Inspection·November 7, 2022

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 #24 was positioned properly in bed and had her meal tray placed within reach to allow the resident to eat in a timely manner following meal tray delivery. This affected one resident (#24) of seven residents reviewed for nutrition. Residents Affected - Few Findings include: Review of medical record revealed Resident #24 was admitted on [DATE] with diagnoses including pneumonia, dyspnea, dysphagia, emphysema and severe protein-calorie malnutrition. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 08/17/22 revealed Resident #24 required limited assistance fro two staff for bed mobility, limited assistance from one for transfers, and (staff) supervision for eating. The assessment revealed Resident #24 had moderately impaired cognition. On 11/02/22 at 11:56 A.M. observation revealed Resident #24 was lying in bed with the head of the bed up. The resident's lunch tray was observed sitting on the over bed table. The over bed table was on the right side of the resident's bed, about an arm length away. At the time of the observation, Resident #24 stated she needed pulled up in bed and could not reach the food on her tray. On 11/02/22 at 12:00 P.M. interview with State Tested Nursing Assistant (STNA) #95 revealed dietary staff passed the resident meal trays. STNA #95 verified Resident #24 needed repositioned/pulled up in bed and the over bed table placed in front of the resident so the resident could eat lunch. STNA #95 verified there were no plate warmers to help keep the food warm until the nursing staff were able to make sure residents were positioned properly and able to reach their food. A delay in ensuring the resident's positioning needs were met had the potential in the resident's food becoming cold before they ate it. On 11/02/22 at 12:10 P.M. interview with Dietary Aide #99 verified dietary staff took meal trays into residents rooms and placed them on the over bed tables. Dietary Aide #99 revealed dietary staff were not permitted to reposition/pull any residents up in bed. Nursing staff were responsible for uncovering the resident's food and making sure residents were in the correct position and able to reach their food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 2 of 24 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 11/07/2022 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #171 was provided privacy during personal (catheter) care. This affected one resident (#171) of one resident reviewed for privacy. Residents Affected - Few Findings include: Review of the medical record revealed Resident #171 was admitted to the facility on [DATE] with diagnoses including trigeminal neuralgia, COVID-19, Alzheimer's disease, benign prostatic hyperplasia, cognitive communication deficit, need for assistance with personal care, sepsis, urinary tract infection, delusional, major depressive disorder, dementia, hypertension, bladder neck obstruction, acute kidney failure and adult failure to thrive. Review of the October 2022 physician's orders revealed Resident #171 had an order for a urinary (Foley) catheter. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 10/16/22 revealed Resident #171 had severely impaired cognition. The assessment revealed the resident required extensive assistance from two staff for toilet use, one staff assist for personal hygiene and he had an indwelling catheter. On 11/02/22 at 3:15 P.M. State Tested Nursing Assistant (STNA) #39 was observed to provide catheter care to Resident #171. During the observation, the STNA failed to close the curtains to the outside windows for privacy. On 11/02/22 at 3:22 P.M. interview with STNA #39 verified she had not closed the curtains to the room for privacy during catheter care. On 11/07/22 at 10:45 A.M. interview with the Director of Nursing (DON) verified the curtains to the resident's room should have been closed during care. Review of the facility policy titled,Resident Rights, dated 01/20/19 revealed the facility would take measures to ensure each resident had the right to personal privacy. Personal privacy included accommodation, medical treatment, written and telephone communication, personal care, visits and meeting with family and resident groups but did not include the right to a private room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 3 of 24 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 11/07/2022 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #10's medical record revealed an admission date of 03/05/19 with diagnoses including Parkinson's disease, progressive supranuclear ophthalmoplegia, palliative care, dementia in other diseases pseudobulbar affect, anxiety disorder, major depressive disorder, psychotic disorder with hallucination due to known physiological condition (dated 08/13/20), dysarthria and anarthria, cognitive communication deficit, and chronic pain syndrome. Residents Affected - Few Review of the medical record for Resident #10 revealed no evidence a Pre-admission Screening and Resident Review (PASARR) was completed following the addition of the 08/13/20 diagnosis of psychotic disorder with hallucination due to a known physiological condition. Review of the 08/06/22 quarterly Minimum Data Set (MDS) 3.0 revealed the resident was noted to be moderately cognitively impaired. The assessment revealed the resident required extensive assistance from two staff for bed mobility, extensive assist from one staff for transfers, dressing, toileting, personal hygiene and bathing. Resident #10 was noted to be occasionally incontinent of bladder. On 11/02/22 at 12:31 P.M. interview with Director of Nursing (DON) #62 confirmed a PASARR was not previously completed for Resident #10 following the mental health diagnosis. The facility initiated a new PASARR on 11/02/22. Based on record review and interview the facility failed to ensure Resident #10 and Resident #41 had an accurate Pre-admission Screening and Resident Review (PASARR) completed. This affected two residents (#10 and #41) of three reviewed for PASARR. Findings include: 1. Review of the medical record revealed Resident #41 was admitted on [DATE] with diagnoses including dementia, cognitive communication deficit, altered mental status, major depressive disorder, anxiety, schizoaffective disorder, and schizophrenia. Review of the PASARR identification screen, dated 07/14/22 revealed Resident #41 did not have a diagnosis of dementia or any indications of serious mental illness which included schizophrenia, mood disorders, delusional disorders, severe anxiety disorder, or other mental disorders that may lead to a chronic disability. The PASARR indicated within the last six months the resident had not been prescribed any psychotropic medications which included antidepressants, antianxiety, antipsychotics, or mood stabilizers. Review of significant change Minimum Data Set (MDS) 3.0 assessment, dated 10/01/22 revealed Resident #41 had severely impaired cognition. Record review revealed Resident #41 received Cymbalta (antidepressant) 60 milligrams (mg) daily, Trazodone (antidepressant) 100 mg daily, and Valproic Acid (anticonvulsant/bipolar disorder) 500 mg four times a day. On 11/02/22 at 1:41 P.M. interview with the Administrator verified Resident #41's PASARR was not completed correctly. The Administrator verified Resident #41 had diagnoses of dementia, cognitive communication deficit, altered mental status, major depressive disorder, anxiety, schizoaffective (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 4 of 24 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 11/07/2022 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 0645 disorder, and schizophrenia upon admission which should have been noted on the PASARR. 