Inspection·April 27, 2023

F 0553 Level of Harm - Minimal harm or potential for actual harm Based on record review, family interview, staff interview, and policy review, the facility failed to hold care conferences where the resident and resident representatives were invited to discuss the resident's care. This affected two (#31 and #157) of two residents reviewed for care plan conferences. The facility census was 48. Residents Affected - Few Finding include: 1. Review of medical record for Resident #31 revealed an admission date of 12/23/20, with diagnoses including acute kidney failure, Alzheimer's disease, and type two diabetes. Review of Minimum Data Set (MDS) assessment of Resident #31 revealed Resident #31 had a Brief Interview of Mental Status 14 that indicated she was cognitively intact. Interview on 04/26/23 at 11:52 A.M., with family of Resident #31 stated she had only had one care conference offered to her which was on 01/03/23. Resident #31 family stated the facility had not called her or informed her at the facility, of care conferences being held. Resident #31 family stated she would like to ask questions about her mother's care. Review of care conferences notes for Resident #31 revealed on 03/20/22, 05/18/22, 10/12/22, 01/11/23, 03/08/23, and 03/15/23 care conferences were held. No care conference for third quarter in year 2022 for Resident #31 was done. There was no documented evidence of the resident or family representative attending the meeting. Interview and record review for Resident #31, on 04/26/23 at 2:20 P.M., with Social Service Director (SSD) #60 and MDS Nurse #63 verified there was not any documentation, which revealed the date and time when the facility notified the family for care conferences from 01/01/22 through current 04/26/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 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 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on record review, observations, family and staff interviews and policy review, the facility failed to inform a resident's family of an injury/change in condition. This affected one (#157) of one resident reviewed for change in condition. The facility census was 48. Findings include: Review of the medical record for the Resident #157 revealed an admission date of 04/18/23, with diagnoses including cellulitis of the left lower limb, and pain. Review of the Minimum Data Set (MDS) assessment revealed the assessment had not yet been completed for Resident #157 but was in process dated 04/25/23, for a new admission. Resident #157 is assessed as having cognitive impairiment. Review of the progress note dated 04/20/23 revealed the resident was switched from her regular bed into a bariatric bed with side rails. Resident had right side weakness and had difficulty holding herself up in bed without them. A progress note dated 04/23/23 revealed. resident was receiving care and was turned on her left side for peri care when the bed moved and resident's hand was caught between moved, side rail and the dresser. Staff immediately informed the nurse who assessed the resident and found increased bruising and swelling of the left hand and wrist. The nurse notified the Director of Nursing (DON) and the Physician Assistant of the injury. Progress notes dated 04/23/23 revealed a physician order was placed for an x-ray of the left hand and the physician was updated with the results. Review of physician orders dated 04/23/23 revealed an order to monitor bruising on the left hand and for the left hand to remain elevated to prevent increased swelling. Review of order dated 04/23/23 revealed an order for a left-hand x-ray. Review of the radiology report for residents left hand dated 04/23/23 revealed resident had moderate soft tissue swelling and no overt acute fracture was seen. Observation on 04/24/23 at 2:33 P.M. revealed Resident #157 had a large bruise on the top of her left hand extending down the fourth and fifth digits and up past the wrist. The bruise was red and purple in color. Interview on 04/25/23 at 9:00 A.M., with Resident #157's family revealed she was not aware of an injury to Resident #157's hand. Resident #157 was observed to show her daughter her bruising and swelling of her hand. Resident #157's daughter asked the resident how it occurred. Resident #157s daughter revealed she was not contacted or informed of the injury/change in condition. Interview on 04/25/23 at 4:55 P.M., with Registered Nurse (RN) #56 confirmed the family was not contacted prior to her leaving her shift and confirmed the progress note does not state resident's family was contacted after injury/change in condition. Review of the policy titled Notification of Change, dated 07/07/22, revealed the facility must inform the resident representative when there is an accident involving the resident which results in injury or requires physician intervention. Documentation of notification or notification attempts (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 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 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road 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 0580 should be recorded in the resident medical record. