Health inspection·January 17, 2024

F 0550 Level of Harm - Actual harm Residents Affected - Few Interview of the Director of Nursing on 01/09/24 at 3:20 P.M. revealed it was not alright for STNA #581 to tell the Resident #9 to go to the bathroom in her incontinence brief and Resident #9 should be assisted to the bathroom when requested. Interview of Resident #9 on 01/10/24 at 10:43 A.M. revealed she kept asking staff to take her to the bathroom and was told she would have to wait. Resident #9 stated when STNA #581 came in the room and told her to go to the bathroom in her incontinence brief it made her feel bad and sad. Resident #9 stated sometimes she cried when she had to go to the bathroom because she had to hold it so long, no one would help her, she could not hold it any longer and went to the bathroom in her pants like a baby. Resident #9 stated her room was at the end of the hall, it was hard to get help and she was often ignored. Review of the facility policy titled Resident Rights revealed the policy included residents had a choice and a voice in how they would be treated. Residents had a right to participate in the decisions that affected the resident's care. Review of the undated facility policy titled Routine Resident Care revealed it was the policy of the facility to promote resident centered care by attending to the total medical, nursing, physical, emotional, mental, social and spiritual needs and honor resident lifestyle preferences while in the care of the facility. The facility would provide routine daily care by a certified nursing assistant with specialized training in rehabilitation, restorative care under the supervision of a licensed nurse including but not limited to maintaining a bladder and bowel training program, providing an environment that contributed to a positive self-image preserved dignity and promoted privacy, routine care by a nursing assistant included but was not limited to the following, toileting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 2 of 28 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to honor Resident #54's preferences regarding when she wanted to get out of bed and how long she remained out of bed. This affected one of resident reviewed for preferences. Findings include: Review of Resident #54's medical records revealed an admission date of 11/03/23. Diagnoses included Multiple Sclerosis and need for personal care assistance. Review of Resident #54's care plan dated 11/03/23 revealed Resident #54 had self care deficits. Interventions included two or more staff for transfers. Review of Resident #54's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had intact cognition and was dependent for transfers. Interview with Resident #54 on 01/09/24 at 7:46 A.M. revealed staff did not return her to bed as she requested. Resident #54 stated she had been left in her wheelchair for more than five hours on occasions. Interview with Resident #54 on 01/10/23 at 11:06 A.M. revealed she requested to be out of bed earlier in the morning and State Tested Nurse Aide (STNA) #585 told her she would assist her out of bed prior to lunch. Interview on 01/10/24 at 2:24 P.M. with STNA #585 revealed she was aware of staff who did not provide timely assistance for Resident #54's transfers. STNA #585 stated there were staff who refused to assist Resident #54 out of bed and also had left Resident #54 up her wheelchair for long periods of time. STNA #585 stated she was aware Resident #54 preferred to be out of bed prior to lunch; however, she had not assisted Resident #54 out of bed because she did not have time. STNA #585 indicated her shift was over at 2:30 P.M. Observation on 01/10/24 at 2:40 P.M. revealed Registered Nurse (RN) #595 and Licensed Practical Nurse (LPN) #603 assisting Resident #54 out of bed via a Hoyer (mechanical) lift. Interview with RN #595 and LPN #603, at time of observation, revealed they were aware Resident #54 preferred to out of bed prior to lunch and were unable to provide information regarding why Resident #54 had not been assisted out of bed prior to the observation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 3 of 28 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 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 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on resident interviews and record review the facility failed to promptly address concerns regarding palatability of food. This affected 105 residents who received meals from the kitchen. Six residents received nothing by mouth (#3, #18, #20, #53, #76 and #90). The census was 111. Residents Affected - Some Findings include: Review of the food council minutes for the past year revealed the following concerns from 01/10/23 through 12/23/23. On 01/10/23: The food is cold mostly at breakfast. Staff are telling residents they do not have something because they don't want to make it. Not using hot plates on the weekends. On 02/21/23: Burnt grilled cheese. Can we have a whole baked potatoe, not half? On 03/15/23: Roast pork and beef could be more tender. On 05/16/23: Condiments are missing on trays. Breakfast is usually cold-are pellet warmers on? and Not getting what is on ticket. On 06/20/23: Cold food. On 07/11/23: Rice is always overcooked. Broccoli is overcooked. Chicken was dry. On 08/24/23: Chicken tenders and patties are hard. Broccoli is overcooked. Diced potatoes are overcooked and mushy; more meat. On 09/12/23: Roast pork and beef are tough. On 10/02/23: Cook fish longer-feels slimy. On 12/13/23: Oven roasted potatoes are rock hard. Interviews on 01/08/24 and 01/09/24 revealed the following 11 complaints about the food. 1. Interview on 01/08/24 at 9:51 A.M. with Resident #59 revealed the food is terrible. It is cold at times. Dinner yesterday had meat that was so hard you could not cut it or put a fork in the fish. I only ate the potatoes, portions are small. 2. Interview on 01/08/24 at 10:06 A.M. with Resident #49 revealed the food was inedible. 3. Interview on 01/08/24 at 10:19 A.M. with Resident #28 revealed meat was tough. Food was cold at times and the portions are small. 4. Interview on 01/08/24 at 11:01 A.M. with Resident #6 revealed they have small portions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 4 of 28 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 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 0565 5. Interview on 01/08/24 at 11:30 A.M. with Resident # 1 revealed The food is hard as a rock. Level of Harm - Minimal harm or potential for actual harm 6. Interview on 01/08/24 at 1:56 P.M. with Resident #31 revealed The eggs are burnt and they try to hide it underneath. They are not following the preferences and the meat is hard. Residents Affected - Some 7. Interview on 01/08/24 at 2:39 P.M. with Resident #7 revealed The food is horrible. 8. Interview on 01/09/24 at 7:51 A.M. with Resident #54 revealed The food is cold everyday. The portions are small and they need more meat. 9. Interview on 01/09/24 at 10:23 A.M. with Resident #260 revealed The food is horrible. They do not use pellets [plate warmers] on the weekends. 10. Interview on 01/09/24 at 10:51 A.M. with Resident #21 revealed Sometimes the food is horrid. Can't cut it with a knife. We eat PBJ's. Sick of it! 11. Interview on 01/09/24 at 4:00 P.M. with Resident #51 revealed they never use pellets on the weekends. Review of the facility policy titled Food: Quality and Palatability, revised 09/2017, revealed food would be palatable, attractive and served at a safe and appetizing temperature. Review of the facility policy titled Ohio Resident Grievance, dated 05/30/19, revealed the facility was to provide resident centered care meeting psychosocial , physical and emotional needs and concerns of the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 5 of 28 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review the facility failed to ensure Resident #76 received the necessary services to maintain clean hair. This affected one (Resident #76) out of three residents reviewed for activities of daily living. The facility census was 111. Residents Affected - Few Findings include: Review of Resident #76's medical record revealed and admission date of 01/13/23 and diagnoses included anoxic brain damage, chronic respiratory failure with hypoxia, and abnormal posture. Review of Resident #76's care plan dated 01/25/23 revealed Resident #76 had an activity of daily living (ADL) self-care performance deficit and required assistance with all ADLs. Resident #76 would maintain current level of function. Interventions included Resident #76 was dependent for shower, bathing and required two or more helpers to assist. Review of Resident #76's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status was not conducted due to Resident #76 was rarely or never understood. Resident #76's upper and lower extremities had impairment on both sides. Resident #76 was dependent on staff for ADLs and used a manual wheelchair. Observation of Resident #76 on 01/08/24 at 3:35 P.M. revealed she was lying in bed with her eyes closed and did not respond when spoken to. Resident #76's hair was very greasy. Observation of Resident #76 on 01/09/24 at 1:38 P.M. revealed she was sitting in a padded chair in her room and her hair remained very greasy. Interview of State Tested Nursing Assistant (STNA) #585 on 01/09/24 at 1:50 P.M. confirmed Resident #76's hair was very greasy. STNA #585 stated Resident #76 was not usually on her assignment and she was shocked at how greasy Resident #76's hair was. STNA #585 stated Resident #76's hair needed washed. Interview of Licensed Practical Nurse (LPN) #508 on 01/09/24 at 1:53 P.M. confirmed Resident #76 had very greasy hair. LPN #508 stated Resident #76 sweated a lot and that contributed to her greasy hair. Review of the facility's undated policy titled Routine Resident Care revealed it was the policy of the facility to promote resident centered care by attending to the total medical, nursing, physical, emotional, mental, social and spiritual needs and honor resident lifestyle preferences while in the care of the facility. The facility would provide routine daily care by a certified nursing assistant under the supervision of a licensed nurse including but not limited to bathing, dressing, eating and hydration and toileting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 6 of 28 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 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 and interview the facility failed to ensure prompt physician notification and timely care related to Resident #65's reddened and painful external genitals. This affected one (#65) of two residents observed for skin impairment. The facility census was 110. Residents Affected - Few Findings include: Review of Resident #65's medical records revealed an admission date of 03/06/23. Diagnoses included multiple sclerosis, muscle weakness and neuromuscular bladder. Review of the care plan dated 12/10/23 revealed Resident #65 was at risk for impaired skin integrity. Interventions included apply barrier cream after incontinence care. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 had intact cognition and was dependent for toileting and personal hygiene. Review of skin assessments dated 12/28/23 and 01/05/24 revealed Resident #65 had no skin impairment. Observation of incontinence care on 01/10/24 at 10:48 A.M. for Resident #65 with State Tested Nursing Assistant (STNA) #585 revealed reddened areas to the head of Resident #65's penis, shaft of penis and scrotum. STNA #585 stated she had not cared for Resident #65 for at least two weeks and was not aware of the reddened areas prior to the current observation. STNA #585 completed Resident #65's incontinence care and applied barrier cream to the reddened areas. Interview with Resident #65 at the time of the observation revealed he had pain in his penis area. Interview on 01/11/24 at 10:23 A.M. with STNA #559 revealed she had cared for Resident #65 the previous week and had observed his reddened penis and scrotum. STNA #559 reported the reddened areas to Licensed Practical Nurse (LPN) #519. At the time of interview STNA #559 performed incontinence care for Resident #65 and indicated the reddened areas to his penis and scrotum appeared to be worse from when she had cared for him the previous week. During the provision of incontinence care STNA #559 exited Resident #65's room and returned with LPN #519. LPN #519 observed Resident #65's penis and scrotum and stated she had not been aware of the reddened areas previously. STNA #559 then stated to LPN #519 she had informed her of the reddened areas the previous week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 7 of 28 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review the facility failed to ensure appropriate care and services to prevent the devopement of an in house pressure ulcer and decline of the pressure ulcer to a Stage four pressure injury (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed). This affected one (Resident #76) of three residents reviewed for pressure ulcers. The facility census was 111. Residents Affected - Few Actual Harm occurred on 11/12/23 when Resident #76, who was non-verbal, dependent on staff for turning and repositioning and had limitations in neck mobility was noted to have deterioration to a left ear wound in which there had been no previous documentation. Documentation dated 11/16/24 indicated the left ear wound declined to a Stage 4 pressure injury measuring 2.8 centimeters (cm) in length by 2.5 cm width with 0.1 cm depth with exposed tissues including muscle, fascia without evidence of adequate interventions being in place to prevent the development of the ulcer. The pressure ulcer wound base was assessed to have 50 to 74 percent granulation, 1 to 24 percent slough and 1 to 24 percent eschar with a moderate amount of serosanguinous drainage. Findings include: Review of Resident #76's medical record revealed and admission date of 01/13/23 and diagnoses included anoxic brain damage, chronic respiratory failure with hypoxia, and abnormal posture. Review of Resident #76's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #76 was rarely or never understood. Resident #76 had upper and lower extremity impairment on both sides. Resident #76 was dependent on staff for activities of daily living and used a manual wheelchair. Review of Resident #76's care plan dated 01/16/23 revealed Resident #76 would not have complications from altered skin integrity (for example, infection) through the review date. Interventions included to apply appropriate pressure reducing appliances such as low air loss mattress, off loading boots, offloading ear pillow, and wheelchair cushion, complete weekly skin checks, encourage Resident #76 to turn and reposition, and physical therapy (PT) and Occupational Therapy (OT) evaluation and treatment as needed for positioning and wound care. Review of Resident #76's progress notes from 07/01/23 through 11/12/23 did not reveal documentation related to a left ear wound. Review of Resident #76's physician orders dated 11/06/23 revealed PT to discharge Resident #76 per discharge summary. There were no orders for a PT consult to evaluate Resident #76 for clavicle, neck brace or offloading. Review of Resident #76's Therapy Referral to Restorative dated 11/06/23 revealed passive range of motion (PROM) to bilateral lower extremities (BLE) to prevent contractures and daily brace application to left knee to be completed one to two times a day, three to five times per week. Range of motion (ROM) to be 15 minutes and brace application for two to four hours. There were no recommendations related to clavicle, neck brace or offloading. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 8 of 28 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 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 0686 Level of Harm - Actual harm Residents Affected - Few Review of Resident #76's progress notes dated 11/12/23 revealed deterioration noted in left ear wound, Telehealth notified, no new orders at this time, would continue with current treatment orders, wound nurse to follow up. Review of Resident #76's Telehealth progress notes dated 11/12/23 timed 2:46 P.M. revealed Resident #76 had a left ear wound for some time. Resident #76 had orders for Dakin's solution (topical antiseptic) and wound care twice a day, however there had not been much improvement. Ear did not appear to be infected and would continue with current orders. Recommend primary provider evaluate this week. Resident #76 might benefit from debridement of the ear. Review of Resident #76's Skin and Wound Note dated 11/16/23 timed 4:54 P.M. revealed Resident #76 had a new Stage 4 pressure injury to her left ear. Measurements were length 2.8 centimeters (cm), width 2.5 cm and depth was 0.1 cm. Calculated area was 7 square cm, exposed tissues included muscle, fascia. Wound base had 50 to 74 percent granulation, 1 to 24 percent slough and 1 to 24 percent eschar. There was a moderate amount of serosanguinous drainage. Treatment recommendations were to cleanse with normal saline, apply silver alginate to base of the wound, and secure with bordered foam. Change dressing daily and as needed. The notes further included Resident #76 was high risk for pressure ulcer formation including impaired nutrition, severe contractures of multiple joints, comorbidities, decreased mobility and history of previous pressure injury. A physical therapy consult was recommended to evaluate for clavicle, neck brace or offloading. Review of Resident #76's Skin and Wound Note dated 01/03/24 revealed Resident #76's left ear Stage 4 pressure ulcer was improving without complications. Measurements were length 1.5 cm, width 1.0 cm, depth 0.1 cm and wound base was 50 to 74 percent epithelial, 50 to 74 percent granulation, 0 percent slough and eschar (dead tissue). Observation of Resident #76 on 01/09/24 at 1:38 P.M. revealed she was sitting in a padded chair in her room, her head was leaning down and to the left, and appeared to be resting on her left shoulder. Resident #76's arms were bent in an upwards position and held against her chest. Resident #76 had her eyes closed and did not respond when spoken to. Interview of Unit Manager/Licensed Practical Nurse (UM/LPN) #603 and Licensed Practical Nurse (LPN) #576 on 01/09/24 at 3:51 P.M. revealed Resident #76 was nonverbal. LPN #576 stated she was not sure why Resident #76 had a pressure ulcer on her left ear, and Resident #76 tended to lay in a way that put pressure on her ear. LPN #576 stated Resident #76 always held her head down and to the left, it was very hard to change her position and it was a never ending battle. Observation of Resident #76 on 01/10/24 at 10:34 A.M. with Clinical Manager/Registered Nurse (CM/RN) #595 revealed Resident #76 was lying