Inspection·November 21, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and he was self-administering the aerosol treatment. LPN #255 revealed he must have had some left from this morning. LPN #255 shut off the aerosol machine and added a new three ml vial of Ipratropium-Albuterol solution to the remaining solution in the aerosol cup, turned the aerosol machine back on and handed the mouthpiece to Resident #32 who continued the treatment. Observation revealed LPN #255 did not assess Resident #32's lung status prior to administration. LPN #255 confirmed she did not observe to see if Resident #32 completed the morning aerosol dose. Review of the Medication Administration Record (MAR) for Resident #32 revealed on 11/21/24 the aerosol treatments were scheduled for 6:00 A.M., 2:00 P.M. and 10:00 P.M.; As needed doses were also scheduled but not signed on 11/21/24 as used. The last dose provided prior to 11/21/24 at 11:48 A.M. was 11/21/24 at 6:00 A.M. 2. Record review for Resident #113 revealed an admission date of 09/19/24. Diagnosis included chronic obstructive pulmonary disease, emphysema, muscle weakness and need for assistants with personal care. Review of the Medicare five-day MDS revealed Resident #113 was cognitively intact. Resident #113 required partial moderate assistants with eating and oral hygiene. Resident #113 had medically complex conditions including COPD. Review of the care plan for Resident #113 dated 09/20/24 revealed Resident #113 had chronic obstructive pulmonary disease and emphysema with shortness of breath while lying flat. Interventions included to administer medications per the physician orders. Review of the physician orders for Resident #113 dated 10/29/24 revealed an order to administer Ipratropium-Albuterol Solution 0.5-2.5 (3) milligram (mg) per three milliliters (ml) one vial inhale orally three times a day. Observation on 11/20/24 at 10:10 A.M. revealed Resident #113 was lying in bed. Observation revealed Resident #113 had an aerosol tubing and mouthpiece lying on the edge of the bed, unbagged. Resident 3113 revealed staff never placed his aerosol tubing in a bag. Observation on 11/21/24 at 10:36 A.M. revealed Resident #113 was lying in bed. Resident #113's medicine cup connected to the tubing still had a clear liquid in the cup. The tubing, cup and mouthpiece were lying on the bed. Resident #113 revealed he was taking a break from the aerosol treatment. Observation of medication administration with LPN #255 on 11/21/24 at 11:53 A.M. revealed Resident #113 still had a clear liquid in the cup of the aerosol tubing. The tubing, cup and mouthpiece was still unbagged. LPN #255 verified the liquid in the aerosol cup was the remainder of the morning dose. LPN #255 confirmed she did not observe to see if Resident #113 completed the morning aerosol dose. Resident #113 dropped the aerosol tubing and mask on the floor, LPN #255 obtained a new mask, placed the new Ipratropium-Albuterol Solution dose in the aerosol med cup and initiated the aerosol treatment. Observation revealed LPN #255 did not assess Resident #113's lung status prior to administration. LPN #255 confirmed she worked on different days throughout the facility and had worked with all residents residing in the facility. Review of the MAR for Resident #113 revealed on 11/21/24 the aerosol treatments were scheduled for A.M., afternoon and HS; The last dose provided prior to 11/21/24 at 11:53 A.M. was 11/21/24 A.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 11/20/24 at 11:58 A.M. with Registered Nurse Unit Manager #274 revealed prior to administering an aerosol treatment, the nurse was required to check the residents pulse ox, check lung sounds pre and post treatment. The nurse was required to stay with the resident until the treatment was complete. Interview on 11/20/24 at 12:02 P.M. with Director of Nursing (DON) revealed nurses were to stay within the area while the resident completed the aerosol treatment and check on the resident frequently to assure the treatment was completed then nurses were to clean the aerosol medicine cup and mouthpiece between uses and keep stored in a plastic bag when not in use to prevent contamination. If the resident did not complete the aerosol treatment, the nurse would notify the physician and never add an additional dose. Review of the facility policy titled, Nebulizer Treatments undated revealed a nebulizer was a medication delivery system that creates a fine mist or aerosol that is directly inhaled for delivery of the medication to the bronchial tree. Collect data for respirations, pulse and breath sounds pretreatment. Place medication in the dispensing container per provider/physician order. Assist resident to administer the treatment including correct holding of the nebulizer dispenser and placing mouth on mouthpiece sealing with closed lips and breathing through mouth. Turn machine on, nurse to remain in close vicinity during treatment. Repeat collection of data for respirations, pulse and lung sounds post treatment. This deficiency represents non-compliance investigated under Complaint Number OH00159291. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2024 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, and record review, the facility failed to assure infection control was maintained during and after aerosol treatments for Resident #32 and #113. This affected two residents (Resident #32 and Resident #113) of three residents reviewed for infection control. Residents Affected - Few Findings include: 1. Record review for Resident #32 revealed an admission date of 07/21/21. Diagnosis included chronic obstructive pulmonary disease, acute and chronic respiratory failure, chronic diastolic congestive diastolic congestive heart failure, Parkinson's disease, muscle weakness and altered mental status. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #32 revealed Resident #32 was cognitively intact. Resident #32 had debility cardiorespiratory conditions with anxiety and depression disorders. Review of the care plan for Resident #32 dated 09/22/21 revealed Resident #32 had an activity of daily living (ADL) self-care performance deficit, requires assistance with ADL's related to Parkinson's, COPD/SOB on rest, exertion and lying flat, chronic respiratory failure/, CHF, and morbid obesity. Interventions included to administer medications per medical provider's orders. Review of the physician orders for Resident #32 dated 11/14/24 revealed Ipratropium-Albuterol Solution 0.5-2.5 (3) milligram (mg) per three milliliters (ml) one vial inhale orally three times a day for COPD and every four hours as needed for wheezing and shortness of breath. Observation on 11/20/24 at 10:08 A.M. revealed Resident #32 was sleeping in his chair next to his bed. Observation revealed multiple items were lying on top the bed including dried food items, empty used Styrofoam cups, an aerosol tubing and mouthpiece (not in a bag), cans, lotion, socks toilet paper rolls and empty wrappers. Observation on 11/21/24 at 10:31 A.M. revealed Resident #32 was sitting up in his chair. Observation revealed the medicine cup connected to the aerosol tubing still had a clear liquid in the cup. The tubing, cup and mouthpiece were lying on the bed unbagged. Observation of medication administration on 11/21/24 at 11:48 A.M. with Licensed Practical Nurse (LPN #255) revealed when the nurse entered the resident room, Resident #32 had his aerosol machine on, and he was self-administering the aerosol treatment. LPN #255 revealed he must have had some left from this morning. LPN #255 shut off the aerosol machine and added a new three ml vial of Ipratropium-Albuterol solution to the remaining solution in the aerosol cup, turned the aerosol machine back on and handed the mouthpiece to Resident #32 who continued the treatment. LPN #255 confirmed she also worked on 11/20/24 and confirmed Resident #32's aerosol tubing, cup, and mouthpiece were never kept in a bag during her shift on either day. LPN #255 also confirmed the mouthpiece or cup were not cleaned between uses. 2. Record review for Resident #113 revealed an admission date of 09/19/24. Diagnosis included chronic obstructive pulmonary disease, emphysema, muscle weakness and need for assistants with personal care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2024 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 - Few Review of the Medicare five-day MDS revealed Resident #113 was cognitively intact. Resident #113 required partial moderate assistants with eating and oral hygiene. Resident #113 had medically complex conditions including COPD. Review of the care plan for Resident #113 dated 09/20/24 revealed Resident #113 had chronic obstructive pulmonary disease and emphysema with shortness of breath while lying flat. Interventions included to administer medications per the physician orders. Review of the physician orders for Resident #113 dated 10/29/24 revealed an order to administer Ipratropium-Albuterol Solution 0.5-2.5 (3) milligram (mg) per three milliliters (ml) one vial inhale orally three times a day. Observation on 11/20/24 at 10:10 A.M. revealed Resident #113 was lying in bed. Observation revealed Resident #113 had an aerosol tubing and mouthpiece lying on the edge of the bed, unbagged. Resident 3113 revealed staff never placed his aerosol tubing in a bag. Observation on 11/21/24 at 10:36 A.M. revealed Resident #113 was lying in bed. Resident #113's medicine cup connected to the tubing still had a clear liquid in the cup. The tubing, cup and mouthpiece were lying on the bed. Resident #113 revealed he was taking a break from the aerosol treatment. Observation of medication administration with LPN #255 on 11/21/24 at 11:53 A.M. revealed Resident #113 still had a clear liquid in the cup of the aerosol tubing. The tubing, cup and mouthpiece was still unbagged. LPN #255 verified the liquid in the aerosol cup was the remainder of the morning dose. LPN #255 verified the tubing, cup, and mouthpiece were not in a bag. LPN #255 confirmed she also worked on 11/20/24 during the day shift and Resident #113's aerosol tubing, cup and mask were not placed in a bag the entire shift on either day. LPN #255 also confirmed the mouthpiece or cup were not cleaned between uses. LPN #255 confirmed she did not observe to see if Resident #113 completed the morning aerosol dose. LPN #255 confirmed she worked on different days throughout the facility and had worked with all residents residing in the facility. Interview on 11/20/24 at 11:58 A.M. with Registered Nurse (RN) Unit Manager (UM) #274 revealed after completing an aerosol treatment the nurse was to rinse the aerosol cup out and restore the aerosol tubing, cup and mouthpiece in a plastic bag. Interview on 11/20/24 at 12:02 P.M. with DON revealed nurses were to stay within the area while the resident completed the aerosol treatment and check on the resident frequently to assure the treatment was completed then nurses were to clean the aerosol medicine cup and mouthpiece between uses and keep stored in a plastic bag when not in use to prevent contamination. If the resident did not complete the aerosol treatment, the nurse would notify the physician and never add an additional dose. Review of Device Cleaning and Infection Control in Aerosol