Inspection·December 5, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm d. Agency LPN #202 stated she was with LPN #208 at station when incident occurred. She stated LPN #208 said please be quiet saying LPN #208 and Resident #44 went back and forth a few times. Interview on 12/05/23 at 1:51 P.M. with Social Service Designee (SSD) #225 stated, though she was not a witness, the comments made by LPN #208 were not appropriate. Residents Affected - Few Interview on 12/05/23 at 2:04 P.M. with LPN #208 revealed she felt she was going back and forth teasing Resident #44 during the shift. She stated she said zip it to the resident. She stated the DON investigated that day and the next day. LPN #208 stated I should not have said those things. I was working too many hours. She acknowledged the DON counseled her. Interview on 12/05/23 at 2:44 P.M. with LPN #207 revealed she was getting report on 11/06/23 around 7:15 P.M. when she heard yelling from the other station. She stated LPN #208 yelled zip it! and pointed her finger at someone stating shut your mouth. LPN #207 went down to see who she was pointing at when she saw Resident #44. LPN #207 asked LPN #208 if everything was alright. She said LPN #208 responded yeah but kept walking away in order to leave facility after her shift. LPN #207 said it was absolutely not okay to speak to a resident like that. Review of the facility policy titled Resident Abuse Prevention Practices, dated 10/2022 revealed the facility did not follow their policy by protecting residents from abuse. Verbal abuse was defined as any use of oral, written, or gestured language that willfully includes disparaging and/or derogatory terms to the residents or their families or within hearing distance, regardless of their age, ability to comprehend or disability. This deficiency represents non-compliance investigated under Complaint Number OH00148473. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365695 If continuation sheet Page 2 of 6 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 12/05/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on record reviews, review of of facility Self-Reported Incident (SRI) history, review of facility internal investigation and staff interview, the facility failed to report an allegation of verbal abuse towards Resident #44 to the State agency. This affected one resident (Resident #44)of three reviewed for abuse. The census was 66. Findings include: Review of the medical record for Resident #44 revealed an admission date of 10/18/23. Diagnoses included nontraumatic intracerebral hemorrhage in hemisphere subcortical, restlessness and agitation, history of falling and neurocognitive disorder with Lewy bodies. Resident #44 was cognitively impaired. Interview on 12/05/23 at 11:10 AM with the Director of Nursing (DON) revealed they had an allegation of abuse on 11/06/23 between Licensed Practical Nurse (LPN) #208 and Resident #44. The DON did not believe an SRI was completed. According to the DON, they did an investigation internally on 11/06/23 and 11/07/23 but did not submit an SRI because one of the witnesses said she did not believe it was abuse. Review of the State agency SRI system revealed there was not an SRI submitted for this allegation. Review of the facility policy titled Resident Abuse Prevention Practices, dated 10/2022 revealed the facility was to report all alleged violations of abuse to the State agency . This deficiency represents non-compliance investigated under Complaint Number OH00148473. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365695 If continuation sheet Page 3 of 6 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 12/05/2023 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on record reviews, review of investigations and interviews with staff the facility failed to thoroughly investigate an allegation of abuse involving Resident #44. This affected one resident (Resident #44) of three residents reviewed for abuse. The census was 66. Residents Affected - Few Findings include: Review of the medical record for Resident #44 revealed an admission date of 10/18/23. Diagnoses included nontraumatic intracerebral hemorrhage in hemisphere subcortical, restlessness and agitation, history of falling and neurocognitive disorder with Lewy bodies. Resident #44 was cognitively impaired. Interview on 12/05/23 at 11:10 AM with the Director of Nursing (DON) revealed they had an allegation of abuse on 11/06/23 between Licensed Practical Nurse (LPN) #208 and Resident #44. The DON stated they did an internal investigation on 11/06/23 and 11/07/23 but did not submit a Self-Reported Incident (SRI) because one of the witnesses said she did not believe it was abuse. Review of Resident #44's medical record and investigation revealed no evidence the wife was notified. The investigation consisted of a statement from the Administrator who interviewed Resident #44 stating he bantered with LPN #208 but that he felt safe. It also consisted of statements from LPN #208, Agency LPN #202, LPN #203 and LPN #207. Review of the witness statements revealed LPN #200, agency LPN #202 and LPN #207 overheard LPN #208 tell Resident #44 to zip it and pointed her finger at resident telling him to shut your mouth as LPN #208 was at a medication cart with agency LPN #202 giving report and counting narcotics. Agency LPN #202's interview with the DON revealed she did not believe it was abuse. Interviews by DON with LPN #200 and LPN #207 