Health inspection·October 31, 2022

F 0554 Level of Harm - Minimal harm or potential for actual harm Interview on 10/25/22 at 11:27 A.M. with Licensed Practical Nurse (LPN) #371 verified Resident #46 had an albuterol inhaler and fluticasone propionate solution in his room. LPN #371 stated Resident #46 did not have a physician order to self-administer medications so she took them from him. LPN #371 stated she was unaware of the facility's process for a resident to self-administer medications but she was certain a physician's order was required and Resident #46 did not have an order to do so. Residents Affected - Few Interview on 10/26/22 at 10:18 A.M., the Director of Nursing (DON) revealed the facility did not have any residents who could self-administer medications. The DON stated the typical process for residents to self-administer medications would include an assessment to ensure the resident could properly administer and secure the medications. The DON stated a nurse had informed her she had forgotten Resident #46's albuterol inhaler and fluticasone propionate solution in Resident #46's room. Additionally, the DON stated Resident #46 wanted to self-administer some of his medications, and was likely safe to do so, but the facility had not assessed him for self-administration. Review of policy titled Self-Administration of Medications, effective 07/01/21, revealed if the resident desired to self-administer medications, an assessment was conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365756 If continuation sheet Page 2 of 20 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 365756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on medical record review, staff interview and review of facility policies, the facility failed to ensure timely physician notification and failed to notify the dietitian of a significant weight change for one (#46) of three residents reviewed for nutrition. The facility census was 80. Findings include: Review of Resident #46's medical record revealed an admission date of 09/16/22. Diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), type II diabetes, atrial fibrillation, heart failure, dementia, major depressive disorder, atherosclerotic heart disease, hypertension and inflammatory disease of prostate. Review of the admission Minimum Data Set (MDS) assessment, dated 09/23/22, revealed Resident #46 was cognitively intact. Additionally, Resident #46 required supervision with eating and had no significant weight loss. Review of a plan of care focus area, initiated 09/22/22, revealed Resident #46 was at risk for nutritional and hydration problems related to diagnoses of COPD, type II diabetes, congestive heart failure (CHF), dementia, coronary artery disease (CAD) and diuretic use. Interventions included allow resident to make choices and preferences of food as able, dietary consult as needed and diet as ordered. Review of Resident #46's current physician orders revealed furosemide tablet 40 milligrams (mg) one tablet by mouth one time a day for fluid retention related to CHF and daily weight due to CHF. Review of weights revealed Resident #46 weighed 200 pounds (lbs) on 09/17/22, 209.7 lbs on 10/16/22, and 210.2 lbs on 10/17/22, which was a 5% gain in one month. Resident #46 weighed 213 lbs on 10/19/22, and 211.5 lbs on 10/21/22. On 10/23/22 the resident weight 222 lbs which was a weight gain of 22 pounds since 09/17/22, indicating a significant weight gain of 11% . Review of a nursing progress note dated 10/25/22 revealed the physician was notified of Resident #46's weight fluctuations. The note was silent for dietitian notification. Interview on 10/26/22 at 3:26 P.M., Unit Manager #346 confirmed the physician was not notified of Resident #46's significant weight changes until 10/25/22 and the dietitian was not notified. Interview on 10/26/22 at 4:02 P.M. of Registered Dietitian (RD) #400 revealed Resident #46 was to be weighed daily to closely monitor his weight due to CHF. RD #400 stated she typically visited the facility weekly and had been at the facility this morning. Additionally, RD #400 reviewed the facility's monthly weight report mid to late month and she had already completed the monthly weight review at the facility prior to the identified significant weight increases noted for Resident #46. RD #400 confirmed the facility had not notified her of Resident #46's significant weight increase. Because she had already completed the monthly weight review at the facility, unless the facility notified her of Resident #46's significant weight increase she would unlikely know of the change until mid to late November. Review of facility policy titled Weight Change Protocol Policy and Procedure, dated 01/01/16, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365756 If continuation sheet Page 3 of 20 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 365756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm revealed when a significant weight loss was identified, the dietitian would be notified of significant weight changes and the dietitian would assess residents with significant weight changes at the next visit. Review of facility policy titled Weight Policy, revised November 2018, revealed the dietitian would be notified of significant changes in weights. Residents Affected - Few Review of facility policy titled Change in Condition and Physician Notification Policy, revised September 2019, revealed the nurse would notify the physician with pertinent information to discuss care for the resident, including notification for abnormal weights. Additionally, notification attempts would occur within 24 hours and the nurse would make timely documentation of the notification. This deficiency represents non-compliance investigated under Complaint Number OH00135803. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365756 If continuation sheet Page 4 of 20 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 365756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, resident interview, and staff interview, the facility failed to ensure resident rooms were maintained in good repair. This affected two (#37 and #75) of four residents reviewed for homelike environment. The facility census was 80. Findings include: Observation on 10/24/22 at 2:46 P.M. of Residents #37 and #75's room revealed no doors on the closet. One closet door was was leaning against the wall, next to the window, and the other door was missing. Interview of Residents #37 and #75 at the time of the observation revealed the closet doors had been broken for a couple of months and both expressed they wished the facility would do something to fix the doors. Residents #37 and #75 stated they were told the doors would not be replaced or repaired and a rod and curtain were going to be installed over the closet opening, but that had not been done either. Observation on 10/26/22 at 7:42 A.M. of Resident #37 and #75's room with the Administrator verified one closet door was leaning against the wall near the window and the other door was missing. Both Resident #37 and #75 stated the closet doors had been broken for approximately two months. The Administrator stated he was unaware the closet doors were broken and stated he would have to check with maintenance. Interview on 10/27/22 at 8:40 A.M. of Maintenance Director (MD) #372 confirmed he was aware the closet doors in Residents #37 and #75's room were broken, noting it had been approximately three months since the doors broke. MD #372 stated he had new doors but was having some trouble due to the age of the doors and ordered new hardware a couple of weeks ago, which had not been delivered yet. MD #372 stated he was unaware one of the closet doors was leaning against the wall and stated he would have the door removed to prevent injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365756 If continuation sheet Page 5 of 20 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 365756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, resident and staff interview, and review of facility policies, the facility failed to ensure nail care was provided to residents dependent for care. This affected one (#75) of three residents reviewed for activities of daily living. The facility census was 80. Residents Affected - Few Findings include: Review of Resident #75's medical record revealed an admission date of 08/06/12 and a readmission date of 04/25/19. Diagnoses included generalized anxiety disorder, pulmonary fibrosis, major depressive disorder, malaise, seizures, heart failure unsteadiness on feet, osteoarthritis, chronic stage II kidney disease, delusional disorders, peripheral vascular disease, hypertension, schizophrenia and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/13/22, revealed Resident #75 was cognitively intact and required limited assistance with personal hygiene. Review of a plan of care focus area revised 11/03/19, revealed Resident #75 had an activities of daily living (ADL) self-care performance deficit related to anxiety, depression, bipolar disorder and panic disorder. Interventions included encourage the resident to participate to the fullest extent possible with each interaction. Additionally, Resident #75's functional status in ADLs fluctuated depending on current presentations and behaviors and to assist with ADLs as required by circumstances. Observation on 10/26/22 at 7:45 A.M. of Resident #75's toenails, with the Administrator present, revealed the toenails of the right foot were long and extended over the end of the resident's toes. Resident #75's left foot toenails were long, extending beyond the tips of her toes, and appeared to be curling upward. Interview on 10/26/22 at 7:45 A.M. at the time of the observation with Resident #75 revealed nursing staff did not cut or trim toenails and she had to wait until the podiatrist came in every three months to have them trimmed. Resident #75 stated her toenails were too long. Interview of the Administrator on 10/26/22 at 7:45 A.M., at the time of the observation, confirmed the findings. The Administrator stated nursing staff were able to trim resident's toenails as long as the resident did not have diabetes and confirmed Resident #75 did not have diabetes. The Administrator stated the podiatrist was due in this week, possibly today. Review of facility policy titled Resident Care Showers, dated October 2020, revealed nails would be observed during routine care and showering for care needs, for example nail trimming. Review of facility policy titled Quality of Life-Dignity, revised August 2009, revealed residents shall be groomed as they wish to be groomed, including hair styles, nails, and facial hair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365756 If continuation sheet Page 6 of 20 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 365756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571 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 observation, medical record review and staff interview, the facility failed to follow physician's orders to [NAME] tubigrips to prevent and reduce edema for one (#44) of one resident reviewed for edema. The facility census was 80. Residents Affected - Few Findings include: Review of Resident #44's medical record revealed an admission date of 03/06/21 and a