Inspection·December 12, 2019

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** 2. Review of Resident #62's medical record revealed an admission date of 11/02/19 with diagnoses that included congestive heart failure, atrial fibrillation and diabetes mellitus. Review of Resident #62's paper chart found no evidence of any advance directives (code status) in place. Further review of the electronic health record revealed Resident #62's code status was blank. Physician's orders were reviewed and found no evidence of any code status. Interview with Registered Nurse (RN) #547 on 12/10/19 at 2:35 P.M. verified no advance directives in the paper chart or the electronic health record for Resident #62. The RN revealed the resident's code status should be entered in the physician's orders, then it self populated the code status in the electronic health record. 3. Review of Resident #64's medical record revealed an admission date of 11/02/19 with diagnoses that included colon cancer, atrial fibrillation and diabetes mellitus. Review of Resident #64's paper chart found no evidence of any advance directives (code status) in place. Further review of the electronic health record revealed Resident #64's code status was blank. Physician's orders were reviewed and found no evidence of any code status. Interview with Registered Nurse (RN) #547 on 12/10/19 at 2:35 P.M. verified no advance directives in the paper chart or the electronic health record for Resident #64. The RN revealed the residents code status should be entered in the physician's orders, then it self populated the code status in the electronic health record. Review of the facility policy titled Advance Care Planning Policy: Advance Directives and Refusal of Care, reviewed 2015, indicated on admission, the facility would determine whether the resident has executed advance directives [e.g. a Living Will, or DPAHC (Durable Power of Attorney for Healthcare Decisions)], and if not, whether the resident would like to execute advance directive. The facility would also determine whether the resident's physician issued a Do Not Resuscitate (DNR) order in another setting (e.g., hospital, home) and whether the resident would like a DNR order issued while in the facility. Based on record review and interview the facility failed to ensure advanced directives were in place for Resident #62, Resident #64 and Resident #233. This affected three residents (#622, #64 and #233) of three residents reviewed for advanced directives. Findings include: 1. Resident #233 was admitted to the facility on [DATE] with diagnoses including osteoarthritis, muscle weakness, and hypertension. Review of Resident #233's electronic medical record and paper medical record did not reveal any advance directives. On 12/10/19 at 5:00 P.M., Registered Nurse (RN) #547 verified Resident #233 did not have any advanced directives in place. Interview with RN #547 on 12/10/19 at 2:35 P.M. revealed advance directive/code status should be obtained upon admission and entered in the physician's orders and placed in the front of the paper (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 2 of 18 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 365494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Hill Community 12200 Strausser St NW Canal Fulton, OH 44614 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 FORM CMS-2567 (02/99) Previous Versions Obsolete medical record. RN #547 also revealed until a resident's code status was determined, the code status defaults to a full code. Review of the facility policy titled, Advance Care Planning Policy: Advance Directives and Refusal of Care, reviewed 2015, revealed on admission the facility would determine whether the resident has executed advanced directives, and if not, whether the resident would like to execute advanced directives. The policy also stated the facility would determine whether the resident's physician had issued a Do Not Resuscitate (DNR) order in another setting and whether the resident would like the DNR order issued while in the facility. Event ID: Facility ID: 365494 If continuation sheet Page 3 of 18 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 365494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Hill Community 12200 Strausser St NW Canal Fulton, OH 44614 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #22's responsible party was contacted timely to discuss dental options and services available for the resident. This affected one resident (#22) of 24 residents reviewed for notification. Findings include: Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, type two diabetes mellitus and major depression. