Health inspection·January 19, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Observation on 01/09/23 at 9:17 A.M. and 10:35 A.M. revealed the call light for Resident #18 was on the floor by the bed not within reach of the resident. On 01/09/23 at 10:35 A.M. an interview with RN #453 verified the call light for Resident #18 was not within the resident's reach. Residents Affected - Some 3. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE]. Diagnoses included frontal temporal neurocognitive disorder, hyperlipidemia, aphasia, sleep disorder, vitamin D deficiency, vascular dementia, anxiety disorder, osteoarthritis, and major depressive disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #38 had severely impaired cognition and required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. Review of the plan of care dated 12/21/22 revealed Resident #38 was at risk for falls as evidenced by scoring tool fall risk assessment. Interventions included to ensure call light was available to the resident. Observations on 01/09/23 at 9:52 A.M. and 10:45 A.M. revealed the call light for Resident #38 was on the floor between the recliner and the bed, not within reach of the resident. On 01/09/23 at 10:45 A.M. an interview with RN #411 verified the call light for Resident #38 was not within the resident's reach. Review of the facility policy titled, Call Light, Answering, dated 12/28/21 revealed the purpose of the policy was to respond to the resident's requests and needs. When the resident was in bed or confined to a chair, staff were to be sure the call light was within their reach. 4. Review of Resident #29's medical record revealed an admission date of 05/11/20 with the diagnoses of anxiety disorder, chronic kidney disease, polyneuropathy, and muscle weakness. Review of Resident #29's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/26/22, revealed she was cognitively independent and needed supervision with one person to physically assist with bed mobility, transfers, and toilet use. Observation on 01/09/23 at 2:41 P.M. revealed Resident #29 sitting in her chair and her call light wrapped around the bed rail. The call light was not within reach. Observation on 01/09/23 at 3:22 P.M. revealed Resident #29 remained in her chair and her call light was wrapped around the bed rail. The call light was not within Resident #29's reach. An interview at the time of the observation with Registered Nurse (RN) #453 verified the call light was not within Resident #29's reach and it should have been. 5. Review of Resident #287's medical record revealed an admission date of 11/30/22 with diagnoses of cellulitis of right lower limb, urinary tract infections, and acute embolism and thrombosis of unspecified deep veins of left lower extremity. Review of Resident #287's admission MDS 3.0 assessment, dated 12/07/22, revealed Resident #387 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 2 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cognitively independent and required the extensive assistance of two staff for bed mobility, transfers, and toileting. Observation on 01/09/23 at 3:30 P.M. revealed Resident #287 sitting in a wheelchair with a call light attached to a black colored article of clothing on the bed behind the wheelchair. An interview with Resident #287 at the time of the observation revealed she did not know where her call light was. The surveyor informed Resident #287 where the call light was but Resident #287 was unable to reach the call light. Resident #287 reported staff assisted her to remove the black colored article of clothing because she couldn't do it alone. Observation on 01/09/23 at 3:50 P.M. revealed Resident #287's call light was still attached to the black article of clothing out of the reach of Resident #287. An interview at the time of the observation with RN #453 verified the call light was not within Resident #287's reach and it should have been. Review of the facility policy titled, Call Light, Answering, dated 12/28/21 revealed the purpose of the policy was to respond to the resident's requests and needs. When the resident was in bed or confined to a chair, staff were to be sure the call light was within their reach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 3 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide evidence in the medical record to support the receiving provider received the appropriate resident care information for continuity of care. This affected one Resident (#62) of one resident reviewed for hospitalization. The facility census was 68. Findings include: Review of Resident #62's medical record revealed she was admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease, unspecified dementia, type two diabetes, essential hypertension, and major depressive disorder. She was discharged from the facility on 12/28/22. Review of Resident #62's medical record revealed a physician order dated 12/28/22 to send Resident #62 to the emergency room for evaluation and treatment. Review of Resident #62's medical record revealed no documentation in the nursing progress notes to support information was sent on 12/28/22 with Resident #62 to the acute care facility for continuity of care. An interview on 01/12/23 at 4:10 P.M. with Licensed Practical Nurse (LPN) #498 revealed the facility did not keep a copy of the transfer form that was sent with residents. LPN #498 reported the facility staff sent the resident's code status, list of medications, assessment findings, and care provided. LPN #498 verified there was no documentation in Resident #62's medical record to support this occurred. An interview on 01/12/23 at 4:30 with the Director of Nursing (DON) revealed the facility did not have a policy on acute transfers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 4 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 0623 Level of Harm - Potential for minimal harm Residents Affected - Many Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review the facility failed to provide notification to the ombudsman regarding transfers and discharges from the facility. This affected one Resident (#62) of one resident reviewed for hospitalization. The total number of residents affected over a three-month review was 64 (Residents #2, #7, #8, #10, #15, #20, #37, #40, #41, #44, #45, #49, #50, #56, #62, #64, #68, #70, #73, #74, #75, #77, #78, #79, #133, #190, #191, #192, #193, #194, #195, #196, #197, #198, #199, #200, #201, #202, #203, #204, #205, #206, #207, #208, #209, #210, #211, #212, #213, #214, #215, #216, #217, #218, #219, #220, #221, #222, #223, #224, #225, #226, #227, and #228. The facility census was 68. Findings include: Review of Resident #62's medical record revealed she was admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease, unspecified dementia, type two diabetes, essential hypertension, and major depressive disorder. She was discharged from the facility on 12/28/22. Review of Resident #62's medical record revealed a physician order dated 12/28/22 to send to the emergency room for evaluation and treatment. Review of Resident #62's medical record revealed no documentation to support the ombudsman received a copy of the written notification of transfer/discharge. An interview on 01/12/23 at 3:28 P.M. with Office Staff #520 revealed she did not notify the ombudsman of Resident #62's transfer. Office Staff #520 reported she had not been notifying the ombudsman of transfers and discharges since September of 2022. Review of facility documentation titled, Resident Transfers for 10/22 revealed the ombudsman was not notified about Residents #40, #41, #56, #70, #73, #133, #190, #191, #192, #193, #194, #195, #196, #197, #198, #199, #200, #201, #202, #203, #204, #205, #206, #207, and #208's transfer/discharges. Review of facility documentation titled, Resident Transfers for 11/22 revealed the ombudsman was not notified about Residents #7, #8, #10, #20, #40 (three times), #41, #56 (two times), #64, #74, #75 (two times), #77, #78, #79, #209, #210, #211, #212, #213, #214, #215, #216, #217, #218, #219, and #220's transfers/discharges. Review of facility documentation titled, Resident Transfers for 11/22 revealed the ombudsman was not notified about Residents #2, #15, #37, #44, #45, #49, #50, #62, #68, #70 (two times), #77, #133, #221, #222, #223 (two times), #224, #225, #226, #227, and #228' transfers/discharges. Review of facility policy titled, Transfer and Discharge Policy, dated 11/28/16, revealed the facility would send a copy of the Discharge Notice to a representative of the Office of the State Long-Term Care Ombudsman. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 5 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on record review, interview, and review of the Minimum Data Set (MDS) manual the facility failed to ensure an annual comprehensive MDS assessment was completed timely. This affected one (Resident #39) of four residents reviewed for timely completion of assessment. Findings include: Review of Resident #39 medical record revealed a 12/24/21 admission with diagnoses including type 2 diabetes, schizophrenia, hypertension, and acute kidney failure. Review of Resident #39's Annual MDS 3.0 assessment, with an Assessment Reference Date (ARD) 12/01/22 revealed the MDS was not completed until 01/03/23. Interview 01/17/23 at 11:35 A.M. with Registered Nurse #522 verified the Annual MDS was not completed within 14 days which was 19 days late. Review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.17.1 October 2019, Chapter 5 Submission and Correction of the MDS assessments included 5.2 timeliness criteria in accordance with the requirements at 42 CFR §483.20(f)(1), (f)(2), and (f)(3), long-term care facilities participating in the Medicare and Medicaid programs must meet the following conditions: For the admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600). For the admission assessment, the Care Area Assessment (CAA) Completion Date (V0200B2) must be no later more than 13 days after the Entry Date (A1600). For the Annual assessment, the CAA Completion Date (V0200B2) must be no later than 14 days after the ARD (A2300). For the other comprehensive MDS assessments, Significant Change in Status Assessment and Significant Correction to Prior Comprehensive Assessment, the CAA Completion Date (V0200B2) must be no later than 14 days from the ARD (A2300) and no later than 14 days from the determination date of the significant change in status or the significant error, respectively. For Entry and Death in Facility tracking records, the MDS Completion Date (Z0500B) must be no later than 7 days from the Event Date (A1600 for an entry record; A2000 for a Death in Facility tracking record). Review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.17.1 October 2019, revealed an admission MDS assessment should be completed no later than the 14th calendar day of the resident's admission (admission date plus13 days) and submitted no later than 45th day of the resident's admission (admission date plus 44 days). A quarterly MDS assessment should be completed no later than the 14th day from the assessment reference date and submitted 14 days after the completion of the MDS assessment. A discharge assessment should be completed no later than 14 days after discharge (discharge date plus 14 days) and should be submitted no later than 14 days after the MDS completion date (MDS completion date plus 14 days). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 6 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the Minimum Data Set (MDS) manual, the facility failed to ensure a quarterly MDS was completed timely. This affected two (Resident #9 and #68) of four residents reviewed for timely completion of assessment. Residents Affected - Few Findings include: 1. Review of Resident #9 revealed a [DATE] admission with diagnoses including congestive heart failure, type 2 diabetes, hallucinations and dementia. Review of Resident #9's Quarterly MDS 3.0 assessment, dated [DATE] revealed the MDS was not completed until [DATE]. Interview [DATE] at 11:35 A.M. with Registered Nurse #522 verified the Quarterly MDS was not completed within 14 days which was 19 days late. Review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.17.1 [DATE], Chapter 5 Submission and Correction of the MDS assessments included 5.2 Timeliness Criteria in accordance with the requirements at 42 CFR §483.20(f)(1), (f)(2), and (f)(3), long-term care facilities participating in the Medicare and Medicaid programs must meet the following conditions: Completion Timing: For all non-admission OBRA and PPS assessments, the MDS Completion Date (Z0500B) must be no later than 14 days after the Assessment Reference Date (ARD) (A2300). For the admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600). For the admission assessment, the Care Area Assessment (CAA) Completion Date (V0200B2) must be no later more than 13 days after the Entry Date (A1600). For the Annual assessment, the CAA Completion Date (V0200B2) must be no later than 14 days after the ARD (A2300). For the other comprehensive MDS assessments, Significant Change in Status Assessment and Significant Correction to Prior Comprehensive Assessment, the CAA Completion Date (V0200B2) must be no later than 14 days from the ARD (A2300) and no later than 14 days from the determination date of the significant change in status or the significant error, respectively. For Entry and Death in Facility tracking records, the MDS Completion Date (Z0500B) must be no later than 7 days from the Event Date (A1600 for an entry record; A2000 for a Death in Facility tracking record). Review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.17.1 [DATE], revealed an admission MDS assessment should be completed no later than the 14th calendar day of the resident's admission (admission date plus 13 days) and submitted no later than 45th day of the resident's admission (admission date plus 44 days). A quarterly MDS assessment should be completed no later than the 14th day from the assessment reference date and submitted 14 days after the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 7 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 0638 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few completion of the MDS assessment. A discharge assessment should be completed no later than 14 days afterdischarge (discharge date plus 14 days) and should be submitted no later than 14 days after the MDS completion date (MDS completion date plus 14 days). 