Inspection·May 26, 2022

F 0656 care would be developed for those residents identified as being at risk for falls. 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: 365695 If continuation sheet Page 2 of 15 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 365695 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doylestown Health Care Center 95 Black Drive Doylestown, OH 44230 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to ensure orthotics and adaptive equipment was implemented per orders including knee braces, Ankle Foot Orthosis (AFO), and slings for Residents #34 and #44. This affected two of two residents (Resident #34 and #44) reviewed for orthotics and adaptive equipment. The facility identified seven residents (Resident #12, #29, #31, #34, #41, #44, and #52) that had adaptive equipment including orthotics, splints, braces and slings. Residents Affected - Few Findings include: 1. Review of medical record for Resident #34 revealed an admission date of 07/26/20. Diagnoses included unspecified dementia with behavioral disturbances, muscle wasting and atrophy to right arm, left arm, other lack of coordination and repeated falls. Review of progress note dated 02/28/22 at 7:36 P.M. revealed Resident #34 sustained a fracture to the right humerus (upper bone in arm). Resident #34 was sent to the emergency room for an evaluation and treatment. Review of physician order dated 03/01/22 revealed an order to wear a sling to upper right extremity daily. Review of the treatment administration record (TAR) for May 2022 revealed staff applied the sling daily except for 05/13/22. Interview on 05/24/22 at 2:00 P.M. with Licensed Practical Nurse (LPN) #543 revealed Resident #34 was compliant with care and was wearing the sling that morning. Interview and observation on 05/24/22 at 2:05 P.M. with Resident #34 and her daughter revealed Resident #34 had not worn the sling for two weeks. The daughter looked for the sling on this day (05/24/22) and could not find it. Observation of Resident #34 revealed the resident was not wearing a sling. Interview on 05/24/22 at 2:10 P.M. with State Tested Nurse Assistant (STNA) #516 and the Director of Nursing (DON) revealed they could not confirm the last time Resident #34 had worn the sling. The DON stated it was not longer than a week and a half. Observations immediately after interview revealed STNA #516, LPN #543 and the DON searched Resident #34's room, closets, and drawers. The sling was not located. The DON stated she would continue to look for the sling and provide an update. Interview on 05/24/22 at 2:40 P.M. with the DON revealed a sling, not Resident #34's sling was located on the medical record cart behind the nurse's desk and placed on Resident #34's arm. The DON confirmed the sling had been missing even though staff were signing it as being applied in the TAR. 2. Review of medical record for Resident #44 revealed an admission date of 09/07/18 and diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, lack of coordination, muscle wasting and atrophy, pain in right knee, and peripheral vascular disease. Review of the care plan dated 08/20/20 revealed interventions included bilateral knee braces and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365695 If continuation sheet Page 3 of 15 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 365695 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doylestown Health Care Center 95 Black Drive Doylestown, OH 44230 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 left AFO were to be applied prior to getting out of bed as Resident #44 reported increased stability transferring with the braces and the braces and left AFO could be worn all day as tolerated. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #44 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of a 14. Resident #44 required extensive assist of one person with bed mobility, transferring and walking. Review of May 2022 physician orders revealed Resident #44 had an order dated 01/24/20 for left AFO when out of bed every shift for transfers and ambulation, and an order dated 11/11/21 for bilateral knee braces on when out of bed as resident desires. Review of the undated facility form labeled, Visual/ Bedside Kardex Report revealed Resident #44 was to have bilateral knee braces and left AFO put on prior to getting out of bed as resident reported increased stability transferring with the braces. The Kardex revealed he could wear all day if he tolerated Interview and observation on 05/23/22 at 11:38 A.M. revealed Resident #44 had a concern that when he got out of bed staff were to put on his knee braces as he felt steadier and safer with them in place, but that staff did not always put them on. Resident #44 revealed he told the staff it hurt his hip when they did not put his braces on, but they continued to not put the braces on. Observation revealed Resident #44 did not have bilateral knee braces or a left AFO in place. Interview and observation on 05/24/22 at 9:19 A.M. revealed Resident #44 was up in his chair, and he did not have on bilateral knee braces or a left AFO. Resident #44 revealed staff got him up this morning and they did not put on his knee