in bed, with her head held down and to the left, both arms were bent and held tightly against Resident #76's chest and her hands were clenched shut. Observation of Resident #76's left ear revealed she had a foam border dressing and the date the dressing was applied could not be read. CM/RN #595 removed the dressing revealing an open area on the left ear, the wound bed was red, and a small to moderate amount of yellow brown drainage was noted. CM/RN #595 stated the area was very moist and confirmed Resident #76 held her head down and to the left and it appeared to be resting on her shoulder. CM/RN #595 stated Resident #76 was contracted on both sides and she used to have a neck pillow which kind of helped, but did not help much. CM/RN #595 stated Resident #76 was not eligible for long term therapy, and was turned every two hours or as needed. Interview of Director of Rehab (DOR) #722 on 01/10/24 at 11:22 A.M. revealed Resident #76 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 9 of 28 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 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 0686 Level of Harm - Actual harm Residents Affected - Few discharged from PT on 11/06/23. Resident #76 wore a left knee brace at night and her therapy was mostly related to positioning with a body pillow for pressure ulcers on the buttocks. Resident #76 was not recommended for restorative for positioning after she was discharge from therapy because she needed repositioned often and the staff should be doing that. Resident #76 had a neck pillow but DOR #722 did not know what happened to the pillow. DOR #722 stated in July 2023 staff was educated for Resident #76's left leaning and pillow placement; however, evidence of the education could not be provided. Resident #76 had no specific therapy related to her head and neck positioning. Resident #76 had a custom wheelchair ordered which came in the third week of December, but the wheelchair had not been adjusted for Resident #76 because she had not been feeling well. Interview of Physical Therapy Assistant (PTA) #501 on 01/10/24 at 11:45 A.M. revealed Resident #76 was not currently receiving PT. When Resident #76 was receiving PT she had a personal neck pillow. The pillow was not required due to tonal abnormalities and was more for comfort. No training was completed regarding head and neck positioning because it was not necessitated. PTA #501 was not aware Resident #76 had a left ear pressure ulcer. Interview of Occupational Therapist (OT) #553 on 01/10/24 at 11:56 A.M. revealed she worked with Resident #76 for positioning but it was more for the trunk and not specifically for the neck. OT #553 confirmed the nursing staff gave Resident #76 a cervical pillow, but she did not know what happened to the pillow and did not remember the last time she saw Resident #76 with the pillow. Interview of State Tested Nursing Assistant (STNA) #511 on 01/10/24 at 12:13 P.M. revealed Resident #76 had a neck pillow, but she did not know what happened to it. STNA #511 last saw the pillow a few months ago. Interview of the Director of Nursing (DON) on 01/10/24 at 3:59 P.M. revealed Resident #76's left ear pressure ulcer was facility acquired. The DON confirmed there was no documentation of Resident #76's left ear wound prior to 11/16/23 except for the documentation on 11/12/23. The DON stated Resident #76's weekly skin check on 11/09/23 did not have documentation of a left ear skin issue. The only documentation the DON could find for Resident #76's left ear was dated 05/04/23 indicating preventative measures using Dakin's solution and Skin Prep (upon application to intact skin Skin Prep forms a protective film the help reduce friction) were initiated. Interview of STNA #505 on 01/11/24 at 1:16 P.M. confirmed Resident #76 had a neck pillow; it was a cloth pillow from the store and probably was thrown away because it was soiled. STNA #505 stated Resident #76 always laid with her head down and to the left, arms bent to her chest and her hands clenched shut. STNA #303 stated when Resident #76 was first admitted she did not lay with her head down and to the left the way it was now and her head position had gradually gotten worse. Review of the facility policy titled Skin Care and Wound Management dated 07/01/16 revealed the policy indicated to develop a care plan for pressure ulcer prevention. Monitor for consistent implementation of interventions and evaluate effectiveness of interventions. Revise intervention and or goals as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 10 of 28 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review the facility failed to ensure restorative therapy services were initiated and completed for Residents #20, #54, #80, #100 and #360 per discharge recommendations from therapy. This affected five (Residents #20, #54, #80, #100 and #360) of 14 residents who had restorative services recommended by therapy. The facility census was 111. Findings include: 1. Review of Resident #80's medical record revealed an admission date of 03/13/23 and diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting the left non-dominant side, chronic obstructive pulmonary disease, and epilepsy. Review of Resident #80's Physical Therapy Discharge summary dated [DATE] included Restorative Nursing Program/Functional Maintenance Program (RNP/FMP), to facilitate Resident #80 maintaining current level of performance and in order to prevent decline, development and instruction in the following RNPs have been completed with interdisciplinary team (IDT), Range of Motion (ROM) (active) and ROM (passive). Review of Resident #80's care plan did not reveal a care plan related to restorative services. Review of Resident #80's Therapy Referral to Restorative dated 09/04/23 revealed active range of motion (AROM), passive range of motion (PROM) of bilateral lower extremities (BLE) to prevent contractures, skin breakdown one to two times a day, five to seven times a week for 10 to 15 minutes. Review of Resident #80's medical record including aide charting from 12/01/23 through 01/09/24 did not reveal evidence restorative services recommendations were completed. Observation on 01/10/24 at 8:30 A.M. revealed Resident #80 was lying in bed on his left side with his legs bent and pulled up towards his chest. Resident #80 stated it was hard for him to move around because his legs did not want to stretch out. Interview of Director of Rehab (DOR) #722 on 01/09/24 at 3:39 P.M. revealed after a resident's therapy was completed a restorative program was recommended for each resident if it was indicated and the recommendations were given to the Director of Nursing (DON). The DON put the recommendations in the task charting in the resident's medical record for the aides to complete. Interview of the DON on 01/10/24 at 9:38 A.M. revealed the facility did not have a restorative program. The DON stated she started working in the facility in September 2023. DOR #722 gave her resident referrals for restorative therapy services when therapy was completed and the DON put the restorative tasks in the residents' medical records for the aides to complete. The DON confirmed Resident #80's medical record aide charting did not have documentation aides provided restorative services. The DON could not say if a referral was not received from DOR #722 or the referral was not put in Resident #80's aide charting. The DON confirmed Resident #80 did not receive restorative services after his discharge from therapy. Interview of State Tested Nursing Assistants (STNAs) #505 and #549 on 01/11/24 at 1:42 P.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 11 of 28 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some revealed if a resident needed restorative therapy services it was documented in the aide charting and if they were not sure if a resident needed services they would check the Point of Care (POC) aide charting. STNA #505 stated if a resident received restorative services it was for a certain amount of minutes each day. STNA #505 stated if an STNA was from an agency or new to the facility they could look in the aide charting to find out which residents needed restorative services. When asked which residents in their assignments received restorative services, STNAs #505 and #549 did not indicate Resident #80 received restorative therapy. Review of the facility's undated policy titled Restorative Program revealed it was the policy of the facility to provide resident centered care that met the psychosocial, physical and emotional needs and concerns of the residents. Safety was a primary concern for the residents, staff and visitors. The purpose of the policy was to provide direction and guidance to the clinical team to assess and implement a plan of action for resident-specific care to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable. Resident evaluation for consideration of the restorative treatment plan would include but was not limited to cognitive abilities to participate independently or with assistance, medical conditions to participate independently or with assistance. Care plan addresses but not limited to types of treatments, measurable objectives, resident goals, provided for increasing and or promotion independence to the extent clinically possible for ROM and mobility. 