2. Review of the medical record for Resident #68 revealed an admission date of [DATE] and a discharge date of [DATE]. Medical diagnoses included congestive heart failure, acute kidney failure and asthma. Resident #68's Quarterly MDS assessment, with an assessment reference date of [DATE], was due to be completed [DATE]. The MDS was still in progress. The resident expired [DATE]. There was not a Death MDS initiated. Interview on [DATE] at 8:33 A.M. with the Registered Nurse (RN) #522 confirmed the Quarterly MDS assessment for Resident #68 was not completed within the required time frames. The Death MDS was not initiated and completed within seven days of death. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 8 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure minimum data set (MDS) assessments were completed and submitted within required timeframes. This affected 10 (Resident's #1, #4, #9, #39, #42, #49, #61, #66, #68, and #69 ) of 10 residents reviewed. The facility census was 68. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 11/09/21 and a discharge date of 12/24/22. Medical diagnoses included atrial fibrillation, dementia, and anxiety. Review of Resident #1's Quarterly MDS assessment, with an assessment reference date of 12/02/22, revealed the assessment was due to be submitted 12/30/22. The MDS assessment was not submitted until 01/10/23, 11 days late. Interview on 01/12/23 at 8:58 A.M. with Registered Nurse (RN) #522 confirmed the Quarterly MDS assessment for Resident #1 was not submitted within the required time frames. RN #522 included she was a new employee, new to MDS and was waiting for the credentials to submit MDS assessments. She was provided the ability to submit 01/10/23. Review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.17.1 October 2019, revealed an admission MDS assessment should be completed no later than the 14 th calendar day of the resident's admission (admission date plus 13 days) and submitted no later than 45th day of the resident's admission (admission date plus 44 days). A quarterly MDS assessment should be completed no later than the 14 th day from the assessment reference date and submitted 14 days after the completion of the MDS assessment. A discharge assessment should be completed no later than 14 days after discharge (discharge date plus 14 days) and should be submitted no later than 14 days after the MDS completion date (MDS completion date plus 14 days). Review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.17.1 October 2019, Chapter 5 Submission and Correction of the MDS assessments included 5.2 Timeliness Criteria in accordance with the requirements at 42 CFR §483.20(f)(1), (f)(2), and (f)(3), long-term care facilities participating in the Medicare and Medicaid programs must meet the following conditions: Completion Timing: For all non-admission OBRA and PPS assessments, the MDS Completion Date (Z0500B) must be no later than 14 days after the Assessment Reference Date (ARD) (A2300). For the admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600). For the admission assessment, the Care Area Assessment (CAA) Completion Date (V0200B2) must be no later more than 13 days after the Entry Date (A1600). For the Annual assessment, the CAA Completion Date (V0200B2) must be no later than 14 days after the ARD (A2300). For the other comprehensive MDS assessments, Significant Change in Status Assessment and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 9 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 0640 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Significant Correction to Prior Comprehensive Assessment, the CAA Completion Date (V0200B2) must be no later than 14 days from the ARD (A2300) and no later than 14 days from the determination date of the significant change in status or the significant error, respectively. For Entry and Death in Facility tracking records, the MDS Completion Date (Z0500B) must be no later than 7 days from the Event Date (A1600 for an entry record; A2000 for a Death in Facility tracking record). 2. Review of the medical record for Resident #68 revealed an admission date of 07/28/22 and a discharge date of 12/27/22. Medical diagnoses included congestive heart failure, acute kidney failure and asthma. Review of Resident #68's Quarterly MDS assessment, with an assessment reference date of 11/23/22, revealed it was due to be submitted 12/17/22. The MDS assessment was not submitted until 01/10/23, 24 days late. Interview on 01/12/23 at 8:33 A.M. with the RN #522 confirmed the Quarterly MDS assessment for Resident #1 was not submitted within the required time frames. 3. Review of the medical record of Resident #9 revealed a 03/29/22 admission with diagnoses including congestive heart failure, type 2 diabetes, hallucinations and dementia. Review of Resident #9's Quarterly MDS 3.0 assessment, dated 11/15/22 revealed the MDS was due to be submitted 12/13/22. The MDS was not submitted until 01/10/23, 31 days late. Review of Resident #9's Quarterly MDS 3.0 assessment, dated 12/10/22 revealed the MDS was export ready on 01/12/23. The MDS was due to be submitted 01/07/23. Interview 01/17/23 at 11:35 A.M. with RN #522 verified the Quarterly MDS assessments were not submitted within the required timeframe. The 11/15/22 MDS was 31 days late. RN #522 included the 12/10/22 MDS was submitted 01/17/23, 10 days late. RN #522 included she was working on getting caught up on the backlog of MDS assessments due. 4. Review of the medical record of Resident #39 revealed a 12/24/21 admission with diagnoses including type 2 diabetes, schizophrenia, hypertension, and acute kidney failure. Review of Resident #39's Annual MDS 3.0 assessment, with an Assessment Reference Date (ARD) 12/01/22 revealed the MDS was not submitted until 01/10/23. Interview on 01/12/23 at 8:35 A.M. with RN #522 verified the Annual MDS was not submitted within the required timeframe and was 12 days late. 5. Review of the medical record of Resident #49 revealed a 02/21/21 admission with diagnoses including cerebral infarction, depression, and hypertension. Review of Resident #49's Annual MDS 3.0 assessment, with an ARD of 11/16/22 revealed the MDS assessment was not submitted until 01/10/23. The MDS was due to be submitted 12/14/22 and was 27 days late. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 10 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 0640 Level of Harm - Minimal harm or potential for actual harm Interview 01/12/23 at 8:45 A.M. with RN #522 verified the Annual MDS assessment was not submitted within the required timeframe. 6. Review of the medical record of Resident #4 revealed a 07/24/21 admission and 12/05/22 discharge with diagnoses including Alzheimer's disease, schizophrenia, and anxiety. Residents Affected - Some Review of Resident #4's Quarterly MDS 3.0 assessment, with an ARD of 11/25/22 revealed the MDS assessment was not submitted until 01/10/23. The MDS assessment was due to be submitted 12/23/22 and was 18 days late. Review of the Death in facility 12/05/22 MDS assessment revealed it was due to be submitted 12/26/22 and was submitted 01/10/23, 15 days late. Interview 01/12/23 at 8:41 A.M. with Registered Nurse #522 verified the Annual and Death MDS assessments were not submitted within the required timeframe. 7. Review of the medical record of Resident #69 revealed a 08/15/22 admission with diagnoses including dementia, hyperlipidemia, and neurocognitive disorder with Lewy Bodies. Review of Resident #69's Quarterly MDS 3.0 assessment, with an ARD of 12/01/22 revealed the MDS assessment was not submitted until 01/10/23. The MDS assessment was due to be submitted 12/29/22 and was 12 days late. Interview 01/12/23 at 8:41 A.M. with RN #522 verified the Quarterly MDS assessment was not submitted within the required timeframe. 8. Review of the medical record of Resident #42 revealed a 08/19/17 admission with diagnoses including anxiety, dementia, hypertension and hypothyroidism. Review of Resident #42's Quarterly MDS 3.0 assessment, with an ARD of 11/25/22 revealed the MDS was not submitted until 01/10/23. The MDS was due to be submitted 12/23/22 and was 18 days late. Interview 01/12/23 at 8:51 A.M. with RN #522 verified the Quarterly MDS assessment was not submitted within the required timeframe. 9. Review of the medical record of Resident #66 revealed a 11/11/21 admission with diagnoses including Alzheimer's disease, anxiety, dementia, and hypertension. Review of Resident #66's Quarterly MDS 3.0 assessment, with an ARD of 12/02/22 revealed the MDS assessment was not submitted until 01/10/23. The MDS assessment was due to be submitted 12/30/22 and was 11 days late. Interview 01/12/23 at 8:54 A.M. with RN #522 verified the Quarterly MDS was not submitted within the required timeframe. 10. Review of the medical record of Resident #61 revealed a 04/27/22 admission with diagnoses including fractured femur, dementia, and hypertension. Review of Resident #61's Quarterly MDS 3.0 assessment, with an ARD of 12/01/22 revealed the MDS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 11 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 0640 Level of Harm - Minimal harm or potential for actual harm assessment was not submitted until 01/10/23. The MDS assessment was due to be submitted 12/29/22 and was 12 days late. Interview 01/12/23 at 8:44 A.M. with RN #522 verified the Quarterly MDS was not submitted within the required timeframe. Residents Affected - Some This deficiency is an example of continued noncompliance to the Complaint Survey completed 12/16/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 12 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the Minimum Data Set (MDS) 3.0 assessments were accurate. This affected two residents (#5 and #25) of seven residents reviewed for accuracy of assessments. The facility census was 68. Residents Affected - Few Finding include: 1. Review of Resident #5's medical record revealed she was admitted to the facility on [DATE] with the diagnoses of wedge compression fracture of Thoracic 11 to Thoracic 12 vertebra, shortness of breath, and chronic peripheral venous insufficiency. Review of Resident #5's admission MDS 3.0 assessment, dated 11/08/22, revealed she was cognitively independent and had active diagnoses of fractures and other multiple trauma, coronary artery disease, shortness of breath, and received one diuretic in the last seven days. There was no diagnosis of chronic peripheral venous insufficiency. An interview on 01/17/23 at 11:44 AM with MDS Coordinator #522 verified Resident #5's MDS assessment was not coded correctly for active diagnoses. MDS Coordinator #522 verified venous insufficiency was not listed in the active diagnoses which resulted in there not being a care plan for chronic peripheral venous insufficiency. 