braces and left AFO when they got him out of bed and transferred him to his wheelchair. Interview on 05/24/22 at 9:24 A.M. with State Tested Nursing Assistant (STNA) #520 revealed STNA #524 and STNA #520 assisted Resident #44 by transferring him from his bed to his wheelchair. STNA #520 said they did not apply the left AFO or knee braces because STNA #520 was unaware he had these as physician orders. STNA #520 revealed she usually checked the Kardex to determine the plan of care for the residents but she had just started working at the facility again and did not have access to the Kardex system so was unable to look up Resident #44's plan of care. Interview on 05/24/22 at 9:40 A.M. with STNA #524 revealed she assisted STNA #520 in transferring Resident #44 from his bed to his wheelchair and STNA #524 was not aware Resident #44 was to have a left AFO or knee braces on when he got out of bed for transferring. Interview on 05/24/22 at 4:42 P.M. with the Director of Nursing verified Resident #44 had an order to have bilateral knee braces and a left AFO when transferring out of bed and the staff should have applied the braces and AFO as ordered. Review of facility policy labeled; General Orthotic Care dated December 2012 revealed make sure the orthotic device was positioned properly. The policy did not include anything regarding following physician orders regarding properly applying knee braces and AFO's. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365695 If continuation sheet Page 4 of 15 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 365695 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doylestown Health Care Center 95 Black Drive Doylestown, OH 44230 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review the facility failed to ensure Resident #16's and Resident #30's respiratory equipment was dated when it was changed last. This affected two of two residents (Resident #16 and #30) reviewed for respiratory care. The facility identified 11 residents (Resident #1, #2, #4, #5, #12, #16, #19, #30, #34, #42, #49) that utilized respiratory equipment. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #16 revealed an admission date 04/02/14 and diagnoses included chronic respiratory failure with hypoxia, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) acute exacerbation, and anxiety. Review of the care plan dated 08/20/20 for Resident #16 revealed she had oxygen therapy related to CHF and COPD. Interventions included medications as ordered, monitor for respiratory distress and report to physician, and oxygen as ordered. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #16 revealed she was intact cognitively and was on oxygen. Review of physician orders for May 2022 revealed Resident #16 had an order for Ipratropium- Albuterol Solution .5-2.5 milligram (mg) per three milliliters (ml) inhale one unit orally three times a day for COPD and one unit inhale orally every four hours as needed for shortness of breath. Review of May 2022 Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident #16 revealed there was no documentation regarding the frequency of when the oxygen tubing was changed or when the nebulizer equipment was changed. Observation of Resident #16's room on 05/24/22 at 7:33 A.M. revealed an aerosol with nebulizer that was not dated on Resident #16's bedside night stand. Observation on Resident #16's room on 05/24/22 at 1:59 P.M. revealed an aerosol with nebulizer that was not dated on Resident #16's bedside night stand. Interview on 05/24/22 at 1:59 P.M. with Licensed Practical Nurse (LPN) #547 verified nebulizer connected to Resident #16's aerosol machine was not dated. Interview on 05/25/22 at 8:13 A.M. with the Director of Nursing (DON) revealed the facility had a cleaning schedule on the 7:00 P.M. to 7:00 A.M. shift that was hung up at each nursing station that included staff were to change the oxygen equipment every Friday. The DON verified when staff changed the respiratory equipment including oxygen and aerosol tubing they were to date the tubing when it was changed. The DON indicated there was no documentation regarding when Resident #16's oxygen or aerosol tubing was changed. Review of undated facility form, labeled, 7p-7a Cleaning Schedule revealed every Friday the nurses were to change oxygen equipment, bag, and date the equipment. Review of facility policy labeled, Oxygen Administration dated January 2019 revealed residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365695 If continuation sheet Page 5 of 15 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 365695 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doylestown Health Care Center 95 Black Drive Doylestown, OH 44230 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 0695 nasal cannula and tubing should be dated and changed weekly. Level of Harm - Minimal harm or potential for actual harm 2. Review of medical record for Resident #30 revealed the resident had an admission date of 11/04/19 and diagnoses included polyosteoarthritis, hypokalemia, essential hypertension, muscle wasting and atrophy of right upper arm, left upper arm, right lower leg, and left lower leg. Residents Affected - Few Review of the care plan dated 11/14/19 with a revision date of 08/03/20 for Resident #30 revealed she had oxygen therapy. Interventions included oxygen settings via nasal cannula at two liters to maintain 90 percent oxygen saturation level and to monitor for signs and symptom of respiratory distress. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 was cognitively impaired and had oxygen therapy. Review of physician orders for May 2022 revealed Resident #30 had an order for oxygen at two liters via nasal cannula to maintain her oxygen saturation level above 90 percent due to previous pneumonia. Observation on 05/23/22 at 9:45 A.M., revealed oxygen was administered to Resident #30 via a nasal cannula. There was no date visible on the oxygen tubing or the nasal cannula. Further observations on 05/24/22 at 12:02 P.M., 05/24/22 at 12:37 P.M., 05/24/22 at 1:59 P.M., revealed the same. Interview on 05/24/22 at 10:18 A.M., with Licensed Practical Nurse (LPN) #506 verified there was no date on Resident #30's oxygen tubing. Interview on 05/25/22 at 8:12 A.M. with the Director of Nursing (DON) verified there should be a date on oxygen tubing. The DON also indicated the facility completed spot audits on Fridays to ensure tubing was changed and dated. The DON verified Resident #30 utilized supplemental oxygen for comfort. Review of facility policy labeled, Oxygen Administration dated January 2019 revealed nasal cannula/tubing should be dated and changed weekly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365695 If continuation sheet Page 6 of 15 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 365695 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doylestown Health Care Center 95 Black Drive Doylestown, OH 44230 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on record review, interview and observation the facility failed to complete pre and post dialysis assessments and failed to update the care plan regarding fistula site. This affected one resident (Resident #26) of one resident reviewed for dialysis. Residents Affected - Few Finding include: Review of the medical record for the Resident #26 revealed an admission date of 07/29/16. Diagnoses included type II diabetes, end stage renal disease and congestive heart failure. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 03/31/22, revealed Resident #26 had intact cognition and received dialysis services. Review of the Care Plan dated 03/31/22 revealed a plan for chronic renal failure related to end stage renal disease. Resident #26 had a dialysis fistula placed in her right arm which failed prior to starting dialysis and a new left arm fistula was put in place. Intervention included to check fistula for bruit and thrill (blood flow) as ordered. Review of the assessments dated from 03/31/22 through 05/23/22 revealed there were no pre and post dialysis assessments provided to Resident #26. Review of the physicians' orders for May 2022 revealed an order for dialysis services on Monday, Wednesdays and Friday. A new order dated 05/25/22 for nurses to check fistula and complete pre and post dialysis assessments two times a day on Monday, Wednesday and Friday. Review of the May 2022 Treatment Medication Record (TAR) revealed on 05/25/22 a new documented sign off to check the fistula (port) and complete pre and post dialysis assessments two times a day on Monday, Wednesday and Friday. Interview on 05/25/22 at 1:35 P.M. with Licensed Practical Nurse #543 revealed she was assigned to Resident #26 and did not conduct a pre or post dialysis assessment or checked the fistula for a bruit or thrill. Observation and interview on 05/25/22 at 1:37 P.M. with Resident #26 revealed her dialysis fistula was placed in her lower right arm. Resident #26 revealed her dialysis ports had failed and had been changed several times. Resident #26 stated she had a port in her left arm, right upper arm, a port in her chest and a current working fistula in the right lower forearm. Interview on 05/25/22 at 3:30 P.M. with the Director of Nursing (DON) verified there were no pre or post dialysis assessments completed since March 2022. Resident #26 returned from the hospital in March 2022 and the pre and post dialysis assessments and fistula assessment were dropped and not put into the computer. Interview on 05/26/22 at 1:00 P.M. with the DON verified that Resident's #26 care plan was not updated with the current fistula location. Review of the facility's undated policy titled Dialysis Services revealed the nursing staff were to complete a pre and post assessment for residents receiving dialysis with each dialysis schedule (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365695 If continuation sheet Page 7 of 15 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 365695 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doylestown Health Care Center 95 Black Drive Doylestown, OH 44230 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 0698 which included an assessment of vital signs. Upon return from dialysis, an assessment was to be completed of the dialysis access site to monitor for complication. 