Health inspection·May 10, 2023

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of staff witness statements, staff interview, and review of facility policy, the facility failed to notify a resident's physician and family after a fall. This affected one (#66) of three residents reviewed for falls. The facility census was 86. Findings include: Review of the medical record for Resident #66 revealed an admission date of 12/04/08. Diagnoses included osteomyelitis of the vertebra in the thoracic region, sepsis due to streptococcus group B, fusion of the spine in the thoracic region, pyothorax, type two diabetes mellitus, cirrhosis of the liver, schizoaffective disorder, anxiety, depressive disorder, osteoarthritis, and chronic obstructive pulmonary disease. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of a fall witness statement date 03/30/23 from Licensed Practical Nurse (LPN) #271 revealed Resident #66 was found on the floor lying on her back in her doorway. Review of a fall witness statement dated 03/30/23 from State Tested Nurse Aide (STNA) #274 revealed Resident #66 was found lying on the floor in her doorway. Review of the nursing notes dated 03/30/23 revealed no documentation of notifications made to the family or physician regarding the fall on 03/30/23. Interview on 05/10/23 at 1:45 P.M., with Assistant Director of Nursing (ADON) #128 verified there was no notification made to Resident #66's family or physician regarding the fall on 03/30/23. ADON #128 stated Resident #66 was her own responsible party. Review of the facility policy, Change in Condition and Physician Notification Policy, revised September 2019, revealed the facility would notify the residents representative and physician when an accident or incident occurs involving the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365756 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 365756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 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 - Some 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 maintain a clean and homelike environment. This affected 14 (#17, #18, #25, #26, #37, #38, #40, #41, #44, #45, #46, #47, #80, and #96) of 31 residents reviewed for environment. The facility census was 86. Findings include: 1. Observation on 05/10/23 at 8:21 A.M. revealed the upper light bulb in Resident #96's overbed light did not work. Interview with Resident #96 during the time of the observation on 05/10/23 at 8:21 A.M. stated the light bulb not working over her bed affected her ability to crochet. 2. Interview and observation on 05/10/23 at 9:52 A.M. with Resident #26 revealed there were broken blinds over the window which was directly above her bed. Resident #26 stated the broken blinds bothered her. Continued interview and observation revealed the soap dispenser in her bathroom was empty. Resident #26 stated it had been empty for five days and it concerned her. There was no additional soap available in the bathroom at that time. 3. Interview and observation on 05/10/23 at 10:01 A.M. with Resident #46 revealed he was concerned about the hole in the wall along side his bed, which measured approximately two inches tall and approximately three inches wide. Continued observation revealed dark brownish-red stains at the bottom edge of the privacy curtain. Resident #46 also reported a concern that the clock in his room did not have a battery. Observations and interview during a tour of the facility on 05/10/23 with Maintenance Director #134 beginning at 11:36 A.M. confirmed a toilet was filled with feces, the water to the toilet was turned off and could not be flushed, and the toilet seat and lid were broken in the bathroom shared by Resident #37 and Resident #38; a toilet was filled with feces and the water to the toilet was turned off so it could not be flushed in the bathroom shared by Resident #40, Resident #41, Resident #44, and Resident #45; a hole in the drywall, approximately two inches long by three inches wide, a soiled privacy curtain, and the mounted clock had no battery in Resident #46's room; the lower light bulb was not functioning above Resident #96's bed; the upper light bulb was not functioning above Resident #80's bed; the hand soap dispenser was empty in Resident #26's room; and the blinds were broken or missing in resident rooms where Resident #17, Resident #18, Resident #25, Resident #26, Resident #40, Resident #41, Resident #46, and Resident #47 resided. Interview on 05/10/23 at 11:36 A.M. with Maintenance Director #134 stated the facility planned to renovate the facility beginning the first week in June 2023, including patching all holes in the walls, painting all rooms, and replacing all dressers. Maintenance Director #134 stated the facility was in the process of replacing all soap dispensers in resident bathrooms. Further observation with Maintenance Director #134 verified no alcohol-based hand sanitizer dispensers were available in the hallway outside Resident #26's room. This deficiency represents non-compliance investigated under Master Complaint Number OH00142692 and Complaint Number OH00142646. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365756 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 365756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 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 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 medical record review, review of a concern form, review of staff witness statements, staff interview, resident interview, and policy review, the facility failed to timely report, investigate, and assess a resident following a fall. Additionally, the facility failed to timely assess a resident's risk for falls. This affected one (#66) of three residents reviewed for falls. The facility census was 86. Findings include: Review of the medical record for Resident #66 revealed an admission date of 12/04/08. Diagnoses included osteomyelitis of the vertebra in the thoracic region, sepsis due to streptococcus group B, fusion of the spine in the thoracic region, pyothorax, type two diabetes mellitus, cirrhosis of the liver, schizoaffective disorder, anxiety, depressive disorder, osteoarthritis, and chronic obstructive pulmonary disease. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 had intact cognition. The resident required supervision for bed mobility, transfers, and ambulation. Review of the fall risk assessment dated [DATE] revealed Resident #66 was at low risk for falls. There were no fall risk assessments completed since 07/08/22. Review of a fall witness statement dated 03/30/23 from Licensed Practical Nurse (LPN) #271 revealed Resident #66 was found on the floor lying on her back in her doorway. Review of a fall witness statement dated 03/30/23 from State Tested Nursing Assistant (STNA) #274 revealed Resident #66 was found lying on the floor in her doorway. Review of the nursing notes dated 03/30/23 through 04/17/23 revealed no documentation of Resident #66's fall on 03/30/23 and no documentation of an assessment after the fall. Review of a concern form dated 04/18/23 revealed it was brought to the attention of management Resident #66 had a fall on 03/30/23 which was not properly documented. There was no documentation noting a fall, no update made to family or nurse practitioner, and no assessment completed per the fall policy. Resident #66 complained of severe pain days following the fall and was administered as needed medications on multiple days. Further review of the concern form dated 04/18/23 revealed on 04/18/23 LPN #271 and STNA #274 informed management Resident #66 had a fall a few weeks back that was not reported by LPN #150. Resident #66 was witnessed on the floor on 03/30/23 by several staff members and the fall was reported to the responsible nurse along with witness statements. LPN #150 had not completed proper documentation or reporting of the fall according to the fall policy. When questioned, LPN #150 stated she must have forgot to do the proper documentation. LPN #150 was placed on a three-day suspension then terminated. Interview on 05/10/23 at 1:45 P.M., with Assistant Director of Nursing (ADON) #128 stated the Director of Nursing (DON) and herself started asking staff questions and found out Resident #66 had a fall on 03/30/23. ADON #128 stated staff members indicated they gave Resident #66's nurse witness statements, but management never received the witness statements or a report of the fall. ADON #128 revealed the DON called LPN #150 and she admitted she forgot to report the fall. ADON #128 verified there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365756 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 365756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm was no documentation of the fall and no documentation of an assessment after the fall. ADON #128 stated they never found the original staff witness statements so they had to have everyone rewrite their statements for the fall on 03/30/23. ADON #128 stated Resident #66 fell on first shift, but was not aware of what time the fall occurred. ADON #128 also verified a fall risk assessment on Resident #66 should have been completed quarterly in October 2022 and January 2023. Residents Affected - Few Review of facility policy titled, Falls and Fall Risk, Managing, revised 08/31/22, revealed resident's fall risk would be assess upon admission, quarterly, with a significant change in status, and status post any fall. Further review of the policy revealed no guidelines for post fall assessments and documentation. This deficiency represents non-compliance investigated under Complaint Number OH00142692. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365756 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 365756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 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, and review of the facility policy, the facility failed to practice appropriate hand hygiene and wear appropriate hair restraints while preparing and distributing food. This had the potential to affect all residents in the facility except Resident #55 who received no food from the kitchen. The facility census was 86. Findings include: 1. Observation on 05/10/23 at 12:15 P.M. revealed Dietary Aide #302 scooped ice from the ice machine and a piece of ice fell on the floor. Dietary Aide #302 picked the ice up off the floor with her bare left hand while wearing a glove on her right hand. Dietary Aide #302 then took the glove off her right hand and threw it in the trash. Dietary Aide #302 then picked up a coffee mug by the handle with her left hand and delivered it to Resident #97. Resident #97 then picked up the mug by the handle and drank from it. Interview at the time of the observation with Dietary Aide #302 confirmed she did not wash her hands after picking ice up off the floor with her bare hand and before handling Resident #97's coffee mug by the handle. 2. Observation on 05/10/23 at 3:15 P.M. revealed Dietary Aide #304 pouring drinks and stirring drinks for the evening meal. Dietary Aide #304 had curly dark hair all over his head and was not wearing a hair net. Interview at the time of the observation with Dietary Aide #304 stated he had never been told he had to wear a hairnet. Interim Dietary Manager #303, who was present during the observation and interview, verified Dietary Aide #304 was not wearing a hairnet and handed a hairnet to Dietary Aide #304. Review of the undated facility policy, Personal Hygiene, revealed staff should wash their hands after touching soiled dishes, foods, or trash, and before putting on gloves or after removing them. Further review revealed hair must be kept clean and kept restrained with a hairnet or cap covering all hair. This deficiency represents non-compliance investigated under Master Complaint Number OH00142692. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365756 If continuation sheet Page 6 of 6