Inspection·December 19, 2023

F 0602 Level of Harm - Minimal harm or potential for actual harm On 10/14/23 the starting count of cards of controlled medications was 38, during the day, two cards were emptied, which would have left 36 cards. Due to the missing medication, the end of day count was 35 cards of medications. The 36 was struck out and 35 was written above it. • Residents Affected - Few On 10/16/23 the starting count for the day was 35 cards of medication. Throughout the day, one card was added and two were emptied which would have left 34 cards of medication. The count read 33, but then was struck out and 34 was penciled in over top. During evening shift when counted, 33 cards of medications were on the cart. • On 10/17/23 the morning shift count started out at 37 after three cards were added. The count remained at 37 throughout the day. On the evening shift count, there were 36 cards to start the shift. None were removed or added and at the end of the day, 37 cards were remaining on the cart, with a 36 that had been struck out due to an error. Review of additional controlled medication counts revealed the count sheets were not labeled and missing dates. Interview on 12/19/23 at 10:27 A.M. with LPN #179 revealed the date the medication went missing (10/15/23) was on a Sunday and she was responsible for passing medications on two units which was difficult due to the amount of residents. LPN #179 reported when medication count was completed the morning of 10/15/23, she and RN #127 were rushing and she remembered pausing because something was strange but I just went with it and did not think much about it until she realized the medication was missing. LPN #179 stated when she realized the medication was not accounted for, she searched shred bins, trash cans, other medication carts and could not find it. LPN #129 did request two nurses from other units to come and count with her to make sure she was counting correctly but they also could not find the medication. LPN #179 stated another nurse texted RN #127 but did not hear back from her. LPN #179 stated she was very busy and did not have time to stop working the whole day. LPN #179 reported Resident #13 was not in pain and slept most of the day. She stated when RN #127 reported back to work that evening, they contacted the Director of Nursing (DON) to inform her of the missing medication and DON requested they keep their phones handy so they could be reached during the investigation. LPN #179 stated her keys stay in her right pocket and she does not believe anyone else has a set of keys. LPN #179 stated she was really trying to get medication pass done and she did not have help so she was unable to report the medication missing at 10 A.M. when she noticed it. Interview on 12/19/23 at 11:04 A.M. with LPN #131 revealed she was working on another unit when LPN #179 requested help to look for missing medication. LPN #131 reported she assisted in searching the medication cart, the narcotic box, the medication room, and looked through expired medications that were waiting to be wasted out. LPN #131 stated she instructed LPN #179 to call the DON. Interview on 12/19/23 at 12:05 P.M. with DON revealed the missing medication should have been reported within two hours of staff noticing it was gone. Education was provided only to the nurse who was working the memory care cart regarding reporting missing medications and pulling from the emergency kit, which does require an authorization from the pharmacy to pull. The DON confirmed norco is available on the emergency kit and LPN #179 should have tried to get an authorization to pull the appropriate medication for Resident #13. DON stated multiple searches for missing medications were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365612 If continuation sheet Page 2 of 5 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 365612 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Summit Acres Nursing Home 44565 Sunset Road Caldwell, OH 43724 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 0602 Level of Harm - Minimal harm or potential for actual harm conducted with no results. Multiple interviews revealed Resident #13 was comfortable throughout the day. DON confirmed the medication counts for the memory care unit medication cart was off on 10/14/23 but she was not made aware until 10/15/23. DON also confirmed the counts were incorrect on 10/16/23 and 10/17/23, she was not made aware of the counts being off and she did not review the medication counts after the initial medications were reported missing on 10/15/23. Residents Affected - Few Interview with the DON on 12/19/23 at 2:40 P.M. revealed the nurse who worked on 10/16/23 was working on getting an authorization for Resident #13 to receive medication to be pulled from the emergency kit which took a while to receive from the pharmacy which is why Resident #13 missed her morning dose. The DON also reported she had reviewed the documentation from 10/13/23 through 10/17/23 regarding the controlled drugs count for memory care unit and there were four lines of medication counts documentation under 10/14/23 and the last two were meant to be 10/15/23 so the count was not incorrect until 10/15/23. Review of a policy titled Medication Administration- General Guidelines revealed medications should be administered in accordance with good nursing principles and practices, the facility should have sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Facility staff should respect the five rights of medication pass to residents which include right resident, right drug, right dose, right route, and right time. The policy also stated if a medication with an active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g. other units) are searched if possible. If the medication cannot be located after further investigation, the pharmacy is contacted, or medication removed from the starter box (emergency kit). This deficiency represents an incidental finding of non-compliance investigated under Complaint Number OH00147879. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365612 If continuation sheet Page 3 of 5 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 365612 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Summit Acres Nursing Home 44565 Sunset Road Caldwell, OH 43724 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to utilize the starter box from the pharmacy to administer the correct medication to a resident when their medication was not able to be located. This affected one resident (#13) of one resident reviewed for medications. The facility census was 82. Findings included: Record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, hypertension, Raynaud's syndrome without gangrene, supraventricular tachycardia, atherosclerotic heart disease of native coronary artery without angina pectoris, insomnia, senile degeneration of the brain, hallucinations, unspecified mood affective disorder, major depressive disorder, anxiety disorder, and tinea unguium. Review of an annual minimum data set (MDS) assessment completed on 10/13/23 revealed Resident #13 had severely impaired cognition. Review of orders revealed Resident #13 was ordered ativan 0.5 milligrams (mg) twice a day for anxiety on 09/06/23, norco 5-325 mg as needed for pain every four hours on 06/14/23, and norco 5-325 mg three times a day for pain on 08/29/23. Review of medication administration record (MAR) from October 2023 revealed Resident #13 did not receive scheduled norco on 10/14/23 at 4:39 P.M. due to refusing medication, 12/15/23 at 8:17 A.M. and 1:35 P.M. due to drug not being available, 10/15/23 evening shift, and 10/16/23 at 9:39 A.M. due to awaiting arrival of medication from pharmacy. Review of a self-reported incident (SRI), reference number 240221, dated 10/16/23 revealed a card that had 11 tablets of norco on it had gone missing for Resident #13. The facility conducted an investigation including staff interviews and a search of all medication carts and medication rooms, and shred boxes with no results. The facility did have nursing staff, Registered Nurse (RN) #127 and Licensed Practical Nurse (LPN) #179, take drug tests which were negative. Statements from RN #127 and LPN #179 revealed they had counted the medications on the morning on 10/15/23 and the count was accurate. LPN #179 was passing medications to Resident #13 at approximately 10:00 A.M. when she realized a card with 11 tablets of norco was missing. LPN #179 did not report missing medication until approximately 7:00 P.M. due to hoping it would turn up and not having enough time to search for the medication herself. The facility was unable to find evidence that either nurse had taken the medication. Interview on 12/19/23 at 12:05 P.M. with the DON confirmed LPN #179 did administer as needed Tylenol to Resident #13 in place of her ordered norco. The DON confirmed norco is available on the emergency kit and LPN #179 should have tried to get an authorization to pull the appropriate medication for Resident #13. DON stated multiple searches for missing medications were conducted with no results. Multiple interviews revealed Resident #13 was comfortable throughout the day. Interview with the DON on 12/19/23 at 2:40 P.M. revealed the nurse who worked on 10/16/23 was working on getting an authorization for Resident #13 to receive medication to be pulled from the emergency kit which took a while to receive from the pharmacy which is why Resident #13 missed her morning dose. Review of a policy titled Medication Administration- General Guidelines revealed medications should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365612 If continuation sheet Page 4 of 5 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 365612 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Summit Acres Nursing Home 44565 Sunset Road Caldwell, OH 43724 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few be administered in accordance with good nursing principles and practices, the facility should have sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Facility staff should respect the five rights of medication pass to residents which include right resident, right drug, right dose, right route, and right time. The policy also stated if a medication with an active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g. other units) are searched if possible. If the medication cannot be located after further investigation, the pharmacy is contacted, or medication removed from the starter box (emergency kit). This deficiency represents an incidental finding of non-compliance investigated under Complaint Number OH00147879. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365612 If continuation sheet Page 5 of 5