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: 365695 If continuation sheet Page 8 of 15 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 365695 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doylestown Health Care Center 95 Black Drive Doylestown, OH 44230 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review the facility failed to maintain a clean and sanitary kitchen and properly store food and food utensils. This had the potential to affect all residents except Resident #1 who received nothing by mouth. The facility census was 55. Findings include: 1. Observations during tour of the kitchen on 05/23/22 from 8:34 A.M. to approximately 9:00 A.M. with Dietary Manager (DM) #562 revealed the prep table had various crumbs on the bottom shelf that housed various steam table pans. The steamer had various crumbs and food debris on the outside of the steamer. On the backside of the second prep table closer to the door there were dried spills running down the table, and underneath on the shelving there were various crumbs and food debris. In the top drawer on the right-hand side and the bottom drawer on the left side had various food debris and crumbs. The reach-in cooler across from this prep table and next to the steam table had various food debris on the floor of the refrigerator. The side of the prep table facing the reach-in cooler had various food crumbs and food debris on the bottom shelf that stored several long pans. Observation of the walk-in in cooler revealed a black floor mat with drainage holes throughout, the floor underneath was very dirty. Observation of the walk-in freezer revealed a reddish floor mat with drainage holes throughout, the floor underneath the mat was very dirty. Observation of the dry goods storage room revealed a bin of dry rice with the scoop stored inside the bin of rice. Interview on 05/23/22 from 8:34 A.M. to approximately 9:00 A.M. with DM #562 verified the above findings and stated general cleaning had fallen behind due to some staffing issues and that the scoop should not be stored in the rice bin. 2. A follow-up visit to the kitchen on 05/24/22 at approximately 9:55 A.M. revealed the air conditioner window unit located next to the knife rack on the wall had a moderate covering of dust. Interview at time of observation with DM #562 verified the window air conditioner was covered with dust. 3. Observation on 05/24/22 at 1:45 P.M. with DM #562 revealed a refrigerator in the [NAME] Medication room had undated individual juice cups with no expiration date. There were 19 apple juice cups, 10 cranberry juice cups and 18 orange juice cups. Interview on 05/24/22 at 1:45 P.M. with DM #562 verified the above finding and stated dietary staff stocked the refrigerator daily. The individual juice cups were delivered frozen and had a 14-day expiration date once thawed. DM #526 revealed the juice cups were to be dated with an expiration date when stocked in the refrigerator. Review of the manufacture's instruction revealed under packaging and storage, frozen cup must remain frozen until ready to use. After thawing, unused portion can remain refrigerated for use up to 14 days. Review of the facility's undated policy titled Corporate Nutrition Services revealed a potential cause of foodborne outbreaks was improper cleaning (washing and sanitizing) of equipment and protecting equipment from contamination of the commercial kitchen. Following guidelines would help ensure food safety and sanitation of the commercial kitchen. The policy included procedures for using the dish (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365695 If continuation sheet Page 9 of 15 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 365695 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doylestown Health Care Center 95 Black Drive Doylestown, OH 44230 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 machine, manual washings and sanitizing, and cleaning fixed equipment. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Storage: Food, Equipment, and Utensils dated February 2019 revealed to prevent contamination from the premises, food, equipment, and utensils must be stored in a clean and dry location and all food was to be labeled and dated. Bulk foods were to be stored in tightly covered sanitized food grade containers. Clear food approved liners were acceptable. Scoop and utensil were to stored in a separate Ziplock bag on top of the corresponding container. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365695 If continuation sheet Page 10 of 15 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 365695 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doylestown Health Care Center 95 Black Drive Doylestown, OH 44230 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the facility policy titled Legionella Policy - Environmental Water Management Program dated May 2022 revealed specified control measures and protocols would be implemented and monitored for Legionella that included: Residents Affected - Many The ice machines to be cleaned quarterly or more if needed. This will be documented quarterly. Hot water tanks to be maintained at temperature of 125 degrees to 130 degrees and tested weekly. Eye wash stations attached to the water source will have water run through the device and will be