readmission date of 09/06/22. Diagnoses included edema, complete traumatic amputation of one right lesser toe, complete traumatic amputation of right great toe, benign prostatic hyperplasia without lower urinary tract symptoms, type II diabetes, dementia, hypertension and schizophrenia. Review of the significant change Minimum Data Set (MDS) assessment, dated 09/20/22, revealed Resident #44 was severely cognitively impaired and required extensive assistance with Activities of Daily Living (ADLs), including extensive two person assistance with dressing. Review of the plan of care initiated 04/12/21 revealed Resident #44 had potential for fluid imbalance related to diuretic use. Interventions included observe resident for signs and symptoms of fluid overload, including edema. Further review of a focus area initiated 09/22/22 revealed Resident #44 had an ADL self care performance deficit related to activity intolerance, dementia, fatigue, wounds, impaired balance and limited mobility. Interventions included assistance with dressing. Review of Resident #44's current physician orders revealed to place tubigrip to bilateral lower extremities every morning and remove at bedtime for edema. Observations on 10/24/22 at 5:58 P.M. and 10/25/22 at 7:30 A.M., 8:42 A.M., 10:02 A.M., 11:20 A.M. and 1:47 P.M. of Resident #44 revealed the Resident did not have tubigrips applied to his bilateral lower extremities. Interview on 10/25/22 at 2:03 P.M. of Licensed Practical Nurse (LPN) #313 revealed she had not observed Resident #44 with tubigrips applied as ordered and was unsure if the resident had them available. LPN #313 stated the resident sometimes removed things like that but she did not believe they were applied today and she did not know anything about the use of tubigrips for Resident #46. Interview on 10/25/22 at 2:07 P.M. with State Tested Nurse Aide (STNA) #347 revealed she was not assigned to care for Resident #44 that day but she had assisted him with care. STNA #347 confirmed Resident #44 did not have tubigrips on. STNA #347 stated she did not know anything about the use of tubigrips and thought the resident's tubigrips may have been in the laundry. STNA #347 stated He probably took them off. Interview on 10/25/22 at 2:09 P.M., Resident #44 revealed staff had not applied tubigrips in several days and was not able to state when the last time he had tubigrips on. Resident #44 indicated he only had gauze wound bandages applied to his feet. Interview on 10/25/22 at 2:13 P.M., STNA #370 revealed she was assigned to provide care today for Resident #46. STNA #370 verified tubigrips had not been applied to Resident #44's bilateral lower extremities as physician ordered. STNA #370 was unable to locate or confirm tubigrips were available (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365756 If continuation sheet Page 7 of 20 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 365756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571 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 for the Resident. STNA #370 stated it was difficult to apply the tubigrips over Resident #44's wound dressings on his feet but stated the real problem was the resident would probably take them off anyway. Additional observations on 10/25/22 at 4:09 P.M. and on 10/26/22 at 6:33 A.M., 8:28 A.M., 9:11 A.M. and 9:30 A.M. revealed Resident #44 was not wearing tubigrips. Residents Affected - Few Interview on 10/27/22 at 9:40 A.M. of Unit Manager (UM) #346 revealed Resident #44 had a significant decline during a recent hospitalization but was slowly returning to his previous functioning level. UM #346 stated tubigrips were ordered by wound care and she believed the facility had a supply of them in central supply. Observation of central supply with UM #346 revealed, after looking behind other supplies and boxes, a box of size A tubigrips was available at the facility. UM #346 was uncertain what size tubigrips Resident #46 required. Observation of Resident #44's room with UM #346 revealed the Resident did not have tubigrips in his room. UM #346 stated tubigrips were typically washed out and hung in the bathroom to dry, but there were none in Resident #44's bathroom. UM #346 was able to locate an ace bandage and stated staff may have been using ace bandages instead of tubigrips. UM #346 explained Resident #44 was at an appointment with wound care and she would follow up with them regarding the order for tubigrips. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365756 If continuation sheet Page 8 of 20 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 365756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and review of facility policy, the facility failed to weigh a resident daily per physician order. This affected one (#46) of three residents reviewed for nutrition. Additionally, the facility failed to ensure nutritional supplements were provided as recommended by the dietitian. This affected one (#44) of three residents reviewed for nutrition. The facility census was 80. Residents Affected - Few Findings include: 1. Review of Resident #46's medical record revealed an admission date of 09/16/22. Diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), type II diabetes, atrial fibrillation, heart failure, dementia, major depressive disorder, atherosclerotic heart disease, hypertension and inflammatory disease of prostate. Review of the admission Minimum Data Set (MDS) assessment, dated 09/23/22, revealed Resident #46 was cognitively intact. Additionally, Resident #46 had no behaviors and no significant weight loss. Review of a plan of care focus area, initiated 09/22/22, revealed Resident #46 was at risk for nutritional and hydration problems related to diagnoses of COPD, type II diabetes, congestive heart failure (CHF), dementia, coronary artery disease (CAD) and diuretic use. Interventions included allow resident to make choices and preferences of food as able, dietary consult as needed and diet as ordered. Review of a physician order, with an order date of 10/14/22 and a start date of 10/15/22, revealed Resident #46 was to be weighed daily due to CHF. Review of Resident #46's weights revealed the resident was not weighed on 10/15/22, 10/18/22, 10/20/22 and 10/22/22. On 09/17/22 the resident weighed 200 (lbs). On 10/16/22 the resident weighed 209.7 pounds (lbs). On 10/23/22 the resident weighed 222 lbs, which was a weight gain of 12.3 pounds, indicating a 6% weight increase from 10/16/22 and an increase of 22 pounds, a significant weight change of 11% since 09/17/22. Interview on 10/26/22 at 4:02 P.M. of Registered Dietitian (RD) #400 confirmed Resident #46 was to be weighed daily to monitor for weight increases due to CHF. RD #400 verified Resident #46 was not weighed daily and the resident's weights had been trending up. RD #400 stated she was unaware of Resident #46's significant weight change. Review of facility policy titled Weight Policy, revised November 2018, revealed the resident would be weighed upon admission, weekly for three weeks following admission, then monthly unless ordered otherwise by the physician, nurse practitioner or dietitian. 2. Review of Resident #44's medical record revealed an admission date of 03/06/21 and a readmission date of 09/06/22. Diagnoses included edema, complete traumatic amputation of one right lesser toe, complete traumatic amputation of right great toe, benign prostatic hyperplasia without lower urinary tract symptoms, type II diabetes, dementia, hypertension and schizophrenia. Review of the significant change MDS assessment, dated 09/20/22, revealed Resident #44 was severely cognitively impaired, required extensive assistance with Activities of Daily Living (ADLs), and had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365756 If continuation sheet Page 9 of 20 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 365756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571 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 0692 weight loss as part of a prescribed weight loss regimen. Level of Harm - Minimal harm or potential for actual harm Review of a plan of care focus area, initiated 03/11/21, revealed Resident #44 was at nutritional and dehydration risk due to therapeutic diet, weight fluctuations, receiving diuretic therapy, type II diabetes, dementia, schizophrenia and poor skin integrity. Interventions included therapeutic diet as ordered, monitor intakes and record, review labs as available and weigh resident per physician orders. Residents Affected - Few Review of a Nutrition Assessment, dated 09/21/22, revealed Resident #44 was receiving diuretic therapy with weight fluctuations expected. Resident #44's oral intake was poor to fair and house supplement two times daily was recommended. Review of current physician orders revealed Resident #44 was on a consistent carbohydrate cardiac diet, regular texture and consistency. There was no physician orders for a nutritional supplements. Interview on 10/25/22 at 4:09 P.M. of Licensed Practical Nurses (LPN) #313 and #402 confirmed Resident #44 was not ordered or provided with any nutritional supplements. Interview on 10/26/22 at 3:22 P.M. of Unit Manager (UM) #346 verified the dietitian had recommended a house supplement two times daily for Resident #44. UM #346 stated the supplement had not been started yet because she had not been able to reach the physician to obtain the order. UM #346 provided a document titled Nutrition Recommendations, dated 09/19/22. The document had Resident #44's name and recommendation for house supplement two times daily. Additional notes written on the document indicated attempts were made to contact the nurse practitioner (NP) on 09/22/22, 10/04/22, and the NP was on vacation the week of 10/13/22. No other attempts to obtain the order for the recommended nutritional supplement were documented. Interview on 10/26/22 at 3:56 P.M. of Registered Dietitian (RD) #400 confirmed she recommended a house supplement two times daily for Resident #44. RD #400 stated Resident #44 had a planned weight loss but the goal now was to maintain his weight. RD #400 stated the recommendation to add the supplement was due to Resident #44 having poor oral nutritional intake. Review of facility policy titled Weight Policy, revised November 2018, revealed the dietitian or physician may order specific nutritional interventions, including supplements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365756 If continuation sheet Page 10 of 20 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 365756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571 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, staff interview, resident interview, and facility policy review, the facility failed to follow physician orders for post dialysis assessments, monitoring the fistula site for complications, and monitoring the fistula for the thrill and bruit for one (#31) of one residents reviewed for dialysis. The facility census was 80. Residents Affected - Few Findings include: Review of Resident #31's medical record revealed an admission date of 09/16/22. Diagnoses included acute kidney failure with dialysis, schizophrenia, diabetes mellitus type 2, psychosis, human immunodeficiency virus (HIV), and a history of breast cancer. Review of Resident #31's