Inspection·June 26, 2025

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure a baseline care plan was implemented for a resident with a tracheostomy or requiring respiratory care. This affected one resident (Resident #186) out of twelve residents reviewed for baseline care plans. The facility census was 32. Findings include: 1. Record review for Resident #186 revealed the resident was admitted to the facility on [DATE] and had diagnoses including malignant neoplasm of the supraglottis, tracheostomy, bipolar disorder, anxiety, muscle weakness, abnormalities of gait and movement, dysphagia, acute embolism and thrombosis, dyspnea, obesity, and diseases of the larynx. Review of the admission Minimum Data Set (MDS) assessment, dated 06/10/25, revealed this resident was assessed to have intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 14 out of 15. Review of physician orders revealed this resident had a tracheostomy upon admission to the facility with orders for daily care including: wear stoma vent at all times, may clean with warm water or may use one-half strength Hydrogen peroxide to loosen crusted blood or secretions from stoma vent, suction and clean stoma as needed to clear secretions that resident cant cough up, monitor stoma for any signs and symptoms of infection every shift, and cover neck wound with Xeroform daily, may wrap with gauze if needed to keep in place. Interview with the Director of Nursing on 06/25/25 at 02:00 P.M. verified a baseline care plan was not in place for respiratory or tracheostomy care for this resident. She stated a care plan was created on 06/25/25 during the annual survey. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 2 of 11 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 06/26/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record reviews, the facility failed to ensure comprehensive care plans were accurately completed for residents who smoked. This affected two residents (#4 and #8) reviewed for smoking. The facility identified seven residents (#1, #4, #8, #13, #17, #18, #29) who resided in the facility and smoked. The facility census was 32. Findings include: 1. Record review for Resident #4 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included hemiplegia and hemiparalysis, dementia, and Chronic Obstructive Pulmonary Disorder (COPD). Review of the annual Minimum Data Set (MDS) assessment, dated 04/16/25, revealed the resident was assessed to have intact cognition. Review of the facility Smoking and Safety assessment, dated 01/14/25, revealed the resident was not assessed to require the use of a smoking apron while smoking. Review of the care plan, dated 06/19/25, revealed the resident was at risk for injury related to smoking. Interventions included a smoking apron was to be worn when smoking. Observation on 06/24/25 at 1:24 P.M. revealed Resident #4 was in the designated smoking area smoking a cigarette. The resident was not wearing a smoking apron. Interviews with Resident #4 and Certified Nursing Assistant (CNA) #150 at the time of the observation confirmed Resident #4 did not wear a smoking apron while smoking. Interview with the Director of Nursing (DON) on 06/25/25 at 4:00 P.M. confirmed Resident #4 had been assessed to not require a smoking apron to be worn while smoking. The DON confirmed the care plan for the resident was not accurately completed. 2. Record review for Resident #8 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included dementia, COPD, and tobacco use. Review of the quarterly MDS assessment, dated 05/13/25, revealed the resident was assessed to have impaired cognition. Review of the facility Smoking and Safety assessment, dated 05/13/25, revealed the resident was not assessed to require the use of a smoking apron while smoking. Review of the care plan, dated 06/20/25, revealed the resident was at risk for injury related to smoking. Interventions included smoking apron to be worn while smoking. Observation on 06/24/25 at 9:22 A.M. revealed Resident #8 was in the designated smoking area smoking a cigarette. The resident was not wearing a smoking apron. Interviews with Housekeeping Aide #190 and Housekeeping Aide #230 at the time of the observation confirmed Resident #8 did not wear a smoking apron while smoking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 3 of 11 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 06/26/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing (DON) on 06/25/25 at 4:00 P.M. confirmed Resident #8 had been assessed to not require a smoking apron to be worn while smoking. The DON confirmed the care plan for the resident was not accurately completed. . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 4 of 11 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 06/26/2025 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 observations, interviews, record reviews, and review of facility policy, the facility failed to ensure residents who were dependent on staff for nail care and meal assistance received care in a timely and appropriate manner. This affected two residents (#2 and #19) out of the three residents reviewed for Activities of Daily Living (ADLs). The facility census was 32. Residents Affected - Few Findings include: 1. Record review for Resident #2 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included hemiplegia and hemiparalysis affecting the left side, dementia, and chronic pain. Review of the quarterly Minimum Data set (MDS) assessment, dated 05/07/25, revealed the resident was assessed to have impaired cognition. Review of the care plan, dated 06/10/25, revealed the resident was at risk/had an ADL self-performance deficit. Interventions included the resident was dependent for personal hygiene. Observation of Resident #2 on 06/23/25 at 1:25 P.M. revealed the resident was lying in bed. The residents fingernails were long and had light brown colored debris caked underneath them. Observation of Resident #2 on 06/25/25 at 8:40 A.M. revealed the resident was lying in bed. The residents fingernails continued to be long with light brown colored debris caked underneath them. Interview with Resident #2 at the time of the observation confirmed the resident wanted his nails to be trimmed and cleaned. Observation of Resident #2 on 06/25/25 at 3:18 P.M. revealed the resident was lying in bed. The residents nails continued to be long with light brown colored debris caked underneath them. Interview with Licensed Practical Nurse (LPN) #350 at the time of the observation confirmed Resident #2's fingernails were long and dirty and needed to be trimmed and cleaned. LPN #350 confirmed nail care was to be completed on residents shower days and as needed in between. Review of the facility policy titled Dignity, most recently reviewed on 04/28/25, revealed residents would be groomed as they wished including nails being clean and clipped. 2. Record review for Resident #19 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Alzheimer's disease, dementia, and dysphagia. Review of the annual Minimum Data Set (MDS) assessment, dated 04/04/25, revealed the resident was assessed to have severely impaired cognition. Review of the care plan, most recently revised on 06/23/25, revealed the resident was at risk for malnourishment/alteration in nutritional status. Interventions included to assist with meals as needed. Observation on 06/25/25 at 8:50 A.M. revealed Resident #19 was lying in bed asleep with the lights off. The residents breakfast meal tray was lying on the tray table several feet away from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 5 of 11 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 06/26/2025 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 residents bed and had not been set up. No staff were present in the residents room. Level of Harm - Minimal harm or potential for actual harm Observation on 06/25/25 at 8:55 A.M. revealed Resident #19 continued to be asleep in bed with the breakfast meal tray lying on the tray table several feet away from the residents bed with the lights off. The meal tray continued to not be set up or offered to the resident. Residents Affected - Few Observation on 6/25/25 at 9:07 A.M. revealed Resident #19 continued to be asleep in bed with the breakfast meal tray lying on the table several feet away from the residents bed with the lights off. The meal tray continued to not be set up or offered to the resident. Observation on 06/25/25 at 9:10 A.M. revealed Resident #19 continued to be asleep in bed with the breakfast meal tray lying on the table several feet away from the residents bed with the lights off. The meal tray had still not been set up. Interview with Certified Nursing Assistant (CNA) #160 at the time of the observation confirmed the breakfast meal tray had been placed in the residents room earlier and had not been set up or offered to the resident. CNA #160 confirmed the resident had to be assisted to consume meals. CNA #160 then entered the residents room, turned on the lights, and asked Resident #19 if she was hungry. CNA #160 then set up the residents breakfast meal tray and began feeding the resident the meal while standing over her. Observation on 06/25/25 at 12:41 P.M. revealed CNA #160 entered Resident #19's room carrying the residents lunch meal tray. CNA #160 set the lunch meal tray down on the residents tray table and exited the room. Observation on 06/25/25 at 12:46 P.M. revealed Resident #19 was sitting up in bed asleep. The residents meal tray was sitting on the tray table in front of her and the food had not been set up or offered to the resident. Observation on 06/25/25 at 12:57 P.M. revealed Resident #19 continued to be asleep in her bed with the lunch meal placed in front of her on the tray table. The food still had not been