2. Review of Resident #100's medical record revealed an admission date of 10/28/23 and diagnoses included unspecified abnormalities of gait and mobility, weakness, and metabolic encephalopathy. Review of Resident #100's Therapy Referral to Restorative dated 11/20/23 revealed walk to dine or walking daily one to two times a day, four to five times per week for 10 to 15 minutes. Resident #100 required contact guard times one and needed to stay close to walker. Resident #100 was recommended to walk 100 to 150 feet using a front wheeled walker. Review of Resident #100's medical record including aide charting from 12/01/23 through 01/09/24 did not reveal documentation restorative services were initiated or provided. Interview of Director of Rehab (DOR) #722 on 01/09/24 at 3:39 P.M. revealed after a resident's therapy was completed a restorative program was recommended for each resident if it was indicated and the recommendations were given to the Director of Nursing (DON). The DON put the recommendations in the task charting in the resident's medical record for the aides to complete. Interview of the DON on 01/10/24 at 9:38 A.M. revealed the facility did not have a restorative program. The DON stated she started working in the facility in September 2023. The DON indicated DOR #722 gave her resident referrals for restorative therapy services when therapy was completed and the DON put the restorative tasks in the resident's medical record for the aides to complete. Follow up interview of the DON on 01/11/24 at 10:56 A.M. revealed Resident #100 was independent and not appropriate for restorative services. Interview of State Tested Nursing Assistants (STNAs) #505 and #549 on 01/11/24 at 1:42 P.M. revealed if a resident needed restorative therapy services it was documented in the aide charting and if they were not sure if a resident needed services they would check the Point of Care (POC) aide charting. STNA #505 stated if a resident received restorative services it was for a certain amount of minutes each day. STNA #505 stated if an STNA was from an agency or new to the facility they could look (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 12 of 28 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some in the aide charting to find out which residents needed restorative services. When asked which residents in their assignments received restorative services, STNAs #505 and #549 did not indicate Resident #100 received restorative therapy. Review of the facility's undated policy titled Restorative Program revealed it was the policy of the facility to provide resident centered care that met the psychosocial, physical and emotional needs and concerns of the residents. Safety was a primary concern for the residents, staff and visitors. The purpose of the policy was to provide direction and guidance to the clinical team to assess and implement a plan of action for resident-specific care to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable. Resident evaluation for consideration of the restorative treatment plan would include but was not limited to cognitive abilities to participate independently or with assistance, medical conditions to participate independently or with assistance. Care plan addresses but not limited to types of treatments, measurable objectives, resident goals, provided for increasing and or promotion independence to the extent clinically possible for ROM and mobility. 3. Review of Resident #360's medical record revealed an admission date of 09/29/23 and diagnoses included chronic obstructive pulmonary disease, unspecified abnormalities of gait and mobility. Review of Resident #360's Therapy Referral to Restorative dated 12/08/23 revealed Resident #360 was recommended transfers to chair, toilet in room, sit-to-stand (STS) transfers to front wheeled walker (FWW) one to two times per day, three to five times a week for 10 to 15 minutes. Amount of assistance was contact guard times one and safety cues for hand placement. Review of Resident #360's medical record including aide charting from 12/01/23 through 01/09/24 did not reveal documentation restorative services were initiated or provided. Interview of Director of Rehab (DOR) #722 on 01/09/24 at 3:39 P.M. revealed after a resident's therapy was completed a restorative program was recommended for each resident if it was indicated and the recommendations were given to the Director of Nursing (DON). The DON put the recommendations in the task charting in the resident's medical record for the aides to complete. Interview of the DON on 01/10/24 at 9:38 A.M. revealed the facility did not have a restorative program. The DON stated she started working in the facility in September 2023. The DON indicated DOR #722 gave her resident referrals for restorative therapy services when therapy was completed and the DON put the restorative tasks in the resident's medical record for the aides to complete. Follow up interview of the DON on 01/11/24 at 10:56 A.M. revealed Resident #360 was continent, used a wheelchair to go to the bathroom and she did not feel he was appropriate for restorative services. Interview of State Tested Nursing Assistants (STNAs) #505 and #549 on 01/11/24 at 1:42 P.M. revealed if a resident needed restorative therapy services it was documented in the aide charting and if they were not sure if a resident needed services they would check the Point of Care (POC) aide charting. STNA #505 stated if a resident received restorative services it was for a certain amount of minutes each day. STNA #505 stated if an STNA was from an agency or new to the facility they could look in the aide charting to find out which residents needed restorative services. When asked which residents in their assignments received restorative services, STNAs #505 and #549 did not indicate Resident #360 received restorative therapy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 13 of 28 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the facility's undated policy titled Restorative Program revealed it was the policy of the facility to provide resident centered care that met the psychosocial, physical and emotional needs and concerns of the residents. Safety was a primary concern for the residents, staff and visitors. The purpose of the policy was to provide direction and guidance to the clinical team to assess and implement a plan of action for resident-specific care to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable. Resident evaluation for consideration of the restorative treatment plan would include but was not limited to cognitive abilities to participate independently or with assistance, medical conditions to participate independently or with assistance. Care plan addresses but not limited to types of treatments, measurable objectives, resident goals, provided for increasing and or promotion independence to the extent clinically possible for ROM and mobility. 4. Review of Resident #20's medical record revealed an admission date of 09/11/20 and diagnoses included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, contracture of muscle right and left hands, and need for assistance with personal care. Review of Resident #20's Physical Therapy Discharge summary dated [DATE] included Restorative Nursing Program/Functional Maintenance Program (RNP/FMP), to facilitate Resident #20 maintaining current level of performance and in order to prevent decline, development and instruction in the following RNPs have been completed with the interdisciplinary team (IDT): bed mobility and range of motion (ROM), active. Review of Resident #20's Wellness/Restorative Referral Form dated 05/15/23 included to increase, maintain bilateral lower extremity (BLE) knee, ankle ROM. Exercises to improve BLE mobility and strength. This was to be completed two to three times per day, six to seven times a week for 10 to 15 minutes. The exercises could be completed by one staff person, and the packet was in Resident #20's room. The exercises included knee, hip, ankle active and passive ROM. Review of Resident #20's care plan revised 05/30/23 did not reveal a care plan related to restorative services. Review of Resident #20's medical record including aide charting from 12/01/23 through 01/09/24 did not reveal evidence restorative services recommendations were completed. Interview of Director of Rehab (DOR) #722 on 01/09/24 at 3:39 P.M. revealed after a resident's therapy was completed a restorative program was recommended for each resident if it was indicated and the recommendations were given to the Director of Nursing (DON). The DON put the recommendations in the task charting in the resident's medical record for the aides to complete. Interview of the DON on 01/10/24 at 9:38 A.M. revealed the facility did not have a restorative program. The DON stated she started working in the facility in September 2023. The DON indicated DOR #722 gave her resident referrals for restorative therapy services when therapy was completed and the DON put the restorative tasks in the resident's medical record for the aides to complete. Interview of State Tested Nursing Assistants (STNAs) #505 and #549 on 01/11/24 at 1:42 P.M. revealed if a resident needed restorative therapy services it was documented in the aide charting and if they were not sure if a resident needed services they would check the Point of Care (POC) aide charting. STNA #505 stated if a resident received restorative services it was for a certain amount of minutes each day. STNA #505 stated if an STNA was from an agency or new to the facility they could look (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 14 of 28 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some in the aide charting to find out which residents needed restorative services. When asked which residents in their assignments received restorative services, STNAs #505 and #549 did not indicate Resident #20 received restorative therapy. Review of the facility's undated policy titled Restorative Program revealed it was the policy of the facility to provide resident centered care that met the psychosocial, physical and emotional needs and concerns of the residents. Safety was a primary concern for the residents, staff and visitors. The purpose of the policy was to provide direction and guidance to the clinical team to assess and implement a plan of action for resident-specific care to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable. Resident evaluation for consideration of the restorative treatment plan would include but was not limited to cognitive abilities to participate independently or with assistance, medical conditions to participate independently or with assistance. Care plan addresses but not limited to types of treatments, measurable objectives, resident goals, provided for increasing and or promotion independence to the extent clinically possible for ROM and mobility. 