2. Review of Resident #25's medical record revealed he was admitted to the facility on [DATE] with the diagnoses of mild intellectual disabilities, major depressive disorder, insomnia, anxiety disorder, cerebral palsy, constipation unspecified and essential hypertension. Review of Resident #25's quarterly MDS 3.0 assessment, dated 10/08/22, revealed he was cognitively dependent and had active mental health diagnoses of anxiety, depression, insomnia and restless, and agitation. There was no diagnosis of schizoaffective disorder. Review of psychology physician notes dated 04/13/22, 05/13/22, 06/13/22, 07/13/22, 09/15/22, 10/19/22, 11/18/22, and 12/28/22 revealed the diagnosis of schizoaffective disorder. An interview on 01/12/23 at 11:53 A.M. with MDS Coordinator #522 revealed the diagnosis of schizoaffective disorder was not listed in the medical diagnoses for the Resident #25 and did not get coded into the MDS which resulted in there not being a care plan for schizoaffective disorder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 13 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record and staff interview the facility failed to ensure a new Preadmission Screening and Resident Review (PASARR) was obtained after a new diagnosis of a mental disorder for Resident #31. This affected one resident (Resident #31) of one resident reviewed for PASARR. Findings include: Review of the medical record revealed Resident #31 was admitted to the facility on [DATE]. Current diagnoses included psychosis, adult failure to thrive, bipolar disorder, anxiety disorder, protein-calorie malnutrition, ventricular tachycardia, osteoarthritis of the knees, chronic kidney disease, visual hallucinations, major depressive disorder, restless leg syndrome, insomnia, hypertension, and diabetes. Review of the Preadmission Screening/Resident Review identification screen dated 03/29/18 revealed Resident #31 was seeking admission to the nursing facility, she had no diagnoses of dementia, Alzheimer's disease, organic mental disorder, serious mental illness, and did not require individualized psychiatric services in the last two years. Resident #31 did not have a diagnosis of mental retardation. Review of the History and Physical from the behavior health admission dated 06/14/21 revealed Resident #31 had a new diagnosis of psychosis. On 01/12/23 at 10:20 A.M. an interview with admission Manager #418 revealed the facility only had the PASARR from when Resident #31 was admitted to another facility on 03/29/18. admission Manager #418 verified Resident #31 had new diagnoses of psychosis and bipolar at the other facility and they had not done a new PASARR when she was admitted to their facility on 05/16/19. On 01/12/23 at 3:31 P.M. an interview with admission Manager #418 revealed the facility missed completing two PASARR screenings for Resident #31 on 03/29/18 and 06/14/22 when she had new mental illness diagnoses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 14 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on record review, interview, and policy review, the facility failed to develop comprehensive plans of care in the areas of activities of daily living (ADL) and activities. This affected two (Residents #20 and #51) of 21 residents reviewed. The facility census was 68. Findings include: 1. Review of Resident #51's medical record revealed a 10/25/22 admission with diagnoses including atrial fibrillation, fistula of intestine, hypertension, umbilical hernia with obstruction with surgical intervention of the digestive system, heart failure, and morbid obesity. Review of the 11/01/22 admission Minimum Data Set (MDS) assessment revealed the resident was independent for daily decision making, extensive assist of two for bed mobility, transfer, and toileting. The resident did not walk, was totally dependent for locomotion off the unit, and extensive assist of one for personal hygiene. Interview 01/09/23 at 3:54 P.M. with Resident #51 revealed his toe nails were long and he needed them cut. His big toenail was really thick. He said he asked to see a podiatrist and had not. He normally had them cut by the podiatrist every nine weeks. Further review of the medical record revealed no evidence of Resident #51 seeing the podiatrist. Review of the plans of care revealed the resident did not have an Activity of Daily Living (ADL) plan of care. Interview on 01/10/23 at 1:44 P.M. with the Director of Nursing (DON) verified the facility did not have an ADL plan of care in place for Resident #51. The DON included they switched electronic documentation 09/01/22 and printed out the plans of care from the old system. They were doing baseline care plans on new admissions. They were currently building the plans of care in the new electronic documentation system for new admissions and long term residents but were not up to date and did not have them completed. 2. Review of Resident #20's medical record revealed an admission date of 10/26/22 with diagnoses of atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified severe protein-calorie malnutrition, chronic obstructive pulmonary disease, weakness, and hypertension. Review of Resident #20's admission Minimum Data Set (MDS) 3.0 assessment, dated 11/02/22, revealed the resident was cognitively independent. The assessment indicated she had minimal difficulty with hearing, her vision was adequate, and her speech was clear. Her very important activities included listening to music, keeping up with the news, and going outside when the weather was good for fresh air. Her somewhat important activities were having books, newspapers, and magazines to read, doing her favorite activities, and participating in religious services or practices. She was not interested in doing group activities. Review of Resident #20's Activities - Initial Review, dated, 11/17/22, revealed she wanted to participate in activities while in the home. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 15 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 0656 Review of Resident #20's plan of care, dated 11/16/22, revealed no care plan for activities. Level of Harm - Minimal harm or potential for actual harm An interview on 01/10/23 at 2:10 P.M. with Marketer #479 revealed Certified Occupation Therapy Assistant (COTA) #462 had the credentials for activities director and she was responsible for the activity assessments and activity care plan development. Residents Affected - Few An interview on 01/11/23 at 7:10 A.M. with Registered Nurse (RN) #453 verified Resident #20 did not have a care plan for activities. Review of the facility policy titled, Care Planning/Interdisciplinary Team, undated, revealed the facility would develop a comprehensive care plan for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, and psychosocial needs that were identified in the comprehensive assessment (MDS). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 16 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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** 2. Review of Resident #51's medical record revealed a 10/25/22 admission with diagnoses including atrial fibrillation, fistula of intestine, hypertension, umbilical hernia with obstruction with surgical intervention of the digestive system, heart failure, and morbid obesity. Residents Affected - Few Review of the admission agreement included on 10/25/22, Resident #51 signed an Authorization for Professional Services. The authorization included a list of the outside professionals who provided service to the facility. The agreement included consent to be treated by and receive services and supplies from the professionals, and an agreement to pay those professionals in full upon receipt of an invoice. Resident #51 authorized the release of health, financial or other information to the professionals so that they could provide services and take any action necessary to bill for those services. Resident #51 signed he understood the persons and entities listed on the attached pages were independent practitioners and were not employees or agents of the facility. He agreed the facility was not responsible for the acts or omissions of any person or entity not directed or controlled by the facility. Review of the 11/01/22 admission Minimum Data Set (MDS) assessment revealed Resident #51 was independent for daily decision making, extensive assist of two for bed mobility, transfer, and toileting. The resident did not walk, was totally dependent for locomotion off the unit, and extensive assist of one for personal hygiene. Interview 01/09/23 at 3:54 P.M. with Resident #51 revealed his toe nails were long and he needed them cut. His big toenail was really thick. He said he asked to see a podiatrist and had not. He normally got them cut by the podiatrist every nine weeks. Review of the record revealed no evidence of Resident #51 seeing the podiatrist. Review of the plans of care revealed Resident #51 did not have an Activity of Daily Living (ADL) plan of care. Interview on 01/10/23 at 1:44 P.M. with the Director of Nursing (DON) verified the facility did not have an ADL plan of care in place for Resident #51. The DON included they switched electronic documentation 09/01/22 and printed out the plans of care from the old system. They were doing baseline care plans on new admissions. They were currently building the plans of care in the new electronic documentation system for new admissions and long term residents but were not up to date and did not have them completed. Interview 01/10/23 at 5:41 P.M. with Licensed Social Worker (LSW) #438 revealed every resident in the facility was seen by the podiatrist unless they refuses. LSW #438 was asked to get a consent from each new resident before the podiatrist arrived. LSW #438 verified Resident #51 was not seen by the podiatrist when last in the facility. LSW #438 did not know why. Interview 01/11/23 at 8:11 A.M. with Resident #51 included he got his toenails cut by a podiatrist every nine months when home. He included he was due to get his toenails cut when he arrived to facility from the hospital. Interview 01/11/23 at 9:01 A.M. with the DON included the podiatrist was at the facility 10/31/22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 17 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and saw the residents on the unit which Resident #51 resided. The podiatrist returned 11/02/22 for the Homestead unit and 11/14/22 for the Gardens Unit. There was no explanation in the record as to why Resident #51 did not see the podiatrist 10/31/22, 11/02/22, or 11/14/22. Review of the medical record revealed no evidence of Resident #51 being out of the facility when the podiatrist was cutting nails on his unit 10/31/22. Based on observation, review of the medical record, staff interview and facility policy review the facility failed to ensure Resident #24 was shaved and the toenails of Resident #51 were trimmed per their preferences. This affected two residents ( Resident #24 and #51) of four reviewed for activities of daily living (ADLs). Findings include: 1. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE]. Diagnoses included pneumonia, multiple sclerosis, diabetes, atrial fibrillation, acute kidney disease, benign prostatic hyperplasia, hypertension, depression, venous insufficiency, and Parkinson's disease. Review of the 14-day Minimum Data Set assessment dated [DATE] revealed Resident #24 had moderately impaired cognition and required extensive assistance of two staff members for personal hygiene. Review of the progress notes from 10/19/22 to 01/12/23 revealed no documentation Resident #24 had refused to be shaved. Review of the plan of care dated 11/28/22 revealed Resident #24 had an ADL self-care performance deficit related to Parkinson's disease. Interventions included the resident was totally dependent on one staff for personal hygiene and oral care. Observation on 01/09/22 at 9:15 A.M., 3:35 P.M., and 5:45 P.M., on 01/10/23 at 7:55 A.M., 4:37 P.M., on 01/11/23 at 8:30 A.M., 12:27 P.M., 2:47 P.M., 4:30 P.M., on 01/12/23 at 7:15 A.M. and 7:30 A.M. revealed Resident #24 had long facial whiskers and had not been shaved. On 01/11/23 at 2:47 P.M. an interview with Resident #24 revealed he had not been shaved for a couple days and did not like his whiskers to get too long. On 01/12/23 at 7:20 A.M. an interview with State Tested Nursing Assistant (STNA) #428 revealed all the residents were to be shaved daily or at least every other day. On 01/12/23 at 7:30 A.M. an interview with Licensed Practical Nurse (LPN) #498 verified the facial whickers on Resident #24 were long and he needed to be shaved. Review of the facility policy titled, Shaving Facial Hair, dated 04/16/22 revealed the residents would receive care to remove facial hair when requested and as necessary as part of routine care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 18 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm 2. Review of Resident #187's medical record revealed a 12/16/22 admission with diagnoses including iron deficiency anemia, benign intracranial hypertension, malignant melanoma of skin, chronic heart failure, ischemia cardiomyopathy, syncope and collapse, type 2 diabetes mellitus, myocardial infarction, peptic ulcer disease, and protein calorie malnutrition. Residents Affected - Few Review of Resident #187's baseline plan of care dated a 12/16/22 included to encourage activities of interest. Review of the 12/16/22 Activities Initial Review revealed Resident #187 enjoyed cooking and baking for neighbors and friends. The resident enjoyed watching game shows on television such as Wheel of Fortune, The Price is Right and Deal or No Deal. The resident also enjoyed putsing around the home. Resident #187 went to Methodist church and wished clergy visits, by any preacher would do. Review of the 12/19/22 Resident Preferences Assessment included it was very important for Resident #187 to listen to music she liked, country. It was very important for her to be around animals, to do things with groups of people, do favorite activities, go outside in fresh air, and somewhat important to participate in religious