Health inspection·April 24, 2025

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on record review, policy review, and interview, the facility failed to ensure there was consistent communication between the facility and the dialysis center regarding Resident #48's health information and hemodialysis treatments. This affected one resident (Resident #48) out of one resident reviewed for dialysis. The facility census was 75. Residents Affected - Few Findings include: Review of the medical record for Resident #48 revealed an admission date of 07/14/23 with diagnosis including but not limited to paraplegia, end stage renal disease, acute kidney failure, and type 1 diabetes mellitus with hypoglycemia. Review of the physician's orders for April 2025 revealed orders for hemodialysis two times a week on Monday and Friday at the outside dialysis facility, send dialysis book with resident, obtain vital signs/assessment and post dialysis vital signs/assessment upon return, check vital sign pre and post dialysis (also check dialysis site) two times a day every Monday and Friday. Review of the dialysis communication binder for Resident #48 revealed only five (5) hemodialysis communication forms for January 2025 to April 2025, some were not completed accurately or at all. The first pre-dialysis communication form in the binder had no name or date, but had vital signs filled in the form. There was no signature of nurse who completed the pre-dialysis form. The post-dialysis form was completed by the dialysis unit with nurse signature and date of 01/10/25. There were no other forms located in the dialysis binder for Resident #48 for February 2025. The next communication form in the binder was dated 03/12/25 which included Resident #48's name date, and vital signs. There was no nurse signature of completion. The post-dialysis form was completed by the dialysis unit. The next communication form in the binder was dated 03/19/25 which included Resident #48's name and date. Nothing was completed on the pre-dialysis form and the post dialysis form was left blank. The next communication form in the binder was dated 03/26/25 which included Resident #48's name and date. Nothing was completed on the pre-dialysis form but it included the nurses' signature and date. The post dialysis form was left blank. The next communication form in the binder was dated 04/11/25 with the completed pre-dialysis information by the facility and post dialysis information by outside facility. Interview on 04/22/25 at 3:16 P.M. with Director of Nursing (DON) confirmed the dialysis communication forms were not being completed accurately or at all. DON confirmed the facility did not have all the dialysis communication forms for Resident #48 for all dialysis days. DON reported he just started the dialysis communication binder this year due to issues prior to getting notes for the dialysis facility. DON confirmed no other dialysis forms other than what is in the dialysis binder, to include only five (5) forms. DON reported there were no other dialysis communication forms available. Interview on 04/23/25 at 8:12 A.M. with Dialysis Registered Nurse (RN) 300 confirmed the outside dialysis facility didn't always receive the communication binder with forms completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 2 of 6 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 04/24/2025 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 0698 Level of Harm - Minimal harm or potential for actual harm Review of facility policy, Outpatient Dialysis Services/Peritoneal Dialysis, revised 03/2022, revealed the facility provides in-house peritoneal dialysis and facilitates outpatient dialysis services to assure uninterrupted provision of care across the continuum. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 3 of 6 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 04/24/2025 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure non-pharmacological interventions were attempted prior to administering Resident #13's as needed anti-anxiety medication. This finding affected one (Resident #13) of five residents reviewed for unnecessary medications. Findings include: Review of Resident #13's medical record revealed the resident was admitted on [DATE] with diagnoses including vascular dementia, cognitive communication deficit and anxiety disorder. Review of Resident #13's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #13's care plans did not reveal interventions including attempting non-pharmacological interventions prior to administering the resident's anti-anxiety medication. Review of Resident #13's physician orders revealed an order dated 03/07/25 to document nonpharmaceutical and pharmaceutical interventions in the nurses notes along with the effectiveness every shift for behavior monitoring; an order dated 03/21/25 (discontinued 04/21/25) for Lorazepam (anti-anxiety) 0.5 mg (milligrams) administer one tablet by mouth every eight hours as needed for anxiety/agitation; and an order dated 04/21/25 for Lorazepam 0.5 mg give one tablet by mouth every eight hours as needed for anxiety/agitation for six months. Review of Resident #13's medication administration records (MARS) from 04/01/25 to 04/22/25 revealed the Lorazepam anti-anxiety medication was administered on 04/01/25 at 2:08 P.M.; 04/03/25 at 