Inspection·November 8, 2023

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, policy review, and interview, the facility failed to provide written notice of discharge to Resident #34 and the ombudsman. This affected one resident (#34) of two residents reviewed for discharge. The facility census was 30. Findings included: Record review revealed Resident #34 admitted to the facility on [DATE] with diagnoses including chronic osteomyelitis, gastro-esophageal reflux disease, bipolar disorder, anxiety disorder, anemia, hypokalemia, insomnia, major depression, and hyperlipidemia. Further review revealed Resident #34 discharged was discharged on 09/21/23. Review of the record revealed no documented evidence a written notice was given to Resident #34 or sent to the ombudsman. Interview on 11/01/23 at 10:15 A.M. with Director of Nursing verified the facility did not have record of a written discharge notice being given to Resident #34 or the Ombudsman. Review of a policy titled Transfer and Discharge (Including AMA) revealed the facility should provide a transfer/discharge notice to the resident/representative and Ombudsman. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 2 of 18 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 11/08/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** 4. A review of Resident #6's medical record revealed he was admitted to the facility from another long term care facility on [DATE]. His diagnoses included schizophrenia, major depressive disorder, psychotic disorder, chronic obstructive pulmonary disease, and diabetes mellitus. A review of Resident #6's PASARR identification screen dated [DATE] revealed the resident was residing in a nursing facility at the time the PASARR identification screen was completed. The reason for the completion of the PASARR identification screen was for an update of a significant change in his condition per the request of the Ohio Department of Mental Health. A brief description of why the resident could not return to the community revealed his family did not feel living in the community was feasible for the resident due to his behaviors caused by his schizophrenia diagnosis and having limited family support. The PASARR identification screen had been completed while the resident was in another nursing facility. A review of the PAS Determination dated [DATE] for the PASARR identification screen completed on [DATE] revealed the resident was approved to receive services in a nursing facility. The approval was for an initial approval and he was approved for 180 days. The rationale given was the resident had the potential for community placement in the future with the following supports: he would benefit from an assisted living environment where he would receive supervision with all activities of daily living (ADL's) and hands on with all instrumental ADL's. He would also benefit from supervision with others due to verbal aggression. His preferred living arrangement was assisted living. Further review of Resident #6's medical record revealed it was absent for any additional PASARR identification screens being completed, after his initial approval for 180 days had been given on [DATE]. On [DATE] at 10:55 A.M., an interview with the Administrator revealed she was not able to find evidence of another Resident Review being completed for the resident after his initial approval of 180 days had expired. She stated he had been admitted to their facility from another nursing facility that closed and they did not have any additional Resident Reviews available for review. She completed a Resident Review for the resident that same day and provided both the Resident Review and the Resident Review Result Notice for review. The Resident Review Result Notice dated [DATE] revealed in order to continue to reside in a Medicaid- certified nursing facility, the resident must be screened for indications of a serious mental illness and developmental disability. A resident review was required for nursing facility residents upon a significant change in their condition and upon the expiration of a previously approved time limited determination. The result of the resident review revealed the resident did not have any indications of a serious mental illness and/ or developmental disability. Based on record review and interview, the facility failed to ensure Pre-admission Screening and Resident Reviews (PASARRs) were accurate, updated, and new mental health diagnoses were sent for a Level II review. This affected four residents (#6, #8, #11, and #13) of four residents reviewed for PASARRs. The facility census was 30. Findings included: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 3 of 18 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 11/08/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1. Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including type II diabetes, hypertension, gastro-esophageal reflux disease, insomnia, and major depressive disorder. On [DATE], Resident #8 received a diagnosis of delusional disorders on [DATE], anxiety on [DATE], and schizoaffective disorder on [DATE]. Review of the medical record revealed Resident #8 had a PASARR completed on [DATE]. An additional PASARR was not completed to include updated mental health diagnoses. Interview on [DATE] at 3:37 P.M. with the Director of Nursing (DON) confirmed a new PASARR had not been completed to include new mental health diagnoses. Review of a policy titled Resident Assessment- Coordination with PASARR Program revealed any resident who exhibits newly evident or possible serious mental disorder, intellectual disability or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include a resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder where dementia is not the primary diagnosis, or a resident whose intellectual disability or related condition was not previously identified an evaluated through PASARR. 2. Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including type II diabetes, gastro-esophageal reflux disease, unspecified mood disorder, anemia, functional quadriplegia, neuromuscular dysfunction of bladder, and chronic pain due to trauma. Resident #11 received additional diagnoses of anxiety disorder on [DATE] and major depressive disorder on [DATE]. Review of the medical record revealed Resident #11 had a PASARR completed on [DATE] which did not include diagnoses of mood disorder, depression or anxiety. Interview on [DATE] at 3:07 P.M. with Licensed Practical Nurse (LPN) #122 confirmed Resident #11's PASARR did not contain diagnoses of depression, anxiety or mood disorder. 3. Record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, gastro-esophageal reflux disease, polyosteoarthritis, schizophrenia, unspecified intellectual disabilities, type II diabetes, hyperlipidemia, hypothyroidism, hypertension, obstructive sleep apnea, insomnia, and mild intellectual disabilities. Review of the medical record revealed a PASARR was completed on [DATE] and did not include diagnoses of major depression, mild intellectual disabilities or unspecified intellectual disabilities. Interview on [DATE] at 3:36 P.M. with the Director of Nursing confirmed PASARR was not updated to included new mental health diagnoses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 4 of 18 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 11/08/2023 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 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** Based on record review, observation, staff interview, and policy review, the facility failed to ensure a resident who was dependent on staff for personal care received the assistance needed with nail care. This affected one resident (#12) of two residents reviewed for activities of daily living (ADL's). Residents Affected - Few Findings include: A review of Resident #12's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Parkinson's disease, difficulty walking, muscle wasting and atrophy, and muscle weakness. A review of Resident #12's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and her cognition was severely impaired. She was not known to have displayed any behaviors or reject care during the seven days of the assessment period. She had a functional limitation in her range of motion of her bilateral lower extremities. A prior quarterly MDS assessment dated [DATE] revealed the resident was totally dependent on two for transfers and was totally dependent on one for personal hygiene/ bathing. A review of Resident #12's care plans revealed the resident had a care plan in place for an alteration in ADL performance related to Parkinson's disease, anxiety/ depression, and a history of falls. The goal was for the resident's needs to be met with regards to her ADL's. The interventions included for the staff to anticipate needs and assist as needed. A care plan for the resident being at risk for impaired skin integrity included the need to keep the resident's fingernails trimmed to an appropriate length. A personal and cultural preference care plan revealed it was the resident's preference to be showered on Sundays, Wednesdays, and Fridays on the day shift. A review of Resident #12's shower sheets revealed the resident last received a bathing activity on 11/05/23 (Sunday). The shower sheet did not document what type of bathing activity occurred or what other personal hygiene care was provided as part of that bathing activity. It did document that a skin assessment had been completed and whether the resident needed her toenails cut. It did not document anything regarding the provision of nail care. On 10/31/23 at 1:32 P.M., an observation of Resident #12 noted her to be sitting in a wheelchair in the dining room for lunch. Her fingernails were noted to be long and in need of being trimmed. On 11/07/23 at 9:00 A.M., a follow up observation of Resident #12 noted her to be lying in bed in a supine position with her head of the bed up. Her fingernails remained long and were still in need of being trimmed. On 11/07/23 at 9:50 A.M., an interview Registered Nurse (RN) #100 revealed the facility documented showers on paper shower sheets when they were completed. She confirmed Resident #12 was to be showered/ bathed every Sunday, Wednesday, and Friday. She verified the resident's last documented shower that she received was on 11/05/23. She reported the resident was generally compliant with care. She described the resident as being passive in her care. She denied she had known the resident to refuse care. The resident may be resistant at times but would allow the task to be completed. On 11/07/23 at 9:56 A.M., an interview with State Tested Nursing Assistant (STNA) #115 revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 5 of 18 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 