granulation tissue or epithelialization. Only pressure ulcers would be staged. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 21 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 Based on observation, record review, interview and facility policy review, the facility failed to ensure timely and necessary care and services were provided to meet the total care needs of all residents. Level of Harm - Actual harm Residents Affected - Few Actual Harm occurred on 09/24/23 at 10:00 P.M. when the facility failed to timely treat and seek medical intervention for Resident #44 following a fall with left hip fracture. On 09/24/23 at 10:30 P.M. Resident #44 was assessed to have an elevated blood pressure of 216/68, followed by multiple other elevated blood pressures. On 09/25/23 at 2:28 A.M. the resident exhibited groin pain and on 09/25/23 at 1:04 P.M. the resident exhibited pain not controlled by Tylenol. The facility did not notify the physician of the pain until 09/25/23 at 6:12 P.M. when an order was given for left hip and femur x-rays and Percocet (a narcotic analgesic) was ordered for pain. The x-rays were not obtained until 09/26/23 and the facility was subsequently informed Resident #44 had a hip fracture on 09/26/23 at 2:00 P.M. The resident arrived at the emergency department on 09/26/23 at 5:03 P.M., 43 hours after the fall occurred, where she rated her pain a 10 on a scale of zero to 10 and presented with signs of deformity in her left hip. Resident #44 had surgical repair of her hip on 09/27/23. Actual harm occurred on 06/12/23 when the facility failed to timely treat and seek medical intervention for Resident #29 following a fall with subsequent nondisplaced fracture of the 5th metacarpal. At the time of the fall, Resident #29 complained of wrist pain, did not receive any pain medications, and no new orders were given for evaluation. On 06/13/23, Resident #29 exhibited worsening injury to her wrist when it began to swell and bruise. The physician and Resident #29's family were not made aware and no further assessment was completed. On 06/14/23 Resident #29 continued to have bruising to her wrist along with edema, and new onset of bruising to her face. Resident #29 was then sent to the hospital for evaluation and treatment where she was diagnosed with nondisplaced fracture of 5th metacarpal. This affected three residents (#29, #44, and #188) of seven residents reviewed for quality of care and treatment. The facility census was 85. Findings included: 1. Review of Resident #44's medical record revealed she was admitted on [DATE] with diagnoses including generalized muscle weakness, unsteadiness on feet, difficulty in walking, chronic obstructive pulmonary disease (COPD), type two diabetes, and hypertensive heart disease. Review of Resident #44's significant change Minimum Data Set (MDS) 3.0 assessment, dated 10/17/23, revealed she was mildly cognitively impaired. Further review revealed she was dependent for sit to stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer, and walking 10 feet. Additionally, the MDS revealed she had not had any falls since the prior assessment. Review of Resident #44's most recent documented vital signs prior to her fall, dated 09/19/23 at 1:48 P.M., revealed her blood pressure was 138/80, her pulse was 78, and her respirations were 20. Review of Resident #44's progress note, dated 09/24/23 at 10:00 P.M. revealed the State Tested Nursing Assistant (STNA) approached the nurse and reported Resident #44 was on the floor. Resident #44 was lying on the floor with her head under the foot of the bed and her legs extended towards the center of the room. There was juice spilled on the floor and her. Resident #44 denied pain other than from hitting her head on the bed. She reported the head pain was when she actively hit it and the pain had gone away. There were no injuries noted from the fall. Resident #44 reported she was trying to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 22 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 Level of Harm - Actual harm Residents Affected - Few switch from lying at the foot of the bed to the head of the bed. Resident #44 reported, I was not walking. I just slipped. Vital signs were within normal limits per her baseline except for an elevated blood pressure. Resident #44's blood pressure was 170/70, her pulse was 68, and her respirations were 16. Neurological assessments were initiated at 10:00 P.M. and normal. The situation with the vital signs were reported to the nurse practitioner and to hospice. Both entities directed to continue to monitor the resident's blood pressure due to the elevated blood pressure could be situational and from being irritated. Review of Resident #44's documented vital signs, dated 09/24/23 at 10:30 P.M., revealed her blood pressure was 216/68 (hypertensive), her pulse was 64, and her respirations were 17. Review of Resident #44's documented vital signs, dated 09/24/23 at 10:45 P.M., revealed her blood pressure was 191/77 (hypertensive), her pulse was 68, and her respirations were 18. Review of Resident #44's fall event documentation, dated 09/24/23 at 11:14 P.M., revealed she had fallen in her room and had pain to the back of her head which she rated a one on a scale of zero to ten. Resident #44's pupils were 3 mm round and brisk to light, her speech was clear, and she was alert and oriented to person and place. There was no change noted in mental status. There was no injury noted, she had range of motion to all four extremities without pain or limitations, there was no rotation/deformity/shortening noted to her lower extremities. Her upper and lower left and right extremities were strong. Review of Resident #44's documented vital signs, dated 09/24/23 at 11:45 P.M., revealed her blood pressure was 145/93 (hypertensive), her pulse was 63, and her respirations were 18. Review of Resident #44's documented vital signs, dated 09/25/23 at 12:15 A.M., revealed her blood pressure was 163/66 (hypertensive), her pulse was 71, and her respirations were 16. Review of Resident #44's progress note, dated 09/25/23 at 12:32 A.M., revealed she voiced complaints of shoulder pain to the STNA. Resident #44 had told the STNA not to tell the nurse. Resident #44 was found lying on her left side when she fell. Resident #44 stated she had always had issues with the shoulder, but falling had just made it sore. Range of motion (ROM) of the shoulder was normal at the time of the fall. Resident #44 now showed pain when moving the shoulder but was still able to more it. Review of Resident #44's documented vital signs, dated 09/25/23 at 12:45 A.M., revealed her blood pressure was 178/68 (hypertensive), her pulse was 71, and her respirations were 16. Review of Resident #44's documented vital signs, dated 09/25/23 at 1:45 A.M., revealed her blood pressure was 178/68 (hypertensive), her pulse was 64, and her respirations were 16. Review of Resident #44's progress note, dated 09/25/23 at 2:28 A.M., revealed she continued to voice complaints about her shoulder and was now voicing complaints about groin pain. Resident #44 would grab her inner thigh when speaking of the pain. The note indicated there were no signs of hip fracture at the time as leg lengths were even. Resident #44 denied pain in the hip area when the nurse touched it. As needed Tylenol was given per physician order. Review of Resident #44's Medication Administration Record (MAR), dated 09/23, revealed on 09/25/23 at 2:28 A.M. she received Tylenol 650 milligram (mg) (no pain level document) and it was effective (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 23 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 for her pain. Level of Harm - Actual harm Review of Resident #44's documented vital signs, dated 09/25/23 at 2:45 A.M., revealed her blood pressure was 160/63 (hypertensive), her pulse was 73, and her respirations were 16. Residents Affected - Few Review of Resident #44's documented vital signs, dated 09/25/23 at 3:45 A.M., revealed her blood pressure was 154/65 (hypertensive), her pulse was 65, and her respirations were 16. Review of Resident #44's interdisciplinary department note, dated 09/25/23 at 9:15 A.M., revealed she had slipped off the edge of the bed while attempting to switch to the other end of the bed. No injury was noted. New interventions of bed in the lowest position so feed can reach the floor due to the resident being short in stature. The facility would monitor the new intervention for effectiveness and notify medical doctor if not effective. Review of Resident #44's MAR, dated 09/2023, revealed on 09/25/23 at 1:04 P.M. she received Tylenol 650 mg (no pain level documented) and it was not effective for pain. Review of Resident #44's Certified Nurse Practitioner (CNP) progress note, dated 09/25/23 at 6:08 P.M., revealed the nurses called and stated Resident #44 had rolled out of bed and hit her head. Resident #44's blood pressure was initially 170/70, then 128/70, then 216/68, then 191/77 and then 145/70. Hospice was aware of the fall. Resident #44's neurological assessments were within normal limits. Resident #44 was denying any pain, and her assessments were within normal limits. There was no pain in hips or rotation upon the nursing assessment. Review of Resident #44's CNP progress note, dated 09/25/23 at 6:12 P.M. revealed the nurses called and stated Resident #44 was now complaining of left hip/leg pain after rolling out of bed. There was no external rotation noted but the pain was new for her. The medical provider's plan of care included: left hip and femur x-ray, Percocet 5/325 mg by mouth every six hours as needed for pain, and if fracture is indicated on the x-rays, please send her to the emergency department as soon as possible. Review of Resident #44's MAR, dated 09/23, revealed no Percocet was administered for pain. Review of Resident #44's progress note, dated 09/25/23 at 9:30 P.M., revealed the portable x-ray provider telephoned and stated they would come on 09/26/23 to complete the x-ray and would call the facility when they were 20 to 30 minutes away. Review of Resident #44's progress note, dated 09/26/23 at 12:22 A.M., revealed she continued to voice complaints of pain in her left hip/leg and x-ray was ordered for this date. Review of Resident #44's physician order, dated 09/25/23, revealed an order for a left upper hip and left femur x-ray. Review of Resident #44's radiology results, dated 09/26/23 at 10:41 CDT, revealed an acute fracture of the femoral neck. Review of Resident #44's progress note, dated 09/26/23 at 2:00 P.M., revealed x-ray results received from portable x-ray provider and the medical director in the facility and aware of the results. Orders were received to send Resident #44 to the emergency department for treatment. The next of kin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 24 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 was contacted along with the hospice provider. Emergency Medical Services (EMS) was notified of need for transport. Level of Harm - Actual harm Residents Affected - Few Review of Resident #44's emergency department report, dated 09/26/23 at 5:03 P.M., revealed she presented to the emergency department from a nursing home with a femur fracture due to a fall two days ago. Her blood pressure was 173/81, her pulse was 79, and her respirations were 28. Resident #44 rated her pain a 10 on a scale of zero to 10 and described it as intermittent, sharp, and nonradiating (stayed in one location). She reported she did not have pain when she was not moving the leg but had significant pain with movement. Resident #44's left leg was shortened and rotated (signs of a hip fracture) and deformity was noted. She was not able to perform range of motion. Review of Resident #44's hospital Discharge summary, dated [DATE], revealed she had a left hip hemiarthroplasty (surgical procedure that involves replacing half of the hip joint) surgery on 09/27/23 to correct her left femoral neck fracture. Telephone interview on 12/11/23 at 10:20 A.M. with CNP #225 revealed she was not informed Resident #44 developed pain in her shoulder on 09/25/23 at 12:32 A.M., developed groin pain on 09/25/23 at 2:28 A.M., or had the many elevated blood pressures. CNP #225 revealed she would have sent Resident #44 out to the emergency department (ED) for assessment and care if Resident #44's hospice company had approved. CNP #225 also revealed when she provided the telephone order for the left hip and femur x-ray it was to be completed stat. CNP #225 revealed she was not informed the portable x-ray was not available until 09/26/23 or she would have sent Resident #44 out the evening of 09/25/23 to the ED for assessment and care if Resident #44's hospice company had approved. Telephone interview on 12/11/23 at 1:35 P.M. with Hospice Nurse #223 revealed based on hospice documentation, they received a phone call on 09/24/23 at 10:45 P.M. that Resident #44 had fallen, but there were no injuries. She reported the next documentation was on 09/26/23 when the facility received x-ray results of a fractured hip and Resident #44 was sent to the local emergency department for care. Hospice Nurse #223 verified there was no documentation to support hospice was notified between the 09/24/23 10:45 P.M. note and the 09/26/23 fracture confirmed by radiology note. Hospice Nurse #223 verified there was no documentation of shoulder pain, groin pain, or elevated blood pressures. Hospice Nurse #223 verified hospice would not have stopped transport to local emergency department for care and services. Interview on 12/11/23 at 2:52 P.M. with the Director of Nursing (DON) verified Resident #44 did have a delay in care and services on 09/24/23 at 10:00 P.M. when she fell out of bed and presented with a blood pressure at 10:30 P.M. of 216/68 and continued to have elevated blood pressures, then continued to develop new symptoms of injury and pain not controlled by the medication ordered. She verified there was an additional delay in care and services when the portable radiology company could not complete the x-rays until 09/26/23. The DON verbalized there was a need for training with their staff regarding residents not experiencing a delay in care and services. Review of the facility policy titled Change in Condition and physician notification policy dated 09/2020 revealed the facilities policy was to promptly identify, respond to, and report changes in the resident condition to the resident's physician. When a change of condition was discovered, the nurse would evaluate the resident and notify the resident's physician with pertinent information and document the findings timely. 2. Record review revealed Resident #29 admitted to the facility on [DATE] with diagnoses including (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 25 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 Level of Harm - Actual harm Residents Affected - Few dementia, atherosclerotic heart disease without angina, atrial fibrillation, psychosis not due to a substance or known condition, hyperlipidemia, ischemic cardiomyopathy, congestive heart failure, anxiety disorder, other depression episodes, mood (affective) disorder, and insomnia. Review of a nursing note from 06/12/23 at 7:05 P.M. by Nurse #235 revealed a hospice aide had notified her Resident #29 was on the floor in the common area. Resident #29 complained of right wrist pain but had no visible injuries, all assessments were within normal limits, vital signs and neuro checks were within normal limits. Review of the medication administration record (MAR) from 06/12/23 revealed Resident #29 did not receive any medication related to her complaint of pain. Review of a nursing note from 06/13/23 at 2:01 P.M. by Registered Nurse (RN) #197 revealed Resident #29 was noted to have bruising to right wrist with slight swelling, but range of motion was intact and there were no complaints of pain. RN #197 did not notify the physician or resident representative of the change in condition. Review of a nursing note from 06/14/23 at 3:59 P.M. by Nurse #235 revealed Resident #29 was noted to have a deformity to her nose with light bruising under her eyes, right wrist noted with edema, redness, and bruising status post fall on 06/12/23. Nurse #235 notified the physician and received a new order to send Resident #29 to the emergency department for evaluation; family was also made aware. Review of nursing note from 06/14/23 at 8:43 P.M. by Licensed Practical Nurse (LPN) #194 revealed Resident #29 would be returning from the emergency department with a diagnosis of right fifth digit metacarpal nondisplaced fracture and was refusing to keep her splint on. Interview on 12/06/23 at 8:52 A.M. with DON revealed an x-ray was not completed at the time Resident #29 fell and complained of pain and the physician was not notified of worsening bruising and swelling until 06/14/23 which demonstrated a delay in care and treatment for the resident. The DON verified the resident had sustained a fracture as a result of the fall. Review of the facility policy titled Change in Condition and physician notification policy dated 09/2020 revealed the facilities policy was to promptly identify, respond to, and report changes in the resident condition to the resident's physician. When a change of condition was discovered, the nurse would evaluate the resident and notify the resident's physician with pertinent information and document the findings timely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 26 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide comprehensive and individualized interventions to Resident #188 to prevent the deterioration of a pressure ulcer. The facility also failed to ensure pressure ulcer assessments were comprehensive and completed weekly. Residents Affected - Few Actual Harm occurred on 12/06/23 when Resident #188, who was admitted with a Stage II (partial-thickness skin loss with exposed dermis) pressure ulcer to the buttocks was identified to have deterioration to the ulcer which was now assessed to be unstageable (obscured full-thickness skin and tissue loss) related to the lack of comprehensive and individuated interventions being in place and lack of ongoing monitoring and timely identification of the wound deterioration. This affected one resident (#188) of one resident reviewed for pressure ulcers. Findings include: Record review revealed Resident #188 was admitted to the facility on [DATE] with diagnoses including unspecified cirrhosis of liver, ascites, unspecified protein-calorie malnutrition, essential (primary) hypertension, hypertensive heart disease without heart failure, acute kidney failure, unspecified, solitary pulmonary nodule, hypo-osmolality and hyponatremia, thrombocytopenia, unspecified. There was no evidence the resident had diagnoses of pressure ulcers on the diagnoses list. Review of Resident #188' Braden score dated 11/06/23 revealed the resident was at risk for the development of pressure ulcers. Review of Resident #188's admission skin event note for pressure dated 11/06/23 revealed the resident had area on the right buttocks that measured 0.5 centimeters (cm) in length by 0.5 cm width. The assessment did not included a documented depth or stage of the pressure ulcer. Review of Resident #188 base line plan of care dated 11/06/23 revealed the resident had a venous/stasis ulcer. The baseline care plan did not reflect pressure ulcers or pressure ulcer risk. Interventions include notifying physician of any adverse finding with skin integrity and to inspect the skin when repositioning, toileting, assisting with activities of daily living (ADL) care and notifying the nurse of any adverse findings. Review of Resident #188's admission Minimum Data Set (MDS) dated [DATE] revealed the resident had a Stage II (partial-thickness skin loss with exposed dermis) pressure ulcer present on admission. Review of Resident #188's plan of care revealed no evidence the facility developed a comprehensive and individualized plan of care related to pressure ulcers. Review of Resident #188's wound management note revealed on 11/10/23 the resident had a pressure ulcer on right buttocks, however no staging of the pressure ulcer was completed. The first wound management note (on 11/10/23 at 2:16 P.M.) reflected the wound measured 1.4 cm in length by 1.9 cm width with 0.1 cm depth and no exudate, granulation tissue present and an order to apply zinc topically. The next wound management note was dated 11/17/23 which reflected the wound measured 0.9 cm by 1.4 cm by 0.1 cm with granulation tissue and was improving. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 27 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm Residents Affected - Few The last wound management note dated 11/21/23 reflected the wound measured 0.9 cm by 0.9 cm by 0.1 cm and had granulation tissue and no exudate. There were no more measurements in the electronic medical record (EMR) after 11/21/23. Review of Resident #188's wound consult notes dated 11/10/23 to 12/01/23 revealed the resident had a Stage II pressure ulcer on her buttocks since admission to the facility. The area measured 1.4 cm by 1.9 cm by 0.1 cm. The wound base was shallow and composed of 100% clean tissue, no drainage, and peri wound area appeared normal. The note indicated to apply Desitin or equivalent to area every shift and as needed. On 11/17/23 the area measured 0.9 cm by 1.4 cm by 0.1 cm assessment of wound bed; continue with Desitin. On 11/21/23 the area was 0.9 cm by 0.9 cm by 0.1 cm; continue treatment and assessment no change. On 12/01/23 the area measured 0.7 cm by 0.9 cm by 0.1 cm; same assessment and treatment. Review of Resident #188's skin integrity related to decreased mobility and ascites plan of care, dated 11/27/23 revealed weekly skin assessment, pressure reduction cushion to chair, and moisture barrier protectant to perineal area as needed. Observation on 12/04/23 at 3:06 P.M. and 12/05/23 at 8:05 A.M., revealed no evidence the resident had a pressure relieving cushion under her while she was noted sitting in her recliner. Observation on 12/06/23 at 7:36 A.M., with Assistant Director of Nursing (ADON) #150 and the Director of Nursing (DON) revealed Resident #188 was sitting in a recliner with her feet on the floor. The staff members stood the resident up and there was no pressure relieving cushion under the resident. The resident had an open area on her buttocks the size of a pea. The area had yellow stingy tissue in the wound bed and the depth appeared to measure 0.3 cm. ADON #150 reported she was the facility wound nurse; however, had not taken any formal classes and she was not aware the wound had declined nor was there any documentation indicating the wound had declined. Interview on 12/06/23 at 8:37 A.M., 10:20 A.M., and 10:44 A.M., with ADON #150 and the DON revealed they had gone back and measured the resident's pressure ulcer. The area measured 0.7 cm by 0.9 cm by 0.3 cm, which was a decline from 12/01/23. The DON confirmed the resident did not have a comprehensive plan of care for the pressure ulcer nor did the resident have a pressure relieving cushion on the chair during the observation at 7:36 A.M. The ADON reported she updated the wound consultant on the measurements, and she indicated to continue to use the zinc and foam dressing. The ADON confirmed she did not update the wound consultant on the changes of the wound bed (yellow slough). The DON reported she would have the medical director look at the wound today as well due to zinc probably not being an appropriate treatment due to the wound being now unstageable. The ADON and DON confirmed the pressure ulcers assessments were not comprehensive to include the staging of the wound. There was no evidence a weekly pressure ulcer assessment was completed by the facility or wound consultant from 11/21/23 to 12/01/23. The facility staff had not documented an assessment since 11/21/23 in the medical record. The ADON reported she had just received the wound consultation notes from the consultant; however, she had not had time to enter the facility notes yet. The ADON reported she usually rounded with the wound consultant and they observed the wounds together. She doesn't enter her notes at that time and would wait until she received the wound consultants' notes. The DON reported the wound measured 0.7 cm by 0.9 cm by 0.3 cm with edges epibole thick and rounded. The wound bed was 85% pale pink granulation and 15% white/yellow slough, however the computer system only allowed staff to enter one option for the wound bed so for example she would have to enter the slough or granulation she couldn't enter both. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 28 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm Residents Affected - Few Review of Resident #188's physician wound consult note dated 12/06/23 revealed the resident was a seen by a digital visit. The wound note indicated the resident's pressure area measured 0.7 cm by 0.9 cm by an undetermined depth (UTD). The wound base was composed of 50% granulation and the wound was unstageable. The wound would likely benefit from debridement when the physician group visited in a couple days. The plan was to protect with Alginate (dressing) until that time. The wound had a moderate amount of serous drainage and a decline in the wound status was noted. The note included, due to the resident's unavailability the electronic data was evaluated and then discussed with the nurse caring for the resident. The resident was in mild transient pain during the wound assessment, which was resolved post assessment. The treatment/dressing was chosen to help promote autolytic debridement of the wound. Interview on 12/06/23 at 2:10 P.M., with the DON reported she had sent an encrypted photo to the wound consult doctor whom oversees the nurse practitioner who comes to the facility and he reviewed the photo and he felt the wound bed was 50% granulation and 50% slough and staged the pressure ulcer as unstageable. Review of the facility undated Pressure Injury Staging Guide revealed a Stage II pressure ulcer was partial-thickness skin loss with exposed dermis. Unstageable pressure ulcers were defined as obscured full-thickness skin and tissue loss. The facility reported they didn't have a policy and procedure related to pressure ulcers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 29 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #44's medical record revealed she was admitted on [DATE] with diagnoses including generalized muscle weakness, unsteadiness on feet, difficulty in walking, chronic obstructive pulmonary disease (COPD), type two diabetes, and hypertensive heart disease. Review of Resident #44's significant change MDS assessment, dated 10/17/23, revealed she was mildly cognitively impaired. Further review revealed she was dependent for sit-to-stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer, and walking ten feet. Additionally, the MDS revealed she had not had any falls since the prior assessment. Review of Resident #44's plan of care, dated 11/04/23, revealed she was at risk for falling related to history of falls and weakness. Interventions included bed in lowest position (entered 09/25/23), non-skid strips to floor by bed (entered 04/19/23), and mat next to bed (entered 12/15/22). Review of Resident #44's physician order, dated 03/10/23, identified she was to a mat to the floor for safety; and physician orders, dated 04/18/23, identified Resident #44's bed was to be kept in the lowest position as the resident would allow and there were to be nonskid strips to the floor in front of the bed. Review of Resident #44's Treatment Administration Record (TAR), dated 12/01/23 to 12/05/23, revealed non-ski strip to floor, bed in low position, and mat to floor were documented as being in place. Observation on 12/04/23 at 7:24 A.M. of Resident #44 lying in bed. Her bed was not in the lowest position, there were no non-skid strips on the floor in front of her bed, and there was no mat in front of her bed. Observation on 12/05/23 at 9:53 A.M. of Resident #44 lying in bed. Her bed was not in the lowest position, there were no non-skid strips on the floor in front of her bed, and there was no mat in front of her bed. Observation on 12/05/23 at 12:44 P.M. of Resident #44 sitting in bed eating lunch, the bed was not in the lowest position, there was no mat on the floor, and no nonskid strips on the floor. Observation was made with Registered Nurse (RN) #137. She verified all three fall interventions were not in place and should have been. She also verified Resident #44's TAR had documentation that the three fall prevention interventions were in place. Review of the facility policy titled, Falls Policy, revised 10/18, revealed it was the policy of the facility to complete a resident fall risk and implantation of interventions to attempt to prevent or reduce falls/accidents and injuries related to falls. Based on record review, observation, interview, and facility policy review the facility failed to ensure effective fall interventions were in place for Residents #29 and #44, and the facility failed to ensure 15-minute checks were completed for Resident #19 when he made statements of self-harm. This affected three (Residents #19, #29, and #44) of five residents reviewed for accidents and hazards. The facility census was 85. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 30 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Findings include: Level of Harm - Minimal harm or potential for actual harm 1. Record review revealed Resident #19 admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain, pneumonia, hydronephrosis, dementia with agitation, atherosclerotic heart disease with angina, hypertension, cardiac arrhythmia, myocardial infarction, hyperlipidemia, depression, and anxiety. Residents Affected - Few Review of a quarterly Minimum Data Set (MDS) assessment completed on 09/28/23 revealed Resident #19 had severely impaired cognition, mild depression, and hallucinations. Review of orders revealed Resident #19 was ordered lorazepam (anti-anxiety) 0.5 milligrams (mg) every hour as needed, Paxil (anti-depressant) 30 mg once a day, and Seroquel (antipsychotic) 25 mg at bedtime. Review of nursing note completed by Licensed Practical Nurse (LPN) #133 on 07/30/23 at 10:06 P.M. revealed Resident #19 stated he was going to kill himself and was looking for a gun. Resident #19 continued by stating he had nothing to live for. LPN #133 charted 15-minute checks would be initiated. Interview on 12/11/23 at 9:53 A.M. with Director of Nursing (DON) revealed there was no documented evidence of 15-minute checks on file. Interview on 12/11/23 at 10:21 A.M. with Social Services Director (SSD) #178 revealed if a resident makes suicidal statements, she does check in to make sure they are alright, then sends a referral to a psychiatrist. SSD #178 stated if the clinical team determines it is necessary, 15-minute checks are implemented, but there is no policy to follow in these situations. SSD #178 reported she was not made aware of Resident #19's thoughts of self-harm. Interview on 12/22/23 at 2:44 P.M. with LPN #133 revealed when Resident #19 had thoughts of self-harm it was usually after a visit from his wife. LPN #133 stated when a resident makes such statements, the facility will monitor the resident one-on-one or 15-minute checks will be started, inform the family, physician, and management. 2. Record review revealed Resident #29 admitted to the facility on [DATE] with diagnoses including dementia, atherosclerotic heart disease without angina, atrial fibrillation, psychosis not due to a substance or known condition, hyperlipidemia, ischemic cardiomyopathy, congestive heart failure, anxiety disorder, other depression episodes, mood (affective) disorder, and insomnia. Review of the physician's orders revealed Resident #29 had an order dated 10/23/21 for a mat to the floor by the bed. Review of the care plan last revised on 11/08/23 revealed the following interventions were in place for Resident #29 regarding falls: Therapy to evaluate and treat on 05/09/23. Staff to assist the resident with transfers as needed on 05/09/18. Provide non-skid footwear on 05/09/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 31 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Keep personal items and frequently used items within reach on 05/09/18. Level of Harm - Minimal harm or potential for actual harm Keep call light within reach on 05/09/18. Ensure the floor is free of liquids and foreign objects on 05/09/18. Residents Affected - Few Encourage the resident to assume standing position slowly on 05/09/18. Encourage the resident to leave the door to the room open as she will allow on 04/29/19. Please provide a clutter reduction activity monthly to be completed by Life Enrichment Assistant on 12/16/19. Offer restroom every two to three hours while awake on 01/13/20. Encourage the resident to leave the bathroom light on to improve visualization of room at night on 01/13/20. Place footwear in the closet as pairs on 07/21/20. Orthostatic blood pressure every shift for 72 hours on 07/21/20. Staff to keep objects out of the walkway on 08/24/20. Leave the light on above the sink at night as resident will allow on 08/26/20. Staff to assist the resident with cleaning room as resident will allow on 09/13/20. Staff to assist resident with dressing and undressing as resident will allow on 11/09/20. Staff to clean up spills from the floor on 11/11/20. Assist the resident with toileting upon arising on 03/29/21. Encourage rest periods after meals on 08/03/21. Staff to take the resident outside in daylight hours if weather is appropriate during periods of restlessness on 08/10/21. Provide diversional activities during periods of restlessness on 08/10/21. Staff to redirect the resident away from congested areas on 08/23/21. Mat to the floor beside the bed and dresser on 10/26/21. Encourage the resident to sit on the outer edge of the dining room on 05/09/22. Check to ensure non-skid footwear is on resident's feet with rounds and care on 08/09/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 32 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Redirect the resident away from other resident's rooms on 10/25/22. Level of Harm - Minimal harm or potential for actual harm Offer rest periods after meals as resident will allow on 01/30/23. Residents Affected - Few Assist the resident with toileting upon rising, after meals, and at bedtime (HS) as the resident will allow on 03/21/23. Non-skid strips to the floor by the bed on 06/26/23. Encourage supervised activities after meals as the resident will allow on 08/14/23. Assist the resident to her room after meals as she will allow on 08/31/23. Bed in lowest position on 09/11/23. Staff to assist the resident with picking up items from the floor on 10/24/23. Mat to floor by bed on 10/27/23. Observations on 12/05/23 at 12:43 P.M., 12/06/23 at 4:37 P.M., and 12/07/23 at 10:46 A.M. revealed a floor mat to the right of Resident #29's bed and no non-skid strips. Interview on 12/07/23 at 10:58 A.M. with State Tested Nursing Assistant (STNA) #132 revealed fall interventions for Resident #29 included gripper socks, floor mat beside bed, and bed in low position. STNA #132 looked under the floor mat in Resident #29's room and there were no non-skid strips in place. Interview on 12/07/23 at 4:30 P.M. with Resident Care Associate (RCA) #163 revealed interventions in place for falls for Resident #29 included a floor mat and keeping an eye on her. RCA #163 did not think there were non-skid strips in Resident #29's room. Interview on 12/11/23 at 2:44 P.M. with LPN #133 revealed Resident #29 does not like to keep her gripper socks on. Interventions for falls for Resident #29 included gripper socks, staff to assist in picking items up off the floor, mat by her bed, and a low led. Interview on 12/11/23 at 5:01 P.M. with the Director of Nursing (DON) confirmed the fall interventions in place were contradictory and were not effective to prevent resident falls. Review of a policy titled Falls Policy revealed current interventions will be reviewed and new interventions implemented to reduce the risk of a fall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 33 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review and interview, the facility failed to ensure a bowel protocol was followed for Resident #9, failed to ensure adequate and proper urinary catheter care was documented and orders were followed for a trial removal of a urinary catheter for Resident #186 and failed to ensure proper infection control measures were maintained during urinary catheter care to prevent Resident #13 from developing a urinary tract infection. This affected one resident (#9) of one resident reviewed for dialysis and two residents (#186 and #13) of two residents reviewed for urinary catheters. Findings included: 1. Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, dependent on renal dialysis, anemia, diabetes, severe protein-calorie malnutrition, dementia, mild with other behavioral disturbance, and hypertension. Review of Resident #9's quarterly Minimum Date Set (MDS) dated [DATE] revealed the resident was always continent of bowel. Review of the Resident #9's incontinence plan of care dated 01/04/23 revealed the resident experienced episodes of incontinence related to medication, decreased mobility, and end stage renal disease (ESRD). Review of Resident #9's bowel records dated 12/01/23 to 12/11/23 revealed no evidence the resident has had any bowel movements during this time period Review of Resident #9's orders and medication administration records (MAR) dated 12/2023 revealed the resident had an order for as needed Senna (stool softener) twice daily, however it was not administered. Interview on 12/11/23 at 12:43 P.M., with the Assistant Director of Nursing (ADON) #150 confirmed there was no documented evidence the resident had a bowel movement from 12/01/23 to 12/11/23. The ADON reported she would have staff implement the bowel protocol right away. Review of Resident #9's bowel records dated 12/11/23 to 12/13/23 revealed no evidence the resident had a bowel movement after staff confirmed on 12/11/23 the resident had not had a bowel movement since 11/30/23. Review of Resident #9's bowel observation note dated 12/11/23 revealed staff had opened an observation note due to the resident not having a bowel movement greater than 10 days, however the form was not completed. Review of Resident #9's orders and medication administration records (MAR) dated 12/2023 revealed the resident had an order for as needed Senna (stool softener) twice daily, however it was not administered. There was no evidence a bowel protocol was implemented or ordered. Interview on 12/13/23 at 8:04 A.M., with the Director of Nursing (DON) confirmed Resident #9 has (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 34 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not had a bowel movement since 11/30/23 even after it was brought to the staff attention on 12/11/23 the facility still never implemented any intervention. The DON confirmed the observation form was not completed on 12/11/23. There was no evidence the resident has had bowel movement for 13 days now. The DON reported the facility did not have a policy or procedure; however, they were orders for bowel protocol. Usually if a resident doesn't have a bowel movement after three days the facility should contact the provider and get orders for the bowel protocol or some type of intervention. 2. Record review revealed Resident #186 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including acute urinary retention and metabolic encephalopathy. Review of Resident #186's hospital discharge order dated 11/24/23 revealed the resident failed a voiding trial on 11/24/23 and an indwelling urinary (Foley) catheter was replaced. Recommended voiding trial in one to two weeks. Observation on 12/04/23 at 4:37 P.M., revealed the resident had a urinary Foley catheter in place. Review of Resident #186's orders and medication/treatment administration records dated 11/24/23 to 12/12/23 revealed no evidence of trial removal of the urinary Foley catheter or documented evidence of Foley catheter care. Review of Resident #186's bladder plan of care dated 12/07/23 revealed the resident used a Foley catheter for diagnoses of urinary retention. There was no evidence the resident had a Foley catheter plan of care prior to 12/07/23. Interview on 12/12/23 at 2:04 P.M. and 3:21 P.M., with the DON confirmed there was no evidence the facility attempted to remove the Foley or documented evidence Foley catheter care was performed. The DON reported there was a set order for Foley care that should automatically show up for staff when they have a resident admitted with a urinary catheter, however there was none entered for Resident #186. The DON confirmed the resident was planning on discharging home next week so she would put in orders for the trial removal of the catheter today. Review of the facility undated policy and procedure titled Perineal Care revealed the following information should be recorded in the resident's medical record: The date and time catheter care were given, the name and title of the individual giving the catheter care, all assessment data obtained, any problems or complications, how the resident tolerated the procedure, and if the resident refused the reason why. 3. On 12/07/23 at 12:54 P.M. State Tested Nursing Assistant (STNA) #102 was observed providing urinary catheter care to Resident #13. The resident's urine was observed to be cloudy in the catheter tubing at the time of the observation. The STNA reported the resident was under hospice care and hospice supplied all the resident's catheter supplies and she was not sure who was responsible for changing the actual urinary catheter and tubing, but verified the tubing was cloudy. Resident #13 reported she thought the tubing was changed last week. During the observation, STNA #102 assisted the resident from her bed into the bathroom which contained only a toilet and laid the urinary catheter drainage bag directly on the floor. The urinary catheter drainage bag had a cover that covered the sides of the bag, but not the bottom of the bag. The STNA washed her hands and filled a water basin up in the sink with warm water and soap. She then applied gloves and pulled down the resident's pants and removed her (incontinence) brief. The STNA left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 35 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the resident on the toilet and walked out to the sink and retrieved a towel and two wet wash clothes which one of the wet wash clothes she applied soap to it. The STNA started at the top of the urinary catheter tubing with the soap wet wash cloth and swiped down the catheter tubing and then changed position and repeated the procedure with the wet washcloth and towel. The STNA did not clean the resident's genitalia area. Next the STNA emptied the water from the basin in the sink and ran new water and soap to clean the resident's perineum area. She cleaned the perineum area and removed her gloves as she exited the bathroom. The STNA did not perform any type of hand hygiene and applied new gloves. The STNA went to the resident's closet and removed a brief and returned to the bathroom and placed a new brief on the resident. As the STNA was attempting to place the Foley bag thorough the resident's pant legs the drain tube came out of the holder and touched the floor. The STNA replaced the drain tube in the holder without cleaning it. The STNA exited the bathroom and removed her gloves and washed her hands. The STNA then assisted the resident to her recliner and placed the urinary drainage bag on the side of the recliner, however the bag was lying directly on the floor. The STNA applied new gloves and removed a measuring container from the bathroom. She placed a paper towel under the measuring container and removed drainage bag and held it above the container and removed the drain tube from the holder and opened the clamp. The measuring container was filled, however there was still a large amount of urine remaining in the drainage bag. She clamped the drain tube and placed it back into the holder without cleaning the drain tube. She emptied the measuring container of urine in the toilet and returned to the resident and repeated the same procedure. At no time was the drain tubing cleaned. The STNA rinsed the graduate container with water and placed it on a paper towel on the back of the toilet to dry. She removed her gloves and washed her hands. Interview on 12/07/23 at 3:11 P.M., with the Director of Nursing (DON) and STNA #102 revealed staff should clean the perineum area as part of catheter care, the drain tube should have been cleaned with alcohol wipes, and the drainage bag and drain tube should never touch the floor. Review of competency checklist for urinary catheter care and emptying a urinary drainage bad dated 06/11/19 revealed to wash hands, explained procedure, place clean supplies on beside stand or over bed table with easy reach, fill was basin 1/2 full of warm water. Put on gloves, provide privacy, place bed protector under the resident, was the residents genitalia and perineum thoroughly with soap and water, rinse, and towel dry. Pour the water down the toilet, and flush. Put on clean gloves, cover resident exposing only perineum. Use a washcloth with warm water and soap to cleanse the labia. Use one area of wash cloth for each downward stroke. Next, change the position of the washcloth and cleanse around the urethral meatus with a clean washcloth rinse with warm water using the above technique. Use a clean washcloth with warm water and soap to clean the catheter from insertion site to approximately 4 inches outward. Secure the catheter utilizing a leg band. Wash and dry hands. Position resident for comfort and ensure call light in reach. Clean bedside stand, put supplies away and wash and dry hands. To empty the urinary drainage bag, place a paper towel on the floor under drainage bag. Position measuring container under the drainage bed. Remove drain tube from holder. Open the drain clamp and let the urine flow into the measuring container. After the bag has emptied clamp the drain. Wipe the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 36 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few drain with an alcohol wipe and discard the wipe. Replace the drain back in the holder. Pour and flush urine down the toilet and rinse the measuring container and remove gloves, wash, and dry hands. Place call light in reach. Review of STNA #102's competency checklist for urinary catheter care and emptying a urinary drain bag revealed it was last completed on 11/16/22. Review of the facility policy titled Catheter Care, Urinary dated 2021 revealed to be sure the catheter tubing and drainage bag were kept off the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 37 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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** Based on medical record review, observation, and interviews the facility failed to ensure residents received nutritional supplements as ordered. This affected one resident (#9) of one resident reviewed for dialysis and one resident (#68) of two residents reviewed for nutrition. Residents Affected - Few Findings include: 1. Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, anemia in chronic kidney disease, dependence on renal dialysis, type one diabetes mellitus with unspecified complications, unspecified sequelae of cerebral infarction, dysphagia following cerebral infarction, unspecified severe protein-calorie malnutrition, vitamin D deficiency, unspecified dementia, mild, with other behavioral disturbance, hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, and chronic bronchitis. Review of Resident #9's current orders dated 12/2023 revealed Ensure Clear twice daily and to start Mighty Shake at bedtime when available. Review of Resident #9's medication/treatment administration records dated 12/01/23 to 12/11/23 revealed on 12/05/24, 12/06/23, 12/10/23 staff charted none for the Mighty Shake; however, did not indicate what none meant. On 12/03/23 and 12/07/23 the resident refused the Mighty Shake, and the other days she took 1-100 percent. The Ensure Clear was to be administered twice daily from 7:00 A.M. to 11:00 A.M. and 7:00 P.M. to 11:00 P.M. The resident was not available for one dose on 12/01/23 and refused on 12/03/23 and 12/07/23, staff charted, none on both doses on 12/06/23 and 12/10/23 and one dose on 12/07/23. The other days and doses the residents' intakes varied from 1-100 percent. Interview on 12/11/23 at 12:38 P.M., with the facilities contracted Registered Dietitian (RD) #220 revealed the facility had no Ensure Clear available for months. The RD reported she had to change the order to Mighty Shakes a few months ago because it was the only supplement the facility was going to provide to residents. The resident was ordered Ensure Clear originally because she had poor intake and diarrhea with the previous supplement she was on. The RD reported she did not realize staff were still documenting the resident was receiving the Ensure Clear because she doesn't look at the administration records/orders. The RD reported she obtained her information from under the supplement tab, and it doesn't indicate the name of the supplement just the percent of intakes. The RD confirmed she had not communicated with the Dialysis Center RD since April 2023 and was not aware if there were any new recommendations or not. Interview on 12/11/23 at 3:21 P.M., with the Dialysis Center RD #221 confirmed communication with the facility regarding Resident #9's care had been difficult. The facilities dietitian had not returned calls, responded to emails, or been available when she had tried to call the facility. The floor staff sometimes don't understand, and it would be beneficial to talk to the dietitian. She had to call the other day and speak to the floor staff to verify what supplements the resident was taking, and she was told the resident was taking two Ensure Clears daily and one Mighty Shake at night. RD #221 reported the facilities RD (RD #220) had just called her to obtain the last three notes for the surveyor and reported she had not been able to open the emails because they were sent encrypted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 38 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 - Few Review of Resident #9's bowel records dated 10/01/23 to 12/13/23 revealed staff were not recording the consistency of the bowel movement (BM) except on 11/30/23 it indicated the resident had loose BM. Observation on 12/12/23 at 10:40 A.M. of the supplements in the main kitchen with the Dietary Manger (DM) #175 revealed there was no evidence of any type of nutritional supplement including Ensure Clear or Mighty Shakes in the kitchen. The DM reported he was new, and he could not recall the last time supplements were ordered. Additional observation on 12/12/23 from 10:48 A.M. to 11:01 A.M. of the 300-, 400-, and 500-unit refrigerators revealed no evidence of nutritional supplements in the refrigerators. Interviews on 12/12/23 from 10:48 A.M. to 11:01 A.M. with State Tested Nurse's Aide (STNA) #110 revealed the facility was out of supplements and had to go out into the community to get them. Someone had bought her one six pack of Boost for her unit. Resident Care Assistant (RCA) #176 reported she worked yesterday and didn't recall seeing any nutritional supplements and confirmed there were none on her unit at this time that she had seen. Licensed Practical Nurse (LPN) #133 reported the facility staff had gone and bought Ensure for her to use today on her unit. The LPN confirmed the facility has not had Ensure Clear for two or three months. Interview on 12/12/23 at 10:51 A.M., with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #150 revealed she was not aware until this morning the facility was out of the Mighty Shakes on the 300, 400, and 500 units. The facility had a staff member go to the local store to buy some supplements. The DON reported the facility has not had Ensure Clear for two months or so and she was not aware Resident #9 had an order for the Ensure Clear, and staff were signing off Resident #9 was receiving it when it was not even available. 