Inspection·November 9, 2022

F 0610 Level of Harm - Minimal harm or potential for actual harm his physical altercation. She confirmed Resident #27 was very upset the night of the altercation. He stated he wanted a cigarette and to sit on the facility porch to calm down. He let himself out with his cigarette and sat on the porch. She stated after about five minutes, she looked outside to check on Resident #27 and he was not there. She and LPN #118 went to look for him and found him at the bottom of the driveway, being physically hit. She confirmed she only gave a statement to law enforcement. Residents Affected - Few Interview with Administrator on 11/09/22 at 10:50 A.M. revealed the investigation for Resident #27 physical altercation could have been more thorough. She confirmed the facility did not ask for or collect a statement from Resident #27's girlfriend. They also did not collect any other statements from residents/staff in the facility. They only collected written statements from law enforcement for Resident #27, LPN #113, and LPN #118. She stated she did not know Resident #27 knew the code to the exterior door; had she known that she would have investigated further. 2. Review of the medical record for Resident #36 revealed an admission date of 06/23/21 and the diagnoses of hemiplegia, hemiparesis, respiratory failure, aphasia, liver cirrhosis and alcohol abuse. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had a Brief Interview of Mental Status (BIMS) of 00 indicating impaired cognition and he required extensive assistance of two staff for bed mobility and transfers and supervision with set up for eating. The assessment also indicated the resident had unclear speech, he was sometimes understood and sometimes understands. Review of the Social Services Note dated 10/14/22 revealed Resident #36 sometimes understands and was sometimes understood, he had aphasia and unclear speech. He was oriented to person and place and has a memory problem and his daily decision making is impaired. Interview on 11/07/22 at 10:55 A.M. with Resident #36's guardian revealed when asked if there had been any concerns regarding resident to resident abuse, she stated she was told he had juice on him and it appeared the residents room mate (Resident #2) had poured the juice on him. She stated they moved Resident #36's room and it was within the last month. Review of the Certification and Licensure System (CALS: A system used for the facility to notify the state agency of abuse related concerns and investigation details) revealed the facility did not submit a Self-Reported Incident (SRI) from the alleged incident on 10/03/22. Review of the facility investigation for the incident on 10/03/22 revealed the following: The Concern/Grievance Form, dated 10/03/22, revealed it was reported by an agency aide that there was juice spilled on Resident #36's head. The aide made the comment that It could've been his roommate that did it. Resident #36 was interviewed and he felt safe, he does not have problems with residents/roommate, there was no physical injury, mental anguish or pain noted/reported. Resident #36 was moved as a precaution. Review of the paper with interview questions on it revealed Resident #36 stated he felt safe in his environment, he did not recall any problems with past roommates, no residents threw juice on him, and he had no problems with any other residents at the facility. Interview on 11/08/22 at 8:32 A.M. with the Administrator revealed it was reported that it was assumed Resident #2 had poured the juice onto Resident #36 and it was not witnessed. Resident #36 also had made a mess that night so there was no evidence that Resident #2 did anything, but they separated them just as a precaution. She stated she asked staff what happened and that she cant just assume (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366014 If continuation sheet Page 2 of 16 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 366014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Hills Rehabilitation and Nursing Center 416 Wooster Road Mount Vernon, OH 43050 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #2 did it. The Administrator revealed Resident #2 has mild behaviors here and there, most of it is usually towards himself and not others, but nothing towards other residents. She stated there was nothing they could prove and nothing to investigate, there was no altercation or reason to believe anything happened and Resident #36 can answer questions and he didn't feel that he was hurt. Interview on 11/08/22 at 3:38 P.M. with the Administrator revealed there was a concern form created when the incident was reported from the agency staff. As the agency staff was leaving, she made the comment It could have been his roommate. She stated they interviewed Resident #36 and he had no injury or pain or anguish. She stated Resident #36 can answer yes and no questions, but he cant verbalize. The Administrator revealed they completed their investigation in morning