documented weekly. Unoccupied rooms and unused water sources will be checked and documented weekly. Environment testing of water is not a Center of Medicare and Medicaid Services (CMS) recommendation to do water cultures for Legionella or other opportunistic water borne pathogens. The facility was unable to provide documented evidence of the above control measures. Review of the CMS Survey and Certification memo 17-30-All dated 06/02/17 revealed to implement a water management program that considers and the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) industry standard and the Center of Disease Control and Prevention (CDC) toolkit, and includes control measures such as physical controls, temperature management, disinfection level control, visual inspections and environmental testing for pathogens. Interview with on 05/26/22 at 2:10 P.M. with the Administrator revealed she was new to the position and could not find any documentation of monitoring for Legionella. The facility revised the policy this month and had not conducted water testing for Legionella. 4. Review of the medical record for Resident #50 revealed an admission date of 04/25/22. Diagnoses included anxiety disorder, insomnia, and dementia with behavioral disturbance. Review of the physician orders for May 2022 revealed an order for Covid-19 precautions during outbreak for residents that are not up to date with all recommended Covid-19 vaccinations. The residents were to be confined to their room and cared for by staff using full personal protective equipment (PPE) for 14 days from initiation of outbreak if no new cases were identified or continue till no new cases identified through testing for 14 days every shift until 05/27/22 with the start date of 05/16/22. Observation on 05/23/22 at 10:18 A.M. revealed Resident #50 in the dining room in his wheelchair with an alarm attached to the wheelchair. Attempted interview at this time with Resident #50 revealed the resident did not respond appropriately to questions. Observation on 05/23/22 at 11:22 A.M. with State Tested Nurse Aide (STNA) #525 of Resident #50's room revealed the resident was not in his room and did not have any signs on the outside of the door to indicate transmission-based precautions (TBP). Interview at this time with STNA #525 verified the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365695 If continuation sheet Page 11 of 15 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 365695 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doylestown Health Care Center 95 Black Drive Doylestown, OH 44230 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 observation and stated Resident #50 may have been taken off TBP but she would have to check with the nurse. Observation on 05/24/22 at 8:17 A.M. revealed Resident #50's room door was closed and no signage indicating TBP. Residents Affected - Many Observation on 05/24/22 at 8:48 A.M. revealed Resident #50 sitting in his room in his wheelchair and no signage to indicated TBP. Interview on 05/24/22 at 9:39 A.M. with Licensed Practical Nurse (LPN) #544 revealed she had a list of residents that were on TBP. LPN #544 stated Resident #50 was listed as being on TBP. Observation on 05/24/22 at 9:44 A.M. of Resident #50 in his room revealed no signage to indication he was on TBP and there were also no biohazard disposable bins. Interview on 05/24/22 at 9:47 A.M. with LPN #544 verified there was no signage outside of Resident #50's door to indicate he was on TBP and no biohazard bins in the resident's room. Review of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic Updated Feb. 2, 2022 revealed the following. Source control options for HCP include: A NIOSH-approved N95 or equivalent or higher-level respirator OR A respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering face piece respirators (Note: These should not be used instead of a NIOSH-approved respirator when respiratory protection is indicated) OR A well-fitting facemask. When used solely for source control, any of the options listed above could be used for an entire shift unless they become soiled, damaged, or hard to breathe through. If they are used during the care of patient for which a NIOSH-approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH-approved N95 or equivalent or higher-level respirator) during the care of a patient with SARS-CoV-2 infection, facemask during a surgical procedure or during care of a patient on Droplet Precautions, they should be removed and discarded after the patient care encounter and a new one should be donned. Review of the CDC Strategies for Optimizing the Supply of Eye Protection updated Sept. 13, 2021 revealed the following. Conventional Capacity Strategies Use eye protection according to product labeling and local, state, and federal requirements. In healthcare settings, eye protection is used by HCP to protect their eyes from exposure to splashes, sprays, splatter, and respiratory secretions. Disposable eye protection should be removed and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365695 If continuation sheet Page 12 of 15 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 365695 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doylestown