11/08/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident required a total assist with her ADL's. She stated the resident received bed baths on her scheduled shower days and her scheduled days were every Sunday, Wednesday and Friday. Bed baths and other bathing activities should include personal hygiene care that included trimming of fingernails when needed. She denied she was the one that bathed the resident on 11/05/23, as she was off that day. She reported the resident was compliant with care for the most part. She stated if the resident did not want her nails trimmed she would pull her hand away. She verified Resident #12's fingernails were long and had not been trimmed when she was bathed on 11/05/23. She asked the resident, if she would allow her to trim her nails, at the time she was asked to verify her fingernails were long. The resident nodded her head up and down and the aide left the room to obtain a pair of nail clippers to trim her nails. The resident was compliant and allowed the aide to trim them, after her long fingernails were brought to the aides' attention. A review of the facility's policy on Nail Care (undated) revealed the purpose of the procedure was to provide guidelines for the provision of care to a resident's nails for good grooming and health. Routine cleaning and inspection of nails would be provided during ADL care on an ongoing basis. Routine nail care, to include trimming and filing, would be provided on a regular schedule. Nail care would be provided between scheduled occasions as the need arose. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 6 of 18 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 11/08/2023 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 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 record review, staff interview, and policy review, the facility failed to ensure a resident who was receiving hospice services had relevant hospice related records (Comprehensive Assessments and Plan of Care and visit notes) readily accessible and part of the resident's medical record to ensure continuity of the resident's care. This affected one resident (#20) of one resident reviewed for hospice services. Residents Affected - Few Findings include: A review of Resident #20's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included protein-calorie malnutrition, chronic obstructive pulmonary disease, and muscle wasting and atrophy. A review of Resident #20's physician's orders revealed he was a Do Not Resuscitate Comfort Care Arrest (DNRCC-A). His physician's orders did not include an order for hospice care/ services despite the resident being identified as receiving hospice services on the facility's roster matrix. A review of Resident #20's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had unclear speech, but was usually able to make himself and understand others. His cognition was severely impaired. Hospice care was indicated to have been provided while he resided in the facility. A review of Resident #20's care plans confirmed he was receiving hospice services for an admitting diagnosis of severe protein-calorie malnutrition. The interventions included the need to discuss/ educate/ and inform the resident/ family/ or responsible party of his care plan interventions and goals following admission, quarterly and as needed (prn). Hospice was to collaborate care with the facility's staff. A review of a hospice binder kept at the nurses' station revealed there was a Hospice IDG Comprehensive Assessment and Plan of Care Update Report for a start of care of 04/21/23. The benefit period identified on that assessment was for 04/21/23 and 07/19/23. The comprehensive assessment and plan of care update report included a list of his terminal diagnosis and other diagnoses related to his terminal prognosis. It also included a current problem list, a plan of care, and medications in place at the time the comprehensive assessment was completed. The binder was absent for an updated Comprehensive Assessment and Plan of Care Update Report for a current benefit period. The binder also included visit notes by the hospice nurse and the home health aide for visits made to the facility when providing hospice visits for the resident. There were no recent visit notes for either the hospice nurse or the home health aide. The last visit note from the hospice nurse was for a visit on 07/03/23 and the last visit note from the home health aide was for a visit on 07/05/23. Findings were verified by the facility's Director of Nursing (DON). On 11/07/23 at 1:09 P.M., an interview with the DON revealed the hospice agency should be providing them with their visit notes after they visited the resident in the facility. She also reported an updated Comprehensive Assessments and Plan of Care Update Report should be made available to them and part of the resident's medical record. She indicated both of those items should be kept in the hospice binder for that particular resident that was kept at each nurses' station. She denied she had any visit notes or an updated assessment in her office that had not been placed in the binder yet. She asked Licensed Practical Nurse (LPN) #122, who was the nurse on duty and assigned to Resident #20's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 7 of 18 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 11/08/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete unit, if hospice had