Health inspection·July 7, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assist bar on the right side of the bed was not properly secured and the top half had been pushed away from the bed. Neither the right or left side assist bar was padded as ordered. On 07/07/23 at 9:27 A.M., an interview with Licensed Practical Nurse (LPN) #11 confirmed Resident #14's call light box was not working properly as it should. She stated the the facility's call light system had not been working for the four months she had been at the facility. The resident's call light box had not been working for at least a week now, but he did have a bell that was provided to him to use in its place. She denied she was able to find the bell in his room that he had last Friday when she worked. She was not sure how long the assist bar on the right side of his bed was not properly secured. She stated, when she worked last Friday, it was in the up position. She confirmed his physician's orders and plan of care indicated he was to have half side rails on his bed as part of his fall prevention interventions and his half side rails were to be padded as part of his seizure precautions. On 07/07/23 at 9:28 A.M., an interview with Resident #14 revealed his call light box had been off his wall for about six months now. The call light box that was sitting on his bedside table had not worked for about two weeks now. He did have a bell that was provided to him, but he claimed a nurse had taken it away from him about a week ago because he said she was tired of him using it. He stated the staff were still coming in to check on him and he could knock on the table when needing help. On 07/07/23 at 9:56 A.M., an interview with State Tested Nursing Assistant (STNA) #15 revealed Resident #14 has had multiple call lights but he just kept breaking them when banging on his side rails with it. It was her understanding that the call light he had was not working, but she was not sure how long ago it quit working properly. She thought he may have been given a bell instead but was not certain of that as she was a float aide and not always in his unit. 2. A review of Resident #18's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included schizophrenia, chronic obstructive pulmonary disease, adult onset diabetes mellitus, and heart failure. A review of Resident #18's quarterly MDS assessment dated [DATE] revealed she had clear speech and was able to make herself understood and was able to understand others. She was indicated to be cognitively intact and was not known to display any behaviors or reject care. She was dependent on staff and required the assist of two for bed mobility and transfers. Ambulation did not occur. She had a functional limitation in her range of motion to her lower extremities bilaterally. A review of Resident #18's care plans revealed she was at risk for falls and potential injury related to dementia and impaired balance. Her care plan was initiated on 12/10/21. Her interventions included the need to have commonly used articles within easy reach to include her call light. On 07/07/23 at 1:40 P.M., an observation of Resident #18 noted her to be lying in bed in a supine position with her eyes open. She was noted to be moaning out. Her room was not noted to have a call light system in place and she did not have a bell present to use to summon staff if assistance was needed. Findings were verified by the Director of Nursing (DON). On 07/07/23 at 1:42 P.M., an interview with the DON revealed she was not able to find a call light in Resident #18's room and denied she had a bell in her room to call for staff assistance. She confirmed Resident #18 was capable of using a call light and should have one made available to her. She was not sure what happened to her call light or why she did not at least a call bell to use in its (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366139 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Hills Skilled Nursing & Rehabilitation 31054 State Route 93 North McArthur, OH 45651 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 place. Level of Harm - Minimal harm or potential for actual harm This deficiency represents non-compliance investigated under Complaint Number OH00143514. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366139 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Hills Skilled Nursing & Rehabilitation 31054 State Route 93 North McArthur, OH 45651 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident council meeting minutes, review of maintenance request forms, review of quotes for the purchase of a new call light system, observation, resident interview and staff interview, the facility failed to ensure they maintained a working call light system in the residents' rooms and bathrooms. This affected 26 of 32 residents (six residents (Resident #2, #9, #12, #17, #19, and #24) the facility identified as not being able to comprehend how or why to use their call light. The facility census was 32. Residents Affected - Some Findings include: A review of the resident council meeting minutes from 04/24/23 through 06/19/23 revealed the residents were complaining of their call lights not functioning properly during the meeting minutes for April 2023. Resolutions to those concerns revealed residents were given bells and a quote was obtained and submitted to fix and/ or replace the call light system. Call lights remained a concern in the May 2023 meeting and the residents reported the staff were not hearing their bells. Doors to the residents' rooms were to be left open so staff could hear the bells. There were no concerns regarding call lights voiced in the June 2023 meeting. A review of maintenance request forms revealed the facility's Administrator indicated a call light issue in room [ROOM NUMBER] was needing to be addressed on 04/24/23. Maintenance department indicated the call light seemed to be working properly and replaced the battery just to be safe. A second maintenance request form was filled out by the Administrator again on 05/17/23 regarding a call light that needed to be looked at. The Administrator indicated she went and turned it on and off and the call light worked, but she wanted it to be double checked. The maintenance director indicated he checked it on 05/17/23 and the call light was working properly. A third maintenance request form from the Administrator on 06/24/23 revealed the call light in room [ROOM NUMBER] was needing to be checked again. She indicated it was working when she checked it. The maintenance director indicated he checked it the same day and found it to be working but the resident in that room preferred to use her bell. A review of a quote from Securitas