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 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 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations, staff interviews, resident and family interviews and policy review, the facility failed to maintain a homelike environment in a resident room. This affected one (#157) of five residents reviewed for environment. The facility census was 48. Findings include: Review of the medical record for the Resident #157 revealed an admission date of 04/18/23, with diagnoses including cellulitis of the left lower limb, and pain. Review of the Minimum Data Set (MDS) assessment had not yet been completed for Resident #157 but was in process dated 04/25/23, for a new admission. Resident #157 is assessed as having cognitive impairiment. Observation on 04/24/23 at 9:00 A.M., 12:20 P.M., 2:33 P.M., and 4:40 P.M., revealed Resident #157 was sitting in bed or in the wheelchair during several observations. A Hoyer lift was observed stored int he room during these observations. Observation and interview on 04/25/23 at 9:00 A.M., with Resident #157 and Resident #157's family revealed the Hoyer lift had been kept in the room most days since admission. Observation of the family member revealed the family unable to sit comfortably next to the resident due to the placement of the Hoyer lift. Observation on 04/25/23 at 11:40 A.M., revealed resident had a Hoyer lift stored in her room. Observation and interview on 04/25/23 at 2:55 P.M., with State Tested Nurse Assistant (STNA) #26 confirmed Resident #157 had a Hoyer lift stored in her room. STNA #26 revealed staff used it for Resident #157's transfer and did not remove it. STNA #26 confirmed Hoyer lift should not be stored in a resident room. Review of the policy titled Personal Property, dated 02/06/19, revealed resident's room should be maintained in a home like environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 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 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm 2. Review of Resident #106's medical record revealed an admission date of 04/05/23, with diagnoses including: malignant neoplasm of unspecified part of unspecified bronchus or lung, Pressure ulcer of right buttock unstageable, generalized anxiety disorder, malignant neoplasm of thyroid gland, chronic obstructive pulmonary disease, atrial fibrillation, secondary malignant neoplasm of brain, and essential hypertension. Residents Affected - Few Review of the 04/12/23, admission Minimum Data Set (MDS) assessment revealed Resident #106 is cognitively intact and requires extensive assistance for personal hygiene, toilet use, dressing, bed mobility, and transfer. The Resident uses a wheelchair to aid in mobility and is frequently incontinent of bowel and bladder. Review of the medical record on 04/24/23 revealed Resident #106 was admitted to Promedica hospice on 04/10/23. Review of the medical record on 04/26/23 at 9:50 A.M., revealed the record contained no evidence of hospice communication notes between the facility and hospice provider of the care being provided for Resident #106. Interview on 04/27/23 at 8:02 A.M., with Social Services Director #60 revealed she was unable to find hospice communication notes for Resident #106. Interview on 04/27/23 at 8:39 A.M., with Social Services Director #60 revealed she sent an email and received notes from the hospice provider and uploaded them to the medical record. She stated they usually email them every week, but they did not for Resident #106. The hospice document information and notes were 78 pages in total. Based on observation, record review, staff interviews and policy reviews, the facility failed to ensure a resident with a wound was assessed timely and evaluate the wound for treatment. This affected one (#157) of two residents reviewed for wound care. The facility identified seven current residents with wounds. The facility failed to correlate hospice services with the facility service for a resident on hospice. This affected one (#106) of one resident reviewed for hospice service. The facility identified three current residents receiving hospice services. The facility census was 48. Findings include: 1. Review of the medical record for the Resident #157 revealed an admission date of 04/18/23, with diagnoses including cellulitis of the left lower limb, and pain. Review of the Minimum Data Set (MDS) assessment revealed the assessment had not yet been completed for Resident #157 but was in process dated 04/25/23, for a new admission. Resident #157 is assessed as having cognitive impairment. Review of KCI wound vacuum (vac) order form dated 04/17/23 revealed resident wound measured 5.3-centimeter (cm) x 6.2 cm x 0.5 cm. Review of hospital record dated 04/18/23 revealed the resident had been diagnosed with Left Lower Extremities (LLE) cellulitis and hematoma requiring debridement of eschar and evacuation of hematoma (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 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 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on 