2. Record review revealed Resident #68 admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, periapical abscess without sinus, alcohol abuse, hypertension, hyperlipidemia, other pancytopenia, gout, gastro-esophageal reflux disease, vascular dementia, and insomnia. Review of the nutrition note from 11/02/23 at 11:26 A.M. by RD #220 revealed Resident #68 had a moderate weight loss in 30 days and had a body mass index (BMI) of 21.9 which was slightly low for his age. RD #220 recommended Resident #68 receive fortified foods with meals to provide additional energy source to promote weight gain to reach ideal BMI of 22-29. Review of the care plan last revised on 11/07/23 revealed a dietary plan of care that stated it was recommended for Resident #68 to receive fortified foods with meals due to moderate weight loss over 30 days. Review of the physician's orders revealed Resident #68 received a new order on 11/03/23 for a Mighty Shake supplement three times a day with meals. Observation on 12/07/23 at 11:45 A.M. revealed Resident #68 did not have a supplement with his meal, and his meal ticket did not mention fortified foods. STNA #132 confirmed fortified foods were not listed on Resident #68's ticket at the time of the observation. [NAME] #155 was also present at this time and revealed there were no fortified foods sent out to the unit, and there were also no supplements in the refrigerator on the unit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 39 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 - Few Interview on 12/11/23 at 12:31 P.M. with RD #220 revealed she is a consultant at multiple buildings and gets them mixed up at times. This facility did not currently offer fortified foods, so her recommendation was made in error. RD #220 stated if the facility did offer fortified foods, that would have been her recommendation. The only supplement the facility was able to offer was Mighty Shakes. RD #220 revealed the facility did not call to inform her fortified foods were unavailable, so she was unable to revise her recommendation. Interview on 12/07/23 at 4:50 P.M. with RD #220 revealed she was unaware Resident #68 was not receiving fortified foods per her recommendation. RD #220 stated typically it is preferred for a resident to receive supplements via food first to promote quality of life and giving actual foods and typically if fortified foods don't work, the facility would then move on to supplement shakes, then an appetite stimulant. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 40 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, resident record review, and facility policy review, the facility failed to ensure Resident #39's enteral tube placement was confirmed prior to administering medications. This affected one resident (#39) of one resident reviewed for tube feeding. The facility census was 85. Findings include: Review of Resident #39's medical record revealed she was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke) due to unspecified occlusion, malignant neoplasm of female breast, asthma, and essential hypertension. Review of Resident #39's quarterly Minimum Data Set (MDS) assessment, dated 10/31/23, revealed she was cognitively intact and had a feeding tube. Review of Resident #39's physician order, dated 07/25/23, identified her enteral tube placement was to be checked by air bolus and aspirating stomach contents before medications and tube feed bolus delivery. Observation on 12/07/23 at 8:81 A.M. of Licensed Practical Nurse (LPN) #187 preparing the morning medications for Resident #39. LPN #187 entered Resident #39's room and administered her inhalers first. LPN #187 then inserted a 60 milliliter (ml) syringe into Resident #39's enteral tube and administered 60 ml of water, followed by her crushed medications. Once all the crushed medications were administered, LPN #187 administered another 60 ml of water. At no time, did LPN #187 assess placement of Resident #39's enteral tube. Interview on 12/07/23 at 9:36 A.M. with LPN #187 verified she did not check Resident #39's enteral tube placement by auscultation or aspiration prior to administering medications and should have. Interview on 12/07/23 at 3:12 P.M. with the Director of Nursing (DON) verified enteral tubes should be assessed for placement prior to medication administration. Review of the undated facility policy titled, Care and Treatment of Feeding Tubes revealed it was the policy of the facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Further review revealed in accordance with facility protocol, licensed nurses will monitor and check that the feeding tube is in the right location: tube placement will be verified before beginning a feeding and before administering medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 41 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 observation, interview, resident record review, and facility policy review, the facility failed to ensure oxygen was administered per physician's order, oxygen tubing was changed per physician's order, and tubing and nebulizer equipment was maintained in a sanitary manner. This affected three residents (#13, #44, and #58) of three residents reviewed for respiratory care. The facility census was 85. Residents Affected - Few Findings include: 1. Review of Resident #44's medical record revealed she was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure unspecified, unspecified asthma, and emphysema. Review of Resident #44's significant change Minimum Data Set (MDS) assessment, dated 10/17/23, revealed she was cognitively impaired and received oxygen therapy. Review of Resident #44's plan of care, dated 11/04/22, revealed she had a potential for shortness of breath while lying flat related to COPD and respiratory failure. One of the interventions revealed administer oxygen per physician's order and as needed. Review of Resident #44's physician's order, dated 03/10/23, identified she was to receive continuous oxygen via a nasal cannula at two liters/minute (l/min). Review of Resident #44's Treatment Administration Record (TAR), dated 12/01/23 to 12/05/23, revealed she had received her oxygen at two l/min. Observation on 12/04/23 at 10:54 A.M. of Resident #44 lying in bed receiving oxygen via a nasal cannula at three l/min and the tubing was dated 12/02/23. Resident #44's nebulizer mask and tubing were also sitting on her nightstand. It was not in a bag for protection from germs, and there was no date documented on the nebulizer tubing. Observation on 12/05/23 at 9:15 A.M. of Resident #44 lying in bed receiving oxygen via a nasal cannula at three l/min and the tubing was dated 12/02/23. Resident #44's nebulizer mask and tubing were also sitting on her nightstand. It was not in a bag for protection from germs, and there was no date documented on the nebulizer tubing. Interview on 12/05/23 at 12:09 P.M. with Resident #44 revealed she knew she had COPD but had never been informed her oxygen should stay at two l/min. Observation on 12/05/23 at 12:15 P.M. with Registered Nurse (RN) #137 of Resident #44 sitting in bed receiving oxygen via a nasal cannula at three l/min. RN #137 verified Resident #44's oxygen was running at three l/min. Observation at the same time of Resident #44's nebulizer mask and undated tubing lying on her nightstand. An interview at the time with RN #137 verified the nebulizer mask should be stored in a clean bag and the tubing should be dated. Interview on 12/05/23 at 12:18 P.M., after reviewing Resident #44's physician's orders, RN #137 verified the oxygen was not being administered as ordered at two l/min. She also verified that since Resident #44 had COPD, the higher dose of oxygen could depress her drive to breath. After reviewing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 42 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 Resident #44's TAR, RN #137 revealed the documentation that she was receiving oxygen at two l/min was not accurate since she was receiving oxygen at three l/min. 2. Review of Resident #58's medical record revealed he was admitted to the facility on [DATE] with diagnoses including COPD with (acute) exacerbation, acute and chronic respiratory failure, respiratory conditions due to other specified external agents, and unspecified chronic bronchitis. Review of Resident #58's quarterly MDS 3.0 assessment, dated 10/20/23, revealed he was mildly cognitively impaired and received oxygen therapy while a resident. Review of Resident #58's plan of care, dated 11/04/22, revealed he had a potential for shortness of breath while lying flat related to COPD and respiratory failure. One of the interventions revealed administer oxygen per physician's order and as needed. Review of Resident #58's physician's order, dated 05/10/23, identified he was to receive continuous oxygen via his nasal cannula at two l/min. Review of Resident #58's TAR, dated 12/01/23 to 12/05/23, revealed he had received his oxygen at two l/min, and his oxygen tubing had been changed on 12/01/23. Observation on 12/04/23 at 2:55 P.M. of Resident #58 lying in bed receiving oxygen via a nasal cannula at three l/min, and the tubing was dated 07/30/23. Resident #58's nebulizer and mouthpiece were sitting on his oxygen concentrator and not stored in a bag. The date on the nebulizer tubing was 11/10/23. Observation on 12/05/23 at 9:13 A.M. of Resident #58 lying in bed receiving oxygen via a nasal cannula at three l/min, and the tubing was dated 07/30/23. Resident #58's nebulizer and mouthpiece were sitting on his oxygen concentrator and not stored in a bag to protect it from germs. Observation on 12/05/23 at 12:20 P.M. with RN #137 of Resident #58 lying in bed receiving oxygen via a nasal cannula at 3.5 l/min. RN #137 verified Resident #58's oxygen was running at 3.5 l/min, and the date on the tubing was 07/30/23. She reported the oxygen tubing had been used for too long and should be changed monthly. Observation at the same time of Resident #58's nebulizer and mouthpiece lying on top of his oxygen concentrator. An interview at the time with RN #137 verified the nebulizer and mouthpiece should be stored in a clean bag. Interview on 12/05/23 at 12:24 P.M., after reviewing Resident #58's physician orders, RN #137 verified the oxygen was not being administered as ordered at two l/min. She also verified that since Resident #58 had COPD, the higher dose of oxygen could depress his drive to breath. After reviewing Resident #58's TAR, RN #137 revealed the documentation that he was receiving oxygen at two l/min was not accurate since he was receiving oxygen at 3.5 l/min and his oxygen tubing was not dated 12/01/23. Review of the facility policy titled, Oxygen Administration, revised 10/10, revealed the purpose of the procedure was to provide guidelines for safe oxygen administration. Further review revealed verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Additionally, the policy revealed adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. 3. Record review revealed Resident #13 admitted to the facility on [DATE] with diagnoses including (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 43 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 multiple sclerosis, neuromuscular dysfunction of the bladder, anxiety disorder, major depressive disorder, hallucinations, and osteoarthritis. Review of the physician's orders revealed Resident #13 received an order for oxygen at two to four liters per nasal cannula continuous as needed for shortness of breath or cyanosis on 03/10/23, change oxygen tubing monthly on 01/07/20, clean external concentrator filter every two weeks on 01/07/20, assess/observe for signs and symptoms of shortness of breath while lying flat on 03/10/23, and head of bed elevated to alleviate/reduce shortness of breath while lying flat on 03/10/23. Observation on 12/05/23 at 10:05 A.M. revealed Resident #13's oxygen tubing was not labeled with a date, and there was a hole in the tubing. Observation on 12/05/23 at 12:03 P.M. revealed Resident #13's oxygen tubing was not labeled with a date, and there was a hole in the tubing. Interview on 12/05/23 at 12:07 P.M. with State Tested Nursing Assistant (STNA) #206 confirmed there was a hole in the oxygen tubing, and it was not dated. Observation on 12/06/23 at 4:55 P.M. revealed Resident #13's oxygen tubing had not been changed. Administrator confirmed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 44 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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, interview, and facility policy review the facility failed to ensure residents had an effective pain management program. This affected two residents (#186 and #188) of three residents reviewed for pain. Residents Affected - Few Findings include: 1. Record review revealed Resident #188 was admitted to the facility on [DATE] with diagnoses including unspecified cirrhosis of liver, ascites, unspecified protein-calorie malnutrition, essential (primary) hypertension, hypertensive heart disease without heart failure, acute kidney failure, unspecified, solitary pulmonary nodule, hypo-osmolality and hyponatremia, thrombocytopenia, unspecified. Review of Resident #188's current physician's orders and medication administration records (MAR) dated 11/06/23 to 12/06/23 revealed the resident was receiving Oxycodone (opioid pain medication) 5 milligrams (mg) once every six hours for pain as needed and she had received 12 doses. There was no evidence non-pharmacological interventions were attempted or pain was assessed prior to administration of the Oxycodone. Review of Resident #188 baseline plan of care dated 11/06/23 revealed the resident had no pain. The resident was receiving analgesics/opioids and diuretics and to administer the medication as ordered and notify the physician if there were any side effects. There was no evidence the resident had edema. Review of Resident #188's care plan for pain dated 11/27/23 revealed the resident had pain related to cirrhosis of the liver and decreased bed mobility. The intervention included administering medication as ordered and notifying the physician if any side effects observed or lack of effectiveness and notifying the physician of increased pain. Observe for and record for verbal and non-verbal signs of pain. Attempt non-pharmacological interventions. Observation on 12/04/23 at 3:06 P.M., of Resident #188 revealed the resident was sitting in a recliner with her feet on the floor and no compression stockings were noted. The resident had severe swelling in her bilateral lower extremities (BLE) and verbalized complaints of pain. The resident reported her current pain management program was not effective due to staff does not administer pain medication timely upon request or not at all upon request. The pain was so bad at night it was affecting her sleep. Review of Resident #188's skilled charting notes dated 11/06/23, 12/04/23, and 12/05/23 revealed the resident had no pain. Observation on 12/06/23 at 7:36 A.M., with Assistant Director of Nursing (ADON) #150 and the Director of Nursing (DON) revealed the resident was sitting in the recliner and her legs were not elevated nor did she have compression stocking in-place. The resident's socks were tight around the top of her legs that left indentation around her legs when they were pushed down by staff. The ADON continued to remove the resident's socks and the resident had severe pitting edema in bilateral lower legs. The left leg had blisters like areas forming on the lower leg. The ADON had assessed the edema by pushing down on the tops of the residents' feet and the front of the legs. The area did not return to normal, and the indentation stayed where the nurse had pushed down. The ADON reported she would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 45 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0697 Level of Harm - Minimal harm or potential for actual harm classify the edema as four plus pitting edema. The resident reported again to the staff the pain was so bad at night in her legs and feet that she couldn't sleep. She confirmed she had requested pain medication and sometimes she doesn't get it all or she must wait a long time to get it. The resident reported she has a high tolerance for pain, but the pain at night was ten on a scale from zero to ten. The DON reported she would have the physician assess the resident today. Residents Affected - Few Interview on 12/06/23 10:00 A.M., with the DON confirmed no documented evidence the physician was notified of the edema or pain. The DON confirmed there was no documented evidence that the pain was assessed prior to administration of the Oxycodone or non-pharmacological attempted prior. The DON reported the nursing staff were new to the facility and were new graduates with not much nursing experience. Review of Resident #188's progress note dated 12/06/28 at 5:28 P.M. revealed the resident continued with increased edema to BLE. The left lower extremity (LLE) was noted with redness and increased warmth. The in-house physician visited and wrote new orders for Keflex (antibiotic) 250 milligrams (mg) twice daily for seven days, complete blood count (CBC) and comprehensive metabolic profile (CMP) in one week and to schedule Oxycodone 5 mg every night as the resident stated the pain was at night and requested pain medication to be given every night. Review of the facility policy titled, Change in Condition and physician notification policy, dated 09/2020, revealed the facilities policy was to promptly identify, respond to, and report changes in the resident condition to the resident's physician. When a change of condition was discovered, the nurse would evaluate the resident and notify the resident's physician with pertinent information and document the findings timely. 