Inspection·December 21, 2021

F 0554 Level of Harm - Minimal harm or potential for actual harm Interview on 12/20/21 at 10:29 A.M. with Resident #42 stated she had been administering the Systane eye drops four times each day with doses given in the morning, before noon, in the afternoon, and at bedtime. Resident #42 stated she told the nurses when she gave herself the eye drops but did not document the medication being administered any where. Resident #42 stated no one talked to her about how often she should administer it, where she should store the medication, or any side effects of taking the medication. Residents Affected - Few Interview on 12/20/21 at 1:13 P.M. with Licensed Practical Nurse (LPN) #536 verified Resident #42 was self-administering her Systane eye drops but was not aware exactly how often Resident #42 was administering the eye drops. LPN #536 stated she knew Resident #42 was administering the eye drops at least twice daily because the nurses administered different eye drops to Resident #42 twice each day and Resident #42 would indicate she gave herself the Systane eye drops at that time. LPN #536 was not aware if Resident #42 was ever assessed to determine if she was able to self-administer medications. Observation on 12/20/21 at 1:30 P.M. of Resident #42's bedroom, with LPN #536, revealed both boxes of Systane eye drops remained on her over the bed table. One box was opened and the other remained sealed. LPN #536 verified the Systane eye drops on Resident #42's over the bed table were the eye drops she was self-administering. Interview on 12/20/21 at 1:37 P.M. with Director of Nursing (DON) stated the facility had an assessment they completed with any resident who was self-administering medications but she was not aware of any resident in the nursing home who were currently self-administering medications. DON stated the resident would need to be assessed on how to read and follow medication instructions and if they were physically and mentally able to administer the medication. DON verified Resident #42 was not assessed for self-administration of her Systane eye drops. Review of a facility policy titled Medication Administration General Guidelines, revised November 2018, revealed residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. Review of a facility policy titled Guidelines for Self-Administration of Medications, dated 05/22/18, revealed residents requesting to self-medicate or has self-medication as part of their plan of care shall be assessed using the facility's self administration of medication assessment within the electronic health record. The resident and/or family/responsible party will be informed of the results of the assessment and whether the resident has been determined to safely self-administer medications. The medication will be kept in a locked drawer in the resident's room. The resident may be supplied with a medication administration record (MAR) to record administration if desired. periodic verification of administration compliance will be observed by nursing staff. A self-administration care plan will be initiated and updated as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365387 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 365387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Briar Hill Health Campus 600 Sterling Dr North Baltimore, OH 45872 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on resident interview, observation, staff interview, and review of facility policy, the facility failed to maintain a clean and sanitary environment. This affected two (#32 and #44) of 24 residents reviewed for environment. The facility census was 49. Findings include: Review of the medical record for Resident #32 revealed ad admission date of 11/03/21. Diagnoses included COVID-19, cerebral infarction (stroke), type II diabetes, chronic obstructive pulmonary disease (COPD), and major depressive disorder. Additional review of the quarterly Minimum Data Set (MDS) assessment, dated 11/26/21, revealed Resident #32 was cognitively intact, required supervision with toilet use, and was always continent of bowel and bladder. Review of the medical record for Resident #44 revealed an admission date of 09/12/21. Diagnoses included wedge compression fracture of the second and fourth lumbar vertebra, heart disease, end stage renal disease, type II diabetes, difficulty walking, lack of coordination, and muscle weakness. Additional review of the quarterly MDS assessment, dated 11/27/21, revealed Resident #44 was severely cognitively impaired, required extensive assistance with toilet use, was occasionally incontinent of bladder, and always continent of bowel. Interview on 12/19/21 at 10:58 A.M. of Resident #32 revealed her bathroom had not been cleaned yet today. Resident #32 stated she was able to use the bathroom without assistance, but the toilet was always dirty and had something smeared all over it. Resident #32 stated she shared the bathroom with Resident #44. Observation of Resident #32's bathroom at the time