revealed LPN #208 could be heard from the other nursing station using a raised voice. The DON's statement revealed her interview with LPN #208 revealed she was in a disagreement with Resident #44, but never acknowledged making these statements to the DON. She wrote a statement she was counseled by the DON on 11/06/23. Included in the file given to surveyor were typed up interviews conducted by Regional Administrator (RA) #205 and Regional Human Resource (RHR) #206 after being informed by both Registered Nurse (RN) #203 and Social Services Designee (SSD) #225 they did not believe an investigation was completed. RN #203 and SSD #225 stated they had always played an active role in investigations before but neither were asked to assist. They also saw LPN #208 come to work each day she was scheduled plus on 11/07/23, her day off, for a meeting. RA #205 and RHR #206 conducted follow-up interviews on 11/10/23. Review of a summary of follow up interviews conducted by RA #205 and RHR #206 included: b. LPN #207 stated she heard yelling and saw LPN #208 pointing finger later discovering it was towards Resident #44. LPN #207 denied seeing LPN #208 acting this way before and stated DON did question her on 11/06/23. c. State Tested Nursing Assistant (STNA) #224 stated she heard someone yelling but did not see anything. She noted Resident #44 was agitated as usual. She denied seeing LPN #208 act that way before. d. LPN #200 stated she reported the incident to RN #203 and then the DON. She stated she heard LPN #208 state zip it then point finger saying shut your mouth. She stood up from her nursing station to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365695 If continuation sheet Page 4 of 6 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 12/05/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm look down the hall. When asked if she removed LPN #208 from situation she stated LPN #208 was already leaving the facility. She stated she never saw her act like that but had heard others complain about her. e. STNA #201 stated she was not present during incident on 11/06/23 but said LPN #208 threw a tantrum about a month ago throwing papers around at nurses station. Stated she sets off easily. Residents Affected - Few f. Agency LPN #202 stated she was with LPN #208 at station when incident occurred. She stated LPN #208 said please be quiet saying LPN #208 and Resident #44 went back and forth a few times but she did not believe it was abusive. g. Quality Assurance (QA)/LPN #220 stated on phone interview the incident was discussed with her on 11/07/23 and felt it was not reportable because the DON did the investigation prior to LPN #208 returning to work. h. RA #205 and RHR #206 stated on 11/14/23 LPN #208 told the Administrator it was a hostile work environment and was putting in her notice. The Administrator allowed her to not work out notice. Interview on 12/05/23 at 1:45 P.M. with RN #203 revealed she was not in the building at the time of the alleged incident but LPN #200 reached out to her so she directed her to tell the DON. RN #203 stated she never heard anything further about it so she questioned corporate when they were in the building on 11/10/23. RN #203 stated she was usually involved in any investigations. She did not notice any investigation being conducted that week. She stated an alleged perpetrator would normally be suspended pending an investigation however she saw LPN #208 in the facility daily. Interview on 12/05/23 at 1:51 P.M. with SSD #225 stated, though she was not a witness, the comments made by LPN #208 were not appropriate. SSD #225 stated she did not know if it was reported so she mentioned something to corporate on 11/10/23. She was concerned there was no investigation because she saw the alleged perpetrator working all week on the same hallway as the specified resident. SSD #225 stated she typically was involved in investigations by interviewing residents. She was not asked to conduct any interviews. Interview on 12/05/23 at 2:44 P.M. with LPN #207 stated she was never questioned by the DON or Administrator. She said she wrote a witness statement on her own and turned it in but there was never any follow-up. LPN #207 said it was absolutely not okay to speak to a resident like that. She said she did not believe the facility handled it appropriately. She knew from past experience what to expect as part of the investigation. Interview on 12/05/23 at 3:41 P.M. with Resident #44's wife revealed she was never notified of the alleged abuse or of any follow-up to the investigation. Interview on 12/05/23 at 4:09 P.M. with the DON revealed she believed the Administrator interviewed other residents as part of the investigation however there were no records of interviews. Review of the facility policy titled Resident Abuse Prevention Practices, dated 10/2022 stated alleged abuse will be thoroughly investigated. The investigation will start immediately and any employee suspected of being involved will be suspended until investigation was completed. The resident or representative will be notified of investigation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365695 If continuation sheet Page 5 of 6 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 12/05/2023 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 0610 This deficiency represents non-compliance investigated under Complaint Number OH00148473. 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 6 of 6