meeting when it was reported that day (10/03/22). She revealed she was not sure why Resident #36's guardian would have a concern with the incident, but also stated the staff didn't feel the investigation needed to go any further after they interviewed Resident #36. She stated they decided it was just better if they moved Resident #36 to a different room. Interview on 11/08/22 at 4:10 P.M. with Regional Director of Operations #127 and the Administrator confirmed there was no additional investigation such as interviews with Resident #2 or the agency aide who mentioned the allegation. They stated the agency aide was on the do not return list after that so they did not interview her. They further confirmed the only documentation regarding the incident was the grievance form and the interview paper completed by Social Services #124 . Interview on 11/09/22 at 8:53 A.M. with Resident #2 revealed he remembered his room mate and he didn't know why he left. He stated he was not sure if Resident #36 poured juice on himself, but he didn't pour anything onto Resident #36. He also stated no one had ever asked him about the incident before. Interview on 11/09/22 at 8:55 A.M. with State Tested Nurse Assistant (STNA) #98 revealed Resident #36 could answer yes or no questions appropriately. Interview on 11/09/22 9:00 A.M. with Resident #36 and STNA #98 present revealed Resident #36 was able to answer yes or no questions and STNA #98 was present (with Resident #36's permission) due to her ability to understand the resident more when he attempts to speak. Resident #36 stated he didn't feel abused or neglected but when asked if anyone ever poured juice on him he nodded yes. When asked if it was his old room mate (Resident #2), he nodded yes. When asked if that was why he moved rooms, he nodded yes. STNA #98 asked him if he was asleep when it happened and he nodded yes. Interview on 11/09/22 9:02 AM with STNA #98 revealed the incident occurred on the night shift and when she came in on her next working day she saw Resident #36 was moved. She stated she thinks it was the ADON who told her Resident #2 poured juice or yogurt or something on his head. She stated she had never seen Resident #2 have any behaviors and Resident #36 never had a behavior of pouring things on his head. Interview on 11/09/22 09:37 AM with the Social Services #124 revealed she did her initial interview with Resident #36 on a Monday, she believed the date was 10/03/22, regarding the incident from 10/03/22. She stated she did not document the first interview, but she reinterviewed Resident #36 yesterday and that was the documented interview (see review of the facility investigation). She revealed the Administrator asked her to interview Resident #36 and didn't ask her to interview anyone else. Social Services #124 revealed Resident #36 use to say yes to everything, but he has since came a long way. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366014 If continuation sheet Page 3 of 16 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 366014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Hills Rehabilitation and Nursing Center 416 Wooster Road Mount Vernon, OH 43050 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 11/08/22 at 7:56 A.M. with Licensed Practical Nurse (LPN) #115 revealed about one month ago she heard from night shift that Resident #2 poured a drink on Resident #36. She stated it was unwitnessed and she could not recall what staff notified her about it, but she notified the previous Director of Nursing (DON) and LPN #122. Interview on 11/08/22 at 8:08 A.M. with LPN #122 revealed she arrived to work on a Monday and heard over the weekend Resident #2 poured juice on Resident #36 so she had him moved that day. She stated she notified the Administrator and she could not recall the date or the staff who were working during the incident and she was not sure if there was an investigation. Review of the facility policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated 11/01/19, revealed it is the facilities policy to investigate all alleged violations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of property and injuries of unknown origin. It stated the Administrator or their designee will notify the state agency of all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident, Misappropriation of resident property and injuries of unknown origin as soon as possible, but no later than 24 hours from the time of the incident/allegation was made known to the staff member. It stated once the Administrator and state agency are notified, an investigation of the allegation violation will be conducted. The investigation will be completed within five working days. The following investigation protocol should be followed: interview the resident, the accused, and all witnesses, if there are no direct witnesses, then interviews may be expanded and obtain a statement from the resident, the accused and each witness. It stated the evidence of the investigation should be