Inspection·August 9, 2023

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 08/08/23 at 4:14 P.M. with Unit Manager (UM) #176 revealed Resident #28 had a drug screen collected on 07/26/23 and revealed Resident #28 had her catheter removed the first week in July and did not have a reason to use a catheter. Interview on 08/09/23 at 9:50 A.M. with Nurse Practitioner (NP) #210 revealed she was informed it was facility policy to order urine specimens with a notation that staff may straight cath if needed. NP #210 revealed several weeks prior to the incident Resident #28 had a Foley catheter in place but confirmed it had been removed the first week of 07/2023. Interview on 08/09/23 at 10:55 A.M. with State Tested Nursing Assistant (STNA) #139 revealed she was working when Resident #28 was straight cathed. STNA #139 revealed the resident typically was able to urinate on a bed pan and revealed she was unsure why the nurse completed a straight catheterization for this urine sample. STNA #139 revealed the resident did not say anything when staff went in and she thought the nurse had already explained what the plan was and reasoning for the straight catheterization and obtained consent from the resident. STNA #139 revealed this did not occur in her presence and could not confirm it was done. STNA #139 revealed she assisted with holding one of the resident's legs and another STNA was helping hold the other leg while the nurse completed the procedure. Interview on 08/09/23 at 2:27 P.M. with Unit Manager (UM) #176 revealed the facility may have issues getting a urine specimen from a bedpan and revealed it would be easier for staff to do a straight cath for a urine specimen for Resident #28. UM #176 acknowledged it being easier for staff was not an appropriate enough reason to straight catheterize a resident, especially without consent and documentation of reasoning. UM #176 confirmed the facility had no documentation the resident had a straight catheterization for the specimen collection on 07/26/23. Review of facility policy titled, Catherization, Intermittent, Female Resident, dated 10/2010, revealed the procedure was to provide guidelines for providing an aseptic insertion of an intermittent catheter. The policy revealed documentation shall include the date and time the procedure was performed, name and title of who performed it, amount of urine drained, description of urine, change in condition of resident, complaint from resident, resident response to treatment, if resident refused why and what intervention was taken. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 2 of 14 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 08/09/2023 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 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and record review, the facility failed to ensure residents were treated with dignity and respect and residents were agreeable to a room search without pressure or threat of police involvement. This affected four residents (#34, #28, #12, and #13) reviewed for dignity. Facility census was 97. Findings include: 1. Review of the medical record for the Resident #34 revealed an admission date of [DATE]. Diagnoses included diabetes, encephalopathy, right below the knee amputation, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive response) required limited assist of one staff for transfer and mobility. A progress note dated [DATE] revealed multiple types of medications were found in the resident's room. The physician was notified of the medications and drug paraphernalia found and new orders were received to hold her medications and collect a 10 panel urine drug screen. A progress note from the Nurse Practitioner dated [DATE] revealed the resident was found with prescription medication, over the counter medication and not prescribed medication in her room as well as suspected marijuana in the room. Interview on [DATE] at 11:50 A.M. with Resident #34 revealed staff were violating her rights. The resident reported staff came into her room and informed her they had reports of her having smoking materials in her room. The resident revealed she had heard facility staff were not allowed to search the person or purses and she revealed she told staff they could look in her room, but they could not search her or her purse. Resident #34 revealed staff present informed her if she did not agree and let staff search all belongings including her purse, they would call the police. Resident #34 reported a staff member then stated, you wouldn't do well in jail. She reported staff then searched her bag and found an old pipe, a vape pen, weed residue and some old pills including Seroquel, Tylenol, and laxatives. Interview on [DATE] at 2:50 P.M. with Interim Director of Nursing (DON) #170 and Regional Nurse #210 revealed resident rooms were searched as staff had heard residents had smoking materials in their rooms. Interim DON #170 and Regional Nurse #210 revealed facility statements from the room searches were signed by the staff involved but did not have resident signatures. Interview on [DATE] at 3:35 P.M. with Social Services Designee (SSD) #182 and Social Services (SS) #183 revealed a new Administrator started recently and had a meeting related to resident smoking and informed residents the smoking policy would be strictly enforced. Interview on [DATE] at 3:52 P.M. with the Administrator revealed nursing staff had reported to management that the residents who smoked had gone outside to smoke and had not requested their smoking materials from staff so staff were suggesting residents had smoking materials (cigarettes and lighters) in their rooms. The Administrator revealed management staff initiated the search of resident rooms due to this concern. The Administrator revealed several residents were upset with the search. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 3 of 14 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 08/09/2023 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 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Administrator revealed she made sure two managers were present for all searches. She revealed staff found smoking paraphernalia and drug paraphernalia in Resident #34's and #28's room. The Administrator revealed residents were informed of the possibility of police involvement if they were unable to conduct a search. She stated she was unsure if searches and seizures were included in the smoking policy, but revealed if it was not, it would be added. She stated they did not contact the police after finding the paraphernalia but instead planned to have residents sign behavior contracts. Interview on [DATE] at 4:14 P.M. with Unit Manager (UM) #176 revealed the room searches occurred after smoking residents did not come to get their smoking materials. UM #176 revealed all residents who smoked on the hall had their rooms searched and four residents had smoking materials found in their rooms. UM #176 revealed the residents consented to the room search and confirmed several residents were upset with the search. She revealed there were residents that were not agreeable to have all items searched (i.e., purses). UM #176 confirmed residents were told if they were adamant in not allowing a search then, the route we would need to take would include calling the police to come and assist in a room search. UM #176 revealed Resident #34 had a pipe or bowl with marijuana residue, nonprescribed pills and vape pens found in her room. UM #176 revealed Resident #34 had reported at the time of the search the items, including the pills, were sent from her previous facility. Interview on [DATE] at 5:49 P.M. with Registered Nurse (RN) #199 revealed concerns related to violations of resident rights by facility management and a history of threatening behaviors, including intimidation, and treating residents as if they had signed their rights away. RN #199 revealed residents had complained that they were inmates in a prison. RN #199 revealed residents had signed blank documents in the medical record without an attached policy so management could change the rules, policy, and contract as they saw fit and then fall back on well the resident signed it. RN #199 revealed residents had asked for a copy in the past of the smoking policy and management declined to provide it. 2. Review of the medical record for the Resident #28 revealed an admission date of [DATE]. Diagnoses included chronic obstructive pulmonary disease, respiratory disease, pulmonary embolism, schizoaffective disorder, weakness, pain and acute fracture of medial malleolus. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact with a BIMS score of 15 and required extensive assistance of one to two staff members for transfers and mobility. A progress note dated [DATE] revealed the resident attempted to save a Clonazepam (sedative) for later in the evening. She stated she had been doing that. The resident was advised that she needed to take pills as ordered and the nurse watched the resident take both pills. The physician was updated. A progress note dated [DATE] revealed the physician switched resident from Clonazepam and started Lorazepam (also a sedative) 0.5 milligrams (mg) at bedtime based on issues with clonazepam. A progress note dated [DATE] revealed multiple types of medications were found in the resident's room. The physician was notified of the controlled medications and drug paraphernalia found with new orders to hold medications and collect a 10 panel drug screen. A progress note dated [DATE] from the Nurse Practitioner reported the resident was found with a myriad of loose pills as well as unprescribed over the counter (OTC) medications. The resident was having altered mental status and was found with nicotine, vapes, and delta 9 vapes. The plan was to hold opiates and Benzodiazepines, Trazadone and Gabapentin until drug screen results were available. Interview on [DATE] at 12:04 P.M. with Resident #28 revealed she was agreeable to staff checking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 4 of 14 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 08/09/2023 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 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her room, but reported she informed staff they could not search in her purse. Resident #28 revealed staff threatened her with calling the police if she did not allow them to look in her belongings. Resident #28 revealed staff found several vapes, some of which belonged to her deceased family member, and staff also found a lighter. Interview on [DATE] at 3:52 P.M. with the Administrator revealed smoking paraphernalia and drug paraphernalia was found in Resident #28's room. Interview on [DATE] at 4:14 P.M. with Unit Manager (UM) #176 revealed Resident #28 had vape pens, over the counter and prescription medications, and dab pens for THC (Tetrahydrocannabinol) usage found in her room. UM #176 revealed the resident had reported at the time that the vapes belonged to family. Review of facility policy titled, Resident Rights, dated 12/2016, revealed employees shall treat residents with kindness. The rights include respect, kindness, and dignity. Review of facility policy titled Dignity, dated 02/2021, revealed each resident should be cared in a manner that promotes and enhances his of her sense of well-being, level of satisfaction with life and feelings of self-worth and esteem. 