services. There was nothing marked on the personalized care planning section, it was left blank. Interview 01/09/23 at 12:50 P.M. with Resident #187 included they had Bingo and bible study. There were not many activities. There was not a calendar to inform the residents of when activities were going to occur so she could plan. Someone came around and told the residents when there was going to be something happening. Resident #187 was sitting in her wheelchair with the television on at the time of the interview. Interview on 01/10/23 at 1:59 P.M. with Marketing #479 included she was assisting with activities. They had not had an Activity Director. The Occupational Therapy Assistant (OTA) had the credentials to be the head of the department. The OTA assisted with care plans and assessments. Marketing #479 revealed the beautician wanted to get the credentials to head the activity department and was looking for a class. The facility had not filled out a monthly activity calendar since 2020 when COVID started. Marketing #479 revealed an Entertainment Calendar was posted instead. The dining room hostesses were to tell the residents if they were having an activity. If they were not in COVID outbreak status they did come together for group activities. They were having unit by unit activities at this time because of the current COVID outbreak. Marketing #479 verified the residents could not plan their days if they did not know when an activity was going to take place. Review of the Entertainment/Activity Shutdown and Approved Times Calendar had a list of items: Movies Monday through Friday on Channel 2, no time given, Church service the 4th Sunday of the month, no time given, and Bingo Tuesday and Thursday and sometimes weekends and holidays, with no time given. Live entertainment weekly, sometimes two to three times a week, no day or times listed. The calendar gave no time of when an activity would be provided. Interview on 01/10/23 at 2:17 P.M. with Activities #492 included the residents wished they had an activity calendar. It had been mentioned to her. Activities #492 reviewed the activity logs since Resident #187 was admitted . She reported Resident #187 had not been to any activity since she was admitted . Activities #482 asked Resident #187 if she wanted to go to an activity once but she said she was waiting on therapy. Activities #492 included Resident #187 did 1:1 activities. Activities #492 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 19 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 0679 Level of Harm - Minimal harm or potential for actual harm will usually document a 1:1 on the log if she was in a room longer than 10 minutes. Activities #492 included she had an activity cart and went room to room with word finds etc. Churches came on Sundays but usually went to the Gardens Unit, not the Rehabilitation Unit where Resident #187's room was located. The facility had no system to track residents, who indicated on their activity interview they wanted clergy visits, to ensure clergy knew they would like a visit. Residents Affected - Few Interview 01/10/23 at 3:01 P.M. with Marketing #479 revealed she received a text from activity staff if someone wanted to see clergy. It was communicated to her via text on 12/19/22 and 01/05/23 Resident #187 wanted clergy visits. Marketing #479 did not know if Resident #187 had received a clergy visit. Marketing #479 indicated it had been wacky about who was doing what. On 01/10/22 at 3:03 P.M. Marketing #479 informed the surveyor the Activity Director's last day of employment with the facility was 10/22/21. Interview 01/10/23 at 3:38 P.M. with Resident #187 included she had asked to see clergy when questioned but had not seen clergy since arriving at facility. Interview 01/12/23 at 9:02 A.M. with the president of resident council included the residents had brought up not having a full time activity director, the lack of activities on the weekends and not being provided an activity calendar. He indicated they just don't have the help to provide services. Review of the facility's 10/20/21 Activity policy included spiritual programming was scheduled to meet the religious needs of the residents. Scheduled activities were announced and posted for residents so they could choose activities of interest. Based on observation, interview, record review and policy review the facility failed to provide activities to meet the residents' needs, and did not provide a scheduled activity calendar or activities on the weekends. This affected two residents (#20 and #187) of two residents reviewed for activities. The facility census was 68. Findings include: 1. Review of Resident #20's medical record revealed an admission date of 10/26/22 with diagnoses of atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified severe protein-calorie malnutrition, chronic obstructive pulmonary disease, weakness, and hypertension. Review of Resident #20's admission Minimum Data Set (MDS) 3.0 assessment, dated 11/02/22, revealed the resident was cognitively independent. The assessment indicated she had minimal difficulty with hearing, her vision was adequate, and her speech was clear. Her very important activities included listening to music, keeping up with the news, and going outside when the weather was good for fresh air. Her somewhat important activities were having books, newspapers, and magazines to read, doing her favorite activities, and participating in religious services or practices. She was not interested in doing group activities. Review of Resident #20's Activities - Initial Review, dated, 11/17/22, revealed she wanted to participate in activities while in the home. Review of Resident #20's plan of care, dated 11/16/22, revealed no care plan for activities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 20 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #20's activities documentation revealed the only documentation of activities since admission was one day on 11/17/22. There was no documentation of refusal of activities. An interview on 01/09/23 at 10:38 A.M. with Resident #20 revealed she did not have any individual activity items in her room. An observation at the time revealed no items in her room like books, newspapers or magazines and there was no music playing. An interview on 01/10/23 at 2:10 P.M. with Marketer #479 revealed the facility did not have an activities director since 10/22/21. She verified there was no electronic health record documentation for activity participation. Marketer #479 revealed Beautician #426 was attempting to get into classes for activity certification. An interview on 01/10/23 at 2:40 P.M. with Activities #492 verified the only documentation of one-to-one activities with Resident #20 was on 11/17/22 and there was no documentation of activity refusal. Observation on 01/10/23 at 3:28 P.M. revealed Resident #20 lying in bed with no activities. Resident #20 did not have a newspaper or any other in room activities and no music was playing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 21 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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, record review, interview, and review of manufacturer guidelines the facility failed to ensure their bowel protocol was implemented, measures were in place for peripheral edema and ear irrigation treatment was provided as ordered. This affected two (Residents #5 and #188) of two residents reviewed for edema, one (Resident #13) of one resident reviewed for communication, and one (Resident #25) of five residents reviewed for unnecessary medication. The facility census was 68. Residents Affected - Some Findings include: 1. Review of Resident #13's medical record revealed a 07/30/19 admission with diagnoses including chronic respiratory failure with hypoxia, morbid severe obesity, type 2 diabetes with diabetic neuropathy, hyperlipidemia, chronic atrial fibrillation, congestive heart failure, hypertension, chronic obstructive pulmonary disease, dependence on renal dialysis, peripheral vascular disease, and depression. Review of the 09/30/22 Quarterly Minimum Data Set (MDS) assessment revealed Resident #13 was independent for daily decision making, had adequate hearing without an aide, required extensive assist of two for bed mobility, had total dependence of two for transfers, did not walk, required extensive assist of two for dressing, toileting, and personal hygiene, was independent with set up only for eating, and received dialysis. Review of Resident #13's care plan revealed a 11/25/22 Activity of Daily Living (ADL) self-care performance deficit related to fatigue and limited mobility. Physician orders included a 08/16/22 order for ear wax removal drops 6.5 percent three drops in each ear for three days then irrigate with flush on day four, a 12/29/22 order for Debrox solution instill one drop in right ear one time a day for ear wax for three days, and a 01/04/23 order for Debrox Solution instill four drops in both ears for three days then irrigate on the fourth day. Interview 01/10/23 at 4:03 P.M. with Resident #13 revealed his right ear was muffled. He indicated he had ear drops and they did not help. They just put the drops in one ear (right), not the left ear. He said they did not flush out his ear after the drops. Resident #13 did not recall being provided a hearing test at the facility. He indicated the left ear was getting plugged also. Review of the Medication Administration Record (MAR) revealed the first two days of ear drops were not signed off as administered on 12/29/22 and 12/30/22. Resident #13 had the drops administered once on 12/31/22. The record revealed no evidence of the resident's ears being irrigated as ordered. There was no evidence of the resident seeing an audiologist or an Eye, Ear, Nose and Throat (ENT) physician related to muffled ear sound. Interview 01/10/23 at 4:58 P.M. with Registered Nurse (RN) #478 verified there was no evidence of the facility flushing Resident #13's ears as ordered after drops were instilled. Interview 01/10/23 at 5:38 P.M. with Licensed Social Worker (LSW) #438 revealed audiology came to the facility. They also transported residents to audiology if requested. She included Resident #13 had not gone to see the audiologist. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 22 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the Debrox product instructions revealed pictures on how to apply drops into ear. There was also a photo on how to insert washer into the ear. Interview 01/11/23 at 10:32 A.M. with the Director of Nursing (DON) included she did not know if they were allowed to irrigate ears at the facility. She knew the order indicated to irrigate but she needed to talk to the doctor and she would want to train staff on how to irrigate ears. The DON indicated Resident #13 had Debrox several times without result and needed to see an ENT. Interview 01/11/23 at 10:54 A.M. with Unit Manager #478 verified the first two days of ear drops were not administered on 12/29/22 and 12/30/22 as ordered. 2. Review of Resident #188's medical record revealed an admission [DATE] with diagnoses including hypertension, vertigo, hyperlipidemia, neoplasm of bladder, acute gastritis with bleeding and duodenal ulcer. Review of the admission assessment included Resident #188's cognition was intact. Observation and interview 01/09/23 at 1:16 P.M. revealed Resident #188 was sitting on the side of her bed. Swelling of bilateral lower extremities (BLE) feet and ankles was observed. Resident #188 revealed the swelling was new and indicated she was not on a diuretic (water pill) and did not wear support hose. Review of Resident #188's weights revealed a weight of 120.6 pounds on 12/29/22 and 130.8 pounds on 01/10/23, a 10.2 pound weight gain. Observation of Resident #188 on 01/12/23 at 9:12 A.M. revealed the resident was sitting on the side of the bed crocheting. The resident continued with BLE edema. Interview 01/12/23 at 5:02 P.M. with Resident #188 included her feet were still swollen. Resident #188 said the doctor saw the swelling and was going to order a water pill but she had not been given one. Resident #188 said she was going home the next day, 01/13/23. Interview 01/12/23 at 5:06 P.M. with Registered Nurse (RN) #453 revealed the Nurse Practitioner (NP) made rounds daily. RN #453 was unaware if the NP knew of the BLE edema. RN #453 looked through the 24 hour reports and found a note on the 01/05/23 report related to Resident #188. The note included the resident had an eight-pound weight increase, two plus edema to BLE and complained of shortness of breath (SOB) during therapy. The note on the 24-hour report was written by RN #452. Interview 01/12/23 at 5:09 P.M. with RN #452 included the NP spoke to Resident #188 about the swelling and wanted to check her kidney function. The NP wanted to do lab work first before giving a diuretic. A Complete Metabolic Panel (CMP) and Complete Blood Count (CBC) were ordered. The blood was collected 01/09/23 and reported on 01/09/23. Blood Urea Nitrogen (BUN) laboratory result was high at 39 milligrams per deciliter (mg/dl), the creatinine was 1.2 