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 had severely impaired cognition scoring a three on the Brief Interview for Mental Status (BIMS) The MDS assessment also revealed Resident #22 had no broken or loose fitting teeth. Resident #22's medical record revealed an initial dental visit on 10/08/19 which Resident #22 refused to attend and a second dental visit on 11/12/19 which revealed a dental treatment plan to fill tooth #3 and a clasp was removed from tooth #15 with possible further extraction of tooth #15. However, review of Resident #22's nursing progress notes revealed no entries regarding dental visits from 10/08/19 through 11/12/19 On 12/09/19 at 11:08 A.M. a telephone interview with Resident #22's son revealed he believed Resident #22 had a broken tooth, Resident #22's son also revealed he was unaware of any dental options available at facility. On 12/11/19 at 1:49 P.M. interview with the Director Of Nursing (DON) verified there was no documentation in Resident #22's chart from 10/08/19 through 11/12/19 regarding the dental visits on 10/08/19 and 11/12/19. The DON also verified the resident's family should have been notified and the documentation should have been done in nursing progress notes. Review of the facility policy titled, Notification and Reporting of Changes in Health Status, Illness, Injury and Death of a Resident, dated 08/12/19, revealed the resident's sponsor or authorized representative was notified when there was a need to alter treatment significantly such as a need to discontinue a existing form of treatment due to adverse consequences, or to commence a new form of treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 4 of 18 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 365494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Hill Community 12200 Strausser St NW Canal Fulton, OH 44614 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice form (SNFABN) to Resident #44 as required. This affected one resident (#44) of three residents reviewed for beneficiary notices. Residents Affected - Few Findings include: Resident #44 was admitted to the facility for skilled nursing services under Medicare part A on 10/12/19. Secondary to Resident #44's medical decline and the decision to be placed onto Hospice services, the facility issued a Notice of Medicare Non-Coverage (NOMNC) with a date of 12/02/19, which was signed by Resident #44's authorized representative on 11/29/19. Review of the facility completed SNF Beneficiary Protection Notification Review form for Resident #44 revealed the facility did not provide a SNFABN for because Resident #44 transitioned onto Hospice services. Staff interview on 12/12/19 at 9:52 A.M. with Registered Nurse (RN) #557 revealed the SNFABN form was not given because the facility did not believe the form had to be given since the family had chosen Hospice services. Review of the facility provided forms they utilize for instructions on when to issue NOMNC's and SNFABN's and how to fill them out revealed the following: Medicare required SNFs to issue the SNFABN to original Medicare beneficiaries prior to providing care Medicare usually covered, but may not pay for in this instance because the care was not medically reasonable and necessary or considered custodial. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 5 of 18 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 365494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Hill Community 12200 Strausser St NW Canal Fulton, OH 44614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - 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 effectively implement their abuse policy and procedure to ensure injuries of unknown origin involving Resident #19 were thoroughly investigated and reported to the State agency. This affected one resident (#19) of one resident reviewed for accidents and injuries of unknown origin. Residents Affected - Few Findings include: Review of Resident #19's medical record revealed an admission date of 09/19/19 with diagnoses that included falls with pelvic fracture, dementia and osteoporosis. Further review of the progress notes revealed on 11/12/19 Resident #19 was attending a scheduled appointment with an orthopedic surgeon for follow up care related to multiple pelvic fractures that occurred prior to admission to the facility. At this appointment, the resident indicated she had pain to her left hip. An x-ray was completed at this time and found evidence of a left femoral neck fracture. Resident #19 was admitted to the hospital and received surgical repair. Review of the medical record prior to 11/12/19 revealed falls in the facility on 9/27/19, 10/13/19, 10/19/19 (twice) and 10/22/19. Review of the fall notes and fall investigations found no evidence of any injuries sustained from these falls. X-rays were completed of the left hip on 10/23/19 and left knee on 10/26/19 with no evidence of any fractures at this time. There was no evidence of any accidents, injury or complaints of pain prior to the orthopedic surgeon appointment on 11/12/19. Resident #19 was re-admitted to the facility on [DATE]. The resident was evaluated by her physician who determined the fracture was pathological in cause due to osteoporosis. Further review of the medical record found no evidence of any facility investigation into the possible cause of the fracture. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation, Injuries of Unknown Source and Misappropriation of Resident Property with a revision date of 12/15/17 revealed the definition of Injury of Unknown Source - 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 extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. All incidents and allegations of abuse, neglect, exploitation, mistreatment and misappropriation of resident property and injuries of unknown source must be reported immediately to the administrator or designee. When possible the State Department of Health (SDH) will be notified by using the online Electronic Information and Dissemination Collection (EIDC) system. The Community will submit an line Self Reported Incident (SRI) form in accordance with the SDH's then-current instructions. Documentation - Evidence of the investigation should be documented. Final