Health inspection·July 26, 2022

F 0561 Level of Harm - Minimal harm or potential for actual harm On 07/21/22 at 1:59 P.M. interview with Director of Nursing (co-DON) #176 verified showers were not provided in accordance with shower sheets/schedules. 2. Review of Resident #38's medical record revealed diagnoses including chronic obstructive pulmonary disease, depression, heart disease, and chronic pain. Residents Affected - Few A quarterly MDS 3.0 assessment, dated 05/24/22 indicated Resident #38 was cognitively intact, able to make himself understood and was dependent on staff for bathing. Review of an undated preference sheet revealed Resident #38 would like to receive three showers weekly in the evening. Review of shower schedules revealed Resident #38 was scheduled to receive a shower on 7 P.M. to 7 A.M. shift on Monday, Wednesday, and Friday. Review of shower documentation between 06/20/22 and 07/19/22 revealed documentation of only one shower being offered/provided the week of 07/10/22-07/16/22. The last shower recorded prior to the interview completed on 07/18/22 was a shower provided on night shift on 07/11/22. On 07/18/22 between 2:47 P.M. and 2:50 P.M. Resident #38 was observed sitting in his room. The resident appeared to be unshaven with facial hair present. At the time of the observation, interview with Resident #38 revealed he was scheduled to receive three showers a week but stated he was not receiving them, being told there was not enough staff. Resident #38 stated he was usually shaved during showers. On 07/21/22 at 1:59 P.M. interview with DON #176 verified showers were not provided in accordance with shower sheets/schedules for Resident #38. 3. Review of Resident #64's medical record revealed diagnoses including left side weakness and paralysis, morbid obesity, anorexia and edema. A quarterly MDS 3.0 assessment, dated 07/03/22 revealed Resident #64 was cognitively intact, able to make himself understood and was dependent on staff for bathing. On 07/18/22 at 2:20 P.M. interview with Resident #64 revealed he was supposed to get a shower every Tuesday and Saturday. However, he stated he usually only got one a week and was told it was because of staffing issues. Review of an undated resident preference sheet revealed Resident #64 would like to be offered more than two showers weekly. However, there was a notation for AM on Tuesday and Friday and the sheet was signed by Resident #64. Review of shower schedules revealed Resident #64 was scheduled for showers on day shift every Tuesday and Saturday. Review of shower documentation between 06/20/22 and 07/19/22 revealed no evidence of a shower being offered/provided 06/21/22, 06/28/22 or 07/19/22. On 07/20/22 at 3:20 P.M. interview with STNA #165 verified Resident #64 was dependent on staff for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 2 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 0561 showers. Level of Harm - Minimal harm or potential for actual harm On 07/21/22 at 1:59 P.M. interview with DON #176 verified showers were not provided in accordance with shower sheets/schedules for Resident #64. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 3 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure timely physician notification for Resident #54's related to significant weight changes and for Resident #14 related to a low blood glucose level. This affected two residents (#14 and #54) of two residents reviewed for physician notifications. Findings include: 1. Review of Resident #54's medical record revealed an admission date of 5/28/22 with diagnoses including congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and hypertension. Review of Resident #54's plan of care, dated 06/24/22 revealed the resident had a potential for alteration in nutrition and hydration related to being overweight, diuretic use, diabetes mellitus, chronic kidney disease, hypertension and COPD. The resident goals included no significant weight changes and to maintain skin integrity. Interventions included assess and report signs of edema to physician, notify the physician/nurse practitioner/family/interdisciplinary team for weight changes and obtain weights as ordered. Review of Resident #54's physician's order, revealed an order, dated 07/01/22 to obtain daily weights and notify the physician if the resident had a greater than three pound weight change in a day or five pounds in a week. Review of Resident #54's admission Minimum Data Set (MDS) 3.0 assessment, dated 07/12/22 revealed the resident had impaired cognation. Review of Resident #54's weight record revealed on 07/04/22 the resident weighed 176 pounds (lbs), on 07/08/22 his weight was 157 lbs, on 07/13/22 his weight was 157.6 lbs, on 07/14/22 his weight was 183 lbs, and on 07/16/22 his weight was 163.2 lbs. On 07/20/22 at 8:36 A.M. Resident #54 was observed sitting in his wheelchair in his room. The resident had oxygen applied and slight edema was noted to his bilateral hands. Review of Resident #54's medical record revealed the physician was not notified of the weight fluctuations until 07/18/22. On 07/21/22 at 2:19 P.M. interview with Director of Nursing (DON) #176 revealed the facility did not notify the physician until 07/18/22 of Resident #54's weight fluctuations. She continued that when the physician was finally notified on 07/18/22 he ordered the diuretic, Lasix 40 milligrams (mg) to be injected intramuscularly in the morning for CHF for two days and then inject 40 mg intramuscularly in the evening for CHF for two days. He also ordered a basic metabolic panel (BMP) to be done 07/22/22. Review of the facility policy titled, Change in Condition, dated 10/18/2001 revealed emergence of an unstable condition would require a physician notification. The unit supervisor or charge nurse would notify the resident, the physician and guardian. The person doing the notification would document all notification in the medial record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 4 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of Resident #14's medical record revealed an admission date of 11/19/21 with diagnoses including diabetes mellitus with diabetic neuropathy, chronic kidney disease and dependence on renal dialysis. Review of Resident #14's quarterly MDS 3.0 assessment, dated 07/12/22 revealed the resident had intact cognation. Review of Resident #14's July 2022 physician's orders revealed an order to obtain the resident's blood sugar four times a day and notify the medical director or nurse practitioner if the blood sugar level was less than 60 or greater than 400. On 07/25/22 at 1:55 P.M. interview with Resident #14 revealed on 07/10/22 he woke up very tired and covered in sweat. He stated the facility nurse checked his blood sugar and revealed it was very low. She provided him and crackers and orange juice which made him feel better. Review of Medication Administration Record revealed on 07/10/22 Resident #14 had a morning blood glucose level of 49. Review of Resident #14's nursing notes from 07/10/22 revealed there was not a note indicating the physician or nurse practitioner were notified of the low blood glucose reading, intervention provided to the resident, or when the resident's blood sugar was rechecked after the reading was obtained. On 07/25/22 at 2:04 P.M. interview with DON #176 confirmed there was no evidence where the physician was notified of Resident #14's low blood glucose level on 07/10/22 as the physician's order directed staff to do. Review of the facility policy titled, Change in Condition, dated 10/18/2001 revealed emergence of an unstable condition would require a physician notification. The unit supervisor or charge nurse would notify the resident, the physician and guardian. The person doing the notification would document all notification in the medial record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 5 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide a bed hold notification to Resident #17 as required. This affected one resident (#17) of two residents reviewed for hospitalization. Findings include: Review of Resident #17's medical record revealed diagnoses including chronic obstructive pulmonary disease, bipolar disorder, insomnia, and right sided weakness and paralysis following a stroke. A nursing note, dated 04/03/22 at 12:22 A.M. revealed Resident #17 had reported having a stomach ache early in the evening and requested Phenergan (medication to prevent vomiting) without effect. While Resident #17 was being re-assessed she felt warm and had an axillary (under the arm) temperature of 104.0 degrees. Her pulse was 122 and oxygen saturation was 91% on room air. Resident #17 requested to go to the hospital and the physician gave an order to send her to the hospital. A nursing note, dated 04/03/22 at 10:28 A.M. revealed the hospital reported Resident #17 was being admitted to the hospital for an elevated white blood count and urinary tract infection. On 07/19/22 at 4:01 P.M. interview with Registered Nurse (RN) #200 verified no bed hold notice was provided when Resident #17 was sent to/admitted to the hospital on [DATE]. RN #200 revealed the receptionist used to provide the bed hold notices but after she quit the new receptionist was not aware she needed to do them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 6 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide timely restorative nursing services to maintain