been leaving those visit notes and assessments when they visited. LPN #122 informed her that they have not. A review of the facility's policy on Hospice Services Facility Agreement (undated) revealed it was the policy of the facility to provide and/ or arrange for hospice services in order to protect a resident's right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility. If hospice care was furnished in the facility through an agreement, the facility would have a written agreement with the hospice that was signed by an authorized representative of the hospice and an authorized representative of the long term care facility before hospice care was furnished to any resident. The written agreement would set out a communication process, including how the communication would be documented between the facility and the hospice provider, to ensure that the needs of the resident were addressed and met 24 hours per day. A designated member of the facility working with hospice representative was responsible for obtaining the most recent hospice plan of care specific to each resident. Event ID: Facility ID: 366139 If continuation sheet Page 8 of 18 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 11/08/2023 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 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 record review and interview, facility failed to ensure new fall prevention interventions were established post-fall for two residents. This affected two residents (#24 and #32) of two residents reviewed for falls. The facility census was 30. Findings included: 1. Record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, hyperlipidemia, muscle weakness, type II diabetes, hypothyroidism, gastro-esophageal reflux disease, heart failure, major depression, hypertension, anemia, and psychotic disorder with delusions. Review of minimum data set (MDS) completed on 08/16/23 revealed Resident #24 had impaired cognition, no behaviors, is occasionally incontinent of bowel, and required total dependence for activities of daily living (ADLs). Review of physician orders revealed Resident #24 used quarter bedrails for a mobility enabler, requires a low bed with floor mat to the open side of the bed, non-skid strips to the floor at bedside, and ted hose daily. Care plan review revealed Resident #24 was at risk for falls related to debilitation, weakness, impaired cognition, an psychoactive medication use with a goal to minimize potentials risk factors related to falls. Fall interventions included bed in low position (05/26/23), encourage non-skid socks when not wearing shoes (05/30/21), floor mat at bedside (05/26/23), non-skid strips on floor at bedside (03/20/23), provide rest periods (11/30/20), and therapy referral PRN (as needed). Review of nursing notes from 07/30/23 at 1:07 P.M. by Registered Nurse (RN) #215 revealed Resident #24 was noted to be lying on the floor on her left side with her hands under her head. Review of fall investigation report also completed by RN #215 revealed Resident #24 was placed on fifteen minute checks for intervention. Review of fifteen minute check log revealed fifteen minute checks were not completed on 07/30/23 from 6 P.M. to 8 P.M., 07/30/23 from 9 P.M. to 07/31/23 at 6 A.M., or 08/01/23 from 9 A.M. to 10:45 A.M. Interview on 11/07/23 at 1:39 P.M. with Assistant Director of Nursing confirmed Resident #24's fall care plan did not contain a new interventions from the fall on 07/30/23 and the immediate intervention of being placed on fifteen minute checks was not completed as ordered. 2. Record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia without behaviors, heart failure, chronic kidney disease, hyperlipidemia, occlusion and stenosis of right carotid artery and left vertebral artery, and chronic obstructive pulmonary disease. Review of a MDS completed on 09/29/23 revealed Resident #32 had impaired cognition, no behaviors, was dependent on staff for bathing, limited assistance of one staff member for all ADLs, and was always continent. Review of orders revealed an order to monitor bump to forehead. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 9 of 18 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 11/08/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of care plan revealed Resident #32 was at risk for falls related to Alzheimer's dementia, weakness, wanders, stroke, chronic obstructive pulmonary disease, and impaired communication with a goal of being free from falls through the next review date. Interventions implemented included anticipate and meet resident's needs (10/04/23); be sure the resident's call light is within reach in the room and encourage use, decrease clutter, commonly used items in reach (10/04/23); ensure the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair (10/04/23); physical therapy to evaluate and treat as ordered or PRN (10/04/23); encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility (10/04/23); the resident needs activities that minimize the potential for falls while providing diversion and distraction (10/04/23); educate the resident/family/caregivers about safety reminders and what to do if a fall occurs (10/04/23); follow facility fall protocol (10/04/23); and the resident needs a safe environment with: even floors free from spills and/or clutter, adequate glare-free light, a working and reachable call light, the bed in low position at