2. Record review revealed Resident #186 revealed was admitted to the facility originally on 11/07/23 and was discharged on 11/19/23 and re-admitted on [DATE] with a diagnosis of fractured vertebra and surgical aftercare following surgery (fusion of spine), urinary retention, pneumonia, severe sepsis with septic shock, and pulmonary embolism. Review of Resident #186's current physician's orders dated 12/2023 revealed the resident had two orders for Percocet's 7.5-325 mg for pain. One order was to administer Percocet one every six hours as needed and one four times daily. Review of Resident #186's MAR dated 11/24/23 to 12/11/23 revealed no evidence the as needed Percocet had been administered. The scheduled Percocet was scheduled from 7:00 A.M. to 11:00 A.M., 12:30 P.M. to 3:30 P.M., 5:00 P.M. to 7:00 P.M. and 8:00 to 11:30 P.M. There were additional comments that indicated on 12/01/23 the medication was administered at 6:38 A.M., 12/02/23 at 6:05 A.M., 12/02/23 8:47 P.M. given at unknown time due to administered by another nurse, 12/03/23 administered at 6:04 A.M., per facilities expectations, 12/03/23 administered at 7:17 P.M., 12/04/23 administered at 6:09 A.M., 12/06/23 administered early at 5:35 A.M., per resident request, 12/07/23 administered at 3:56 P.M. administered early per resident request, 12/08/23 administered early at 6:23 A.M., per residents request, and 12/11/23 administered at 6:47 A.M. Review of Resident #186 Percocet narcotic control sheet dated 11/12/23 revealed the order was to take one Percocet by mouth four times daily for pain. Number #7 pill was not signed off by a staff member nor was the date amount used or wasted completed. One 11/27/23 the resident only received three doses (order for four times daily). On 12/02/23 the resident received six doses; however, there was nothing marked on the MAR that an as needed dose was administered). On 12/10/23 the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 46 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few received five does; however, there was nothing marked on the MAR that the as needed Percocet was administered. Several times of administration times were not legible or not documented. Further review revealed no evidence there was as needed a Percocet control sheet or card. Review of Resident #186's pain plan of care dated 12/07/23 revealed the resident was at risk for pain related to recent surgery to repair fracture, peripheral vascular disease, ankylosing, spondylitis, gastric reflux disease, and rheumatoid arthritis. The intervention included administering medication as ordered and to notify the physician of any side effects observed or lack of effectiveness. Interview on 12/12/23 at 12:26 P.M., with Resident #186 revealed his pain was not controlled. The resident described the pain as a dull pain in his back and legs. Interview on 12/12/23 at 2:00 P.M., with the DON reported she had spoken to the pharmacist and the as needed Percocet script had run out and was not rewritten. The DON confirmed there was no evidence on the MAR that the as needed Percocet was administered; however, there were two days the resident received more than four doses. The DON confirmed there was no evidence staff had signed out #7 on the control sheet. The DON confirmed the way the times were set up for the schedule times was not an effective way to manage pain since one staff could give the first dose as late 11:00 A.M. and the next dose could be given as early as 12:30 P.M. The DON also verified staff did not include times on the Narcotic control sheets indicating what time the medication was administered and there was no way of telling in the electronic medical record to ensure there was enough time between does. The facility did not have a policy on administering when the times are set up at 7:00-11:00 A.M., 12:30 to 3:30 P.M., etc. but the expectation would be for the medication to be given within those time frames and not before or after. The DON reported she was going to change the administration time to set times to ensure the medication was administered every eight hours. Review of the undated facility policy titled Pain Management revealed the facility must ensure that pain management was provided to residents who require such services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 47 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to maintain communication with the dialysis center. This affected one resident (#9) of one resident reviewed for dialysis. Residents Affected - Few Findings include: Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, anemia in chronic kidney disease, dependence on renal dialysis, type one diabetes mellitus with unspecified complications, unspecified sequelae of cerebral infarction, dysphagia following cerebral infarction, unspecified severe protein-calorie malnutrition, vitamin D deficiency, unspecified dementia, mild, with other behavioral disturbance, hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, and chronic bronchitis. Review of Resident #9's medical record dated 10/01/2023 to 12/11/23 revealed no evidence of notes from the dialysis center regarding care, diet, or treatments. Review of Resident #9's renal failure plan of care dated 01/04/23 revealed to coordinate care with the dialysis center. The resident scheduled days were Monday, Wednesday, and Friday. Interview on 12/11/23 at 12:38 P.M. with the facilities contracted Registered Dietitian (RD) #220 revealed she had not communicated in some time with the dialysis centers RD. The RD reported she doesn't receive dialysis communication information and she would have to call the dialysis center to get notes for the surveyor. Interview on 12/11/23 at 3:21 P.M., with the Dialysis Center RD #221 confirmed communication with the facility regarding Resident #9's care had been difficult. The facilities dietitian had not returned calls, responded to emails, or been available when she had tried to call the facility. The floor staff sometimes don't understand, and it would be beneficial to talk to the dietitian. She had to call the other day and speak to the floor staff to verify what supplements the resident was taking, and she was told the resident was taking two Ensure Clears daily and one Mighty Shake at night. RD #221 reported the facilities RD (RD #220) had just called her to obtain the last three notes for the surveyor and reported she had not been able to open the emails because they were sent encrypted. Interview on 12/11/23 at 3:46 P.M., with the Director of Nursing (DON) revealed she was not able to find documented evidence the dialysis center had sent notes back to the facility regarding the resident care and treatment. The facility completed an observation note and sent it with the resident on dialysis days; however, there was no evidence the dialysis center had sent any notes or records back. She had called the dialysis center, and they were faxing notes for the last three months as soon as possible. Review of the undated facility policy titled Dialysis Care revealed the facility would ensure residents that receive daily treatment are safe, well assessed, and that the facility collaborates care with the dialysis center. Registered dietitian to evaluate the resident's nutrition, hydration needs, and restrictions as it related to the resident's renal condition. The nurse will complete an assessment of the resident prior to leaving facility and upon return to the facility. Upon return from dialysis center, the nurse will review the communication form sent to dialysis, if the dialysis center fails/refuse to provide communication, document on the form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 48 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and facility policy review the facility failed to ensure the daily staffing data was posted daily and included the facility name per the regulation. This had the potential to affect all 85 residents residing in the facility. Residents Affected - Many Findings include: Observation on 12/04/23 at 9:10 A.M. revealed the daily staffing data posting was noted on the wall in the hallway heading towards the 200 halls. The posting didn't include the facility name and the last posting was dated 11/30/23. Observation of daily staffing data posts dated 12/04/23, 12/05/23, 12/06/23, and 12/07/23 revealed no evidence the facility name was posted on the daily posting. Interview and observation on 12/04/23 at 9:12 A.M., with Receptionist #151 confirmed the daily staffing data posting was only posted in the hallway by the office and the last one posted was 11/30/23, and today was 12/04/23. Interview on 12/04/23 at 10:08 A.M. and 12/13/23 at 8:26 A.M., with the Director of Nursing (DON) confirmed the daily staffing data posting had not been updated since 11/30/23, and the name of the facility was not included on the daily posting. The DON confirmed the daily posting was only posted in one area on the hallway heading towards 200 halls. Review of the undated facility staffing policy revealed the facility would provide sufficient and competent staff to meet the care and services needs for all residents in accordance with their care plans and facility assessment. The direct care staffing would be posted daily in a prominent place and readily accessible to residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 49 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and implement an effective and comprehensive plan to address the dementia/behavioral health care needs of Resident #47 to prevent a resident to resident altercation resulting in harm to Resident #29. Residents Affected - Few Actual harm occurred on 11/23/23 when Resident #47 physically pushed Resident #29 after Resident #29 tried to take a paper away from Resident #47. As a result of the altercation, Resident #29 fell to the ground, hitting her head on a wheelchair, leaving a laceration which required three staples. This affected two residents (#47 and #29) of six residents reviewed for abuse. The facility census was 85. Findings included: Record review revealed Resident #29 admitted to the facility on [DATE] with diagnoses including dementia, atherosclerotic heart disease without angina, atrial fibrillation, psychosis not due to a substance or known condition, hyperlipidemia, ischemic cardiomyopathy, congestive heart failure, anxiety disorder, other depression episodes, mood (affective) disorder, and insomnia. Review of nursing note from 11/23/23 at 2:30 P.M. by Registered Nurse (RN) #137 revealed Resident #29 had tried to take a paper away from Resident #47, when Resident #47 shoved Resident #29 backwards. Resident #29 hit her head and back on a wheelchair and had a one inch laceration at the bottom of the back of her head. Staff had to hold pressure to the laceration until the ambulance arrived. Family was notified of the incident. Review of nursing note from 11/24/23 at 6:26 A.M. by Licensed Practical Nurse (LPN) #133 revealed Resident #29 was returning to the facility from the emergency department with three staples in the back of her head. Review of nursing notes for Resident #47 revealed there was not a note made to document the incident. Review of a Behavior Event assessment completed on 11/23/23 at 6:59 P.M. by RN #137 revealed immediate actions by the facility included redirecting Resident #47 and relocating to a quiet location. Review of Resident #47's care plan revealed no interventions in place regarding Resident #47's aggressive behaviors toward other residents. Interview on 12/11/23 at 2:44 P.M. with LPN #133 revealed Resident #47 does have some behaviors that are very territorial regarding his belongings. Interview on 12/07/23 ar 4:30 P.M. with Resident Care Associate (RCA) #163 revealed Resident #47 can be aggressive when he is writing and coloring on his papers. RCA #163 stated he has seen Resident #47 push someone and reminded him he cannot push other residents which usually calmed him down. RCA #163 stated the intervention in place to protect other residents from Resident #47 when he was agitated was to keep an eye on him. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 50 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0744 Interview on 12/11/23 at 2:44 P.M. with LPN #133 revealed Resident #47 does have some behaviors that are very territorial regarding his belongings. Level of Harm - Actual harm Residents Affected - Few Interview on 12/11/23 at 5:01 P.M. with Director of Nursing (DON) revealed the intervention in place to prevent Resident #47 from having aggressive behaviors towards other residents was redirection due to a lack of the resident's cognition. Interview on 12/12/23 at 11:05 A.M. with the Director of Nursing (DON) revealed the location of 15-minute checks for Resident #47 following incident on 11/23/23 could not be located. Interview on 12/12/23 at 1:56 P.M. with State Tested Nursing Assistant (STNA) #132 revealed Resident #47 does get agitated at times, specifically when he was writing with his pen and paper and if he thought someone was stealing it, he would let them know. STNA #132 stated she was not aware of any interventions in place to prevent Resident #47 from becoming aggressive with other residents. Interview on 12/12/23 at 2:16 P.M. with STNA #148 revealed Resident #47 had behaviors regarding his pen and papers, and if he was told to move them from the table during meals, he would use the bathroom in the dining room chair. STNA #148 stated interventions in place to prevent Resident #47 from becoming aggressive with other residents included taking Resident #47 to his room to calm down. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 51 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. 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 interviews, the facility failed to provide medically related social services to ensure Resident #19 maintained the highest practicable psychosocial well-being. This affected one resident (#19) of one resident reviewed for medically necessary social services. This facility census was 85. Residents Affected - Few Findings include: Record review revealed Resident #19 admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain, pneumonia, hydronephrosis, dementia with agitation, atherosclerotic heart disease with angina, hypertension, cardiac arrhythmia, myocardial infarction, hyperlipidemia, depression, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment completed on 09/28/23 revealed Resident #19 had severely impaired cognition, mild depression, and hallucinations. Review of the physician's orders revealed Resident #19 was ordered lorazepam (antianxiety) 0.5 milligrams (mg) every hour as needed, Paxil (anti-depressant) 30 mg once a day, and Seroquel (antipsychotic) 25 mg at bedtime. Review of the nursing note completed by Licensed Practical Nurse (LPN) #133 on 07/30/23 at 10:06 P.M. revealed Resident #19 stated he was going to kill himself and was looking for a gun. Resident #19 continued by stating he had nothing to live for. Interview on 12/11/23 at 10:12 A.M. with Social Services Director (SSD) #178 revealed if a resident was having thoughts of self-harm or symptoms of depression, she would follow up with the resident to ensure they were at baseline and their well-being was taken care of. If a resident was having struggles with mental health, a referral was made to a psychiatrist immediately. SSD #178 reported there was not a policy or procedure in place for when residents make suicidal statements, but the facility ensures their safety and assesses whether the resident had access or means. SSD #178 reported she was not notified Resident #19 stated he wanted to harm himself. Interview on 12/11/23 at 2:44 P.M. with LPN #133 revealed when Resident #19 makes statements about self-harm, staff asks if he needs anything, try to engage him in activities, or take him to lay down for a nap. LPN #133 stated Resident #19 usually struggles with mental health after he has visits with his wife. LPN #133 reported the staff can call the social worker when they need her; however, they know the residents on the memory care unit more than the social worker, so they do not always notify her of incidents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 52 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to ensure antibiotic medication to treat an infection for Resident #186 was properly ordered/transcribed following a hospitalization to ensure the resident received all doses ordered of the medication. This affected one resident (#186) of five residents reviewed for medication review. Findings include: Review of the facility November 2023 infection control log revealed Resident #186 was admitted with pneumonia and sepsis that was confirmed by chest x-ray on 10/28/23. The log noted the resident received Rocephin (antibiotic) from 11/08/23 to 11/21/23; (however, the resident was noted to be hospitalized from [DATE] to 11/24/23). Record review revealed Resident #186 was originally admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, pneumonia due to other streptococci (bacteria), severe sepsis with septic shock, pulmonary embolism, pulmonary nodule, and chronic obstructive pulmonary disease (COPD). The resident was transferred to the hospital and then re-admitted on [DATE] with a diagnosis of pneumonia. Review of Resident #186's hospital re-admission orders dated 11/24/23 revealed to continue the antibiotic, Rocephin 2 grams (gm)/50 milliliters (ml) intravenously until 11/25/23 as prescribed. The resident had diagnoses including strep bovis bacteremia (had been ordered antibiotic treatment for four weeks by another local hospital), right pneumothorax, left-side necrotizing pneumonia versus malignancy, and had tested positive for COVID-19 on 11/22/23. Review of Resident #186's physician's orders for November 2023 revealed the Rocephin was discontinued on 11/21/23 (even though the resident was transferred to the hospital on [DATE]). There was no evidence the Rocephin order was re-written upon the resident's re-admission on [DATE]. Interview on 12/12/23 at 2:00 P.M., with the Director of Nursing (DON) confirmed the resident did not receive the Rocephin as ordered following re-admission on [DATE] as noted in the hospital re-admission orders paperwork. Review of the facility undated Antibiotic Stewardship policy revealed antibiotics were powerful tools for fighting and preventing infections. Every antibiotic prescribed must be documented in the medical record for every resident, regardless of prior prescriptions or documentation elsewhere. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 53 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 record review, staff interview, and policy review, the facility failed to ensure pharmacy recommendations made as part of the residents' monthly medication regimen review were addressed by the physician and/or addressed timely. This affected three residents (#4, #19, and #25) of five residents reviewed for unnecessary medications. Findings include: 1. A review of Resident #4's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included unspecified dementia and bipolar disorder. A review of Resident #4's physician's orders revealed he had orders to receive Zyprexa (an antipsychotic medication) 10 milligrams (mg) by mouth twice a day. He also had an order to receive Zyprexa 10 mg intramuscular (IM) every eight hours as needed for severe aggression and agitation. A review of Resident #4's monthly medication regimen reviews revealed the resident's medications were reviewed monthly by the consulting pharmacist since his admission to the facility. Recommendations were made based on those monthly reviews on 08/07/23 and 11/05/23. A review of Resident #4's pharmacy recommendation dated 08/07/23 revealed the consulting pharmacist informed the physician that according to new Centers for Medicare and Medicaid (CMS) guidelines regarding as needed (prn) antipsychotics, those prn medications could only be written for 14 days initially and could only be re-ordered if the prescriber visited the resident and extended the order. The pharmacist recommended the physician evaluate and consider discontinuing the Zyprexa 10 mg IM every eight hours prn if they felt it was appropriate. There was no documented evidence of the physician responding to that recommendation, and the resident continued to have an order for the Zyprexa to be given every eight hours prn for severe aggression and agitation. A review of Resident #4's pharmacy recommendation for 11/05/23 revealed the consulting pharmacist had recommended to the physician that he consider a gradual dose reduction attempt for the resident's use of Zyprexa 10 mg by mouth (po) twice daily (BID). There was no documented evidence of the physician responding to that recommendation, and the resident continued to receive Zyprexa 10 mg po BID. On 12/13/23 at 8:30 A.M., an interview with the Director of Nursing (DON) confirmed the pharmacy recommendations made on 08/07/23 and 11/05/23 were not addressed by the physician after the recommendations were made by the pharmacist as part of the resident's monthly medication regimen review. She acknowledged the resident had an order to receive Zyprexa 10 mg IM every eight hours prn for severe aggression and agitation greater than the 14 days it should have been initially ordered for without being evaluated by a physician for the continued use past the initial 14-day period. She stated she reached out to the psychiatrist as well and did not see where he had addressed the pharmacy recommendations either. She reported she did not see where the resident had any order changes pertaining to the scheduled and prn Zyprexa since they had been first ordered. A review of the facility's policy on Antipsychotic Medication Use, revised December 2016, revealed antipsychotic medications would be prescribed at the lowest possible dosage for the shortest period (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 54 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 of time and were subject to gradual dose reduction and re-review. Residents who were admitted from the community or transferred from a hospital and who were already receiving antipsychotic medications would be evaluated for the appropriateness and indications for use. The interdisciplinary team would re-evaluate the use of antipsychotic medications at the time of admission and/ or within two weeks to consider whether the medication could be reduced, tapered, or discontinued. PRN orders for antipsychotic medications would not be renewed beyond 14 days unless the healthcare practitioner had evaluated the resident for the appropriateness of that medication. 2. A review of Resident #25's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, unspecified psychosis, restlessness and agitation, anxiety disorder, and depression. A review of Resident #25's physician's orders revealed the resident had an order to receive Seroquel (an antipsychotic medication) 50 mg po three times a day (TID). That order had been in place since 01/14/23. The resident also had an order to receive Depakote (a mood stabilizer) 250 mg BID. That order originated on 06/21/23. A review of Resident #25's pharmacy recommendation dated 03/06/23 revealed the consulting pharmacist recommended the physician to consider a GDR attempt for the use of Seroquel 50 mg po TID. The pharmacist's recommendation was from a monthly medication regimen review that had been completed on 03/06/23. The physician did not respond to the consulting pharmacist's recommendation for a GDR consideration for the use of Seroquel until 05/23/23 (over two months after the recommendation was made). Findings were verified by the DON. A review of Resident #25's pharmacy recommendation dated 07/17/23 revealed the consulting pharmacist recommended a GDR consideration for the use of Depakote as part of their monthly medication regimen review. There was no documented evidence supporting that recommendation had been addressed by the physician. On 12/13/23 at 8:30 A.M., an interview with the DON revealed she was not able to find any evidence of the physician responding to the pharmacy recommendation made on 07/17/23 pertaining to the Depakote. She had to contact the pharmacy to obtain a copy of that recommendation and did not see where the physician had acted upon the recommendation. She also acknowledged the pharmacy recommendation pertaining to a GDR consideration for the use of Seroquel made on 03/06/23 was not addressed timely by the physician as the physician did not act upon the recommendation until two and a half months after the recommendation was made. She reported they have had difficulty getting the physician to respond timely or at all to the pharmacist's recommendations when made. 3. Record review revealed Resident #19 admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain, pneumonia, hydronephrosis, dementia with agitation, atherosclerotic heart disease with angina, hypertension, cardiac arrhythmia, myocardial infarction, hyperlipidemia, depression, and anxiety. Review of a quarterly Minimum Data Set (MDS) assessment completed on 09/28/23 revealed Resident #19 had severely impaired cognition, mild depression, and hallucinations. Review of orders revealed Resident #19 was ordered lorazepam (antianxiety) 0.5 milligrams (mg) every hour as needed, Paxil (anti-depressant) 30 mg once a day, and Seroquel (antipsychotic) 25 mg at bedtime. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 55 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 a pharmacy recommendation from 03/06/23 revealed a recommendation was made to decrease the antipsychotic, risperidone. The physician did not review the recommendation until 06/22/23. Interview on 12/13/23 at 12:20 P.M. with the DON confirmed the physician's signature on the pharmacy recommendation from 03/06/23 was dated for what appeared to be 06/22/23. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 56 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 observation, record review, facility policy review and interview the facility failed to ensure Resident #189's pulse (heart rate) was obtained prior to the administration of Digoxin, a cardiac glycoside medication, as ordered by the physician to ensure the medication was only administered when necessary. This affected one resident (#189) of three residents observed for medication administration. The facility census was 85. Residents Affected - Few Findings included: Review of Resident #189's medical record revealed he was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke) due to thrombosis, hypertensive heart disease with heart failure, acute systolic (congestive) heart failure, and cardiomyopathy. Review of Resident #189's five day Minimum Data Set (MDS) 3.0 assessment, dated 11/30/23, revealed he was mildly cognitively impaired. Review of Resident #189's physician's orders revealed an order, dated 11/28/23, for Digoxin (a cardiac glycoside that enhances the contractility of the heart, but lowers the heart rate) 125 microgram (mcg) (0.125 milligram (mg) orally with special instructions to not give if pulse (heart rate) was under 60. The order indicated the resident's pulse was to be taken apical, once a day. Review of Resident #189's vital signs revealed his most recent pulse was obtained on 12/06/23 at 6:11 A.M. and was 68 beats per minute. Review of Resident #189's Medication Administration Record (MAR), dated 12/2023, revealed his Digoxin had been administered on 12/01/23, 12/02/23, and 12/05/23 without his pulse being checked prior to administration. On 12/07/23 at 7:35 A.M. Registered Nurse (RN) #157 was observed preparing the morning medications for Resident #189. RN #157 prepared Resident #189's medications including his Digoxin. She entered Resident #189's room and administered his oral medications, including the Digoxin, without first obtaining the resident's heart rate. She then continued to administer his inhalers and an intravenous antibiotic. Interview on 12/07/23 at 7:42 A.M. with RN #157 verified she did not obtain Resident #189's heart rate prior to administering the Digoxin. She verified she knew she needed to check the heart rate prior to administering the medications and didn't know why she didn't today. She verified it was potentially dangerous to administer Digoxin when a person's pulse was below 60. RN #157 then obtained Resident #189's pulse and it was 63. Interview on 12/07/23 at 3:12 P.M. with the DON verified residents who were receiving Digoxin should have their pulse assessed prior to administration of the Digoxin medication. Review of the facility policy titled, Medication Administration - General Guidelines, revised 01/2018, revealed medications were administered as prescribed in accordance with good nursing practices and only by persons legally authorized to do so. Further review revealed medications were administered in accordance with written orders of the prescriber. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 57 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 record review, review of a medication error report, staff interview, and policy review, the facility failed to ensure Abnormal Involuntary Movement Scale (AIMS) assessments were performed on a resident receiving antipsychotic medications to identify any side effects related to their use. They also failed to ensure a resident did not receive an extra dose of an anti-anxiety medication that was outside the orders given by the physician. This affected two residents (#4 and #28) of five residents reviewed for unnecessary medications. Findings include: 1. A review of Resident #4's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included unspecified dementia and bipolar disorder. A review of Resident #4's physician's orders revealed he had an order to receive Zyprexa (an antipsychotic medication) 10 milligrams (mg) by mouth (po) twice a day (BID). The order had been in place since 07/31/23. Resident #4's electronic medical record (EMR) was absent for any evidence of an AIMS assessment having been completed since his admission to the facility on [DATE] despite him having received an antipsychotic medication on a scheduled basis. Findings were verified by the Director of Nursing (DON). On 12/12/23 at 2:50 P.M., an interview with the DON confirmed Resident #4 was receiving Zyprexa 10 mg BID as ordered. She acknowledged his EMR did not show evidence of an AIMS assessment being completed to test him for abnormal involuntary movements that can be associated with antipsychotic use. She initially thought their admission nursing assessment included an AIMS assessment, but she acknowledged that it did not. She then thought the quarterly nursing assessment would have included an AIMS assessment but acknowledged one had not been completed for the resident since his admission to the facility on [DATE]. She followed up with the surveyor a short time later and reported she had an AIMS assessment completed for the resident. A review of the facility's policy on Antipsychotic Medication Use, revised December 2016, revealed nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician: neurological side effects that included akathisia, dystonia, extrapyramidal effects, akinesia, or tardive dyskinesia (repetitive involuntary movements such as grimacing and eye blinking often caused by long-term use of some psychotropic medications. 2. A review of Resident #28's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia with anxiety and anxiety disorder. A review of Resident #28's physician's orders revealed the resident had an order to receive Xanax (an anti-anxiety medication) 0.25 mg po once a day in the evening between 7:00 P.M. and 11:00 P.M. The order originated on 10/24/23. A review of Resident #28's nurses' progress notes revealed a nurse's note dated 11/17/23 by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 58 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 Licensed Practical Nurse (LPN) #187 that indicated the resident was given a Xanax at 4:00 P.M. LPN #187 indicated the nurse on the previous shift gave it without signing off the electronic medication administration record (eMAR). LPN #187 indicated in the nurse's note that she gave the resident a Xanax at 8:00 P.M. as scheduled. A review of an event report for Resident #28's medication error occurring on 11/17/23 revealed the resident was given a dose of Xanax at 4:00 P.M. that the nurse did not document the medication as having been given on the eMAR resulting in the resident being given an extra dose when her scheduled dose of Xanax was given at 8:00 P.M. The medication error report incorrectly identified the medication as being Ativan when they were to indicate what the correct order was. LPN #187 who completed the event report inadvertently identified the medication as Ativan 0.5 mg at bedtime as being the medication involved. The progress notes that were pulled and made part of the event report (medication error report) correctly identified Xanax as being the medication involved in the medication error. A review of Resident #28's eMAR for November 2023 revealed LPN #187 signed off that she had given the resident her scheduled dose of Xanax 0.25 mg po as ordered every day in the evening. The eMAR indicated the window for administration was between 7:00 P.M. and 11:00 P.M. There was no dose of Xanax marked as having been given on 11/17/23 at 4:00 P.M. nor did the resident's physician's order allow for a dose to be administered at that time. The resident did not have an as needed (prn) order for Xanax as it was only ordered on a scheduled basis. A review of Resident #28's controlled drug use record for Xanax confirmed two doses of Xanax 0.25 mg were administered to the resident on 11/17/23. A dose was indicated to have been given to the resident on 11/17/23 at 4:00 P.M. by LPN #168. A second dose was documented as having been given on 11/17/23 at 8:00 P.M. by LPN #187. On 12/13/23 at 10:20 A.M., an interview with the DON confirmed Resident #28 received an extra dose of Xanax 0.25 mg on 11/17/23 as two doses were signed out as having been given to the resident in the afternoon/ evening of 11/17/23. She acknowledged the first dose that was signed out for 11/17/23 at 4:00 P.M. was outside the window of administration for the resident to receive her scheduled dose of Xanax that was ordered to be given between 7:00 P.M. and 11:00 P.M. She verified LPN #168 had signed out a dose on the controlled drug use record for 11/17/23 at 4:00 P.M. but did not sign the dose as having been given on the eMAR. As a result, LPN #187 administered the scheduled dose of Xanax 0.25 mg to the resident on 11/17/23 at 8:00 P.M. and signed it off on the eMAR. The resident received double the dose of Xanax on 11/17/23 at 0.5 mg had been given instead of the 0.25 mg that was ordered. She was asked why LPN #168 would have given the resident