documented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366014 If continuation sheet Page 4 of 16 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 366014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Hills Rehabilitation and Nursing Center 416 Wooster Road Mount Vernon, OH 43050 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 - Minimal harm or potential for actual harm Residents Affected - Few 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 medical record review, staff interview, and facility policy review, the facility failed to notify the state long term care ombudsman of discharges. This affected one (Resident #42) of two resident discharges reviewed. Findings Include: Resident #42 was admitted to the facility on [DATE]. Her diagnoses were acute respiratory failure with hypoxia, multiple sclerosis, type II diabetes, hypertension, anxiety disorder, major depressive disorder, neuropathy, hyperlipidemia, and osteoarthritis. Review of her Minimum Data Set (MDS) assessment, dated 08/01/22, revealed she was cognitively intact. Review of Resident #42 medical records revealed she was discharged from the facility to the hospital on [DATE]. Review of all her medical records reveal no documentation to support the facility notified the state long term care ombudsman's office of this discharge as required. Interview with Administrator on 11/09/22 at 11:40 A.M. confirmed they have no evidence they contacted the state long term care ombudsman when Resident #42 was discharged to the hospital. She confirmed it should have been completed. Review of facility Transfer of Discharge Documentation policy, dated December 2016, revealed no documentation or guidance within the policy about notifying the state long term care ombudsman about a transfer or discharge. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366014 If continuation sheet Page 5 of 16 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 366014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Hills Rehabilitation and Nursing Center 416 Wooster Road Mount Vernon, OH 43050 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to provide a bed hold notice at the time of discharge to the hospital. This affected one (Resident #42) of two resident discharges reviewed. Findings Include: Resident #42 was admitted to the facility on [DATE]. Her diagnoses were acute respiratory failure with hypoxia, multiple sclerosis, type II diabetes, hypertension, anxiety disorder, major depressive disorder, neuropathy, hyperlipidemia, and osteoarthritis. Review of her Minimum Data Set (MDS) assessment, dated 08/01/22, revealed she was cognitively intact. Review of Resident #42 medical records revealed she was discharged from the facility to the hospital on [DATE]. Review of all her medical records reveal no documentation to support the provided a bed hold notification at the time of hospital discharge as required. Interview with Administrator on 11/09/22 at 11:40 A.M. confirmed they have no evidence they provided a bed hold notification when Resident #42 was discharged to the hospital. She confirmed it should have been completed. Review of facility Bed Hold and Returns policy, dated March 2017, revealed prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366014 If continuation sheet Page 6 of 16 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 366014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Hills Rehabilitation and Nursing Center 416 Wooster Road Mount Vernon, OH 43050 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 medical record review and staff interview, the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASRR) documents were accurate to resident current conditions and diagnoses. This affected two (Resident #20 and Resident #27) of three residents reviewed for PASRR. Findings Include: 1. Resident #20 was admitted to the facility on [DATE]. Her diagnoses were chronic respiratory failure, asthma, chronic obstructive pulmonary disease, osteoarthritis, heart failure, anemia, hypertension, congestive heart failure, anxiety disorder, panic disorder, psychosis, psychotic disorder with delusions, major depressive disorder, and sciatica. Review of Resident #20 PASRR document, dated 12/08/20, revealed under Section D, the diagnoses listed were mood disorder, panic or other severe anxiety disorder, depression, and insomnia. Review of her diagnoses list, she also had the following diagnoses that should have been indicated/updated on her PASRR document: unspecified psychosis, which was added on 07/27/22, and psychotic disorders, which was added on 04/26/22. Review of Resident #20's Minimum Data Set (MDS) assessment, dated 10/26/22, revealed she was cognitively intact. Interview with Social Services Designee #124 on 11/09/22 at 9:35 A.M. confirmed the PASRR documents provided were the most up to date. She confirmed she was not clear on the guidelines when to update the PASRR document. She confirmed Resident #20 had diagnoses that were not listed on PASRR documents and should have