mg/dl, Blood Urea Nitrogen (BUN)/creatinine ratio high at 33 mg/dl. The levels were normal on 12/30/22 with a BUN at 19 mg/dl. There were no further interventions ordered. Review of a 01/13/23 progress note included the physician was updated Resident #188 had bilateral pitting edema. The resident complained of shortness of breath during therapy. The resident had a nine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 23 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some pound weight gain. The physician was aware of labs and ordered Lasix (a diuretic), 40 milligram (mg) for three days. The physician stated the resident was weak and would need monitored for the Lasix therapy. Review of the Physician orders revealed the order for the Lasix 40 mg was not written until 01/17/23. Review of the Medication Administration Record revealed Resident #188 was not administered a first dose of Lasix until 01/17/23. Observation and interview 01/17/23 at 8:34 A.M. revealed Resident #188 was sitting on the side of her bed. Her feet, ankles and lower legs were edematous with 2 plus (3-4 millimeters of depression, rebounding in 15 seconds or less) edema. Resident #188 said she did not go home due to the swelling in her legs. She said they started her on a diuretic. Interview 01/17/22 at 11:22 A.M. with RN #453 verified the doctor ordered Lasix 40 mg for three days on Friday, 01/13/23. RN #453 verified she wrote the progress note on 01/13/23 indicating the physician was notified and ordered Lasix. RN #453 verified she did not write a telephone order for the Lasix. She indicated she thought the NP would write the prescription when he made rounds. RN #453 revealed she did not know why no one called for the prescription. RN #453 noticed on 01/17/23 the Lasix order was never written so RN #453 started the Lasix. RN #453 verified the Lasix 40 mg for three days should of been started 01/13/23 and was started five days after the physician gave the verbal order for Lasix. 3. Review of Resident #5's medical record revealed she was admitted to the facility on [DATE] with the diagnoses of wedge compression fracture of Thoracic 11- Thoracic 12 vertebra, shortness of breath, and chronic peripheral venous insufficiency. Review of Resident #5's admission Minimum Data Set (MDS) 3.0 assessment, dated 11/08/22, revealed she was cognitively independent and had active diagnoses of fractures and other multiple trauma, coronary artery disease, shortness of breath, and received one diuretic in the last seven days. Review of Resident #5's physician order, dated 11/02/22, revealed she was to wear compression/support socks one time a day. Review of Resident #5's Treatment Administration Records (TARs), dated 11/22, 12/22, and 01/23, revealed the compression socks were documented as having been applied daily as ordered. Review of Resident #5's nursing progress notes since admission revealed multiple entries regarding edema to her lower legs and feet. There was no documentation regarding compression socks or the refusal of compression socks. Observation on 01/09/23 at 12:57 P.M. of Resident #5 sitting in her chair with her feet on the floor. Her feet were swollen, and she was wearing regular socks. An interview at the time with Resident #5 revealed she did not have her slippers on due to the swelling in her feet. She reported she had not been wearing her compression socks for a while. Observation on 01/10/23 at 3:32 P.M. of Resident #5 sitting in a wheelchair with a young female visitor in her room. Resident #5's feet were noted to be swollen and she was wearing regular socks. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 24 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview on 01/11/23 at 2:30 P.M. with a family member of Resident #5 revealed Resident #5 had swelling in her feet for years and wearing compression socks and elevating her feet usually helped. An observation at the time of interview revealed Resident #5 was wearing regular socks and her feet and lower legs were swollen. Observation on 01/12/23 at 8:00 A.M. of Resident #5 up in bathroom with assistance of State Tested Nurse Assistant (STNA) # 444. Resident #5 was wearing regular socks. Observation on 01/12/23 at 9:40 A.M. of Resident #5 sitting in chair with her feet elevated and wearing regular socks. An interview at the time with Resident #5 revealed the staff had not been putting her compression socks on for a while. She reported that one of the staff members said the socks were making the swelling worse. Observation on 01/12/23 at 9:44 A.M. with Registered Nurse (RN) #452 verified the compression socks were not on Resident #5, but they were in the top drawer of her chest of drawers. RN #452 reported that sometimes Resident #5 did not want to wear the compression socks. An interview on 01/12/23 at 9:46 A.M. with Resident #5 revealed she had never refused her compression socks. An interview on 01/12/23 at 10:21 A.M. with STNA #444 revealed she did not know Resident #5 had compression socks and she did not put them on her on 01/11/23 or 01/12/23. STNA #444 reported the nurses did not inform her to put them on Resident #5 and the socks were not on her sheet that informed the STNAs what care each resident needed. An interview on 01/12/23 at 10:26 A.M. with RN #453 revealed the order for Resident #5's compression socks was on the TAR and the nurse was to direct the STNAs to apply to compression socks. 4. Review of Resident #25's medical record revealed he was admitted to the facility on [DATE] with the diagnoses of mild intellectual disabilities, major depressive disorder, insomnia, anxiety disorder, cerebral palsy, constipation unspecified and essential hypertension. Review of Resident #25's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/18/22, revealed he was cognitively impaired and had an active diagnosis of constipation. Review of Resident #25's physician order, dated 09/04/22, revealed an order for Dulcolax tablet delayed release (Bisacodyl) give 5 milligram (mg) by mouth every 24 hours as needed for constipation. Review of Resident #25's bowel movement documentation completed by State Tested Nurse Assistants revealed he had several days without a bowel movement. Review of Resident #25's Medication Administration Record (MAR) for 09/22 revealed no Dulcolax was administered when he did not have a bowel movement from 09/23/22 to 09/26/22. Review of Resident #25's MAR for 10/22 revealed no Dulcolax administered when he did not have a bowel movement from 10/03/22 to 10/08/22, from 10/10/23 to 10/13/22, and from 10/20/22 to 10/26/22. Review of Resident #25's MAR for 11/22 revealed Dulcolax was administered on 11/08/22 when he had not had a bowel movement from 11/04/22 to 11/08/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 25 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Review of Resident #25's MAR for 01/23 revealed Dulcolax was administered on 01/06/23 when he had not had a bowel movement from 01/02/23 to 01/06/23. An interview on 01/11/23 at 9:31 A.M. with Registered Nurse (RN) #453 and Licensed Practical Nurse (LPN) #498 verified that Resident #25 did not receive as needed medications for constipation as ordered by the physician. Both revealed that if a resident did not had a bowel movement for three days, then on the fourth day an intervention should be initiated. Both RN #453 and LPN #498 revealed that if a resident had an as needed medication order for constipation, then it should be administered on day four of not having a bowel movement. Event ID: Facility ID: 365838 If continuation sheet Page 26 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, observation, staff interviews and facility policy review, the facility failed to ensure Resident #31 was turned and repositioned every two hours, failed to have a treatment order in place for four days for a new open area, and failed to have weekly measurements and assessments documented in the resident's medical record. This affected one resident ( Resident #31) of two residents reviewed for pressure ulcers. Residents Affected - Few Findings include: Review of the medical record revealed Resident #31 was admitted to the facility on [DATE]. Current diagnoses included psychosis, adult failure to thrive, bipolar disorder, anxiety disorder, protein-calorie malnutrition, ventricular tachycardia, osteoarthritis of the knees, chronic kidney disease, visual hallucinations, major depressive disorder, restless leg syndrome, insomnia, hypertension, and diabetes. Review of the quarterly Minimum Data set assessment dated [DATE] revealed Resident #31 had intact cognition, required extensive assistance od two staff members for bed mobility ,was incontinent of bladder and bowel, and had no unhealed pressure ulcers. Review of November 2022 treatment administration record revealed Resident #31 had an order for moisture barrier cream after each incontinence episode dated 08/23/22. Review of the Treatment Administration Record (TAR) revealed no documentation of a treatment order from 10/08/22 to 10/12/22 for Resident #31's coccyx and left buttock area. Review of the progress note dated 11/10/22 timed 1:17 A.M. revealed Resident #31 had an open area to her coccyx with foam to pad and protect. Review of the progress note dated 11/11/22 at 10:00 P.M. revealed the dressing to the moisture associated skin damage to buttocks/coccyx of Resident #31 was soiled. The area was cleansed and the dressing was changed. Further review of the physician's orders revealed Resident #31 had an order dated 11/12/22 for a dressing to the buttock/coccyx, change every day, cleanse per protocol, and apply Mepilex. Review of November 2022 TAR revealed Resident #31 had an order for dressing to the buttocks/coccyx every day, apply Mepilix dated 11/13/22 which was discontinued on 11/15/22. Review of the wound note dated 11/15/22 at 1:14 P.M. revealed Resident #31 had a new Stage III pressure ulcer (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed) to the coccyx and left buttock with a new onset date on 11/08/22. The wound measured 3.5 centimeters (cm) by 7.0 cm by 0.1 cm with 30 percent slough (dead tissue), small amount of serosanguinous drainage. A new order was obtained to cleanse with Normal saline, apply Medihoney to wound bed, cover with foam daily and as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 27 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 needed. Level of Harm - Minimal harm or potential for actual harm Review of the plan of care dated 11/15/22 revealed Resident #31 had a stage III pressure ulcer from the coccyx to the right buttock or had a potential for pressure ulcer development related to immobility. Interventions included avoid positioning on her back, administer treatments as ordered, assess/record/monitor wound healing weekly, length, width and depth where possible. Residents Affected - Few Review of the medical record revealed there was no evidence a skin assessment or measurements were obtained on 11/22/22. Review of the wound note dated 11/29/22 revealed Resident #31 had a Stage III pressure ulcer to the left buttock. The area measured 7.5 cm by 3.0 cm by 0.3 cm with 40 percent slough, moderate amount of serosanguinous drainage. Continue the same treatment. The wound was improving. Review of the progress note dated 01/01/23 at 8:00 A.M. revealed Resident #31 had a black area to the left calf measuring 2.5 cm by 1.1 cm and a pink area to the right knee measuring 2.4 cm by 1.2 cm and a new order was obtained for a pillow to be placed between the legs/bony prominence to prevent skin breakdown. Review of the January 2023 physicians orders revealed Resident #31 had orders for pressure reducing mattress with overlay to prevent skin breakdown, wheelchair support cushion as tolerated, wound team to see and suggest treatment, moisture barrier cream after each incontinence episode, pressure relieving boots as tolerated, and apply 250 milligrams of Flagyl (oral antibiotic) to the coccyx wound topically daily. Further review of the medical record revealed there was no evidence a skin assessment or measurements were obtained on 01/10/22. Continuous observations on 01/11/23 from 8:22 A.M. through 12:10 P.M. revealed Resident #31 was on her back in the same position without facility staff changing her position. At 10:23 A.M. Register Nurse (RN) #465 administered morphine sulfate to Resident #31 for complaints of pain On 01/11/22 at 11:58 A.M. interview with RN #465 revealed dependent residents were to be turned and repositioned every two hours. On 01/11/23 at 12:01 P.M. interview with State Tested Nursing Assistant (STNA) #413 revealed she had not turned or repositioned Resident #31. Observation on 01/11/23 at 12:10 P.M. revealed Resident #31 was on her back, the air mattress on her bed was set at static low air loss and at 150 pounds. There was a small amount of drainage from the bottom of her coccyx foam dressing on the bed pad. There was a small amount or redness at the top of her spine between her shoulder blades but unable to see her coccyx due to the large foam dressing covering her entire coccyx and buttocks. On 01/11/23 at 12:10 P.M. interview with STNA #433 revealed