Xanax outside of the window for administration and replied it was likely that the resident was asking for it. She acknowledged there was not a prn order for the resident to receive Xanax and should not have been given outside the parameters set by the physician's orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 59 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident record review, policy review and interview the facility failed to maintain a medication error rate of less than five (5) percent (%). The medication error rate was calculated to be 7.69% and included three medication errors of 39 medication administration opportunities. The facility also failed to ensure inhalation medications were administered following manufacturer recommendations for proper use and to prevent compliacations. This affected three residents (#39, #66, and #189) of three residents observed for medication administration. The facility census was 85. Residents Affected - Few Findings included: 1. Review of Resident #189's medical record revealed he was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke) due to thrombosis, hypertensive heart disease with heart failure, acute systolic (congestive) heart failure, and cardiomyopathy. Review of Resident #189's five day Minimum Data Set (MDS) 3.0 assessment, dated 11/30/23, revealed he was mildly cognitively impaired. Review of Resident #189's physician order, dated 11/28/23, revealed he was to receive Digoxin (a cardiac glycoside that enhances the contractility of the heart, but lowers the heart rate) 125 microgram (mcg) (0.125 milligram (mg) orally with special instructions to not give if pulse (heart rate) was under 60. The order indicated to take pulse apical, once a day. Review of Resident #189's vital signs revealed his most recent pulse was obtained on 12/06/23 at 6:11 A.M. and was 68 per minute. On 12/07/23 at 7:35 A.M. Registered Nurse (RN) #157 was observed preparing the morning medications for Resident #189. RN #157 prepared Resident #189's medications including his Digoxin. She entered Resident #189's room and administered his oral medications, including the Digoxin, without obtaining a heart rate. She then continued to administer his inhalers and an intravenous antibiotic. Interview on 12/07/23 at 7:42 A.M. with RN #157 verified she did not obtain Resident #189's heart rate prior to administering the Digoxin. She verified she knew she needed to check the heart rate prior to administering the medications and didn't know why she didn't today. She verified it was potentially dangerous to administer Digoxin when a person's pulse was below 60. RN #157 then obtained Resident #189's pulse and it was 63. Interview on 12/07/23 at 3:12 P.M. with the Director of Nursing verified residents who were receiving Digoxin should have their pulse assessed prior to administration of the Digoxin. 2. Review of Resident #66's medical record revealed she was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of unspecified part of the lung, chronic obstructive pulmonary disease, hypothyroidism, and shortness of breath. Review of Resident #66's admission MDS 3.0 assessment, dated 09/14/23, revealed she was cognitively intact. Review of Resident #66's physician's orders, dated 09/07/23, revealed she was to receive Symbicort (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 60 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (budesonide-formoterol - a corticosteroid inhaler) HFA aerosol inhaler 160-4.5 micrograms (mcg)/actuation, administer two puffs inhalation twice a day; and a physician order, dated 09/07/23, identified she was to receive Spiriva (tiotropium bromide) inhalation device 18 mcg, administer two puffs twice a day. Observation on 12/07/23 at 8:14 A.M. of Licensed Practical Nurse (LPN) #187 preparing the morning medications for Resident #66 revealed the LPN prepared Resident #66's medications and the Spiriva in the medication cart for Resident #66 was not the correct dosage. The Spiriva in the medication cart was 2.5 mcg and not 18 mcg as ordered. LPN #187 reported she would not administer the Spiriva. LPN #187 entered Resident #66's room and administered her Symbicort first. LPN #187 did not direct or offer Resident #66 to rinse her mouth and spit the water out. LPN #187 then administered Resident #66's oral medications. Interview on 12/07/23 at 9:35 A.M. with LPN #187 verified she did not administer the Spiriva as ordered and she did not have Resident #66 rinse her mouth and spit after the administration of the Symbicort inhaler. She verified residents should rinse and spit after administration of a corticosteroid inhaler. Interview on 12/07/23 at 11:02 A.M. with LPN #187 verified she had not contacted the pharmacy or the physician regarding the Spiriva not being available for administration. LPN #187 reported she marked it as not available on the Medication Administration Record (MAR), dated 12/23. Review of Resident #66's MAR, dated 12/23, revealed the Spiriva was documented as not available. Review of Resident #66's progress notes, reviewed on 12/07/23 at 11:12 A.M., revealed no documentation of the pharmacy or the physician being notified of the unavailability of the Spiriva. Interview on 12/07/23 at 3:12 P.M. with the DON verified if a resident's medication is not available, the pharmacy and physician should be notified. Review of the Symbicort medication insert, revised 12/2017, revealed after you finish taking Symbicort, rinse your mouth with water. Spit out the water. Do not swallow it. 3. Review of Resident #39's medical record revealed she was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke) due to unspecified occlusion, malignant neoplasm of female breast, asthma, and essential hypertension. Review of Resident #39's quarterly MDS 3.0 assessment, dated 10/31/23, revealed she was cognitively intact and had a feeding tube while a resident. Review of Resident #39's physician order, dated 08/22/23, identified she was to receive Symbicort (budesonide-formoterol - a corticosteroid inhaler) HFA aerosol inhaler 160-4.5 (mcg)/actuation, administer two puffs inhalation with special instructions to rinse mouth with water after using and do not swallow, twice a day; and physician order, dated 08/22/23, identified she was to receive Omeprazole-sodium bicarbonate packet 20-1,680 milligrams (mg), administer on packed via gastric tube. Observation on 12/07/23 at 8:81 A.M. of LPN #187 preparing the morning medications for Resident #39. LPN #187 prepared Resident #39's medications and the Omeprazole-sodium bicarbonate packet was not available. LPN #187 verbalized she was not concerned about not having the Omeprazole sodium (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 61 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bicarbonate packet because Resident #39 was receiving Omeprazole 20 mg also. LPN #187 entered Resident #39's room and administered her inhalers first. LPN #187 did not direct or offer Resident #39 to rinse her mouth and spit the water out. LPN #187 then administered Resident #39's medications via her enteral tube. Interview on 12/07/23 at 9:36 A.M. with LPN #187 verified she did not administer the Omeprazole sodium bicarbonate packet as ordered and she did not have Resident #39 rinse her mouth and spit after the administration of the Symbicort inhaler. She verified residents should rinse and spit after administration of a corticosteroid inhaler. Interview on 12/07/23 at 11:03 A.M. with LPN #187 verified she had not contacted the pharmacy or the physician regarding the sodium bicarbonate packet not being available for administration. Review of Resident #39's MAR, dated 12/2023, revealed her Omeprazole-sodium bicarbonate packet 20-1,680 mg was marked a not available. Review of Resident #39's progress notes, reviewed on 12/07/23 at 11:10 A.M., revealed no documentation of the pharmacy or the physician being notified of the unavailability of the Omeprazole-sodium bicarbonate packet 20-1,680 mg. Interview on 12/07/23 at 3:12 P.M. with the DON verified if a resident's medication is not available, the pharmacy and physician should be notified. Review of the Symbicort medication insert, revised 12/2017, revealed after you finish taking Symbicort, rinse your mouth with water. Spit out the water. Do not swallow it. Review of the facility policy titled, Medication Administration - General Guidelines, revised 01/2018, revealed medications are administered as prescribed in accordance with good nursing practices and only by persons legally authorized to do so. Further review reveals medications are administered in accordance with written orders of the prescriber. Additionally, if a medication with a current, active order cannot be located in the mediation cart/drawer, other areas of the medication cart, medication room, and facility (e.g., other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted, or medication may be removed from the emergency drug supply. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 62 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Observation on 12/12/23 at 7:35 A.M. with the Administrator revealed as the Administrator and surveyor were walking down the 300 hall a medication cart was observed to be unlocked and unsupervised outside room [ROOM NUMBER]. Interview on 12/12/23 at 7:35 A.M. with the Administrator confirmed the cart was left unlocked and unsupervised. The Administrator locked the medication cart at time of finding. Review of the facility policy titled, Storage of Medications, revised 04/2007, revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals shall be stored in the packaging, container, or other dispensing systems in which they are received. Further review revealed the nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Based on observation, interview, and facility policy review, the facility failed to ensure medications were appropriately packaged, labeled, and secured. This affected three medication carts of three medication carts (Connections 300 Hall, Front 500 Hall and Back 500 Hall) observed and one medication room (Connections 300 Nurses' Station) of one medication room observed. The facility census was 85. Findings included: 1. Observation on 12/07/23 at 8:01 A. M. of the Connections 300 Hall medication cart revealed 18 whole or one-half pieces of medication loose in the second drawer of the medication cart. This was verified during the observation by Registered Nurse (RN) #157. She also verified it was not proper storage to have loose medication in the drawers of the medications cart. 2. Observation on 12/07/23 at 8:39 A.M. of the Front 500 Hall medication cart revealed 20 whole or one-half pieces of medication loose in the second drawer of the medication cart. There was also a multi-dose bottle of Lantus insulin (opened and 1/2 used) labeled for Resident #57 with no documented date of opening on the bottle, and a multi-dose bottle of Lantus insulin (opened and 1/2 used) and a multi-dose bottle of Insulin Lispro (opened and almost empty) labeled for Resident #11 with no documented dated of opening on the bottle. The loose medications and undated insulin bottles were verified during the observation by Licensed Practical Nurse (LPN) #187. She also verified it was not proper storage to have loose medication in the drawers of the medication cart or insulin bottles not properly dated when opened. LPN #187 also reported she thought insulin was good for 90 days once opened. Review of undated pharmaceutical guidance titled, Highlights of Prescribing Lantus provided by the facility revealed after Lantus insulin vials had been opened (in-use) they could be used for up to 28 days. Review of undated pharmaceutical guidance titled, Highlights of Prescribing Insulin Lispro provided by the facility revealed after Insulin Lispro vials had been opened (in-use) they could be used for up to 28 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 63 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 3. Observation on 12/07/23 at 9:37 A.M. of the Back 500 Hall medication cart revealed 16 whole or one-half pieces of medication loose in the second drawer of the medication cart. This was verified during the observation by Licensed Practical Nurse (LPN) #187. She also verified it was not proper storage to have loose medication in the drawers of the medications cart. 4. Observation on 12/07/23 at 10:49 A.M. of the Connection 300 Nurses' Station medication refrigerator revealed two open and used multi-dose bottles of purified tuberculin for tuberculosis testing. Neither of the bottles had been dated when they were opened. RN #157 verified the tuberculin bottles had been used, had not been dated and should have been. She verified there was no way to know how long they had been open. Interview on 12/07/23 at 3:12 P.M. with the DON verified multi-dose bottles of insulin and tuberculin should be dated when opened and there shouldn't be loose medication in the medication carts. Review of undated pharmaceutical guidance titled, Tuberculin Purified Protein Derivative provided by the facility revealed vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Review of the facility policy titled, Storage of Medications, revised 04/2007, revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals shall be stored in the packaging, container, or other dispensing systems in which they are received. Further review revealed the nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 64 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0791 Provide or obtain dental services for each resident. 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 appropriately communicate dental concerns involving Resident #30. This affected one resident (#30) of four residents reviewed for dental services. The facility census was 85. Residents Affected - Few Findings included: Review of Resident #30's medical record revealed she was admitted to the facility on [DATE] with diagnoses including major depressive disorder, single episode, adjustment disorder, suicide attempt, suicidal ideations, generalized anxiety disorder, unspecified atrial fibrillation, and essential hypertension. Review of Resident #30's quarterly Minimum Data Set (MDS) dated [DATE], revealed she was cognitively intact and did not have any broken or loosely fitting full or partial dentures, or mouth or facial pain. Review of Resident #30's physician orders, dated 07/06/23 revealed the resident may see a dentist as needed. Review of Resident #30's progress note, dated 11/09/23 and documented by Registered Dietitian (RD) #220, revealed Resident #30 reported some dental pain related to broken teeth, but stated it was not affecting her oral food intake and denied having any chewing or swallowing difficulties. Interview on 12/04/23 at 10:40 A.M. with Resident #30 revealed she had been waiting to see the dentist for six months. She reported she did not have any pain but did have a cracked tooth on the right upper side. Resident #30 reported she had discussed it with the nurse upon admission and later with the dietitian. Interview on 12/11/23 at 11:10 A.M. with Social Services Director (SSD) #178 revealed she was not aware of any dental concerns for Resident #30. Interview on 12/11/23 at 11:43 A.M. with RD #220 revealed she did not inform anyone of Resident #30's pain and should have. She reported she usually focuses more on swallowing and informs the speech therapist of difficulties swallowing. She verified she should also focused on pain and let the nurses know if a resident is complaining of dental pain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 65 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, facility policy review and interview, facility failed to prepare foods in a sanitary manner and failed discard food items that were out of date/expired. This had the potential to affect 84 of 84 residents who received meal trays from the kitchen. The facility census was 85. Findings included: 1. On 12/04/23 from 8:39 A.M. to 9:12 A.M. observations made during the initial tour of the kitchen revealed the following concerns: A plastic container with cheddar cheese which expired on 12/03/23. A container of dried, crispy onions with a best by date of 10/27/23. A dented can of strawberry pie filling. Two bags of baby spinach with a use by date of 11/25/23. There was no operational thermometer in the walk-in refrigerator. Interview on 12/04/23 at 9:12 A.M. with Director of Food Services (DFS) confirmed the above findings/concerns at the time of the observations. 