Inspection·August 11, 2025

F 0684 Level of Harm - Actual harm Residents Affected - Few note dated [DATE] timed 7:20 P.M. revealed Resident #68 was administered a dose of Hydromorphone (a narcotic pain medication) one (1) mg by mouth as needed for pain/dyspnea. The note referenced Resident #68 complained of bilateral knee pain. Review of the [DATE] Medication Administration Review (MAR) for Resident #68 revealed the resident reported a pain level of eight out of 10 on the pain scale when administered as needed Hydromorphone 1 mg on [DATE] at 7:20 P.M. Review of the health status note dated [DATE] timed 7:24 P.M. revealed Resident #68 complained of bilateral knee pain. However, there was no visible sign of edema, redness, or discoloration. Scheduled pain medications given and as needed dose given. Review of the orders-administration note dated [DATE] timed 12:14 A.M. revealed Resident #68 was administered Ativan oral 0.5 mg tablet by mouth for anxiety/agitation. Resident #68 was lying in bed yelling for momma. The note indicated one-to-one, television, snacks had been provided. Resident #68 was checked and changed for incontinent care, and the resident refused to go to the restroom. With interventions, resident began becoming tearful. The note additionally referenced music was also attempted, and all interventions were without positive effect. Review of the health status note dated [DATE] timed 6:09 A.M. revealed vital signs of blood pressure 108/58, pulse 60, and respirations 16, temperature 98.4 degrees Fahrenheit (F) and 95% pulse oxygen saturation on room air. Resident #68 was alert and oriented to person only. She was confused to time, place and situation. Resident #68 refused to leave her clothes or brief on. When staff verbalized step-by-step what they were going to do, the resident became combative and kicked at staff with both legs. Resident #68 was provided reassurance with positive effect. Resident #68 left in safe position with all safety devices in place and reapproached. Resident #68 continued to take off clothes, blankets, and brief all shift. No further complaints of pain or discomfort this shift. Review of the orders-administration note dated [DATE] timed 9:49 A.M. revealed Resident #68 was administered Ativan 0.5 mg by mouth for anxiety/agitation. During morning care, the resident was fighting and screaming out due to pain in her right leg. Review of the orders-administration note dated [DATE] timed 9:52 A.M. revealed Resident #68 was administered a dose of Hydromorphone one (1) mg as needed for pain/dyspnea. The note stated while rolling Resident #68 in bed to change her, she was screaming out because of pain in her right leg. Review of the [DATE] MAR for Resident #68 revealed the resident reported a pain level of 10 out of 10 on the pain scale when administered as needed Hydromorphone 1mg on [DATE] at 9:52 A.M. However, record review revealed no evidence the resident's source of pain was assessed or the physician was notified on [DATE]. Review of the orders-administration note dated [DATE] timed 10:54 A.M. revealed the resident refused application of tubi-grips (elastic stockings commonly used to treat swelling) to her bilateral lower legs. The note referenced the tubi-grips were held due to complaint of pain with legs today and Resident #68 did not want them on. Review of the health status note dated [DATE] timed 4:14 P.M. revealed Resident #68 had been crying out and stripping clothes off her in bed off and on this shift, even with as needed medication. When turned, resident holds her right thigh and cried, it hurts help me. Staff tried to comfort but it was not working. As needed medication not helping as much as it should. The note referenced Hospice was called and a nurse visit was requested. However, there was no evidence the facility notified the physician or comprehensively assessed the source of the resident's pain at this time. Review of the orders-administration note dated [DATE] timed 4:32 P.M. revealed Resident #68 was administered Ativan 0.5 mg tablet by mouth for anxiety/agitation. Resident kept removing clothes and was very restless and anxious lying in bed but did not want to get up. Review of the health status note dated [DATE] timed 6:09 P.M. revealed the Hospice nurse arrived around 4:30 P.M. Hospice provided new orders to start Hydromorphone two (2) mg every four hours orally, Hydromorphone two (2) mg every two hours orally as needed for pain/shortness of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365695 If continuation sheet Page 2 of 7 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 08/11/2025 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 - Actual harm Residents Affected - Few breath, and Lorazepam (Ativan) 0.5 mg every eight hours orally. The Hospice doctor would send scripts to pharmacy. Review of the hospice skilled narrative note dated [DATE] revealed as needed visit due to unrelieved pain and agitation. Resident #68 had been screaming in pain since the night before. Facility Nurse (FN) reported Resident #68's pain seemed more severe with repositioning on right side. He believed her right lower extremity may be the focal point of pain. Per FN, resident was agitated as well. The resident was taking off her nightgown and screaming for most of the night and large part of today. Review of the health status note dated [DATE] timed 10:47 A.M. revealed Resident #68 was yelling