Healthcare dated 05/09/23 revealed the facility obtained a quote to address the issues they were having with their call light system. The quote included a aerial server upgrade bundle with server, aerial network manager (Comtrol), and installation of a call light system for the total amount of $7,064.06. The quote was signed off by the facility's Administrator on 06/28/23 to approve the work to be done. On 07/07/23 at 9:11 A.M., an observation of the facility noted some of the residents to have the use of a call light system that allowed them to push a button on a call light cord to summon assistance. Other residents were noted to have the use of a bell to ring for staff assistance. Resident #18 was noted to have his call light box off his wall and sitting on his bedside table. He was using his call light to tap on his bedside table. An attempt to activate his call light by pushing a button on the front of his call light box was unsuccessful in getting his call light to activate. He was not noted to have a bell or any other means to alert staff of any assistance he may need. On 07/07/23 at 9:27 A.M., an interview with Licensed Practical Nurse (LPN) #11 revealed Resident #18's call light had been off his wall for at least four months now. That was how long she had worked at the facility. She stated the staff just sets it on his bedside table to he could push the button when he needed something. She confirmed his call light box did not activate a signal when the button (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366139 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Hills Skilled Nursing & Rehabilitation 31054 State Route 93 North McArthur, OH 45651 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on the front of it was pushed. She indicated it had not worked for about a week now. He had a bell in his room that he could ring if needing assistance but it was not currently in his room when she was asked to check. She claimed it was there last Friday when she worked, but she was not sure what happened to it. On 07/07/23 at 9:28 A.M., an interview with Resident #18 revealed the call light box had been off his wall for about six months now. The call light box that was sitting on his bedside table had not been working for about two weeks now. He confirmed he did have a bell to ring but claimed it had been taken away by a nurse a week ago because she was tired of him using it. He indicated he used his call light when he needed changed after being incontinent, but stated the staff still came in and checked him and changed him every couple of hours. On 07/07/23 at 9:56 A.M., an interview with State Tested Nurse Aide (STNA) #15 revealed Resident #18 required total assist for care. She confirmed he was incontinent of his bowel and bladder and the aides checked and changed him every two hours. She denied he knew when he was incontinent and did not use his call light for assistance with incontinence care as reported by the resident. He had been given multiple call lights but he broke them while banging them on his side rails. They had multiple call lights in the building that were off the walls and being placed on the residents' bedside tables. Some of the residents wanted it like that. She thought his call light box had been ripped off the wall but was not sure how. She claimed it was on the wall when she went into maternity leave back in December 2022 and when she came back to work it was off. They had it sitting on his bedside table and he broke it while hitting it on his bedside table. It was her understanding that it was not working. She was not sure on the length of time it had not been working. She thought he had a bell to use but was not certain of that as she was a float aide and was not always on the second floor where the resident resided. On 07/07/23 at 11:46 A.M., an interview with Resident #31 revealed his call light system in his room had not been working for about two months now. He had been given a bell to use in its place. He had to ring it a couple of times to get the staff to assist him. He would give it a couple of rings, wait five to 10 minutes and then ring it again if the staff had not come by then. It was usually answered after the first time he rang it without him having to ring it a second time. On 07/07/23 at 11:51 A.M., an interview with Resident #23 revealed his call light in his room was not working either. He had been given a bell to ring in place of his call light. He would ring his bell, wait five minutes and then ring it again. Staff usually responded by his second time ringing the bell. On 007/07/23 at 11:56 A.M., an interview with Resident #13 revealed she had a bell to use if she needed anything but denied she ever used it. She stated she was able to take care of herself for the most part. They have been using the bell for about three months now. The call light system in her room was still in place and appeared to be activated when the button on the call cord was pushed. The call for assistance was transmitted and showed on a computer screen down at the first floor nurses' station. The second floor's nurses station (the floor the resident resided on) did not have a computer screen to show a call light had been activated. The call light system used by the facility did not have a light over the door, nor did it have an audible alarm that sounded. On 07/07/23 at 12:01 P.M., further interview with LPN #11 revealed the residents on the second floor calls for assistance was to go to the pagers carried by the aides. She confirmed Resident #13's call light did not send a message to the aides' pager to show it had been activated. Without them (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366139 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Hills Skilled Nursing & Rehabilitation 31054 State Route 93 North McArthur, OH 45651 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some having a computer screen at the nurses' station that showed where a call light was activated from and pagers not always receiving a message when a call light was activated they would not know if a resident needed assistance unless they rang their bells. She again indicated the problems with the call lights had been going on since she started working and she was not sure what was being done to fix it. She denied all the residents who were capable of using a call light had access to the bells. They had only given them out to the residents who could use them and were known to have an issue with the call light system in their rooms. She recalled Resident #5 had an issue where her call light was showing as if it was going off when no one in the room activated the call light. She took the surveyor back to