3. Interview on [DATE] at 1:55 P.M. with Resident #12 and #13 revealed staff informed Resident #12 they were going to search his room and when the resident objected, the resident reported the managers told him he signed a form at admission that staff could do what they wanted with his room and his belongings. At this time, Resident #12's roommate (Resident #13) commented the facility was a prison and he feel like an inmate to which Resident #12 agreed. They revealed that according to the facility they had signed away their rights when they were admitted . Resident #12 revealed staff found smoking materials including a lighter and a cigarette. The resident reported he had previously turned in two packs of cigarettes, but when the facility lost his cigarettes, he started keeping them in his room again where they would be safe. Review of the undated policy titled, Resident Smoking/Use of Electronic Cigarette Policy, revealed this facility may check periodically to determine if residents have any smoking/use of electronic cigarette articles in violation of our smoking/use of electronic cigarette policies. Staff shall confiscate any such articles and shall notify the Charge Nurse, Director of Nursing, and Administrator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 5 of 14 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 08/09/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, medical record review, and poilicy review, the facility failed to ensure a care plan was updated with smoking interventions after smoking materials were found in a resident's room. This affected one resident (#34) of three reviewed for care plans. Facility census was 97. Findings include: Review of the medical record for the Resident #34 revealed an admission date of 12/26/22. Diagnoses included diabetes, encephalopathy, right below knee amputation, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and required limited assist of one staff for transfer and mobility. Review of the plan of care dated 08/01/23 revealed no information related to the resident storing illicit items in her room including non-prescribed medications and over the counter medications, or smoking materials. The resident's care plan reported she smoked and had interventions for assessment of smoking, assist with smoking, and assist with smoking cessation program. A progress note on 07/26/23 revealed multiple types of medications were found in resident's room. The physician was notified of the controlled medications and drug paraphernalia found and new orders to hold medications and collect a 10 panel urine drug screen. A progress note from the Nurse Practitioner dated 07/27/23 revealed the resident was found with a pipe, vapes, prescription medication, over the counter medication and not prescribed medication in her room as well as suspected marijuana in the room. Further review of Resident #34's care plan revealed interventions were added on 08/08/23 to include storage of smoking materials at the nurses' station and room searches for potential smoking materials. Interview on 08/08/23 at 11:50 A.M. with Resident #34 revealed staff came into her room and informed her they had reports of her having smoking materials in her room and were completing a search of the room. The resident reported staff searched her purse and found an old pipe a vape pen, weed residue and some old pills including Seroquel, Tylenol, and laxatives. Interview on 08/08/23 at 3:35 P.M. with Social Services Designee (SSD) #182 and Social Services (SS) #183 revealed Resident #34 had interventions added to her care plan on 08/08/23 to include that smoking materials needed to be located at the nursing station and that the resident's room could be checked by staff for smoking materials. SSD #182 confirmed she entered new interventions into the care plan on 08/08/23 and revealed the care plan was not updated after the incident of finding smoking materials in resident's room on 07/26/23. Review of the undated and untitled facility policy about care plans revealed care plans were developed and implemented for each resident. The care plan shall be reviewed and updated after a significant change, when a desired outcome was not met, after readmission and quarterly and should include interventions to address sources of problems as well as symptoms or triggers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 6 of 14 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 08/09/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Review of the undated policy titled, Resident Smoking/Use of Electronic Cigarette Policy, any smoking/use of electronic cigarette-related restrictions and concerns shall be noted on the care plan, including ramifications if Smoking/Use of Electronic Cigarette policy is not followed. All personnel caring for the resident shall be alerted to any potential uses. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 7 of 14 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 08/09/2023 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, medical provider interview, medical record review, and policy review, the facility failed to ensure a resident's pain was adequately monitored and treated for two residents (#34 and #28) of two reviewed for pain. Facility census was 97. Residents Affected - Few Findings include: 1. Review of the medical record for the Resident #34 revealed an admission date of [DATE]. Diagnoses included diabetes, encephalopathy, right below knee amputation, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and required limited assist of one staff for transfer and mobility. Review of the plan of care dated [DATE] revealed no information related to residents storing illicit items in her room including non-prescribed medications and over the counter medications, or smoking materials. Review of physician orders for [DATE] revealed an order for a one time 10 panel drug screen with instructions to straight catheterize the patient if needed. The resident's pain medication orders were as follows: -Trazadone HCl tablet 50 millgrams (mg) give 0.5 tablet by mouth at bedtime for insomnia ordered [DATE] -Clonazepam (Klonopin) tablet 0.5 mg give one tablet by mouth twice daily for bipolar disorder ordered [DATE] -Pregabalin (Lyrica) capsule 200 mg give 1 capsule by mouth three times daily for complete amputation of right lower leg ordered [DATE]. An additional 75 mg capsule give 1 capsule three times daily for 14 days added [DATE]. -Oxycodone HCl tablet 15 mg give one tablet every 6 hours for chronic pain [DATE] and stopped [DATE]. -Hydroxyzine pamoate oral capsule 25 mg give one capsule by mouth three times a day for anxiety/withdrawal signs and symptoms order dated [DATE] to [DATE] and again ordered [DATE] -Acetaminophen tablet 325 mg give 2 tablets by mouth three times daily for pain ordered on [DATE] to [DATE] -Acetaminophen tablet 500 mg give 2 tablets by mouth twice a day for pain not to exceed 3000 MG daily order started [DATE] -Ibuprofen oral tablet 200 mg give 600 mg by mouth three times daily ordered on [DATE] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 8 of 14 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 08/09/2023 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 0697 Level of Harm - Minimal harm or potential for actual harm Review of pain monitoring on the Medication Administration Record (MAR) dated 07/2023 revealed the resident had rated her pain at 0/10 every shift except for four shifts from [DATE] to [DATE]. On [DATE], Resident #34 rated her pain at 10/10 then 09/10. On the [DATE], the resident rated her pain at 3/10 then 7/10. On [DATE], the resident rated her pain at 6/10 then 5/10. On [DATE], the resident rated her pain at 4/10 then 3/10. On [DATE], the resident rated her pain at 7/10 then 5/10. Residents Affected - Few Review of the MAR dated 07/2023 revealed the pain medication the resident was given from [DATE] to [DATE] included Acetaminophen 650 mg once on [DATE], once on [DATE], twice on [DATE], once on [DATE] and once on [DATE], Acetaminophen 1000 mg once on [DATE], and Ibuprofen 600 mg once on [DATE]. A progress note dated [DATE] revealed multiple types of medications were found in the resident's room. The physician was notified of the medications and drug paraphernalia found and new orders were received to hold the resident's medications and collect a 10 panel urine drug screen. A progress note from Nurse Practitioner dated [DATE] revealed the resident was found with prescription medication, over the counter medication and not prescribed medication in her room as well as suspected marijuana in the room. A major interdisciplinary meeting was held regarding safety and legal concerns with a plan to hold her medications (Oxycodone, Trazadone, Klonopin, and Llyrica) until toxicology was obtained and reorder medications as appropriate for symptom control and resident safety after the lab result was reviewed. On [DATE] the Assistant Director of Nursing informed staff of the resident's medications being on hold for 30 days pending drug screen results. A progress note dated [DATE] revealed the resident was complaining of symptoms of withdrawal and asked for the physician to be contacted. Vitals were within normal limits, and the resident was tearful and revealed she was feeling like she was crawling out of her skin. Staff contacted the physician who ordered Hydroxyzine (antihistamine) 25 mg three times daily as needed. Review of drug panel results dated [DATE] revealed no results. A handwritten note with no date from the Interim Director of Nursing revealed sample had spilled and the lab had to be redrawn. Review of a drug panel collected on [DATE] and resulted [DATE] revealed the resident had a presumptive positive of Tetrahydrocannabinol (THC). Interview on [DATE] at 11:50 A.M. with Resident #34 revealed staff searched her purse and found an old pipe, a vape pen, weed residue and some old pills including Seroquel, Tylenol, and laxatives. The resident revealed she was told they would stop all her controlled medications and perform a toxicology screen before the medications would resume. Resident #34 revealed the facility got her urine that night and then had to get it again a few days later. Resident #34 revealed she was going through withdrawal and had uncontrolled pain. She reported she had been on opiates since her below the knee amputation several years ago and reported her pain to several different staff and was told they could not help as she was not allowed to have her medication