5. Review of Resident #54's medical record revealed an admission date of 11/03/23 and diagnoses included multiple sclerosis, unspecified abnormalities of gait and mobility, and weakness. Review of Resident #54's Therapy Referral to Restorative included right knee brace four to five hours daily, hip abduction brace daily one time a day, six to seven times a week for four hours. Amount of assistance was one person to don brace. Review of Resident #54's medical record including aide charting from 12/01/23 through 01/09/24 did not reveal documentation restorative services were initiated or provided Interview of Director of Rehab (DOR) #722 on 01/09/24 at 3:39 P.M. revealed after a resident's therapy was completed a restorative program was recommended for each resident if it was indicated and the recommendations were given to the Director of Nursing (DON). The DON put the recommendations in the task charting in the resident's medical record for the aides to complete. Interview of the DON on 01/10/24 at 9:38 A.M. revealed the facility did not have a restorative program. The DON stated she started working in the facility in September 2023. The DON indicated DOR #722 gave her resident referrals for restorative therapy services when therapy was completed and the DON put the restorative tasks in the resident's medical record for the aides to complete. Interview of State Tested Nursing Assistants (STNAs) #505 and #549 on 01/11/24 at 1:42 P.M. revealed if a resident needed restorative therapy services it was documented in the aide charting and if they were not sure if a resident needed services they would check the Point of Care (POC) aide charting. STNA #505 stated if a resident received restorative services it was for a certain amount of minutes each day. STNA #505 stated if an STNA was from an agency or new to the facility they could look in the aide charting to find out which residents needed restorative services. When asked which residents in their assignments received restorative services, STNAs #505 and #549 did not indicate Resident #54 received restorative therapy. Review of the facility's undated policy titled Restorative Program revealed it was the policy of the facility to provide resident centered care that met the psychosocial, physical and emotional needs and concerns of the residents. Safety was a primary concern for the residents, staff and visitors. The purpose of the policy was to provide direction and guidance to the clinical team to assess and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 15 of 28 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete implement a plan of action for resident-specific care to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable. Resident evaluation for consideration of the restorative treatment plan would include but was not limited to cognitive abilities to participate independently or with assistance, medical conditions to participate independently or with assistance. Care plan addresses but not limited to types of treatments, measurable objectives, resident goals, provided for increasing and or promotion independence to the extent clinically possible for ROM and mobility. Event ID: Facility ID: 365771 If continuation sheet Page 16 of 28 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review the facility failed to provide care and services to ensure Resident #59 was provided incontinence care timely and Resident #80's urine specimen was sent to the lab timely and urinary tract infection treated promptly. This affected one resident (Resident #59) of three residents reviewed for incontinence and one resident (Resident #80) of three residents reviewed for urinary tract infections. The facility census was 111. Findings include: 1. Review of Resident #59's medical record revealed an admission date of 02/24/21 and diagnoses included cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, type two diabetes mellitus with hyperglycemia, and need for assistance with personal care. Review of Resident #59's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #59 was cognitively intact. Resident #59 was dependent on facility staff for toileting and personal hygiene. Review of Resident #59's care plan dated 03/05/21 revealed Resident #59 had incontinence of bowel and bladder at times. Resident #59 would remain free of skin breakdown due to incontinence. Interventions included check Resident #59 for incontinence, wash, rinse, and dry perineum and change clothing as needed after incontinence episodes; Resident #59 used disposable incontinence briefs and change as needed, and Resident #59 preferred double briefs. Interview of Resident #59 on 01/08/24 at 9:46 A.M. revealed Resident #59 had not had her incontinence brief changed since last night. Resident #59 stated it often happened that her incontinence brief was not changed timely and sometimes it was not changed until after lunch was served. Resident #59 stated it was uncomfortable lying in urine. Observation of State Tested Nursing Assistants (STNAs) #549 and #723 providing incontinence care for Resident #59 on 01/08/24 at 10:18 A.M. revealed Resident #59 was wearing two incontinence briefs which were saturated with urine. Resident #59's sheet, and reusable chux pad were wet with urine and an outline of dried yellow urine could be seen around the wet urine on both the sheet and reusable chux pad. Resident #59 stated she was not changed timely, her incontinence brief was not changed often enough and that was why she requested two incontinence briefs. STNAs #549 and #723 confirmed Resident #59's two incontinence briefs were saturated with urine and her sheet and chux pad were wet with urine and also had dried urine on them. STNAs #549 and #723 stated the night shift aides did not always change residents timely and it depended on what aides were working. STNA #549 stated some night shift aides changed residents timely and some did not. Resident #59's bottom and top of posterior thighs were a little reddened, and there was no skin breakdown. Review of Resident #59's aide charting revealed Resident #59's incontinence brief was changed on 01/07/24 at 11:27 P.M. and there was no further evidence Resident #59's incontinence brief was changed until 01/08/24 at 1:14 P.M. Interview of the Director of Nursing (DON) on 01/11/24 at 7:09 A.M. revealed typically it would not be alright for a resident to have two incontinence briefs on, but if it was their preference it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 17 of 28 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few would be allowed. The DON was not aware Resident #59 requested two incontinence briefs because she was not changed timely and would look into the matter. Review of the facility's undated policy titled Routine Resident Care revealed it was the policy of the facility to promote resident centered care by attending to the total medical, nursing, physical, emotional, mental, social and spiritual needs and honor resident lifestyle preferences while in the care of the facility. The facility would provide routine daily care by a certified nursing assistant with specialized training in rehabilitation, restorative care under the supervision of a licensed nurse including but not limited to toileting, providing care for incontinence with dignity and maintaining skin integrity. 