the room and further questioned Resident #5 about the problems she was having. She checked the call light in that room and confirmed it was not currently working. Resident #5 was noted to have a bell in her room to use in place of her call light, but her roommate Resident #20 did not have one. Resident #20 was reported to be a recent admission and had not been given a bell to use in place of her call light. Resident #5 offered to ring her bell on behalf of Resident #20 when she needed assistance but acknowledged she was not always present in the room to be able to ensure Resident #20 had access to means of calling for staff assistance. The bathroom in room [ROOM NUMBER], that was shared with the room across the hall, did not have a call light system in the bathroom. The mount on the wall, where the call light box was supposed to be, was without a call light box. There was no bell in the bathroom for the residents and/ or staff to use, if they needed assistance. LPN #11 then reported she had talked with the facility's DON and was told to get Resident #18 a bell for his room as he needed one. She obtained a cow bell from the desk at the nurses' station and took it to his room. Resident #18 was confirmed to have a cow bell and was able to demonstrate how to use it for staff assistance if needed. On 07/07/23 at 12:14 P.M., an interview with Maintenance Director #19 revealed he had been the facility's maintenance director since November 2021. He reported they initially had one resident in room [ROOM NUMBER] that had concerns about her call light. She complained of her call light a lot. He would check it and found it to be working and would just change the battery as a precaution. Since then, they have had other complaints. They got a quote to update their call light system and recently was approved. They were going to be replacing the current system they had. He has replaced multiple batteries in the call light boxes and it was getting expensive to change. He had been pushing just to get the system replaced and they will be replacing the current Bluetooth system as they were two operating systems behind. If a resident had an issue with their call light, they gave them a bell. Most of the residents' call lights were still working. Some of the residents that had bells still had working call lights. He denied he was doing any weekly monitoring or audits to ensure those residents who were still using the old call light system had a proper functioning call light. They waited until a resident complained before they checked it out. On 07/07/23 at 12:29 P.M., an interview with the DON confirmed the call light issue had been going on since the end of April/ beginning of May 2023. They talked to maintenance about it and was told the system was outdated. They then talked to the regional office and was told to have maintenance get a quote, which he did. She confirmed Resident #18 should have had access to a call light or at least a bell if his call light was not working in his room. She confirmed only those residents with call light issues were given bells. She did a whole house audit in May 2023 to identify which residents did not have a functioning call light. Those that were not working properly received a call bell. She denied she was performing any ongoing audits to ensure those residents whose call lights were found to be working in May 2023 were still working properly today. The residents usually let them know if there was a problem with their call light, so she would just check then. She was asked to provide a list of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366139 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maple Hills Skilled Nursing & Rehabilitation 31054 State Route 93 North McArthur, OH 45651 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some residents who were capable of using their call light and still had the use of the facility's old call light system. She identified 16 of the 32 residents as fitting that category. She was asked to assist with determining if those 16 residents call lights were still functioning properly. On 07/07/23 from 1:28 P.M. to 1:45 P.M., those 16 residents call lights were checked for proper functioning. Resident #1's call light was tested and was able to be activated but it showed a different room's call light had been activated when checking the computer screen at the first floor nurses' station. Resident #26's room also was able to be activated, but it too gave a different location of where the call light originated from other than the resident's room. Resident #28's call light was found not to be working when she was indicated to be able to use and was still using the facility's old call light system that was thought to be in proper working order. Resident #30's call light in her room did not work. She had been given a bell but her bell was not within reach as it was on top of her wardrobe. She indicated she had pushed her call light several times last night and did not receive a response from the staff. Resident #18, who resided on the second floor, was not noted to have a call light , nor did she have a bell to use to call for assistance. The DON identified her as being a resident that was able to use a call light and was still using the facility's old call light system. She did not know why the resident did not have a call light or a bell present in her room. Resident #16's call light did not send a message to the aides' pager when her call light was activated. She resided on the second floor and staff on the second floor would not know that she needed assistance without a message being received on the pager. Resident #15's call light did not activate when pushed but the DON discovered she had the call light for bed B and not the call light for bed A where she resided. The call light for bed A did activate when it was activated after being placed on Resident #15's side of the room. Resident #11's call light did not activate when pushed and Resident #10's call light showed that it was coming from room [ROOM NUMBER]'s bathroom when Resident #10 resided in room [ROOM NUMBER]. Some of the call lights tested on the second floor did show up as a message on the aides pager after a significant delay, while others did not. The DON acknowledged the call lights they thought were still functioning properly were found not to be when tested. She stated the Administrator was going to go out and purchase some bells to ensure all residents that were capable of using a call light had access to one and they had one in every bathroom. This deficiency represents non-compliance investigated under Complaint Number OH00143514. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 7 of 7