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: 365494 If continuation sheet Page 5 of 24 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 11/07/2022 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview the facility failed to ensure Resident #10, who required staff assistance for activities of daily living, received adequate and proper assistance with meals. This affected one resident (#10) of 22 sampled residents. Residents Affected - Few Findings include: Review of Resident #10's medical record revealed an admission date of 03/05/19 with diagnoses including Parkinson's disease, progressive supranuclear ophthalmoplegia, palliative care, dementia in other diseases, pseudobulbar affect, anxiety disorder, major depressive disorder, psychotic disorder with hallucination due to known physiological condition, dysarthria and anarthria, cognitive communication deficit, and chronic pain syndrome. Review of the 08/06/22 quarterly Minimum Data Set (MDS) 3.0 assessment revealed Resident #10 was moderately cognitively impaired. The assessment revealed the resident required extensive assistance from two staff for bed mobility and extensive assistance from one staff for transfers, dressing, eating, toileting, personal hygiene, and bathing. Review of the 09/06/22 speech therapy notes for Resident #10 revealed modified barium swallow results indicated significant aspiration on all oral intakes including thin liquids, nectar thick liquids, honey thick liquids and puree solids. Precautions listed were aspiration, purred foods and thin liquids with no straw. Review of physician's orders for Resident #10 revealed an order, dated 09/06/22 for a regular pureed texture diet with thin liquids and no straws. On 11/02/22 at 8:32 A.M. observation of the second-floor dining room revealed Resident #10 being assisted with breakfast by State Tested Nursing Assistant (STNA) # 74. The resident was observed to have glasses of liquids with straws in them. Interview at the time of the observation with STNA # 74 confirmed she had been using a straw in Resident #10's beverages. STNA #74 stated she was told by other staff to use straws for drinks for the resident because it was easier. On 11/02/22 at 10:17 A.M. interview with Director of Nursing (DON) #62 confirmed Resident #10's diet order included a regular diet with pureed texture and thin liquids with no straws. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 6 of 24 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 11/07/2022 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of medical record revealed Resident #51 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including respiratory failure, syncope and collapse, retinal detachment, major depressive disorder, and anxiety disorder. Residents Affected - Some Review of activity participation documentation from August 2022 revealed Resident #51 attended seven group activities with 12 days of no documentation of the resident participating or refusing activities. The activity participation documentation from September 2022 revealed the resident did not attend any group activities with 25 days of no documentation of the resident participating in or refusing activities. The activity participation documentation from October 2022 revealed Resident #51 attended one group activity, and had 19 days with no documentation of the resident participating in or refusing activities. Review of the quarterly MDS 3.0 assessment, dated 10/04/22 revealed Resident #51 was cognitively intact and had moderately impaired vision. The assessment revealed the resident required (staff) supervision for bed mobility and transfers and extensive assistance from one staff for locomotion off the unit. On 10/31/22 at 10:13 A.M. interview with Resident #51 revealed her husband was no longer able to push her wheelchair to activities. The resident stated she was unable to attend any activities unless someone took her in her wheelchair. A care plan, initiated on 11/02/22 revealed Resident #51 was dependent on staff for activities, cognitive stimulation, and social interaction due to being blind. Interventions included the need for assistance to attend out-of-room activities as desired and staff to assist with activities of choice. On 11/02/22 at 2:59 P.M. interview with the Life Enrichment Director revealed Resident #51 sometimes attended happy hour and live music. The Life Enrichment Director revealed activity aides were to go to the resident's room and ask if the resident would like to attend an activity. If the resident did not want to attend an activity, the activity staff were to document the resident refused. The Life Enrichment Director verified Resident #51 was unable to attend activities without assistance. On 11/07/22 at 9:58 A.M. interview with the Administrator revealed activity staff had been educated on documenting if a resident did not want to attend an activity. The Administrator felt the documentation provided might not have reflected if Resident #51 was offered and refused to attend activities or if the resident was not offered assistance to activities. Based on observation, record review, facility policy and procedure review and interview the facility failed to develop and implement a comprehensive and individualized activity program to meet the total care needs of all residents. This affected five residents (#28, #51, #56, #57 and #171) of nine residents reviewed for activities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 7 of 24 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 11/07/2022 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 0679 Findings include: Level of Harm - Minimal harm or potential for actual harm 1. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, atherosclerotic heart disease, chronic lymphocytic leukemia, hypertension, need for assistance with personal care, psychosis, chronic kidney disease, diverticulosis, major depressive disorder, and anxiety disorder. Residents Affected - Some Review of the activity assessment, dated 05/09/22 revealed Resident #28 enjoyed exercise, music, talking, and social gatherings. The resident had been admitted to the facility for long-term care placement. The assessment noted the resident enjoyed conversations with others and her sister-in-law often took her out of the facility. Review of the plan of care revealed Resident #28 did not have an activities plan of care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/29/22 revealed Resident #28 had severely impaired cognition. The assessment revealed the resident required extensive assistance from staff for bed mobility, dressing, eating, toilet use and personal hygiene. Review of the August 2022 activity attendance records revealed Resident #28 had attended two activities, on 08/01/22 at 2:59 P.M. and 08/24/22 at 2:59 P.M. with no refusals documented for the whole month. Review of the September 2022 activity attendance records revealed Resident #28 had attended six activities, on 09/13/22 at 2:59 P.M., 09/14/22 at 2:59 P.M., on 09/15/22 at 2:59 P.M., on 09/18/22 at 2:59 P.M. and 09/28/22 at 2:59 P.M. with one refusal documented for the whole month. Review of the October 2022 activity attendance record revealed Resident #28 had not attended any activities with no refusals documented for the whole month. On 11/01/22 at 2:25 P.M., 11/02/22 at 9:40 A.M., 11:45 A.M., 12:12 P.M., and 3:26 P.M. and 11/03/22 at 9:40 A.M. and 1:44 P.M. revealed Resident #28 was observed in her room with no music playing, no television on and no activities being attempted with her. On 11/01/22 at 2:45 P.M. interview with Activity Director (AD) #124 revealed there were three activity personnel. They worked 8:00 A.M. to 4:00 P.M. or 9:00 A.M. to 5:00 P.M. She stated they rotated every week who conducted activities in the Memory Care Unit. She stated there were no times on the memory care activity calendars for activities because they were self-guided activities or the nursing staff provided the activities. She stated she just took coloring pages down to the unit for the residents to do. She placed them in the common area. She verified there was no Halloween craft on 10/31/22 because they had a Halloween party on the Long-Term Care (non memory care) side. She also verified there was no Let's Move on 11/01/22 in the morning because there was only one activity staff working and he had to be on the nursing home (non secured side) for exercise. On 11/02/22 at 11:00 A.M. interview with State Tested Nursing Assistant (STNA) #54 revealed nursing assistant staff did not have time to do activities for residents on the memory care unit. She indicated they just give the resident(s) coloring paged to color and turn music on. On 11/02/22 at 11:05 A.M. interview with STNA #78 revealed the nursing assistant try to do activities with the resident(s) when they had time but it was really hard when there was only one nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 8 of 24 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 11/07/2022 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 0679 assistant; it was hard to do. Level of Harm - Minimal harm or potential for actual harm On 11/02/22 at 2:10 P.M. interview with Social Service Designee (SSD) #24 verified Resident #28 did not have a activities plan of care completed. She stated she and AD #124 had just gone through and completed activity care plans because they were not up to date. Residents Affected - Some On 11/02/22 at 3:00 P.M. interview with AD #124 revealed when they record attendance they write on a blank piece of paper and then transfer it onto the resident's attendance log in the electronic medical record in point click care. She verified there was only a few activities documented for Resident #28 from August 2022 and September 2022 and none during October 2022. On 11/07/22 at 10:00 A.M. interview with the Administrator revealed activity staff were asking residents to attend activities, however they were not capturing who they asked and who refused. He stated the activity staff had been in-serviced on documentation. Review of the facility policy titled, Activity/Community Life Programs, dated 12/18/18 revealed an ongoing program of activities was designed to meet the needs of each resident. The resident had a right to participate and attend activities. Activity programs consisted of individual, small/large group and indoor and outdoor activities and outing which are designed to meet the needs and interests of each resident. 2. Review of the medical record revealed Resident #56 was admitted t o the facility on 11/30/21 with diagnoses including dementia, suicidal ideations, major depressive disorder, generalized anxiety disorder, hemiplegia, psychosis, need for assistance with personal care, cognitive communication deficit, dysphagia, adjustment disorder, repeated falls, prostate cancer and heart failure. Review of the plan of care, dated 04/22/19 revealed Resident #56 had little or no activity involvement related to his preference not to participate. Interventions included the resident was on Hospice care and all staff were to assist with channel preferences while in the room, offer to call his family on hi tablet, assistance to do activities, invite family members to activities, and remind him he may leave an activity at any time. Review of the Activity Assessment, dated 05/25/22 revealed Resident #56 enjoyed music, trivia, puzzles, religious events, television and movies. Review of the modification to the quarterly MDS 3.0 assessment, dated 08/22/22 revealed Resident #56 had severely impaired cognition. Review of the August 2022 activity attendance record revealed Resident #56 had attended no activities with no refusals documented for the whole month. Review of the September 2022 activity attendance record revealed Resident #56 had attended one activity on 09/18/22 at 2:59 P.M. with no refusals documented for the whole month. Review of the October 2022 activity attendance record revealed Resident #56 had attended no activities with no refusals documented for the whole month. On 11/01/22 at 2:23 P.M. and 4:23 P.M., 11/02/22 at 9:30 A.M., 11:02 A.M., 1:30 P.M. and 3:33 P.M. and 11/03/22 at 9:45 A.M. Resident #56 was observed in his room in bed with no music playing, no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 9 of 24 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 11/07/2022 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 0679 television on and no activities being attempted with him. Level of Harm - Minimal harm or potential for actual harm On 11/01/22 at 2:45 P.M. interview with Activity Director (AD) #124 revealed there were three activity personnel. They worked 8:00 A.M. to 4:00 P.M. or 9:00 A.M. to 5:00 P.M. She stated they rotated every week who conducted activities in the Memory Care Unit. She stated there were no times on the memory care activity calendars for activities because they were self-guided activities or the nursing staff provided the activities. She stated she just took coloring pages down to the unit for the residents to do. She placed them in the common area. She verified there was no Halloween craft on 10/31/22 because they had a Halloween party on the Long-Term Care (non memory care) side. She also verified there was no Let's Move on 11/01/22 in the morning because there was only one activity staff working and he had to be on the nursing home (non secured side) for exercise. Residents Affected - Some On 11/02/22 at 11:00 A.M. interview with State Tested Nursing Assistant (STNA) #54 revealed nursing assistant staff did not have time to do activities for residents on the memory care unit. She indicated they just give the resident(s) coloring paged to color and turn music on. On 11/02/22 at 11:05 A.M. interview with STNA #78 revealed the nursing assistant try to do activities with the resident(s) when they had time but it was really hard when there was only one nursing assistant; it was hard to do. On 11/02/22 at 3:00 P.M. interview with AD #124 revealed when they record attendance they write on a blank piece of paper and then transfer it onto the resident's attendance log in the electronic medical record in point click care. She verified there was only a few activities documented for Resident #56 as noted above. On 11/07/22 at 10:00 A.M. interview with the Administrator revealed activity staff were asking residents to attend activities, however they were not capturing who they asked and who refused. He stated the activity staff had been in-serviced on documentation. Review of the facility policy titled, Activity/Community Life Programs, dated 12/18/18 revealed an ongoing program of activities was designed to meet the needs of each resident. The resident had a right to participate and attend activities. Activity programs consisted of individual, small/large group and indoor and outdoor activities and outing which are designed to meet the needs and interests of each resident. 3. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety, muscle weakness, need for personal assistance, cognitive communication deficit, COVID-19, psychotic disorder, hypertension, insomnia,and depression. Review of the plan of care revealed Resident #57 did not have an activity plan of care. Review of the Activity Assessment, dated 06/14/22 revealed Resident #57 enjoyed reading, gardening/plants, music, cards, religious events, conversing, crafts, television and movies. Review of the August 2022 activity attendance records revealed Resident #57 had attended two activities, on 08/07/22 at 2:59 P.M. and on 08/25/22 at 2:59 P.M. with no refusals documented. Review of the September 2022 activity attendance record revealed Resident #57 had attended three activities, on 09/12/22 at 2:59 P.M., 09/13/22 at 2:59 P.M. and on 09/19/22 at 2:59 P.M. with one (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 10 of 24 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 11/07/2022 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 0679 refusal for the whole month. Level of Harm - Minimal harm or potential for actual harm Review of the October 2022 activity attendance record revealed Resident #57 had attended one activity, on 09/14/22 at 2:59 P. M with four refusals documented for the whole month. Residents Affected - Some Review of the quarterly MDS 3.0 assessment, dated 10/02/22 revealed Resident #57 had moderately impaired cognition. On 11/01/22 at 4:21 P.M., 11/02/22 at 9:20 A.M., 12:10 P.M., and 11/03/22 at 9:35 A.M. and 1:33 P.M. Resident #57 was observed sitting in her room with no music playing, no television on and no activities being provided for her. On 11/01/22 at 2:45 P.M. interview with Activity Director (AD) #124 revealed there were three activity personnel. They worked 8:00 A.M. to 4:00 P.M. or 9:00 A.M. to 5:00 P.M. She stated they rotated every week who conducted activities in the Memory Care Unit. She stated there were no times on the memory care activity calendars for activities because they were self-guided activities or the nursing staff provided the activities. She stated she just took coloring pages down to the unit for the residents to do. She placed them in the common area. She verified there was no Halloween craft on 10/31/22 because they had a Halloween party on the Long-Term Care (non memory care) side. She also verified there was no Let's Move on 11/01/22 in the morning because there was only one activity staff working and he had to be on the nursing home (non secured side) for exercise. On 11/02/22 at 11:00 A.M. interview with State Tested Nursing Assistant (STNA) #54 revealed nursing assistant staff did not have time to do activities for residents on the memory care unit. She indicated they just give the resident(s) coloring paged to color and turn music on. On 11/02/22 at 11:05 A.M. interview with STNA #78 revealed the nursing assistant try to do activities with the resident(s) when they had time but it was really hard when there was only one nursing assistant; it was hard to do. On 11/02/22 at 2:10 P.M. interview with Social Service Designee (SSD) #24 verified Resident #57 did not have a activities plan of care completed. She stated she and AD #124 had just gone through and completed activity care plans because they were not up to date. On 11/02/22 at 3:00 P.M. interview with AD #124 revealed when they record attendance they write on a blank piece of paper and then transfer it onto the resident's attendance log in the electronic medical record in point click care. She verified there was only a few activities documented for Resident #57 as noted above. On 11/07/22 at 10:00 A.M. interview with the Administrator revealed activity staff were asking residents to attend activities, however they were not capturing who they asked and who refused. He stated the activity staff had been in-serviced on documentation. Review of the facility policy titled, Activity/Community Life Programs, dated 12/18/18 revealed an ongoing program of activities was designed to meet the needs of each resident. The resident had a right to participate and attend activities. Activity programs consisted of individual, small/large group and indoor and outdoor activities and outing which are designed to meet the needs and interests of each resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 11 of 24 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 11/07/2022 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 0679 Level of Harm - Minimal harm or potential for actual harm 4. Review of the medical record revealed Resident #171 was admitted to the facility on [DATE] with diagnoses including trigeminal neuralgia, COVID-19, Alzheimer's disease, benign prostatic hyperplasia, cognitive communication deficit, need for assistance with personal care, sepsis, urinary tract infection, delusional, major depressive disorder, dementia, hypertension, bladder neck obstruction, acute kidney failure and adult failure to thrive. Residents Affected - Some Review of the Activity Assessment, dated 10/16/22 revealed Resident #171 enjoyed reading, sports, exercise, music, special events, cards, conversing, outdoors, social gatherings, television and movies. Review of the admission MDS 3.0 assessment, dated 10/16/22 revealed Resident #171 had severely impaired cognition. Review of the plan of care revealed Resident #171 did not have a activities plan of care. Review of the October 2022 activity attendance records revealed Resident #171 attended one activity, on 10/16/22 at 2:59 P.M. with no refusals documented for the whole month. On 11/01/22 at 4:22 P.M., 11/02/22 at 9:35 A.M., 11:20 A.M., 3:15 P.M. and 11/03/22 at 