or improve the ambulatory abilities of Resident #36 following the resident's discharge from physical therapy. This affected one resident (#36) of three residents reviewed for activities of daily living. Residents Affected - Few Findings include: Review of Resident #36's medical record revealed diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, morbid obesity, generalized muscle weakness and muscle wasting and atrophy. Review of a Physical Therapy (PT) evaluation, dated 04/06/22 revealed Resident #36 was referred due to experiencing a fall in the facility with a resultant decline in functional mobility. PT was to address balance, bed mobility, transfers, gait and strength to enable Resident #36 to return to his prior level of function and reduce the risk of falls. At the time of evaluation Resident #36 ambulated five feet with a front wheeled walker with contact guard assistance. A PT Discharge summary, dated [DATE] indicated Resident #36 was consistently able to ambulate 20-25 feet with a front wheeled walker with stand by assistance. Discharge recommendations were for 24 hour care, home exercise program and indicated there was no restorative program to refer Resident #36 to. On 07/18/22 at 4:15 P.M. interview with Resident #36 reported he had been on therapy and believed he was making progress. The resident believed therapy was discontinued due to insurance reasons. Resident #36 stated he needed restorative (nursing) services so he could maintain/improve his ambulatory status but stated it was not offered. On 07/20/22 at 10:18 A.M. interview with Therapy Director #126 revealed the facility had a period where they did not have a restorative program (since at least September 2021). On 05/01/22, the facility started with in-house therapy services with a goal to initiate a restorative program within four months. A restorative aide had been hired and was supposed to start 08/01/22. Therapy Director #126 revealed she believed Resident #36 would benefit from a restorative program but there was none to refer him to when he was discharged from PT. However, she did believe since he could benefit he would be added to a restorative case load when the new restorative aide began employment 08/01/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 7 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 Based on observation, record review, review of shower schedules and interview the facility failed to ensure Resident #15, #38 and #64, who were dependent on staff for bathing were provided baths/showers according to their preference and schedule. This affected three residents (#15, #38 and #64) of 13 residents interviewed regarding their ability to make choices for bath/shower preferences. Residents Affected - Few Findings include: 1. Review of Resident #15's medical record revealed diagnoses including end stage renal disease, morbid obesity, type 2 diabetes mellitus, depression, and heart disease. A quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/12/22 revealed Resident #15 was moderately cognitively impaired, was able to make herself understood and was able to understand others. The assessment indicated no rejection of care and dependency on staff for bathing. On 07/18/22 at 3:01 P.M. interview with Resident #15 revealed she would like to be bathed every other day but stated she received one bath every week or two. Review of a shower preference sheet revealed Resident #15 wanted two bed baths a week on day shift with a preference for morning. Review of the shower schedule revealed Resident #15 was scheduled to receive a bed bath on the 7 P.M. to 7 A.M. shift on Monday, Wednesday and Friday. Review of bathing sheets revealed only two baths were offered/provided the week of 07/10/22 to 07/16/22. On 07/20/22 at 6:05 A.M. interview with Registered Nurse (RN) #115 revealed at times there was not enough staff on night shift. For example, at times there were two nursing assistants for the entire facility and staff were not able to provide showers/baths as scheduled. On 07/20/22 at 6:22 A.M. interview with State Tested Nursing Assistant (STNA) #108 revealed there were usually two to three nursing assistants working on night shift and staff could only do rounds to reposition residents, provide incontinence care and respond to call lights. There were times when showers/baths could not be provided. On 07/20/22 at 3:20 P.M. interview with STNA #165 verified Resident #15 was dependent on staff for bathing needs. On 07/21/22 at 1:59 P.M. interview with Director of Nursing (DON) #176 verified showers were not provided in accordance with shower sheets/schedules. 2. Review of Resident #38's medical record revealed diagnoses including chronic obstructive pulmonary disease, depression, heart disease, and chronic pain. A quarterly MDS 3.0 assessment, dated 05/24/22 indicated Resident #38 was cognitively intact, able to make himself understood and was dependent on staff for bathing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 8 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 Review of an undated preference sheet revealed Resident #38 would like to receive three showers weekly in the evening. Review of shower schedules revealed Resident #38 was scheduled to receive a shower on 7 P.M. to 7 A.M. shift on Monday, Wednesday, and Friday. Residents Affected - Few Review of shower documentation between 06/20/22 and 07/19/22 revealed documentation of only one shower being offered/provided the week of 07/10/22-07/16/22. The last shower recorded prior to the interview completed on 07/18/22 was a shower provided on night shift on 07/11/22. On 07/18/22 between 2:47 P.M. and 2:50 P.M. Resident #38 was observed sitting in his room. The resident appeared to be unshaven with facial hair present. At the time of the observation, interview with Resident #38 revealed he was scheduled to receive three showers a week but stated he was not receiving them, being told there was not enough staff. Resident #38 stated he was usually shaved during showers. On 07/21/22 at 1:59 P.M. interview with DON #176 verified showers were not provided in accordance with shower sheets/schedules for Resident #38. 3. Review of Resident #64's medical record revealed diagnoses including left side weakness and paralysis, morbid obesity, anorexia and edema. A quarterly MDS 3.0 assessment, dated 07/03/22 revealed Resident #64 was cognitively intact, able to make himself understood and was dependent on staff for bathing. On 07/18/22 at 2:20 P.M. interview with Resident #64 revealed he was supposed to get a shower every Tuesday and Saturday. However, he stated he usually only got one a week and was told it was because of staffing issues. Review of an undated resident preference sheet revealed Resident #64 would like to be offered more than two showers weekly. However, there was a notation for AM on Tuesday and Friday and the sheet was signed by Resident #64. Review of shower schedules revealed Resident #64 was scheduled for showers on day shift every Tuesday and Saturday. Review of shower documentation between 06/20/22 and 07/19/22 revealed no evidence of a shower being offered/provided 06/21/22, 06/28/22 or 07/19/22. On 07/20/22 at 3:20 P.M. interview with STNA #165 verified Resident #64 was dependent on staff for showers. On 07/21/22 at 1:59 P.M. interview with DON #176 verified showers were not provided in accordance with shower sheets/schedules for Resident #64. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 9 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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** 2. Review of Resident #17's medical record revealed diagnoses including [NAME] Syndrome (Ogilvie syndrome is a rare condition that affects the large intestines (colon). Although the signs and symptoms mimic those of an intestinal blockage, there is no physical obstruction. Instead, the symptoms are due to nerve or muscle problems that affect peristalsis (the involuntary, rhythmic muscular contractions that move food, fluid, and air through the intestines)), irritable bowel syndrome without diarrhea, and constipation. Residents Affected - Few A plan of care, initiated 03/14/17 revealed Resident #17 was at risk for constipation related to decreased mobility, history of constipation, medication use, irritable bowel syndrome, Ogilvies Syndrome, history of obstruction and ileus (the inability of the intestine to contract normally leading to a build-up of food material), megacolon (abnormally enlarged colon) and abdominal distention. The care plan indicated Resident #17 received medications to ensure her stools were on the loose consistency related to diagnoses. The care plan indicated Resident #17 took medications to ensure her stools were on the loose consistency related to diagnoses. The care plan indicated Resident #17 refused laxatives at times. Interventions included administering medication as ordered. Review of bowel movement records from 06/21/22 to 07/19/22 revealed no bowel movement was recorded from 06/20/22 through 06/23/22, 07/01/22 to 07/04/22 or 07/13/22 to 07/18/22. Review of the July 2022 Medication Administration Record (MAR) revealed an order for milk of magnesia (MOM) every six hours as needed for constipation with no record of the MOM being offered or administered. An order for a fleet enema every 72 hours as needed for no bowel movement in three days revealed no evidence the fleet enema was offered after