04/14/23 and wound vac was placed on wound and would need to continue the wound vac at the Skilled Nursing Facility. Review of the physician order dated 04/18/23 to 04/20/23 and again on 04/20/23 revealed an order for a weekly skin assessment using a task scale (0, 1, or, 2) with instructions to open a new event for newly identified skin issues. Review of physician orders for 04/19/23 to 04/25/23 identified orders for LLE to cleanse wound and peri wound with normal saline and pat dry. Protect peri wounds with skin barrier film and drape. Apply black foam to the wound base and bridge off wound. Obtain seal using drape. Run wound vac at 125 low continuous suction. Change Monday, Wednesday, and Friday; change the canister weekly and as needed. Protect the leg from tubing using abdominal pad and wrap with kerlix followed by ace wrap. A second order was made on 04/25/23, which clarified the order to be completed on Monday, Wednesday, and Friday. Review of the progress notes dated 04/18/23 revealed the resident arrived at the facility with a wound vac intact. Progress note dated 04/19/23 (entered on 04/26/23 at 6:59 P.M.) revealed the nurse changed resident's wound vac dressing. The wound was noted to measure 7.25 cm x 5.5 cm with no drainage noted in wound and small amount of drainage noted to the wound vac canister. Small round bruised area noted above the peri wound site. A progress note dated 04/24/23 (entered on 04/26/23 at 7:11 P.M.) revealed the nurse changed the resident's wound vac dressing. The wound was noted to measure 7.25 cm x 5.5 cm with no drainage noted in wound and small amount of drainage noted to the wound vac canister. A progress note dated 04/26/23 revealed the nurse changed the resident's wound vac dressing. The wound was noted to have no drainage. A small bruise above wound area noted to be healing well. A photograph was taken of the wound to provide to wound Nurse Practitioner for evaluation. Review of the plan of care dated 04/24/23 revealed Resident #157 was at risk for skin impairment with a wound to the left lower extremity with orders for a wound vac, monitor wound for signs of infections and weekly skin review. Interview on 04/25/23 2:10 P.M., with the Director of Nursing (DON) confirmed no documentation was found in the electronic medical record related to resident's would treatments including wound assessments and documentation of wound appearance, size, and description. DON revealed the only documentation was the weekly assessments in the treatment administration record (TAR) where staff document a 0, 1, or 2 based on where the resident had no wounds, a new wound, or an existing wound, but confirmed this gives no description of the wound. The DON revealed wound description and appearance would only be documented if wound were worsening. Observation and interview on 04/26/23 at 10:25 A.M., of Resident #157's wound treatment along with a second surveyor, Registered Nurse (RN) #58 and trainee RN #73 revealed the left lower leg wound vac was removed. A possible new skin issue discovered by RN #58, who could not confirm or deny that the circular 1 bright red skin issue above the open surgical area was there during previous wound assessments. RN #58 stated she did not know where this additional skin issue came from. RN #58 stated she does not remember when she did the wound vac dressing change last Wednesday 04/19/23, if the circular skin issue was there. RN #58 stated she did not measure or document the look, size, consistency, and peri wound in the electronic chart or hard chart. RN #58 confirmed the facility had taken a picture to show the Nurse Practitioner when she comes to see wound residents, as she did not come to facility during any wound vac ordered changes. Interview on 04/26/23 at 2:35 P.M., with DON who stated the facility currently had the night shift nurse (wound nurse) round with wound Nurse Practitioner, which comes early Thursday. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 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 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road 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 0684 confirmed the wound providers had not yet observed or assessed Resident #157's wound. Level of Harm - Minimal harm or potential for actual harm Interview on 04/27/23 at 9:48 A.M., with RN #58 and DON revealed after surveyor questioned, RN #58 placed notes in Resident #157's chart related to wound care performed over the previous week. RN #58 confirmed she was instructed to put in a late entry for wound treatments. RN #58 revealed she looked at the admission record for the measurements and revealed she could remember the specific resident's wound measurements from memory after providing wound care over the prior week. RN #58 revealed she also did not remember her previous statement made regarding being unsure if she had noticed the bruise about one inch atop of the wound bed. DON confirmed no documentation was done prior to the state survey team mentioning concerns. DON confirmed the wound nurse and wound Nurse Practitioner have not been involved and monitored care for resident, but a photo was taken on 04/26/23 to show to the wound Nurse Practitioner DON revealed now that we know resident was a focus she has an appointment with the wound clinic on 04/28/23. Residents Affected - Few Review of the policies titled Skin Tears- Abrasions and Minor Breaks or Cuts Care, dated 09/2013, and facility policy titled Skin Integrity Policy, dated 07/11/22, revealed wounds should be monitored timely and have documentation of monitoring that describes the appearance of the wound including description and size of the wound. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 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 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. 2. Review of Resident #45's medical record revealed an admission date of 03/30/21, with diagnoses including: osteomyelitis of vertebra, sacral and sacrococcygeal region, encounter for other orthopedic aftercare, limitation of activities due to disability, muscle weakness, generalized anxiety disorder, anemia, schizoaffective disorder, altered mental status, periprosthetic fracture around internal prosthetic right knee joint, periprosthetic fracture around internal prosthetic left knee joint, age-related osteoporosis without current pathological fracture, displaced fracture of proximal phalanx of right great toe, and visual hallucinations. Review of the 03/01/23, Minimum Data Set (MDS) significant change assessment revealed Resident #45 is severely cognitively impaired and requires total dependence for transfer, bathing, personal hygiene, and toilet use. Resident #45 requires extensive assistance for bed mobility, dressing. The Resident uses a wheelchair to aid in mobility and has an indwelling urinary catheter and has an ostomy. Review of Progress Notes dated 11/11/22 at 3:04 P.M., revealed Resident #45 had a fall without injury noted during transfer from wheelchair to bed with staff assist. The following was reported during transfer Resident #45 shoe came off and staff member tripped and lost balance causing both staff member and the resident to go to the floor. Resident #45 landed on her knees and did not hit her head. Immediate intervention was for the resident to be two persons always assist transfers. A message was left for the family and the Physician was notified. Review of the facility fall event investigation dated 11/11/22 revealed Resident #45 had a fall during a transfer and the intervention was to make the resident a two person assist for all transfers. The provided fall documentation did not identify there were two staff present for the transfer and that a staff member slipped on a puddle on the floor. Interview on 04/26/23 at 3:36 P.M., with State Tested Nurse Aide (STNA) #37 revealed she and another STNA were transferring Resident #45 from the wheelchair to the bed when she stepped in a puddle on the floor, and she slipped and fell, and the resident fell to the floor also. Interview on 04/27/23 at 10:32 A.M., with the Director of Nursing (DON) verified the progress note and fall event investigation did not mention the same reason for the fall, if there was two people during the transfer, and a thorough investigation was not completed to address the questions. Based on observations, record review, staff and resident interviews and policy review, the facility failed to ensure residents remained free of accidents/ hazards and failed complete a thorough fall investigation. This affected two (#157 and #45) of five residents reviewed for accidents and hazards. The facility census was 48. Findings include: 1. Review of the medical record for the Resident #157 revealed an admission date of 04/18/23, with diagnoses including cellulitis of the left lower limb, and pain. Review of the Minimum Data Set (MDS) assessment revealed the assessment had not yet been completed for Resident #157 but was in process dated 04/25/23, for a new admission. Resident #157 is assessed as having cognitive impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 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 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the progress note dated 04/20/23 revealed the resident was switched from her regular bed into a bariatric bed with side rails. Resident #157 had right side weakness and had difficulty holding herself up in bed without them. Review of therapy notes dated 04/20/23 revealed the resident required max assistance of two staff to roll and bed mobility. Review of therapy notes dated 04/21/23 revealed the resident required max assistance with rolling in bed. Review of the progress note dated 04/23/23 revealed the resident was receiving care and was turned on her left side for peri care when the bed moved, and resident's hand was caught between the bed rail and the dresser. Staff immediately informed the nurse who assessed the resident and found increased bruising and swelling of the left hand and wrist. The nurse notified the Director of Nursing (DON) and the Physician Assistant of the injury. Progress notes dated 04/23/23 revealed a physician order was placed for an x-ray of the left hand and the physician was updated with the results. Review