been. 2. Resident #27 was admitted to the facility on [DATE]. His diagnoses were encounter for orthopedic aftercare following surgical amputation, diabetes, type II diabetes, moderate protein calorie malnutrition, acute kidney failure, bipolar disorder, post traumatic stress disorder, anxiety disorder, anemia, major depressive disorder, and schizoaffective disorder. Review of Resident #27 PASRR document, dated 02/18/22, revealed under Section D, the document indicated he had no mental health diagnoses. Review of his diagnoses list, he had the following diagnoses that should have been indicated/updated on h PASRR document: bipolar disorder, Post Traumatic Stress Disorder, anxiety disorder, which were added to her diagnoses list on 02/21/22, and schizoaffective disorder, which was added on 04/25/22. Review of his Minimum Data Set (MDS) assessment, dated 09/30/22, revealed he was cognitively intact. Interview with Social Services Designee #124 on 11/09/22 at 9:35 A.M. confirmed the PASRR documents provided were the most up to date. She confirmed she was not clear on the guidelines when to update the PASRR document. She confirmed Resident #27 had diagnoses that were not listed on PASRR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366014 If continuation sheet Page 7 of 16 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 366014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Hills Rehabilitation and Nursing Center 416 Wooster Road Mount Vernon, OH 43050 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 documents and should have been. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366014 If continuation sheet Page 8 of 16 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 366014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Hills Rehabilitation and Nursing Center 416 Wooster Road Mount Vernon, OH 43050 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 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected two (Resident #20 and Resident #27) of three residents reviewed for PASRR. Findings Include: 1. Resident #20 was admitted to the facility on [DATE]. Her diagnoses were chronic respiratory failure, asthma, chronic obstructive pulmonary disease, osteoarthritis, heart failure, anemia, hypertension, congestive heart failure, anxiety disorder, panic disorder, psychosis, psychotic disorder with delusions, major depressive disorder, and sciatica. Review of Resident #20 PASRR document, dated 12/08/20, revealed under Section D, the diagnoses listed were mood disorder, panic or other severe anxiety disorder, depression, and insomnia. But review of her diagnoses list, she also had the following diagnoses that should have been indicated/updated on her PASRR document: unspecified psychosis, which was added on 07/27/22, and psychotic disorders, which was added on 04/26/22. There was no documentation to support these significant mental health changes were communicated to the state mental health agency. Review of her Minimum Data Set (MDS) assessment, dated 10/26/22, revealed she was cognitively intact. Interview with Social Services Designee #124 on 11/09/22 at 9:35 A.M. confirmed the PASRR documents provided were the most up to date. She confirmed she was not clear on the guidelines when to update the PASRR document. She confirmed Resident #20 had diagnoses that were not listed on PASRR documents and should have been. She also communicated she did not notify the state mental health agency when the significant mental health changes were identified. 2. Resident #27 was admitted to the facility on [DATE]. His diagnoses were encounter for orthopedic aftercare following surgical amputation, diabetes, type II diabetes, moderate protein calorie malnutrition, acute kidney failure, bipolar disorder, post traumatic stress disorder, anxiety disorder, anemia, major depressive disorder, and schizoaffective disorder. Review of Resident #27 PASRR document, dated 02/18/22, revealed under Section D, the document indicated he had no mental health diagnoses. But review of his diagnoses list, he had the following diagnoses that should have been indicated/updated on his PASRR document: bipolar disorder, Post Traumatic Stress Disorder, anxiety disorder, which were added to her diagnoses list on 02/21/22, and schizoaffective disorder, which was added on 04/25/22. There was no documentation to support these significant mental health changes were communicated to the state mental health agency. Review of his Minimum Data Set (MDS) assessment, dated 09/30/22, revealed he was cognitively intact. Interview with Social Services Designee #124 on 11/09/22 at 9:35 A.M. confirmed the PASRR documents provided were the most up to date. She confirmed she was not clear on the guidelines when to update the PASRR document. She confirmed Resident #27 had diagnoses that were not listed on PASRR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366014 If continuation sheet Page 9 of 16 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 366014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Hills Rehabilitation and Nursing Center 416 Wooster Road Mount Vernon, OH 43050 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 0646 documents and should have been. She also communicated she did not notify the state mental health agency when the significant mental health changes were identified. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366014 If continuation sheet Page 10 of 16 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 366014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Hills Rehabilitation and Nursing Center 416 Wooster Road Mount Vernon, OH 43050 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. Based on interview, record review and policy review, the facility failed to ensure Resident #1's falls were thoroughly investigated and new interventions were implemented to prevent falls. This affected one resident (Resident #1) out of one residents reviewed for falls. Findings include: Review of Resident #1's medical record revealed an admission date of 04/15/21 with diagnoses including dementia, altered mental status, muscle weakness, and cogitative communication deficit. Review of Resident #1 care plan revealed the resident was at risk for falls related to weakness, deconditioning, unsteady gait, and recent falls. Interventions which were all dated 04/15/21 and included, ensure non skid footwear, bed in lowest position, keep call light within reach, keep frequently used items within reach, and keep room free of clutter. Review of Resident #1's fall investigation information, dated 07/22/22, revealed the resident was found on the floor and was lifted to bed using the hoyer lift. The investigation did not examine how, where, or why the resident fell. The facility did not put in place an intervention to help prevent further falls. Review of Resident #1's fall investigation information, dated 09/22/22, revealed the nurse heard the resident yelling for help and found her sitting on the floor with her legs in front of her and her back against the wall. The investigation revealed the resident was trying to go to the bathroom. The investigation revealed the floor was wet, but did not indicate how they became wet. An intervention was put in place to ensure that the bathroom is free from spills. Further review of the residents care plan revealed the intervention was never put in place. Review of Resident #1's fall investigation, dated 09/24/22, revealed the resident was found on the floor on her right side in the fetal position. The resident stated she hit her head. An assessment was done and the resident was assisted to bed. The investigation did not state how the resident fell, where she fell, or what she was doing to lead to the fall. The intervention was for the resident to keep her bed low. Further investigation into the care plan revealed that an intervention for a low bed was already put into place on 04/15/21. Review Resident #1's quarterly Minimum Data Set (MDS) assessment, dated 10/04/22, revealed the resident had impaired cognition. The resident required extensive assistance of two plus for bed mobility and transfers. Interview on 11/09/22 at 9:49 A.M. with Director of Nursing confirmed the facility was not properly investigating how Resident #1 was falling, did not put proper interventions in place, and was not assessing whether the interventions were implemented after falls. Review of the facility policy, Assessing Falls and Their Causes, dated 10/2010, revealed within 24 hours of a fall the nursing staff will begin to try to identify possible or likely causes of the incident. The facility will refer to resident specific evidence including medical history, known functioning impairment, and staff will also evaluate chains of event or circumstances preceding a recent fall. When a resident falls, interventions will be recorded in the residents medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366014 If continuation sheet Page 11 of 16 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 366014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Hills Rehabilitation and Nursing Center 416 Wooster Road Mount Vernon, OH 43050 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and policy and procedure review, the facility failed to ensure Resident #27's medications were reviewed monthly by a pharmacist and failed to ensure Resident #20 and Resident #21's pharmacy recommendations were timely addressed with appropriate rationale for action taken. This affected three residents (Resident #20, #21 and #27) out of five residents reviewed for unnecessary medications. Findings include: 1. Review of medical record for Resident #27 revealed readmission date of 02/21/22 with no cognitive deficits. The resident was admitted with diagnoses including right leg below amputation, acute kidney failure, bipolar and post traumatic stress syndrome. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was independent with activities of daily living Review of Resident #27 electronic medical record revealed the pharmacist reviewed his medications on 03/29/22 and 4/29/22. Review of Resident #27 paper chart revealed the pharmacist reviewed the residents medications monthly from May 2022 to October 2022 . Interview on 11/08/22 at 2:15 P.M. with Administrator confirmed the facility provided all the pharmacy documentation for pharmacy reviews. She verified a pharmacist did not review Resident #27 medications on 11/2021. 12/2021 ,1/2022 and 02/2022. Review of the Medication Regimen Reviews Policy and Procedure, dated 04/2007, revealed the consultant pharmacist shall review the medication regimen of each resident at least monthly. 2. Resident #20 was admitted to the facility on [DATE]. Her diagnoses were chronic respiratory failure, asthma, chronic obstructive pulmonary disease, osteoarthritis, heart failure, anemia, hypertension, congestive heart failure, anxiety disorder, panic disorder, psychosis, psychotic disorder with delusions, major depressive disorder, and sciatica. Review of Resident #20 pharmacy recommendation, dated 07/22/22, revealed the recommendation for a gradual dose reduction (GDR) for Clonazepam. The pharmacy recommendation was not reviewed and addressed until 09/26/22. Review of her Minimum Data Set (MDS) assessment, dated 10/26/22, revealed she was cognitively intact. Interview with Director of Nursing (DON) on 11/09/22 at 9:49 A.M. confirmed the medication recommendations were completed two months after the initial recommendations were made. She confirmed they should have been reviewed and addressed much sooner. 3. Review of the medical record for Resident #21 revealed an admission date of 09/03/21 and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366014 If continuation sheet Page 12 of 16 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 366014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Hills Rehabilitation and Nursing Center 416 Wooster Road Mount Vernon, OH 43050 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 0756 diagnoses of dementia, depression, bipolar disorder. Level of Harm - Minimal harm or potential for actual harm Review of the care plan dated 09/08/21 revealed Resident #21 used psychotropic medications related to behavior management, dementia and depression with interventions to administer medications as ordered, consult with pharmacy and physician to consider dosage reduction when clinically appropriate at least quarterly. The care plan dated 04/07/22 revealed the resident used antidepressant medications related to depression with interventions to administer medications as ordered and monitor for side effects of the medications. Residents Affected - Few Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition and he was independent for activities of daily living (ADL). Review of the physician orders for Resident #21 revealed order for Aripiprazole 2 milligrams (mg) daily (started 09/10/22) for depression and Citalopram 5 mg daily for depression. From 09/06/21 through 09/10/22 the resident was receiving Aripiprazole 5mg with instructions to administer half of a tablet (to equal 2.5 mg) daily for depression. Review of Resident #21's gradual dose reductions (GDR) revealed the following: On 04/29/22, the pharmacy GDR stated the resident was receiving the following psychoactive medications that were due for review per regulations, Aripiprazole 5 mg with instructions to administer half of a tablet (to equal 2.5 mg) daily for depression and Citalopram 5 mg daily for depression and to consider a dose reduction for one of the two medications. On 05/17/22 the GDR revealed the resident was using Citalopram 5 mg daily since 10/26/21 and if that therapy was required to prevent future depressive episodes, to document to that effect in the notes. The physician check-marked an option to continue the antidepressant therapy and a dose reduction was contraindicated. On 08/10/22 the physician documented (for the 05/17/22 GDR) that they disagreed with the GDR because the mood was stable without a dose reduction. On 08/17/22 the GDR revealed the resident was using Citalopram 5 mg daily since 10/26/21 and if that therapy was required to prevent future depressive episodes, to document to that effect in the notes. The physician check-marked an option to continue the antidepressant therapy and a dose reduction was contraindicated, but there were no further documentation as to why the dose reduction would have been contraindicated. Review of nurses notes revealed on 04/29/22 revealed there was a medication regimen review with a GDR request. On 08/10/22 the Certified Nurse Practitioner (CNP) recommended a GDR was contraindicated for Citalopram 5 mg daily. Interview on 11/09/22 at 9:49 A.M. with the Director of Nursing (DON) confirmed the late GDR review for May 2022 that was reviewed in August 2022 and also confirmed the August 2022 GDR had no rationale for why the recommendation was declined. Interview on 11/09/22 at 9:56 A.M. with the DON confirmed the April GDR was not filled out by the physician and was