2. Review of Resident #80's medical record revealed an admission date of 03/13/23 and diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting the left non-dominant side, chronic obstructive pulmonary disease, and epilepsy. Review of Resident #80's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #80 had moderate cognitive impairment. Resident #80 was dependent on staff for Activity of Daily Living (ADL). Review of Resident #80's care plan dated 03/24/23 revealed Resident #80 was incontinent of urine related to impaired cognition, impaired mobility, neurological conditions. Resident #80 would decrease frequency of incontinence episodes. Interventions included to observe for signs and symptoms of a urinary tract infection such as pain, burning, cloudiness, fever, altered mental status, foul smelling urine etcetera. Observe and report to medical provider if identified. Review of Resident #80's progress notes dated 12/22/23 at 10:26 A.M. revealed Resident #80 was having hematuria (blood in urine). The Nurse Practitioner was notified and new orders were given for a STAT (immediate) Complete Blood Count with differential, Basic Metabolic Panel, and urinalysis, culture and sensitivity. The Nurse Practitioner was made aware the urinalysis and urine culture and sensitivity could not be collected until 12/26/23 due to the holiday. Review of Resident #80's physician orders from 12/22/23 through 12/28/23 did not reveal orders for a urinalysis or a urine culture and sensitivity. Review of Resident #80's physician orders dated 12/28/23 revealed urine for urinalysis and urine culture and sensitivity to be collected for pickup on 12/29/23. Review of Resident #80's progress notes from 12/23/23 through 01/02/24 did not reveal further documentation related to the appearance of Resident #80's urine or symptoms of a urinary tract infection. The progress notes did not have documentation regarding Resident #80's orders for a urinalysis and urine culture and sensitivity. Review of Resident #80's progress notes dated 01/02/24 at 12:51 P.M. revealed an order was placed for a urinalysis and a urine culture and sensitivity to be completed on 01/03/24. Review of Resident #80's physician orders dated 01/02/24 revealed an order for a urinalysis and a urine culture and sensitivity to be collected for lab pickup on 01/03/24. Review of Resident #80's progress notes dated 01/02/24 at 3:10 P.M. revealed a urine specimen was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 18 of 28 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 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 0690 collected via straight catheter for lab pick up on 01/03/24. Level of Harm - Minimal harm or potential for actual harm Review of Resident #80's progress notes dated 01/04/24 at 12:25 P.M. revealed Resident #80's urinalysis results showed white blood cells greater than 50, culture and sensitivity pending. Residents Affected - Few Review of Resident #80's Lab Results Report revealed Resident #80's urinalysis with culture and sensitivity was reported on 01/07/24 at 2:51 P.M. The Report included Resident #80's urine had greater than 100,000 colony forming units per milliliter of Escherichia Coli (E Coli). Review of Resident #80's progress notes dated 01/08/24 at 2:47 P.M. revealed Resident #80's urinalysis was reviewed by the Nurse Practitioner and new orders for Cipro (antibiotic) 250 milligrams (mg) by mouth two times a day for three days for urinary tract infection. Review of Resident #80's physician orders dated 01/08/24 at 2:56 P.M. revealed Ciprofloxacing HCl Oral tablet 250 mg, give 250 mg by mouth every morning and at bedtime for E Coli for three days. Interview of Clinical Manager/Registered Nurse (CM/RN) #595 on 01/09/24 at 4:27 P.M. revealed she was the Infection Preventionist for the facility. CM/RN #595 revealed when a resident (not hospice)had symptoms of a urinary tract infection the Nurse Practitioner was notified and orders were obtained for a urinalysis and culture and sensitivity. The specimen was usually collected within 48 hours. Pain with urination, change in color or smell, and blood in urine were all symptoms of a urinary tract infection. If the nurse was not able to obtain the urine specimen within 48 hours for reasons like she was not able to straight cath the resident, the resident was incontinent, or the resident refused then the Nurse Practitioner or physician would be notified. Interview of Licensed Practical Nurse (LPN) #584 on 01/10/24 at 8:53 A.M. revealed on 12/22/23 an aide told her Resident #80 had blood in his urine. LPN #584 contacted the Nurse Practitioner and received an order for a urinalysis and culture and sensitivity. LPN #584 could not obtain the urine specimen right away because the lab was closed for the Christmas holiday and Resident #80's urinalysis and culture and sensitivity would have to wait until 12/26/23 to be collected. The lab would not collect a STAT urine on the weekends or holidays. LPN #584 stated Resident #80 was for sure straight cathed on 12/26/23 because she was told on 12/27/24 that a urinalysis was pending. Interview of the Director of Nursing (DON) on 01/10/24 at 1:27 P.M. revealed an attempt to collect Resident #80's urine was made on 12/28/23's night shift for pick up on 12/29/23. The attempt to collect Resident #80's urine was unsuccessful because enough urine could not be collected from the straight cath. The DON stated Resident #80's urine was unable to be collected until 01/02/24 because the lab would not take urine specimens on any weekend. The DON did not see any documentation in Resident #80's progress notes regarding why the urine specimen was not collected before 01/02/24 including if the Nurse Practitioner or Physician was informed that the urine could not be collected. The DON was off work on those days and did not know why the urine was not collected sooner. The DON stated she would think the antibiotics should have been started before 01/08/24. The urinalysis results were reported on 01/03/24 and the urine culture and sensitivity results were reported on 01/07/24. Review of the facility lab STAT (immediately) Test List dated 10/2022 included urinalysis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 19 of 28 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure monitoring of residents on oxygen for complications such as skin integrity issues, failed to ensure protective foam was applied to oxygen tubing to protect skin integrity, and failed to ensure current physician orders for the use of oxygen. This affected four (#6, #22, #40 and #45) of five residents observed for oxygen therapy. The facility census was 110. Residents Affected - Some Findings include: 1. Review of Resident #6's medical records revealed an admission date of 08/29/23. Diagnoses included respiratory failure and chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had intact cognition. Review of the care plan dated 12/03/23 revealed Resident #6 had COPD. Interventions included provide oxygen therapy as ordered and change oxygen tubing per policy. Review of current physician orders for January 2024 revealed no orders related to oxygen therapy. Interview on 01/08/24 at 11:07 A.M. with Resident #6 revealed she wore her oxygen continuously and she had a sore area to the back of her right ear. Resident #6 stated she had requested foam ear pieces to be placed on her oxygen tubing over a month ago, however she had not been given them. Observation at time of interview revealed a reddened area to the back of Resident #6's right ear with a small amount of blood around the reddened area. Interview on 01/09/24 at 3:03 P.M. with Resident #6 revealed she still did not have any foam placed on her oxygen tubing. At time of interview Registered Nurse (RN) #595 entered Resident #6's room and confirmed no foam on the oxygen tubing and Resident #6 had a reddened area to her right ear. RN #595 stated foam should be placed on the oxygen tubing for residents who wore continuous oxygen. 2. Review of Resident #40's medical records revealed an admission date of 01/28/23. Diagnoses included chronic obstructive pulmonary disease (COPD). Review of care plan dated 09/22/23 revealed Resident #40 had COPD. Interventions included administer oxygen as ordered and change oxygen tubing per policy. Review of current physician orders for January 2024 revealed Resident #40 was ordered oxygen at four liters per minute. Observation on 01/09/24 at 3:20 P.M. revealed Resident #40 was in a wheelchair in his room. Resident #40 had toilet tissue wrapped around his oxygen tubing near his ear. Interview with Resident #40 at time of observation revealed the oxygen tubing had irritated his ears and he had asked the staff to place foam to the tubing over a month ago. Resident #40 further stated he had cut a piece of the oxygen tubing a long time ago (unable to state specific timeframe) that was placed in his nose because it had irritated the inside of his nose and caused a blister. Observation revealed the prong intended to sit inside the left nostril had been cut. LPN #576 confirmed the observations and stated Resident #40 should have had foam dressing to his oxygen tubing to protect the skin behind his ears and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 20 of 28 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 his oxygen tubing should have been changed once Resident #40 had cut the nasal prong off. Level of Harm - Minimal harm or potential for actual harm 3. Review of Resident #45's medical records revealed an admission date of 04/24/23. Diagnoses included asthma. Residents Affected - Some Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had intact cognition. Review of Resident #45's care plan dated 10/12/23 revealed Resident #45 had asthma. Interventions included administer oxygen as ordered and change oxygen tubing per policy. Review of current physician orders for January 2024 revealed no orders regarding oxygen therapy. Observation on 01/09/24 at 3:14 P.M. revealed Resident #45 was resting in bed. Further observation revealed no foam to Resident #45's oxygen tubing. At the time of the observation, Licensed Practical Nurse (LPN) #576 confirmed there was no protective foam on the oxygen tubing to protect the skin behind Resident #45's ears. LPN #576 stated Resident #45 should have had foam placed on the oxygen tubing. 