night, handrails on wall, personal items within reach (10/04/23). Observation on 10/31/23 at 9:49 A.M. revealed Resident #32 was sitting in her recliner asleep with scattered purple bruising to her right cheek and eye as well as uneven floors in resident's room and the linoleum in the bathroom split and rising. Interview on 11/01/23 at 9:50 A.M. was attempted with Resident #32, due to impaired cognition Resident #32 was unable to recall what happened to her eye. Review of nursing notes from 10/22/23 revealed Resident #32 had an unwitnessed fall. Fall investigation completed by RN #215 revealed Resident is confused and new to using a walker which caused the fall. Resident #32 was placed on fifteen minute checks for an immediate intervention. Interview on 11/01/23 at 3:23 P.M. with Licensed Practical Nurse (LPN) #122 confirmed the uneven flooring in Resident #32's room. Interview on 11/02/23 at 2:27 P.M. with Assistant Director of Nursing confirmed no new interventions had been put in place for Resident #32 regarding fall on 10/22/23 or bruising that occurred due to the fall. Review of a policy titled Fall Prevention Program revealed fall interventions will be monitored for effectiveness, the plan of care will be revised as needed, and when any resident experiences a fall the facility should review the resident's care plan and update as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 10 of 18 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 11/08/2023 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, and policy review, the facility failed to ensure residents, who were identified as having had significant weight loss, had new nutritional interventions implemented timely to address their known weight loss. This affected two residents (#9 and #24) of two residents reviewed for nutrition. Residents Affected - Few Findings include: 1. A review of Resident #9's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included congestive heart failure, adult onset diabetes mellitus, and major depressive disorder. A review of Resident #9's physician's orders revealed she had an order to receive a frozen nutritional supplement twice a day at lunch and dinner. The nutritional intervention had been in place since 07/25/23. A review of Resident #9's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. Her height was 60 inches and her weight was 103 pounds. She was not identified as having had a significant weight loss at that time. A review of Resident #9's active care plans revealed she had a care plan in place for the potential for an alteration in nutrition and hydration related to her advanced age, chronic diseases, therapeutic diet, variable meal intakes, nutrition supplementation required, history of significant weight changes, history of abnormal lab values, and psychoactive medication use. She also had a history of a tube feeding placement and frequent supplement refusals. The care plan was updated to reflect she had a significant weight loss (SWL) in October 2023. The goal was for the resident to be adequately nourished as evidenced by no significant weight changes. The interventions included providing supplements as ordered and document acceptance, obtain weights as ordered and referral to the Registered Dietician (RD) as needed. A review of Resident #9's weights recorded under the vital sign tab of the electronic medical record (EMR) revealed the resident weighed 106.9 pounds on 09/06/23. Her weight obtained on 10/06/23 revealed she weighed 98.8 pounds, which was a 8.1 pound/ 7.58% weight loss in the last 30 days. Her last weight obtained on 10/29/23 was 99.1 pounds. A review of Resident #9's progress notes revealed a dietary note by Dietary Tech #135 that was dated for 10/02/23. The note indicated the resident had an annual nutrition review completed on that date. Her body weight at that time was 103 pounds and no recent significant weight changes were identified. Her meal intakes were variable with 25-100% consumed at most meals. She was indicated to have received additional nutrition support via a frozen nutritional treat twice a day with good acceptance. A review of a nurse's progress note by the facility's Assistant Director of Nursing (ADON) dated 10/06/23 at 3:45 P.M. revealed Resident #9 required a re-weight for monthly weights. The first weight obtained was 97.7 pounds and the second weight obtained was 98.8 pounds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 11 of 18 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 11/08/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of a weight change note by Dietary Tech #135 dated 10/09/23 at 8:01 P.M. revealed Resident #9's weight was noted to be 98.8 pounds. It reflected a 7.6% (8.1 pound) loss in one month, 8.9% (9.7 pound) loss in three months, and a 12.1% (13.6 pound) loss in six months. The dietary tech acknowledged the resident's weight loss reflected a SWL. The note indicated the resident continued to receive additional nutrition support via a frozen nutritional treat twice a day with good acceptance. No significant changes in her nutrition regimen was identified. The dietary tech planned to continue with weekly weights and would continue to monitor her as needed. A review of Resident #9's medication administration record (MAR) for September and October 2023 revealed the nursing staff were documenting the resident's acceptance of her frozen nutritional supplement