out and complained of pain in the right leg/hip. The note stated the resident was a two assist with care and staff were unable to turn the resident on her right side during brief change due to complaints of pain and crying out. When hands-on care was completed, the resident stopped complaining. Review of the health status note dated [DATE] timed 12:37 P.M. revealed order for x-ray of right hip due was ordered by Physician #84 due to the resident's complaints of pain. The note included x-ray company was called and would be out to the facility that day to obtain the x-rays. Review of the July MAR for Resident #68 revealed the resident reported a pain level of eight out of 10 on the pain scale when administered as needed Hydromorphone 2 mg on [DATE] at 12:46 P.M. Review of the hospice skilled narrative note dated [DATE] revealed Resident #68 was grimacing at times and grabbing her right leg. The note referenced the hospice nurse spoke with the FN who informed this nurse that the facility physician ordered an x-ray examination of the resident's right hip due to pain. The hospice nurse called the hospice physician who ordered to discontinue x-ray due to possible transitioning and no recent falls. The note further referenced a call was received from a family member of Resident #68 who wanted the x-ray examination completed to know if it was arthritis or a fracture causing the resident's increased pain. Review of the health status note dated [DATE] timed 2:27 P.M. revealed the x-ray was cancelled by the hospice doctor and Resident #68's family was notified. Review of the hospice skilled narrative note dated [DATE] revealed upon arrival, called the resident by name and the resident partially opened her eye. Tremors began and the resident started removing nightgown and blanket. FN stopped by, explained her assessment of terminal agitation with right hip guarded pain and denied the resident had any falls or injury. The note revealed symptoms started this past Wednesday ([DATE]). The hospice nurse called the resident's daughter and provided an update, and the family decided to continue with the x-ray examination. Review of the health status note dated [DATE] timed 1:39 A.M. revealed the x-ray examination was reordered due to the resident's complaints of continued pain. Resident #68 had signs of pain by moaning and guarding her right hip. The x-ray company was called, and the facility was awaiting a return call. Pain medication was given as ordered per hospice. Review of the health status note dated [DATE] timed 10:16 A.M. revealed x-ray was at the facility to perform the ordered x-ray examination. Review of the radiology results report dated [DATE] timed 11:09 A.M. of Resident #68's x-ray to the right hip revealed a unilateral examination with pelvis imaging was performed. The report revealed findings of a displaced intertrochanteric fracture. Review of the health status note dated [DATE] timed 12:28 P.M. revealed the x-ray showed intertrochanteric fracture of the right hip. Hospice was notified and would return call with any new orders. Resident #68's POA aware and will be updated again when hospice called back. Review of a facility Self-Reported Incident dated [DATE] revealed on [DATE] staff noted that Resident #68 was complaining of pain when they were providing care. An x-ray examination was performed, and the x-ray revealed a displaced intertrochanteric fracture. Upon notification of x-ray results and injury, the facility began an investigation to determine the cause of injury. Staff who worked with the resident from [DATE] to [DATE] were interviewed and statements were obtained regarding the status of the resident, care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365695 If continuation sheet Page 3 of 7 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 08/11/2025 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 - Actual harm Residents Affected - Few provided and if anything unusual occurred. During the investigation it was discovered that on [DATE] at 11:00 P.M. during walking rounds, Resident #68 was observed by staff on the floor mat at the side of her bed. The resident was assisted back to bed by three staff after the nurse assessed. Witness statements received from those staff members present regarding details from that instance. No other staff interviews revealed any situation out of the ordinary that would contribute to an injury. Resident #68 had a diagnosis of dementia and was unable to state how the injury may have occurred. Resident #68's husband also resided in the same room and had dementia with a Brief Interview for Mental Status (BIMS) of 4 (severely cognitively impaired) and was unable to provide any meaningful information. Based on the facility's investigation, the facility was able to conclude that the resident's fall on [DATE] was the probable cause of her fracture. Review of a witness statement within the SRI investigation authored by CNA #88 dated [DATE] revealed, On Monday, [DATE], [Resident #68] did not express any complaints of pain throughout the shift and appeared comfortable. On Tuesday, [DATE], after the resident was laid down for bed. She began groaning. When asked if she was in pain, she stated that her knees were hurting. I immediately notified the nurse on duty, and the nurse conducted an assessment of the resident. Review of the witness statement within the SRI investigation authored by CNA #86 