Inspection·September 9, 2024

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility did an in-service on showers in July and August and an in-service on 09/05/24 for documenting in the electronic medical record. 2. Medical record review revealed Resident #70 was admitted to the facility on [DATE] with diagnoses including fracture of right lower leg, subsequent encounter for closed fracture with routine healing right ankle/foot, need assistance with personal care, weakness, abnormal posture, other abnormalities of gait and mobility, spondylosis without myelopathy or radiculopathy, cervical region, elevated white blood cell count, retention of urine, elevation of levels of liver transaminase levels, concussion without loss of consciousness, subsequent encounter, other fracture of fourth lumbar vertebra, subsequent encounter for fracture with routine healing, unspecified displaced fracture of seventh cervical vertebra, subsequent encounter for fracture with routine healing, traumatic arthropathy, left knee, contusion of unspecified part of neck, subsequent encounter, unspecified fracture of sternum, subsequent encounter for fracture with routine healing right side of sternum, multiple fractures of ribs, right side, subsequent encounter for fracture with routine healing right ribs, person injured in unspecified motor-vehicle accident, traffic, laceration without foreign body of abdominal wall, left lower quadrant without penetration into peritoneal cavity, subsequent encounter-left lower abdomen laceration, fracture of fourth lumbar vertebra, fracture of right ilium, subsequent encounter for fracture with routine healing-right posterior iliac crest, unspecified fracture of left ilium, subsequent encounter for fracture with routine healing-left iliac bone, other specified injuries of abdomen, subsequent encounter-right lower d quad wall hernia, other specified injuries of abdomen, subsequent encounter-seat belt trauma, laceration without foreign body of left middle finger without damage to nail, and subsequent encounter-left middle finger laceration. Review of Resident #70's five-day MDS dated [DATE] revealed the resident was dependent on staff for shower/bathing. Review of the concern log dated 07/2024 revealed Resident #70 had concerns regarding showers/bath. On 07/30/24 Resident #70 reported she was not receiving baths, not even bed baths, due to staff were telling her they didn't have enough people working. The resolution was to talk to staff to remind them not to say things like that to resident and try to figure out another day and time to correct the problem. Review of the concern log dated 08/2024 revealed Resident #70 had concerns again regarding showers. The resident reports she was still not receiving showers. Staff were telling her they were short (staffed) since she has been admitted . Therapy has given her one shower and washed her hair. The resolution was to have first shift provide shower, audits, and staff education. Review of the shower schedule (undated) revealed Resident #70 was scheduled for showers/baths on Tuesday, Thursday and Saturday. Review of Resident #70's shower sheets dated 07/11/24 to 09/09/24 revealed the resident received a shower on 08/02/24, 08/13/24, 08/22/24, 08/28/24, an undated date between 08/29/24 to 09/07/24. Review of therapy notes dated 09/04/24 revealed the resident completed her own sponge bath. Review of Resident #70 electronic medical record dated 07/11/24 to 09/09/24 revealed the resident received one shower on 08/20/24. Review of audits sheet completed 08/06/24, 08/08/24, 08/10/24, 08/13/24, 08/15/24, 08/17/24, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365612 If continuation sheet Page 2 of 4 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 09/09/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 08/20/24 by the Assistant Director of Nursing (ADON) #136 indicated Resident #70 had received showers those given days. Interview on 09/09/24 at 10:00 A.M., with Resident #70 confirmed she had voiced concerns to the facility due she wasn't receiving showers per preference. The facility staff told her they were short staffed, or they can't do her shower because they have 10 others to do, or it was too close to the end of their shift. The resident reported she may have had five showers in the last month. Interview on 09/09/24 at 12:53 P.M., with the DON confirmed there was no documented evidence the resident received a shower from 07/11/24 to 08/01/24 and no evidence the resident received a shower/bath on 08/03/24, 08/06/24, 08/08/24, 08/10/24, 08/15/24, 08/17/24, 08/24/24, 08/27/24, 08/31/24, 09/03/24, or 09/05/24. The DON confirmed the audits the ADON completed on 08/06/14 were inaccurate due to there was no shower sheets that indicated a shower was provided, on 08/08/24 the resident received a bed bath not a shower, there was no shower sheet completed for 08/10/24, on 08/15/24 the shower sheet indicated the resident received a bed bath, not a shower, there was no shower sheet for 08/17/24, and on 08/20/24 the resident received a bed bath not a shower. 3. Medical record review revealed Resident #52 was admitted to the facility on [DATE] with diagnoses including heart failure, obesity, difficulty walking, respiratory failure, diabetes, and diabetic neuropathy. Review of the shower sheet (undated) revealed Resident #52's shower/bath days were Tuesday and Saturday. Review of Resident #52's shower sheets dated 08/01/24 to 09/09/24 revealed the resident refused a shower on 08/06/24, on 08/14/24 received a shower, refused on 08/20/24, received a shower on 08/24/24, 08/31/24, and 09/02/24. There was no documented evidence the resident received a shower on 08/01/24, 08/08/24, 08/13/24, 08/15/24, 08/22/24, 08/27/24, 08/29/24, 09/03/24, or 09/05/24. Review of Resident #52's electronic medical record dated 08/01/24 to 09/09/24 revealed the resident only received one shower on 08/31/24 and required physical help in part of the bathing. Interview on 09/09/24 at 12:16 P.M. with Resident #52 revealed she doesn't receive showers per preference. The resident reported the staff would come in and offer and say they will be back to get her, and no one returns. The resident showed the surveyor a stack of linens and bath towels lying on the bed that have been there for two days now. The resident pointed to her shampoo that was in her basket on her walker for two days now as well. The resident reported she requires staff to go in shower room with her due to her oxygen. The resident reported she hasn't had a shower for 3 to 4 days now. Interview on 09/09/24 at 12:59 P.M., with the DON confirmed there was no documented evidence the resident has received a shower on 08/01/24, 08/08/24, 08/13/24, 08/15/24, 08/22/24, 08/27/24, 08/29/24, 09/03/24, or 09/05/24. Review of the facility policy titled Shower/Tub Bath (dated 04/18/24) revealed it's the facility's policy to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Encourage the resident to participate in the bath. Stay with resident throughout the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365612 If continuation sheet Page 3 of 4 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 09/09/2024 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 0677 Level of Harm - Minimal harm or potential for actual harm bath. Never leave the resident unattended in the tub or shower. The following information should be recorded on the resident's bath sheet: date the shower/tub bath was performed, if the resident refused, name of individuals assists, and any skin observation noted. This deficiency represents non-compliance investigated under Complaint Number OH00157392. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365612 If continuation sheet Page 4 of 4