Inspection·August 6, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility's policy on Food Receiving and Storage (undated) revealed foods shall be received and stored in a manner that complied with safe food handling practices. Food services or other designated staff, would maintain a clean food storage area at all times. This deficiency represents incidental findings of non-compliance investigated under Complaint Number OH00155914. Event ID: Facility ID: 365147 If continuation sheet Page 2 of 9 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 08/06/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of quotes for equipment replacement, review of a facility issued check, review of the administrator's notes, review of daily temperature log sheets, review of correspondence with the facility's chemical supplier, and staff interview, the facility failed to ensure the hot water tank that supplied the washing machines were properly maintained in a working order to provide adequate hot water to the washers or utilize appropriate bleach or bleach alternative products to properly disinfect/ sanitize linens and residents' personal clothing. This affected all residents that resided in the facility. The facility's census was 95. Residents Affected - Many Findings include: Observations of the facility's laundry room on 08/05/24 at 11:15 A.M. revealed they had two washing machines that were used to process the facility and residents' laundry. The hot water tank that provided the washing machines with hot water was leaking and was currently not in use according to Maintenance Director #100 (who accompanied the surveyor during tour of the building). The leaking of water was noted to be coming out from under the hot water tank. Maintenance Director #100 indicated the bottom of the hot water tank was rusted out and would have to be replaced. He had shut the hot water tank down so it would not burn up, due to it leaking water and not being able to maintain the appropriate amount of water within the tank. He had ran a line of cold water to the washing machines so they could still be used, but did not have any hot water running to them. He stated bleach should be used when washing all items that they were laundering. The washing machines not having hot water had been an issue for about a month or so. It (hot water tank) started dripping, but then started leaking more. He claimed they were in the process of getting that hot water tank replaced. It was a special order and had been ordered with them expecting it any day now. On 08/05/24 at 1:45 P.M., an interview with Laundry Aide #115 revealed she worked in the facility's laundry room two days a week and had worked in the facility for the past 11 years. She confirmed they did not have any hot water being supplied to the washing machines in the facility's laundry room. She reported the problem with the lack of hot water in the laundry room had been going on a a few months now. She reported they had chemicals that they used in the washing machines and pointed out where they were and what they were. There were five gallon buckets of different cleaning products to include N-Surf P Laundry Detergent, N-[NAME] Laundry Brightener (bleach), Boost Plus (for stain lifting) and a fabric softener product. She indicated the only water they had going to the washing machines at that time was cold water. She was asked about the facility's process for running linens and residents' personal clothing through the washing machines. She stated she followed the Laundry Wash Formula Menu that was posted on the wall that told them what setting to enter for the type of items they were washing. She denied bleach would be used when washing the residents' personal clothing that was colored. She denied they had any bleach alternative such as an oxygen activated bleach or color safe bleach for the residents' colored personal clothing. She was not sure how they were ensuring the clothing items washed without bleach were getting properly sanitized when not using any hot water. On 08/05/24 at 1:54 P.M., further interview with Maintenance Director #100 (who was also the facility's laundry/ housekeeping supervisor) revealed the problem with the hot water tank started the first week or so of July 2024. Within a week or so of it leaking, he shut it down and was running straight cold water to the washing machines. He indicated they were supposed to be adding bleach to the washing machine with each items being laundered. The bottom of the hot water tank had rusted and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 3 of 9 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 08/06/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many needed to be replaced. They obtained a quote to get it replaced, but they had the air conditioning unit go down around the same time and that took precedent over getting the hot water tank replaced. When informed the laundry aide that was interviewed indicated bleach was not being used in the wash cycles when laundering the residents' colored personal clothes, he stated it should have been. He did not think the settings put as much bleach in as when doing linens and other whites but thought there was some bleach being added. He later acknowledged the setting being entered when laundering the residents' colored personal clothing did not have bleach going into it, as was reported by the laundry aide. Review of a quote from a local plumbing contractor dated 07/02/24 revealed the facility received an estimate for replacing the hot water heater that supplied hot water to the facility's laundry room. The total amount of the replacement was $18,200.00. Review of a check (Check #2411) from the facility to the local plumbing company revealed they had issued a check to the plumbing company for the amount of $18,200.00. The date on the check was 07/05/24. Review of the facility's administrator's notes documented on a personal note pad revealed on 07/01/24 he had spoke with a person at 11:30 A.M. regarding washer temperatures. It was recommended by the person he spoke to add additional chemicals (bleach- double as usual) to clean clothes. It was clarified by the administrator that the person mentioned in his notes regarding the recommendation for the use of double the bleach was a life safety code specialist that did a lot through the Ohio Healthcare Association. Review of a correspondence from the facility's chemical company's Director of Operations to the facility revealed he sent the letter accompanying another letter below written by [NAME] Industries Inc. (company of the washing machine products used by the facility) in 2023 regarding disinfection of textiles in the laundering process, giving information on the disinfection taking place in the washers, even when washing in cold water. The letter further indicated consistent