4. Review of Resident #22's medical records revealed an admission date of 07/29/22. Resident #22 had a diagnosis of chronic obstructive pulmonary disease (COPD). Review of the care plan dated 12/18/23 revealed Resident #22 had COPD. Interventions included administer oxygen as ordered and change oxygen tubing per policy. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had intact cognition. Review of current physician orders for January 2024 revealed no orders related to oxygen therapy. Observation on 01/09/24 at 3:17 P.M. revealed Resident #22 was up in a wheelchair in her room. Further observation revealed no foam to Resident #22's oxygen tubing. At the time of the observation, Licensed Practical Nurse (LPN) #576 confirmed there was no protective foam on the oxygen tubing to protect the skin behind Resident #22's ears. LPN #576 stated Resident #22 should have had foam placed on the oxygen tubing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 21 of 28 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of Resident #59's medical record revealed an admission date of 02/24/21 and diagnoses included cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, type two diabetes mellitus with hyperglycemia, and need for assistance with personal care. Review of Resident #59's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #59 was cognitively intact. Resident #59 was dependent on facility staff for toileting and personal hygiene. Review of Resident #59's care plan dated 03/05/21 revealed Resident #59 had incontinence of bowel and bladder at times. Resident #59 would remain free of skin breakdown due to incontinence. Interventions included check Resident #59 for incontinence, wash, rinse, and dry perineum and change clothing as needed after incontinence episodes; Resident #59 used disposable incontinence briefs and change as needed, and Resident #59 preferred double briefs. Interview on 01/08/24 at 9:49 A.M. revealed Resident #59 did not always get out of bed, even though she would like to get out of bed. Resident #59 often chose not to get out of bed because when she did agree to get out of bed the State Tested Nurse Aides (STNAs) did not put her back to bed when she was ready. Resident #59 stated the STNAs told her she had to wait and the STNAs on the next shift would put her to bed. Resident #59 indicated she waited long periods of time before she was assisted into her bed. Observation of STNAs #549 and #723 providing incontinence care for Resident #59 on 01/08/24 at 10:18 A.M. revealed Resident #59 was wearing two incontinence briefs which were saturated with urine. Resident #59's sheet, and reusable chux pad were wet with urine and an outline of dried yellow urine could be seen around the wet urine on both the sheet and reusable chux pad. Resident #59 stated she was not changed timely, her incontinence brief was not changed often enough and that was why she requested two incontinence briefs. STNAs #549 and #723 confirmed Resident #59's two incontinence briefs were saturated with urine and her sheet and chux pad were wet with urine and also had dried urine on them. STNAs #549 and #723 stated the night shift aides did not always change residents timely and it depended on what aides were working. STNA #549 stated some night shift aides changed residents timely and some did not. Resident #59's bottom and top of posterior thighs were a little reddened, and there was no skin breakdown. Interview on 01/11/24 at 1:42 P.M. of STNA #549 revealed staffing could be better. STNA #549 stated the residents on the long term care hall, which is where she was usually assigned, required a lot of care and often two people were needed for transfers and to provide care for the residents. STNA #549 stated residents often had to wait for their care because she had to search for another STNA or nurse to help her and it took time to find someone. STNA #549 stated charting often did not get completed because she was too busy caring for residents. 6. Observation on 01/08/24 at 2:14 P.M. of Resident #105 revealed he was sitting in a wheelchair in the entrance to his room and asked the surveyor to put him back to bed. Resident #105 resided in a room towards the end of the hall and there were no staff in the hall or at the nursing station. Resident #105 stated a little louder than the first time he asked, please put me back to bed, I am tired. There were still no staff in sight and the surveyor told Resident #105 she would find a staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 22 of 28 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many person to assist him into bed. Resident #105 stated even louder please, please put me back to bed. Resident #105 said please help me. Observation of Resident #105's bed revealed the mattress was bare and did not have sheets or bed linens on it. The surveyor searched for a few minutes and found State Tested Nursing Assistant (STNA) #585 to help Resident #105. STNA #585 stated Resident #105 was not in her assignment, but she would put him back to bed. STNA #585 had to find sheets and a blanket and make the bed before she could help Resident #105 to lay down. Based on observation, record review, and interviews with staff and residents the facility failed to have sufficient staffing. This affected Residents #6, #10, #50, #36, #54, #59 and #105 and had the potential to affect all residents. The census was 111. Findings include: 1. Interview on 01/08/24 at 11:01 A.M. with Resident #6 revealed she waited over two hours for her call light to be answered on occasions. Interview on 01/08/24 at 10:34 A.M. with Resident #10 revealed she did not get her medications in a timely manner most days, it was inconsistent. She stated she did not get regular showers or bed baths. Interview on 01/08/24 at 2:20 P.M. with Resident #50 regarding staffing revealed They need more. When are they going to close this place? Interview on 01/08/24 at 2:41 P.M. with Resident #36 revealed he was told on more than one occasion not to put his call light on during meal tray pass. He also stated he made his own bed because staff did not get to it timely. Interview on 01/09/24 at 7:46 A.M. with Resident #54 revealed staff had not provided timely assistance into bed. Resident #54 stated she had been left in her wheelchair for more than five hours on occasions. 2. Observations throughout the survey from 01/08/24 through 01/11/24 revealed excessive call lights use and State Tested Nurse Aides (STNAs) appeared to be rushed and overwhelmed. Residents were observed in the halls looking for staff assistance. Interview on 01/10/24 at 2:15 P.M. with STNA #624 revealed concerns related to staffing. STNA #624 stated he was aware of residents on the C and D hall that had not received timely care that included incontinence care and showers. STNA #624 stated call lights had not been answered timely on occasions due to not enough staff. Interviews on 01/10/24 from 4:00 P.M. through 500 P.M. with STNA #505, STNA #539 and STNA #549 revealed they had up to 12 to 17 residents on their assignment at times. They stated there were many residents who required mechanical lifts and the acuity levels of the residents on Units C and D was high. STNA #505 stated charting did not get completed because they did not have time. Interview on 01/11/24 at 11:40 A.M. with STNA #559 revealed concerns related to staffing. STNA #559 stated there was not enough staff to provide timely incontinence care on occasions. STNA #559 stated residents had to wait long periods of time for their call lights to be answered and sometimes it took 45 minutes or longer to answer call lights. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 23 of 28 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the assignment sheets for Units C and D revealed there were 23 residents who needed assistance with transfers via a mechanical lift requiring two staff members. Interview with Licensed Practical Nurse #603 on 01/10/24 at 5:10 P.M. verified the number of residents on the C and D units needing mechanical lifts. 3. Review of Resident #54's medical records revealed an admission date of 11/03/23. Diagnoses included Multiple Sclerosis and need for personal care assistance. Review of Resident #54's care plan dated 11/03/23 revealed resident had self care deficits. Interventions included two or more staff for toileting, transfers and bathing. Review of Resident #54's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had intact cognition. Resident #54 was dependent for toileting and transfers. Interview on 01/10/23 at 11:06 A.M. with Resident #54 revealed she had requested to be out of bed earlier in the morning and stated State Tested Nurse Aide (STNA) #585 had told her she would assist her out of bed prior to lunch. Interview on 01/10/24 at 2:24 P.M. with STNA #585 revealed she was aware of staff who not provided timely assistance for Resident #54's transfers. STNA #585 stated there had been staff that refused to assist Resident #54 out of bed and also had left Resident #54 up her wheelchair for long periods of time. STNA #585 stated she was aware Resident #54 preferred to be out of bed prior to lunch, however she had not had time before the end of her shift at 2:30 P.M. to assist Resident #54 out of bed. STNA #585 stated there was not enough staff to provide timely care on occasions and stated at times she was lucky to be able to perform two rounds of incontinence care during her shifts. STNA #585 said the residents on the C and D hall had a hight acuity level and there was not enough staff to provide timely care to those residents. Observation on 01/10/24 at 2:40 P.M. revealed Registered Nurse (RN) #595 and Licensed Practical Nurse (LPN) #603 assisting Resident #54 out of bed via a Hoyer (mechanical) lift. Interview with RN #595 and LPN #603 at time of observation revealed they were aware Resident #54 preferred to out of bed prior to lunch time and were unable to provide information regarding why Resident #54 had not been assisted out of bed prior to the observation. 