Resident #72 had no record of a bowel movement for 72 hours from 06/20/22 through 06/23/22, 07/01/22 to 07/04/22 or 07/13/22 to 07/18/22. On 07/20/22 at 1:12 P.M. interview with DON #176 verified there was no record of a bowel movement from 06/20/22 through 06/23/22, 07/01/22 to 07/04/22 or 07/13/22 to 07/18/22. DON #176 verified there was no indication MOM or enemas were offered as ordered during these time periods. Based on observation, record review and interview the facility failed to ensure weight monitoring was completed as ordered for Resident #54, who had a diagnosis of congestive heart failure and failed to ensure a comprehensive and individualized bowel regimen was implemented for Resident #17 as ordered. This affected two residents (#17 and #54) of five residents reviewed for quality of care and/or nutrition. Findings include: 1. Review of Resident #54's medical record revealed an admission date of 05/28/22 with diagnoses including congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and hypertension. Review of Resident #54's recent weights revealed the resident had experienced a significant weight gain. On 06/16/22 the resident weighed 176 pounds and on 06/20/22 his weight was 191 pounds. Record review revealed an order, dated 07/01/22 to obtain daily weights. Record review revealed the facility failed to obtain weights for Resident #54 as ordered on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 10 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 07/02/22, 07/05/22, 07/06/22, 07/07/22, 07/10/22, 07/11/22, 07/12/22 and 07/15/22. Level of Harm - Minimal harm or potential for actual harm On 07/20/22 at 8:36 A.M. Resident #54 was observed sitting in his wheelchair in his room. The resident had oxygen applied, and slight edema was noted to his bilateral hands. Residents Affected - Few On 07/21/22 at 2:19 P.M. interview with Director of Nursing (DON) #176 verified the resident, who had a diagnosis of CHF did not have a daily weight obtained as ordered on 07/02/22, 07/05/22, 07/06/22, 07/07/22, 07/10/22, 07/11/22, 07/12/22 and 07/15/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 11 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure residents with limited range of motion (ROM) received restorative therapy to maintain function or prevent decline in ROM. This affected four residents (#4, #8, #12 and #57) of five residents reviewed for range of motion. Findings include: 1. Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, history of falling, and need for continuous supervision. Further review of Resident #8's medical record revealed no evidence the resident was receiving restorative therapy. Review of Resident #8's activity of daily living (ADL) plan of care, initiated 03/30/22 revealed the resident was at risk for developing complications associated with decreased ADL self-performance. Interventions included to encourage resident to slow down and look before propelling wheelchair. The resident self-propelled wheelchair backwards. Review of Resident #8's therapy screen, dated 06/29/22 revealed Resident #8 had declined in bed mobility from independent to extensive assistance, locomotion from independent to limited assist, transfers from independent to limited assist, ambulation from limited assist to extensive assist, dressing from supervision to extensive assistance, toilet use from independent to limited assist, and personal hygiene from independent for extensive assist. An additional note indicated the resident discontinued from physical therapy on 04/28/22 and occupational therapy on 04/26/22. Review of Resident #8's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/15/22 revealed the resident had limited ROM on one side of the upper extremity and impairment of both sides of the lower extremity. On 07/18/22 at 2:41 P.M. interview with Resident #8 revealed she had declined in ROM and she was just started on therapy. The resident reported she had not received any type of restorative ROM program to prevent decline. On 07/21/22 at 7:34 A.M. interview with Therapy Manager #126 revealed the resident would have benefited from a restorative program, however the facility did not have a restorative program to refer to, so it was not included on therapy discharge notes. The resident had OT and PT in April 2022 and currently had noted decline and was required to be picked back up for OT and PT this month. On 07/21/22 at 11:04 A.M. interview with Registered Nurse (RN) #200 revealed there had been a miscommunication with therapy and the facility had a restorative program. The RN reported the floor staff were responsible for restorative until 08/01/22 then it would be transferred to the therapy department. RN #200 revealed the Therapy Manager would write recommendation today. 2. Record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, psychomotor deficit, hemiplegia and hemiparesis following cerebral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 12 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 0688 infarction affecting left non-dominant side, lack of coordination, muscle weakness and unsteadiness on feet. Level of Harm - Minimal harm or potential for actual harm Further review of Resident #12's medical record revealed no evidence the resident had received or was receiving restorative therapy. Residents Affected - Some Review of Resident #12's MDS dated [DATE] revealed the resident had ROM impairment on one side of the upper and lower extremity. Review of Resident #12's ADL plan of care initiated on 08/22/20 revealed the resident was at risk for developing complications associated with decreased ADL self-performance. The resident required assistance with ADL's. On 07/18/22 at 2:48 P.M. interview with Resident #12 revealed she had limited ROM in the left arm. However, she had not received restorative therapy. The resident reported she would benefit for therapy and would participate if it was offered. On 07/21/22 at 7:34 A.M. interview with Therapy Manager #126 revealed Resident #12 would benefit from a restorative therapy program, however the facility did not have a restorative program to refer the resident to at this time. On 07/21/22 at 11:04 A.M. interview with Registered Nurse (RN) #200 revealed there had been a miscommunication with therapy and the facility had a restorative program. The RN reported the floor staff were responsible for restorative until 08/01/22 then it would be transferred to the therapy department. RN #200 revealed the Therapy Manager would write recommendation today. 3. Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including pressure ulcers, end stage renal disease, cerebral infarction, contracture of left and right ankle and muscle weakness. Further review of Resident #57's medical record revealed no evidence the resident had or was currently receiving restorative therapy. Review of Resident #57's ADL plan of care, initiated 12/18/19 revealed the resident was at risk for developing complications associated with decreased ADL self-performance. The resident required staff assistance with ADL care. Review of Resident #57's staff referral screen, dated 06/12/22 revealed the resident had pain in a body part, increased stiffness in lower and upper extremity and limited ROM. Review of Resident #57's therapy screen, dated 07/01/22 revealed the resident had noted decline in bed mobility and needed skilled therapy to address bed mobility and contracture management. Review of Resident #57 MDS 3.0 assessment, dated 07/08/22 revealed the resident had ROM impairment to bilateral lower extremities. Review of Resident #57 therapy notes dated 07/01/22 to 07/14/22 revealed no evidence the resident was referred to restorative therapy after discharge on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 13 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 07/20/22 at 10:35 A.M. interview with Therapy Manager #126 revealed Resident #57 would benefit from a restorative program, however it was not recommended on the therapy discharge as the facility did not have a restorative program to refer him to. On 07/21/22 at 11:04 A.M. interview with Registered Nurse (RN) #200 revealed there had been a miscommunication with therapy and the facility had a restorative program. The RN reported the floor staff were responsible for restorative until 08/01/22 then it would be transferred to the therapy department. RN #200 revealed the Therapy Manager would write recommendation today. 4. Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including palliative care, cerebral infarction, hemiplegia and hemiparesis, left foot drop and history of falls. Further review of Resident #4's medical record revealed no evidence the resident was receiving or had received restorative therapy. Review of Resident #4's ADL plan of care, initiated on 03/04/20 revealed the resident was at risk for developing complications associated with decreased ADL self-performance. The resident required staff assistance with ADL care Review of Resident #4's MDS 3.0 assessments, dated 04/05/22 and 07/05/22 revealed the resident had declined and required more staff assistance with bed mobility and transfers. The resident had ROM impairment to bilateral lower extremities. On 07/21/22 at 7:34 A.M. interview with Therapy Manager #126 revealed the resident had been on hospice for years and therapy did not screen hospice residents. The therapy manager also thought the resident could not be offered restorative services related to hospice. Therapy Manager #126 revealed the resident could benefit from restorative therapy. On 07/21/22 at 10:01 A.M. interview with Director of Nursing (DON) #176 revealed a hospice resident could participate in restorative therapy if it was recommended by therapy. On 07/21/22 at 11:04 A.M. interview with Registered Nurse (RN) #200 revealed there had been a miscommunication with therapy and the facility had a restorative program. The RN reported the floor staff were responsible for restorative until 08/01/22 then it would be transferred to the therapy department. RN #200 revealed the Therapy Manager would write recommendation today. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 14 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 observation, record review and interview the facility failed to provide adequate supervision to Resident #63 to prevent the resident from leaving the facility unsupervised and failed to ensure fall safety interventions were in place for Resident #55 as planned to prevent injury associated with fall risk. This affected two residents (#55 and #63) of seven residents reviewed for accidents. Findings include: 1. Review of Resident #63's closed medical record revealed diagnoses including dementia with behavioral disturbance, type 2 diabetes mellitus, wandering, Alzheimer's disease, impulsiveness and anxiety disorder. Review of a hospital emergency department provider note, dated 06/21/22 revealed Resident #63 had fallen a couple days prior to the hospital visit while hiking along the road trying to get to North Carolina. Resident #63 was at a different nursing home with several attempts of leaving this nursing home. The nursing home was attempting to place Resident #63 in a more secure facility when Resident #63's daughter and ex-wife decided to try to take him home. As a result, Resident #63 jumped out of the window (of the home) and was found walking down the highway. The emergency department note indicated Resident #63 had also been evaluated at the hospital on [DATE] and was placed at a post-acute facility due to diagnosis of dementia. The note indicated Resident #63 escaped from that facility multiple times before his wife and daughter took him home. Overnight, he jumped out of a window and was found wandering. Review of hospital admission referral paper work, dated 06/22/22 indicated an emergency department note from 05/04/22 which indicated Resident #63's son reported the resident was trying to hitchhike to Virginia where his son lived. It indicated Resident #63 was escaping through the window. This was the second time in two days Resident #63 was picked up wandering the streets trying to hitchhike to Virginia. Resident #63 was unable to recall being at the hospital two days prior but indicated both times he was trying to get to Virginia where he believed he lived alone. In reality, Resident #63 had not been to Virginia in over 40 years. Resident #63 was admitted to this facility on 06/25/22. A hand written note (not dated but appeared to be a report sheet) revealed notations indicating Resident #63 was a flight and fall risk. Resident #63 had been housed in the emergency room for almost three days while the hospital looked for placement for him. Resident #63 was alert to himself. A nursing note, dated 06/25/22 at 3:00 P.M. revealed Resident #63 was admitted to a room on the facility secured behavioral unit. Resident #63 was introduced to staff and oriented to his room and the unit. An admission assessment, dated 06/25/22 (locked 6/30/22) revealed Resident #63 was alert, confused and wandering. Resident #63 was admitted to the secured behavior unit, was full weight bearing and transferred and ambulated independently. A progress note, dated 06/25/22 at 10:00 P.M. noted Resident #63 returned from the hospital via stretcher. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 15 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 There were no notes indicating the reason Resident #63 was sent to the hospital on or around 06/25/22. Level of Harm - Minimal harm or potential for actual harm An elopement risk assessment dated [DATE] indicated Resident #63 was physically capable of leaving the facility. Other risk factors included restlessness, wandering, roaming, pacing, and exit seeking behaviors. Resident #63 had a history of elopement and lack of awareness of safety needs. Residents Affected - Few A discharge plan of care, dated 07/15/22 indicated Resident #63 was admitted to the facility behavioral unit on 06/25/22 with diagnoses of altered mental status and dementia with behavioral disturbance. Within hours of admission, Resident #62 unscrewed the window and wandered down the hill. Resident #63 obtained a skin tear from briars, was sent to the emergency room for evaluation and returned. On 07/20/22 at 12:05 P.M. interview with Registered Nurse (RN) #200 revealed the incident occurred the day of admission shortly after Resident #63 had arrived. The investigation showed Resident #63 used a knife to get out of the window to manipulate the lock and he went down over the hill and was found by staff, sent to the hospital and was put on one on one supervision until the time of discharge. Resident #63 was discharged to an Alzheimer's facility. RN #200 indicated the activity director found Resident #63 down over the hill behind the facility. Resident #63 was sitting on the ground under a tree and had sustained a skin tear. On 07/20/22 at 12:52 P.M. interview with Activity Director #100 revealed she was not the person who found Resident #63 but was one of the first staff to reach him after he had been located. Activity Director #100 stated it was a pretty warm day and Resident #63 was sweaty when found. Staff convinced Resident #63 to return to the facility to get something to drink. Activity Director #100 stated the terrain down to where Resident #63 was located was a little rough and Resident #63 was wearing sandals. On 07/20/22 at 1:30 P.M. interview with the Administrator revealed the facility investigation showed Resident #63 arrived at the facility at 3:00 P.M. and nursing had started an assessment. The nurse had asked the aide to get Resident #63's weight. The nursing assistant was not able to find Resident #63 when he went to weigh him. The Administrator revealed the windows had been secure. The Administrator verified the resident had come from a nursing home with a history of exit seeking and that was why he was placed on the secure unit. Resident #63 had been provided a meal tray after his arrival. State Tested Nursing Assistant (STNA) #165 was the one who spotted Resident #63 because he had a white shirt on. An incident report and investigation were provided after the interview. Review of the Incident/Accident report revealed the incident occurred on 06/25/22 at 4:00 P.M. in the B hall activity room. Resident #63 was confused before the incident. Resident #63 was admitted at approximately 3:00 P.M. Around 4:00 P.M. Resident #63 was missing and staff noticed screws had been removed from the window and the window in the activity room was open. A skin tear was noted to the hand (not specified). Resident #63 was sent to the hospital for evaluation and was returned to the facility. The facility started a weekly audit for maintenance to check the windows in the behavior unit to ensure they were closed and could not be opened. Witness statements included: a. A witness statement by Registered Nurse (RN) #116 dated 06/28/22 indicated at approximately 3:45 P.M. Licensed Practical Nurse (LPN) #174 reported he could not find a resident so they immediately went out to the employee parking lot and the 300 hall and looked over the hill. Temporary Nursing Assistant (TNA) #141 was sent out in his car to check the surrounding roads. RN #116 returned to the facility and called the Administrator then went back to B hall and started searching rooms again. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 16 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 When RN #116 entered Resident #50's room he said he saw Resident #63 over by the window in the activity room. RN #116 indicated she went over to the window and noticed it was about 2-3 inches open and she notified LPN #174 on the walkie. At 4:00 P.M. she notified the Administrator Resident #63 could not be found. At approximately 4:10 P.M. the Administrator was notified Resident #63 was found but still over the hill and they were trying to bring him up. Residents Affected - Few b. A witness statement by LPN #174 indicated TNA #141 notified him Resident #63 was missing as he was doing the admission. After searching it was noticed a window was partially open. The administrator and everyone in the building were notified to assist with the search and police were called. Resident #63 was found safely on the south end of the building 50 yards from the building. The county 911 was called. The statement indicated Resident #63 was last seen at 3:30 P.M. and found at 4:00 P.M. c. A witness statement by Activity Director #100 dated 06/28/22 indicated she was notified by a nursing assistant that a resident was missing. She went to get her car after originally not seeing him over the hill. STNA #165 yelled she thought it might be Resident #63 down under the tree so she started over the hill and a couple nurses had started down and thought maybe some aides. Activity Director #100 stated she got