Therapy/Respiratory Care dated 06/01/15 revealed cleaning an aerosol tubing or mouthpiece after each use is crucial to prevent the buildup medication residue, bacteria and potential contaminants that can lead to infection, clog the device, and affect the proper delivery of medication when used again. Storage included to store in a plastic bag or and airtight container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2024 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 Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident wheelchairs were maintained in a clean and sanitary manner. This affected four residents (Resident #13, Resident #18, Resident #32, Resident #18, and Resident #105) of five residents observed for sanitary wheelchairs. Findings include: 1. Record review for Resident #32 revealed an admission date of 07/21/21. Diagnosis included Parkinson's disease and muscle weakness. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #32 revealed Resident #32 was cognitively intact. Resident #32 used a wheelchair for mobility. Resident #32 had debility cardiorespiratory conditions with anxiety and depression disorders. Review of the care plan for Resident #32 revealed Resident #32 had an activity of daily living (ADL) self-care performance deficit and required assistance with ADL's related to Parkinson's. Observation on 11/20/24 at 10:08 A.M. revealed Resident #32 was sleeping in a bedside chair. Observation revealed Resident #32's back rest on his wheelchair was fringed with multiple tears. Observation revealed the seat cushion had a large tear exposing the foam inside. Under the cushion revealed a large amount of dried food crumbs and particles. The frame of the wheelchair was covered in a thick film of dust and the foot pedals had a large amount of embedded dirt. Observation and interview on 11/20/24 at 10:15 A.M. with Certified Nursing Assistant (CNA) #321 confirmed the condition of Resident #32's wheelchair. CNA #321 revealed night shift was supposed to clean wheelchairs. Interview on 11/20/24 at 11:28 A.M. with Resident #32 revealed They never clean my wheelchair, it's always dirty, I am just use to it. 2. Record review for Resident #18 revealed an admission date of 11/13/24. Diagnosis included postprocedural seroma of the skin and subcutaneous tissue, need for assistants with personal care and muscle weakness. Review of the Brief Interview for Mental Status dated 11/14/24 revealed Resident #18 was cognitively intact. Review of the Fall Risk Observation tool revealed Resident #18 used a wheelchair for mobility. Review of the Nursing admission assessment dated [DATE] at 3:43 P.M. revealed Resident #18 required a wheelchair for longer distances, the wheelchair was provided by the facility. Observation on 11/20/24 at 10:32 A.M. revealed Resident #18 was sitting in the lounge. The right armrest of Resident #18's wheelchair had multiple tears. The wheel chair frame had a large amount of thick dust and behind the locks was a buildup of food crumbs. Interview with Resident #18 at this time revealed the facility had not cleaned his chair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365771 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2024 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 Residents Affected - Some Observation and interview on 11/20/24 at 10:36 A.M. with Director of Maintenance confirmed Resident #18's wheelchair right armrest had multiple tears. The wheel chair frame had a large amount of thick dust and behind the locks was a buildup of food crumbs. 3. Record review for Resident #105 revealed an admission date of 09/21/24. Diagnosis included paraplegia, muscle weaknesses, lack of coordination, and need for assistance with personal care. Review of the admission Medicare five-day MDS dated [DATE] revealed Resident #105 was cognitively intact. Resident #105 used a wheelchair for mobility. Resident #105 required substantial/maximum assistants with transfers. Observation on 11/20/24 at 10:34 A.M. revealed Resident #105 was sitting in the lounge. Resident #105 revealed staff never cleaned his wheelchair. Observation revealed the entire frame and behind the locks had thick filmy dust covering. Observation and interview on 11/20/24 at 10:35 A.M. with Director of Maintenance confirmed Resident #105's wheelchair frame and behind the locks had a thick filmy dust covering. 4. Record review for Resident #13 revealed an admission date of 08/15/24. Diagnosis included surgical aftercare following surgery on the circulatory system, chronic obstructive pulmonary disease, muscle weakness, difficulty in walking, and need for assist with personal care. Review of the quarterly MDS dated [DATE] revealed Resident #13 was severely cognitively impaired. Resident 13 used a wheelchair for mobility and required supervision or touch assistants with transfers to and from the bed. Observation on 11/20/24 at 10:37 A.M. revealed Resident #13 was sitting in the lounge. Observation of the wheelchair revealed a large amount of very thick filmy dust on the entire frame of the wheelchair with dried food particles behind the handbrakes. Observation and interview on 11/20/24 10:38 A.M. with Director of Nursing (DON) confirmed Resident #13's wheelchair had thick filmy dust on the entire frame of the wheelchair with dried food particles behind the handbrakes. DON revealed the resident wheelchairs had a weekly cleaning schedule and Resident #13's wheelchair should have been cleaned. This deficiency represents non-compliance investigated under Complaint Number OH00159291. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365771 If continuation sheet Page 7 of 7