twice a day as ordered with lunch and supper. The MAR for September 2023 revealed the resident refused the frozen nutritional supplement 50 times out of 60 opportunities. The MAR for October 2023 revealed the frozen nutritional supplement was refused 59 out of the 60 opportunities it was offered to the resident. The MAR's disputed what the dietary tech had documented about the resident having good acceptance of her frozen nutritional supplement. Further review of Resident #9's progress notes revealed the resident was seen by Registered Dietician (RD) #140. RD #140 indicated in her note that the resident was identified as a SWL at three and six months when her current weight of 99.1 pounds showed a 8.7% (9.4 pound) loss in three months and a 11.8% (13.3 pounds) in six months. She reviewed the resident's meal intakes and indicated a variable meal intake with the resident eating between 76-100% for one meal, 51-75% for six meals, 25-50% for 10 meals, 0-25% for four meals over the last seven days. She also noted that the resident received a frozen nutritional supplement, which was consistently refused per the MAR. She recommended discontinuing the use of the frozen nutritional supplement as a nutrition intervention and ordered a house supplement at 240 milliliters once a day to address her SWL. There was no evidence in the resident's progress notes of her being seen or having had an advanced level provider address her known weight loss until 10/25/23. That note by the nurse practitioner also indicated a good acceptance of the frozen nutritional supplement that was not supported by what was documented on the MAR's. The advanced level provider did not make any changes to her nutritional interventions to address her weight loss and no new interventions were made until the resident was seen by the registered dietician on 10/31/23. On 10/31/23 at 1:14 P.M., an interview with Resident #9 revealed she was concerned about having had weight loss. She reported her weight had went down to 99 pounds. She was also concerned with the supplement she was being given. She stated all the facility had was supplements that were vanilla or chocolate, which she did not like. She reported she only liked the wild berry flavor that the facility was trying to get in. On 11/01/23 at 10:32 P.M., an interview with the Director of Nursing (DON) revealed she was not aware of Resident #9 having had a significant weight loss in the past month. She could not recall discussing the resident's weight loss in any of their clinical meetings. She confirmed Dietary Tech #135 was the facility's dietary tech and was usually there on Mondays. The RD they used visited the facility less often. She confirmed the resident had a significant weight loss, as was noted on 10/06/23, with no evidence of a new nutrition intervention being implemented to address her weight loss until 10/31/23. She acknowledged the dietary tech had indicated in her notes the resident had a good acceptance of her frozen nutrition supplement, which was not supported by what was documented on the MAR's. She confirmed the MAR's for September and October 2023 showed the frozen nutritional supplement was consistently being refused when offered. She also confirmed no new nutritional intervention was put in place until the registered dietician saw the resident on 10/31/23 (25 days after the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 12 of 18 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 11/08/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few significant weight loss was noted). She also acknowledged there was no documentation to support the resident's physician/ advanced level provider had been notified of her weight loss until 10/25/23, which was 19 days after the significant weight loss was noted. A review of the facility's Assisted Nutrition and Hydration policy (undated) revealed residents in the facility would maintain adequate parameters of nutrition, to the extent possible, to ensure each resident was able to maintain the highest practicable level of well-being. The facility would provide nutritional care to each resident, consistent with the resident's comprehensive assessment. They were also to recognize, evaluate, and address the needs of every resident, including but not limited to, the resident at risk or already experiencing impaired nutrition. 2. Record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, hyperlipidemia, muscle weakness, type II diabetes, hypothyroidism, gastro-esophageal reflux disease, dysphagia, heart failure, major depression, hypertension, anemia, and psychotic disorder with delusions. Review of minimum data set (MDS) completed on 08/16/23 revealed Resident #24 has impaired cognition, no behaviors, is always incontinent of bladder and occasionally incontinent of bowel, requires total dependence for activities of daily living (ADLs), and had a weight loss that was not a result of a physician prescribed weight loss regimen. Review of orders revealed Resident #24 uses lipped plates with meals, [NAME] cups, a regular diet with pureed texture, and ted hose daily. Review of Resident #24's care plan revealed resident has potential for nutrition deficits/weight changes related to advanced age, multiple chronic health problems, altered consistency diet, psychoactive medication use, overweight status, self-feeding difficulties, chronic edema, history of weight gain or