Health inspection·August 2, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. 9. Observations made during the annual survey from 07/25/22 through 08/02/22 of the facility revealed the following rooms had large areas of missing or gouged drywall behind the residents' bed, missing paint on the door entrance and yellow stained floor in the bathroom for residents (#26, #43, #35, #52, #51, #53, #88, #39, #01, #61, #69, #77, #03 and #207). Interview and observations on 08/01/22 at 2:44 P.M., with the Maintenance Assistant #117 verified the above observations of the large areas of missing or gouged drywall on the wall behind the bed, missing paint on door entrance and yellow stained floors in bathroom needed to be repaired. The Maintenance Assistant #117 stated all building repairs were on hold until the fire system was repaired. He had no specific date of when the repairs would begin. An interview on 08/01/22 at 2:56 P.M., with the Housekeeping Director #101 revealed the facility stripped and waxed the floor in every room and hallway one time per year. The Housekeeping Director stated currently the machine that stripped the floors was not working and was being repaired. She had no specific date of when the floor machine would be repaired. Based on observation and staff and family interviews, the facility failed to maintain a clean homelike environment. This affected 22 residents (#08, #18, #35, #50, #56, #58, #80, #86, #26, #43, #35, #52, #51, #53, #88, #39, #01, #61, #69, #77, #03, and #207) of 110 residents environment observed. The facility census was 110. Findings include: 1. Observation of Resident #50's room on 07/25/22 at 1:48 P.M. revealed the windows have what appears to be dark paint dripping down the panes and appeared hazy. An empty resident bed with no mattress in place was observed. Plastic and metal silverware, cups, and bowls were observed on the windowsill, on the small chair ledge around the room, on the floor of the closet, and on the bathroom floor. 2. Observation of Resident #18's room on 07/25/22 at 1:58 P.M. revealed scratches on the wall by the bed were grooved into the dry wall. The windows had what appeared to be dark paint dripping down the panes and were hazy. The floor was sticky when walked across and dark pieces of debris were observed on the floor. 3. Observation of Resident #35's room on 07/25/22 at 2:05 P.M. revealed the windows had clear and red jelly cling decorations that are melting and running down the window. A wooden board running down the entire wall at the head of the bed has a three-inch area broken out by Resident # 35's headboard. The wooden board also has multiple large scratches by the chair in the room. 4. Observation of Resident #56's room on 07/25/22 at 2:59 P.M. revealed the windows had what appeared to be dark paint dripping down the panes and appeared hazy. 5. Observation of Resident #80's room on 07/25/22 at 3:31 P.M. revealed the windows have what appeared to be dark paint dripping down the panes and appeared hazy. Multiple scratches were observed on the wall heating unit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 2 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm 6. Observation of Resident #08's room on 07/25/22 at 3:38 P.M. revealed the windows have what appeared to be dark paint dripping down the panes and appeared hazy. Interview with State Tested Nursing Assistant (STNA) #213 on 07/25/22 at 3:42 P.M., verified the above observations of Resident #08, #18, #35, #56, and #80's rooms. Residents Affected - Some 7. Observation of Resident #58's room on 07/26/22 at 7:45 A.M. revealed dark pieces of debris observed on the floor. The windows had what appeared to be dark paint dripping down the panes and appeared hazy. 8. Observation of Resident #86's room on 07/26/22 at 7:54 A.M. revealed the windows had what appeared to be dark paint dripping down the panes and appeared hazy. The floor was sticky when walked across and dark pieces of debris were observed on the floor. Interview on 07/28/22 at 4:25 P.M., with the son of Resident #72 revealed he was concerned about the lack of cleanliness including mold especially on the secured unit. Interview with STNA #202 on 07/26/22 at 8:06 A.M., verified the above findings for Resident #58, and # 86's rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 3 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete a comprehensive assessment using the resident assessment instrument (RAI) within 14 calendar days after admission. This affected one resident (#404) of three residents reviewed who were admitted within the past 30 days. The facility census was 110. Findings include: Review of the medical record for Resident #404 revealed an admission date of 07/17/22. The resident had diagnoses including fracture of right tibia, chronic kidney disease with dialysis three times a week, diabetes mellitus, rheumatoid arthritis, hypertension, and positive for COVID-19. Review of a Minimum Data Set (RAI) assessment dated [DATE], which documented it was in progress, revealed it only had sections C, D, E, and K completed. The other sections were not complete. The assessment had an assessment reference date of 07/30/22 and the facility system stated the assessment was two days past due. A comprehensive RAI had not been completed since admission. Interview with the Director of Nursing on 08/01/22 at 2:10 P.M., verified the admission comprehensive RAI had not been completed on time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 4 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 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** Based on medical record review, observation, and interview, the facility failed to accurately document a residents assessment on the resident assessment instrument. This affected one resident (#03) of 35 resident assessments reviewed. The facility census was 110. Residents Affected - Few Findings Include: Review of Resident #03's medical record revealed an admission date of 09/25/18. Diagnoses included Parkinson's disease, dementia without behaviors, congestive heart failure, osteoporosis and history of falls. Review of the physician orders for July 2022 revealed Resident #03 received passive range of motion for movement and prevention of contractures, admitted to hospice services, a regular pureed texture diet with thin liquids, double portions for weight loss and a Boost (supplement) 240 milliliters by mouth three times daily for weight loss. Review of the recorded monthly weights revealed Resident #03 weighed 150 pounds on 12/02/21, 145 pounds on 12/08/21, 148 pounds on 01/08/22, 138 pounds on 03/08/22, 133 pounds on 04/18/22, 128 pounds on 05/08/22 and 06/08/22 and 124 pounds on 07/11/22. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #03 was severely cognitively impaired with clear speech. Resident #03 required extensive assistance of two persons for transfers, bed mobility, toilet use, dressing, personal hygiene and bathing. Resident #03 required extensive assistance of one person for eating, and did not ambulate. The comprehensive assessment indicated Resident #03 did not have impaired range of motion to bilateral upper or lower extremities or weight loss and was not coded as receiving hospice services. Review of the quarterly MDS dated [DATE] indicated Resident #03 was rarely understood and severely cognitively impaired. Resident #03 required extensive assistance of two persons for transfers, bed mobility, toilet use, dressing, and bathing. Resident #03 required extensive assistance of one person for eating and personal hygiene. The comprehensive assessment indicated Resident #03 did not have impaired range of motion to bilateral upper or lower extremities. The assessment indicated Resident #03 had weight loss and was not on a prescribed weight loss regimen. Resident #03 was not coded as receiving hospice services. An observation on 07/27/22 at 8:36 A.M. of Resident #03 revealed the resident was lying in bed on his back with the head of the bed elevated about 35 degrees. Resident #03 left leg was across his body with the left foot hanging over the right side of the bed. An interview on 07/27/22 at 8:42 A.M. with Licensed Practical Nurse (LPN) #149 revealed Resident #03 did not get up out of bed due to his leg contracture and the resident was always in the same position. An interview on 07/27/22 at 11:20 A.M., with the Therapy Director #502 revealed Resident #03 came in to the facility with a fractured left hip, fell, and broke the hip replacement. Resident #03's family did not want another surgery and he returned to the facility for therapy. Occupational and Physical Therapy both worked with Resident #03 however the resident could not tolerate stretching or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 5 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few exercise. Resident #3 was unable to tolerate the hip abductor as well. Resident #03 does not have a formal restorative or exercise program, but received range of motion per nursing with care for his left leg contracture. An interview on 08/01/22 at 1:44 P.M. with LPN #108, who completed the MDS, verified the assessment was not accurate based on the information in Resident #03's medical record. LPN #108 said she reviewed the physician orders, the progress notes, and the other assessments to gather the information for the assessment. The facility did not have a policy regarding accurate MDS assessments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 6 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 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 Based on medical record review and staff interview, the facility failed to accurately complete the Preadmission Screening and Resident Review (PASRR) for an individual with a mental disorder. This affected one resident (#25) of five residents reviewed for PASRR. The facility census was 110. Residents Affected - Few Findings include: Review of the medical record for Resident #25 revealed an admission date of 12/30/21. The resident had a diagnosis of Schizophrenia (08/07/16) upon admission. An admission Minimum Data Set assessment completed 01/06/22 included a diagnosis of Schizophrenia. Review of a PASRR result notice dated 12/29/21 revealed a section for indications of serious mental illness, which included Schizophrenia. Schizophrenia had not been marked as a diagnosis for Resident #25. The result notice stated the resident had no indications of serious mental illness. Interview with Social Service Director #103 on 07/26/22 at 2:15 P.M. confirmed the PASRR review had not been accurately completed by the previous admission director. She confirmed Resident #25 had a diagnosis of Schizophrenia upon admission, which was not included on the PASRR screening form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 7 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 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 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the self-reported incident (SRI), interview, and policy review, the facility failed to ensure residents were discharged to a safe location. This affected one resident (#73) of four residents reviewed for discharge. The facility census was 110. Residents Affected - Few Findings include: Review of the medical record for Resident #73 revealed an admission date of 03/05/22 from acute hospital and was discharged on 07/06/22 to the local emergency department. Diagnoses included cerebral infarction, dissection of vertebral artery, type one diabetes mellitus with neuropathy, hypertension, anxiety, depression, chronic viral hepatitis C, hemiplegia affecting left non dominant side, ataxia, hypothyroidism, hyperlipidemia, muscle weakness, abnormalities of gait and mobility, needs assistance with personal care and other psychoactive substance abuse. Review of the unplanned discharge return not anticipated Minimum Data Set (MDS) dated [DATE] indicated Resident #73 was cognitively intact and independent with daily decision making. Resident #73 required supervision with bed