Health inspection·December 18, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #38's physician's orders revealed a telephone order had been received on 11/04/25 at 3:33 P.M. for a U/A and C&S being ordered for the following morning. The resident was indicated to have surgery on 11/11/25. Review of the U/A and C&S collected on 11/04/25 at 3:18 P.M. revealed the culture results were received on 11/07/25 (Friday) at 2:44 P.M. The culture results showed mixed pathology with greater than or equal to three organisms being isolated indicating probable contamination. There was instructions to contact the laboratory within 48 hours if identification was clinically indicated. Resident #38's medical record was absent for any evidence of the facility contacting the lab as instructed or to contact the urologist's office, who ordered the lab pre-operatively prior to her planned surgical procedure on 11/11/25, on 11/07/25 for further instructions. Review of a nurse's progress note by Registered Nurse (RN) #115 on 11/10/25 at 3:58 P.M. revealed the nurse made several calls to the urologist's office at the hospital where Resident #38 was supposed to have her procedure performed at to check on the schedule for surgery. She received a message earlier at 3:55 P.M. from the urologist's office that if they did not have the urine culture results within 30 minutes the resident was not going to be able to have her surgical procedure done on 11/11/25. Review of a nurse's progress note dated 11/11/25 at 1:35 P.M. indicated the previous U/A sample was contaminated and a new order was received for a U/A and C&S to be drawn on Wednesday 11/12/25. Resident #38 had been seen by her advanced level provider on 11/11/25 for hematuria (blood in urine) and dysuria (pain upon urination) That specimen was collected on 11/11/25 at 11:20 P.M. Review of a nurse's progress note dated 11/13/25 at 12:17 A.M. revealed Resident #38's nurse practitioner was made aware of blood being noted in the incontinent brief of the resident and indicated she would assess the resident while in the facility the next morning. The resident was seen at 10:32 A.M. and was transferred to the ER for an evaluation. Review of SRI #267413 with a discovery date of 11/11/25 revealed the SRI was being completed for an allegation of neglect. The involved resident was Resident #38 and the facility staff were indicated to be the alleged perpetrator. The initial source of the allegation was marked as being an unusual circumstance. A brief description of the allegation revealed a doctor's office was alleging neglect. The narrative summary of the incident revealed on 11/11/25, the DON was alerted by the nurse that they had received a call from the urology doctor's office for Resident #38 alleging neglect. The Administrator was notified and the investigation was initiated. Resident #38 was diagnosed with acute pyelonephritis, unspecified dementia, hydronephrosis, and tubulointerstitial nephritis. Upon interview, Resident #38 had not voiced any concerns related to her doctor's appointments. Review of her medical records and labs were completed and the labs were noted with contamination. The physician and urologist were made aware. A repeat draw was rescheduled. The lab (U/A) was obtained via straight catheterization and results were sent to the physician and the urologist for review prior to an upcoming appointment. Interview with staff revealed the lab results took longer to result, leading to rescheduling of the procedure. Upon obtaining the finalized U/A results, the urine had been contaminated resulting in the doctor's office requesting another draw before the rescheduled procedure. Interview with the doctor's office revealed they alleged neglect due to not receiving U/A results in the span of time that they thought that they should have. The doctor's office requested U/A be obtained day before the procedure. Upon interview with the lab, U/A results partially finalize within 24 hours and final results within 72 hours. As a result of the facility's investigation, they unsubstantiated the allegation, as the evidence did not show neglect occurred. Review of witness statements as part of the facility's investigation into the alleged neglect revealed statements were obtained from multiple nurses. A written statement from LPN #134 obtained 11/11/25 revealed when she came to work on the weekend of 10/25/25 and 10/26/25, it was passed on that an order had been found sitting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 2 of 6 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 12/18/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on the fax machine Friday the 24th for a U/A to be collected for Resident #38. The urine had to be collected on Sunday the 26th, due to the lab coming at 12:00 A.M. Monday morning (27th) in order for it to be sent out in time for surgery. She had trouble getting the order into the lab server and after a couple of hours, she asked another nurse (LPN #130) for help. LPN #130 also had trouble, but was able to finally get the lab order in. Both of them forgot that they needed to print out a new list of all the labs needed for Monday, so when she reported to RN #124 that he needed to get a urine, he did not have a printed lab order. From her understanding, the lab refused to take the urine. Review of a witness statement from RN #124 revealed, on 11/09/25, he received report that Resident #38's surgery may have been moved to 11/11/25. On 11/10/25, he gave report that Resident #38's surgery may have been moved to 11/11/25, and he stated the lab had picked up Resident #38's urine specimen and that the appointment book had the resident's name written on the 11th (11/11/25) with no other information provided. Review of a written statement from the facility's Assistant Director of Nursing (ADON) revealed she phoned Resident #38's daughter in regards to the resident's surgery being canceled. She explained to the family that the facility was creating a time line of events to find out where the break down occurred. The family was informed that the facility had launched an investigation known as an SRI and what it was. It was explained to the family that the resident's urine was obtained, but came back contaminated and would be collected again. Review of a written statement from RN #115 (not