Health inspection·December 9, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was 4:30 P.M. Resident #12 then got mad and stated it was ridiculous and she was in pain. CNA #178 stated there was nothing she could do, Resident #12 stated another nurse had passed medications early before, and CNA #178 responded at some point, well if your brain isn't working, don't you think you could have forgot? The nurse then entered the room and had both aides return to their hall. Review of a care plan dated 07/26/25 revealed Resident #12 was at risk for pain related to cancer, gout, chronic pain syndrome, and diabetic neuropathy. The goal was to maintain a daily routine and verbalize they are comfortable daily by target date. Interventions included but were not limited to administer pain medications as ordered and observe for effectiveness, observe and report any side effects; coordinate with therapy as needed to provide medications as ordered and as needed by resident to promote comfort and encourage participation with therapy; observe for episodes of breakthrough pain and medicate as ordered or contact physician as needed; offer additional non-pharmacologic interventions, dim lights, soft music, position changes, music, television, and conversations/distractions; and remind resident that reporting pain early may improve effectiveness of pain medication. Interview on 12/09/25 at 4:45 P.M. with the Administrator confirmed a witness statement stated Resident #12 was so upset she was shaking and one revealed Resident #12 was told her brain is broken. During the interview, the Administrator disagreed this was abuse because there were no negative outcomes and no intent to harm the resident. 2. Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including autosomal dominant limb girdle muscle dystrophy and weakness. Review of an MDS dated [DATE] revealed Resident #22's cognition remained intact. Review of a self-reported incident (SRI) dated 09/19/25 revealed an allegation of verbal abuse from Dietary Coordinator (DC) #310 to Resident #22. Witnesses stated DC #310 cussed and yelled at Resident #22 after the resident cussed and insulted her about his missing lunch tray. After the exchange, DC #310 left the room and continued to cuss under her breath as she went up the hallway passing residents and staff. A thorough investigation was completed and the allegation of verbal abuse was unsubstantiated due to lack of willful intention to harm Resident #22, however DC #310 was terminated for unprofessional behavior or conduct. Review of a witness statement dated 09/19/25 by DC #310 revealed she received a call stating Resident #22 did not get a tray, but she knew good and well he received a tray. DC #310 went to check the cart when Resident #22 called her into his room and yelled at her for always getting his tray wrong. DC #310 explained she did not get his tray wrong, but Resident #22 called her an expletive (f**king b*tch) and she told the resident to shut up. DC #310 stated she knew she should not have said that but she reached her boiling point. Review of a witness statement dated 09/19/25 by the Assistant Director of Nursing (ADON) #155 revealed she was standing in the dining area speaking with staff members during lunch time, witnessed DC #310 walk into the dining area stating she made the food Resident #22 requested and you guys need to find the f**king tray. DC #310 then walked into Resident #22's room and ADON #155 was not able to hear the entire conversation but did hear DC #310 use the word f*ck and the resident began screaming in response. DC #310 left the resident's room and walked back through the dining area stating I'm over this f**king place loud enough for family members and residents in the area to hear. Resident #22 continued screaming after DC #310 left his room so ADON #155 entered the room to ensure he was safe and to attempt therapeutic communication. Resident #22 stated nobody is going to come in here and talk to me like that calling me f**king stupid. ADON #155 did not hear DC #310 call Resident #22 stupid and only heard the profanity. Review of a witness statement dated 09/19/25 by CNA #224 revealed she was coming back to a resident room to fix food and DC #310 headed towards Resident #22's room, they began fighting and Resident #22 called DC #310 a f**king b*tch then she said f*ck you to him. CNA #224 stated she was standing at Resident #22's door way (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 12/09/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete then left to get another resident their food. Resident #22 would always complain his food was messed up. Review of a witness statement dated 09/19/25 by Licensed Practical Nurse (LPN) #177 revealed while passing medications, she heard yelling and saw DC #310 come out of a room yelling, f*ck this place, I'm over it. Review of a witness statement dated 09/19/25 by Resident #22 transcribed by the Administrator revealed he had no issues at lunch, did not need anything, and had no issues with DC #310. Interview on 12/09/25 at 3:51 P.M. with the Administrator revealed staff did witness DC #310 yelling and cussing in the facility and DC #310 admitted to telling Resident #22 to shut up but because there was no willful intention to abuse, it would not substantiated as an allegation of verbal abuse. The Administrator stated Resident #22 could not recall an incident or did not feel bothered enough to discuss it. The Administrator stated DC #310 was fired for unprofessionalism and misconduct. Interview on 12/09/25 at 4:29 P.M. with Resident #22 revealed he was able to recall the incident with DC #310 and he was over it now. Resident #22 stated in the moment, he was very angry a staff at the facility would tell him to shut the f*ck up. Resident #22 admitted he did also yell at DC #310. Review of a policy titled Resident Rights dated 05/01/25 revealed the facility would make every effort to assist each resident in exercising his/her rights to assure the resident is always treated with respect, kindness, and dignity. Review of an undated policy titled Abuse, Mistreatment, Neglect, Injuries of Unknown Source, and Misappropriation of Resident Property revealed the facility will not tolerate abuse by anyone. Abuse is defined by the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This deficiency represents an incidental finding of non-compliance investigated under Master Complaint Number 2655536. 