mobility, transfers, ambulation, dressing, eating, toilet use, personal hygiene and bathing. The active discharge planning was already occurring for the resident to return to the community and no referral was needed to local contact agency. Review of the current physician orders for July 2022 revealed an order dated 07/06/22 for immediate discharge to the local hospital due to the resident was a danger to others. Review of the plan of care revealed no care plan related to behavioral issues that could be a danger to himself or others. The plan of care for potential altered mood disorder related to new environment, health issues, homeless, and need for stabilization included interventions of one to one visits as needed, administer medications as ordered, assess for depression, ensure a safe environment, identify stressors, monitor for behaviors and refer to a counseling source. The plan of care for diabetes mellitus included the interventions of avoid exposure to extreme heat and cold, monitor and inspect feet daily for open areas, blisters or sores, diabetic medication as ordered, monitor and document any psychosocial problem areas or financial problems with paying for special foods or medications and refer to social services or community resources to assist, monitor for understanding of disease process and refer to podiatry for foot/nail care. Review of the nursing progress dated from 03/05/22 through 07/06/22 revealed no documentation of behavioral issues or problems. Review of the social service admission note dated 03/07/22 at 4:38 P.M. revealed Resident #73 was admitted on [DATE] from a hospital located in another city. His diagnosis included a cerebral vascular accident. The resident was alert and oriented with good recall. Resident #73 was homeless with no income or community support. The discharge plan was very uncertain at this time. Review of the social service quarterly note dated 06/09/22 at 1:41 P.M. revealed Resident #73 was very pleasant, alert and oriented. The resident had adjusted well to his stay at the facility. Resident #73 discharge plans were uncertain due to the resident was homeless with no income and family/community support. Resident #73 enjoyed all the activities and interacting with staff and other residents. Review of the social services note dated 07/06/22 at 2:30 P.M. revealed Resident #73 was notified by the Administrator with the Unit Manager present, of his immediate discharge. Resident #73 was provided a copy of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 8 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 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 0660 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the discharge notice, appeal rights and the bed hold letter. The local police department was present to assist with discharge. The resident agreed to allow the facility to pack the personal belongings. The facility transported Resident #73 to local hospital emergency department. Review of the Ohio Notice of discharge date d 07/06/22 revealed Resident #73 was presented with the notice stated date of discharge was 07/06/22 due to the safety of other individuals was endangered. The specific reason was Resident #73 punched another resident in the face. The place of discharge was left blank. Review of the facility Discharge summary dated [DATE] at 3:57 P.M. revealed Resident #73 was discharged to the hospital due to aggressive behavior. Resident #73 was independent with activities of daily living, alert and oriented, and was moved to an alternate setting. Review of the SRI filed by the facility on 07/06/22 revealed Resident #65 alleged Resident #73 struck him in the face. The facility investigated and the report was unsubstantiated. An interview on 07/26/22 at 3:50 P.M. with the Director of Nursing (DON) revealed she was present at the facility on 07/06/22 the day of immediate discharge. The DON stated the facility completed and filed the SRI due to Resident #73 punched another resident in the face. However, the SRI was not substantiated due to lack of evidence. The DON stated the other resident (Resident #65 ) repeated the exact story to the police, the social services director and the physician who was on site. The DON stated she believed the resident, thus initiating an immediate discharge to Resident #73. Resident #73 was discharged to the emergency department at a local hospital around 4:00 P.M. on 07/06/22. The police escorted him out of the building. The residents physician was on site and wrote a progress note regarding Resident #73 behavior making him a threat to others at the facility. The next day, 07/07/22, Resident #73 arrived at the facility via van transportation (a cab) to retrieve his belongings. At that time the DON provided Resident #73 with a list of his medications, all of the medications on the list, the number of pills and the resident signed the list with a witness. The DON had not provided Resident #73 with insulin syringes or a means to monitor his blood sugars. The DON stated the resident had a Libre system on his arm to monitor his blood sugars, and the resident stated he had insulin syringes. The DON was asked if the Libre system expired or needed replaced, and she responded with yes the system needed replaced every 14 days. However, the DON did not provide any Libre system monitors to the resident. Review of the list of medications provided to Resident #73 by the DON and the instructions dated 07/07/22 revealed the following medications and discharge instructions were provided to the resident. 1. One vial of Lispro insulin 2. One vial of Lantus insulin 3. Sertraline (antidepressant) 39 tablets 4. Levothyroxine (a thyroid hormone) 26 tablets 5. Gabapentin (anticonvulsant) 6 tablets 6. Busperione (antianxiety) 15 tablets (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 9 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 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 0660 7. Topiramate (anticonvulsant) 60 tablets Level of Harm - Minimal harm or potential for actual harm 8. Tamsulosin (urinary retention medication) 22 capsules 9. Atorvastatin (a medication for high cholesterol) 29 tablets Residents Affected - Few 10. Hydroxyzine hydrochloride (antihistamine) 15 tablets 11. Ibuprofen (pain reliever) 18 tablets 12. Sertraline (antidepressant) 14 tablets An interview on 07/26/22 at 3:55 P.M., with the Administrator revealed Resident #73 had punched another resident in the face and that was grounds for immediate discharge. The Administrator stated she was informed of the incident around 2:20 P.M. on 07/06/22 and immediately began an investigation. The Administrator completed and submitted the SRI but did not substantiate the incident due to lack of evidence. Yet the Administrator felt strongly about discharging Resident #73 immediately due to the incident. Review of the physician discharge progress note dated day of service as 07/06/22, untimed, revealed the chief complaint was urgent evaluation due to aggressive behavior. Per staff reports, the staff heard noises in a resident's room, and found Resident #73 in another resident's room (Resident #65) where Resident #73 had Resident #65 cornered and was in his face. Upon further evaluation, bruising was noted to the left side Resident #65 face. Resident #65 stated Resident #73 hit him in the face two times and kicked him in the back several times. Resident #65 stated he had not defended himself. A formal investigation was initiated per the facility Administrator. Also the local police department was contacted and conducted an investigation. The case was discussed with the facility Administration including the DON and social services. The safety of the residents especially the vulnerable residents was discussed and an immediate discharge for Resident #73 was initiated. Resident #73 was transported to local hospital emergency department. This information was discussed with the resident who voiced understanding of the situation however, denied the charges. An interview on 07/27/22 at 2:17 P.M., with the Ombudsman revealed she felt the system as a whole failed Resident #73. The Ombudsman stated the resident called her on 07/06/22 around 3:00 P.M. and stated he was scared and had no place to go. Resident #73 stated the facility was kicking him out. At that point the Ombudsman contacted the Administrator who stated Resident #73 was being discharged to the local emergency department for an evaluation for an isolated incident involving another resident. On 07/07/22, (unable to recall the time), the Ombudsman contacted the facility to check on the resident and to ensure he returned from the hospital. The nurse (no name) stated Resident #73 was discharged from the facility. The Ombudsman then called social services at the local hospital and was informed the resident was sent home. The Ombudsman stated the resident doesn't have a home, and inquired what address he was discharged to. The social worker stated the address of discharge was 230 Cherry Street (the facility's address). The Ombudsman called the facility again and spoke to the Administrator who stated after further investigation the incident was not isolated and the facility issued the resident a discharge to the local hospital. The Ombudsman stated to the Administrator, The hospital was not a safe place for discharge. The Administrator responded with, He (Resident #73) was given his medications and belongings. That was the end of the conversation. The Ombudsman has no forwarding address, phone number or any information as to the whereabouts of Resident #73. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 10 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 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 0660 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview on 07/27/22 at 2:29 P.M. with social services #500 at the emergency department of the local hospital revealed (per residents chart) Resident #73 was discharged to a friends house with a friend. There was no contact information listed or address. The prior note dated 07/07/22 untimed stated the hospital called and notified the facility Resident #73 needed his medications. The facility Administrator stated the resident would not be allowed inside the facility, however, the Administrator stated someone would meet the resident outside with his medications and belongings. Review of the facility policy titled Admission, Transfer and Discharge Register dated 06/08 revealed residents would have a safe discharge. This deficiency substantiates Complaint Number OH00134241. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 11 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff and resident interview, the facility failed to provide assistance with adequate nail care, hair care and bathing. This affected one resident (#95) of three residents reviewed for activities of daily living. The facility census was 110. Residents Affected - Few Findings include: Review of the medical record for Resident #95 revealed an admission date of 09/30/19 with diagnosis of exacerbation of chronic obstructive pulmonary disorder, weakness, congestive heart failure and hypertension. Review of the annual Minimum Data Set (MDS) dated [DATE] indicated Resident #95 had mild cognitive impairment with behaviors. Resident #95 required extensive assistance of two persons for bed mobility, transfers, dressing, and toilet use. Resident #95 required extensive assistance of one person for bating and limited assistance of one person for personal hygiene. Review of Resident #95's shower/bathing documentation from 07/01/22 through 07/26/22 revealed the resident refused a shower/bath on 07/01/22 and received a shower on 07/26/22. There were no other showers or baths documented as offered or received. Observations on 07/25/22 at 11:30 A.M., on 07/28/22 at 12:52 P.M. and on 08/01/22 at 1:14 P.M. revealed Resident #95 had long, jagged fingernails with black substance under the fingernails and his hair was unkempt and oily. An interview on 07/28/22 at 12:52 P.M., with Resident #95 revealed he was not sure when he last had a shower or a bath. An interview on 07/28/22 at 3:42 P.M., with State Tested Nursing Assistant (STNA) #210 revealed a bath/shower would include nail and hair care. An interview on 08/01/22 at 1:18 P.M., with Licensed Practical Nurse (LPN) #149 confirmed Resident #95 had long, jagged, soiled fingernails and oily hair. The facility did not provide a policy on showers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 12 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident and staff interview, and policy review, the facility failed to ensure staff transferred a resident who was non weight bearing on one leg safely. This affected one resident (#404) of five residents reviewed for falls. In addition, the facility failed to ensure adequate supervision of smoking materials for resident's who smoked. This affected three residents (#30, #66, and #451) of three residents reviewed for smoking. The facility identified 27 residents (#02, #09, #10, #12, #14, #16, #21, #30, #33, #38, #47, #48, #64, #65, #67, #70, #74, #76, #77, #78, #79, #83, #88, #89, #94, #100, and #457) who smoked at the facility. Residents #66 and #451 were not identified by the facility as smokers. In addition, the facility failed to provide adequate supervision of medication administration to ensure medications were not left at bedside. This affected one resident (#95) of one residents reviewed for accidents related to medications. The facility census was 110. Findings include: 1. Review of the medical record for Resident #404 revealed an admission date of 07/17/22. The resident had diagnoses including fracture of right tibia from a fall, chronic kidney disease with dialysis three times a week, and positive for COVID-19 (positive test on 07/16/22). A baseline plan of care dated 07/19/22 stated the resident was a two plus person physical assist with transfers, had a history of falls, and had fallen in the last month resulting in a right tibia fracture. A Minimum Data Set Assessment in progress dated 07/24/22 stated the resident had a Brief Interview for Mental Status score of 15, indicating intact cognition. A physician's order on 07/17/22 stated the resident was non weight bearing on the right leg. There was a physician's order dated 07/19/22 for physical therapy five times a week for four weeks and included therapeutic exercise, neuromuscular re-education, gait training therapy, and manual therapy techniques. There was a physician's order on 07/26/22 to be ready for pick up at 6:15 A.M. for dialysis on Tuesday, Thursday, and Saturday. (Returns around lunch time). Review of a physical therapy evaluation on 07/19/22 revealed Resident #404 was being seen after repair of a right leg fracture following a fall getting into a car. X-rays had shown fractures of the distal tibia/fibula and medial malleolus. Now being seen for therapy to improve deficits with mobility tasks. Was non weight bearing on the right lower extremity. The evaluation stated she felt unsteady when standing, unsteady when walking, and worried about falling. The resident had no complaints of pain. The evaluation stated she was tired after dialysis and demonstrated deficits with bed mobility and strength. She was unable to stand or ambulate on 07/19/22. Review of the physical therapy visit notes revealed on 07/20/22, 07/22/22, 07/25/22, 07/26/22, and 07/27/22 she had physical therapy with no pain present. Review of a physical therapy visit note on 07/28/22 by Physical Therapy Assistant (PTA) #500 revealed during physical therapy her left knee gave out during standing with PTA and Occupational Therapy Assistant on both sides. She was lowered to floor by therapists in a sitting position. Therapists then went to nursing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 13 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm A nurses note on 07/28/22 at 1:03 P.M. stated therapy staff notified this nurse that resident was lowered to the floor during a transfer. Resident #404 was observed sitting on the floor in her room next to her bed on her bottom. Resident assessed. No apparent injuries noted. Resident denies pain. Resident assisted to bed by hoyer lift. Residents Affected - Some A physician's order was obtained on 07/28/22 for a hoyer lift to be used for all transfers. Interview with Resident #404 on 07/28/22 at 3:30 P.M., revealed upon entering the room the resident was visibly crying. She stated that earlier in the day, two therapists were helping her to stand. She stated her right left was already broken. She stated she had told the therapists she was weak and did not want to try to stand since she had just returned from dialysis that morning. She stated they had her stand anyway. She stated her left leg buckled and she went down to the floor. She stated the therapy staff had not used a gait belt during standing. ( A gait belt is a belt put around a patients waist that staff grasps to assist with getting up or walking and to prevent falls). She was upset, continued crying through the interview, and stated she was having bad pain in her right leg (seven out of 10 on a scale of one to 10). She stated she would be seeing the orthopedic physician on 07/29/22 for a follow up. Interview with Occupational Therapy Assistant (OTA) #501 on 07/28/22 at 3:35 P.M. revealed she had assisted PTA #500 with providing therapy for Resident #404 on 07/28/22. She stated that while standing, the resident's left knee gave out. She stated the resident was non weight bearing on the right leg. She stated they had not applied a gait belt to the resident and were holding onto her underwear. She stated the resident was lowered to the floor. She confirmed a gait belt should have been applied and made it easier to hold onto and steady a patient. She stated nursing was then notified of the resident being on the floor. A Nurse Practitioner note on 7/29/22 at 11:42 A.M. revealed she was asked to see Resident #404 due to a fall on 07/28/22. The note stated she was in care for closed right tibia fracture with surgical intervention. Is seeing orthopedic physician today for follow up. Resident stated she was working with physical therapy when she got weak and her legs just went out from under her. She is non weight bearing on the right leg and she took the brunt of the fall/slide on her left leg. Complaining of ankle feeling loose or stretched from the event but no pain. She stated she can not take her prescribed pain medication due to constipation. The note stated: Pain in left leg. Ensure gait belt was used at all times when patient is allowed to stand again (currently on hoyer lift orders). Resident #404 was seen by the orthopedic physician on 07/29/22. X-rays were completed and showed no issues. The note indicated the resident should remain non weight bearing on the right leg but could now ambulate with crutches. Review of a physical therapy note on 07/29/22 revealed the resident was having pain with movement in bilateral lower extremities of 8 out of 10 on a scale of ten. The noted stated she had seen the orthopedic physician and no damage was done from incident the prior day. Interview with Director of Rehab #502 on 08/01/22 at 8:15 A.M. revealed therapy staff should use a gait belt for all transfers and all patients that require hands on with transfers and gait. She stated that she was aware that a gait belt had not been used for Resident #404 resulting in a fall, as both therapists and the resident had told her. She stated that PTA #500 did not have a reason for not using a gait belt. She stated that she had spoken to the resident on 07/28/22 and the resident was crying and having pain in her right leg related to the fall. She stated the resident is weak in her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 14 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some left leg and non weight bearing on the right leg. She stated she felt it was better to work on transfers and walking on days opposite of her dialysis days. Interview with PTA #500 on 08/01/22 at 8:50 A.M. revealed Resident #404 had told him she was tired and weak due to dialysis on 07/28/22 prior to her fall. He confirmed he and OTA #501 assisted her to stand anyway. He stated they were finishing and her left knee gave out. The two therapists were on either side of her but did not have a gait belt on the resident. He did not provide a reason. She was lowered to the floor. He confirmed staff were to use a gait belt with transfers and ambulation. Review of the facility policy titled Safe Lifting and Movement of Residents, dated 2001 and revised July 2017 revealed in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts) and mechanical lifting devices. The facility also provided a form titled Proper Body Mechanics and Safe Transfer Techniques. It stated a gait belt is required to be used for all transfers. 2. Review of the medical record for Resident #66 revealed an admission date of 05/03/22 with diagnoses including diabetes, chronic kidney disease, hypertension, and heart failure. The resident had a physician's order dated 5/17/22 for oxygen at two liters per nasal cannula to keep oxygen saturation greater than 90 percent. Review of an admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Resident #66 required extensive assistance with transfers and supervision with locomotion and eating. Record review revealed there was no smoking assessment for Resident #66. There was no evidence the resident had been made aware of the smoking guidelines. Resident #66 was not identified by the facility as being a smoker. Interview with Resident #66 on 07/26/22 at 9:58 A.M., revealed she was a smoker and keeps her cigarettes and lighter in her room. A lighter was observed laying on her bedside table. She stated her cigarettes were in her drawer. An oxygen concentrator was observed in the room but the resident was not using the oxygen. She stated that if the nurses see the lighter or cigarettes, they will take them. A follow-up interview on 07/28/22 at 8:55 A.M. Resident #66 stated she was getting ready to go smoke. She stated a resident across the hall (Resident #79) was keeping her cigarettes for her. She went across the hall to Resident #79's room and he got a cigarette out of a packet in his drawer in his room and gave one cigarette to her. She then propelled her wheelchair down the hall to the exit door. The staff told her smoke time was not until 10:00 A.M. She was holding the cigarette in her hand and went back towards her room. Interview with Resident #79 on 07/28/22 at 12:45 P.M. confirmed he kept cigarettes for Resident #66 and that she came and got one this morning. Interview with Licensed Practical Nurse (LPN) #218 on 07/28/22 at 12:50 P.M. revealed residents are not supposed to keep cigarettes or lighters in their posession. She stated they are distributed by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 15 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff when it is time to smoke. She stated some residents do have cigarettes and lighters and refuse to give them up. She stated if staff saw residents with cigarettes or lighters, residents are supposed to give them up. She stated Resident #66 just recently started smoking and was getting her cigarettes somewhere other than from staff. Interview with the Administrator on 07/28/22 at 3:00 P.M. confirmed a smoking assessment had not been completed for Resident #66. She stated she was not aware that the resident smoked. 