she was not sure what time she turned Resident #31 last but it was right after breakfast. She verified it had been over three and half hours since they has last turned Resident #31. Observation on 01/11/23 at 2:51 P.M. revealed Resident #31 was positioned on her back. Interview at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 28 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 this time with STNA #413 verified Resident #31 was not to be positioned on her back. Level of Harm - Minimal harm or potential for actual harm Observation of wound care on 01/11/23 at 12:45 P.M. revealed Licensed Practical Nurse (LPN) #498 and RN #478 providing wound care to the coccyx of Resident #31. During the procedure LPN #498 did not wash her hands or change her gloves after cleaning the coccyx wound with wound wash and gauze. LPN #498 then proceeded to pick up a clean four-by-four gauze placing the crushed Flagyl on the four-by-four gauze and picking up the gauze with her contaminated/unclean gloves and placing onto Resident #31's coccyx. The coccyx wound was very large with black tissue around the edge of the wound, the wound bed was bright red with a large amount of tan colored drainage. The old dressing was not dated as to when it was applied, this was verified at the time of the observation by LPN #498. Residents Affected - Few On 01/11/23 at 4:00 P.M. Interview with LPN #498 revealed the facility did not stage a wound until the wound nurse came in and evaluated the wound. The wound nurse gave orders over the phone for treatments until she visited. LPN #498 stated all the wound measurements/grids were documented in the nursing progress notes. On 01/11/23 at 4:19 P.M. interview with LPN #498 verified there was no documented treatment order for Resident #31's coccyx wound until 11/13/22. LPN #498 also verified moisture barrier cream was not appropriate for an open area. On 01/12/23 at 10:53 A.M. an interview with RN #478 revealed the wound team did not come into the facility on [DATE] and verified there was no documentation in the computer regarding wound care on 11/22/22. RN #478 indicated wound care was provided and since there was no change in the wound they did not put document in the computer. RN #478 stated on 01/10/23 the wound team gave up Resident #31's wound care to hospice. RN #478 verified there were no wound measurements or skin assessment document in Resident #31's chart. Review of the facility policy titled, Turning and Repositioning, dated 10/17/19 revealed the facility understood the need for residents to change position periodically to avoid muscles stiffness, skin breakdown, and pressure ulcers. Because too much pressure on one area for too long could cause a decrease in circulation, pressure ulcers could develop. The facility would turn and reposition periodically. Bed bound resident should be turned and reposition at least every two hours. Review of the facility policy titled, Dressing Change Policy, dated 11/13/20 revealed the purpose of the procedure was to provide guidelines for dressing changes to protect wounds from injury and to prevent the introduction of bacteria. Review of the facility policy titled, Pressure Ulcer Protocol, dated 11/13/20 revealed a Stage III was a full thickness loss extending through the dermis, to involve the subcutaneous tissue, presented as a shallow crater. Slough could be present. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 29 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure falls risk interventions were consistently implemented. This affected one out of two residents reviewed for accidents (Resident #16). The facility census was 68. Findings include: Review of Resident #16's medical record revealed diagnoses including schizoaffective disorder, vascular dementia without behavioral disturbance, delusional disorders, unspecified psychosis, bipolar disorder, major depressive disorder, insomnia, syncope, peripheral vascular disease, and osteoarthritis. A falls risk assessment dated [DATE] revealed Resident #16 was at risk for falls related to need for assistance with transfer, poor balance, syncope, and inability to walk without assistance. Review of the Minimum Data Set (MDS) assessment completed 11/10/22 revealed Resident #16 was cognitively intact and required extensive assistance for bed mobility and transfers. Review of the care plan interventions triggered from the MDS assessment completed on 11/10/22 indicated Resident #16 needed a tilt and space wheelchair, frequent rest periods to prevent fatigue, ensure call light was in reach, mat to floor beside bed due to resident rolled out of bed and liked to lay sideways in bed. Observation on 01/10/23 at 8:45 A.M. revealed Resident #16 resting quietly in lowered bed with an anti-roll wedge in place, and call light in reach. There was not mattress/pad on the floor beside the bed as care planned. Interview on 01/10/23 at 8:45 A.M. with Registered Nurse (RN) #440 confirmed Resident #16 was in bed and there was no mattress/pad on the floor beside Resident #16's bed. Observation on 01/11/23 at 2:40 P.M. revealed Resident #16 resting quietly in bed and there was no mattress/pad on the floor beside the bed. Interview on 01/11/23 at 2:42 P.M. with State Tested Nurse Aide (STNA) #413 verified the mattress/pad was not on the floor beside the bed as care planned. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 30 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 observations, interviews, and record review the facility failed to obtain an order for oxygen administration for Resident #9. This affected one of two residents (Resident #9) reviewed for oxygen administration. The facility identified 35 residents on oxygen therapy, Residents #3, #5, #6, #7, #9, #12, #13, #16, #18, #19, #21, #27, #31, #33, #34, #35, #36, #37, #38, #39, #46, #47, #48, #49, #53, #57, #59, #60, #66, #67, #71, #73, #184, #187, and #284. Residents Affected - Few Findings include: Review of medical records for Resident #9 revealed diagnoses of acute on chronic systolic congestive heart failure, acute bronchospasm, obstructive sleep apnea, chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #9 was cognitively intact and had continuous oxygen in use. Review of the Care Plan for Resident #9 dated 08/24/22 revealed the resident had altered respiratory status/difficulty breathing related to COPD. The care plan addressed signs and symptoms of poor oxygenation and administering aerosols and inhaled medications as needed. There was no mention of using oxygen continuously. Review of Resident #9's physician orders revealed there was not an order for use of continuous oxygen. Observation on 01/09/23 at 2:46 P.M. revealed Resident #9 with oxygen flowing at three liters per minute via nasal cannula. During an interview on 01/10/23 at 1:50 P.M., Resident #9 stated she had been using oxygen for 20 years. Resident #20 had a portable oxygen saturation monitor and checked her oxygen saturation once or twice a day and when not feeling well. Resident #20 said her goal was to keep her oxygen saturation between 93 95 percent but it had decreased as low as 88 percent when she was not feeling well. Interview on 01/10/23 at 2:00 P.M. with Registered Nurse (RN) #440 confirmed there was no oxygen order in Resident #9's medical record. Interview on 01/10/23 at 4:55 P.M. with Unit Manger #478 revealed there was no facility policy for oxygen administration. Each individual resident's order was used to guide practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 31 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on record review an interview, the facility failed to assess a fistula for dialysis access. This affected one (Resident #13) of one resident reviewed for dialysis. The facility identified three (Residents #13, #51 and #70) residents in the facility receiving hemodialysis. Residents Affected - Few Findings include: Review of Resident #13's medical record revealed a 07/30/19 admission with diagnoses including chronic respiratory failure with hypoxia, morbid severe obesity, type 2 diabetes with diabetic neuropathy, hyperlipidemia, chronic atrial fibrillation, congestive heart failure, hypertension, chronic obstructive pulmonary disease, dependence on renal dialysis, peripheral vascular disease, and depression. Further review of Resident #13's record revealed the fistula was placed in the left upper arm on 08/15/22. The discharge instructions included check your fistula/graft everyday. If the sensation/thrill feels different or you don't feel it at all, call your physician immediately. If the area is red, swollen, painful, oozing, has a bad odor, or feels bad when touched call your physician, If you develop fever of chills, call your physician. Review of the 09/30/22 Quarterly Minimum Data Set assessment revealed Resident #13 was independent for daily decision making, had adequate hearing without an aide, required extensive assist of two for bed mobility, was totally dependent of two for transfers, did not walk, required extensive assist of two for dressing, toileting, personal hygiene, and was independent set up only for eating, and received dialysis. Review of Resident #13's plans of care revealed a 11/21/22 plan indicating Resident #13 required hemodialysis related to chronic kidney disease. Interventions included to monitor fistula/graft for signs and symptoms of infection, hemorrhage, along with bruit and thrill (if fistula or graft). Report abnormal finding to physician and dialysis center. Review of the physician orders revealed Resident #13 received hemodialysis on Tuesday, Thursday and Saturday. There was no order to monitor the fistula site daily for bruit and thrill. There was not an order if the sensation/thrill felt different or was not felt at all to call physician immediately, if the area was red, swollen, painful, oozing, had a bad odor, or felt bad when touched to call physician, or if fever of chills, call physician. Review of the treatment sheets revealed no evidence of the fistula site being assessed daily. Review of the progress notes from 12/12/22 through 01/11/23 revealed one fistula assessment was documented in the time period on 12/30/22. Interview of Resident #13 on 01/10/23 at 4:19 P.M. included he had been going to hemodialysis since March 2022. He revealed he had a fistula in the left upper arm that he was receiving his dialysis perfusion through. He stated during dialysis treatments he still was not pumping as much through the fistula as they wanted so they switched and used the port in his chest. He indicated he returned from dialysis with a dressing over his fistula that was removed the next day. He revealed in dialysis they always checked his fistula but at the facility there was only one nurse who had checked the fistula. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 32 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Level of Harm - Minimal harm or potential for actual harm Interview 01/11/23 at 10:47 A.M. with Registered Nurse (RN) #478 verified there was no evidence of the fistula cite being assessed except one entry in the progress notes in the last month. RN #478 included the order to check the fistula site must not have been entered as ordered on the 08/15/22 discharge instructions. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 33 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review the facility failed to ensure residents were assessed for the risk of entrapment from bed rails prior to their use. This affected two residents (#14 and #20) of five residents reviewed for accidents. The facility census was 68. Findings include: 1. Review of Resident #14's record revealed an admission date do 10/03/22 with the diagnoses of paroxysmal atrial fibrillation, essential hypertension, a history of falling, muscle weakness, and unspecified fall, subsequent encounter. Review of Resident #14's admission Minimum Data Set (MDS) 3.0 assessment, dated 10/10/22, revealed the resident was cognitively independent, needed extensive assistance of one person to assist with bed mobility, and needed limited assistance of one person to assist with transfer and toilet use. Review of Resident #14's bed rail assessment dated [DATE] revealed it was not completed. Review of Resident #14's current physician orders revealed no order for use of bed rails. Observation on 01/09/23 at 9:41 A.M. revealed Resident #14 lying in bed with one-half bed rails to the upper end of bed in the raised position. Observation on 01/10/23 at 7:30 A.M. revealed Resident #14 lying in bed with one-half bed rails at the upper end of the bed in the raised position. An interview on 01/10/23 at 1:19 P.M. with State Tested Nurse Assistant (STNA) #459 verified Resident #14 had one-half bed rails to the upper part of her bed and they were raised when she was in the bed. An interview on 01/11/23 at 9:45 A.M. with Registered Nurse (RN) #453 verified Resident #14 did not have an assessment for the use of bed rails. 