set up or offered to the resident. Observation on 06/25/25 at 1:00 P.M. revealed CNA #160 entered the room of Resident #19 and opened the residents food containers. CNA #160 assisted the resident to consume some of the lunch meal tray then exited the room. Observation on 06/25/25 at 1:26 P.M. revealed CNA #160 again entered the room of Resident #19 and began assisting her to consume more of the lunch meal tray. CNA #160 again exited the room Observation on 06/25/25 at 1:33 P.M. revealed CNA #160 again entered the room of Resident #19 and began assisting the resident to consume more the lunch meal tray. CNA #160 finished assisting the resident, moved the tray table containing the lunch meal away from the resident, then exited the room. Interview with Licensed Practical Nurse (LPN) #350 on 06/25/25 at 1:45 P.M. confirmed Resident #19 had experienced a decline in condition and was dependent on staff to assist her with consuming meals. Review of the facility policy titled Dignity, most recently reviewed on 04/28/25, revealed residents independence and dignity in dining was to be promoted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 6 of 11 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 06/26/2025 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 - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure fall interventions were in place per the plan of care and failed to ensure a fire blanket was available in the designated smoking area. This affected one resident (#8) out of the two residents reviewed for falls and had the potential to affect the seven residents (#1, #4, #8, #13, #17, #18, and #29) identified by the facility as smoking in the designated smoking area. The facility census was 32. Findings include: 1. Record review for Resident #8 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included dementia, COPD, and tobacco use. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/13/25, revealed the resident was assessed to have impaired cognition. Review of the care plan, dated 06/20/25, revealed the resident was at risk for falls. Interventions included a Call Do Not Fall Sign. Review of the nurses progress note, dated 05/06/25, revealed Resident #8 came to the nurses station and stated she fell in her room. The resident stated she fell putting her shoes on, then stated she fell back in the bed, then stated she fell on the floor in front of her bed rushing to go smoke. The root cause of the fall was determined to be the resident was in a rush to smoke and the intervention was to place a Call Don't Fall sign on the wall. Observation on 06/25/25 at 9:16 A.M. revealed there was not a Call Don't Fall sign present in Resident #8's room. Interview with Licensed Practical Nurse (LPN) #350 at the time of the observation confirmed there had been a Call Don't Fall sign on the residents wall by the mirror but it was no longer there. LPN #350 confirmed she would replace the sign immediately. 2. Observation on 06/24/25 at 9:19 A.M. revealed residents were outside in the designated smoking area smoking cigarettes. No fire blanket was present in the designated smoking area. Interview with Housekeeping Aide #190 and Housekeeping Aide #230 on 06/24/25 confirmed residents utilized the designated smoking area while smoking cigarettes. They confirmed there was not a fire blanket present in the designated smoking area. Observation on 06/24/25 at 1:24 P.M. revealed residents were outside in the designated smoking area smoking cigarettes. No fire blanket was present in the designated smoking area. Interview with Certified Nursing Assistant (CNA) #150 at the time of the observation confirmed there was not a fire blanket present in the designated smoking area. CNA #150 stated she would use clothing, her hand, or a smoking apron to extinguish flames if a resident were to catch on fire while smoking. Interview with Maintenance Director #490 on 06/25/25 at 10:30 A.M. confirmed he had ordered a fire blanket on 06/24/25 and had placed it in the designated smoking area on 06/25/25. Review of the facility policy titled Smoking Policy, revised 01/2025, revealed residents are to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 7 of 11 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 06/26/2025 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 smoke in outside designated smoking areas if determined to be a safe smoker as assessed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 8 of 11 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 06/26/2025 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy, the facility failed to ensure dialysis communication forms were utilized to ensure communication between the facility and the dialysis center. This affected one resident (#16) of one resident reviewed for dialysis. Facility census was 32. Residents Affected - Few Review of Resident #16's medical record revealed an