dated [DATE] revealed, [DATE] at 11:00 P.M., Resident #68 complained about pain. It was hard to change her, so we did it in the bed! She didn't get up at all that night. It took two people to change her, and I reported to the nurse about her crying about pain. Review of the health status note dated [DATE] timed 12:00 P.M. authored by the DON revealed Physician #84 in and was updated that this resident was observed on the floor by staff on [DATE] around 11:00 P.M. as walking [rounds] were completed. The nurse and two nurse aides assisted the resident back into bed. Review of the health status note dated [DATE] timed 12:24 P.M. authored by the DON revealed this nurse and the social worker updated Resident #68's daughter that the resident was observed by staff on [DATE] during walking around on the floor beside her bed. The resident was assisted back into bed by three staff. Review of the corrective discipline record dated [DATE] revealed LPN #74 received a verbal warning for an incident on [DATE] at 11:00 P.M. that any change in plane was considered a fall. The record included CNA reported Resident #68 on [DATE] was on the floor at the foot of the bed. No incident report, progress note, or notification was made to the primary care physician or the family. With any incident, report and document an incident report, progress note, and notify physician and resident representative. LPN #74 signed the form on [DATE]. Interview on [DATE] at 7:25 A.M. with LPN #74 revealed on [DATE] at 11:00 P.M., Resident #68 was observed sitting on the floor next to her bed. LPN #74 stated she did not consider that a fall because the resident had only fallen a couple of inches. LPN #74 and CNA #78 put Resident #68 back to bed. LPN #74 verified she did not obtain vital signs after the fall, did not assess range of motion after the fall, and did not notify the physician, hospice or the resident's family of the fall. LPN #74 was unsure if she notified the [DATE] oncoming nurse of Resident #68 falling and being found on the floor. Interviews were attempted via telephone with CNA #78 on [DATE] at 8:40 A.M. and on [DATE] at 9:35 A.M., however the interviews were unsuccessful. Interview on [DATE] at 10:10 A.M. with the Director of Nursing (DON) revealed Physician #84 did not actually assess Resident #68 on [DATE] because the resident was sleeping so Physician #84 only observed the resident. The DON verified Physician #84 was not notified on [DATE] of Resident #68's fall that occurred on [DATE] at 11:00 P.M. because at that time, the facility was unaware the resident had fallen. The DON also verified the SRI investigation concluded Resident #68's right hip fracture was a result of the fall on [DATE] at 11:00 P.M. Review of the facility's Accident and Incident policy dated 2008 revealed if the incident was a fall, check for limited range of motion, bruises, pain, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365695 If continuation sheet Page 4 of 7 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 08/11/2025 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete lacerations, swelling and vital signs. If the fall involved a possible head injury, check the pupils and level of consciousness, obtain a statement of what occurred from anyone who witnessed the incident and/or resident if capable, notify the attending physician if the resident has sustained any serious injury, notify the family or responsible party, write an incident report, notify your supervisor, and notify the oncoming nurse. This deficiency represents non-compliance investigated under Complaint Number 2576943 and Self-Reported Incident Control Number 1281390. Event ID: Facility ID: 365695 If continuation sheet Page 5 of 7 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 08/11/2025 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review and interview, the facility failed to implement fall interventions, as determined necessary by the comprehensive care plan for Resident #13. This affected one resident (#13) of three residents revealed for falls. The census was 66. Findings Include: Review of the medical record for Resident #13 revealed an admission date of 09/24/24 with diagnoses of history of falling, atrial fibrillation, anxiety disorder, moderate dementia with agitation, difficulty walking, lack of coordination, cognitive communication deficit, multiple fractures of ribs, intracapsular fracture of right femur, and fracture of facial bones. Resident #13 resided on the secured, memory care unit. Review of a health status note dated 06/23/25 timed 10:44 A.M. revealed Resident #13 was heard yelling for help, this time resident was sitting on floor with legs bent, knees bent in front of her, and back leaning against side of bed. Resident #13 had no injuries. Resident #13 denied any new pain. The resident was assessed and assisted off floor with gait belt and two assist. Resident #13 was transferred to the wheelchair with an alarm and brought into the dining room with staff observation. The DON, nurse practitioner, and the resident's family were notified. Review of the health status note dated 06/23/25 timed 3:05 P.M. revealed an intervention blue mat to left side of bed and Dycem (a non-slip material) was ordered to be placed at the edge of the bed to help prevent sliding off bed. Review of Resident #13's physician's orders revealed an order dated 06/23/25 for Dycem to be placed to the edge of