3. Review of the medical record for Resident #30 revealed an admission date of 03/15/22 and diagnoses including hemiplegia, congestive heart failure, diabetes, and chronic kidney disease. Review of a Resident and Care Team Partnership Agreement/Behavioral Contract signed by Resident #30 on 03/16/22 revealed it stated the resident understood there are designated smoking times and areas on the premises. All smoking material will be retained and stored by the nursing staff for all residents who choose to smoke. No fire igniting material is allowed on a resident's posession at any time and is prohibited. This includes my room and on my person. A designated staff member will supervise the residents during all smoke times. Violation of this contract and the above rules will result in my smoking privileges being revoked for a period to be determined by the seriousness of the violation. Consequences: first violation: smoking privileges are revoked for 24 hours; second violation: revoked for 48 hours; third violation: revoked for 72 hours; fourth violation: revoked for one week; fifth violation: will result in discharge of the facility. A Minimum Data Set assessment completed 05/04/22 indicated a BIMS score of 13, indicating intact cognition. It stated the resident required supervision with activities of daily living. Review of a smoking assessment completed 06/27/22 revealed the resident smoked two to five cigarettes per day. It stated the resident needed the facility to store lighter and cigarettes. It stated the resident had been educated on the smoking policy. Resident #30 had a plan of care for potential for injury related to smoking cigarettes. The care plan stated to secure cigarettes and lighters at nurses station and resident will smoke with supervision. Interview with Resident #30 on 07/28/22 at 2:01 P.M. revealed she kept her cigarettes in her purse. Observations at the time revealed a pack of cigarettes in her purse beside her in her wheelchair. Interview with LPN #218 on 07/28/22 at 12:50 P.M. revealed residents are not supposed to keep cigarettes or lighters in their posession. She stated they are distributed by staff when it is time to smoke. She stated some residents do have cigarettes and lighters and refuse to give them up. She stated if staff see residents with cigarettes or lighters, residents are supposed to give them up. 4. Clinical record review revealed Resident #451 was admitted on [DATE] with diagnoses including lung cancer and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. Resident #451 had a smoking agreement she signed dated 07/15/22 that all smoking materials were retained and stored by the nursing staff. The contract stated violations of this behavior contract and the smoking rules would result in revoked smoking privileges for a period to be determined. The fifth violation could resulted in the resident's discharge. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 16 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Review of the list of residents that smoked revealed #451 was not listed. Level of Harm - Minimal harm or potential for actual harm Review of a smoking assessment dated [DATE] revealed the resident could light her own cigarette and was a supervised smoker. According to the assessment, the resident was educated and agreed to comply with the smoking policy. Residents Affected - Some Interview with LPN #218 revealed residents were not supposed to keep cigarettes or lighters in their rooms or on their person. Smoking materials were distributed by staff. Resident #451 refused to give up her cigarettes and lighter to be secured. Observation on 07/28/22 at 1:52 P.M. of Resident #451 revealed she was sitting in her wheelchair in the hallway with a cigarette in her hand and lighter in lap. Interview with the resident at that time verified she kept her cigarettes and lighter with her belongings in her room at all times. The resident denied ever lighting a cigarette inside the facility. Interview on 07/28/22 at 2:00 P.M. with LPN #218 revealed last week an agency State Tested Nursing Assistant (STNA) she was not familiar with told her Resident #451 had an ignited cigarette in the hall of the facility. LPN #218 stated she immediately observed the resident holding an cigarette that was not ignited in the hall. LPN #218 verified she did not report the concern to anyone including the charge nurse and Director of Nursing (DON) and did not document a note the resident was failing to follow the smoking agreement and turning in smoking materials to nursing. Interview with the DON on 07/28/22 at 2:25 P.M. revealed she was not aware the resident was not turning in smoking materials to the nurses to be secured. Review of the policy titled Resident smoking/use of electronic cigarette policy with no date revealed no resident shall hold on their person or in their room cigarettes, tobacco, lighters or electronic cigarettes. Any family member or visitor must give all smoking materials to the charge nurse to be secured. The facility staff may check periodically to determine if residents had any smoking materials in violation of the policy and notify the charge nurse, Director of Nursing and Administrator. 5. Review of Resident #95 medical record revealed an admission date of 09/30/19 with diagnosis including exacerbation of chronic obstructive pulmonary disorder, weakness, congestive heart failure and hypertension. Review of the physician orders for 07/22 revealed Resident #95 was prescribed the following medications: Buspirone (antianxiety) 7.5 milligrams (mg) by mouth three times daily, Lisinopril (antihypertensive) 10 mg by mouth every morning, Baclofen (muscle relaxer) 20 mg by mouth at bedtime, Hydroxyzine-hydrochloride (antihistamine) 50 mg by mouth three times daily, Amlodipine Besylate (antihypertensive) 10 mg by mouth daily, Remeron (antidepressant) 7.5 mg by mouth at bedtime, Ferrous Sulfate (supplement) 325 mg by mouth two times daily, Thiamin B-1 (supplement) 100 mg by mouth daily, Melatonin (supplement for sleep) 9 mg by mouth at bedtime, Albuterol (a medication for bronchospasm) sulfate aerosol powder breath activated two puffs every eight hours as needed and Advair diskus (a bronchodilator) inhaler 500-50 mcg per dose one puff two times daily. Review of the annual Minimum Data Set (MDS) dated [DATE] indicated Resident #95 had mild cognitive impairment with behaviors including rejection of care. Resident #95 required extensive assistance of two persons for bed mobility, transfers, dressing, and toilet use. Resident #95 required limited assistance of one for personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 17 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the nursing progress notes revealed a note dated 07/25/22 at 2:00 P.M. indicated Resident #95 was education on the importance of taking his medications after being observed to pocket the medications in his mouth. A new order was received from the physician to crush all medications. The resident was aware. Review of the plan of care for Resident #95 revealed the resident had behaviors of verbally disruptive, resistive to care, false accusations, derogatory remarks regarding staff. Interventions did not address refusing to take medications, cheeking medications or spitting them out. Review of the self medication administration assessment dated [DATE] for Resident #95 revealed the resident was not capable of administering self medications. An observation on 07/25/22 at 8:50 A.M. of Resident #95 over the bed table across his lap in bed. On the over the bed table was two white pills and a hand held inhaler (unable to read label). Resident #95 refused to answer when asked why the medications were on the table. An interview on 07/25/22 at 8:52 A.M. with LPN #149 confirmed the two small white pills were on the over the bed table along with a hand held inhaler. LPN #149 stated she stayed with Resident #95 this morning and ensured he swallowed his medications. Resident #95 had a history of cheeking his medications and spitting them out. Upon further investigation of the over the bed table there were five small white round pills located in a stack of banjo picks. LPN #149 stated one of the medications looked like Norvasc (blood pressure medication) and the medications had been on the table a while. Review of Resident #95 blood pressures for the past two weeks revealed no concerns with hypertension from not taking blood pressure medications. A follow-up interview on 08/01/22 at 1:14 P.M. with Resident #95 revealed he spit out medications that made him nauseous. Resident #95 stated he reported this to the nurse. When asked if the resident was aware of the order to crush all medications, Resident #95 became upset and told the surveyor to leave. Review of the facility policy titled Administering Medications did not address ensuring the resident swallowed all medications before the nurse left the room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 18 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 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 medical record review, observations, resident and staff interview, the facility failed to maintain acceptable parameters of nutritional status, which included monitoring weight status and following up on nutritional recommendations. This affected five residents (#25, #33, #61, #97, and #404) of 11 residents reviewed for nutrition. The facility census was 110. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #404 revealed an admission date of 07/17/22. The resident had diagnoses including chronic kidney disease with dialysis three times weekly, diabetes mellitus, and positive for COVID-19. The resident had physician's orders on 07/17/22 for a regular diet and daily weights. Review of weight records revealed Resident #404 had a weight of 258.5 pounds on 07/18/22. Review of a dietary progress note by the dietetic technician on 07/20/22 at 1:43 P.M. revealed Resident #404 was receiving a regular diet. Weight fluctuations expected due to dialysis. A recommendation was made to add a house liquid protein supplement 30 milliliters daily for extra protein. There was no evidence of any follow up to obtain a physician's order for the protein supplement. As of 08/01/22, there was no evidence the resident was receiving a protein supplement as recommended. Review of weight records revealed on 07/27/22 the resident weighed 239.6 pounds (18.9 pound loss in 9 days). On 07/28/22 the weight was 239.8 pounds. Review of a dietary progress note on 07/29/22 at 2:48 P.M. by the Dietician revealed the resident was noted to have a significant weight loss of 18.3 pounds (7.1 %) in 30 days. The note stated as the resident continues to undergo dialysis, recommend diet change to regular with no added salt/diabetic with no potatoes, tomatoes, oranges, orange juice, or bananas. It was also recommended to add a house renal supplement one carton twice daily and agree with nutritional associates recommendation on 07/20/22 for house liquid protein 30 milliliters daily. As of 08/01/22, there was no evidence of any follow up on the recommendations made by the dietician on 07/29/22. The diet had not been changed and the supplements had not been implemented. Interview with the Director of Nursing (DON) on 08/01/22 at 2:10 P.M. revealed the Dietetic Technician and Dietician had not communicated their recommendations to nursing so the physician could be notified for physician's orders for the changes that were recommended. She confirmed the nutritional recommendations for Resident #404 had not been implemented. 2. Review of the medical record for Resident #25 revealed an admission date of 12/30/21 and diagnoses including schizophrenia, hypertension, duodenal ulcer, and anxiety disorder. Review of an admission Minimum Data Set assessment completed 01/06/22 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. It stated the resident required supervision only for eating, was 63 inches tall, weighed 160 pounds, and had no weight loss. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 19 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 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 - Some Review of a dietary progress note on 01/07/22 by the Dietetic Technician stated the resident was receiving a mechanical soft diet. The note stated an admission weight was pending and they were using a weight from her previous admission [DATE]) of 160 pounds for her current body weight. Review of a dietary progress note on 02/11/22 by the Dietetic Technician stated a February weight was pending and were still using a weight of 160 pounds from her previous admission [DATE]) as a current body weight. There were no recommendations made. There was no evidence Resident #25 was weighed until 03/22/22 (approximately three months after admission). The resident weighed 168.2 pounds. Review of the weight records revealed on 04/07/22 the resident weighed 139.4 pounds (a 28.8 pound loss in one month). Review of a weight change progress note on 04/07/22 at 5:18 P.M. by the Dietetic Technician revealed 28.8 pound, 17.1% weight loss. The note stated her intakes would not elicit this type of weight loss. No edema noted at this time. It was recommended to obtain a re-weight. There was no evidence the resident was weighed again until 04/18/22. (11 days after the previous weight). The resident weighed 141.6 pounds. Review of a weight change progress note on 04/22/22 at 9:59 A.M. by the Dietetic Technician revealed a 26.6 pound, 15.8% weight loss since 03/22/22. The note stated her intakes would not elicit this type of weight loss. Weight has remained stable since 04/07/22. No edema noted. No recommendations were made except to monitor weekly weights. Review of the weekly weights completed on 04/25/22 a weight of 143 pounds was obtained. The residents weight maintained and on 07/11/22 she weighed 145.8 pounds. Review of a quarterly Minimum Data Set assessment on 04/30/22 indicated weight loss and not on a prescribed weight loss program. Interview with Resident #25 on 07/26/22 at 11:27 A.M. revealed she was aware of her weight loss but did not know why or if anything was done about it. Observations on 07/27/22 at 8:19 A.M. of the breakfast meal revealed Resident #25 received sausage gravy and two slices of toast, a box of cold cereal, and coffee. The resident ate approximately half of her sausage gravy. She stated she could not digest bread and did not eat the toast. She received no milk for the cold cereal and it was unopened. Review of the facility policy titled Weighing and Measuring the Resident, dated 2001 and revised March 2011 revealed the purpose of this procedure was to determine the resident's weight to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident. It stated weight is usually measured upon admission and monthly during the resident's stay. It stated the threshold for significant unplanned and undesired weight loss/gain would be based on the following criteria: 1 month 5% loss is significant, greater that 5% is severe; 3 months 7.5% loss is significant, greater than 7.5% is severe; 6 months 10% loss is significant, greater than 10% is severe. The policy did not address doing re-weights to verify accuracy of the weight after a significant loss/gain was identified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 20 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 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 - Some Interview with the Director of Nursing on 07/27/22 at 3:40 P.M. confirmed Resident #25 was not weighed for approximately three months after admission. She confirmed residents are to be weighed on admission and then monthly. She stated if a re-weight was recommended, it should be done within a couple of days of the previous weight. She confirmed the recommended re-weight was done 11 days after it was recommended. 3. Review of the medical record for Resident #33 revealed and admission date of 12/01/20 and diagnoses including cerebrovascular disease, dysphagia, hemiplegia, diabetes, and chronic obstructive pulmonary disease. The resident had a physician's order 01/05/21 for monthly weights. Review of an annual Minimum Data Set assessment on 09/17/21 indicated a BIMS score of 10, indicating moderately impaired cognitive status. The resident required supervision only with eating. A weight gain was noted. Review of the weight records revealed a weight of 196 pounds in October 2021. On 01/05/22 the resident weighed 214.2 pounds. There was no evidence of a weight in February 2022. Review of a Dietary progress note on 02/09/22 at 12:18 P.M. by the Dietetic Technician revealed her current body weight of 214.2 pounds triggered her for a significant weight gain times 30/90 days. It stated her intakes would not elicit this type of weight gain. February weight pending at this time. Recommend obtaining a re-weight. There was no evidence the resident was weighed again until 03/05/22. (No weight from 01/05/22 to 03/05/22). Review of the weight on 03/05/22 Resident #33 weighed 216.7 pounds. Review of a Weight Change progress note on 03/25/22 at 12:38 P.M. by the Dietetic Technician revealed weights of 196 on 10/05/21, 214.2 on 01/05/22, and 216.7 on 03/05/22. The note recommended obtaining a re-weight. Intakes would not elicit this type of weight gain. There was no evidence of a weight again until 05/04/22. On 05/04/22 the resident weighed 188 pounds (28.7 pound weight loss in two months). Review of a Weight Change progress note on 05/06/22 at 11:55 A.M. by the Dietetic Technician revealed 28.7 pound, 13.2% weight loss since 03/05/22. The note stated the resident had required assistance with some meals in the past 14 days. Intakes have declined with most meals consumed between 0-50% over the past 14 days. Weight loss likely due to decreased intakes. Recommend adding weekly weights and adding boost 240 milliliters twice daily. Record review revealed an order for the boost twice daily on 05/10/22 and weekly weights on 05/17/22. The next weight on 05/16/22 was 186.4 pounds. On 05/17/22 she weighed 186.5 pounds. Weekly weights continued and on 07/12/22 a weight of 170.8 pounds was obtained. Resident #33 was started on speech therapy and a pureed diet was ordered. On 07/26/22 a weight of 169 pounds was obtained. Review of the nurses notes revealed a lump was noted in the resident's breast on 03/19/22. Testing was done including ultrasound, mammogram, biopsy. The biopsy showed breast cancer. The resident was scheduled for a mastectomy. Observations on 07/27/22 at 8:23 A.M. of the breakfast meal revealed staff attempted to assist the resident to eat a pureed diet. The resident took a couple bites and refused to eat anymore. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 21 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 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 - Some Review of the facility policy titled Weighing and Measuring the Resident, dated 2001 and revised March 2011 revealed the purpose of this procedure was to determine the resident's weight to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident. It stated weight is usually measured upon admission and monthly during the resident's stay. It stated the threshold for significant unplanned and undesired weight loss/gain would be based on the following criteria: 1 month 5% loss is significant, greater that 5% is severe; 3 months 7.5% loss is significant, greater than 7.5% is severe; 6 months 10% loss is significant, greater than 10% is severe. The policy did not address doing re-weights to verify accuracy of the weight after a significant loss/gain was identified. Interview with the Director of Nursing on 07/27/22 at 3:55 P.M. confirmed monthly weights were not obtained in February or April 2022 as ordered. 4. Review of the medical record for Resident #61 revealed an admission date of 05/01/22 with diagnosis including chronic obstructive pulmonary disorder, schizoaffective disorder, dysphagia, dementia, type two diabetes mellitus and unspecified psychosis. Review of the current physician orders for July 2022 revealed Resident #61 was ordered a regular, mechanical soft textured diet with thin liquids on 05/12/22. On 10/14/21 an order for the staff to offer a sandwich, cereal or any alternative if the resident refused the meal from the kitchen. An order dated 02/10/22 for Resident #61 to receive Boost (a supplement) three times daily for weight management. Resident #61 was to be weighed monthly. Review of the annual Minimum Data Set (MDS) dated [DATE] indicated Resident #61 was severely cognitively impaired with disorganized thinking. Resident #61 required extensive assistance of two persons for bed mobility, transfers, dressing, and toilet use. Resident #61 required set up of meal for eating. Resident #61 had no problems with chewing or swallowing and was coded for weight loss. Review of Resident #61's monthly weights revealed Resident #61 weight was 144 pounds on 07/11/22, 138 pounds on 06/02/22, 118 pounds on 05/03/22, 139 pounds on 04/03/22, 138 pounds on 01/03/22, 149 pounds on 12/03/21, 128 pounds on 09/03/21, and 158 pounds on 08/27/22. There were now weights for March 2022, February 2022, November 2021 and October 2021. Review of the progress notes revealed a dietary note dated 09/08/21 at 2:31 P.M. indicated Resident #61 current weight was 128 pounds a ten percent change in 30 days. The dietitian recommended a reweigh as oral intakes would not elicit this type of weight loss. The dietitian quarterly noted dated 09/17/22 2:02 P.M. indicated Resident #61 triggered for significant weight loss for 30, 90 and 180 days previously noted. Recommendations were to re-weigh resident as current weight was 128 pounds on 09/08/21. The dietitian progress note dated 11/20/21 at 2:03 P.M. indicated Resident #61 weighed 128 pounds on 09/08/21 and recommended a re-reweigh. The dietitian progress note dated 12/03/21 at 1:58 P.M. indicated Resident #61 weighed 128 pounds on 09/08/21 and again recommended a re-weigh. Review of the plan of care last updated 06/02/22 revealed Resident #61 had the potential for nutritional risk and malnutrition related to dementia, type two diabetes mellitus, dysphagia and psychosis. Interventions included diet, labs and weight as ordered. Observations of Resident #61 on 07/25/22 at 11:48 A.M. and on 07/26/22 at 9:03 A.M. revealed Resident #61 ate most of her meal and was able to feed herself. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 22 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 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 An interview on 08/01/22 at 9:29 A.M. with the Director of Nursing (DON) confirmed the dietitian recommendations for a re-weigh were not followed or acted upon. The DON also confirmed the dietitian used the same monthly weight for three months when completing the assessment due to no weights were obtained. Residents Affected - Some Unable to reach the dietitian on 08/01/22 at 9:50 A.M. left voice message and no return call. Review of the facility policy titled Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol, revised 09/17 revealed the nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. 