admission date of 07/23/24. Medical diagnoses included osteomyelitis, diabetes mellitus type 2, severe calorie malnutrition, alcoholic cirrhosis of liver without ascites, end stage renal disease, anxiety, anemia, dependence on dialysis, right below the knee amputation, thrombocytopenia, and atrial fibrillation. Review of Resident #16's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively intact, dependent for toilet and tub/shower transfers, and required assistance for mobility and was wheelchair dependent. Review of Resident #16's care plan dated 06/06/25 revealed Resident #16 will experience no complications related to dialysis through review date. Interventions included checking for new orders upon return from dialysis and coordinating care with dialysis center. Review of Resident #16's physician orders for 05/14/25 revealed dialysis days on Monday, Wednesday, Friday, pick up time 05:00 A.M. with return time 12:30 P.M. Review of Resident #16's physical chart for April 2025, May 2025, and June 2025 revealed missing Dialysis Communication Forms for 04/02/25, 04/23/25, 05/12/25, 05/14/25, 05/16/25, 05/28/25, 06/04/25, 06/06/25, 06/13/25, and 06/18/25. Interview with staff nurse #350 on 06/25/26 at 12:05 P.M. confirmed some communication forms are missing from Resident #16's chart and sometimes dialysis does not send forms back with resident post dialysis appointment. Staff Nurse #350 stated that dialysis center will call facility if there are any changes. Interview with Director of Nursing (DON) on 06/25/25 at 04:08 P.M. confirmed all forms for each dialysis encounter should be in resident's chart and if they are not staff should call dialysis center for communication. Facility policy titled Dialysis care dated 08/21 (reviewed 08/24) stated It is the policy of this facility to ensure residents that receive dialysis treatment are safe, well assessed, and that the facility collaborates care with the dialysis center. Policy further stated Upon return from dialysis, the nurse will review the communication form sent to dialysis center. If the dialysis center fails/refuses to provide communication, document on the form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 9 of 11 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 06/26/2025 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews and completion of a facility provided meal test tray the facility failed to provide palatable meals at the appropriate temperature. This affected all thirty-one residents who receive their meals from the kitchen with the exception of one resident (#20), who does not receive them. The facility census was 32. Residents Affected - Some Findings include: Review of resident concern logs and resident council minutes on 06/24/25 revealed multiple entries of food temperature complaints. Test tray completed on 06/25/25 at 01:05 P.M. and included one beef enchilada, black beans, Mexican corn, and fruit punch. All food items were cool to taste with varying temperatures including corn temperature of 109 degrees Fahrenheit and black bean temperature of 108 degrees Fahrenheit. Both items cool to taste. Interview with Dietary Manager #699 on 06/25/25 at 1:10 P.M. verified both items did not have an appropriate temperature after being the last meal tray served. Interview with Resident #29 on 06/25/25 at 1:40 P.M. revealed her meals are served cool sometimes once she is served her meal tray in her room. Interview with Resident #185 on 06/25/25 at 1:45 P.M. revealed her food is served cold sometimes. This deficiency represents noncompliance for Complaint Number OH00166168. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 10 of 11 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 06/26/2025 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interviews the facility failed to maintain all kitchen equipment in a clean, serviceable, and operational manner. This affected all residents who received meals from the kitchen with the exception of one resident (#20) who did not receive them. The facility census was 32. Findings include: Observation of the kitchen on 06/23/25 at 09:13 A.M. revealed the lift up door for the ice machine was broken and falling off when gently lifted. The overhead stove hood was visibly soiled with heavy layer of dust and multiple cobwebs hanging over the cooking area. The gas stove range was also visibly soiled with heavy dry burnt on foods from accidental spills. Interview with Dietary Manager #699 on 06/23/25 09:35 AM. verified she did not know how to remove the hood vents to clean them, and that someone was supposed to show her the process before he left but never did. Also stated the ice machine has been broken for as long as she has worked here. She also verified the stove top was visibly soiled and that there were multiple substances that had been burned onto it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 11 of 11