Health Care Center 95 Black Drive Doylestown, OH 44230 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 discarded after use. Reusable eye protection should cleaned and disinfected after each patient encounter. Level of Harm - Minimal harm or potential for actual harm Shift eye protection supplies from disposable to reusable devices (i.e., reusable face shields or goggles). Residents Affected - Many Consider preferential use of powered air purifying respirators (PAPRs) or full facepiece elastomeric respirators which have built-in eye protection. Ensure appropriate cleaning and disinfection after each use if reusable face shields or goggles are used. Based on interview, observation, record review, review of guidance from the Centers for Disease Control and Prevention(CDC) the facility failed to ensure infection control procedures were followed to prevent the potential spread of Covid-19 and Legionella. This affected Residents #5, #50, #403, #452 and had the potential to affect all 55 residents residing at the facility. Findings include: 1. Review of medical record for Resident #5 revealed an admission date of 02/04/22 and diagnoses included chronic respiratory failure with hypoxia, hypertension, and anxiety. Review of Resident #5's immunization record revealed Resident #5 refused the COVID-19 vaccinations. Review of the care plan dated 02/05/21 revealed Resident #5 was at risk for infection related to COVID-19. Interventions included provide respiratory isolation. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had intact cognition and required extensive assist of one person with bed mobility, dressing, toileting, and personal hygiene. Review of physician orders dated May 2022 revealed Resident #5 had an order dated 05/16/22 for COVID-19 precautions during outbreak for residents that were not up to date with COVID-19 vaccinations. The order revealed the residents should be confined to their rooms and cared for by staff using full personal protective equipment (ppe) for 14 days. Observation on 05/23/22 at 9:54 A.M. revealed Resident #5 was in her bed and activated her call light. On the outside of her room door was a rack that contained ppe including masks, gloves, and gowns. No sign was observed on her door indicating Resident #5 was on isolation. State Tested Nursing Assistant (STNA) #800, who was from an agency walked into Resident #5's room wearing the N95 mask and eye protection. STNA/#800 then proceeded to assist Resident #5 with moving items from the residents bedside nightstand to the bed table that was positioned in front of the resident. STNA #800 exited the room without washing her hands. Interview on 05/23/22 at 10:01 A.M. with STNA #800 revealed she was from an agency, and this was her first day at the facility. When STNA #800 arrived on duty she received a brief report regarding which residents to get up but was not given information regarding who was on respiratory droplet precautions or any other type of isolation. STNA #800 was not aware Resident #5 was on respiratory droplet precautions as she did not see a sign on the door, only a rack containing ppe hanging on the door. STNA #800 verified she did not apply a gown or gloves when entering Resident #5's room and verified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365695 If continuation sheet Page 13 of 15 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 365695 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doylestown Health Care Center 95 Black Drive Doylestown, OH 44230 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 - Many she was within six feet of Resident #5 when she assisted the resident. STNA #800 also verified when exiting Resident #5's room she did not wash her hands, cleanse, or change her eye protection, or change her N95 mask. Interview on 05/23/22 at 10:08 A.M. with Registered Nurse (RN) #533 revealed Resident #5 was on respiratory droplet precautions because the facility had a staff member test positive. As a precaution the facility placed anyone that was unvaccinated or not up to date with COVID-19 vaccination on respiratory droplet precautions. RN #533 verified STNA #800 should have donned gloves, gown, N95 mask and eye protection prior to entering Resident #5's room. RN #533 also verified STNA #800 should have washed her hands, changed her N95 mask and cleansed her eye protection upon exiting Resident #5's room. RN #533 verified there was not a sign visible on Resident #5's door indicating she was on respiratory isolation but when she moved the rack containing ppe a sign was visible that indicated Stop! See Nurse Before Entering. RN #533 said STNA #800 should have received in report at the beginning of the shift who was on isolation. Review of facility policy labeled, Droplet Plus Precautions dated 03/31/20 revealed the facility used droplet plus precautions to decrease the risk of droplet transmission of infectious agents specifically COVID-19. The policy indicated droplets could be generated by a resident coughing, sneezing, talking, or during the performance of procedures. Residents that were not up to date with COVID-19 vaccinations that had known close contact with an individual with COVID-19 would be placed in precautionary isolation a minimum of seven days. The policy revealed a N-95 mask, face/ shield and/ or eye protection, isolation gowns, and gloves were to be worn for droplet plus precautions. 