with CDC guidelines during laundering, the pH levels were increasing and decreasing regardless of water temperature; the ambient temperatures were elevated during the drying process; there were multiple bath exchanges or changes of water during the wash; and the appropriate levels of chlorine bleach and sour were in use. Further information from the manufacturer of the laundry products the facility used revealed more information was provided by the company to their customers to address concerns about Clostridium Difficile, Covid-19, and other pathogens that were prevalent in institutional facilities. It further went on to say, the disinfection of textiles was accomplished in the laundering process by virtue of a combination of factors as previously stated above. In addition, it included the need to use appropriate levels of Chlorine bleach or color safe Hydrogen Peroxide, and a neutralizing sour (acid). If the above steps were employed to disinfect contaminated linens in all healthcare operations and were consistent with CDC recommendations, a kill level of 99.9% or better could be obtained when processing linens. Review of the facility's daily temperature log sheets for July 2024 revealed the logs included a temperature of the laundry room water temperature. The log was noted to consistently have the temperature of 146 degrees Fahrenheit (F.) recorded as being the temperature obtained, even during the time the laundry room's hot water tank was shut down and only cold water was being provided to the washing machines. On 08/05/24 at 4:12 P.M., a follow up interview was completed with Maintenance Director #100. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 4 of 9 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 08/06/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many confirmed the water temperatures recorded on their logs for the laundry water temperature was not accurate. He stated he had left that log blank, when the facility's hot water tank that supplied the laundry room was down, and was told he had to put in a temperature that was not actually obtained. He further stated they had just received the check for the hot water tank replacement that day and the plumbing company came over and picked it up that morning. He indicated the hot water tank had been ordered (as of 08/05/24) and not previously as he indicated earlier. It was expected that the replacement hot water tank would be installed this coming Friday. This deficiency represents non-compliance investigated under Complaint Number OH00155914. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 5 of 9 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 08/06/2024 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of quotes for equipment replacement, review of a facility issued check, and staff interview, the facility failed to ensure the hot water tank that supplied the washing machines were properly maintained in a working order to provide adequate hot water to the facility's washing machines to be able to properly disinfect/ sanitize linens and the residents' personal clothing. This affected all residents that resided in the facility. The facility's census was 95. Residents Affected - Many Findings include: Observations of the facility's laundry room on 08/05/24 at 11:15 A.M. revealed they had two washing machines that were used to process the facility and residents' laundry. The hot water tank that provided the washing machines with hot water was leaking and was currently not in use, according to Maintenance Director #100 (who accompanied the surveyor during tour of the building). The leaking of water was noted to be coming out from under the hot water tank. Maintenance Director #100 indicated the bottom of the hot water tank was rusted out and would have to be replaced. He had shut the hot water tank down, so it would not burn up due to it leaking water and not being able to maintain the appropriate amount of water within the tank. He had ran a line of cold water to the washing machines so they could still be used, but did not have any hot water running to them. The washing machines not having hot water had been an issue for about a month or so. He claimed they were in the process of getting that hot water tank replaced. It was a special order and had been ordered with them expecting it any day now. On 08/05/24 at 1:45 P.M., an interview with Laundry Aide #115 revealed she worked in the facility's laundry room two days a week and had worked in the facility for the past 11 years. She confirmed they did not have any hot water being supplied to the washing machines in the facility's laundry room and the problem had been going on for a few months now. She reported they had chemicals that they used in the washing machines and pointed out where they were and what they were. There were five gallon buckets of different laundry products to include N-Surf P Laundry Detergent, N-[NAME] Laundry Brightener (bleach), Boost Plus (for stain lifting) and a fabric softener product. She indicated the only water they had going to the washing machines at that time was cold water. She was asked about the facility's process for running linens and residents' personal clothing through the washing machines. She stated she followed the Laundry Wash Formula Menu that was posted on the wall that told them what setting to enter for the type of items they were washing. She denied bleach would be used when washing the residents' personal clothing that were colored. She denied they had any bleach alternative such as an oxygen activated bleach or color safe bleach for the residents' colored personal clothing. She was not sure how they were ensuring the clothing items washed without bleach were getting properly sanitized when not using any hot water. On 08/05/24 at 1:54 P.M., an interview with Maintenance Director #100 (who was also the facility's laundry/ housekeeping supervisor) revealed the problem with the hot water tank started the first week or so of July 2024. Within a week or so of it leaking, he shut it down and was running straight cold water to the washing machines. He indicated they were supposed to be adding bleach to the washing machine with each of the items being laundered. The bottom of the hot water tank had rusted and needed to be replaced. They obtained a quote to get it replaced, but they had the air conditioning unit go down around the same time and that took precedent over getting the hot water tank replaced. When informed the laundry aide that was interviewed indicated bleach was not being used in the wash cycles when laundering the residents' colored personal clothes, he stated it should have been. He did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 6 of 9 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 08/06/2024 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many