to him first and saw him get up on his hands and knees and start to crawl and she took off running toward him. Resident #63 had a knife and bag of chex mix with him. She asked where he was going and he replied he was trying to get home. Resident #63 refused to give her the butter knife stating he needed it for protection. Activity Director #100 encouraged Resident #63 to return to the facility to get a cold drink, helped him up off the ground and he handed her the knife so she threw it out of his reach. Resident #63 had a skin tear on his left hand. Resident #63 stated he fell but was not hurt. With the help of two other staff, Resident #63 was assisted back to the facility. Resident #63 had to stop for rest breaks. Staff sat with Resident #63 in the activity room until the ambulance arrived. On 07/20/22 at 2:17 P.M. interview with LPN #174 revealed he was assigned to Resident #63 when he was admitted and had started the admission assessment. He asked TNA #141 to get a weight. About 20 minutes later, TNA #141 reported he went to get the weight and was unable to locate Resident #63. LPN #174 stated he recalled being told when he received report about Resident #63 that he had to be watched because he had a history of elopement. The person who gave him report told him Resident #63 would seem fine one minute then the next minute would be jumping out the window. LPN #174 stated he had worked on the secure unit and didn't put much thought into what was said until he heard Resident #63 was missing. Staff checked each room and was unable to locate Resident #63 so he reported it to other staff. LPN #174 stated there was one aide on the unit the entire time. LPN #174 stated another resident on the unit who was alert and oriented told staff he had seen Resident #63 at the window. Resident #63 had jumped out a window at another facility and was found in the ditch. Staff started searching outside and a STNA found Resident #63 down in a ravine maybe 60 yards from the facility under a tree holding a butter knife and twizzlers. Law enforcement had been notified of Resident #63 missing. When the police arrived they refused to go down into the ravine stating it was too steep. On 07/20/22 at 3:04 P.M. interview with STNA #107 revealed she left at 3:00 P.M. the day Resident #63 was admitted and TNA #141 took over for her. (The Administrator had identified STNA #107 as working at the time Resident #63 eloped). On 07/20/22 at 3:20 P.M. interview with STNA #165 verified she was the person who originally located Resident #63. However, she had difficulty getting down the hill because of all the holes and tire tracks. Activity Director #100 reached Resident #63 first. STNA #165 indicated she did not stay because Resident #63 was getting agitated and did not want surrounded by people. STNA #165 stated there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 17 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 were a lot of briars going down into the ravine. Level of Harm - Minimal harm or potential for actual harm On 07/21/22 at 2:22 P.M. interview with TNA #141 revealed he could not recall what time Resident #63 arrived at the facility on the day of admission. TNA #141 reported he and STNA #107 were at the desk before she left at 3:00 P.M. TNA #141 stated he recalled Resident #63 walking around in circles. Resident #63 started doing his rounds and he was the only nursing assistant on the secure unit at that time. LPN #174 was at the desk working on Resident #63's admission. When he got to Resident #63's room he realized he was not there and could not find him so he immediately notified the nurse and searched the unit. TNA #141 stated he had been made aware Resident #63 was a flight risk. When Resident #63 could not be located inside the facility he got his car and started driving down the highway because the resident had a history of wandering on the highway. When TNA #141 got the message Resident #63 had been found he returned to the facility and helped Activity Director #100 get Resident #63 back up the hill. Police refused to go down the hill. TNA #141 stated Resident #63 had to stop for frequent rest breaks because he was winded. The ground was rippled from ruts from tire tracks, had thorn bushes and the grass was high. Residents Affected - Few Review of the facility's Elopement and Unsafe Wandering policy, revised 04/28/21 indicated the facility would utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Residents would be assessed for risk of elopement and unsafe wandering following admission, periodically throughout their stay and as determined as necessary by the interdisciplinary care plan team. The interdisciplinary team would evaluate the unique factors contributing to risk in order to develop a person-centered care plan. Adequate supervision would be provided to aide in preventing accidents or elopements to the extent possible. 2. Review of Resident #55's medical record revealed an admission date of 03/16/22 with diagnoses including Alzheimer's disease with early onset, dementia, restless and agitation and a history of falling. Review of Resident #55 Fall Risk Assessment, dated 05/11/22 reveled the resident was at risk for falling. Review of Resident #55's nursing note, dated 05/17/2022 revealed a State Tested Nursing Assistance (STNA) called the nurse to the resident's room. The resident was found on his hands and knees on the floor of his room. The resident was assessed to have an abrasion to his right elbow. Review of a fall investigation, dated 05/17/22 revealed the resident was attempting to walk in his room and was found on the floor. A new intervention was initiated for the resident to wear elbow protectors. Review of Resident #55's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/21/22, revealed the resident had impaired cognition. The assessment also indicated the resident required limited assistance with one personal physical assistance for locomotion on the unit. Review of Resident #55's care plan, dated 07/03/22 revealed the resident was at risk for impaired mobility with an intervention for elbow protectors to help prevent injury in case of a fall. On 07/18/22, 07/20/22, 07/21/22 and 07/25/22 random observations of Resident #55 at various times (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 18 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 of the day revealed the resident was not wearing elbow protectors. In addition, the resident was observed to have a shuffling gait when walking and used the walls at times for guidance while ambulating down the halls. On 07/25/22 at 9:46 A.M. interview with STNA #145 revealed he was very familiar with Resident #55 and helped get him ready that morning. He revealed the resident had an unsteady gait and needed assistance with ambulating at times. He indicated he was unaware the resident was to have elbow protectors as he had never seen elbow protectors on the resident or in the resident's room. At this time, an observation was done of the resident's room with STNA #145 and elbow protectors could not be located. On 07/25/22 at 10:10 A.M. interview with Director of Nursing (DON) #148 and Registered Nurse #200 confirmed elbow protects were to be in place as a fall intervention for Resident #55. DON #148 confirmed they were not in place and stated she would obtain a pair and place them in the resident's room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 19 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 observation, record review, review of the dietitian job description, nutrition best practice review, facility policy and procedure review and interview the facility failed to ensure the dietitian or qualified dietary employee timely assessed and addressed a significant weight gain for Resident #8. In addition, the facility failed to ensure weight changes were timely communicated to the resident's physician. This affected one resident (#8) of two residents reviewed for food choices. Residents Affected - Few Findings include: Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, Crohn's disease, depression, gastro-esophageal reflux disease, hypokalemia, vitamin D deficiency, hypocalcemia and absence of other specified parts of the digestive tract. Review of Resident #8's potential for alteration in nutrition plan of care revealed interventions and goals included no unplanned significant weight changes and notify physician and family of weight changes. Review of Resident #8's dietary notes revealed on 04/05/22 the dietician completed an admission assessment which indicated the resident's current weight was 142 pounds (#) and her body mass index was 22.9 indicating normal weight. The intervention included to continue monitoring weights, intakes and laboratory results. Resident #8's goal included no unplanned significant weight changes Review of Resident #8's weights, dated 03/30/22 to 06/25/22 revealed the resident's weight on admission was 139 pounds (#). Resident #8's next weight was obtained on 05/06/22 and the resident had gained 11# and weighed 150#. The next weight was on 06/10/22 and resident gained an additional 24# and weighed 174#. The resident had gained 35# in two months. On 06/25/22 the resident had lost #16 and weighed #158 due to a hospitalization. There was no evidence the resident was weighed weekly for four weeks after her admission on [DATE] or re-weighed after the noted significant weight gains on 05/06/22 and 