2. On 12/06/23 at 11:15 A.M. observation of tray line/meal preparation revealed of the lunch meal, which included corned beef hash and scrambled eggs revealed the following concerns: At 11:22 A.M., [NAME] #155 touched her left ear with her left hand and did not wash her hands before continuing to prepare food. At 11:29 A.M., Dining Services Assistant (DSA) #112 touched her mask, then proceeded to touch the microwave an other plates. At 11:31 A.M., DSA #171 touched her mask, then her cheek, her apron and then placed her hands on her hips. She did not wash her hands and proceeded to use tongs to grab bread for grilled cheese, then put gloves on to handle the grilled cheese to add butter before placing it on the grill. At 11:34 A.M. [NAME] #155 put on oven mitts, got additional food out of the oven, took off the oven mitts then proceeded to work without performing hand hygiene. At 11:37 A.M., DSA #171 touched her left, lower back then proceeded to place fries in the deep fryer. At 11:38 A.M. [NAME] #155 touched the refrigerator handle to retrieve mashed potatoes, put them in the microwave, the continued to prepare food. At 11:44 A.M. DSA #171 placed her hand on her left hip while cooking, then continued to place food on a plate without performing hand hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 66 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0812 Level of Harm - Minimal harm or potential for actual harm At 11:47 A.M. [NAME] #155 unplugged a heated delivery cart, moved the cart forward towards the tray line, plugged in back in, then proceeded plating food to serve. At 11:53 A.M. DSA #171 tucked a strand of hair behind her ear, touched her mask, then began serving again. Residents Affected - Many At 12:07 P.M. DSA #171 touched her mask then prepared a hamburger. Interview on 12/06/23 at 12:13 P.M. with [NAME] #155 confirmed all observations. Review of a policy titled Food Preparation and Service revealed staff should adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 67 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 observation, facility policy review and interview, the facility failed to develop and implement a comprehensive infection control program to prevent the spread of infection. The facility failed to ensure hand hygiene was performed when passing residents their meals in their rooms and failed to ensure a glucometer was cleaned and disinfected after use. This had the potential to affect eight residents (#2, #14, #16, #27, #52, #57, #193, and #195) observed during lunch service and three residents (#11, #44, and #57) who required blood glucose monitoring using the shared glucometer from the 500 front medication cart. The facility census was 85. Residents Affected - Some Findings included: 1. Observation on 12//11/23 at 7:59 A.M. as Licensed Practical Nurse (LPN) #187 prepared to obtain a finger stick blood sugar (FSBS) from Resident #11 revealed LPN #187 obtained her supplies and cleaned the glucometer with Swovo Medical and Commercial Disinfecting Wipe for approximately 10 seconds. LPN #187 then completed hand hygiene, applied (donned) gloves and proceeded to Resident #11's room. LPN #187 used a tissue as a barrier around the glucometer as she held it. LPN #187 put a test strip in the glucometer, punctured Resident #11's finger after cleaning it with alcohol and placed a drop of blood on the test strip which was inserted into the glucometer. After obtaining a fasting blood sugar (FSBS) reading, LPN #187 completed hand hygiene and the lancet and test strip were disposed of in the sharp container. LPN #187 placed the glucometer on top of the medication cart and then in the top right drawer of the medication cart without cleaning/disinfecting the glucometer. An interview at the time of the observation with LPN #187 verified she did not clean or disinfect the glucometer after using it to obtain an FSBS on Resident #11. LPN #187 stated, I thought I only had to do it between residents. This surveyor explained that any germs in Resident #11's room or on her hands as LPN #187 was touching her and then the glucometer were now on the glucometer, on the top of the medication cart, and in the top right drawer of the medication cart. LPN #187 then obtained a Swovo Medical and Commercial Disinfecting Wipe and cleaned the glucometer. LPN #187 verified she did not realize the SWOVO Medical and Commercial Disinfecting Wipe needed to make contact with the glucometer for two minutes for COVID-19 virus killing to be effective. Interview on 12/11/23 at 8:11 A.M. with the Director of Nursing (DON) verified glucometers should be cleaned and disinfected after use on a resident and prior to being returned to the medication cart for infection control. Interview on 12/13/23 at 3:30 P.M. with the DON revealed the front 500 unit medication cart glucometer could have been used on two additional residents, Resident #44 and #57. At the time of the interview, she also indicated there were no residents on the unit with hepatitis or human immunodeficiency virus (HIV). Review of the SWOVO Medical and Commercial Disinfecting Wipe flier, provided by the facility, revealed under product details of a two minute killing time for COVID-19 and documentation the wipe killed 99.9% of bacteria in 15 seconds. Review of the facility policy titled, Obtaining a Fingerstick Glucose Level, revised 10/2011, revealed clean and disinfect reusable equipment between uses according to the manufacturer's instructions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 68 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 and current infection control standards of practice. Level of Harm - Minimal harm or potential for actual harm 2. On 12/04/23 at 12:05 P.M. State Tested Nursing Assistant (STNA) #136 was observed delivering lunch meals to residents on the 500 unit. STNA #136 delivered a lunch meal to Resident #52. While in Resident #52's room, STNA #136 set up his meal, touched his over bed table, and physically assisted him from lying in the bed to sitting on the side of the bed to eat. Residents Affected - Some STNA #136 then exited Resident #52's room and walked to the meal cart to retrieve the next tray for Resident #57. She did not perform hand hygiene prior to retrieving Resident #57's tray. After placing drinks and rolled silverware with napkin on the meal tray, STNA #136 delivered the meal to Resident #57, placed it on her over bed table, and then adjusted the over bed table for Resident #57. STNA #136 exited Resident #57's room and walked to the meal cart to retrieve the next tray for Resident #16. She did not perform hand hygiene prior to retrieving Resident #16's tray. After placing rolled silverware with napkin on the meal tray (no drink needed because Resident #16 was holding her drink), STNA #136 delivered the meal to Resident #16's room and placed it on the over bed table. Resident #16 was in the hallway in her wheelchair and STNA #136 assisted Resident #16 into her room by pushing her wheelchair. Resident #16 wanted her meal on her nightstand and STNA #136 placed it on her nightstand for her. STNA #136 then washed her hands in the restroom diagonal from the nurses' station on the unit. Interview on 12/04/23 at 12:12 P.M. with STNA #136 verified she did not perform hand hygiene between providing residents their meals and after touching items and residents in the rooms. She reported she thought she only had to perform hand hygiene after delivering and assisting three residents and not between each resident. Review of policy titled Food Preparation and Service revealed food and nutrition services staff, including nursing services personnel, should wash their hands before serving food to residents. Review of the facility undated policy titled, Guidelines for Handwashing/Hand Hygiene, revealed handwashing was the single most important factor in preventing transmission of infections. Hand hygiene was a general term that applied to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Further review revealed all health care workers shall utilize hand hygiene frequently and appropriately. Health care workers shall use hand hygiene at times such as: before/after preparing/serving meals, drinks, tube feedings, etc., and before/after having direct physical contact with residents. 3. On 12/04/23 STNA #109 was observed passing lunch meal trays. The following concerns were identified during the observation related to infection control: At 11:50 A.M., STNA #109 delivered a tray to Resident #195, helped set up the meal, exited the room and did not sanitize her hands. At 11:57 A.M., STNA #109 delivered a tray to Resident #2, set up the tray, exited the room and did not sanitize her hands. At 11:58 A.M., STNA #109 delivered a tray to another resident, exited the room, sanitized hands, then entered Resident #27's room to get the resident repositioned in bed, exited the room and did not sanitize her hands. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 69 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 At 12:03 P.M. STNA #109 grabbed another tray and delivered it to Resident #14 and then exited the room without sanitizing her hands. Level of Harm - Minimal harm or potential for actual harm At 12:08 P.M., STNA #109 delivered a tray to Resident #193 and did not sanitize her hands. Residents Affected - Some Interview 12/04/23 at 12:12 P.M. with STNA #109 confirmed above observations. Review of policy titled Food Preparation and Service revealed food and nutrition services staff, including nursing services personnel, should wash their hands before serving food to residents. Review of the facility undated policy titled, Guidelines for Handwashing/Hand Hygiene, revealed handwashing was the single most important factor in preventing transmission of infections. Hand hygiene was a general term that applied to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Further review revealed all health care workers shall utilize hand hygiene frequently and appropriately. Health care workers shall use hand hygiene at times such as: before/after preparing/serving meals, drinks, tube feedings, etc., and before/after having direct physical contact with residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 70 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of invoice documents, facility policy review and interview, the facility failed to ensure immunizations were provided timely and as requested. This affected two residents (#9 and #34) and had the potential to affect 38 additional residents identified on a facility log to have consented to receiving a pneumococcal vaccine in September 2023 without evidence of administration. The facility census was 85. Residents Affected - Some Findings included: 1. Record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including respiratory disease, heart disease, hepatitis, and diabetes. Review of Resident #34's immunization consent form dated 09/11/23 revealed the resident consented to receive the pneumococcal, influenza (flu), and COVID vaccine. Review of Resident #34's immunization record revealed the resident had received a pneumococcal vaccine in 11/11/21 from an outside care setting. There was no evidence of the type of pneumococcal vaccine the resident had received at that time. Following the resident's consent (in September 2023), there was no evidence the resident received a pneumococcal, or COVID vaccine in 2023 as requested. The resident did not receive the influenza vaccine until 12/10/23 after the State agency annual survey had begun. 2. Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, anemia in chronic kidney disease, dependence on renal dialysis, type 1 diabetes mellitus with unspecified complications, unspecified sequelae of cerebral infarction, dysphagia following cerebral infarction, unspecified severe protein-calorie malnutrition, vitamin D deficiency, unspecified dementia, mild, with other behavioral disturbance, hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, and chronic bronchitis. Review of Resident #9's immunization consent form dated 09/11/23 revealed the resident consented to the pneumococcal, flu, and COVID vaccine. Review of Resident #9's immunization record revealed no evidence the resident had ever received a pneumococcal vaccine. There was no evidence the resident received a pneumococcal or COVID vaccine in the facility after providing consent in September 2023. The resident did not receive the influenza vaccine until 12/10/23 after the State agency annual survey had begun. Review of the facility invoices dated 09/12/23 revealed no evidence the facility had ordered pneumococcal or COVID-19 vaccines to ensure they were available and administered to residents as required/requested. Interview on 12/13/23 at 9:15 A.M. and 11:00 A.M., with the Director of Nursing (DON) confirmed Resident #34 and #9 had consented to all three vaccines. The flu vaccine was administered on 12/10/23; however, the DON indicated the COVID booster was on a national shortage and not available. During the interviews, the DON originally reported the pneumococcal vaccines were ordered in September 2023, but stated she had not received it nor had she followed up to see why it was not delivered. Upon further investigation the DON confirmed the pneumococcal vaccines were never actually ordered nor did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 71 of 72 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 365147 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Oaks Health Center 4114 North State Route 376 NW McConnelsville, OH 43756 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the facility have any pneumococcal vaccines in stock to administer. The DON reported she called the pharmacy on this date (12/13/23) and they indicated they would deliver pneumococcal vaccines today and she would start administering the immunization today. During the interview, the DON revealed there were 38 additional residents, who had consented to receive a pneumococcal vaccine in September 2023 who had not received the vaccination as of this date. The DON reported she had not reached out to the local health department or any other entity to see if the facility could obtain COVID vaccines. Review of the facility undated policy titled COVID-19 Prevention and Management revealed each resident would be offered the COVID-19 vaccine unless medically contraindicated or the resident has already been immunized. Review of the facility undated policy titled Immunization Prevention and Control revealed all residents would be offered the pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. The facility policy did appear to be consistent with the current recommendations from the Centers for Disease Control (CDC) related to pneumococcal vaccination recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 72 of 72

Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.

Citations

37 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0568GeneralS&S Dpotential for harm
F568 - Accounting and Records
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
0578GeneralS&S Dpotential for harm
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
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.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
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.
0759GeneralS&S Dpotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
0761GeneralS&S Fpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0880GeneralS&S Epotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0690GeneralS&S Dpotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0692GeneralS&S Dpotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0697GeneralS&S Dpotential for harm
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
0698GeneralS&S Dpotential for harm
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
0744SeriousS&S Gactual harm
F744 - A resident who displays or is diagnosed with dementia, receives the
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
0883GeneralS&S Epotential for harm
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
0756GeneralS&S Dpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0757GeneralS&S Dpotential for harm
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
0600GeneralS&S Dpotential for harm
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
0609GeneralS&S Dpotential for harm
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
0623GeneralS&S Cno actual harm
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
0625GeneralS&S Cno actual harm
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
0644GeneralS&S Epotential for harm
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
0645GeneralS&S Dpotential for harm
F645 - Preadmission Screening for individuals with a mental disorder and individuals
PASARR screening for Mental disorders or Intellectual Disabilities
0656GeneralS&S Epotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0657GeneralS&S Epotential for harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
0684SeriousS&S Gactual harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0686SeriousS&S Gactual harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0693GeneralS&S Dpotential for harm
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
0732GeneralS&S Cno actual harm
F732 - Nurse Staffing Information
Post nurse staffing information every day.
0745GeneralS&S Dpotential for harm
F745 - The facility must provide medically-related social services to attain or
Provide medically-related social services to help each resident achieve the highest possible quality of life.
0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0791GeneralS&S Dpotential for harm
F791 - Dental Services
Provide or obtain dental services for each resident.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0222GeneralS&S Epotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
0271GeneralS&S Epotential for harm
Have exits that are accessible at all times.
0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
0521GeneralS&S Fpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

FAQ · About this visit

Common questions about this visit

What happened during the December 18, 2023 survey of HIGHLAND OAKS HEALTH CENTER?

This was a inspection survey of HIGHLAND OAKS HEALTH CENTER on December 18, 2023. The surveyor cited 37 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at HIGHLAND OAKS HEALTH CENTER on December 18, 2023?

Yes, 37 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Inspection·December 18, 2023