of physician orders dated 04/23/23 revealed an order to monitor bruising on the left hand and for the left hand to remain elevated to prevent increased swelling. Review of order dated 04/23/23 revealed an order for a left-hand x-ray. Review of the radiology report for residents left hand dated 04/23/23 revealed the resident had moderate soft tissue swelling and no overt acute fracture was seen. Review of the plan of care dated 04/24/23 revealed Resident #157 had impaired cognitive skills related to decision making. The care plan revealed residents required assistance with activities of daily living including. The interventions did not detail what level of intervention needed for bed mobility. Observation on 04/24/23 at 2:33 P.M., with Resident #157 revealed the resident had a large bruise on the top of her left hand extending down the fourth and fifth digits and up past the wrist. The bruise was red and purple in color. Interview on 04/25/23 at 2:10 P.M., with DON confirmed Resident #157 did not have an order for bed rails in the electronic medical record. DON revealed the facility will need to reach out to the medical provider for an order for the bedrails and confirmed resident has signed a consent from for the bedrails. DON confirmed no investigation was completed related to the injury sustained to resident's hand on 03/23/23 and revealed education was completed for some staff to ensure the bed was placed in a locked position before providing resident care. DON revealed State Tested Nurse Assistant (STNA) #20 was providing care when this incident occurred. Interview on 04/25/23 at 2:55 P.M., with STNA #26 revealed there was no system in place to determine what level of assistance a resident required and stated, it depends on the residents' mood. STNA #26 revealed they typically ask the residents about what level of assistance they require for activities of daily living and transfers. STNA #26 revealed Resident #157 ranges between a one to two person assist and was able to help with bed mobility, so then aides could provide care without second aid. Interview on 04/25/23 at 4:30 P.M., with DON revealed the care plan should have the number of staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 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 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road 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 0689 Level of Harm - Minimal harm or potential for actual harm assistance residents required. DON confirmed the care plan did not include this information due to being a baseline care plan. DON confirmed the therapy notes would state the level of assistance residents required. DON confirmed the therapy notes prior to the hand injury incident on 04/23/23 stated the resident required two staff assist for bed mobility. DON confirmed only one STNA was providing care and assisting Resident #157 with bed mobility when this incident occurred. Residents Affected - Few Interview on 04/25/23 at 4:55 P.M., with Registered Nurse (RN) #56 revealed Resident #157 had been injured due to staff not locking the brakes before providing care and the resident's bed moving; jamming Resident #157's hand between the bed rail and the nightstand. Interview on 04/26/23 at 2:11 P.M., with STNA #20 revealed she was performing incontinence care and assisted resident in rolling over. When the resident rolled the bed moved due to being unlocked and smashed resident's left hand between the bedrails and the nightstand. When the resident was injured, STNA reported she informed the nurse to check and assess the resident. STNA #20 confirmed she did not ensure the resident's bed brake were locked prior to assisting her and confirmed she assisted her alone without a second staff member present. Review of the policy titled Safe Lifting and Movement, dated 05/31/18, revealed the facility should protect the safety and well-being of staff and residents. Resident safety and medical condition would be incorporated into goals and when moving residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 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 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on record review and staff interview, the facility failed to timely act upon a pharmacy drug regimen review to draw laboratory test. This affected one (#45) of five residents reviewed for unnecessary medications. The facility census was 48. Findings include: Record review of Resident #45 revealed an admission date of 03/30/21, with diagnoses including: osteomyelitis of vertebra, sacral and sacrococcygeal region, muscle weakness, type 2 diabetes mellitus without complications, generalized anxiety disorder, anemia, schizoaffective disorder, altered mental status, and visual hallucinations. Review of a pharmacy recommendation dated 01/03/23 revealed a recommendation to monitor lipid panel and liver function tests every six months. The Physician Assistant agreed with the recommendation to draw the lab. Review of Resident #45 medical record on 04/27/23 revealed no documentation of a lipid panel and liver function tests being completed. Interview on 04/27/23 at 10:32 A.M., with the Director of Nursing (DON) verified there was not a lipid panel and liver function completed for Resident #45. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 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 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, record review, staff interviews, and policy review, the facility failed to maintain infection control practices during a dressing change. This affected one (#157) of one resident observed for dressing change. The facility identified seven residents who currently have wounds. The facility census was 48. Residents Affected - Few Findings include: Review of the medical record for the Resident #157 revealed an admission date of 04/18/23, with diagnoses including cellulitis of the left lower limb, and pain. Review of the Minimum Data Set (MDS) assessment revealed the assessment had not yet been completed for Resident #157 but was in process dated 04/25/23, for a new admission. Resident #157 is assessed as having cognitive impairment. Review of KCI wound vacuum (vac) order form dated 04/17/23 revealed resident wound measured 5.3-centimeter (cm) x 6.2 cm x 0.5 cm. Review of hospital record dated 04/18/23 revealed the resident had been diagnosed with Left Lower Extremities (LLE) cellulitis and hematoma requiring debridement of eschar and evacuation of hematoma on 04/14/23 and wound vac was placed on wound and would need to continue the wound vac at the Skilled Nursing Facility. Review of the physician order dated 04/18/23 to 04/20/23 and again on 04/20/23 revealed an order for a weekly skin assessment using a task scale (0, 1, or, 2) with instructions to open a new event for newly identified skin issues. Review of physician orders for 04/19/23 to 04/25/23 identified orders for LLE to cleanse wound and peri wound with normal saline and pat dry. Protect peri wounds with skin barrier film and drape. Apply black foam to the wound base and bridge off wound. Obtain seal using drape. Run wound vac at 125 low continuous suction. Change Monday, Wednesday, and Friday; change the canister weekly and as needed. Protect the leg from tubing using abdominal pad and wrap with kerlix followed by ace wrap. A second order was made on 04/25/23, which clarified the order to be completed on Monday, Wednesday, and Friday. Observation and interview on 04/26/23 at 10:25 A.M., of Resident #157's wound treatment along with a second surveyor, Registered Nurse (RN) #58 and trainee RN #73 revealed the left lower leg wound vac was removed. RN #58 had two sets of identical scissors, which were being used during the treatment. RN #58 removed ace wrap, then cut with scissors the kerlix wrap that was around left lower leg. RN #73 assisted in putting a bath towel down under Resident #157's left leg. RN #58 used 4 inches () by 4 sterile gauze with normal saline to clean the peri wound area first on resident's left leg at wound site. RN #58 then took 4 by 4 sterile gauze to clean the wound bed. RN #58 then used another 4 by 4 sterile gauze to clean the wound bed, and then the peri wound. RN #58 then took the bath towel that was under the left lower leg and wrapped Resident #157's entire lower leg. RN #58 then pat dry the peri wound, and wound bed with the bath towel and drying off. Interview on 04/26/23 at 10:35 A.M., with RN #58 stated she did use the bath towel to pat dry the peri wound, and wound bed. Observation on 04/26/23 at 10:40 A.M., reveled RN #58 was standing at Resident #157's end of left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 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 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hopewell Grove Rehabilitation and Healthcare 60 Marietta Road 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few side of bed, by the privacy curtain. RN #58 was cutting the second plastic draping to be applied to the peri wound, and had used her surgical glove at palm, to push the privacy curtain away from her cutting draping for wound vac treatment. No attempt to discard surgical gloves or hand hygiene currently. Observation on 04/26/23 at 10:50 A.M., revealed RN #58 used the same scissors that were used to cut the old kerlix dressing at the removal of dressing. RN #58 used the scissors to cut the black foam to put in the wound bed. Interview on 04/26/23 at 11:05 A.M., with RN #58 verified she did touch the curtain with her left hand before preceding to cut and apply the draping to the peri wound for the wound vac. RN #58 verified, she did not take off dirty gloves after touching the curtain or hand hygiene. RN #58 verified she did not clean both scissors before wound vac treatment. RN #58 verified she did not know what scissors were clean or dirty, when cutting the black foam that was placed in the wound bed. Review of the policy titled Skin Integrity Policy dated 07/11/22, revealed the resident receives care, which was consistent with professional standards of practice, to prevent avoidable skin integrity issues and prevent residents with impaired skin integrity, to promote healing and prevents infections from occurring. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 14 of 14