5. Review of the medical record for Resident #97 revealed an admission date of 04/01/21 with diagnosis including acute and chronic respiratory failure, congestive heart failure, type two diabetes mellitus, vitamin deficiency, tracheostomy, and Percutaneous (through the skin) endoscopic gastrostomy (PEG) tube for feeding and medications. Review of the admission MDS dated [DATE] indicated Resident #97 was cognitively intact with anxious and fearful mood. Resident #97 required extensive assistance of two persons for bed mobility, transfers, toilet use, and bathing. Resident #97 was dependent on staff for eating. Resident #97 had unplanned weight loss and received nutrition via PEG tube. Review of the monthly weights revealed Resident #97 weighed 266 pounds on 08/11/21, 266 pounds on 09/05/21, 269 pounds on 11/08/21, 268 pounds on 12/05/21, 252 pounds on 02/05/22, 255 pounds on 03/05/22, 256 pounds on 06/22/22, 243 pounds on 06/29/22 and 06/30/22, 242 pounds on 07/04/22, 242 pounds on 07/05/22, 242 pounds on 07/06/22, 237 pounds on 07/08/22 and 240 pounds on 07/22/22. There were no weights for 10/21, and 01/22. Resident #97 was hospitalized from [DATE] through 06/22/22 with diagnosis of cerebral infarction. Review of the dietitian progress note dated 07/20/22 at 3:06 P.M. revealed Resident #97 was sent to the emergency department on 07/17/22 due to tube feeding formula was coming from his tracheostomy. He returned to the facility on [DATE], sent back to the emergency department on 07/18/22 and was diagnosed with aspiration pneumonia. Resident #97 now receiving 120 ml of Jevity 1.5 bolus feeding every six hours. This provided the resident with 480 ml of tube feeding per day, 719 calories and 30.5 grams of protein. The intake from the tube feeding regimen does not meet estimated needs of the resident at this time. Current body weight (07/08/22) was 237 pounds triggering a significant weight loss over 30 days previously noted. The dietitian recommended increasing the Jevity 1.5 bolus feeding of 120 ml to every four hours. This would provide the resident with 1,200 ml per day, 1,797 calories and 76.5 grams of protein. This increase would meet the residents estimated needs. Review of the current monthly orders on 07/28/22 for 07/22 revealed Resident #97 was Nothing by Mouth (NPO) and had the following orders: enteral feeding every six hours of 120 milliliters (ml) bolus feeding of Jevity 1.5, check PEG tube placement prior to flushing and before medication administration, document any residual, flush PEG tube with 60 ml of water prior to bolus feeding, check for residual and placement before the flush, 150 ml of free water flush via PEG tube every four hours, flush PEG tube with 60 ml of water after bolus feeding, flush PEG tube with 30 ml of water after medication administration, head of the bed at 45 degrees at all times, and monthly weights. An interview on 07/28/22 at 10:28 A.M. with Unit Manager LPN #113 confirmed the dietitian recommendation on 07/20/22 of increasing Resident #97 PEG tube feeding of Jevity 1.5 120 ml to every four (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 23 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 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 hours was not faxed or called the physician to obtain an order. The UM #113 stated the process was all dietitian recommendations would be faxed to the physician the same day or printed and placed in the physician folder. The UM #113 was unable to locate the dietitian recommendations from 07/20/22 and stated she would notify the physician immediately. The physician order was written and implemented on 07/28/22 at 12:00 P.M. Residents Affected - Some Review of the facility policy title Tube Feeding, dated 09/17 revealed the dietitian would review the residents orders for caloric needs and make recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 24 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, review of personal finances, resident and staff interviews, the facility failed to provide medically-related social services for a resident who needed assistance with financial matters. This affected one (#70) of 35 sampled residents. The facility census was 110. Residents Affected - Few Findings include: Review of the medical record for Resident #70 revealed an admission date of 09/24/20 and a readmission date of 09/29/21. Review of the Minimum Data Set (MDS) assessment completed on 06/07/22 revealed a Brief Interview for Mental Status score of 12, indicating moderately impaired cognitive status. The resident had diagnoses including vision loss in both eyes and anxiety disorder. Review of Social Service note on 06/29/22 at 5:30 P.M.,stated Resident #70 was alert and oriented and required assistance with activities of daily living related to his blindness and receives hospice services. Interview on 07/25/22 at 10:47 A.M., with Resident #70 revealed he had not received his pension check for several months. He stated he had asked to see social services, who had not visited. Review of Hospice Social Worker notes dated 07/25/22 at 1:00 P.M., revealed Resident #70 asked writer to read his mail to him. Discussed his pension and that contact will need to be made for follow up. Hospice Social Worker contacted pension company who stated that the resident had not received a pension check since September due to having an old address and the checks were being returned to them. The resident's address was then changed to his current address at the facility and he would then receive his checks. Interview on 07/26/22 at 3:05 P.M., with Business Office Manager #102 revealed the facility handled funds for Resident #70. She stated that he normally received a social security check, which came to the facility, and a $400.00 pension check, which was mailed to the resident. She stated Resident #70 would then sign the pension check and turn it over to the facility as part of payment for his stay. However, she stated he had not received his pension check since September 2021. She confirmed she was aware he had not been receiving his pension check since September 2021, but had not had time to work on it. She stated this was something social services normally did but the facility had multiple changes in social workers. Review of the resident's trust account with the facility revealed he had a current balance of $0. Interview on 07/27/22 at 8:29 A.M., with Resident #70 revealed he had hospice staff help him call his pension company on 07/25/22 as it had been bothering him about not getting his check for so long and no one at the facility had helped him with it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 25 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and policy review, the facility failed to ensure foods were stored in at appropriate temperatures in order to prevent foodborne illness. This had the potential to affect all 109 residents who consumed foods prepared and stored in the kitchen. The facility identified one resident (#97) who did not receive foods prepared/stored in the kitchen and was to receive nothing by mouth. The census was 110. Findings include: Observations with [NAME] #151 during the tour of the kitchen on 07/25/22 at 8:15 A.M., revealed the reach in refrigerator #2's internal thermometer read 48 degrees Fahrenheit, and contained three large trays of portioned pudding as well as three large pans of raw chicken. Reach in refrigerator #3's internal thermometer read 50 degrees Fahrenheit, and contained a half pan of very hot oatmeal and small pan of hot sausage gravy. There were three cases of liquid eggs stored in reach in refrigerator #3. [NAME] #151 confirmed the internal thermometer readings of reach in refrigerators #2 and #3 at that time. Observations on 07/26/22 at 7:25 A.M. revealed pureed foods for lunch were prepared in a steamtable pan and were placed in a hot holding container. At that time, interview with [NAME] #191 revealed she prepared the pureed foods for lunch before 7:00 A.M. that morning and placed them in the hot holding container which had no temperature reading. Continued observations on 07/26/22 at 8:25 A.M. with [NAME] #191 revealed the pureed food was now in an oven set at 200 degrees Fahrenheit. At that time the temperatures of the pureed foods were obtained by [NAME] #191 which revealed the pureed chicken was 134 degrees Fahrenheit, the pureed mashed potatoes were 72 degrees Fahrenheit, and the pureed green beans were 113 degrees Fahrenheit. Interview with Dietary Manager #100 on 07/26/22 at 8:30 A.M. revealed the preparation of the pureed foods for lunch should not be started prior to 9:00 A.M. and the pureed food should be heated quickly in a hot oven. Lunch was not served every day until after 11:15 A.M. Review of the policy titled Food Preparation and Service, dated 04/2019, revealed the Danger Zone for food temperatures was from 41 to 135 degrees Fahrenheit which promoted the rapid growth of pathogenic microorganisms that caused foodborne illness. Potentially hazardous foods foods included meats, poultry, eggs, and milk products which were maintained below 41 degrees or above 135 degrees and not remain in the danger zone. The longer foods remained in the danger zone the greater the risk for harmful pathogens. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 26 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff interviews and policy review, the facility failed to follow the policy of disposing of food waste in the kitchen in containers with tight fitting lids. The finding potentially affected 109 residents who consumed foods prepared in the kitchen except for Resident #97 who consumed nothing by mouth. The census was 110. Residents Affected - Some Findings include: Kitchen observation on 07/25/22 at 8:30 A.M. revealed two trash containers half full of food waste in dish room and production areas with no lids to cover the trash. The trash containers were not in use by staff at that time. Interview with Dietary Manager #100, at that time of the observation, verified the two trash containers with garbage and no lids. Observation on 08/02/22 at 8:45 A.M., revealed two trash containers half full of food waste in dish room and production areas with no lids to cover the trash. The trash containers were not in use by staff at that time. Interview with Dietary Manager #100, at that time of the observation verified the two trash containers with garbage and no lids. Review of the policy titled Disposal of Garbage and Refuse revised October 2021, revealed all garbage containers with food waste must be kept covered when not in continuous use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 27 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 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 observations, staff interviews, medical record review, review of facility census, review of COVID tracking log, review of the facility staff and visitor COVID-19 screening questionnaire log and policy reviews, the facility failed to ensure staff used the proper personal protective equipment (PPE) when providing care to residents who were either positive for COVID-19 or in quarantine for possible COVID-19; failed to ensure staff sanitized or wash their hands after removing gloves; failed to ensure proper signage was posted for residents in isolation/quarantine; failed to properly quarantine residents with possible COVID-19 exposure; and failed to properly screen residents and visitors for symptoms of COVID-19. This had the potential to affect 110 of 110 residents residing at the facility. The facility census was 110. Residents Affected - Many Findings include: 1. Review of the medical record for Resident #405 revealed an admission date of 07/22/22. Review of hospital records revealed the resident tested positive for COVID-19 by PCR testing on 07/19/22. On 07/22/22, upon admission to the facility, the resident had a physician's order for droplet isolation precautions. Observations on 07/25/22 at 11:34 A.M., revealed the door to Resident #405's room to be closed. There was no sign on the door or near Resident #405's room to indicate he was on any type of isolation precautions or to see the nurse prior to entering. A PPE cart was located outside the room. Interview on 07/25/22 at 11:45 A.M., with Licensed Practical Nurse (LPN) #186, confirmed Resident #405 was positive for COVID-19 and was on contact and droplet precautions. She confirmed there was no signage on his door to indicate the precautions or to see the nurse. She stated she did not know why it was not there and confirmed it should have been. Observations on 07/25/22 at 12:01 P.M., revealed Central Supply Clerk #175 to take a lunch tray into Resident #405's room. She wore a gown, gloves, N95 mask, and a face shield. After leaving the room and walking away, she confirmed she did not change her N95 mask or clean her face shield after leaving the room of the resident positive for COVID-19. Interview on 07/25/22 at 12:25 P.M., with the Director of Nursing, revealed staff should clean their face shield after leaving the room of a COVID-19 positive resident. She stated she was not aware staff needed to change their N95 mask after leaving the room of a COVID-19 positive resident and before caring for another resident on the hall without COVID-19. She stated the residents who are positive for COVID-19 should have signs on their doors to indicate they are on isolation precautions. 