quarterly Minimum Data Set (MDS) assessment, dated 08/26/22, revealed the resident had a high cognitive function. Review of Resident #31's most recent care plan revealed due to requiring dialysis the resident must have the arteriovenous fistula in the left arm assessed for signs and symptoms of infection or bleeding. If bleeding occurred the staff was to apply pressure and reinforce the dressing or call 911 for transport to the emergency room. Resident #31 should have staff palpate for thrill and auscultate bruit as ordered and as needed. The resident received dialysis every Monday, Wednesday, and Friday. Review of Resident #31's medical record revealed a physician's order dated 06/28/21 for post dialysis assessments to be completed every evening shift on Mondays, Wednesdays, and Fridays. A physician's order dated 06/30/21 indicated for the resident to receive a pre-dialysis assessment on every day shift every Monday, Wednesday, and Friday. Review of Resident #31's Treatment Administration Record (TAR) dated September 2022 revealed the post dialysis assessment was not completed on 09/02/22, 09/07/22, 09/16/22, and 09/21/22. Review of Resident #31's medical record revealed a physician's order dated 10/11/21 to check bruit and thrill and to monitor the left fistula site for redness, swelling, fever of 101 degrees Fahrenheit or higher, any numbness or tingling in the arm, or severe pain. The physician was to be notified if any of these symptoms were noted. Review of Resident #31's TAR dated October 2022 revealed the nursing staff failed to assess the resident's thrill and bruit and failed to monitor the left fistula site on 10/05/22 and 10/06/22 on second and third shift, on third shift on 10/13/22, on 10/17/22 for first shift, on 10/21/22 for second shift, and on first and second shift on 10/23/22. Interview with the Director of Nursing on 10/27/22 at 11:25 A.M. verified the nursing staff failed to follow physician orders to document Resident #31's post dialysis assessment, failed to monitor the residents bruit and thrill, and failed to monitor the resident's fistula site for any complications. Interview with Resident #31 on 10/27/22 at 1:22 P.M. revealed the nurses failed to check fistula site every shift. Review of the undated facility policy titled Dialysis Care, revealed bruit and thrill of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365756 If continuation sheet Page 11 of 20 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 365756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571 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 Level of Harm - Minimal harm or potential for actual harm fistula was to be assessed every shift for patency and recorded on Medication Administration Record (MAR). Fistula sites are to be checked every shift for signs and symptoms such as bleeding, edema, warmth, redness, and itching. Any unusual signs will be reported to physician for further instructions. The nurse will complete an assessment of the resident prior to leaving the facility and upon return to facility for each dialysis visit. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365756 If continuation sheet Page 12 of 20 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 365756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on review of the Centers for Medicare & Medicaid Services (CMS) Payroll Based Journal (PBJ) report, staff interview, review of posted daily staff levels, and review of staff timecards, the facility failed to ensure eight hours of daily registered nurse (RN) coverage. This affected all 80 residents of the facility. Findings include: Review of the CMS PBJ report, dated July 2022, revealed the facility had a high number of days without RN coverage. Interview on 10/26/22 at 2:25 P.M. of Scheduler #304 revealed the facility utilized agency staff to cover open shifts to ensure the daily requirement of RN coverage. Review of the daily posted staffing from 09/01/22 through 10/25/22 revealed the facility did not have RN coverage on the following dates: 09/05/22, 09/14/22, 09/18/22, 09/22/22, 09/23/22, 09/24/22, 10/16/22 and 10/22/22. Additionally, on 09/17/22 the facility only had RN coverage for four hours. Review of timecards confirmed the facility did not have RN coverage for eight hours on each of the above dates. Interview on 10/27/22 at 6:59 A.M. of the Administrator confirmed facility census had not been below 60 during the time period from 09/01/22 through 10/25/22. The Administrator stated the DON had provided RN floor coverage outside of her DON hours but confirmed the DON was not working on the above dates. Additionally, the Administrator confirmed the DON was off work 09/12/22 through 09/26/22. Corporate Nurse (CN) #320 was in the building in the DON's absence to cover the DON duties. The Administrator verified without the use of the DON the facility did not meet the eight hour daily requirement for RN coverage. This deficiency represents non-compliance investigated under Complaint Number OH00135778. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365756 If continuation sheet Page 13 of 20 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 365756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Potential for minimal harm Based on personnel record review and staff interview, the facility failed to complete State Tested Nurse Aide (STNA) performance evaluations timely. This affected two (#370 and #324) of four personnel records reviewed for performance evaluations. This had the potential to affect all 80 residents. Residents Affected - Many Findings include: Review of STNA #370's personnel record revealed a hire date of 03/16/12. The last completed performance evaluation was dated 08/19/21. Review of STNA #324's personnel record revealed a hire date of 06/08/22. There was no 90 day performance evaluation completed. Interview on 10/27/22 at 11:01 A.M., Business Office Manager (BOM) #351 verified STNA #370 and STNA #324 did not have current performance evaluations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365756 If continuation sheet Page 14 of 20 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 365756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview, resident interview, and facility policy review, the facility failed to administered medications as ordered to one (#31) out of six residents reviewed for unnecessary medications. This had the ability to affect all residents. The facility census was 80. Residents Affected - Few Findings include: Review of Resident #31's medical record revealed an admission date of 09/16/22. Diagnoses included acute kidney failure with dialysis, schizophrenia, diabetes mellitus type 2, psychosis, human immunodeficiency virus (HIV), and a history of breast cancer. Review of Resident #31's quarterly Minimum Data Set (MDS) assessment, dated 08/26/22, revealed the resident had a high cognitive function. Review of Resident #31's most recent care plan revealed medications were to be administered as ordered by the physician. Review of Resident #31's medical record revealed physician's order dated 10/28/21 for Sevelamer hydrochloride (HCl) (phosphorus lowering medication) tablet 800 milligrams (mg) for hyperphosphatemia with meals. Review of Resident #31's Medication Administration Record (MAR) dated September 2022 revealed on 09/07/22 and 09/29/22 the residents Sevelamer HCI failed to be administered at 5:00 P.M. with meals. Review of Resident #31's MAR dated October 2022 revealed on 10/06/22 the resident failed to be administered their Sevelamer HCI at 5:00 P.M. Review of Resident #31's medical record revealed a physician's order dated 04/14/22 for two tablets of sodium bicarbonate (antacid) tablet 650 mg to be administered twice daily for heartburn; an order dated 08/06/21 for Biktarvy (antiretroviral) 50-200-25 mg to be given by mouth at bedtime for HIV; an order dated 07/20/21 for Fiber-Lax (laxative) tablet to be administered by mouth twice daily for constipation; and an order dated 07/20/21 for risperidone (antipsychotic) 2 mg to be given by mouth two times a day for schizophrenia. Review of Resident #31's October 2022 revealed the resident failed to receive Biktarvy 50-200-25 mg, Fiber-Lax, risperidone, and sodium bicarbonate at 8:00 P.M. on 10/06/22, 10/15/22, and 10/21/22. Interview with the Director of Nursing on 10/27/22 at 11:25 A.M. verified that the nursing staff failed to document Resident #31's medications were administered and did not document why it had not been administered per facility policy. Interview with Resident #31 on 10/27/22 at 1:22 P.M. revealed there were several nights she failed to receive her medications recently but she could not recall the exact dates. Review of the facility policy titled Administering Medications, dated 12/2012 revealed medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders.) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365756 If continuation sheet Page 15 of 20 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 365756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571 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. Based on observation, staff interview, review of the Pot Sink Sanitation Record, review of manufacturer's recommendations, review of work orders, and review of facility policy, the facility failed to ensure foods were properly stored and labeled after opening. Additionally, the facility failed to ensure adequate sanitization of dishes. This affected all 79 residents who received food from the kitchen. The facility identified one resident (#69) who did not receive food from the kitchen. The facility census was 80. Findings include: 1. Observation on 10/24/22 at 8:36 A.M. of kitchen revealed the reach in refrigerator in the food preparation area had an opened and undated package of turkey luncheon meat wrapped in plastic wrap; an opened and undated package of roast beef luncheon meat wrapped in plastic wrap; three packages of opened, unlabeled and undated cheese wrapped in plastic wrap; a plastic container of unlabeled and undated pears; a plastic container of unlabeled and undated gravy; a metal container of unlabeled and undated spaghetti sauce; and a plastic container of undated and unlabeled shredded lettuce. Interview at the time of the observation with Dietary Supervisor (DS) #354 verified the above findings. Observation on 10/24/22 at 8:52 A.M. of the reach in refrigerator located in the dry storage room revealed an opened and undated package of cheese blend and two packages of opened and undated parmesan cheese. Interview with DS #354 at the time of the observation verified the findings. Observation on 10/24/22 at 10:34 A.M. of the reach in freezer located in the dry storage room revealed an uncovered, undated and unlabeled metal pan, approximately one-quarter full, of ice cream cake. Dietary Assistant (DA) #310 verified the finding and stated he believed the cake had been served the previous evening. Review of facility procedure titled Leftovers, undated, revealed proper storage techniques included food should be wrapped, labeled with name of item, and dated; food should be discarded if not used within three days; and if food is part of an opened can, the remaining product should be moved into an appropriate storage container and labeled with item