the resident's bed. Review of the health status note dated 06/27/25 timed 3:31 P.M. revealed at 1:50 P.M., Resident #13's alarm was sounding, and the resident could be heard saying help. The nurse and CNA went to room and found the resident lying on floor beside the bed on her back and buttocks, with her head towards the bathroom. The CNA reported she had just toileted the resident five minutes earlier and had laid the resident in bed per her request. A behavioral tech saw Resident #13 slide out of bed onto floor and onto her buttocks and then into a lying position on the floor and did not see Resident #13 hit her head. Resident #13 had no complaints or signs or symptoms of pain or discomfort. The note concluded that a new order for a body pillow to the outside of the bed was to be used while the resident was in bed. Review of Resident #13's physician's orders revealed an order dated 06/28/25 for a full body pillow to be used to the left (open) side of the bed each shift. Review of the fall care plan revised on 06/28/25 revealed Resident #13 was a risk for falls related to dementia and poor safety awareness. Interventions included: body pillow on bed next to resident and gripper on the edge of the bed. There was no evidence Resident #13 removed fall interventions from her bed. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #13 was severely cognitively impaired, had continuous inattention and disorganized thinking, use a walker, was independent with bed mobility, required supervision or touching assistance with walking 10 feet, required partial/moderate assistance with oral hygiene, and upper body dressing, and required substantial/maximal assistance with toileting, bathing, and lower body dressing. Review of the Fall Risk assessment dated [DATE] revealed Resident #13 had intermittent confusion, had a history of falls, and used a wheelchair. Resident #13 was assessed as high risk of falls. Observation on 08/05/25 at 11:47 A.M. revealed Resident #13 was sitting in a wheelchair in the secured memory care dining room next to an activity assistant during an activity. Resident #13 was sitting quietly. At 12:05 P.M., Resident #13 attempted to rise from her wheelchair while in the dining room. The alarm on the wheelchair sounded and a housekeeper assisted the resident back into her wheelchair. At 2:15 P.M., Resident #13 was lying in bed, asleep. The full body pillow was lying across the recliner seat next to the resident's bed and Dycem was not on the edge of either side of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365695 If continuation sheet Page 6 of 7 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 08/11/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the bed. Assistant Director of Nursing (ADON) #87 was notified that the resident's body pillow was missing from the left side of her bed. CNA #80 was observed putting the body pillow to the left side of Resident #13 underneath the bottom sheet. Interview, during the observation, with CNA #80 revealed CNA #80 did not assist Resident #13 to bed after lunch. Interview on 08/05/25 at 2:25 P.M. with CNA #82 revealed CNA #82 had assisted the resident of bed and the resident was supposed to have the body pillow underneath her body sheet to prevent the resident from falling. Interview on 08/05/25 at 2:39 P.M. with LPN #81 verified Resident #13 did not have Dycem on either side of the bed while the resident was in bed. Interview on 08/05/25 at 2:48 P.M. with CNA #80 verified Resident #13's body pillow had been sitting on the resident's recliner and not in the bed with the resident. Interview on 08/11/25 at 2:05 P.M. with the DON verified it was her expectation that if a fall intervention was listed on the care plan, the intervention would be in place for the resident. Review of the facility policy, Fall Prevention and Fall Management, revised November 2024 revealed fall management included to develop a care plan with interviews based on risk review and follow care plan for transfer status and staff assistance required. When a fall occurs, the following protocol will be followed by the nurse: assess the resident's vital signs, level of consciousness and orientation to the environment, assess the resident's body of any injury and will assess range of motion as able. The assessment will include neurological assessment if resident hit their head or displays a change in level of awareness/consciousness of if fall unwitnessed and unable to determine if resident hit their head, will not move the resident from the floor until the basic physical assessment is complete, complete a Risk Management/quality assurance (QA) incident report, implement a plan of care intervention to reduce the risk of another fall based on the initial evaluation and investigation, notify the physician of the fall and assessment., notify the resident/resident's representative of the incident and intervention, document the assessment of the resident and any orders/interventions in the medical record, and the QA incident report and fall incident investigation are forwarded to the DON and are reviewed by the interdisciplinary team to discuss the need for further evaluation, investigation or intervention implementation. This deficiency represents non-compliance investigated under Complaint Number 2576943 and Self-Reported Incident Control Number 1281390. Event ID: Facility ID: 365695 If continuation sheet Page 7 of 7