Health inspection·November 15, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few breath. She could not say if Resident #42 did or did not do it. LPN #200 did not get a statement from STNA #203. On a different note, LPN #200 stated Resident #42 was in an out of other resident's rooms on 11/10/23. She said Resident #40 complained of him pulling her arm then pulled her out of bed but LPN #200 did not believe she was pulled out of bed. She stated the arm was not reddened nor did they have to assist resident back up. She stated she hung a stop sign across the doorway which seemed to be effective in keeping Resident #42 out of her room. Phone interview on 11/15/23 at 5:03 P.M. with STNA #203 revealed she walked into Resident #52's room to see Resident #42 holding the pillow on her face and pushing it down. She stated she physically stopped him. He was a little agitated when she walked him out of the room. She stated Resident #52 looked scared during the ordeal. STNA #203 said she informed both LPN #200 and LPN #210 who said she would speak to the ADON and DON. She stated she was never asked or called to make a statement. Interview at 5:30 P.M. with Clinical Manager (CM) #204 and Regional LNHA (RLNHA) #205 stated the facility was not aware potential abuse happened because they only had the statement from the nurse stating she did not believe it was abuse. They stated they initiated an SRI for the incident on 11/07/23 after being informed during the complaint survey. They verified STNA #203 should have been interviewed as her name was in the statement by LPN #200. Review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 11/21/16, revealed all incidents and allegations of Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation Resident Property and all Injuries of Unknown Source must be reported immediately to the Administrator or designee. The facility must have evidence that all alleged violations were thoroughly investigated. This deficiency represents non-compliance investigated under Complaint Number OH00148317. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366024 If continuation sheet Page 2 of 4 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 366024 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sycamore Run Nursing and Rehab Ctr 6180 State Route 83 N Millersburg, OH 44654 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 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on record reviews and interviews the facility failed to thoroughly investigate an allegation of abuse reported on 11/07/23 involving Resident #42. This affected one (Resident #42) of four residents reviewed for abuse. The census was 99. Residents Affected - Few Findings included: Review of the medical record for Resident #42 revealed an admission date of 10/20/23. Diagnoses included neurocognitive disorder with lewy bodies, unspecified dementia, type 2 diabetes mellitus and hypo-osmolality and hyponatremia. Review of the admission Minimum Data Set (MDS) assessment, dated 10/27/23, revealed Resident #42 had impaired cognition. The resident was independent with locomotion on unit and room. Review of behaviors and moods revealed Resident #42 exhibited physical and verbal behaviors and other behaviors toward others one to three times a week. He exhibited rejection of care and wandering on a daily basis. It stated his behaviors had no impact on others. Interviews on 11/15/23 at 9:40 A.M. during the entrance conference with Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed there were no current self-reported incidents (SRIs). Interview on 11/15/23 from 12:00 P.M. to 5:11 P.M. with Licensed Practical Nurse (LPN) #208, State Tested Nursing Assistant (STNA) #206, STNA #207 and STNA #209 revealed they had concerns with Resident #42's behaviors. They stated they heard he had put a pillow over another resident's mouth but did not witness it. STNA #206 and STNA #207 stated they were not aware Resident #42 was on every 15-minute checks however LPN #208 and STNA #209 were aware and had documented it. Staff stated no one stopped them from charting any behaviors or reporting abuse. LPN #208 stated there was not anything documented in the chart about alleged incident of Resident #42 putting a pillow over Resident #52's face or of him pulling Resident #40 out of bed. She stated the night nurse (LPN #200) should have documented what she knew. Interviews with Housekeeper (HSKPR) #210, HSKPR #211 revealed they had no specific information. HSKPR #210 stated she worked that unit but stayed away from him. They stated none of the other housekeepers voiced concerns. Interview on 11/15/23 at 4:00 P.M. with the DON revealed she heard various reports of alleged incidents with Resident #42 but no one said they saw anything particularly about alleged incident on 11/07/23. She stated she started an investigation folder but felt like everything she heard staff saying was hearsay. The DON stated there was no documentation in the chart about alleged incidents though she said she asked staff to document if something occurred. She stated she spoke to LPN #200 who told the DON Resident #42 was climbing into bed with other resident but there was no physical aggression or harm. LPN #200 told her she redirected Resident #42 and he had not put a pillow over Resident #52's face. Surveyor asked DON to present investigation folder. The DON was gone for at least 30 minutes and returned with a folder with two statements about the alleged incident on 11/07/23. The statements, dated 11/07/23, were authored by the DON and ADON after interviewing LPN #200 together. Both stated LPN #200 did not believe Resident #42 was holding pillow over face of other resident (Resident #52) but rather was moving pillows around. The one statement added that an STNA (STNA #203) may have been a witness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366024 If continuation sheet Page 3 of 4 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 366024 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sycamore Run Nursing and Rehab Ctr 6180 State Route 83 N Millersburg, OH 44654 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 Continued interview with DON revealed she said she left two voicemails for STNA #203 to obtain a statement but did not receive a return phone call. When asked if STNA #203 was disciplined for not following protocol, she said no. She verified she did not pursue further investigation based on LPN #200's interview. The DON stated she was completing an SRI for the incident that happened on this date (11/15/23) between Resident #42 and Resident #41. Residents Affected - Few Phone interview on 11/15/23 at 4:31 P.M. with LPN #200 revealed she was told by STNA #203 on 11/07/23 that Resident #42 was forcefully holding a pillow over Resident #52's face. LPN #200 stated Resident #42 was coming out of the room and did not appear agitated. Resident #52 was not gasping for breath. She could not say if Resident #42 did or did not do it. LPN #200 did not get a statement from STNA #203. On a different note, LPN #200 stated Resident #42 was in an out of other resident's rooms on 11/10/23. She said Resident #40 complained of him pulling her arm then pulled her out of bed but LPN #200 did not believe she was pulled out of bed. She stated the arm was not reddened nor did they have to assist resident back up. She stated she hung a stop sign across the doorway which seemed to be effective in keeping Resident #42 out of her room. Phone interview on 11/15/23 at 5:03 P.M. with STNA #203 revealed she walked into Resident #52's room to see Resident #42 holding the pillow on her face and pushing it down. She stated she physically stopped him. He was a little agitated when she walked him out of the room. She stated Resident #52 looked scared during the ordeal. STNA #203 said she informed both LPN #200 and LPN #210 who said she would speak to the ADON and DON. She stated she was never asked or called to make a statement. A subsequent interview on 11/15/23 at 5:15 P.M. with DON revealed the DON continued to state she left a voicemail but did not pursue investigation because she had the nurse's statement saying the nurse did not believe the situation happened. Interview at 5:30 P.M. with Clinical Manager (CM) #204 and Regional LNHA (RLNHA) #205 stated the facility was not aware potential abuse happened because they only had the statement from the nurse stating she did not believe it was abuse. They stated they initiated an SRI for the incident on 11/07/23 after being informed during the complaint survey. They verified STNA #203 should have been interviewed as her name was in the statement by LPN #200. Review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 11/21/16, revealed all incidents and allegations of Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation Resident Property and all Injuries of Unknown Source must be reported immediately to the Administrator or designee. The facility must have evidence that all alleged violations were thoroughly investigated This deficiency represents non-compliance investigated under Complaint Number OH00148317. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366024 If continuation sheet Page 4 of 4