of the interview revealed a small garbage can sitting to the left of the toilet. The garbage can was full. There was an unknown reddish-brown substance smeared on the back of the toilet seat and a quarter sized black spot dried on interior of the toilet bowl. Observations on 12/19/21 from 1:30 P.M. through 4:30 P.M. revealed the garbage in Resident #32's bathroom had been emptied, but the toilet had not been cleaned. Observation on 12/20/21 at 9:50 A.M. of Resident #32's bathroom revealed the toilet continued to have a reddish-brown substance smeared on the back of the toilet seat and the quarter sized dried black substance on the interior of the toilet remained. Interview at the time of the observation on 12/20/21 at 9:50 A.M. with Environmental Services Associate (ESA) #568 revealed resident rooms were to be cleaned daily, including the bathroom. ESA #568 stated staff did not have checklists and just knew what needed to be done based on daily assignment area. ESA #568 verified there was an unknown substance on Resident #32's toilet. ESA #568 stated staff were aware the toilet was frequently dirty and she tried to check Resident #32's bathroom each day before she left at the end of her shift. ESA #568 verified both Resident #32 and Resident #44 utilized that bathroom. Interview on 12/21/21 at 6:56 A.M. with Licensed Practical Nurse (LPN) #564 revealed Resident #32 was independent with toilet use, but Resident #44 required staff assistance with using the restroom. Review of facility policy titled Room Cleaning - Health Center Rooms, revised 06/23/20, revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365387 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 365387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Briar Hill Health Campus 600 Sterling Dr North Baltimore, OH 45872 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 0584 resident rooms were cleaned daily, including cleaning and disinfecting bathrooms. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365387 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 365387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Briar Hill Health Campus 600 Sterling Dr North Baltimore, OH 45872 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to monitor for edema and ensure non-pharmaceutical interventions were implemented to minimize the occurrence of lower extremity edema for one (#36) of 24 residents reviewed for timely care and treatment. The facility census was 49. Residents Affected - Few Findings include: Review of the medical record for Resident #36 revealed an admission to the facility on [DATE]. Diagnoses included Alzheimer's disease, dementia, type 2 diabetes mellitus, liver disease, anemia, hyperlipidemia, benign prostatic hyperplasia, COVID-19, peripheral vascular disease, hypertension, depression, and history of acute kidney failure. Review of the most current Minimum Data Set (MDS) assessment, dated 11/25/21, identified the resident with moderately impaired cognition, requires staff supervision for the completion of activities of daily living, utilizes a wheel chair for mobility, frequently incontinent of bladder, continent of bowel, and receives a diuretic medication daily. Review of the physician orders revealed orders dated 10/16/19 for the diuretic hydrochlorothiazide 25 milligrams (mg) once daily. On 12/13/21 the physician ordered the diuretic hydralazine 20 mg three times daily. Review of plan of care implemented 03/18/20 addressed the resident's administration of a diuretic medication. On 11/27/21 the plan of care was reviewed and revised with interventions including: observe cardiovascular system and fluid status to determine effectiveness of diuretic therapy (e.g., edema, jugular vein distention, mental confusion, shortness of breath, abnormal breath sounds, abnormal heart sounds), administer medications in accordance with physician orders, observe and report effectiveness as needed. There were no interventions to prevent/decrease edema other than the diuretic use. Review of the nursing progress notes did not revealed Resident #36 was being assessed for the presence of edema, or was experiencing any edema. Observation on 12/19/21 at 10:17 A.M. revealed Resident #36 in his room seated in a wheelchair with his feet to the floor. Interview at this time, Resident #36 asked What are they doing about the swelling in my feet and legs? He then lifted his pant legs exposing the bilateral lower extremities. The resident's sport socks were constricting both ankles with approximately 3+ edema to the bilateral lower extremities. including the lower legs/calves. Interview on 12/20/21 at 10:55 A.M., Licensed Practical Nurse (LPN) #570 revealed no knowledge Resident #36 had bilateral lower extremity edema. Observation with LPN #570 at the time of the interview noted LPN #570 to assess Resident #36 with 3+ edema to both lower extremities extending up from both feet to the lower legs. LPN#570 confirmed there was no information contained in the medical record documenting Resident #36 was being assessed for any edema and verified no interventions were in place to prevent or decrease any edema. Interview on 12/20/21 at 11:09 A.M. the Director of Nursing verified Resident #36 had no additional interventions in place to address bilateral lower extremity edema other than diuretic medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365387 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 365387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Briar Hill Health Campus 600 Sterling Dr North Baltimore, OH 45872 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 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, and staff interview, the facility failed to follow up with a physician for treatment of fungal infection on the toe nails for one (#24) of 24 residents reviewed for comprehensive foot care. The facility census was 49. Residents Affected - Few Findings include: Review of the record for Resident #24 revealed an admission to the facility on [DATE]. Diagnoses included metabolic encephalopathy, urinary tract infection, acute kidney failure, dysphasia, atrial fibrillation, chronic kidney disease, major depression, dementia, cerebral vascular disease, and hypertension. Review of the Minimum Data Set (MDS) assessment, dated 11/15/21, Resident #24 was alert, able to make needs known, dependent on staff for the completion of activities of daily living, and at risk for skin breakdown with no concerns listed. Review of a physician clinical note dated 12/01/21 documented Resident #24 with multiple toenails with fungal infection. The clinical note lacked documentation implementing a treatment for the infection. Interview on 12/19/21 at 9:59 A.M., Resident #24 stated her physician discovered toe nail fungus to both great toes and no treatment has been implemented. The resident further stated Having fungus on my body is disgusting. Resident #24 stated she wanted the condition resolved. Observation on 12/20/21 at 7:46 A.M. Resident #24 was noted in bed with State Tested Nurse Aide (STNA) #575 providing morning hygiene. Resident #24's feet were exposed with her bilateral great toenails noted to have the presence of a yellow substance. Interview with STNA #575 at the time of the observation verified the presence of the yellow substance. Interview on 12/20/21 at 8:05 A.M., STNA #508 revealed Resident #24's toe condition was reported to a nurse. Interview on 12/20/21 at 10:45 A.M., Licensed Practical Nurse (LPN) #570 revealed she was unaware Resident #24 was discovered with toenail fungus and confirmed no treatment had been initiated. Interview on 12/20/21 at 1:58 P.M., the Director of Nursing (DON) confirmed Resident #24 was assessed with a fungus infection to the toe nails and no treatment was noted. The DON verified nursing did not follow-up to obtain a treatment for the fungus infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365387 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 365387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Briar Hill Health Campus 600 Sterling Dr North Baltimore, OH 45872 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** Based on medical record review, observation, staff interview, and review of Safety Data Sheet, the facility failed to ensure hazardous chemicals on the 100-Hall of the facility were secured. This had the potential to affect one resident (#251) residing on the 100-Hall, and identified by the facility as being cognitively impaired and independently mobile. The facility census was 49. Findings include: Review of the medical record revealed Resident #251 was admitted on [DATE]. Diagnoses included COVID-19, altered mental status, dementia with behavioral disturbance, and schizoaffective disorder. Review of the admission Minimum Data Set (MDS) assessment, dated 12/13/21, revealed Resident #251 was severely cognitively impaired. Observation on 12/19/21 at 10:11 A.M. of the soiled linen room located next to the shower room on the 100-Hall revealed the door was not locked. Inside the soiled linen room was a cabinet hanging on the wall. A sign posted on the cabinet stated not to leave the key in the lock. Further observation revealed the cabinet was not locked and a key was hanging on the side of the cabinet. Inside the unlocked cabinet were bottles of disinfectant cleaner approximately half-full , one bottle of deodorizer approximately three-quarter full , and three full eight ounce bottles of personal cleanser. Interview on 12/19/21 at 10:38 A.M. with Life Enrichment Director (LED) #549 verified both the door to the soiled linen closet and the cabinet inside of the closet were unlocked. LED #549 locked the cabinet, verified it was supposed to be locked and she would remind the staff of this. Observations on 12/20/21 from 8:10 A.M. through 9:50 A.M. of the soiled linen closet on the 100-Hall revealed the door to the soiled linen closet and the cabinet holding the chemicals in the closet was unlocked. Interview on 12/20/21 at 9:50 A.M. with Environmental Services Associate (ESA) #568 