Inspection·December 5, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete receipt for the purchase of the rollers for the closet door and stated the facility had not made any written documentation of Resident #38's request to repair the closet door. During an interview on 12/05/2025 at 9:11 AM, the Director of Nursing (DON) stated that she expected the maintenance department to have a team approach for repairs such that staff and residents reported any concerns found related to the environment and she expected the maintenance department to conduct routine rounds of the facility's environment to identify any concerns or repair needs. The DON stated that Resident #38's closet door should not have taken a month and a half to repair as that amount of time was not reasonable. 2. During an interview on 12/01/2025 at 11:33 AM, Resident #57 stated there was water damage to the ceiling in their room. Resident #57 stated that the water damage was like that since the resident moved into the room in 2018. Resident #57 stated the water damage was not reported because the damage was there when the resident moved in, and since staff allowed the resident to move into a room with water damage to the ceiling the resident did not think there were any plans to fix it or do anything about it. Resident #57 further stated that they would like to have the water damage to the ceiling repaired. During an interview on 12/04/2025 at 10:43 AM, the Maintenance Director stated that for the past four years he repaired leaking pipes from the sprinkler system, which had resulted in water damage to the ceiling, and once the leak was repaired, the maintenance staff replaced the ceiling tiles. During a follow-up interview on 12/05/2025 at 8:37 AM, the Maintenance Director stated his department did not have a practice of completing room rounds to identify areas in need of repair. He stated that the ceiling in that room should have been repaired and looked at, to make sure there was no mold growth. During an interview on 12/05/2025 at 9:11 AM, the Director of Nursing (DON) stated that she expected the maintenance staff to conduct routine monitoring to identify areas that needed attention and repair water damage. 3. During an observation of Resident #70's room on 12/01/2025 at 9:45 AM a large area to the ceiling did not have the ceiling texture spray applied. That area of the ceiling had a smooth finish while the remainder of the ceiling was covered with the ceiling texture spray. During a second observation of Resident #70's room on 12/04/2025 at 6:30 PM it was revealed the ceiling had not had texture spray applied to the smooth portion of the ceiling. A receipt dated 11/05/2025 provided by the Maintenance Director revealed that ceiling texture spray was purchased. During an interview on 12/05/2025 at 9:05 AM, the Maintenance Director stated that he purchased the ceiling texture spray on 11/05/2025 to spray on the ceiling after he repaired water damage to the ceiling. He stated that he repaired a leaking pipe in the ceiling from the sprinkler system before Resident #70 moved in, but Resident #70 moved into the room before he had a chance to apply the ceiling texture spray. During an interview on 12/05/2025 at 9:11 AM, the Director of Nursing (DON) stated that she expected the maintenance department to have a team approach for repairs such that nursing staff and residents reported to the maintenance department any concerns found related to the environment. The DON stated she expected the maintenance staff to conduct routine monitoring to identify areas that needed attention and make all needed repairs prior to a resident moving into a room. This deficiency represents non-compliance investigated under Complaint Number 1376435. Event ID: Facility ID: 365648 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 365648 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Knoll Post-Acute and Senior Living 4400 Vannest Avenue Middletown, OH 45042 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, interview, and facility policy review, the facility failed to store food in accordance with professional standards for food service safety. This deficient practice had the potential to affect all residents who received food from the kitchen. The facility census was 53. Findings include: A facility policy titled, Food Receiving and Storage, revised November 2022, revealed a section titled Dry Food Storage, that specified, 4. Dry foods that are stored in bins are removed from original packaging, labeled, and dated ‘use by' date). Such foods are rotated using a ‘first in-first out' system. The policy continued, Refrigerated/Frozen Storage 1. All foods stored in the refrigerator or freezer are covered, labeled, and dated ( use by date). During an observation of the initial tour of the kitchen on 12/01/2025 at 9:25 AM, the walk-in freezer contained three trays of disposable foam cups filled with ice. Two trays of cups were uncovered. There was a bag containing brown rectangular objects that were undated. An observation of the walk-in cooler revealed a pitcher labeled pink lemonade with a date of 11/30/2025 noted. An observation of the dry goods storage room revealed the following open and undated items: a bag of cereal, in its originally packaging, a bag of powdered sugar secured in a plastic bag with a closure, two bags of pasta in their original packaging and one bag of spaghetti in its original packaging. During an observation on 12/02/2025 at 10:25 AM, the walk-in freezer contained three trays of disposable foam cups filled with ice. Two trays of cups were uncovered. A bag that contained rectangular shaped objects remained unlabeled and undated. An observation in the dry goods storage room revealed an opened bag of cereal, in its original packaging, undated. A bag of powdered sugar remained secured in a plastic storage bag with a closure that was unlabeled and undated, two bags of pasta, in the original packaging, opened and undated, and one bag of spaghetti, in its original packaging, opened and undated. During an interview on 12/03/2025 at 1:45 PM, Dietary Aide #4 revealed that all open food items in the walk-in freezer should be covered and labeled with the date they were prepared. During an interview on 12/03/2025 at 2:00 PM, Dietary Aide #5 revealed all food items should contain a date when the item was opened. She stated most food items were good for seven days and should be labeled with a use-by date. She stated various food items had different use-by dates. She stated items stored in the cooler should be wrapped tightly and labeled with the date opened prior to being placed in the cooler. Dietary Aide #5 stated items in the freezer should be labeled and dated and if possible, placed back in the original box. Dietary Aide #5 stated the facility used buckets to place dry goods in once they were opened, but these items should also be dated. During an interview on 12/03/2025 at 2:25 PM, the Dietary Manager stated she expected all dried goods to be labeled with a received date, open date, and a use-by date. The Dietary Manager stated that the discard date was changed for dry goods once they were opened, and food items should be discarded in three to five days. The Dietary Manager stated she expected the dietary employee who opened the item to secure a label with an open and discard date. She stated the cooks were responsible for auditing food in the refrigerator each shift, and the cook and prep cook should monitor food items in the freezers. She stated food items removed from the freezer should be returned to the freezer with a label that contained an open and discard date and should when possible be placed into the original container for storage. The Dietary Manager stated that the dietary aides, prep cooks, cooks, and her assistant were responsible for ensuring all open items were correctly dated and removed when out of date. The Dietary Manager indicated that the disposable foam cups were prepped over the weekend and not used by dietary staff once they located the standard dinnerware but stated the cups should be covered when in the freezer. During observation on 12/03/2025 at 2:55 PM, with the Dietary Manager, she removed an opened (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365648 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 365648 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Knoll Post-Acute and Senior Living 4400 Vannest Avenue Middletown, OH 45042 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 FORM CMS-2567 (02/99) Previous Versions Obsolete and undated bag of hashbrowns from the freezer. The Dietary Manager also removed a clear, undated zip bag of powdered sugar, two bags of opened and undated pasta, and an opened, undated bag of spaghetti from the dry storage area. During an interview on 12/03/2025 at 9:21 AM, the Director of Nursing (DON) revealed she was not familiar with all the kitchen policies but knew where to find them. She stated that good practice should be to cover and date all open food items, and her expectation was that staff would follow all policies. Event ID: Facility ID: 365648 If continuation sheet Page 4 of 4