4. Review of the medical record for Resident #10 revealed an admission date of 04/13/23. Diagnoses included chronic kidney disease, type two diabetes mellitus and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #10 revealed she was dependent for showers. Review of Resident #10's shower sheets revealed she received bed baths on 12/11/23, 12/18/23, 01/04/24 and 01/08/24. Interview on 01/10/24 at 5:10 P.M. with Licensed Practical Nurse #603 revealed there was no other documentation regarding showers/bed baths for Resident #10. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 24 of 28 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and interview the facility failed to ensure expired medications were discarded. This had the potential to affect 51 residents residing on the A and C halls. Facility census was 111. Findings include: Observation of medication administration on 01/09/23 at 10:02 A.M. with Licensed Practical Nurse (LPN) #576 for Resident #51 revealed LPN #576 obtained a bottle of aspirin 81 milligrams (mg). Further observation revealed the aspirin had an expiration date of December 2023. LPN #576 confirmed the expiration date and stated she did not check the expiration date prior to preparing the medications. Further observation of the medication cart with LPN #576 revealed a bottle of oyster shell supplement with an expiration date of November 2023 and multiple loose unidentifiable pills in various areas of the drawers. LPN #576 confirmed the loose pills and expired medications and stated she did not check the medication cart and was not aware of who was responsible for checking the carts. Observation of another medication cart on 01/09/23 with Registered Nurse (RN) #529 revealed a bottle of vitamin C with an expiration date of October 2023, a bottle of Optium (vitamin supplement) with an expiration date of December 2023 and aspirin 325 mg with an expiration date of August 2023. RN #529 verified the expired medications and stated she did not check the expiration dates prior to administering medications. Review of facility's undated policy titled Stock Medications revealed medications were to be discarded when out of date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 25 of 28 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the Centers for Disease Control (CDC) Considerations for Preventing Spread of Covid-19, the facility failed to maintain proper infection control procedures to prevent the spread of infection. This affected four residents (#7, #42, #65 and #88) and had the potential to affect eight residents (#17, #26, #42, #47, #52, #56, #71 and #102) residing on the D hall. The facility census was 110. Residents Affected - Some Findings include: 1. Review of Resident #42's medical records revealed an admission date of 04/22/23. Diagnoses included respiratory failure and chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had intact cognition. Resident #15 required set up assistance with eating and was dependent with toileting. Review of physician orders dated 01/05/24 revealed Resident #42 was on droplet precautions related to Covid positive results. Observation on 01/08/24 at 8:40 A.M. revealed signs posted outside of Resident #42's room that indicated Resident #42 was on isolation precautions and gown, gloves, mask and face shield were required prior to entering the room. Further observation revealed State Tested Nursing Assistant (STNA) #527, who was wearing a surgical mask, don a gown and gloves prior to entering Resident #42's room. Observation of the isolation bin located outside of Resident #42's room revealed the bin only contained gowns. Interview with STNA #42 upon exiting Resident #42's room revealed Resident #42 was Covid positive. STNA #42 confirmed she did not wear an N95 mask or eye protection while in Resident #42's room. STNA #527 was unaware a N95 was required when entering Resident #42's room. STNA #527 confirmed the isolation bin located outside of the room did not contain masks or face shields and stated surgical masks were located at the nurses station and she was unaware of where to locate a N95 mask or face shield. Interview on 01/10/24 at 12:45 P.M. with Registered Nurse (RN) #595 revealed she was the infection preventionist. RN #595 confirmed Resident #42 was Covid positive and stated staff were required to wear gown, gloves, N95 mask and eye protection prior to entering a Covid positive room. Review of facility policy titled Precaution and Transmission Based Precautions, revised 06/25/21 revealed staff were required to wear N95 mask, face shield, gown and gloves during care of Covid positive residents. Review of the CDC guidance updated 11/30/23 revealed recommended infection prevention and control practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection includes health care providers who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH approved particulate respirator with N95 filters or higher, gown, gloves, or a face shield that covers the front and sides of the face. 2. Observation of wound care for Resident #88 with Licensed Practical Nurse (LPN) #569 and the Wound Nurse Practitioner (WNP) on 01/09/24 at 2:20 P.M. revealed Resident #88 had a wound to his sacrum (tailbone) area and wounds to his left foot. LPN #569 and WNP did not disinfect the bedside table (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 26 of 28 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some before placing the wound care supplies onto the bedside table. LPN #569 and WNP cleansed Resident #88's sacral wound and did not change their gloves prior to placing a clean dressing to the wound. LPN #569 and WNP proceeded to cleanse Resident #88's wounds on his left foot, wearing the same gloves that were worn during care of the sacral wound. LPN #569 and WNP cleansed Resident #88's foot wound and did not change their gloves prior to placing a new dressing to the foot wounds. Interview with LPN #569 and the WNP, after completion of wound care, confirmed they did not disinfect the beside table prior to placing wound supplies on it and they did not change their gloves or complete hand hygiene during wound care. 3. Observation of incontinence care for Resident #65 with State Tested Nurse Aide (STNA) #585 on 01/10/24 at 10:48 A.M. revealed Resident #65 was incontinent of stool. STNA #585 provided Resident #65 with incontinence care and did not remove her soiled gloves or wash her hands prior to assisting Resident #65 with dressing. Interview with STNA #585 on 01/10/24 at 11:57 A.M. confirmed STNA #585 did not change her soiled gloves after providing incontinence for Resident #65 stating I guess I never thought of doing that. 4. Observation of incontinence care for Resident #7 with State Tested Nurse Aide (STNA) #585 on 01/10/24 at 11:57 A.M. revealed Resident #7 was incontinent of urine. STNA #585 provided Resident #7 with incontinence care and did not remove her soiled gloves or wash her hands prior to applying lotion to Resident #7's arms and legs. Interview with STNA #585 confirmed she did not change her soiled gloves after providing incontinence care for Residents #7 and stated I guess I never thought of doing that. After the incontinence care was completed for Resident #7, Licensed Practical Nurse (LPN) #576 entered Resident #7's room to administer insulin. LPN #576 administered the insulin into the subcutaneous tissue of Resident #7's abdomen without wearing gloves. Interview with LPN #576 at time of observation revealed she should have worn gloves during insulin administration but she had forgotten. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 27 of 28 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 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copley Health Center 155 Heritage Woods Drive Copley, OH 44321 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 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and interview the facility failed to provide a clean and sanitary environment. This affected Resident #18. The facility census was 110. Residents Affected - Few Findings include: Observation on 01/10/24 at 11:15 A.M. revealed Resident #18 was in bed and non verbal. Further observation revealed a tube feeding pole next to the resident's bed that had dried tube feeding formula on it. Dried tube feeding formula was also observed on the wall behind the pole and underneath the pole. Further observation revealed a towel underneath the tube feeding pole that had dried tube feed and gnats on it. At time of observation Licensed Practical Nurse (LPN) #576 entered Resident #18's room and confirmed the observation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 28 of 28