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 12/09/2025 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, policy review, and facility investigation report review, the facility failed to ensure allegations of abuse were thoroughly investigated. This affected one (#22) of two residents reviewed for abuse. The facility census was 89. Findings include:Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including autosomal dominant limb girdle muscle dystrophy and weakness. Review of an minimum data set (MDS) assessment dated [DATE] revealed Resident #22's cognition remained intact. Review of a self-reported incident (SRI) dated 09/19/25 revealed an allegation of verbal abuse from Dietary Coordinator (DC) #310 to Resident #22. Witnesses stated DC #310 cussed and yelled at Resident #22 after the resident cussed and insulted her about his missing lunch tray. After the exchange, DC #310 left the room and continued to cuss under her breath as she went up the hallway passing residents and staff. A thorough investigation was completed and the allegation of verbal abuse was unsubstantiated due to lack of willful intention to harm to Resident #22, however DC #310 was terminated for unprofessional behavior or conduct. Review of a witness statement dated 09/19/25 by DC #310 revealed she received a call stating Resident #22 did not get a tray, but she knew good and well he received a tray. DC #310 went to check the cart when Resident #22 called her into his room and yelled at her for always getting his tray wrong. DC #310 explained she did not get his tray wrong, but Resident #22 called her an expletive (f**king b*tch) and she told him to shut up. DC #310 stated she knew she should not have said that but she reached her boiling point. Review of a witness statement dated 09/19/25 by the Assistant Director of Nursing (ADON) #155 revealed she was standing in the dining area speaking with staff members during lunch time, witnessed DC #310 walk into the dining area stating she made the food Resident #22 requested and you guys need to find the f**king tray. DC #310 then walked into Resident #22's room and ADON #155 was not able to hear the entire conversation but did hear DC #310 use the word f*ck and the resident began screaming in response. DC #310 left the resident's room and walked back through the dining area stating I'm over this f**king place loud enough for family members and residents in the area to hear. Resident #22 continued screaming after DC #310 left his room so ADON #155 entered the room to ensure he was safe and to attempt therapeutic communication. Resident #22 stated nobody is going to come in here and talk to me like that calling me f**king stupid. ADON #155 did not hear DC #310 call Resident #22 stupid and only heard the profanity. Review of a witness statement dated 09/19/25 by certified nursing assistant (CNA) #224 revealed she was coming back to a resident room to fix food and DC #310 headed towards Resident #22's room, they began fighting and Resident #22 called DC #310 a f**king bitch then she said f*ck you to him. CNA #224 stated she was standing at Resident #22's door way then left to get another resident their food. Resident #22 would always complain his food was messed up. Review of a witness statement dated 09/19/25 by Licensed Practical Nurse (LPN) #177 revealed while passing medications, she heard yelling and saw DC #310 come out of a room yelling, f*ck this place, I'm over it. Review of a witness statement dated 09/19/25 by Resident #22 transcribed by the Administrator revealed the resident had no issues at lunch, did not need anything, and had no issues with DC #310. There was no evidence additional residents were interviewed regarding allegations of abuse despite staff statements indicating family and residents were in the dining area while DC #310 walked away cussing on 09/19/25 during the interaction with Resident #22. Interview on 12/09/25 at 3:51 P.M. with the Administrator revealed staff did witness DC #310 yelling and cussing in the facility and DC #310 admitted to telling Resident #22 to shut up but because there was no willful intention to abuse, it would not substantiated as an allegation of verbal abuse. The Administrator stated Resident #22 could not recall an incident or did not feel bothered enough Residents Affected - Few (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 12/09/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete to discuss it. The Administrator stated DC #310 was fired for unprofessionalism and misconduct. The Administrator confirmed no additional residents were interviewed because no additional residents were affected since the incident happened in Resident #22's room and in the hallway. Review of an undated policy titled Abuse, Mistreatment, Neglect, Injuries of Unknown Source, and Misappropriation of Resident Property revealed the facility will not tolerate abuse by anyone. Abuse is defined by the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Allegations of abuse should be investigated and the investigation should be completed within five working days which do not include weekends or legal holidays. The investigation should include interviewing the resident, the accused and all witnesses. Witnesses generally include anyone who witnessed or heard the incident; came in close contact with the resident the day of the incident (including other residents and family members); and employees who worked closely with the accused employee and/or alleged victim. If there are no direct witnesses, then the interviews may be expanded to cover all employees on the unit, or as appropriate, the shift. Written statements from the resident, if possible the accused, and each witness should be obtained, the record should be reviewed, and employment files should be reviewed. The investigation should be documented. This deficiency represents an incidental finding of non-compliance investigated under Master Complaint Number 2655536. Event ID: Facility ID: 365612 If continuation sheet Page 5 of 5