2. Review of Resident #20's medical record revealed an admission date of 10/26/22 with diagnoses of atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified severe protein-calorie malnutrition, chronic obstructive pulmonary disease, weakness, and hypertension. Review of Resident #20's admission MDS 3.0 assessment, dated 11/02/22, revealed the resident was cognitively independent and needed limited assistance of one person to physically assist with bed mobility, transfer, and toileting. Review of Resident #20's bed rail assessment dated [DATE] revealed it was not completed. Review of Resident #20's current physician orders revealed no order for bed rails. Observation on 01/09/23 at 10:52 A.M. revealed Resident #20's lying in bed with one-half bed rails (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 34 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 0700 to the upper end of bed in the raised position. Level of Harm - Minimal harm or potential for actual harm Observation on 01/10/23 at 7:20 A.M. revealed Resident #20 lying in bed with one-half bed rails to the upper end of bed in the raised position. Residents Affected - Few An interview on 01/10/23 at 1:19 P.M. with STNA #459 verified resident #20 was lying in her bed and had one-half bed rails to the upper part of her bed in the raised position. Observation on 01/10/23 at 03:28 P.M. of Resident #20 lying in bed with one-half bed rails to the upper end of bed raised. An interview on 01/11/23 at 9:45 A.M. with RN #453 verified Resident #20 did not have an assessment for the use of bed rails. Review of the facility policy titled, Proper Use of Bed Rails, undated, revealed an assessment must be made to determine the resident's symptoms or reason for using bed rails. When used for mobility or transfer, an assessment should include a review of the resident's bed mobility; and ability to transfer between positions, to and from bed or chair, to stand and toilet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 35 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and interview, the facility failed to ensure Resident #26 did not receive excessive doses of antibiotics. This affected one (Resident #26) of two residents reviewed for antibiotic use. The facility identified six additional residents receiving antibiotics at the time of the survey (Residents #12, #22, #31, #70, #133 and #284). Facility census was 68. Residents Affected - Few Findings include: Review of Resident #26's medical record revealed diagnoses including peripheral vascular disease, arthritis, anemia and depression. On 08/29/22, an order was written for administration of cephalexin (antibiotic) 500 milligrams (mg) four times a day for a wound to start 09/01/22. The order indicated the stop date for the antibiotic was to be determined at the next wound appointment. A wound center note dated 08/31/22 indicated Keflex was ordered by the Infectious Disease doctor. An order from the Infectious Disease doctor dated 08/31/22 indicated cephalexin 500 mg was to be administered three times a day. There was no evidence the order from the Infectious Disease doctor was transcribed or the physician was notified to discontinue the original order to administer the cephalexin four times a day. Medication Administration Records revealed Resident #26 received two doses of the cephalexin on 09/01/22 then four doses of cephalexin every day until 11/16/22 when the order was decreased to three times a day. Review of a wound note from Certified Nurse Practitioner (CNP) #700 dated 11/08/22 indicated Resident #26 was seen for re-evaluation and management of a left knee abscess in the setting of an infected prosthetic knee joint. It was a chronic and reoccurring wound over the past several months. The note indicated no follow up with Infectious Disease was noted and gave instructions to follow up with infectious disease regarding the long term antibiotic plan. An order written 11/08/22 to follow up with infectious disease was discontinued on 11/10/22 without documentation as to the rationale. On 01/11/23 at 4:08 P.M., the Director of Nursing (DON) verified the cephalexin ordered by the infectious disease doctor was not transcribed on 08/31/23 and the resident should have only been receiving the cephalexin three times a day. The DON stated she had been told Resident #26 had canceled a couple appointments previously but was unable to state with certainty if an appointment with the Infectious Disease doctor had been made after the order was given on 11/08/22 or why it was discontinued. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 36 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 - Few 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 staff interview the facility failed to ensure ophthalmic (eye drops) medication was dated as to when opened and discarded after eight weeks. This affected one of 10 residents receiving eye drops, Resident #11. Findings include: Observation of medication storage on 01/11/23 at 9:39 A.M. with Registered Nurse (RN) #478 revealed one bottle of latanoprost eye drops for Resident #11 with a handwritten date of 10/31 with no year indicated. The pharmacy sticker on the bottle indicated to discard six weeks after opening if not refrigerated. RN #478 verified the latanoprost eye drops should have been discarded. Review of manufacturer guidelines for the storage and handling of latanoprost eye drops revealed unopened bottle should be stored refrigerated at 36 degrees Fahrenheit (F) to 46 degrees F. Once a bottle is opened it may be stored at 36 degrees F to 77 degrees F for eight weeks. Protect from light. Protect from freezing. Interview on 01/11/23 at 9:45 A.M. with Pharmacy Technician #701 indicated all eye drops were to be discarded after six weeks if not stored in the refrigerator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 37 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview and facility policy review the facility failed to provide food in a form to meet the nutritional needs of residents. This had the potential to affect eight residents (#23, #31, #32, #38, #42, #57, #61, and #286) receiving a pureed diet. The facility census was 68. Findings include: Observation on 01/10/23 at 8:55 A.M. revealed Dietary Aid (DA) #494 place seasoned cooked cubed chicken in the Robot Coupe and pureed the chicken. DA #494 added broth and continued to puree the chicken. When DA #494 was done, she tasted the chicken and reported it was ready to serve. Observation of the pureed chicken revealed the texture was rough. Upon tasting the pureed chicken it was stringy and needed to be chewed. Dietary Supervisor #499 looked at the pureed chicken as she was getting ready to taste it and stated she could tell from looking at it that the chicken puree was not the correct consistency. Dietary Supervisor #499 reported it did not look like mashed potatoes and it should. Review of the Diet Order Tally Report - All Special Diets dated 01/09/23, revealed Residents #23, #31, #32, #38, #42, #57, #61, and #286 received a pureed diet. Review of the facility's undated policy Puree Preparation Standard revealed puree thickness should be the consistency of pudding. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 38 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility policy review the facility failed to ensure food was stored under sanitary conditions. This had the potential to 67 residents receiving food from the facility's kitchens. One resident (#3) did not receive nutrition from the kitchen. The facility census was 68. Findings include: 1. Observation on 01/10/22 at 9:43 A.M. of the Garden Unit Nutrition Refrigerator thermometer revealed a temperature of 52 degrees Fahrenheit (F). This was verified at the time of observation by Registered Nurse (RN) #440. An interview at the time with RN #440 revealed the temperature should be less than 39 degrees F. Items in the refrigerator were soda, pudding, and condiments. Review of the facility policy titled, Food Safety and Sanitation, undated, revealed stored food was to be handled to prevent contamination and growth of pathogenic organisms by having refrigerated food stored at or below 41 degrees Fahrenheit. 2. Observation on 01/09/23 at 8:50 A.M. revealed the ice machine had dark spots on the plastic guard and dark substance in the ice. Dietary Supervisor #415 verified at the time of the observation that the ice machine plastic guard should not have black spots on it and there should not be a black substance in the ice. Review of the kitchen 2021 to 2022 Ice Machine Inspection form revealed it was last inspected, cleaned, and sanitized on 12/14/22. 3. Observation on 01/11/23 at 11:55 A.M. of the ice machine in the 900-unit revealed a black substance on the white guard and dirty vents in the front of the ice machine. This was verified at the time of observation by Dietary Supervisor #499 and Chef #439. Chef #439 reported he did not know the last time it was cleaned because the maintenance department took care of cleaning the ice machine. Review of the 900-unit 2021 to 2022 Ice Machine Inspection form revealed it was last inspected, cleaned, and sanitized on 12/04/22. Review of the facility policy titled, Food Production Policy, dated 06/20/22, revealed when using mechanized equipment for food production staff were to ensure that the equipment was clean and sanitized prior to use. 4. Observation on 01/09/23 at 8:40 A.M. revealed food items in the main kitchen refrigerators were not labeled and/or dated and expired. Items in the walk-in refrigerator included a container of baked beans not labeled or dated, a container of cream of mushroom soup not labeled or dated, one- and one-half pounds of sliced ham not dated, Jell-O with a used by date of 01/06/23, a one-quart container of biscuits with a use by date of 01/05/23, a one-quart container of chicken noodle soup with a use by date of 01/04/23, a one-quart container of chicken noodle soup with a use by date of 01/07/23. Items in the produce refrigerator included a container of tomato slices not dated, a partially used bag of spinach dated 12/12/22 and liquefied, a bag of green onions which were brown and not dated, and a partial bag of celery which was very limp. All these items were verified at the time of the observation of not being labeled appropriately or used by the date they should have been by Dietary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 39 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Supervisor #415. Level of Harm - Minimal harm or potential for actual harm Review of Diet Order Tally Report - All Special Diets, dated 01/09/23, revealed Residents #3 received no food from the facility kitchens. Residents Affected - Many Review of the facility policy titled, Food Safety and Sanitation, undated, revealed stored food was to be handled to prevent contamination and growth of pathogenic organisms by having time and temperature control for safety (TCS) foods (including leftovers) labeled, covered, and dated when stored. 5. Observation of the 900-unit (Pat's Porch) kitchen on 01/09/23 at 12:10 P.M. with [NAME] #422 revealed the stove door had something brown spilled down the outside of it. [NAME] # 422 verified he had not used the stove today. The trash can had food spilled down the side and on the top of it, there was a plate on the counter with a large amount of butter covered with a plastic wrap with no date. Numerous items in the upstairs kitchen refrigerator were not dated when opened including pitchers of orange juice, cranberry juice, grape juice, sweet tea, unsweetened tea, a quart container of half and half, a quart container of heavy cream, and a Styrofoam container of cut up peppers and onions. There was a half-gallon jug of chocolate milk which expired on 01/04/23. Observation of the dry storage pantry revealed Ziploc storage bags with white chocolate chips, pecans, two bags of milk chocolate chips, two bags of white rice, three bags of pasta with no original package available and no date as to when they were opened. Also, there were two boxes of cherry Jell-O and three bags of vanilla pudding opened in a Ziploc bag with no date as to when they were opened. All the concerns were verified by [NAME] #422 during the tour. 6. Review of the upstairs refrigerator temperature logs on Pat's Porch for December 2022 revealed no documentation temperatures were obtained on 12/01/22, 12/03/22, 12/04/22, 12/05/22, 12/06/22, 12/07/22, 12/23/22, 12/26/22, and 12/27/22. Review of the downstairs refrigerator temperature logs on Pat's Porch for December 2022 revealed no documentation temperatures were obtained on 12/02/22, 12/03/22, 12/04/22, 12/05/22, 12/06/22, 12/07/22, 12/23/22, 2/26/22, and 12/27/22. Review of the dishwasher temperature logs on Pat's Porch for December 2023 revealed no documentation temperatures were obtained on 12/01/22, 12/02/22, 12/03/22, 12/04/22, 12/05/22, 12/06/22, 12/07/22, 12/23/22, 12/26/22 and 12/27/22. Review of the upstairs refrigerator temperature logs on Pat's Porch for January 2023 revealed no documentation temperatures were obtained on 01/01/23, 01/02/23, 01/05/23 and 01/06/23. Review of the downstairs refrigerator temperature logs on Pat's Porch for January 2023 revealed no documentation temperatures were obtained on 01/01/23, 01/02/23, 01/05/23 and 01/06/23. Review of the dishwasher temperature logs on Pat's Porch for January 2023 revealed no documentation temperatures were obtained on 01/05/23 and 01/06/23. On 01/09/23 at 12:20 P.M. an interview with [NAME] #422 verified the temperature logs for the refrigerators and dish washer on the 900 unit were not completed daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 40 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on review of Quality Assessment and Assurance (QAA) meeting sign in sheets and interview, the facility failed to ensure the Medical Director or his designee attended quarterly meetings. This had the potential to affect all 68 residents in the facility. Residents Affected - Many Findings include: Review of the QAA meeting attendance signature sheets revealed there was not a physician present at the 12/30/22 fourth quarter meeting. Interview 01/17/23 at 9:07 A.M. with the Director of Nursing (DON) verified there was not a physician present at the quarterly QAA meeting in December 2022. She stated she was going to have him read the minutes and sign the sheet the next time he came in to the facility. Review of the 2017 Quality Assurance and Performance (QAPI) policy did not include the Medical Director/physician was to attend meetings quarterly as regulated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 41 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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, policy review and interview, the facility failed to ensure appropriate infection control measures were implemented during dressing changes and pericare. This affected one (Resident #31) of two residents reviewed for pressure ulcers and one (Resident #57) resident observed for incontinence care. The facility census was 68. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE]. Current diagnoses included psychosis, adult failure to thrive, bipolar disorder, anxiety disorder, protein-calorie malnutrition, ventricular tachycardia, osteoarthritis of the knees, chronic kidney disease, visual hallucinations, legal blindness, major depressive disorder, restless leg syndrome, insomnia, hypertension, and diabetes. Review of the 09/26/22 Quarterly Minimum Data Set Assessment revealed Resident #31 was independent for daily decision making, required extensive assistance of two staff members for bed mobility, was incontinent of bladder and bowel, was at risk for pressure ulcers, utilized pressure reducing mattress and seat cushion, and had no unhealed pressure ulcers. Observation 01/11/23 at 1:14 P.M. of Resident #31's dressing change to her right knee and left shin with Registered Nurse (RN) #478 and Licensed Practical Nurse (LPN) #498 revealed the resident's old dressings was off. The overbed table was cleansed, a wax paper barrier was placed, and cleaning and dressing supplies were placed on the wax paper. LPN #498 washed her hands and gloved. LPN #498 sprayed Skin Integrity Wound cleaner on the right knee pressure ulcer, which was approximately four inches by one inch, open, bright red with tan/brown slough, and cleaned the wound with a gauze pad. Without removing her gloves or washing her hands LPN #498 sprayed the unstageable left shin pressure ulcer, which was approximately two inches by one inch, open, bright red with tan/brown slough, with Skin Integrity Wound Cleaner and cleansed the area with gauze using the same gloved hand she used to cleanse the right knee pressure ulcer. LPN #498 then removed her gloves and washed her hands, tore off a piece of Maxisorb to size for the right knee pressure ulcer and covered the pressure ulcer with Optifoam. LPN #498 removed her gloves and washed her hands, tore off a piece of Maxisorb to size for the left shin unstageable pressure ulcer and covered with Optifoam. LPN #498 bagged the soiled items for the trash removed gloves and cleansed the overbed table. Interview 01/11/23 at 1:23 P.M. with LPN #498 verified she sprayed the right knee and cleansed the pressure ulcer and then switched to the pressure ulcer on the left shin, cleansed it without changing her gloves and washing her hands. LPN #498 verified cross contamination could occur when using the same contaminated gloves when moving from one wound to another wound. Review of the facility policy titled, Dressing Change Policy, dated 11/13/20 revealed the purpose of the procedure was to provide guidelines for dressing changes to protect wounds from injury and to prevent the introduction of bacteria. The policy did not address how to prevent cross contamination when moving from one wound to another. 3. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE]. Current diagnoses included psychosis, adult failure to thrive, bipolar disorder, anxiety disorder, protein-calorie malnutrition, ventricular tachycardia, osteoarthritis of the knees, chronic kidney (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 42 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 disease, visual hallucinations, major depressive disorder, restless leg syndrome, insomnia, hypertension, and diabetes. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #31 had intact cognition, required extensive assistance of two staff members for bed mobility, was incontinent of bladder and bowel, and had no unhealed pressure ulcers. Observation of wound care on 01/11/23 at 12:45 P.M. revealed Licensed Practical Nurse (LPN) #498 and Registered Nurse (RN) #478 providing wound care to the coccyx of Resident #31. During the procedure LPN #498 did not wash her hands or change her gloves after cleaning the coccyx wound with wound wash and gauze. LPN #498 then proceeded to pick up a clean four-by-four gauze, placed crushed Flagyl on the four-by-four gauze, then placed the gauze onto Resident #31's coccyx. The coccyx wound was very large with black tissue around the edge of the wound, the wound bed was bright red with a large amount of tan colored drainage. Review of the facility policy titled, Dressing Change Policy, dated 11/13/20 revealed the purpose of the procedure was to provide guidelines for dressing changes to protect wounds from injury and to prevent the introduction of bacteria. 2. Review of Resident #57's record revealed the resident was admitted to the facility on [DATE] with the diagnoses of vascular dementia with behavioral disturbance, essential hypertension, type two diabetes, and hyperlipidemia. Review of Resident #57's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/19/22, revealed the resident was rarely/never understood, had short-term and long-term memory problems and was always incontinent of bowel and bladder. Observation on 01/11/23 at 11:09 A.M. of perineal care for Resident #57 by State Tested Nurse Assistant (STNA) #547 and STNA #425 revealed STNA #547 using Resident #57's bedside table without a barrier to hold the supplies (water basin, laundry bag, towels, washcloths, soap, and barrier cream). During the perineal care, STNA #547 splashed water from the basin onto the bedside table with the rinse cloth after using it on Resident #57. STNA #547 hung the washcloth used to rinse Resident #57 over the edge of the basin and water dripped from the washcloth onto the bedside table. When STNAs #547 and #425 were finished, they did not clean or disinfect Resident #57's bedside table. An interview on 01/11/23 at 11:25 A.M., immediately following the completion of the perineal care, with STNAs #547 and #425 verified the bedside table should have been cleaned after perineal care was provided to Resident # 57. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 43 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review the facility failed to ensure sufficient information was obtained prior to initiation of antibiotics. This affected two Residents (#70 and #286) of four residents reviewed for infections. The facility census was 68. Residents Affected - Few Findings include: 1. Review of Resident #70's record revealed the resident was admitted to the facility on [DATE] with diagnoses of encounter for other orthopedic aftercare, chronic kidney disease, intervertebral disc disorders with myelopathy thoracic regions. Review of Resident #70's admission Minimum Data Set (MDS) 3.0 assessment, dated 11/13/22, revealed she was cognitively independent. Resident #70's most recent readmission to the facility was on 12/30/22. Review of Resident #70's nursing progress notes revealed she returned to the facility from an acute care facility on 12/12/22. Review of Resident #70's physician order, dated 12/12/22, revealed Daptomycin Solution Reconstituted (an antibiotic) 500 milligrams (mg), use 500 mg intravenously one time a day every Monday, Wednesday, Friday for a wound wash. Review of Resident #70's Medication Administration Record (MAR) dated 12/22 revealed she received Daptomycin solution reconstituted 500 mg intravenously one time a day every Monday, Wednesday, and Friday for wound wash as ordered. Review of Resident #70's care plan dated 01/04/23 revealed the resident had an infection of the back surgical incision. The goal was the resident would exhibit healing of wounds. Interventions included administer antibiotics as per medical doctor orders, monitor wound condition each treatment, and monitor lab values related to type of infection and report suspicious findings to physician. Review of the McGeer (used to evaluate antibiotic use) form for Resident #70, dated 12/12/22, revealed a handwritten note authored by the Director of Nursing (DON ) indicating the hospital refuses to send culture. An interview on 01/11/23 at 4:09 P.M. with the DON revealed the hospitals were not releasing medical information like culture and sensitivities without a release of information signed by the resident or Power Of Attorney (POA). The DON reported the facility did not have Resident #70 or her POA sign a release of information to obtain the culture and sensitivity to verify the antibiotic was sensitive to the organism causing the infection. On 01/11/23 at 4:45 P.M. Registered Nurse (RN) #453 provided Resident #70's culture and sensitivity, dated 12/08/22, from the hospital. Review of the culture and sensitivity revealed Resident #70's wound was methicillin resistant staphylococcus aureus (MRSA) positive. An interview on 01/12/23 at 8:27 A.M. with RN #453 verified she was able to get Resident #70's culture and sensitivity results by calling the acute care facility and then sending a fax requesting the results. She reported she was able to get the results without a signed release of information. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 44 of 45 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 365838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hennis Care Centre of Dover 1720 Cross Street Dover, OH 44622 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of Resident #286's medical record revealed an admission date of 01/06/23 with the diagnoses of benign prostatic hyperplasia without lower urinary tract symptoms and unspecified protein-calorie malnutrition. Review of Resident #286's admission MDS 3.0 assessment, dated 01/13/23, revealed he was cognitively independent. Review of Resident #286's physician order dated 01/07/23 revealed Resident #286 was to receive ceftriaxone sodium solution reconstituted (an antibiotic) two grams intravenously every 24 hours for infection. Review of Resident #286's Medication Administration Record (MAR) for January 2023 revealed Resident #286 received the ceftriaxone as ordered. Review of Resident #286's McGeer form, dated 01/06/22, revealed it was not completed. None of the boxes were marked to justify the use of the antibiotic for a skin and soft tissue infection. A handwritten note authored by the DON indicated the hospital refused to send lab specimen culture unless family signed release. An interview on 01/09/23 at 7:53 P.M. with Resident # 286 revealed he had an infection in his right hip that must be treated and resolved prior to him getting a total hip replacement. An interview on 01/12/23 at 8:27 A.M. with RN #453 verified she did not have the culture and sensitivity results for Resident #286 and did not know what the organism of the infection was. RN #453 revealed she would have to get a release of information signed by the resident or POA which had not been done. Review of the Medical Director's reports dated 03/22, 04/22, and 05/22 revealed trouble with nurse practitioner following antibiotic stewardship. An interview on 01/12/23 at 12:04 P.M. with the DON, who was the Infection Preventionist, verified the facility nurse practitioner had been educated on the issue of starting antibiotics prior to having culture and sensitivity results. Review of the facility policy titled, Antibiotic Stewardship Program, revised 08/16, revealed culture reports, sensitivity data, and antibiotic usage reviews were included in surveillance activities. Data analysis would include data gathered during surveillance. The surveillance was used to oversee infections and spot trends and the information would be based on infection criteria utilizing the McGeer's criteria related to symptoms and laboratory findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365838 If continuation sheet Page 45 of 45