losses, and variable meal intake. One new intervention was added in 04/24/23 for adaptive equipment with meals as ordered. Review of Resident #24's weight records revealed a 13.02% weight loss between 09/06/23 with a weight of 184 pounds to 10/30/23 with a weight of 160 pounds. Review of dietary note from 09/06/23 revealed Resident #24 had a significant weight loss which was determined to be related to edema and nutritional services will continue to follow to monitor. Review of dietary note from 10/02/23 revealed Resident #24 continued to have a weight loss but current nutrition regimen remained appropriate and dietary will continue to monitor. Review of dietary note from 10/30/23 reviewed and Resident #24 continued with weight loss with decreased consumption of meals. A new recommendation was given for house supplement 240 milliliters once a day per family member recommendation. Review of nursing notes from 09/06/23 through 10/30/23 revealed no notes regarding Resident #24 having edema. Interview on 11/07/23 at 1:31 P.M. with Director of Nursing confirmed there was no documentation regarding edema being a concern with nursing staff from 09/06/23 to 10/30/23 therefore the resident's weight loss would not be contributed to edema and there was no nutritional intervention for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 13 of 18 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 11/08/2023 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 0692 weight loss that began on 09/06/23 until a supplement was implemented on 10/30/23 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: 366139 If continuation sheet Page 14 of 18 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 11/08/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure artificial nutrition via gastrostomy tube (g-tube) was completed per professional standards. This affected one resident (#135) of one resident reviewed for tube feeding. The facility census was 30. Findings included: Record review revealed Resident #135 was admitted to the facility on [DATE] with diagnoses including aphasia, down syndrome, autistic disorder, type II diabetes, respiratory disorders, hypertension, gastrostomy status, major depression, anemia, dysphagia, gastro-esophageal reflux disease, and hyperlipidemia. Review of minimum data set assessment from 10/18/23 revealed Resident #135 was dependent on staff for eating and had a feeding tube. Review of orders revealed Resident #135 had an order from 10/11/23 for a nothing by mouth (NPO) diet. On 10/11/23 the resident was ordered enteral feed order every six hours for g-tube, flush peg tube with 200 cubic centimeters (cc's) every six hours, enteral feed order every day and night shift for g-tube flush peg tube with 30 milliliters (ml) of warm water prior to medication administration and flush peg tube with 10 ml of warm water in between each medication then flush peg tube with 30 ml of warm water after final dose of medication administered, and check for g-tube placement every shift. On 10/23/23, resident was ordered enteral tube feed order every shift for g-tube external feed phone diabeta source via g-tube at 60 ml per hour for 22 hours delivered via g-tube and total volume to be infused is 1320 ml per 24 hours; turn off at 12 P.M. and turn on at 2 P.M. may turn off for care/services and to remain off from 12 P.M. to 2 P.M. daily. Review of care plan revealed Resident #135 was at risk for alteration in nutrition and hydration related to alternative nutrition via feeding tube, chronic disease, and active diagnosis of protein calorie malnutrition. Observation on 11/02/23 at 2:34 P.M. revealed Resident #135 was lying in bed and alert and feeding tube was not started. Observation on 11/02/23 at 3:03 P.M. revealed the tube feeding was not in place for Resident #135 while she rested in her room. Interview on 11/02/23 at 3:50 P.M. with Licensed Practical Nurse (LPN) #122 revealed she had thought the tube feeding was supposed to start again at 4 P.M. for Resident #135, she did confirm the order stated tube feeding should have started at 2 P.M. and the time must have changed when the order for amount of feeding had changed. Observation on 11/02/23 at 4:00 P.M. revealed LPN #122 was preparing to administer tube feed to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 15 of 18 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 11/08/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #135. The feeding tubing was noted to be on the floor. LPN #122 prepared warm water for flush prior to administering tube feed. When LPN #122 administered the flush, only approximately one third of the flush went through the g-tube. LPN #122 then removed the remaining water from the uncapped syringe, then reconnected the syringe and applied it to resident's g-tube to push air through and did not check placement of the g-tube with a stethoscope before proceeding. LPN #122 then connected the tube to Resident #135's g-tube and began to feed her. Interview with LPN #122 immediately following observation confirmed she did not check proper placement of the feeding tube prior to administering the tube feed formula. Interview on 11/02/23 at 4:25 P.M. with the Director of Nursing confirmed LPN #122 should have checked placement of g-tube before proceeding with feeding Resident #135. Review of a policy titled Appropriate Use of Feeding Tubes revealed feeding tubes will be