9:24 P.M.; 04/04/25 at 8:44 P.M.; 04/05/25 at 12:15 P.M.; 04/06/25 at 12:01 P.M.; 04/06/25 at 8:52 P.M.; 04/09/25 at 9:35 A.M.; 04/11/24 at 10:57 A.M.; 04/12/25 at 9:57 P.M.; 04/13/25 at 10:10 P.M.; 04/16/25 at 8:44 A.M.; 04/18/25 at 6:36 P.M.; 04/20/25 at 11:21 A.M.; and 04/20/25 at 9:06 P.M. Review of Resident #13's progress notes from 04/01/25 to 04/22/25 revealed no evidence non-pharmacological interventions were attempted prior to administering the as needed anti-anxiety medication. Interview on 04/22/25 at 1:44 P.M. with the Director of Nursing (DON) confirmed Resident #13's medical record did not have evidence non-pharmacological interventions were attempted prior to administering as needed anti-anxiety medications. Interview on 04/23/25 at 8:38 A.M. with Registered Nurse (RN) MDS #188 confirmed Resident #13's care plans were not complete and accurate and did not include an intervention for staff to attempt non-pharmacological interventions prior to administering the resident's anti-anxiety medication. Review of the Antipsychotic/Psychotropic Drugs policy revised 01/31/23 revealed antipsychotic and psychotropic drug therapy shall be used only when it was necessary to treat a specific condition. Gradual dose reductions and behavioral interventions, unless contraindicated, would be used to reduce or discontinue the use of antipsychotic and psychotropic drugs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 4 of 6 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 04/24/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview and facility policy review the facility failed to implement enhanced barrier precautions during Resident #38's wound care. This deficient practice affected one resident (Resident #38) out of three residents reviewed for transmission based precautions. The facility census was 75. Residents Affected - Few Findings Include: Review of Resident #38's medical record revealed admission date 03/11/25 with diagnoses including but not limited to fracture of right shoulder, dislocation of right shoulder, dementia, and depression. Review of Resident #38's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #38 required assistance from staff to complete activities of daily living (ADL) tasks and required a sling to be worn on the right arm/shoulder related to a fractured right shoulder. Resident #38 had impaired cognition with a Brief Interview Mental Status (BIMS) score of five out of a possible 15. Review of Resident #38's physician orders dated 04/01/25 to 04/23/25 revealed an order dated 04/08/25 to cleanse spine with normal saline and pat dry. Apply Medihoney and cover with clean dry dressing. Change daily and as needed (PRN) if soiled, an order dated 04/08/25 to follow [NAME] Wound Care, and an order dated 04/21/25 for Resident #38 to be on enhanced barrier precautions (EBP) every shift for wound. Review of Resident #38's Treatment Administration Record (TAR) dated 04/08/25 to 04/22/25 revealed the order dated 04/08/25 to cleanse spine with normal saline and pat dry. Apply Medihoney and cover with clean dry dressing. Change daily and as needed (PRN) if soiled, was marked as completed daily. Review of Resident #38's at risk for skin alteration care plan dated 04/14/25 revealed Resident #38 had a pressure area Stage III to mid back with interventions including pressure reducing mattress and treatment as ordered, and enhanced barrier precautions (EBP) care plan related to chronic wounds (pressure ulcers) dated 04/22/25 with interventions including high contact resident care activities requiring EBP: performing wound care. Review of Resident #38's full skin assessment dated [DATE] revealed the initial wound assessment for pressure area to mid back measuring 5.8 centimeters (cm) by 1.0 cm by 0.1 cm with light drainage noted. Observation on 04/22/25 at 1:58 P.M. revealed Licensed Practical Nurse (LPN) #145 and LPN #190 completing wound dressing change for Resident #38. LPN #145 and LPN #190 entered Resident #38's room, washed their hands and donned gloves. Both LPN #145 and LPN #190 did not follow EBP protocol and don Personal Protective Equipment (PPE) prior to entering Resident #38's room. Further observation of Resident #38's room revealed there was no PPE cart available, there was no notification sign to reflect Resident #38 having EBPs, and there were no soiled linen bins for the used PPE to be placed after use. An interview on 04/22/25 at 2:15 P.M. with LPN #145 confirmed Resident #38 was ordered to have EBPs in place due to the wound located on the back and there was not a notification sign on the door, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365494 If continuation sheet Page 5 of 6 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 04/24/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete there was no PPE available outside the door for staff use, and there were no soiled linen bins in the room for soiled linen to be placed. Review of the facility's policy titled Isolation Precautions dated 03/2025 revealed Enhanced Barrier Protection (EBP) are used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning gown and gloves during high contact care activities. EBPs are indicated for residents with wounds, infection and/or indwelling medical devices. Event ID: Facility ID: 365494 If continuation sheet Page 6 of 6