2. Review of the medical record for Resident #404 revealed an admission date of 07/17/22. Review of hospital records revealed the resident tested positive for COVID-19 by PCR testing on 07/16/22. On 07/17/22, upon admission to the facility, the resident had a physician's order for droplet isolation precautions. Observations on 07/25/22 at 11:35 A.M., revealed the door to Resident #404's room to be closed. There was no sign on the door or near Resident #404's room to indicate she was on any type of isolation precautions or to see the nurse prior to entering. A PPE cart was located outside the room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 28 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 07/25/22 at 11:45 A.M., with Licensed Practical Nurse (LPN) #186, confirmed Resident #404 was positive for COVID-19 and was on contact and droplet precautions. She confirmed there was no signage on her door to indicate the precautions or to see the nurse. She stated she did not know why it was not there and confirmed it should have been. Observations on 07/25/22 at 12:00 P.M., revealed LPN #186 to take a lunch tray into Resident #404's room. She wore a gown, N95 mask, and a face shield. She did not wear gloves to carry the meal tray into the room. After leaving the room and walking away, she confirmed she did not change her N95 mask or clean her face shield after leaving the room of the resident positive for COVID-19. She stated she put on gloves after entering the room. Review of the facility census and COVID tracking log revealed there were 42 residents on the second floor with two of them being positive for COVID-19: Residents #404 and #405. The staff on the second floor cared for the residents who were positive for COVID-19 and the residents who were not. Interview with the Director of Nursing on 07/25/22 at 12:25 P.M., revealed staff should clean their face shield after leaving the room of a COVID-19 positive resident. She stated she was not aware staff needed to change their N95 mask after leaving the room of a COVID-19 positive resident and before caring for another resident on the hall without COVID-19. She stated the residents who are positive for COVID-19 should have signs on their doors to indicate they are on isolation precautions. 3. Observations on 07/26/22 at 10:22 A.M., revealed Receptionist #167 to have on gloves and complete a COVID-19 nasal swab test for a staff member at the front receptionist's desk. After completing the swab test, Receptionist #167 removed her gloves and, without washing or sanitizing her hands, began typing on a computer at the desk. Interview on 07/26/22 at 10:22 A.M., with Receptionist #167 confirmed she did not wash or sanitize her hands after removing her gloves. She stated she forgot. 4. Review of the facility staff and visitor COVID-19 screening questionnaire log revealed revealed on 07/17/22 (Sunday) at approximately 12:00 P.M., State Tested Nursing Assistant (STNA) #199 screened in prior to work. She answered yes to the question do you have any of the following symptoms: fever, cough, shortness or breath, diarrhea, pink eye, sore throat, loss or taste or smell. There was no evidence anyone assessed STNA #199 to determine what her symptoms were or if she should proceed to work. Review of the schedule revealed she worked from 12:00 P.M. to 6:00 P.M. in the facility. Interview with STNA #199 on 08/01/22 at 1:00 P.M., confirmed she marked yes to the question regarding symptoms on the screening log on 07/17/22. She stated that week her whole household had tested positive for COVID-19 so she marked it yes. She stated she was not having any symptoms at that time but wanted to make sure if she should work. She stated she was not tested for COVID-19 that day. She confirmed she was not evaluated by anyone after marking yes to symptoms on 07/17/22. Review of the facility staff and visitor COVID-19 screening questionnaire log revealed revealed on 07/18/22 (Monday) at approximately 5:40 A.M., Agency STNA #503 screened in prior to work. She answered yes to the question do you have any of the following symptoms: fever, cough, shortness or breath, diarrhea, pink eye, sore throat, loss or taste or smell. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 29 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many There was no evidence anyone assessed Agency STNA #503 to determine what her symptoms were or if she should proceed to work. Interview with Agency STNA #503 on 08/01/22 at 3:50 P.M., confirmed she marked yes to the question regarding symptoms on the screening log on 07/18/22. She stated she had called off sick the day before with a fever and that is why she marked on the log that she had symptoms. She stated she was not sure if she should work. She stated she talked with a nurse (did not know who) who stated they should talk to the on call manager. She stated she proceeded to work and never heard back from anyone about marking yes on the screening log. She stated she started vomiting at work and left at 3:00 P.M. Review of the facility staff and visitor COVID-19 screening questionnaire log revealed on 07/22/22 (Friday) at approximately 12:00 P.M., Visitor #504 screened in for Resident #351. Visitor #504 answered yes to the question do you have any of the following symptoms: fever, cough, shortness or breath, diarrhea, pink eye, sore throat, loss or taste or smell. There was no evidence anyone assessed Visitor #504 to determine what her symptoms were or if she should visit Resident #351. Interview on 07/28/22 at 10:45 A.M., with the Administrator revealed if someone answers yes to a question on the screening questions for COVID-19, it says stop and go see a nurse. A nurse is to assess the person for what their symptoms are. She stated she also receives an alert message that a question was answered yes. Any yes triggers for an assessment of the individual. If yes to symptoms, an assessment needs to be done to determine if a staff member can proceed to work. Interview on 07/28/22 at 2:15 P.M., with Regional Director of Clinical Services #505 confirmed the facility did not have any documentation of what symptoms the staff or visitors had that marked yes to symptoms of COVID-19 or that any of them were assessed for being able to work or visit. She stated if someone marks yes to symptoms, they are tested and if they test negative, they are allowed to work. She stated an employee only needed to be cleared by their physician to work if they test positive. Interview on 07/28/22 at 2:20 P.M., with the Director of Nursing revealed she did not know who Visitor #504 was. She confirmed there was no evidence the visitor was assessed to determine if she should visit. She stated that is someone answers yes to any of the screening questions, she gets an email. However, if it happens on a weekend, she does not get emails at home. If she gets an email, she calls the nurse and they go talk to the person who answered yes, and if they have symptoms, they need to test them for COVID-19. 5. Review of Resident #96's medical record revealed an admission date of 06/23/22. Diagnoses included: sepsis, acute and chronic respiratory failure, chronic kidney disease, benign prostatic hyperplasia, lymphedema, obesity, cellulitis of right lower limb, and congestive heart failure. Review of the minimum data set (MDS) assessment dated [DATE] revealed Resident # 96 required extensive assistance with bed mobility, toileting, hygiene, and dressing. He was totally dependent for dressing and required supervision for eating. He did not resist care and did not wander. Review of a physician's order for COVID isolation precautions for seven days starting on 07/19/22 was noted. Interview with Director of Nursing on 07/25/22 at 9:41 A.M., revealed Resident #96 was in isolation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 30 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 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 but had not tested positive for COVID-19. Level of Harm - Minimal harm or potential for actual harm Observation of Resident #96's room from the hallway on 07/25/22 at 11:52 A.M. revealed Resident # 96 lying in bed. Resident # 96's door was open. There was not any type of device to hold personal protective equipment (PPE) outside of the room observed. A sign showing how to don and doff PPE was observed taped on the door. Residents Affected - Many Observation on 07/25/22 at 12:02 P.M., revealed Registered Nurse (RN) #193, Licensed Practical Nurse (LPN) #216, and State Tested Nurse Aide (STNA) #213 entering Resident #96's room through the already open door without donning gowns or gloves outside of room or inside of room. All were wearing N95s mask and face shields when entering the room. RN #193, LPN #216, and STNA #213 were observed leaving Resident #96's room without changing their N95 mask or cleansing their face shields. Interview at the time of the observation, with RN #193 stated Resident # 96 is still on quarantine isolation for COVID-19 precautions. Interview on 07/25/22 at 12:05 P.M., with LPN #216 verified she, RN #193, and STNA #213 did not have on a gown when assisting Resident #96. Interview on 07/25/22 at 12:07 P.M., with LPN #216 verified Residents #96 and # 56's doors were open but should be closed because of quarantine status and no PPE was available outside of Resident #96 or Resident #56's rooms. Observation on 07/25/22 at 12:11 P.M., revealed STNA #213 deliver Resident #96's lunch tray. STNA #213 did not don a gown and gloves before entering Resident #96's room. When exiting the room. She did not close the door. The PPE cart was outside of Resident # 96's room with closed door during observation on 07/26/22 at 8:02 A.M. 6. Review of Resident #56's medical record revealed an admission date of 08/10/20. Diagnoses included: type two diabetes, bipolar disorder, psychotic disorder, anxiety disorder, and major depressive disorder. Review of the MDS assessment dated [DATE] revealed Resident #56 required supervision with transfers, bed mobility, ambulation, toileting, and eating. He was a one person assist for hygiene, bathing, and dressing. He did not resist care and he did not wander. Review of a physician's order for COVID precautions for 14 days starting on 07/21/22 was noted. Interview with Director of Nursing on 07/25/22 at 9:41 A.M., revealed Resident #56 was in isolation but had not tested positive for COVID-19. Observation of Resident #56's room from the hallway on 07/25/22 at 11:49 A.M., revealed Resident #56 was lying in bed. Resident #56's door was open. There was not any type of device to hold personal protective equipment (PPE) outside of the room observed. A sign showing how to don and doff PPE was observed taped on the door. Interview on 07/25/22 at 12:07 P.M., with LPN #216 verified Resident #56's room door was open, and no PPE was available outside of room. Interview on 07/25/22 at 3:54 P.M., with the Director of Nursing (DON), revealed Resident #56 was placed on isolation due to roommate being positive for COVID and was exposed. The PPE cart was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 31 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 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 outside of Resident # 56's room with closed door during observation on 07/26/22 at 8:02 A.M. Level of Harm - Minimal harm or potential for actual harm Observation though out the survey revealed Resident #56 was observed walking down 3 [NAME] Unit hallway without a mask in place on 07/26/22 two times between 8:04 A.M. and 8:52 A.M. STNA #202 and STNA #213 were observed watching Resident #56 without attempting to escort back to room. Resident #56 walked through the 3 [NAME] Unit common room and down another hall towards the secured unit doors before turning around and walking back both times. The first time Resident # 56 was walking, unmasked, in the unit for a total of three minutes. The second time, Resident # 56 was walking, unmasked in the unit for six minutes. Residents #35, #42, #50, and #68 were in the common room during Resident #56's walks. Residents Affected - Many Observation on 07/27/22 at 8:53 A.M., of STNA #202, revealed she enter Resident #56's room without donning