until her labs came back. Resident #34 reported she finally got assistance from staff on [DATE] when the nurse contacted the physician for some relief from her withdrawal symptoms and was given medication to help with the symptoms. Resident #34 stated the facility did not manage her pain and symptoms. Interview on [DATE] at 11:56 A.M. with Licensed Practical Nurse (LPN) #115 revealed she worked with Resident #34 during the timeframe when her medications were held. She revealed the resident had reported she was crawling out of her skin and needing something to help with withdrawal. LPN #115 revealed she contacted the physician and was given a medication order for withdrawal symptoms. LPN #115 revealed the resident had reported pain but had Oxycodone on hold and had orders for Acetaminophen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 9 of 14 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 08/09/2023 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on [DATE] at 4:14 P.M. with Unit Manager (UM) #176 revealed she was unsure if staff were assessing residents specifically for withdrawal symptoms and knew what to look out for regarding withdrawal symptoms. Interview on [DATE] at 9:50 A.M. with Nurse Practitioner (NP) #210 revealed staff were not provided education related to withdrawal symptoms after the medications were held for Resident #34. She stated staff had previously been educated after a previous diversion situation but was unsure when that had occurred, but reported it was within the last year. NP #210 revealed she provided education to both residents on withdrawal symptoms and what to expect. NP #210 revealed she could not recall if staff reached out to her about the resident's pain being uncontrolled or residents having symptoms of withdrawal. Interview on [DATE] at 10:34 A.M. with Registered Nurse (RN) #135 revealed she had received no training since hire in relation to withdrawal symptoms and what to look out for. Interview on [DATE] at 2:27 P.M. with Unit Manager (UM) #176 confirmed Resident #34's pain scored increased after the oxycodone was stopped. UM #176 confirmed the facility had no documentation staff was monitoring pain and pain control including follow up after pain medication was given to ensure it was effective and if it was not what steps were taken. UM #176 found a notation in the medical record that staff had marked pain control as ineffective on [DATE] but was unable to provide to surveyor. UM #176 confirmed the medical record showed no evidence of follow up or staff contacting the medical provider after the resident experienced high pain ratings without effective control. UM #176 revealed as the manager, she would expect staff to check with the resident and if they had reported pain, review the orders and provide ordered pain medications. Staff should check back in with residents after an appropriate amount of time and see if the intervention/medication was effective and if not contact the medical provider for further guidance. UM #176 also confirmed this process should be documented in the medical record. 2. Review of the medical record for the Resident #28 revealed an admission date of [DATE]. Diagnoses included chronic obstructive pulmonary disease, respiratory disease, pulmonary embolism, schizoaffective disorder, weakness, pain and acute fracture of medial malleolus. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact with a BIMS of 15 and required extensive assistance of one to two staff members for transfers and mobility. Review of physician orders dated [DATE] to [DATE] revealed the resident had a Foley catheter placed due to weight bearing status and could be removed when weight bearing status was lifted. The Foley catheter was removed on [DATE]. Physician orders dated [DATE] to [DATE] revealed an order for a 10 panel urine screen with note: may straight cath if needed. The resident's pain medication orders were as follows: -Trazadone HCl tablet 100 mg give 150 mg tablet by mouth at bedtime for insomnia ordered [DATE]. -Tizanidine HCl oral tablet 4 mg give one tablet three times daily for muscle spasms ended on [DATE]. -Medication held then gradual dose reduction started on [DATE] evening dose Tizanidine HCl oral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 10 of 14 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 08/09/2023 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 0697 capsule 2 mg give one capsule three times daily for muscle spasms ordered on [DATE]. Level of Harm - Minimal harm or potential for actual harm -Gabapentin capsule 100 mg give 2 capsules by mouth three times a day for pain ordered [DATE]. -Oxycodone HCl tablet 5 mg give one tablet every 4 hours for pain [DATE] and stopped [DATE]. Residents Affected - Few -Acetaminophen tablet 650 mg give 1 tablets by every four hours as needed for pain. -Ibuprofen oral tablet 400 mg give one tab every 4 hours as needed for pain. Review of pain monitoring on the MAR dated 07/2023 revealed the resident had typically rated her pain at 0/10 or 3/10 to 6/10 with one shift showing a rating on 9/10 pain and one shift showing a 10/10 from [DATE] to [DATE]. The last four and a half days prior to stopping the Oxycodone resident rated her pain at 0/10. On [DATE], Resident #28 rated her pain at 10/10 then 10/10. On [DATE], the resident rated her pain at 10/10 then 8/10, then 10/10. On [DATE], the resident rated her pain at 10/10 then 08/10 then 7/10. On [DATE], the resident rated her pain at 