not think the settings put as much bleach in as when doing linens and other whites but thought there was some bleach being added. He later acknowledged the setting being entered when laundering the residents' colored personal clothing did not have bleach going into it, as was reported by the laundry aide. Review of a quote from a local plumbing contractor dated 07/02/24 revealed the facility received an estimate for replacing the hot water heater that supplied hot water to the facility's laundry room. The total amount of the replacement was $18,200.00. Review of a check (Check #2411) from the facility to the local plumbing company revealed they had issued a check to the plumbing company for the amount of $18,200.00. The date on the check was 07/05/24. On 08/05/24 at 4:12 P.M., a follow up interview was completed with Maintenance Director #100. He stated the facility was given the check for the hot water tank replacement that day and the plumbing company came over and picked it up earlier that morning. He indicated the hot water tank had been ordered (as of 08/05/24) and not when he had previously indicated. It was expected that the replacement hot water tank would be installed this coming Friday. This deficiency represents non-compliance investigated under Complaint Number OH00155914. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 7 of 9 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 08/06/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, review of work invoices, review of quotes for plumbing work that needed to be done, and staff interview, the facility failed to ensure the basement area utilized for food storage was maintained in a clean/ sanitary manner as a leaking sewer pipe was not timely repaired. This had the potential to affect all residents residing in the facility. The facility census was 95. Findings include: On 08/05/24 at 11:25 A.M., an observation of the facility's basement revealed they were utilizing the basement for the storage of refrigerated and frozen food items, as well as dry food goods. The basement was noted to have one large room that contained a box freezer and some storage of dry food goods on shelves along the wall. Further back was a walk in refrigerator and a walk in freezer. Towards the back of the basement there were three rooms. A small storage room at the back left corner, a larger storage room in the back center, and a dry food storage area in the back right corner. There was a strong sewage odor present in the basement that was more prevalent the further back you went in the basement. The sewage odor was strongest in the central back room where sewage was noted to have leaked from a sewer pipe and was puddled up on the floor. Not all of the floor was under the sewage that had been leaking out. The brownish-black liquid from the sewer pipe was coming from the right side wall towards and the puddle extended to the middle of the floor. There were a lot of gnats or fruit flies flying around that central back room. Some of the gnats or fruit flies were observed in the dry food storage room as well and were noted to have landed on boxes and other packaged food being stored in that room. The facility's Administrator accompanied the surveyor and Maintenance Director #100 down to the basement during the tour. He was not forth coming of any problems they had in the basement pertaining to a leaking sewer pipe. It was not until the surveyor entered that area in an effort to identify the source of the smell that it was known they had a leaking sewer pipe. On 08/05/24 at 11:30 A.M., an interview was conducted with Maintenance Director #100. He initially indicated the sewer pipe had been leaking for the past month and a half or so. He later reported the problems with the leaking sewer pipe had been an ongoing issue for the past three months. He stated they had a local plumbing company come and patch it, but the repairs did not work. It started to leak three to four days, after the patch was done. They had to periodically go in and clean the sewage off the floor that had continuously leaked from the sewer pipe. He acknowledged there was a strong, foul odor in the basement where they were storing food and where employees were around. There were a lot of gnats or fruit flies that were flying around the room where the leaking sewer pipe was and they were also in other areas of the basement that was being used to store food. Invoices and work orders were requested for review for the repairs to the sewer line that had been attempted and any quotes for future repairs they intended to make. Review of a invoice from a local plumbing company dated 07/09/24 revealed they came to the facility in response to a sewer line leaking. The balance due was $262.99. A description of the work done included Clemet and plumbing labor. Review of a quote obtained from Mr. Rooter Plumbing dated 07/25/24 revealed the facility received a quote from the plumbing company for the amount of $3,500.00. The description of the work needed was for any type of underground dig job, bursts, or liners. On 08/05/24 at 1:54 P.M., a follow up interview with Maintenance Director #100 revealed he had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 8 of 9 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 08/06/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many taken pictures of the leaking sewer pipe and had sent it to the Administrator and the facility's owner. Quotes were obtained from a local plumbing company as well as from a chain plumbing company from a nearby area. He indicated the bids were an open ended bid as they were not sure what all they would get into when they had to dig up the concrete of the basement floor that the sewer pipe ran into. The leak was approximately six inches from the floor and they would have to have a certain length of good pipe to tie into at the T piece. The quote from the national chain plumber had been obtained weeks ago and the quote from the local privately owned plumbing company was within a week after they attempted to patch the leak unsuccessfully. He denied any approvals had been made for the quotes to get the work done until that day (08/05/24). He stated they have the national chain plumbing company scheduled to come this coming 08/08/24 at 9:00 A.M. He did not feel the repair to the leaking sewer pipe was timely. He indicated they had to wait to get an approval for any work to be done and that sometimes did not always happen that fast. They have had a lot that had been in disrepair the past few months that they had been working on such as the HVAC units but had not got to taking care of the leaking sewer drain yet. This deficiency represents non-compliance investigated under Complaint Number OH00155914. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365147 If continuation sheet Page 9 of 9