9:50 A.M. Resident #171 was observed in his room with no music playing, no television on and no activities being attempted with him. On 11/01/22 at 2:45 P.M. interview with Activity Director (AD) #124 revealed there were three activity personnel. They worked 8:00 A.M. to 4:00 P.M. or 9:00 A.M. to 5:00 P.M. She stated they rotated every week who conducted activities in the Memory Care Unit. She stated there were no times on the memory care activity calendars for activities because they were self-guided activities or the nursing staff provided the activities. She stated she just took coloring pages down to the unit for the residents to do. She placed them in the common area. She verified there was no Halloween craft on 10/31/22 because they had a Halloween party on the Long-Term Care (non memory care) side. She also verified there was no Let's Move on 11/01/22 in the morning because there was only one activity staff working and he had to be on the nursing home (non secured side) for exercise. On 11/02/22 at 11:00 A.M. interview with State Tested Nursing Assistant (STNA) #54 revealed nursing assistant staff did not have time to do activities for residents on the memory care unit. She indicated they just give the resident(s) coloring paged to color and turn music on. On 11/02/22 at 11:05 A.M. interview with STNA #78 revealed the nursing assistant try to do activities with the resident(s) when they had time but it was really hard when there was only one nursing assistant; it was hard to do. On 11/02/22 at 2:10 P.M. interview with Social Service Designee (SSD) #24 verified Resident #171 did not have a activities plan of care completed. She stated she and AD #124 had just gone through and completed activity care plans because they were not up to date. On 11/02/22 at 3:00 P.M. interview with AD #124 revealed when they record attendance they write on a blank piece of paper and then transfer it onto the resident's attendance log in the electronic medical record in point click care. She verified there was only one activity noted for Resident #171 during October 2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 12 of 24 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 11/07/2022 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete On 11/07/22 at 10:00 A.M. interview with the Administrator revealed activity staff were asking residents to attend activities, however they were not capturing who they asked and who refused. He stated the activity staff had been in-serviced on documentation. Review of the facility policy titled, Activity/Community Life Programs, dated 12/18/18 revealed an ongoing program of activities was designed to meet the needs of each resident. The resident had a right to participate and attend activities. Activity programs consisted of individual, small/large group and indoor and outdoor activities and outing which are designed to meet the needs and interests of each resident. Event ID: Facility ID: 365494 If continuation sheet Page 13 of 24 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 11/07/2022 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, record review and interview the facility failed to ensure Resident #19, who required staff assistance for activities of daily living (ADL) care received adequate urinary/urostomy catheter care to prevent urine odors and to promptly identify symptoms of a urinary tract infection. This affected one resident (#19) of three residents reviewed for dignity. Findings include: Review of Resident #19's medical record revealed an admission date of 08/24/21 with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris, acute kidney failure, dysphagia, oropharyngeal phase, dementia, and a history of urinary tract infections and bladder cancer. Review of the 08/15/22 annual Minimum Data Set (MDS) 3.0 assessment for Resident #19 revealed a Brief Interview of Mental Status (BIMS) score of 10 (out of 15) which indicated moderate cognitive impairment. The assessment revealed the resident required extensive assistance from one staff for dressing and personal hygiene, extensive assistance from two staff for transfers and toileting and was totally dependent upon staff for bathing. Resident #19 was noted to be occasionally incontinent of bowel. Review of care plan for Resident #19 revealed the resident had a urostomy catheter for malignant neoplasm of bladder and history of urinary tract infections (UTIs) which was initiated on 09/06/21. Interventions included monitoring and recording signs and symptoms of UTI which included burning, blood-tinged urine, cloudiness, no output, and foul-smelling urine. On 11/01/22 at 2:06 P.M. and 3:54 P.M., 11/02/22 at 7:45 A.M., 8:27 A.M., 12:13 P.M. and 3:50 P.M. and 11/03/22 at 9:56 A.M. and 12:15 P.M. observation revealed Resident #19 was in his room with a strong urine smell both in the room as well as outside his room in the hallway. On 11/03/22 at 10:08 A.M. interview with State Tested Nursing Assistant (STNA) #74 confirmed a strong urine smell in the hallway outside of Resident #19's room. On 11/03/22 at 10:11 A.M. interview with STNA #105 revealed she frequently smelled a strong urine smell coming from Resident #19's room. On 11/07/22 at 11:12 A.M. interview with Director of Nursing (DON) #62 revealed if a resident's room had a strong smell, staff would try to do catheter care more frequently and would add cranberry juice or cranberry pills to the resident's regimen. DON #62 revealed Resident #19 had a urostomy, had two UTIs within a two-month period, and was not on cranberry tablets or receiving cranberry juice. DON #62 revealed the resident had been observed taking the connector from the catheter bag and twisting it and try to empty it. Resident #19 had previously been provided education related to changing or emptying his catheter bag. DON #62 stated housekeeping does clean the resident's room but was not aware of them going in more frequently related to the urine odor. DON #62 confirmed there was no type of air freshener in or outside the resident's room. On 11/07/22 at 12:10 P.M. interview with DON #62 revealed signs of symptoms of urinary tract infections should be charted in the nursing progress notes. DON #62 confirmed the facility was unable to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 14 of 24 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 11/07/2022 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 0690 provide documentation of progress notes recording urine odor for Resident #19. 