10/10 then 7/10 then 9/10. On [DATE], the resident rated her pain at 10/10 then 6/10. Review of the MAR dated 07/2023 revealed the pain medication the resident was given from [DATE] to [DATE] included Acetaminophen 650 mg once on [DATE], three times on [DATE], three times on [DATE], three times on [DATE] and twice on [DATE], Ibuprofen 400 mg once on [DATE], once on [DATE], once on [DATE] and once on [DATE]. A progress note dated [DATE] revealed the resident attempted to save a Clonazepam for later in the evening, she stated she had been doing that. The resident was advised that she needed to take her pills as ordered and watched the resident take both pills. The physician was updated. A progress note dated [DATE] revealed the physician switched the resident from Clonazepam and started Lorazepam 0.5 mg at bedtime based on issues with clonazepam. A progress note dated [DATE] revealed multiple types of medications were found in the resident's room. The physician was notified of the medications and drug paraphernalia found with new orders to hold medications and collect a 10 panel drug screen. A Progress note on [DATE] revealed the NP was holding the resident's sedating medications including Trazadone, Tizanidine, Gabapentin and Oxycodone. The progress note dated [DATE] from the Nurse Practitioner reported the resident was found with a myriad of loose pills as well as unprescribed over the counter medications. The resident was having altered mental status and was found with nicotine, vapes, and delta 9 vapes. The plan was to hold her opiates and benzodiazepines, Trazadone and Ggabapentin until the drug screen results were available. The note stated the resident was NOT at risk for withdrawal during this brief hold period. A progress note dated [DATE] revealed that the lab results had returned and the physician noted he had received them. A progress note from the NP dated [DATE] revealed the resident's drug screen was reviewed with positive THC and negative for opiates and benzodiazepines which she had a prescription for and had been receiving. The note reported the resident was requesting when she would get her opiates back and verbally expressing high levels of pain but showed no outward signs of pain or distress. The plan was to continue Xanaflex (Tizanidine) and Neurontin (Gabapentin) as well as lidocaine patches to her left shoulder with Ibuprofen and Tylenol and biofreeze as needed. The NP planned to hold the Oxycodone until the NP and physician could discuss a decision on opiates. The NP also started Meloxicam (anti-inflammatory) 5 mg daily. A progress note dated [DATE] revealed the physician had evaluated the resident and was discontinuing the Oxycodone with a plan to continue Levothyroxine (for hypothyroidism) and add biofreeze to bilateral lower extremity for pain, and vicks vapor rub for pain three times daily as needed. The resident requested the physician to return. After the physician met again with the resident and labs were ordered, the Vistaril (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 11 of 14 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 08/09/2023 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 0697 (antihistamine) and Ibuprophen orders was changed. Level of Harm - Minimal harm or potential for actual harm Review of a drug screen dated [DATE] and resulted on [DATE] revealed the resident was positive for THC only. Residents Affected - Few Interview on [DATE] at 12:04 P.M. with Resident #28 revealed staff completed a room search and found several vapes, some of which belonged to her deceased family member, and a lighter. The resident revealed staff informed her they would stop her medication until a drug screen could be completed. Resident #28 reported she informed staff she was in pain and having symptoms of withdrawal and revealed she was unable to restart medication until she was seen by the provider. The resident stated the facility did not manage her pain and symptoms. The resident reported symptoms of nausea, pain, and chills. She denied wanting to restart the Oxycodone and reported she had already gone through her withdrawal and was afraid they would take it away again and leave her with nothing. Interview on [DATE] at 12:21 P.M. with State Tested Nursing Assistant (STNA) #121 revealed Resident #28 was reporting more pain than usual with care and revealed the resident had recently broken her ankle. STNA #121 revealed she had informed nursing of the pain reported by Resident #28 and was informed her meds were on hold. Interview on [DATE] at 9:50 A.M. with Nurse Practitioner (NP) #210 revealed staff were not provided education related to withdrawal symptoms after the medications were held for Resident #28. She stated staff had previously been educated after a previous diversion situation but was unsure when that had occurred, but reported it was within the last year. NP revealed she provided education to both residents on withdrawal symptoms and what to expect. She stated Residents #28 had reported increased pain but was showing no outward signs of withdrawal or pain. Interview on [DATE] at 10:55 A.M. with STNA #139 revealed Resident #28 had complained of pain during the days following her medications being held on [DATE]. Interview [DATE] at 2:27 P.M. with Unit Manager (UM) #176 confirmed Resident #28's pain score increased after her Oxycodone was stopped. Review of facility policy titled, Pain assessment management, dated 03/2020, revealed staff shall identify