dated) revealed on 11/10/25, the urologist's office called. A nurse tried to transfer the call to the first floor, but the call did not come. A return call was placed to the office of Resident #38's urologist on three separate occasions. A message was left at the second floor nurse's station that the urologist office would would call the Administrator and they wanted the results of the U/A C&S that had previously been ordered. She was told by a nurse in report that labs and U/A C&S results were sent to the urologist and they were good for Resident #38 to get her surgery. They received a call from the urologist office on 11/11/25 at 9:16 A.M. that the surgery had been canceled for that day, as they did not receive the results of the U/A C&S. On 12/16/25 at 10:56 A.M., an interview with RN #115 revealed she was familiar with Resident #38 and took care of her while she was in the facility. She described the resident as being a sick lady and had procedures done before she came to the facility. They had more procedures they wanted to do after she came to the facility. The resident had a scheduled procedure for her kidney stones. The facility had problems with the lab companies they used. They used four different ones in the past couple of months. The hospital did not accept what they had sent and they had to repeat the U/A. She was not sure why it had not been accepted and did not report any knowledge of the prior sample being contaminated. On 12/18/25 between 2:14 P.M. and 3:24 P.M., email correspondence with the facility's Director of Nursing verified concerns with Resident #38's pre-operative testing before her planned cystoscopies were not completed as ordered. She acknowledged there was no documented evidence in the resident's electronic medical record (EMR) that a U/A and C&S had been obtained as ordered prior to her scheduled cystoscopy on 10/28/25. She indicated that she had not had a copy of the AVS for the resident's hospital stay between 10/03/25 and 10/15/25 until 12/18/25, when it was requested for review. She acknowledged the order for the U/A and C&S was given via a telephone order on 10/25/25 and was supposed to be completed on 10/27/25, prior to the resident's scheduled procedure on 10/28/25. She confirmed there was an issue with the lab company the facility used not taking the urine sample, after it had been collected, due to there not being a lab order for a U/A on the updated lab requisition sheet. She confirmed the nurses entering that lab order did not print off the most recent lab slip that would have included all the labs that were to be done that morning, including the U/A and C&S. She acknowledged by not completing the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 3 of 6 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 12/18/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete U/A and C&S as ordered, Resident #38's scheduled procedure had to be rescheduled on 11/11/25. She further acknowledged there was no evidence of the urologist's office being notified on 11/07/25 (Friday) at 2:22 P.M., when the results of the U/A that had been collected on 11/04/25 at 3:18 P.M. came back as being probable contamination in the final report. It was not until 11/10/25 at 3:58 P.M. that the facility's nurses reached out to the urologist's office to check on the status of her scheduled surgery planned for 11/11/25. They were informed that the surgical procedure would not be performed unless they were able to provide the U/A C&S results in the next 30 minutes. She acknowledged if the facility's staff would have reached out to the urologist's office on 11/07/25, when it was known the prior U/A had been contaminated, they could have got a new order to repeat the U/A and C&S that evening and possibly could have had the final U/A and C&S report back on 11/10/25 preventing the scheduled procedure from being cancelled a second time. The deficient practice was corrected on 11/17/25 when the facility implemented the following corrective actions: Whole House Audit of all lab orders to ensure that they were completed as ordered and the results were reported to the physicians. DON/ Designee assessed the affected residents for adverse effects related to delayed lab draws. IDT met and discussed alternate measures for lab draws in the event the lab company did not come to the facility for the lab draw. All nurses were educated by 11/17/25 on their responsibility of entering, ensuring labs were obtained, and following up on lab results as ordered. DON/ Designee will audit orders/ lab draws daily in the clinical meeting. DON/ Designee will audit all labs three times a week for four weeks to ensure ongoing compliance. Medical Director was notified through Ad hoc QAPI process. Results of the daily/ weekly audits would be taken to the monthly QAA meeting and reviewed by the IDT for ongoing compliance. This deficiency represents non-compliance investigated under Complaint Number 2692521. Event ID: Facility ID: 366139 If continuation sheet Page 4 of 6 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 12/18/2025 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's cycle menu, review of food temperature logs, staff interview, and policy review, the facility failed to ensure residents received food that was procured from their food service supply company and was prepared in the facility's kitchen to ensure proper food handling and preparation to safe guard it from possible food-borne illnesses. This affected eight (Resident #5, #6, #11, #20, #22, #24, #31, and #35) out of 36 residents who resided in the facility. Findings include: Review of the facility's cycle menu for Week #1 of the Spring and Summer Menu revealed the scheduled meal for lunch on 09/16/25 included chicken tortilla rice bowl as the main entree. They were also having seasoned black beans, corn, and a Mexican Wedding Cookie. The cycle menu did not include an alternate meal choice, other than what was on the facility's alternate/ always available menu. Review of a food temperature log for the meals served on 09/16/25 revealed the dietary staff obtained hot food temperatures of the food items served for the lunch meal. Temperatures were obtained for the main entree chicken tortilla rice bowl and for the black beans and creamed corn. Lasagna was included under the