2. Review of the medical record for Resident #452 revealed an admission date of 05/10/22 and diagnoses included hypertension, diabetes, chronic obstructive pulmonary disease, seizures, and displaced trimalleolar fracture of right leg. Review of Resident #452's vaccination record revealed he received the COVID-19 vaccines on 02/05/21 and on 03/05/21 and received the booster on 05/18/22. Review of the care plan dated 05/11/22 for Resident #452 revealed no information regarding respiratory droplet precautions upon admission. Review of physician orders for May 2022 revealed Resident #452 had an order dated 05/18/22 for droplet-plus isolation for new and re-admissions (COVID-19 precautions) that were not up to date with COVID-19 vaccination for observation and testing. The order revealed isolation was to continue for seven days and the resident was to receive COVID-19 testing between days five and seven and if the testing was negative then his isolation was to be discontinued on day eight. Observation on 05/23/22 at 12:37 P.M. revealed Licensed Practical Nurse (LPN) #506 donned appropriate personal protective equipment (ppe) to enter Resident #452's room (on respiratory droplet precautions). LPN #506 assisted in setting up Resident #452's meal tray. LPN #506 doffed the ppe, performed hand hygiene and exited the room. LPN #506 proceeded to the dining cart to obtain another tray to pass. Interview on 05/23/22 at 12:39 P.M. with LPN #506 verified Resident #452 was on respiratory droplet precautions. LPN #506 confirmed she did not clean the eye protection upon exiting Resident #452's room. LPN #506 stated, no, I have to be honest I did not know I was supposed to cleanse my eye protection after exiting a room on respiratory precautions; she revealed she had not been trained to do that. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365695 If continuation sheet Page 14 of 15 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 365695 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doylestown Health Care Center 95 Black Drive Doylestown, OH 44230 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 Interview on 05/24/22 at 7:20 A.M. with the Director of Nursing (DON) verified staff were to cleanse their eye protection after exiting a room of a resident on respiratory droplet precautions. The DON verified Resident #452 was on respiratory droplet precautions because he was not up to date on his vaccines upon admission and they had an employee test positive. As a precaution the facility placed any resident not up to date with vaccination or unvaccinated on respiratory droplet precautions for eight days per physician order. Residents Affected - Many Review of facility procedure labeled, Examples of Safe Donning and Removal of Personal Protective Equipment (PPE) dated March 2011 revealed if goggles and face shield were contaminated remove, handle by the clean head band and/ or earpiece and place in designated receptacle for reprocessing or in waste container. 3. Review of medical record for Resident #403 revealed an admission date of 05/17/22 and diagnoses included orthopedic aftercare following surgical amputation, diabetes, and hypertension. Review of Resident #403's immunization record revealed Resident #403 was unvaccinated against the COVID-19. Review of physician orders dated May 2022 revealed Resident #403 had an order dated 05/18/22 for droplet-plus isolation for new and re-admission (COVID-19 precautions) that were not up to date with COVID-19 vaccination for observation and testing. The order revealed isolation was to continue for seven days and Resident #403 was to receive COVID-19 testing between days five and seven and if the testing was negative then may discontinue the isolation on day eight. Review of the care plan dated 05/25/22 revealed Resident #403 was at risk for infection related to COVID-19. Interventions included provide respiratory isolation. Observation on 05/23/22 at 12:44 P.M. revealed State Tested Nursing Assistant (STNA) #530 donned appropriate ppe to enter Resident #403's room (on respiratory droplet precautions). STNA #530 assisted in setting up Resident #403's meal tray. STNA #530 doffed the ppe, performed hand hygiene and did not cleanse her eye protection after exiting the room. She proceeded to the dining cart to obtain another tray to pass. Interview on 05/23/22 at 12:46 P.M. with STNA #530 verified she did not cleanse her eye protection after leaving Resident #403's room who was on respiratory droplet precautions. She revealed she was never educated that she needed to do that. Review of facility procedure labeled, Examples of Safe Donning and Removal of Personal Protective Equipment (PPE) dated March 2011 revealed if goggles and face shield were contaminated remove, handle by the clean head band and/ or earpiece and place in designated receptacle for reprocessing or in waste container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365695 If continuation sheet Page 15 of 15