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: 365494 If continuation sheet Page 15 of 24 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 11/07/2022 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 #57 was provided a physician ordered weight loss supplement, failed to ensure the resident was provided the appropriate serving size of meat during the lunch meal on 10/31/22 and failed to ensure the resident was provided adequate and timely assistance with eating. This affected one resident (#57) of eight residents reviewed for food and nutrition. Residents Affected - Few Findings include: Review of the medical record revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety, muscle weakness, need for personal assistance, cognitive communication deficit, COVID-19, psychotic disorder, hypertension, insomnia, and depression. Review of the weight record for Resident #57 revealed an admission weight of 175 pounds on 06/10/11 and then a weight of 186 pounds on 06/11/22 and 06/12/22 and a current weight (10/27/22 note) of 160.4 for a 13.98 percent decrease. Review of the plan of care, dated 06/13/22 revealed Resident #57 was at increased risk for alterations in nutrition related to the diagnoses of dementia and body mass index indicates obesity, needs assistance with meals. Interventions included administer medication as ordered, food snack at 10:00 A.M. and bedtime, monitor/document/report to physician for signs and symptoms of dysphagia, monitor/document/report to physician for signs and symptoms of malnutrition, muscle wasting and significant weigh loss, weekly weights, laboratory tests, provide diet as ordered, dietitian to evaluate and make diet changes recommendation, and Boost Breeze two times daily with lunch and dinner. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/02/22 revealed Resident #57 had moderately impaired cognition and required limited (staff) assistance with eating. The MDS reflected the resident had a significant weight loss. Review of the October 2022 physician's orders revealed Resident #57 had an order for Boost Breeze supplement twice daily at lunch and dinner (initiated 09/26/22). Review of the dietary note, dated 10/27/22 revealed Resident #57 weighed 160.4 pounds and triggered for a significant weight loss for three months. The assessment noted the resident was eating 25 to 100 percent of all meals which was slowing improving. Maintenance interventions included Boost Breeze (supplement) two times a day at lunch and dinner, food snacks at 10:00 A.M. and at bedtime. The note indicated will continue the current plan and monitor for significant changes. On 10/31/22 at 11:45 A.M. observation in the Lakeside dining room revealed Dietary Aide #37 was serving pork loin to the residents which did not appear to be an appropriate portion size. Interview at 11:58 A.M. Dietary Aide #37 revealed she did not know what the appropriate serving size for the meat was supposed to be. Two meal carts had left the Lakeside serving area to be delivered to the units for residents, including Resident #57. On 10/31/22 at 12:05 P.M. review/observation of the portion size of the pork loin with Dietary Manager #20 revealed it was to weigh three or more ounces. Dietary Manager #20 went to the Lakeside/Willow dining room and weighed the pork loin, and it only weighed 1.8 ounces. He verified at this time (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 16 of 24 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 11/07/2022 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 Dietary Aide #37 had not served the residents in the Lakeside and [NAME] units the correct amount of pork loin. Dietary Manager #20 instructed the Dietary Aide to serve the remaining residents one and half pieces of meat. Resident #57 had not been provided one and half pieces of meat. Review of the menu for 10/31/22 revealed residents were to receive herb pork loin, red skinned mashed potatoes, corn and apple dump cake. Review of the facility spreadsheet for 10/31/22 revealed a serving size for the pork loin was three ounces. On 11/02/22 at 11:38 A.M. Resident #57 was observed to receive her meal. The resident received Shepard's pie (stew, mashed potatoes and a biscuit), cake, iced tea, and a fruit drink. She did not receive the Boost Breeze supplement. Continued observations on 11/02/22 from 11:38 A.M. to 12:31 P.M. revealed no staff member assisted Resident #57 to eat. The resident was assessed to require staff (limited) assistance. At 12:31 P.M. Resident #25 went into the room of Resident #57 and asked her to come out into the hallway and sit with him. State Tested Nursing Assistant (STNA) #78 stopped him and told him she would bring the resident out for him. She brought Resident #57 out into the lounge area without attempting to assist her to eat (the resident had not consumed the whole meal) or offer the resident anything else to eat. She verified she had not helped the resident eat or ask her if she wanted anything else to eat. She also verified at that time, Resident #57 had not receive a Boost Breeze on her meal tray. On 11/02/22 at 12:33 P.M. interview with Licensed Practical Nurse #110 revealed she had not attempted to assist Resident #57 to eat during the lunch meal. On 11/02/22 at 12:35 P.M. interview with STNA #54 revealed she had not attempted to assist Resident #57 to eat during the lunch meal. On 11/03/22 at 11:15 A.M. interview with Dietitian #67 revealed it was very important for the staff to follow the spreadsheet for the amount of protein because she calculated the daily protein intake for weight loss interventions. She stated Resident #57 had a boost supplement ordered and staff needed to make sure the resident was receiving it as she also based her interventions off the amount of Boost the resident's drank. Review of the undated facility policy titled, Feeding, revealed confusion, arm or hand immobility, injury, weakness or restriction on activities or positions may prevent a resident from feeding themselves. Feeding a resident then becomes a key nursing responsibility. Injured or debilitated residents may experience depression and subsequently anorexia. Meeting such residents' nutritional needs required determining food preferences, conduct feeding in a friendly, unhurried manner, encourage self-feeding to promote independence and dignity. This deficiency represents non-compliance investigated under Complaint Number OH00137226. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 17 of 24 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 11/07/2022 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation and staff interview the facility failed to maintain sufficient levels of staffing to ensure adequate supervision was provided to residents during meal service on the memory care unit. This affected nine residents (#1, #2, #6, #28, #33, #56, #64, #171 and #172) of 16 residents on the Memory Care Unit (Willow). Findings include: On 11/02/22 at 8:40 A.M. observation of the breakfast meal revealed there was one nurse, two State Tested Nursing Assistants and one Hospice aide in the Lakeside dining room assisting residents to eat On 11/01/22 from 8:50 to 9:05 A.M. there were no staff observed on the [NAME] (secured memory care) unit to provide supervision for Resident #1, #2, #6, #28, #33, #56, #64, #171 and #172 who were observed with their breakfast trays in front of them. On 11/01/22 at 9:10 A.M. interview with State Tested Nursing Assistant (STNA) #9 verified there were no staff on the [NAME] unit while the residents had their food. She indicated the staff had been pulled to help assist with feeding residents in the Lakeside dining room. On 11/07/22 at 10:45 A.M. interview with the Director of Nursing verified there should be a staff member on the [NAME] (secured care) unit at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 18 of 24 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 11/07/2022 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide emergency dental services when Resident #51 had a broken tooth. This affected one resident (#51) of one reviewed for dental services. Residents Affected - Few Findings include: Review of medical record revealed Resident #51 was admitted on [DATE] and readmitted on [DATE] with diagnoses including respiratory failure, syncope and collapse, retinal detachment, major depressive disorder, and anxiety disorder. Review of dental care services provided revealed Resident #51 had radiographic images on 12/09/21. An appointment note, dated 06/16/22 at 11:05 A.M. revealed Resident #51 had an appointment with an oral surgeon on 06/28/22. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 06/06/22 revealed Resident #51 had no chipped or cracked teeth. The quarterly MDS 3.0 assessment, dated 10/04/22 revealed Resident #51 was cognitively intact. Review of a nursing progress note, dated 10/16/22 at 5:00 P.M. revealed Resident #51 requested soft foods. The resident stated she had an x-ray and it broke off part of a bottom tooth and it was difficult to chew due to her teeth not aligning correctly. Soft foods were provided as requested. A nursing progress note, dated 10/17/22 at 1:34 A.M. revealed Resident #51 had been offered potato chips or a cookie for snack at bedtime. Resident #51 stated she could not eat the chips because they were too hard. The resident stated she had been having trouble with her tooth since she went to see the dentist and they broke her tooth. A physician order, dated 10/17/22 at 5:48 P.M. revealed Resident #51 was ordered a mechanical soft diet. Review of the care plan, dated 10/20/22 revealed Resident #51 was at increased risk for alteration in nutrition related to mechanically altered diet due to difficulty chewing due to broken tooth. Interventions included diet as ordered and registered dietician to evaluate and make diet change recommendations as needed. Review of care plan, dated 10/23/21 revealed Resident #51 had oral/dental health problems or the potential for oral/dental health problems related to upper dentures not fitting and lower partial being broken. Interventions included to coordinate arrangements for dental care as needed, monitor/document/report to medical doctor signs and symptoms of oral/dental problems that need attention such as pain and teeth missing, loose, broken, eroded, or decayed. On 10/31/22 at 10:23 A.M. interview with Resident #51 revealed the dentist had broken a tooth so she now received mechanical soft food. The resident also stated she needed new dentures but could not get bottom teeth pulled due to heart issues. An observation revealed Resident #51 had a few bottom teeth. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 19 of 24 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 11/07/2022 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 0791 Level of Harm - Minimal harm or potential for actual harm On 11/07/22 at 11:23 A.M. interview with the Director of Nursing (DON) verified there was documentation Resident #51 had a broken tooth. The DON stated the resident had seen an oral surgeon on 10/26/22 but there were no notes from the visit available. The DON was unsure why Resident #51 did not get new dentures and was not aware the resident had difficulty chewing or pain from broken tooth. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00137226. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 20 of 24 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 11/07/2022 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, review of the facility menu, review of the facility spreadsheet, review of facility policy and procedure and staff interview the facility failed to ensure all residents on the Lakeside unit and [NAME] unit were served the correct/proper serving size of meat during the lunch meal on 10/31/22. This affected 11 residents (#1, #6, #25, #32, #33, #42, #45, #49, #57, #61 and #171) of the 28 residents on the Lakeside and [NAME] units. The facility census was 72. Findings include: Review of the menu for 10/31/22 revealed residents were to receive herb pork loin, red skinned mashed potatoes, corn and apple dump cake. Review of the facility spreadsheet for 10/31/22 revealed the serving size for the pork loin was three ounces. On 10/31/22 at 11:45 A.M. observation in the Lakeside dining room revealed Dietary Aide #37 was serving pork loin to the residents which did not appear to be an appropriate portion size. On 10/31/22 at 11:58 A.M. interview with Dietary Aide #37 revealed she did not know what the appropriate serving size for the meat was supposed to be. Two meal carts had left the Lakeside serving area to be delivered to the units for residents, including Resident #1, #6, #25, #32, #33, #42, #45, #49, #57, #61 and #171. On 10/31/22 at 12:05 P.M. review/observation of the pork loin with Dietary Manager #20 revealed it should be three ounces or more. A pork loin from the main dining room on the first floor was weighed and noted to be 3.4 ounces. Dietary Manager #20 then went to the Lakeside/Willow dining room and weighed the pork loin which was only 1.8 ounces. Dietary Manager #20 verified Dietary Aide #37 was not serving the residents on the Lakeside and [NAME] units the correct amount/portion of pork loin. Dietary Manager #20 instructed the dietary aide to serve the remaining residents one and half pieces of meat. On 11/03/22 at 11:15 A.M. interview with Dietitian #67 revealed it was very important for the staff to follow the spreadsheet for the amount of protein because she calculated the daily protein intake for residents as part of weight loss interventions. Review of the facility policy titled, Food and Drink, dated 12/11/19 revealed the facility would provide each resident with a nourishing, palatable, well-balanced diet that met his/her daily nutritional and special dietary needs and drinks, including water and other liquids to maintain resident hydration, taking into consideration the preferences of each resident. This deficiency represents non-compliance investigated under Complaint Number OH00137226. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 21 of 24 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 11/07/2022 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #56 received food items in bite sized pieces as ordered and beverages/drinks per his preference. This affected one resident (#54) of six residents reviewed for nutrition. Finding include: Review of the medical record revealed Resident #56 was admitted to the facility on [DATE] with diagnoses including dementia, suicidal ideations, major depressive disorder, generalized anxiety disorder, hemiplegia, psychosis, need for assistance with personal care, cognitive communication deficit, dysphagia, adjustment disorder, repeated falls, prostate cancer and heart failure. Review of the modification to the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/22/22 revealed Resident #56 had severely impaired cognition. The assessment revealed the resident required (staff) supervision for eating and received a mechanically altered diet. Review of the October 2022 physician's orders revealed Resident #56 had an order for a regular mechanically soft diet with soft and bite sized pieces of food. On 11/02/22 at 8:55 A.M. observation of the breakfast meal revealed Resident #56 was sitting upright in bed with his breakfast in front of him. The resident had been served a bowl of oatmeal, Boost supplement, an orange fruit drink and a full-sized breakfast sandwich with ground ham, scrambled eggs and cheese. Review of the meal ticket, dated 11/02/22 revealed Resident #56's preferences were coffee with cream and splenda and a cranberry juice. The ticket also reflected the resident was to have soft food in bite sized pieces. On 11/02/22 at 9:10 A.M. interview with State Tested Nursing Assistant #9 verified Resident #56 did not receive coffee or cranberry juice and his food was not cut up in bite size pieces. Review of the facility policy titled, Food and Drink, dated 12/11/19 revealed the facility would provide each resident with a nourishing, palatable, well-balanced diet that met his/her daily nutritional and special dietary needs and drinks, including water and other liquids to maintain resident hydration, taking into consideration the preferences of each resident. This deficiency represents non-compliance investigated under Complaint Number OH00137226. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 22 of 24 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 11/07/2022 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 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. 2. On 10/31/22 at 12:16 P.M. observation of the lunch meal on the Memory Care unit revealed State Tested Nursing Assistant (STNA) #78 wore gloves while she was passing out meal trays without changing her gloves or washing her hands in between residents. During the observation, STNA #78 went into Resident #1's touched her blanket and table and then went into Resident #60's room with her meal tray and placed it on her tray table wearing the same gloves. The STNA Then went into Resident #6's room and placed the meal on the resident's bedside table, opened her silverware, cut up her pork, picked up her fork and gave the resident a bite of food. The STNA exited the room and then wearing the same gloves, took a meal tray into Resident #18's room, moved the resident's bedside table over to the bed and opened the utensils, set up the tray (opened apple sauce) and gave the resident a bite of applesauce all without changing her gloves or washing her hands. On 10/31/22 at 12:25 P.M. interview with STNA #78 verified she had not changed her gloves or washed her hands as she was passing out the meal trays as noted above. The STNA indicated she was concerned about the food getting cold so she did not stop to wash her hands or change her gloves. On 11/07/22 at 10:45 A.M. interview with the Director of Nursing revealed staff should not be wearing gloves to pass the meal trays unless they were cutting up a resident's food. He stated the staff needed to perform hand hygiene (hand washing) between residents. This deficiency represents non-compliance investigated under Complaint Number OH00137226. Based on observation, facility policy and procedure review and interview the facility failed to ensure staff washed their hands during the passing of the meal trays, failed to ensure the cleanliness of kitchen areas and timely and proper disposal of outdated/expired foods and failed to ensure dish machine temperatures were monitored to prevent contamination and/or food borne illness. This had the potential to affect 71 of 71 residents who received meal trays from the kitchen. The facility census was 72. Findings include: 1. On 10/31/22 at 8:32 A.M. observation during the initial kitchen tour revealed the following: a. The walk-in refrigerator had an unidentified spill which was white in color was noted under the right-side shelving unit that extended half of the length of the refrigerator and had also leaked into the refrigerator walkway. A saturated white towel was on the floor of the walkway. Observation while inside the walk-in freezer revealed two packages of undated frozen cinnamon rolls noted by themselves on the shelf. Observation of the reach in refrigerator revealed a plastic container with cut pears with a packaged use by date of 10/22/22, an open five-pound container of cottage cheese dated with a use by date of 10/17/22, and an open 64-ounce container of deli style tuna salad with a use by date of 10/20/22. All items were confirmed at the time of the observation by Dietary #80. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 23 of 24 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 11/07/2022 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 0812 Level of Harm - Minimal harm or potential for actual harm b. On 10/31/22 at 8:45 A.M. observation in the dish room revealed the gages for the dish machine were not working. Interview at the time of the observation with Dietary #37 revealed a service company had been out 10/24/22 to service the dish machine and replaced the booster. The dish machine booster read 184 degrees Fahrenheit. Dietary #37 confirmed the dish machine gages were not functioning and were on order for replacement. Residents Affected - Many On 10/31/22 at 9:54 A.M. interview with [NAME] #31 revealed the dish machine booster was set to 185 degrees Fahrenheit and temperatures had not been recorded on a log sheet since the replacement of the booster on 10/24/22. c. On 10/31/22 at 11:25 A.M. observation in the kitchen revealed ten packages of 12 count hot dog buns were observed with a use by date of 10/17/22, two 12 count packages of hot dog buns were observed with the use by date of 10/10/22, and one package of 12 count hot dog buns was observed with a use by date of 10/13/22. Interview at the time of the observation with Dietary Manager #20 confirmed the expired items as well as confirmation he was unable to provide a temperature log for the dish machine since the repairs were done on 10/24/22. Review of undated facility policy titled Labeling and Dating revealed all foods that had been opened must have the date of opening, the produce name if need be and a use by date. All foods that had been opened must have the date of opening. Most perishable foods were labeled for seven days. Review of 2005 facility policy titled Food Storage revealed all refrigerator units were always kept clean and in good working condition. Food should be covered, labeled and dated. Review of 06/2011 facility policy titled Dish Machine Temperature Log revealed the dishwashing staff would monitor and record dish machine temperatures to assure proper sanitizing of dishes. Staff would be trained to record dish machine temperatures for the wash and rinse cycles at each meal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 24 of 24