name and date. Additionally, all food storage areas should be monitored daily to identify any food items that must be discarded or used. 2. Observation on 10/24/22 at 8:44 A.M. of the three-compartment sink revealed the facility utilized the sink to wash dishes, with the dishes being sanitized with quaternary ammonia. Observation of the sanitization compartment of the sink revealed the sanitization level was less than 10 parts per million (ppm). Interview with DS #354 at the time of the observation verified the sanitization level was not sufficient. DS #354 stated the equipment was recently serviced and he was unsure why the sanitizer was not dispensing into the sanitization compartment. DS #354 confirmed the three compartment sink was utilized by kitchen staff to wash pots, pans, and utensils and those dishes were not run through the dishwasher for sanitization. Observation on 10/24/22 at 10:36 A.M. of the kitchen revealed DA #306 walk to the three compartment sink and pick up serving utensils that were drying. DA #306 verified the serving utensils had been washed in the three compartment sink and the sanitizer had not been repaired yet, resulting in the no sanitizer being used when washing the dishes. DA #306 returned to the steam table and placed the serving utensils into the prepared foods and began plating lunch for residents. DA #306 stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365756 If continuation sheet Page 16 of 20 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 365756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571 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 sanitizer had not worked all day today and she was unsure why. Level of Harm - Minimal harm or potential for actual harm Review of the Pot Sink Sanitation Record on 10/24/22 at 10:36 A.M. revealed no sanitizer testing entries for 10/24/22. Residents Affected - Many Review of the sanitizer's manufacturer's directions revealed the quaternary ammonia was an effective sanitizer when prepared at 200 ppm. Observation on 10/25/22 at 9:30 A.M. of the three-compartment sink in the kitchen revealed a bottle of sanitizer/disinfectant sitting on the sink. Interview of DS #354 at the time of the observation revealed the servicing company had been out on 10/24/22 to check the function of the sanitizer dispenser and discovered the dispenser had a leak, resulting in no sanitizer being dispensed into the sanitization compartment of the sink. DS #354 stated parts had to be ordered to repair the dispenser and staff had to manually add one ounce of sanitizer for every three gallons of water until the dispenser could be repaired. Review of the Pot Sanitation Record on 10/25/22 at 9:30 A.M. revealed sanitization testing results had been entered on 10/24/22 at 5:00 A.M. and 11:00 A.M., with each test resulting in a sanitization level of 200 ppm. Interview of DS #354 at the time of the observation verified the entries on 10/24/22 at 5:00 A.M. and 11:00 A.M. were inaccurate because it had already been determined there was no sanitizer detected during observations made by this surveyor on 10/24/22. During a follow-up interview on 10/25/22 at 11:45 A.M., DS #354 stated the company who serviced the sanitizer dispenser for the three-compartment sink was at the facility at approximately 9:30 A.M. on 10/24/22 and remained at the facility for a couple of hours. DS #354 stated the sanitizer test result on the Pot Sink Sanitization Record on 10/24/22 at 5:00 A.M. was entered in error but the 11:00 A.M. entry was correct because the servicing company had confirmed by that time the sanitizer dispenser was not working and staff began manually adding sanitizer to the water. DS #354 stated he added the sanitizer to the sanitization compartment at approximately 10:00 A.M., which was why a test result was entered on 10/24/22 at 11:00 A.M. DS #354 provided this surveyor with the work order from the dispenser servicing company. DS #354 verified he signed the work order on 10/24/22 at 12:31 P.M. and confirmed he signed the work order when the technician completed work on the sanitizer dispenser. Additionally, DS #354 confirmed the work order indicated the technician spent approximately 0.5 hours at the facility, placing the technician at the facility at approximately 12:00 P.M. on 10/24/22. DS #354 verified staff manually added sanitizer to the sanitization compartment after the service technician left, indicating there was no sanitizer in the sanitization compartment until after 12:30 P.M. and the 11:00 A.M. test result entered on the Pot Sink Sanitization Record was inaccurate. Observation on 10/26/22 at 9:00 A.M. of DS #354 test the sanitizer level in the sanitization compartment of the three-compartment sink revealed a sanitization level of 150 ppm. DS #354 added additional sanitizer to the water in the sanitization compartment. Review of facility policy titled Pot Sink, undated, revealed all pots and large wares would be cleaned and sanitized using the pot sink. Further review revealed the third compartment was used to sanitize with a sanitizing solution mixed at a concentration specified on the manufacturers label and to test chemical sanitizer concentration using an appropriate test strip. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365756 If continuation sheet Page 17 of 20 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 365756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, review of a fall report and review of facility policy, the facility failed to ensure a resident's medical record reflected information related to a fall for one (#75) of one resident reviewed for falls. The facility census was 80. Findings include: Review of Resident #75's medical record revealed an admission date of 08/06/12 and a readmission date of 04/25/19. Diagnoses included generalized anxiety disorder, pulmonary fibrosis, major depressive disorder, malaise, seizures, heart failure unsteadiness on feet, osteoarthritis, chronic stage II kidney disease, delusional disorders, peripheral vascular disease, hypertension, schizophrenia and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/13/22, revealed Resident #75 was cognitively intact, required supervision for activities of daily living, including bed mobility, ambulation, dressing, and toilet use and limited assistance with personal hygiene. Further review revealed Resident #75 had no falls. Review of a plan of care focus area initiated 07/27/21 revealed Resident #75 was at risk for falls related to medications, foot deformity, anxiety, panic disorder and bipolar disorder. Interventions included appropriate footwear while ambulating, remind and encourage to use walker with ambulation and resident educated on sitting down when dizzy. Review of a Fall Risk assessment dated [DATE] revealed Resident #75 scored four, indicating a low risk for falls. Further review of Resident #75's electronic medical record (EMR) revealed no information related to Resident #75 falling. Interview on 10/24/22 at 2:44 P.M. of Resident #75 revealed she fell in the lounge area a few days ago following the Resident Council meeting. Interview on 10/25/22 at 2:04 P.M., Licensed Practical Nurse (LPN) #313 confirmed Resident #75 had fallen on 10/21/22 in the lounge area of the facility. LPN #313 stated Resident #75 had a bruise on her right arm as a result of the fall and complaint of knee and hip pain earlier in the week. An x-ray was taken and there were no acute findings. Interview on 10/26/22 at 1:57 P.M., the Director of Nursing (DON) confirmed nursing staff were to complete a progress note to document a resident's fall. The DON verified Resident #75's EMR contained no progress notes or other information related to a fall on 10/21/22. The DON stated a fall report was completed and was included in the facility's risk management. During a follow up interview on 10/26/22 at 2:15 P.M., the DON provided a fall report, dated 10/21/22, documenting Resident #75's fall. The fall report included information related to the fall, notifications made and the assessment completed by nursing. The DON verified the fall report was part of the facility's risk management program and was not included in Resident #75's EMR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365756 If continuation sheet Page 18 of 20 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 365756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571 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 0842 Review of facility policy titled Falls Policy, revised October 2018 revealed relevant information would be documented regarding the fall, assessment, notifications and interventions. 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: 365756 If continuation sheet Page 19 of 20 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 365756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehouse Country Manor 11239 Waterville St Whitehouse, OH 43571 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, staff interview, and review of maintenance work orders, the facility failed to maintain a clean and sanitary environment for 41 residents (Resident #05, #07, #08, #09, #14, #15, #16, #17 #18, #22, #23, #24, #29, #32, #33, #39, #41, #42, #43, #45, #47, #48, #53, #55, #56, #57, #60, #63, #66, #67, #68, #72, #73, #74, #76, #130, #131, #132, #133, #134, and #230) residing on the secured unit. The facility census was 80. Findings include: Interview on 10/24/22 at approximately 12:00 P.M. with State Tested Nurse Aide (STNA) #347 revealed black mold was all over and growing in the soiled utility room located on the secured unit of the facility. STNA #347 reported the door was opened and closed frequently throughout the day and she was concerned about residents breathing in the mold spores. STNA #347 reported the mold had been reported to administration and remained unaddressed for over one year. Observation on 10/24/22 at 4:07 P.M. black mold was located all over the back and lower left walls of the soiled utility room. A large section of drywall was cut out of the back wall, and pipes were exposed and actively leaking into a bucket. Interview at the time of the observation with Licensed Practical Nurse (LPN) #395 and STNA #398 verified the presence of the black mold. Staff reported the black mold had been present and growing in the soiled utility room for a long time and had not been addressed. Interview on 10/27/22 at 8:58 A.M. with Maintenance Director #372 verified the mold had been present for awhile. Maintenance Director #372 reported he had cut out a portion of the wall, sprayed, and was waiting for the area to dry up. Maintenance Director #372 acknowledged the leaking pipe and stated he just needed to get in there to fix it. Review of maintenance work orders for 05/01/22 through 10/25/22 identified no work orders pertaining to mold. The facility identified 41 residents (#05, #07, #08, #09, #14, #15, #16, #17 #18, #22, #23, #24, #29, #32, #33, #39, #41, #42, #43, #45, #47, #48, #53, #55, #56, #57, #60, #63, #66, #67, #68, #72, #73, #74, #76, #130, #131, #132, #133, #134, and #230) residing on the secured unit. This deficiency represents non-compliance investigated under Complaint Number OH00132831. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365756 If continuation sheet Page 20 of 20