blank. Review of the facility policy and procedure titled Medication Regimen Reviews Policy and Procedure, dated April 2007, revealed the consultant pharmacist shall review the medication regimen of each resident at least monthly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366014 If continuation sheet Page 13 of 16 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 366014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Hills Rehabilitation and Nursing Center 416 Wooster Road Mount Vernon, OH 43050 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 interview, record review and policy review, the facility failed to ensure Resident #243 was monitored while receiving anticoagulant (blood thinning) medication. This affected one resident (Resident #243) out of five residents reviewed for medication monitoring. Residents Affected - Few Findings include: Review of Resident #243's medical record revealed an admission date of 10/31/22 with diagnoses including chronic atrial tribulation, chronic kidney disease, and hypertension. Review of Resident #243's November 2022 physician orders revealed an order for Apiarian (anticoagulant) 5 milligrams (mg) by mouth two times daily for atrial tribulation. Review of Resident #243's care plan, dated 11/01/22, revealed the resident is ask risk for bleeding related to anticoagulant therapy. Interventions included for the facility to monitor the resident for increased bruising and monitor for signs and symptoms of bleeding. Continued review of the resident's medical record revealed there was no documentation showing the monitoring being done. Interview on 11/08/22 at 3:02 P.M. the Director of Nursing confirmed Resident #243 was admitted on Apiarian which is an anticoagulant medication. She continued it was her expectation that the facility would follow the care plan and monitor for bruising and bleeding and that this was not done. Review of the facility policy, Anticoagulation Clinical Protocol dated 09/22, revealed the facility should assess for signs and symptoms related to adverse drug reactions related to anticoagulant therapy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366014 If continuation sheet Page 14 of 16 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 366014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Hills Rehabilitation and Nursing Center 416 Wooster Road Mount Vernon, OH 43050 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 record review and staff interview, the facility failed to ensure Quality Assessment and Assurance (QAA) committee meetings were conducted quarterly. This had the potential to affect all 42 residents in the facility. Residents Affected - Many Findings Include: Review of the facility QAA committee meeting minutes revealed the most recent QAA Committee meetings were 01/26/22 and 02/23/22. There were no further quarterly meetings completed for 2022. Interview on 11/09/22 at 1:02 P.M. with Administrator confirmed the last QAA committee meeting was January and February of 2022 and they had not had a meeting since. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366014 If continuation sheet Page 15 of 16 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 366014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Hills Rehabilitation and Nursing Center 416 Wooster Road Mount Vernon, OH 43050 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 0947 Level of Harm - Minimal harm or potential for actual harm Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on interview and record review, the facility failed to provide State Tested Nurses Aides (STNA) 12 hours of continuing competency training a year. This affected all 42 residents who reside in the facility. Residents Affected - Many Findings include: Review of the personal files revealed: 1. STNA #97 was hired on 09/25/18, but had not received 12 hours of yearly competency training, including dementia management, providing services for cognitively impaired individuals, or mental health education. 2. STNA #92 was hired on 08/11/21, but had not received 12 hours of yearly competency training, including dementia management, providing services for cognitively impaired individuals, or mental health education. 3. STNA #96 hired on 10/29/20, but had not received 12 hours of yearly competency training including, dementia management, providing services for cognitively impaired individuals, or mental health education Interview on 11/09/22 at 12:14 P.M. with Administrator confirmed the facility had not been doing annual training on dementia management, cognitive impairments, or mental health. She verified the facility provides care for residents who have dementia, cognitive impairments,and mental health disorders. She stated staff are not receiving these annual training's and the facility plans to set up a system to ensure staff who have worked in the facility over a year receive their 12 hours of annual training. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366014 If continuation sheet Page 16 of 16