a gown or gloves. She was wearing a N95 and face shield. She did not change the N95 mask or cleanse the face shield when she exited the room. Interview on 07/27/22 at 8:54 A.M., with STNA #202 confirmed she did not have a gown on while in Resident #56's room. STNA #202 stated she thinks Resident #56 is still on quarantine and he did not test positive. He was just around someone who did. And it is hard to keep some of these people in their rooms. Observation on 07/28/22 at 10:28 A.M., of Housekeeper #197, revealed Resident #56's door open with Housekeeper #197 cleaning the floor without a gown on. A N95 mask and a face shield were in place. Housekeeper #197 was observed exiting the room leaving the door open. She did not change her N95 mask or cleanse her face shield. Interview on 07/28/22 at 10:31 A.M., with Housekeeper #197 was unable to verbalize if she was required to utilize the PPE in the cart by Resident #56's door before entering the room to clean it. Housekeeper #197 stated she thinks he is in isolation, but he keeps coming out. When asked if she was required to utilize the PPE prior to entering a room when a sign was on the door and a PPE cart was beside the door, Housekeeper #197 stated she didn't know. Review of the undated policy titled Coronavirus (COVID-19) Policy and Procedure Policy Statement Policy Interpretation and Implementation, revealed all staff members are to wear personal protective equipment (PPE). PPE includes a N95 mask, face shield or goggles, gown, and gloves. For exposed residents, they will be placed in droplet precautions. The care of each resident should be rendered without cross contact by changing all PPE between residents. Review of the policy titled Isolation-Categories of Transmission Based Precautions dated 2001 and revised October 2018, revealed when a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. The signage informs the staff of the type of CDC precautions, instructions for use of PPE, and/or instructions to see a nurse before entering the room. Review of the undated policy titled Coronavirus Policy and Procedure, revealed for COVID-19 positive residents staff should wear full PPE: face shield/goggles, N95 mask, gown, and gloves for care of resident. Remove N95 mask and discard upon leaving the COVID-19 positive room. Staff should clean all non-disposable equipment with approved cleaning products, to avoid cross-contamination. Staff are to clean their hands before and after use of gloves. All visitors, employees, ancillary staff, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 32 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many vendors will be screened by questionnaire and temperature. If an employee displays any COVID-19 related symptoms, the employee should not report to work and should immediately report to their physician for additional guidance and follow up. All staff must have their temperature taken upon entering the facility. Staff should not report to their assigned work area until this task has been completed. Any staff member that exhibits signs and/or symptoms of COVID-19 will be tested for COVID and advised to be cleared by their physician to work. This deficiency substantiates Complaint Number OH00133697. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 33 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the Resident COVID-19 Vaccination Log, staff interview, and review of facility policy, the facility failed to ensure residents and/or their representatives were offered COVID-19 vaccines and/or boosters and were provided education regarding the COVID-19 vaccines. This affected 11 (Residents #25, #30, #33, #34, #35, #50, #56, #58, #86, #95, and #453) out of 11 residents reviewed for COVID-19 vaccinations. The facility census was 110. Findings include: 1. Review of the Resident COVID-19 Vaccination Log revealed it contained 105 resident names. Of those 105 residents, 56 residents were documented as receiving a primary vaccination series. Of the 56 residents who had received a primary vaccination series, only 11 residents had received one booster vaccine. No resident had received two booster vaccines. The following five residents had not received any COVID-19 vaccination: Resident #30 was was admitted on [DATE], Resident #35 who was admitted on [DATE], Resident #50 who was admitted on [DATE], Resident #86 who was admitted on [DATE], and Resident #95 who was admitted on [DATE]. Medical record review for Residents #30, #35, #50, #86, and #95, revealed there was no evidence that the residents and/or their responsible party had been provided with education on the COVID-19 vaccine including the risks, benefits, or potential side effects. There was no evidence the residents and/or their responsible party agreed to or declined the administration of the COVID-19 vaccine. Interview with the Director of Nursing (DON) on 08/02/22 at 9:00 A.M. revealed she had asked Resident #30, #35, #50, #86, and #95 and/or their representative if they wanted the COVID-19 vaccine on 07/13/22, however they all declined. The DON confirmed there was no evidence the COVID-19 vaccine had been offered prior to 07/13/22 even though some of the residents had resided at the facility for one to two years. 2. The following six residents had not received a COVID-19 booster vaccine: Resident #25 received the primary Pfizer vaccine series on 01/12/21 and 02/02/21, Resident #33 received the primary Pfizer vaccine series on 01/12/21 and 02/02/21, Resident #34 received the primary Pfizer vaccine series on 12/22/20 and 01/12/21, Resident #56 received the primary Pfizer vaccine series on 12/22/20 and 01/12/21, Resident #58 received the primary Moderna vaccine series on 04/07/21 and 05/05/21, Resident #453 received the primary Pfizer vaccine series on 01/12/21 and 02/02/21. Review of the medical records for Residents #25, #33, #34, #56, #58, and #453, revealed no evidence of the resident and/or their responsible party having been provided education on the COVID-19 vaccine boosters including any risks, benefits, or potential side effects. There was no evidence the residents or their responsible party agreed to or declined a booster vaccine. Interview with the Director of Nursing (DON) on 08/02/22 at 9:00 A.M. revealed she asked Residents #25, #33, #34, #56, #58, and #453, or their responsible parties if they wanted a COVID-19 vaccine booster on 07/13/22 and they all declined. The DON confirmed there was no documentation that the Residents #25, #33, #34, #56, #58, and #453, or their responsible parties declined the COVID-19 vaccine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 34 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete booster. She confirmed there was no evidence a COVID-19 booster had been offered prior to 07/13/22, when Residents #25, #33, #34, #56, #58, and #453, had completed their primary vaccine series in 2021. Review of the facility policy titled COVID-19 Vaccine Policies and Procedures, updated 04/04/22, revealed COVID-19 vaccinations will be offered to all residents (or their representative if they cannot make health care decisions) unless such immunization is medically contraindicated, per CDC guidance, or the individual has already been immunized. All residents/representatives will be educated on the COVID-19 vaccine they are offered in a manner they can understand, including information on the benefits and risks consistent with CDC and/or FDA information. Residents/representatives will be provided the opportunity to refuse the vaccine and/or change their decision about vaccination at any time. The facility will maintain documentation for all residents on COVID-19 vaccination, including primary series, boosters and additional doses. For residents, the information will be documented in their medical record. The information to be documented includes: The resident or representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine. Whether the resident or their representative consented to the vaccine. If yes: which vaccine was administered, which dose, any additional doses or boosters, and dates. If no, reason for and documentation of refusal: medical, religious, or delayed vaccination status. Event ID: Facility ID: 365597 If continuation sheet Page 35 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, staff interview, and family interview, the facility failed to maintain a safe and comfortable environment on the Three [NAME] Unit. This had the potential to affect all 22 residents (#8, #11, #15, #18, #19, #26, #31, #35, #42, #43, #45, #50, #56, #58, #68, #72, #80, #81, #85, #86, #96, and #351) residing on the Three [NAME] Unit. The facility census was 110. Findings include: Observation on 07/27/22 at 9:03 A.M. revealed two large gray trash cans in the middle of hallway on the Three [NAME] Unit outside of the medication room with blankets wrapped around the bottom of each trash can. A clear fluid was dripping from a vent in the ceiling above the trash cans and was dripping from the metal supports of the ceiling. Observation on 07/27/22 at 11:05 A.M. revealed a small black trash can in the hallway of the Three [NAME] Unit outside of the medication room with clear fluid dripping from the ceiling into the trash can. The large gray trash cans observed on 07/27/22 at 9:03 A.M. remained in place. Further observation of hallway area revealed an electrical panel cover on the wall across from the medication room. The electrical panel cover's bottom right corner was pulled out from the wall approximately two inches. Observation of a window air conditioner at the other end of the three [NAME] Unit hallway by the stairwell revealed the plastic accordion shaped pieces had brown and black debris on it. Condensation was noted on the window and surrounding area around the window air conditioner. There were areas around where the window air conditioner was inserted which were not sealed to the outside. Interview with Housekeeper #172 on 07/27/22 at 11:08 A.M. confirmed the above observations. Interview on 07/28/22 at 4:25 P.M. with the son of Resident #72 revealed he was concerned the ceiling on third floor leaked, when it rained outside, and staff had to use buckets to catch the ceiling leaks. He further expressed confused that the residents on the secured unit were potentially sticking their hands in the dirty water. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 36 of 37 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 365597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westmoreland Place 230 Cherry St Chillicothe, OH 45601 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observations, resident and staff interview, and policy review, the facility failed to provide an effective pest control program. This affected two (Resident #17 and #41) out of three residents reviewed for pest control. The census was 110. Residents Affected - Few Findings include: 1. Observation on 07/25/22 at 11:35 A.M. of Resident #17's room revealed multiple flying insects in the room and around the Resident #17. At that time, Resident #17 stated the flies bothered him while he ate his meals. Observation on 07/28/22 at 8:13 A.M. of Resident #17's room revealed there were multiple flying insects in the room. Interview with Housekeeping Supervisor #101 at the time of the observation revealed there were multiple flies in Resident #17's room while he was eating breakfast. 2. Observation on 07/25/22 at 12:23 P.M. revealed multiple flying insects in Resident #41's room. Interview with Resident #41 at that time revealed the flies bothered him especially when he was trying to sleep. Observation on 07/28/22 at 8:41 A.M. revealed there were multiple flying insects in Resident #41's room. Interview with Housekeeping Supervisor #101 at the time of the observation revealed there were multiple flies in Resident #41's room. Review of the policy titled Pest Control, dated 05/2008, revealed the facility maintained an on going pest control program to ensure the facility was free of insects. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 37 of 37