revealed the door to the soiled linen closet did not have a lock. ESA #568 verified the cabinet inside of the soiled linen closet was unlocked and held chemicals that were accessible to residents. Interview on 12/20/21 at 9:55 A.M. with Licensed Practical Nurse (LPN) #536 revealed Resident #251 was a new admission to the facility from the assisted living. LPN #536 stated Resident #256 moved to the facility due to increased confusion and forgetfulness. Review of the Safety Data Sheet, issue date 01/11/18, for the disinfectant cleaner revealed the disinfectant was harmful if swallowed and caused severe skin burns and eye damage. Additional review revealed the disinfectant should be kept in locked storage. Review of the Safety Data Sheet, Revision E, for the personal cleanser revealed the cleanser was harmful if swallowed, caused serious eye irritation and damage. Review of the Safety Data Sheet, undated, for the deodorizer, revealed the deodorizer caused serious eye damage or eye irritation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365387 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 365387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Briar Hill Health Campus 600 Sterling Dr North Baltimore, OH 45872 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 The facility identified Resident #251 to be the only resident on the 100-Hall who was independently mobile and had cognitive impairment. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365387 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 365387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Briar Hill Health Campus 600 Sterling Dr North Baltimore, OH 45872 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, staff interview, and review of a facility policy, the facility failed to properly store foods and maintain the kitchen in a sanitary manner. This affected all 49 residents in the facility who the facility identified as receiving food from the kitchen. Findings include: Observation of the facility kitchen on 12/19/21 at 9:45 A.M. revealed pre-sliced deli meats stored in a plastic bin on the bottom shelf of the walk in refrigerator. Inside the plastic bin revealed opened bags of bologna, corned beef, pepperoni, ham, and turkey which were placed inside plastic zip sealed bags inside the plastic bin. The bag of ham had a slimy liquid covering the bag. Further inspection revealed a slimy liquid covered all the bags of meat inside the plastic bin and a bag of sliced bologna was noted to not be fully sealed and leaking the slimy liquid. Observation of a food label sticker placed on the bag of bologna revealed a used by date of 11/28/21. A second bag of bologna inside the plastic bin had a food label sticker with a used by date of 12/13/21. Interview on 12/19/21 at 9:49 A.M. with Director of Food Services (DFS) #531 stated the used by dates should be seven days from when the food item was opened. DFS #531 verified the bologna was outside the used by dates. DFS #531 also confirmed the slimy liquid all over each bag of pre-sliced meat and threw the meat away. Additional observation of the walk in refrigerator on 12/19/21 at 9:52 A.M., after hand washing was completed, revealed a green metal rack which had salad dressings stored on the top shelf. Closer inspection of the metal grates and the underside of the shelf revealed a grayish-white fuzzy growth along the length of the metal shelf and between the grates directing under the bottles of salad dressing. Located under the top metal shelf were open boxes of fresh fruits and vegetables. Observation of the walk in freezer on 12/19/21 at 9:56 A.M. revealed a bag of opened French fries which were not properly sealed and exposed to the elements in the freezer, five breaded chicken tenders that were laying loose inside a plastic bin with other sealed meats, and a breaded meat patty that was also laying loose inside a separate plastic bin which contained other meats in the sealed packages. Interview on 12/19/21 at 10:02 A.M. with DFS #531 stated she was not sure when the last time the walk in refrigerator was deep cleaned but estimated it was around a month ago. DFS #531 verified the grayish-white fuzzy growth on the length of the top shelf and stated it was most likely mold growth from spilled food items. DFS #531 then observed the open bag of French fries and the two plastic bins in the freezer that contained the loose breaded meat tenders and patty and confirmed they should have been secured and stored in containers of some kind and not left open to air. Review of a facility policy titled Food Labeling and Dating Policy, dated 03/18/19, revealed any food product removed from its original container, has a broken seal, or has been processed in any way must have a label. The food label must have the item name, the date and time the food was labeled, the use by date, initials of the person labeling the item, and securely cover the food item. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365387 If continuation sheet Page 9 of 9