miscellaneous category despite it not being one of the food items on the cycle menu. There was no temperature recorded for the lasagna to show the dietary staff checked to ensure it was at the proper temperature before being served to residents. On 12/16/25 at 10:25 A.M., an interview with Certified Nursing Assistant (CNA) #121 revealed she used to work in the facility's kitchen, but was now working as a nursing assistant. She reported several months ago that she made lasagna in her home and brought it in to the residents to eat. She initially denied knowledge of any staff ever doing that and did not think that was something they were were able to do. It was not until she was directly asked, if she had cooked lasagna at home and brought in to the residents, that she admitted doing so. The residents had requested it as their special meal for the month and she could not tell them no. She stated she made a big old pan of it. She was told by the facility's previous Director of Nursing (DON) that she shouldn't do that, but did it anyway. On 12/16/25 at 10:56 A.M., an interview with RN #115 revealed there was one time that the residents asked for something special to be made for one of their meals. A staff member volunteered and brought in a lasagna that had been cooked at home for the residents. She confirmed CNA #121 was the staff member that brought the lasagna in and all residents that wanted it ate it. She was not sure what the facility's policy was on food brought in from outside sources. They allowed residents to do it (have food brought from home) and residents also had the right to order out for food from nearby restaurants, so she did not see what the difference was. On 12/16/25 at 12:34 P.M., an interview with Licensed Practical Nurse (LPN) #130 revealed there was one occasion a couple of months ago, when a staff member brought food in for the residents. It was a lasagna tray that had been cooked at home by CNA #121. She questioned if that was permitted to be done, but was told that someone there at the time had approved it. She had always been taught that no outside food could be brought in and shared with the residents. On 12/16/25 at 1:23 P.M., an interview with CNA #125 revealed she was aware of the special meal that was provided to the residents in the past couple of months or so. The residents picked what special meal they wanted each month. CNA #121 made two great big pans of lasagna at home and served it to the residents in the facility. She went into the kitchen and told the dietary staff they were not allowed to do that, but was told it had been approved. She then went to the Administrator, who told her that it had been approved and she was the one that approved it. The Administrator told her it was no different than the residents ordering out for food. She told the Administrator it was different, as those local restaurants the residents ordered food from were still inspected by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366139 If continuation sheet Page 5 of 6 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 12/18/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete local health department and the aide's home where the lasagna was made was not inspected. On 12/16/25 at 3:08 P.M., an interview with Dietary Manager #108 revealed she had been the facility's Dietary Manager since March 2025. She was off the day a staff member cooked lasagna at home and brought into the facility for the residents. She did not find out about it until after it had already happened. She stated once she was aware, she put a stop to outside food being brought in, after that. It was not something the staff were able to do. Her dietary staff were not permitted to bring any outside food into the kitchen. The food they served had to come from the food service supply company the facility contracted with. She heard previous talk that an aide was talking about doing that, but nothing had been decided. She did an education with all her dietary staff during their next scheduled meeting that her rules and the State's rules were not to bring any outside food into the kitchen. She reported the residents had requested lasagna, as part of their special meal request during their Resident Council meeting. They usually prepared those special request meals in the facility's kitchen with the dietary staff preparing it. She informed the rest of the management team during the morning meeting that she had educated her dietary staff and that was not to happen again. She acknowledged the food temperature log for the lunch meal served on 09/16/25 did not show evidence that the dietary staff checked the temperature of the lasagna, after it had been prepared at a staff member's home, and before it was served to the residents. She acknowledged when food was obtained and prepared outside of the facility, they were not able to ensure food items used in the baking process was not expired and food was handled and prepared in a manner that protected the residents from any food-borne illnesses. Review of the facility's policy on Food Brought in from Outside Sources and Personal Food Storage obtained from a publication from [NAME] and Associates, Inc. Chapter 3: Food Production and Food Safety revealed it did not directly address food prepared and brought in by facility staff in their own home for resident consumption. The policy indicated food brought to the facility by family members or friends for a loved one or for a special event would be handled using safe food handling guidelines. Designated staff should monitor foods and beverages brought in from outside sources for storage in facility pantries, refrigeration units, or personal room refrigerator units. The procedure indicated families, volunteers, and others not employed by the facility would be educated on safe food handling and storage techniques by designated facility staff. Staff should examine food for quality (visual, smell, packaging) to identify potential concerns. The food and nutrition services department should ensure that once food was brought to the facility from an outside source that reheating and hot/ cold handling of leftovers was appropriate. This deficiency represents non-compliance investigated under Complaint Number 2692521. Event ID: Facility ID: 366139 If continuation sheet Page 6 of 6