pain. This include assessing for potential pain, recognizing presence of pain, identifying pain, addressing causes, developing and implementing approaches for pain management, identifying strategies for levels of pain, monitoring effectiveness of interventions, and modifying approaches as necessary. The policy revealed acute pain should be addressed every 30 to 60 minutes after onset and of new pain or worsening of existing pain. Staff shall monitor resident responses to pain interventions. If pain was not adequately controlled, the medical team including the physician shall reconsider approaches and make adjustments as indicated. Staff shall document residents reported pain level with adequate detail (enough to gauge the status of pain and effectiveness of interventions for pain. The physician shall be notified of the presence of pain including prolonged or unrelieved pain. This deficiency represents non-compliance investigated under Complaint Number OH00145029. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 12 of 14 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 08/09/2023 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and medical record review, revealed the facility failed to ensure a laboratory result was followed up on in a timely manner. This affected one resident (#34) of two reviewed for laboratory results. Facility census was 97. Residents Affected - Few Findings include: Review of the medical record for the Resident #34 revealed an admission date of 12/26/22. Diagnoses included diabetes, encephalopathy, right below knee amputation, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and required limited assist of one staff for transfer and mobility. Review of physician orders for 07/26/23 revealed a one time order for a 10 panel drug screen with instructions to straight catheterize if needed. Review of a progress note dated 07/26/23 revealed multiple types of medications were found in the resident's room. The physician was notified of the medications and drug paraphernalia found and new orderswere received to hold medications and collect a 10 panel urine drug screen. A progress note from the Nurse Practitioner dated 07/27/23 revealed the resident was found with prescription medication, over the counter medication and not prescribed medication in her room as well as suspected marijuana in the room. A major interdisciplinary meeting was held regarding safety and legal concerns with a plan to hold medications (Oxycodone, Trazadone, Klonopin, and Lyrica) until toxicology results were obtained and reviewed. Review of drug panel results dated 07/26/23 revealed no results. A handwritten note with no date from the Interim Director of Nursing (DON) revealed the specimen had spilled and the facility would complete a drug screen in house. Review of the drug panel dated 07/31/23 revealed the resident had a presumptive positive of Tetrahydrocannabinol (THC). Interview on 08/08/23 at 11:50 A.M. with Resident #34 revealed she was told by staff they would be stopping all her controlled medications and performing a toxicology screen before the medications would resume. Resident #34 revealed the facility got her urine that night and then had to get it again a few days later. She stated she was going through withdrawal and pain for several days without assistance from staff or medication for symptoms. Resident #34 reported eventually her toxicology result came back and was positive for THC. She reported she had been on opiates since her below the knee amputation several year ago and reported her pain to several different staff and was told they could not help as she was not allowed to have her medication until her labs came back. Interview on 08/08/23 at 11:56 A.M. with Licensed Practical Nurse (LPN) #115 revealed she worked with Resident #34 during the timeframe when her medications were held. She revealed the resident had reported she was crawling out of her skin and needing something to help with withdrawal. LPN #115 revealed she contacted the physician and was given a medication order to help the resident with her reported symptoms. LPN #115 revealed the resident had reported improvement in symptoms after the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 13 of 14 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 08/09/2023 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 0770 Level of Harm - Minimal harm or potential for actual harm medication was provided. LPN #115 revealed the resident had complained of pain but the facility was still awaiting her lab results to come back. Interview on 08/09/23 at 10:55 A.M. with State Tested Nursing Assistant (STNA) #139 revealed Resident #34 had her drug screen completed by urinating in a collection device in the toilet on 07/26/23 night shift. Residents Affected - Few Interview on 08/09/23 at 2:25 P.M. with Interim DON #170 revealed she had followed up with the lab on I think 07/28/23 and was informed the lab had spilled the sample. Interim DON #170 reported the facility then had the inhouse lab complete the toxicology test on 07/31/23. Interim DON #170 was unable to provide reasoning or evidence why the lab was not checked on or collected in a timely manner after being told on 07/28/23 that it had spilled. Interim DON #170 confirmed the importance of getting the results as the medical team was awaiting lab results for medication and treatment decisions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365597 If continuation sheet Page 14 of 14