Reports - As with the initial report, when possible, the SDH will be notified by using the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 6 of 18 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 365494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Hill Community 12200 Strausser St NW Canal Fulton, OH 44614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete online EIDC system. The Community will submit an online SRI form in accordance with the SDH's then current instructions. On 12/11/19 at 2:10 P.M., interview with the Director of Nursing (DON) verified Resident #19's fracture was found during orthopedic appointment on 11/12/19 and had surgical repair at the hospital. She denied any fall or injuries prior to appointment prior to 11/12/19. The DON revealed the facility was made aware of fracture, she met with Registered Nurse (RN) #547 and physician and determined it was a pathological fracture. The DON further verified there was no documentation in the resident's medical record of any investigation completed into the injury and the facility did not complete a self reported incident to the State agency for the injury of unknown origin. Event ID: Facility ID: 365494 If continuation sheet Page 7 of 18 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 365494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Hill Community 12200 Strausser St NW Canal Fulton, OH 44614 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 and interview the facility failed to ensure injuries of unknown origin involving Resident #19 were reported to the State agency as required. This affected one resident (#19) of one resident reviewed for accidents and injuries of unknown origin. Findings include: Review of Resident #19's medical record revealed an admission date of 09/19/19 with diagnoses that included falls with pelvic fracture, dementia and osteoporosis. Further review of the progress notes revealed on 11/12/19 Resident #19 was attending a scheduled appointment with an orthopedic surgeon for follow up care related to multiple pelvic fractures that occurred prior to admission to the facility. At this appointment, the resident indicated she had pain to her left hip. An x-ray was completed at this time and found evidence of a left femoral neck fracture. Resident #19 was admitted to the hospital and received surgical repair. Review of the medical record prior to 11/12/19 revealed falls in the facility on 9/27/19, 10/13/19, 10/19/19 (twice) and 10/22/19. Review of the fall notes and fall investigations found no evidence of any injuries sustained from these falls. X-rays were completed of the left hip on 10/23/19 and left knee on 10/26/19 with no evidence of any fractures at this time. There was no evidence of any accidents, injury or complaints of pain prior to the orthopedic surgeon appointment on 11/12/19. Resident #19 was re-admitted to the facility on [DATE]. The resident was evaluated by her physician who determined the fracture was pathological in cause due to osteoporosis. Further review of the medical record found no evidence of any facility investigation into the possible cause of the fracture. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation, Injuries of Unknown Source and Misappropriation of Resident Property with a revision date of 12/15/17 revealed the definition of Injury of Unknown Source - 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 extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. All incidents and allegations of abuse, neglect, exploitation, mistreatment and misappropriation of resident property and injuries of unknown source must be reported immediately to the administrator or designee. When possible the State Department of Health (SDH) will be notified by using the online Electronic Information and Dissemination Collection (EIDC) system. The Community will submit an line Self Reported Incident (SRI) form in accordance with the SDH's then-current instructions. Documentation - Evidence of the investigation should be documented. Final Reports - As with the initial report, when possible, the SDH will be notified by using the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 8 of 18 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 365494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Hill Community 12200 Strausser St NW Canal Fulton, OH 44614 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 FORM CMS-2567 (02/99) Previous Versions Obsolete online EIDC system. The Community will submit an online SRI form in accordance with the SDH's then current instructions. On 12/11/19 at 2:10 P.M., interview with the Director of Nursing (DON) verified Resident #19's fracture was found during orthopedic appointment on 11/12/19 and had surgical repair at the hospital. She denied any fall or injuries prior to appointment prior to 11/12/19. The DON revealed the facility was made aware of fracture, she met with Registered Nurse (RN) #547 and physician and determined it was a pathological fracture. The DON further verified there was no documentation in the resident's medical record of any investigation completed into the injury and the facility did not complete a self reported incident to the State agency for the injury of unknown origin. Event ID: Facility ID: 365494 If continuation sheet Page 9 of 18 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 365494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Hill Community 12200 Strausser St NW