Inspection·September 16, 2024

F 0677 ready to be assisted off the toilet. Level of Harm - Minimal harm or potential for actual harm Observation on 09/13/24 at 10:21 A.M. revealed Resident #57's roommate, Resident #68, requested STNA #105 to provide incontinence care, because the resident just had a bowel movement. STNA #105 gathered supplies and began to provide incontinence care to Resident #68. Residents Affected - Few Observation on 09/13/24 at 10:24 A.M. revealed Resident #57 remained in the bathroom on the toilet with the door closed. Resident #57 began crying and repeatedly asking for help as STNA #105 assisted Resident #68 with getting dressed. Observation on 09/13/24 at 10:27 A.M. revealed STNA #105 assisted Resident #57 off the commode and into her wheelchair. Interview with STNA #105 on 09/13/24 at 10:29 A.M. confirmed Resident #57 required staff assistance with toileting, and she was unable to provide timely toileting assistance because she had to assist other residents. Review of the facility policy titled Activities of Daily Living dated 09/15/23 revealed the facility staff would provide needed assistance with completion of care for residents who were unable to perform their own ADLs. This deficiency represents noncompliance investigated under Complaint Number OH00157059 and Complaint Number OH00156868. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 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 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2024 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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital progress notes, staff interview, observation, resident interview, and review of the facility policy, the facility failed to ensure a resident received medication timely and as ordered by the physician. Actual Harm occurred when the facility failed to administer two scheduled doses of Suboxone (a medication used for opioid withdrawal) resulting in Resident #52 experiencing nausea, diaphoresis (sweating), and discomfort and resulted in the resident being transported to the hospital and admitted for opioid withdrawal symptoms. This affected one (Resident #52) of three residents reviewed for medication administration. The facility census was 72 residents. Findings include: Review of the medical record for Resident #52 revealed the resident was admitted on [DATE] with diagnoses including a history of intravenous (IV) drug use. Review of the physician's orders for Resident #52 revealed an order dated 09/12/24 for eight milligrams (mg) of Suboxone every twelve hours for opioid dependence. Review of the Medication Administration Record (MAR) for Resident #52 dated 09/12/24 revealed the staff documented the resident was not administered the evening dose of Suboxone as ordered by the physician. There was no documentation in Resident #52's record regarding the rationale for omission of the evening dose of Suboxone nor was there documentation of physician notification of the missed dose. Review of the MAR for Resident #52 dated 09/13/24 revealed the staff documented the resident was not administered the morning dose of Suboxone as ordered by the physician. There was no documentation in Resident #52's record regarding the rationale for omission of the morning dose of Suboxone nor was there documentation of physician notification of the missed dose. Review of the hospital progress note for Resident #52 dated 09/13/24 revealed the resident presented to the emergency room complaining of withdrawal symptoms due to not receiving scheduled doses of Suboxone at the facility and was admitted to the hospital. The resident was documented to have been receiving Suboxone since May of 2024 for the treatment of substance abuse. Interview with Licensed Practical Nurse (LPN) #200 on 09/13/24 confirmed Resident #52 was admitted during the afternoon on 09/12/24 and had not received scheduled doses of Suboxone on the evening of 09/12/24 or the morning of 09/13/24 due to the medication not being available. Observation on 09/13/24 at 12:40 P.M. of Resident #52 revealed the resident was lying on her left side and was curled into a ball. The resident was sweating and appeared to be uncomfortable. Interview on 09/13/24 at 12:40 P.M. with Resident #52 confirmed she was sweating, nauseous, and very uncomfortable. Resident #52 confirmed she had not received the scheduled doses of Suboxone ordered by the doctor since being admitted to the facility the day prior. The resident stated she had received the last dose of Suboxone in the hospital at 8:00 A.M. on 09/12/24 and did not receive scheduled doses the evening of 09/12/24 or the morning of 09/13/24. The resident stated she believed she was beginning to experience withdrawal symptoms due to missing scheduled medication doses. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 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 365694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2024 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 0755 Level of Harm - Actual harm Telephone interview on 09/13/24 at 1:46 P.M. with Nurse Practitioner (NP) #500 confirmed Resident #52 was likely experiencing withdrawal symptoms due to not receiving scheduled doses of Suboxone on 09/12/24 and 09/13/24. NP #500 confirmed staff should have notified the physician or NP of the medication not being available for administration. Residents Affected - Few Interview on 09/13/24 at 2:05 P.M. with Licensed Practical Nurse (LPN) #20 confirmed Resident #52 had been transferred to the hospital for evaluation due to complaints of nausea, sweating, and not feeling well due to missing scheduled doses of Suboxone. Review of the facility policy titled Medication Administration dated September 2018 revealed medications were to be administered in accordance with written orders of the prescriber. This deficiency represents noncompliance investigated under Complaint Number OH00156868. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365694 If continuation sheet Page 4 of 4