06/10/22 or significant weight loss on 06/25/22. There was no evidence of any dietary notes the month of May or June 2022 when the significant weight gain was noted both months. eview of Resident #8's progress notes and assessments tab revealed no evidence the resident had been assessed when there was a noted significant weight gain on 05/06/22 and 06/10/22 nor was there evidence the physician was notified of the significant weight gain on 05/06/22 or 06/10/22 or loss on 06/25/22. The next dietary note, dated 07/02/22 reflected the resident was a re-admission. Her current weight was 158# and body mass index were 25.5 which indicated normal weight. The resident had a significant weight loss of 16# in two weeks and significant weight gain of 16# in three months. New interventions included a night snack, boost breeze (supplement) twice daily and nutritional education as needed. On 07/18/22 at 2:46 P.M. interview with Resident #8 revealed the resident reported the food was terrible and her lunch meal tray was observed in her room untouched. The resident reported her, and her roommate bought snacks and food from Amazon and Sam's Club and had it delivered (due to the facility food being so bad). There were card board boxes of snacks observed in the room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 20 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 On 07/19/22 at 12:06 P.M. and 1:31 P.M. interview with Registered Dietician (RD) #179 revealed she had never spoken to the resident regarding her nutritional needs during her assessments, nor had she completed a nutritional assessment on 05/06/22 or 06/10/22 when there was a noted significant weight gain. The RD reported the reason she did not complete an assessment was because it was a significant weight gain not a loss. The RD also verified there was no evidence the resident was re-weighed for accuracy with the noted significant weight changes or evidence the physician was notified of the weight changes. The RD reported in June 2022 the facility had noted concerns with weight loss and had implemented a plan of correction to monitor meal intakes and ensure staff were recording weights. There was nothing noted in the plan regarding weight gain or physician notification. On 07/19/22 at 2:24 P.M. interview with RD #179 revealed the facility did not have a nutritional policy and procedure and stated the facility followed the nutrition best practices, which she provided a copy of. Review of nutrition best practice, dated 09/2016 revealed obtain a weekly weight for the resident for four weeks following admission and obtain re-weigh for gain/loss equal to or greater than five pounds if over 100#. Residents who were identified to be at nutritional risk would be reviewed by the at-risk committee and the supervised dietary technician would refer resident and intervention discussed at this meeting to the registered dietician for oversight and review. This included residents with unplanned weight loss or gain of 5% in 30 days or 10% in 180 days. Review of facility policy titled Change of Condition, dated 04/2013 revealed a change of condition was defined as deterioration in health status related of a significant change in the resident's clinical condition or status. The unit supervisor or charge nurse would notify the resident, physician, and guardian of all changes. The person doing the notification may document all notifications. Review of undated Dietitian job description revealed responsibilities and major duties included to assess and document the nutritional needs of each resident in accordance with the resident's comprehensive assessment and care plan. Counsel resident regarding dietary likes and dislikes, appetite, for habits, and therapeutic menus. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 21 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to maintain adequate levels of staffing to ensure all residents received necessary care and treatment, including timely bathing/showers and/or supervision to prevent elopement. This affected five residents (#35, #15, #38, #64 and #63) and had the potential to affect all 63 residents residing in the facility. Findings include: 1. On 07/19/22 at 10:29 A.M. interview with Resident #35 revealed concerns with the facility staffing. The resident reported staff response to call lights was sometimes slow. The resident elaborated and indicated call light response was usually within 20-25 minutes but sometimes took longer on the evening shift. Resident #35 stated one night the prior week there was only one nursing assistant for the entire building. On 07/21/22 at 8:57 A.M. interview with Human Resources (HR) manager #130 verified on night shift on 07/15/22 Temporary Nursing Assistant (TNA) #122 had to leave early at 9:45 P.M. for an emergency to take her son to the hospital. That left two nursing assistants and two nurses working. At 5:09 A.M., one of those aides left resulting in only one nursing assistant being present for a census of 66 until another aide arrived at 6:14 A.M. HR manager #130 revealed the Administrator was present from 10:00 P.M. to 2:00 A.M. that night and helped answer call lights but verified the Administrator was not trained to provide direct resident care. HR manager #130 verified there were only two aides working between 7:14 P.M. and 8:52 P.M. the evening of 07/16/22 because she had two nursing assistants off work due to COVID-19 and one call off. The census was 66. On 07/21/22 at 10:05 A.M. interview with the Administrator revealed the facility had not activated their emergency staffing protocol related to the COVID outbreak. 2. Review of Resident #15's medical record revealed diagnoses including end stage renal disease, morbid obesity, type 2 diabetes mellitus, depression, and heart disease. A quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/12/22 revealed Resident #15 was moderately cognitively impaired, was able to make herself understood and was able to understand others. The assessment indicated no rejection of care and dependency on staff for bathing. On 07/18/22 at 3:01 P.M. interview with Resident #15 revealed she would like to be bathed every other day but stated she received one bath every week or two. Review of a shower preference sheet revealed Resident #15 wanted two bed baths a week on day shift with a preference for morning. Review of the shower schedule revealed Resident #15 was scheduled to receive a bed bath on the 7 P.M. to 7 A.M. shift on Monday, Wednesday and Friday. Review of bathing sheets revealed only two baths were offered/provided the week of 07/10/22 to 07/16/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 22 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 07/20/22 at 6:05 A.M. interview with Registered Nurse (RN) #115 revealed at times there was not enough staff on night shift. For example, at times there were two nursing assistants for the entire facility and staff were not able to provide showers/baths as scheduled. On 07/20/22 at 6:22 A.M. interview with State Tested Nursing Assistant (STNA) #108 revealed there were usually two to three nursing assistants working on night shift and staff could only do rounds to reposition residents, provide incontinence care and respond to call lights. There were times when showers/baths could not be provided. On 07/20/22 at 3:20 P.M. interview with STNA #165 verified Resident #15 was dependent on staff for bathing needs. On 07/21/22 at 1:59 P.M. interview with Director of Nursing (DON) #176 verified showers were not provided in accordance with shower sheets/schedules. 3. Review of Resident #38's medical record revealed diagnoses including chronic obstructive pulmonary disease, depression, heart disease, and chronic pain. A quarterly MDS 3.0 assessment, dated 05/24/22 indicated Resident #38 was cognitively intact, able to make himself understood and was dependent on staff for bathing. Review of an undated preference sheet revealed Resident #38 would like to receive three showers weekly in the evening. Review of shower schedules revealed Resident #38 was scheduled to receive a shower on 7 P.M. to 7 A.M. shift on Monday, Wednesday, and Friday. Review of shower documentation between 06/20/22 and 07/19/22 revealed documentation of only one shower being offered/provided the week of 07/10/22-07/16/22. The last shower recorded prior to the interview completed on 07/18/22 was a shower provided on night shift on 07/11/22. On 07/18/22 between 2:47 P.M. and 2:50 P.M. Resident #38 was observed sitting in his room. The resident appeared to be unshaven with facial hair present. At the time of the observation, interview with Resident #38 revealed he was scheduled to receive three showers a week but stated he was not receiving them, being told there was not enough staff. Resident #38 stated he was usually shaved during showers. On 07/21/22 at 1:59 P.M. interview with DON #176 verified showers were not provided in accordance with shower sheets/schedules for Resident #38. 4. Review of Resident #64's medical record revealed diagnoses including left side weakness and paralysis, morbid obesity, anorexia and edema. A quarterly MDS 3.0 assessment, dated 07/03/22 revealed Resident #64 was cognitively intact, able to make himself understood and was dependent on staff for bathing. On 07/18/22 at 2:20 P.M. interview with Resident #64 revealed he was supposed to get a shower every Tuesday and Saturday. However, he stated he usually only got one a week and was told it was because of staffing issues. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 23 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of an undated resident preference sheet revealed Resident #64 would like to be offered more than two showers weekly. However, there was a notation for AM on Tuesday and Friday and the sheet was signed by Resident #64. Review of shower schedules revealed Resident #64 was scheduled for showers on day shift every Tuesday and Saturday. Review of shower documentation between 06/20/22 and 07/19/22 revealed no evidence of a shower being offered/provided 06/21/22, 06/28/22 or 07/19/22. On 07/20/22 at 3:20 P.M. interview with STNA #165 verified Resident #64 was dependent on staff for showers. On 07/21/22 at 1:59 P.M. interview with DON #176 verified showers were not provided in accordance with shower sheets/schedules for Resident #64. 5. On 07/20/22 at 6:05 A.M. during an interview with RN #115, the RN revealed she did not believe the facility was sufficiently staffed to monitor residents and deal with residents with behavior problems. As an example, RN #115 stated the facility had a resident who was able to leave the facility through a window and was found behind the facility. RN #115 could ot recall the resident's name at the time of the interview. On 07/20/22 at 6:22 A.M. interview with STNA #108 revealed the resident who left the facility through the window was Resident #63. Review of Resident #63's closed medical record revealed diagnoses including dementia with behavioral disturbance, type 2 diabetes mellitus, wandering, Alzheimer's disease, impulsiveness, and anxiety disorder. Review of a hospital emergency department provider note, dated 06/21/22 revealed Resident #63 had fallen a couple days prior to the hospital visit while hiking along the road trying to get to North Carolina. Resident #63 was at a different nursing home with several attempts of leaving the nursing home. The nursing home was attempting to place Resident #63 in a more secure facility when Resident #63's daughter and ex-wife decided to try to take him home. As a result, Resident #63 jumped out of the window and was found walking down the highway. The emergency department note indicated Resident #63 had also been evaluated at the hospital on [DATE] and was placed at a post-acute facility due to dementia. The note indicated Resident #63 escaped from that facility multiple times before his wife and daughter took him home. Overnight, he jumped out of a window and was found wandering. Review of hospital admission referral paper work, dated 06/22/22 indicated an emergency department note from 05/04/22 which indicated Resident #63's son reported the resident was trying to hitchhike to Virginia where his son lived. It indicated Resident #63 was escaping through the window. This was the second time in two days Resident #63 was picked up wandering the streets trying to hitchhike to Virginia. Resident #63 was unable to recall being at the hospital two days prior but indicated both times he was trying to get to Virginia where he believed he lived alone. In reality, Resident #63 had not been to Virginia in over 40 years. Resident #63 was admitted to this facility 06/25/22. A hand written note (not dated but appeared to be a report sheet) revealed notations indicating Resident #63 was a flight and fall risk. Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 24 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 0725 Level of Harm - Minimal harm or potential for actual harm #63 had been housed in the emergency room for almost three days while the hospital looked for placement for him. Resident #63 was alert to himself. A nursing note, dated 06/25/22 at 3:00 P.M. revealed Resident #63 was admitted to a room on the secured behavioral unit. Resident #63 was introduced to staff and oriented to his room and the unit. Residents Affected - Many An admission assessment, dated 06/25/22 (locked 6/30/22) indicated Resident #63 was alert, confused and wandering. Resident #63 was admitted to the secured behavior unit, was full weight bearing, and transferred and ambulated independently. A progress note, dated 06/25/22 at 10:00 P.M. indicated Resident #63 returned from the hospital via stretcher. There were no notes indicating the reason Resident #63 was sent to the hospital on or around 06/25/22. An elopement risk assessment, dated 06/25/22 indicated Resident #63 was physically capable of leaving the facility. Other risk factors included restlessness, wandering, roaming, pacing, and exit seeking behaviors. Resident #63 had a history of elopement and lack of awareness of safety needs. A discharge plan of care, dated 07/15/22 revealed Resident #63 was admitted to the facility behavioral unit on 06/25/22 with diagnoses of altered mental status and dementia with behavioral disturbance. Within hours of admission, Resident #63 unscrewed the window and wandered down the hill. Resident #63 obtained a skin tear from briars, was sent to the emergency room for evaluation and returned. On 07/20/22 at 2:17 P.M. interview with Licensed Practical Nurse (LPN) #174 revealed he was assigned to Resident #63 when he was admitted and had started the admission assessment. LPN #174 stated Temporary Nursing Assistant (TNA) #141 was working with him on the behavior unit that night. Review of census information revealed there were 22 residents residing on the secure unit on 06/25/22. On 07/20/22 at 3:04 P.M. interview with STNA #107 revealed she left at 3:00 P.M. the day Resident #63 was admitted and TNA #141 took over for her. (The Administrator had identified STNA #107 as working at the time Resident #63 eloped). On 07/21/22 at 2:22 P.M. interview with TNA #141 revealed he could not recall what time Resident #63 arrived at the facility on the day of admission. TNA #141 verified after STNA #107 left at 3:00 P.M. he was the only nursing assistant working the secured unit. LPN #174 was at the desk and thought he was working on the admission paper work. TNA #141 stated he was doing rounds when he was unable to locate Resident #63. Review of the facility Elopement and Unsafe Wandering policy, revised 04/28/21 revealed adequate supervision would be provided to aide in preventing accidents or elopements to the extent possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 25 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, record review, facility policy and procedure review and interview the facility failed to properly store and/or date opened medications. This had the potential to affect all 63 residents residing in the facility. Findings include: 1. On 07/20/22 at 7:49 A.M. observation of medication storage revealed six loose, unlabeled pills in the bottom of the second drawer of the A front medication cart. The six loose, unlabeled pills were in the compartment for Resident #58. An interview, at the time of the observation, with Registered Nurse (RN) #112 verified the six loose, unlabeled pills were not stored properly. On 07/20/22 at 10:22 A.M. interview with Director of Nursing (DON) #176 verified medications loose in the drawer of the medication cart were not an acceptable practice for properly storing medications. Review of the facility policy titled Medication Storage, dated 06/21/17 revealed medication and biologicals were to be stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. Remedi dispenses medication in packaging/container that meet the regulatory requirements. Medication shall be kept in these packages/container. The policy also revealed outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction. 2. On 07/20/22 at 8:15 A.M. observation of medication storage revealed one undated open, multi-dose vial of tuberculin (biological used for tuberculosis skin testing). An interview, at the time of the observation, with DON #148 verified there was no date on the open vial of tuberculin. She also verified all multi-dose medications and biologicals should be dated when opened. She was unable to verify when the tuberculin solution was opened. Review of the facility document titled Tuberculin Purified Protein Derivative, PPD - Administration Information, revised 07/23/14 revealed after initial entry into the vial, the multi-dose vial may be stored at two-eight degree Celsius (35-46-degree Fahrenheit) for up to thirty days; protect from light and do not freeze. The document also revealed discard any multi-dose vial not used within the 30-day time period. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 26 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 0772 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure laboratory testing was obtained for Resident #57 as ordered by the physician. This affected one resident (#57) of six residents reviewed for unnecessary medication use. Finding include: Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including osteomyelitis of vertebra, sacral, and sacrococcygeal region and stage four pressure ulcer of the sacral region. Review of Resident #57's physician's orders revealed an order, dated 07/01/22 for a Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) every Friday related to antibiotic use until 08/12/22. The resident had an order for the antibiotic, Cefepime two grams intravenously every Tuesday, Thursday, and Saturday for osteomyelitis until 08/11/22. A plan of care revealed Resident #57 was at risk for alteration in skin integrity. Interventions included laboratory testing as ordered. Review of Resident #57's laboratory testing results revealed no evidence the CBC or BMP was obtained as ordered on 07/08/22 or 07/15/22. On 07/20/22 at 10:35 A.M. interview with Director of Nursing #176 verified the resident did not have a CBC or BMP completed on 07/08/22 or 07/15/22 as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 27 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #36's medical record revealed diagnoses including chronic obstructive pulmonary disease, type 2 diabetes mellitus and heart failure. Residents Affected - Many Record review revealed Resident #36 had documentation of COVID vaccines/boosters administered 12/30/20, 01/26/21 and 11/22/21. A physician's order, dated 07/14/22 revealed Resident #36 was to be placed in contact and droplet precautions every shift for COVID-19 precautions for seven days. The order was discontinued 07/18/22 and a new order was written to start contact and droplet precautions every shift for possible exposure. On 07/18/22 at 10:44 A.M. Resident #36's call light was observed to be activated/on. Two staff (not identified at that time) were observed applying personal protective equipment (PPE) to enter the room. At 10:49 A.M. Director of Nursing #148 and State Tested Nursing Assistant (STNA) #177 exited the room with N95 masks on. The N95 masks were removed outside the room and disposed of. Without performing hand hygiene, both staff picked up new surgical masks and applied them. At the time of the observation, interview with DON #148 verified she and STNA #177 had not performed hand hygiene between removing the N95 masks and applying surgical masks. DON #148 revealed there should have been hand sanitizer in the cart outside Resident #36's room. After searching the cart, STNA #177 verified she was unable to find hand sanitizer. On 07/19/22 at 12:11 P.M., Therapy Director #126 was observed knocking on Resident #36's door and entering his room to deliver his meal tray. Therapy Director #126 was wearing goggles and a surgical mask. No gown, N95 mask or gloves were applied. Therapy Director #126 exited Resident #36's room at 12:15 P.M. and started up the hall. At the time of the observation, interview with Therapy Director #126 verified she had not applied/donned appropriate PPE and had not disinfected her goggles after leaving Resident #36's room. Therapy Director #126 indicated she did not realize Resident #36 was in isolation/quarantine. 3. Review of Resident #117's medical record revealed an admission date of 07/16/22. Documentation indicated Resident #117 received Pfizer COVID vaccines 11/07/21 and 12/22/21. A physician's order, dated 07/16/22 revealed Resident #117 was to be started on contact and droplet precautions every shift for COVID-19 admission precautions for ten days. The order was discontinued 07/18/22 and an order was written for contact and droplet precautions every shift for COVID-19 admission precautions until 07/23/22 at 11:59 P.M. On 07/18/22 at 10:31 A.M., interview with Registered Nurse (RN) #129 revealed she was uncertain why there were no signs posted at Resident #117's to indicate the resident was isolation or why there was no isolation cart/PPE outside Resident #117's room. At 12:00 P.M., Licensed Practical Nurse (LPN) #174 was observed preparing Resident #117's medications, applied PPE and entered the room. At 12:19 P.M., LPN #174 left Resident #117's room and removed his N95 mask touching the outside of mask to dispose of it. Without performing hand hygiene, LPN #174 applied a surgical mask. LPN #174 stated he had no hand sanitizer with him. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 28 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the facility Novel Coronavirus Prevention and Response, revised 04/13/22 revealed interventions to prevent the spread of COVID-19 within the facility included educating staff and visitors on proper use of personal protective equipment and application of standard, contact and droplet transmission precautions, including eye protection, posting applicable signage regarding transmission based precaution, making personal protective equipment available immediately outside of the resident's room where indicated, implementing procedures to identify, monitor and quarantine (where indicated) others who may have been exposed if COVID-19 disease was confirmed in accordance with Centers for Disease Control (CDC) guidelines. Managing a resident who had been treated for COVID-19 illness or vaccinated for COVID-19 included utilizing transmission-based precautions per CDC guidelines. Considerations for admitting residents with suspected or confirmed COVID-19 indicated residents admitted or re-admitted would be quarantined per CDC guidelines. The policy was not specific as to admitting a resident without confirmed or suspected COVID. Review of the CDC Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes (updated Feb. 2, 2022) revealed empiric use of Transmission-Based Precautions (quarantine) was recommended for residents who were newly admitted to the facility and for residents who had close contact with someone with SARS-CoV-2 infection if they were not up to date with all recommended COVID-19 vaccine doses. In general, quarantine was not needed for asymptomatic residents who were up to date with all COVID-19 vaccine doses or who had recovered from SARS-CoV-2 infection in the prior 90 days. On 07/20/22 at 9:54 A.M. interview with RN #112 revealed the facility had been able to verify Resident #117 was up to date on COVID vaccines on 07/20/22 so isolation was discontinued at that time. RN #112 verified she worked when Resident #117 was admitted but did not do his admission which was when it was usually determined if residents required quarantine. RN #112 revealed she could not recall isolation being initiated but she didn't know if there was an order. 4. On 07/18/22 beginning at 12:42 P.M. observation of the lunch meal service revealed STNA #177 was observed to ask STNA #104 to pull up her (STNA #177's) surgical mask as it was sliding down below her nose. The STNA was holding a meal tray and could not properly re-apply the mask at that time. STNA #104 used her bare hands and pulled STNA #177's mask above her nose. STNA #104 did not perform any type of hand hygiene after touching STNA #177 mask and continued to hand Resident #46 a clothing protector and then delivered a lunch tray to room [ROOM NUMBER]. On 07/18/22 at 12:43 P.M. interview with STNA #104 verified she had touched STNA #177's surgical mask, then handed Resident #46 a clothing protector and then delivered a meal tray to room [ROOM NUMBER] without performing any type of hand hygiene after she had touched STNA #177 contaminated mask. Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National emergency dated 03/13/20, review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, observation, record review, facility policy and procedure review and interview the facility failed to maintain proper infection control practices during resident care to prevent the spread of infection including COVID-19. This affected four residents (#36, #46, #117 and #218) and had the potential to affect all 63 residents residing in the facility. Findings include: 1. Review of Resident #218's medical record revealed an admission date of 07/08/22. The resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 29 of 30 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 366177 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Pointe Care Center 68637 Bannock Road St Clairsville, OH 43950 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 0880 testing log for COVID-19 revealed the resident tested positive for COVID-19 on 07/14/22. Level of Harm - Minimal harm or potential for actual harm Review of Resident #218's physician orders revealed an order, dated 07/14/22 for contact droplet (isolation)precautions every shift for COVID-19 for 10 days. Residents Affected - Many On 07/21/22 at 12:43 P.M. Therapy Aide #159 was observed to exit Resident #218's room wearing a surgical mask. On the outside of the door revealed a sign indicating the resident was COVID-19 positive and was on contact/droplet precautions. Beside the door was an isolation cart with a box of surgical masks sitting on top. On 07/21/22 at 12:43 P.M. with Therapy Aide #159 revealed she entered Resident #218's room to provide care with a surgical mask, gown, gloves and goggles. She stated she did not know she was supposed to apply an NIOSH-approved N95 mask, and just grabbed a mask from on top of the isolation cart. She also confirmed she did not clean her goggles upon exiting the room. Review of the CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic,dated 02/02/22 revealed a NIOSH-approved N95 or equivalent or higher-level respirator would be worn during the care of a patient with a SARS-CoV-2 infection or during care of a patient on droplet precautions. They should be removed and discarded after the patient care encounter and a new one should be applied/donned. Review of the facility policy titled Donning and Doffing PPE for COVID-19, dated 02/04/22 reveled the facility would implement the CDC guidelines for use of personal protective equipment when caring for residents with confirmed or suspected COVID-19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366177 If continuation sheet Page 30 of 30