Canal Fulton, OH 44614 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #32's medical record revealed an admission date of 12/14/16 with diagnoses that included Stage III (full thickness skin loss, subcutaneous fat may visible but bone, tendon or muscle is not exposed) sacral pressure ulcer and morbid obesity. Residents Affected - Few Review of weekly pressure ulcer assessments revealed a Stage III pressure ulcer to the sacrum on 10/15/19 to 12/11/19. Review of the Minimum Data Set (MDS) 3.0 resident assessments revealed a significant change assessment with a reference date of 11/26/19. The MDS assessment indicated Resident #32 currently had an unhealed pressure ulcer. However, the assessment did not identify Resident #32 had a Stage III pressure ulcer. Interview with Registered Nurse (RN) #557 on 12/11/19 at 4:00 P.M. verified Resident #32's significant change MDS with a reference date of 11/26/19 did not identify the resident's Stage III pressure ulcer. Based on record review and staff interview the facility failed to accurately code the comprehensive Minimum Data Set (MDS) 3.0 assessment related to antibiotic use for Resident #1 and pressure ulcers for Resident #32. This affected two residents (#1 and #32) of 22 residents whose MDS 3.0 assessments were reviewed. Findings include: 1. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with the diagnoses of acute osteomyelitis, pneumonitis due to the inhalation of food and vomit, diabetes, diabetic neuropathy, acute respiratory failure, epilepsy, sepsis, cerebral infarction, mild cognitive impairment, malignant neoplasm of thyroid gland, delirium, apnea, and convulsions. Review of the five day Minimum Data (MDS) Set 3.0 assessment dated [DATE] revealed Resident #1 had intact cognition and had not received an antibiotic medication. Review of the physician's orders for December 2019 revealed Resident #1 had an order dated 11/27/19 for intravenous medication Piperacillin-tazobactam (antibiotic) 3.375 grams every eight hours until 12/29/19 for sepsis. Interview on 12/11/19 at 04:09 P.M. with Registered Nurse (RN) #557 revealed the five-day MDS dated [DATE] was not coded correctly to identify antibiotic use for Resident #1 and a modification would be done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 10 of 18 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 365494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Hill Community 12200 Strausser St NW Canal Fulton, OH 44614 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 Based on record review and staff interview the facility failed to ensure weights were obtained and as needed diuretic medications were administered as ordered by the physician to ensure the appropriate treatment for Resident #36 who had a diagnosis of congestive heart failure. This affected one resident (#36) of five residents reviewed for unnecessary medication use. Residents Affected - Few Findings include: Review of Resident #36's medical record revealed an admission date of 02/02/16 with a diagnosis that included congestive heart failure. Review of the current physician's orders revealed daily weights were to be obtained and Zaroxolyn (diuretic medication) 2.5 milligrams (mg) was to be administered once every day as needed (PRN) for a three pound weight gain. Review of the daily weight records revealed no daily weights obtained on 12/08/19, 12/07/19, 11/29/19, 11/24/19, 10/18/19, 10/12/19, 10/05/19, 09/30/19, 09/25/19, 09/20/19 or 09/12/19. Further review of the daily weights found a three pound weight gain on 12/5/19 (3.1 pounds), 11/27/19 (3.4 pounds), 11/20/19 (4.3 pounds), 11/14/19 (6.0 pounds), 11/9/19 (3.3 pounds), 11/05/19 (3.6 pounds), 11/01/19 (3.6 pounds), 10/23/19 (9.5 pounds), 10/14/19 (4.5 pounds), 10/11/19 (6.7 pounds), 10/09/19 (8.7 pounds), 09/23/19 (3.8 pounds), 09/19/19 (5.3 pounds) and 09/11/19 (17.3 pounds). Review of the Medical Administration Record (MAR) for the months of September to December 2019 revealed the PRN Zaroxolyn was administered twice on 11/25/19 and 10/09/19. Review of the facility policy titled Weight with revision date of 11/14 revealed all residents would be weighed within 24 hours of admission/readmission unless not indicated or refused. Weight would be obtained daily for three days and then weekly times four weeks and then monthly thereafter or at the direction of the Dietitian/Physician. Interview with the Director of Nursing and Registered Nurse (RN) #567 on 12/11/19 at 2:20 P.M. verified daily weights were not obtained as ordered and PRN Zaroxolyn orders were not followed as indicated by the physician when the resident had a gain of three or more pounds as noted above. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 11 of 18 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 365494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Hill Community 12200 Strausser St NW Canal Fulton, OH 44614 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 observation, record review and interview the facility failed to ensure Resident #1 received thickened liquids as ordered and Resident #6, #20, #42 and #46 received nutritional supplements as ordered to promote optimal nutrition. This affected five residents (#1, #6, #20, #42 and #46) of seven residents reviewed for nutrition and hydration. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with the diagnoses of acute osteomyelitis, pneumonitis due to the inhalation of food and vomit, diabetes, diabetic neuropathy, acute respiratory failure, epilepsy, sepsis, cerebral infarction, mild cognitive impairment, malignant neoplasm of thyroid gland, delirium, apnea, and convulsions. Review of the five day Minimum Data (MDS) Set 3.0 assessment dated [DATE] revealed Resident #1 had intact cognition, required supervision with eating, was on a therapeutic diet and held food and liquids in his mouth and cheeked after meals. Review of the physician's order dated 12/04/19 revealed Resident #1 had an order for honey consistency liquids. Review of the dietary note dated 12/05/19 at 10:54 A.M. revealed Resident #1 was upgraded to a regular diet with a mechanically soft texture and honey consistency liquids. Observation on 12/09/19 at 12:22 P.M. revealed Resident #1 had received an eight ounce glass of regular thin iced tea. The resident had drank half the glass of iced tea. Review of the lunch diet card dated 12/09/19 revealed Resident #1 was to receive honey think liquids. An interview on 12/09/19 at 12:24 P.M. State Tested Nursing Assistant #533 indicated the resident was to get honey think liquids. She verified at this time Resident #1 had not received honey thick liquids. 2. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with the diagnoses of Parkinson's disease, hemoptysis, malignant neoplasm of the lungs, cognitive communication deficit, over-active bladder, insomnia, anxiety disorder, dysphagia, diabetes and major depression. Review of the quarterly MDS assessment dated [DATE] revealed Resident #6 had intact cognition, required supervision with eating and received Hospice services. Review of the December 2019 physician's orders revealed Resident #6 had an order dated 04/27/18 to receive a food snack twice a day to prevent weight loss and a order dated 10/30/19 for nutritional juice once a day for weight maintenance. Review of the A.M. supplement sheet dated 12/11/19 revealed Resident #6 was to receive a Magic cup (frozen supplement). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 12 of 18 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 365494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Hill Community 12200 Strausser St NW Canal Fulton, OH 44614 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 the December 2019 Medication Administration Record (MAR) revealed Resident #6 consumed zero percent of her food snack. Observation on 12/11/19 at 1:30 P.M. revealed supplements for the 10:00 A.M. supplement administration on the back hall of the second floor for four residents (Resident #6, #20, #42 and #46) were still sitting on nurse's station. The magic cup was melted and the two nutritional juices and boost glucose control were warm to touch. An interview at this time with STNA #512 revealed she did not know why the morning supplements had not been passed out to the residents. She verified they were warm and had not been administered to Resident #6 #20, #42 and #46. An interview on 12/11/19 at 1:44 P.M. with Dietary Aide #604 revealed the tray of morning supplements were brought up to the unit at 10:00 A.M. He had brought up to the unit the 2:00 P.M. tray of supplements and took the tray of warm supplements back to the kitchen. 3. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with the diagnoses of sarcoidosis, muscle weakness, generalized osteoarthritis, gastroesophageal reflux disease, heart failure, vascular dementia, opioid dependence, malignant neoplasm of breast, chronic kidney disease, atherosclerotic heart disease, major depression, generalized anxiety disorder, dementia, acute gastritis, dysphagia, and cognitive communication deficit. Review of the significant change MDS 3.0 assessment dated [DATE] revealed Resident #20 had moderately impaired cognition, required extensive assistance with eating and received Hospice services. Review of the December 2019 physician's orders revealed Resident #20 had an order dated 12/10/19 for a Magic cup two times a day and an order dated 10/02/19 for nutritional juice three times a day. Review of the A.M. supplement sheet dated 12/11/19 revealed Resident #20 was to receive a nutritional juice. Review of the December 2019 MAR revealed Resident #20 consumed 180 milliliters (mls) of her nutritional drink. Observation on 12/11/19 at 1:30 P.M. revealed supplements for the 10:00 A.M. supplement administration on the back hall of the second floor for four residents (Resident #6, #20, #42 and #46) were still sitting on nurse's station. The magic cup was melted and the two nutritional juices and boost glucose control were warm to touch. An interview at this time with STNA #512 revealed she did not know why the morning supplements had not been passed out to the residents. She verified they were warm and had not been administered to Resident #6 #20, #42 and #46. An interview on 12/11/19 at 1:44 P.M. with Dietary Aide #604 revealed the tray of morning supplements were brought up to the unit at 10:00 A.M. He had brought up to the unit the 2:00 P.M. tray of supplements and took the tray of warm supplements back to the kitchen. 4. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease, aphasia, anorexia, dysphagia, anxiety disorder, diabetes, and dementia. Review of the significant change MDS 3.0 assessment dated [DATE] revealed Resident #42 had impaired cognition, required extensive assistance with eating and received Hospice services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 13 of 18 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 365494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Hill Community 12200 Strausser St NW Canal Fulton, OH 44614 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 the December 2019 physician's orders revealed Resident #42 had an order dated 05/15/19 for 80 milliliters of 2 Cal HN (liquid supplement) and an order dated 11/08/19 for Boost Glucose Control ( liquid supplement). Review of the A.M. supplement sheet dated 12/11/19 revealed Resident #42 was to receive a Boost Glucose Control. Review of the December 2019 MAR revealed Resident #42 consumed zero milliliters (mls) of her Boost Glucose Control. Observation on 12/11/19 at 1:30 P.M. revealed supplements for the 10:00 A.M. supplement administration on the back hall of the second floor for four residents (Resident #6, #20, #42 and #46) were still sitting on nurse's station. The magic cup was melted and the two nutritional juices and boost glucose control were warm to touch. An interview at this time with STNA #512 revealed she did not know why the morning supplements had not been passed out to the residents. She verified they were warm and had not been administered to Resident #6 #20, #42 and #46. An interview on 12/11/19 at 1:44 P.M. with Dietary Aide #604 revealed the tray of morning supplements were brought up to the unit at 10:00 A.M. He had brought up to the unit the 2:00 P.M. tray of supplements and took the tray of warm supplements back to the kitchen. 5. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease, heart failure, moderate protein calorie malnutrition, vascular dementia without behavioral disturbance, major depressive disorder, chronic kidney disease with heart failure, aphasia and dementia without behavioral disturbance. Review of the significant change MDS 3.0 assessment dated [DATE] revealed Resident #46 had severely impaired cognition, require extensive assistance with eating and was received Hospice services. Review of the December physician's orders revealed Resident #46 had an order for nutritional juice three times a day for weight management dated 09/10/19. Review of the A.M. supplement sheet dated 12/11/19 revealed Resident #46 was to receive a nutritional juice. Review of the December 2019 MAR revealed Resident #46 consumed 120 mls of his nutritional juice. Observation on 12/11/19 at 1:30 P.M. revealed supplements for the 10:00 A.M. supplement administration on the back hall of the second floor for four residents (Resident #6, #20, #42 and #46) were still sitting on nurse's station. The magic cup was melted and the two nutritional juices and boost glucose control were warm to touch. An interview at this time with STNA #512 revealed she did not know why the morning supplements had not been passed out to the residents. She verified they were warm and had not been administered to Resident #6 #20, #42 and #46. An interview on 12/11/19 at 1:44 P.M. with Dietary Aide #604 revealed the tray of morning supplements were brought up to the unit at 10:00 A.M. He had brought up to the unit the 2:00 P.M. tray of supplements and took the tray of warm supplements back to the kitchen. Review of the undated facility policy, titled Supplements/Nourishments, revealed nourishments would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 14 of 18 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 365494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Hill Community 12200 Strausser St NW Canal Fulton, OH 44614 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 FORM CMS-2567 (02/99) Previous Versions Obsolete be available to the residents who required additional supplementation due to physical conditions such as consumption of a small amount of food at meals, need to gain weight , receiving nutrient depleting medications or modified diet guidelines. Nourishments would be prepared by the Dining Services Department and delivered to the nurses' stations. Each nourishment would be labeled with resident's name, room number, product, date and time the nourishment was to be given. Upon receipt of the nourishments, nursing personnel was responsible for delivering the nourishments to specified residents and assisting the residents as necessary. Event ID: Facility ID: 365494 If continuation sheet Page 15 of 18 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 365494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Hill Community 12200 Strausser St NW Canal Fulton, OH 44614 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. Based on record review and staff interview the facility failed to ensure Resident #36, who received as needed anxiolytic medications had proper physician documentation for an indication for use. This affected one resident (#36) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #36's medical record revealed an admission date of 02/02/16 with diagnoses that included anxiety, schizoaffective disorder and borderline personality. Further review of the physician's orders revealed long term use of Ativan (anxiolytic medication) one milligram (mg) every eight hours as needed (PRN) for 120 days. The PRN Ativan was reordered on 08/06/19 and 12/10/19. Further review of the medical record found no evidence of any progress notes from Resident #36's physician, nurse practitioner or psychiatrist documenting the rationale for using the PRN Ativan longer than a 14 day period. Interview with the Director of Nursing and Registered Nurse (RN) #567 on 12/11/19 at 2:20 P.M. verified there was no documentation for rationale or indication of extended PRN Ativan usage for Resident #36. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 16 of 18 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 365494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Hill Community 12200 Strausser St NW Canal Fulton, OH 44614 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** Based on observation, record review and staff interview the facility failed to properly store medication in the [NAME] unit medication cart, [NAME] unit medication cart, and [NAME] unit medication cart. This affected nine residents (#26, #35,#43, #46, #56 #61 #62, #74, #83) and had the potential to affect all residents residing in the facility. The facility census was 87. Findings Include: 1. Observation on 12/12/19 at 10:50 A.M. of the [NAME] unit medication cart with Licensed Practical Nurse (LPN) #544 revealed a bottle of artificial tears eye drops not dated when opened for Resident #26, a bottle of artificial tears eye drops not dated when opened for Resident #74, a vial of Humalog insulin not dated when opened for Resident #62, and a vial of Lantus insulin not dated when opened for Resident #35. Interview on 12/12/19 at 10:55 A.M. LPN #544 verified a bottle artificial tears eye drops not dated when opened for Resident #26, a bottle of artificial tears eye drops not dated when opened for Resident #74, a vial of Humalog insulin not dated when opened for Resident #62, and a vial of Lantus insulin not dated when opened for Resident #35. 2. Observation on 12/12/19 at 10:57 A.M. of the [NAME] medication cart with LPN #610 revealed a bottle of Timolol maleate 0.25 percent (%) eye drops not dated when opened for Resident #61, an bottle of Travatan Z 0.004% eye drops not dated when opened for Resident #61, a bottle of Travoprost 0.004% eye drops not dated when opened for Resident #46, and a bottle for Latanoprost 0.005% eye drops not dated when opened for Resident #43. Interview on 12/12/19 at 11:00 P.M. LPN #610 verified a bottle of Timolol maleate 0.25% eye drops not dated when opened for Resident #61, an bottle of Travatan Z 0.004% eye drops not dated when opened for Resident #61, a bottle of Travoprost 0.004% eye drops not dated when opened for Resident #46, and a bottle for Latanoprost 0.005% eye drops not dated when opened for Resident #43. 3. Observation on 12//12/19 at 11:20 A.M. of the [NAME] medication cart with LPN #595 revealed a bottle of prednisone acetate eye drops for Resident #56 not dated when opened, a bottle for artificial tears eye drops not dated when opened for Resident #56, and a vial of Humalog insulin not dated when opened for Resident #83. Interview on 12/12/19 at 11:25 A.M. LPN #595 verified a bottle of prednisone acetate eye drops for Resident #56 not dated when opened, a bottle for artificial tears eye drops not dated when opened for Resident #56, and a vial of Humalog insulin not dated when opened for Resident #83. Review of the facility policy titled General Dose Preparation and Medication Administration, dated 01/01/13 revealed the facility staff should enter the date opened on the label of medications with shortened expiration dates examples; insulin, irrigation solutions, etc. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 17 of 18 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 365494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Hill Community 12200 Strausser St NW Canal Fulton, OH 44614 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 0825 Provide or get specialized rehabilitative services as required for a 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 ensure Resident #54 received therapy services as ordered after a hospitalization. This affected one resident (#54) of 18 residents reviewed for orders during the annual survey. Residents Affected - Few Findings include: Resident #54 was initially admitted to the facility on [DATE] with diagnoses including cerebral infarction, hemiplegia and hemiparesis affecting right dominant side, and dysphagia. Resident #54's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #54 had moderately impaired cognition scoring a 12 on the Brief Interview for Mental Status (BIMS) and required total dependence from two people for transfers. Resident #54's medical record revealed a hospital admission on [DATE] with a readmission to the facility on [DATE]. Further review of Resident #54's hospital transfer orders dated 11/19/19 revealed orders for Physical Therapy, Occupational Therapy, and Speech Therapy. Review of Resident #54's medical record revealed no documentation or orders from any of the three therapies after the readmission to the facility. Phone interview on 12/09/19 at 2:55 P.M. with Resident #54's representative revealed Resident #54 had not received any therapies since readmission to the facility and when the facility was questioned, the representative was informed therapy orders did not come from the hospital. Staff interview with Registered Nurse (RN) #547 on 12/10/19 verified Resident #54 did not receive any therapies, including therapy evaluations after his return from the hospital. RN #547 also stated the normal procedure for when a resident was either admitted or readmitted to the facility was to have one nurse enter the hospital or referring facility orders into the computer and another nurse then check the orders to ensure nothing was missed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 18 of 18