utilized in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 16 of 18 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 11/08/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, review of the menu's spreadsheet, staff interview, and policy review, the facility failed to ensure appropriate serving sizes were provided in accordance with the facility's menu's spreadsheet. This affected 19 residents (#1, #3, #4, #5, #6, #8, #9, #11, #13, #14, #15, #17, #18, #21, #26, #29, #31, #32, and #136) who the facility identified as receiving regular/ no added salt/ and carbohydrate controlled diets. Findings include: On 11/01/23 at 12:40 P.M., an observation of the lunch meal process served from the facility's kitchen revealed residents receiving regular diets, no added salt diets, and carbohydrate controlled diets did not receive the appropriate serving size of zucchini and summer squash vegetable blend on their meal tray. Multiple residents' trays (for those residents on those types of diets) were observed to only receive one scoop of the vegetable blend by Dietary [NAME] #177 using a 2 oz spoodle, before being placed in a food cart to be delivered to the units. Prior to the tray line, Dietary [NAME] #177 indicated the serving size of the zucchini and summer squash blend was four ounces and she would have to give two scoops to each resident to equal a four ounce serving. A review of the menu's spreadsheet for cycle day 11's lunch meal revealed the residents on a regular/ no added salt/ carbohydrate controlled diet was to receive four ounces of zucchini and summer squash with their meal. The utensil specified to provide the proper serving size of the vegetable blend was to be a 4 ounce spoodle. On 11/01/23 at 12:46 P.M., findings were verified by Dietary Manager #200. She consulted with Dietary [NAME] #177 and confirmed the residents on a regular diet/ no added salt diet/ carbohydrate controlled diet were to receive a 4 ounce serving. She informed Dietary [NAME] #177 that she should be using a 4 ounce spoodle or giving each resident two scoops of the vegetable blend if using a two ounce spoodle. Dietary [NAME] #177 was noted to pull out another metal tray of the zucchini and summer squash from the oven and placed it in the pan on the steam table. She commented that she would give out 4 ounce servings until she ran out as that was all she had. A review of the facility's policy on Menus and Adequate Nutrition (undated) revealed the purpose of the policy was to assure menus were developed and prepared to meet resident choices including their nutritional needs, while using established guidelines. The facility would ensure that menus met the nutritional needs of residents in accordance with established national guidelines. Menus were to be followed as posted. The facility's dietician or other clinically qualified nutrition professional would review all menus for nutritional adequacy and approve the menus. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 17 of 18 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 11/08/2023 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 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, staff interview, and policy review, the facility failed to ensure food was prepared and served in a sanitary manner. This had the potential to affect all residents that received meals from the facility's kitchen. The facility's census was 30. Findings include: On 11/01/23 at 11:02 A.M., a visit to the facility's kitchen was made to observe the pureed food process, obtain food temperatures prior to tray line and to observe the meal process. During the pureed food process, Dietary [NAME] #177 was observed to pull her N-95 mask down by grasping the outside of her mask with her bare hands. She would then raise her mask after talking to re-cover her mouth and nose. She would then handle food equipment such as pans and food processing equipment with her same bare hands without performing hand hygiene. She was also noted to touch the outside of her N-95 mask when she had gloves while handling trays used to place the residents' food on. She did not remove her gloves or performing hand hygiene before she continued with the serving of the residents' food. Findings were verified by Dietary Manager #200. On 11/01/23 at 12:36 P.M., an interview with Dietary Manager #200 revealed she was not aware of Dietary [NAME] #177 touching the outside of her N-95 mask without performing proper hand hygiene during the preparation and serving of food during the lunch meal process. She acknowledged the outside of the N-95 mask was considered contaminated and hand hygiene should have been performed after each contact the dietary cook had with the outside of her N-95 mask. A review of the facility's policy on Handwashing Guidelines for Dietary Employees (undated) revealed handwashing was necessary to prevent the spread of bacteria that may cause foodborne illnesses. Dietary employees should keep their hands and exposed portions of their arms clean. Dietary employees shall clean their hands immediately before engaging in food preparation including working with exposed food, clean equipment and utensils. They should also wash their hands after they had touched anything unsanitary, after hands had touched bare human body parts other than clean hands such as the face, nose, hair etc. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 18 of 18