Inspection visit

InspectionSeptember 6, 2019

SUNNYSLOPE NURSING HOMECMS #36624932 citations on this visit

32 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 32 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Residents #4 and #5 were served meals with regular dinner ware and failed to ensure Resident #35 was able to use the telephone when desired. This affected three of six residents reviewed for choices. Findings include: 1. Resident #4 was admitted to the facility on [DATE] with brain cancer requiring chemotherapy (CTX) and cerebral infarct with left sided hemiplegia. The resident had isolation precautions posted. Review of the current care plans revealed there was nothing addressing the use of the plastic silver ware. Review of the nurses note dated 07/18/19 revealed the resident was requesting silverware. The resident indicated he was going to stab the resident who stole his bag of chips. Review of the physician's order dated 07/21/19 revealed the resident was to have plastic silverware for all meals. Review of the behavior note dated 07/21/19 revealed the resident told the nurse if he did not get regular silverware back they would be picking him off the floor. Review of the quarterly minimum data set (MDS) 3.0 dated 07/25/19 revealed the resident was cognitively intact and had behaviors that were threatening and/or yelling out one to three days of the reference period. Review of the nutrition progress note dated 08/14/19 revealed the resident was using plastic ware at all meals for safety. On 09/03/19 at 5:20 P.M., interview with the resident revealed he was forced to eat using plastic ware because he threatened to stab another resident with a knife awhile ago because the resident stole a bag of potato chips from him. He stated he was not going to do it, he was just mad, but no one had talked to him again about it. They just took away regular dinner and silver ware. On 09/04/19 at 11:18 A.M., interview with State Tested Nurse Aide (STNA) #14 revealed the resident was not allowed to have regular dinner ware because about a month ago he threatened to stab another resident with a knife. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 40 Event ID: 366249 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 09/04/19 at 12:05 P.M. and 4:59 P.M., the resident was observed eating in his room with all plastic ware not just plastic silver ware as ordered. The resident was having a difficult time eating due to the small plastic utensils. He was spilling food on himself and on the floor. On 09/05/19 at 9:30 A.M., interview with Physician #60 revealed he was not aware the resident was restricted to using plastic dinner ware. On 09/05/19 at 10:40 A.M. interview with Registered Nurse (RN) #34 revealed she thought the plastic ware was initially because the resident threatened to stab another resident with a knife but then it continued for CTX precautions while the resident was in isolation. RN #34 verified the resident complained about having to use the plastic ware. On 09/06/19 at 11:05 A.M., interview with RN #8 verified she did not think Resident #4 would do anything and verified there had not been any follow up related to restricting the resident's use of regular dinner ware. RN #8 was aware the resident was very upset about not being able to use regular dinner ware. RN #8 verified the order was only for plastic silverware yet the resident was receiving plastic ware for everything including cups, plates and bowls. RN #8 revealed this was related to the resident's isolation due to being on CTX and possible concerns with staff if they came in contact with any bodily fluids not because of any behaviors. 2. Resident #5 was admitted to the facility on [DATE] with diagnoses which included schizophrenia, depression and difficulty walking. Review of the 03/08/19 quarterly minimum data set (MDS) 3.0 revealed the resident was cognitively intact and had behaviors including verbal and other behavioral symptoms one to three days and rejection of care four to six days during the reference period. Review of the current care plan, initiated 03/13/19, revealed the resident was disruptive, socially inappropriate, refused care, threw objects in his room and out into hallway and yelled out at staff. Goals included the resident would demonstrate fewer episodes of verbally and/or physically abusive behaviors and would voice anger and/or frustration through appropriate channels. There were no individualized interventions to allow the resident to achieve the goals set. Interventions included anticipate needs, provide calm reassurance, redirection with distractions assessing effectiveness and include the resident in his care. Review of the nurses note dated 05/20/19 revealed on 05/17/19 the resident attempted to hit another resident with silverware who was sitting on the other side of the dining room. Review of the physician's order initiated 05/20/19 revealed to serve all meals with plastic ware. Review of the 06/04/19 quarterly minimum data set (MDS) 3.0 revealed the resident was cognitively intact and had physical/other behavior symptoms and rejected care one to three days during the reference period. Review of the nurses note dated 07/21/19 revealed the resident threw a piece of ham across the dining room because he did not like ham. On 09/03/19 at 9:55 A.M., interview with the resident revealed he did not like having to eat off of plastic ware for meals and did not know why he had to. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 2 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 On 09/03/19 at 12:10 P.M., Resident #5 was observed eating in his room with plastic ware. Level of Harm - Minimal harm or potential for actual harm On 09/04/19 at 11:18 A.M., interview with STNA #14 revealed the resident was not allowed to have regular dinner ware because he threw things occasionally. Residents Affected - Few On 09/04/19 at 2:15 P.M. interview with RN #8 revealed the resident ate most of his meals in his room or in the breezeway. She verified the resident threw silverware during a meal on 05/19/19 and after that he was not permitted to have regular silverware and had to eat off of plastic ware. She verified the resident had not thrown any silverware since 05/19/19 yet the resident remained on plastic ware during all meals. She verified there was no interdisciplinary meeting to discuss the concern with the resident On 09/05/19 at 8:00 A.M., Resident #5 was observed propelling himself in the wheelchair in the dining room, turning on the television and then going to a table and reading a newspaper. On 09/05/19 at 10:45 A.M., interview with RN #34 revealed the resident was placed on plastic ware in May 2019 because he threw silverware in the dining room. She did not think the resident threw it an anyone specific. RN #34 verified the resident had not thrown any silverware since then yet he remained on plastic ware for all meals. RN #34 verified the resident usually ate in his room. 3. Resident #35 was admitted on [DATE] with diagnoses including but not limited to obsessive compulsive disorder, suicidal ideations, major depressive disorder, psychosis, cognitive communication deficit, and paranoid schizophrenia disorder. Resident #35's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed her cognition was intact. Resident #35 had a guardian over person. Resident #35's active comprehensive care plan for impaired activities of daily living (ADL) revealed she required staff assistance to complete some of her ADLs due to diagnoses of schizophrenia and generalized muscle weakness. If Resident #35 resisted care, the facility was not to attempt to force care, and return at a later time to complete care. The facility was to offer and honor choices whenever possible, and allow the resident to state preferences. Review of Resident #35's medical record revealed it was silent of any restrictions as a result of declining showers. Review of Resident #35's shower sheets from 07/01/19 to 09/02/19, revealed Resident #35 refused a shower on 07/09/19, 07/10/19, 07/13/19, 07/18/19, 07/23/19, 07/28/19, 08/02/19, 08/11/19, 08/21/19, 08/22/19, 08/28/19, 08/29/19. Resident #35's medical record did not indicate whether or not she had a shower on 09/02/19. Interview on 09/03/19 at 12:04 P.M. with Resident #35 revealed she did not take a shower yesterday, and when she refused a shower she was not allowed to use the phone or go outside. Resident #35 revealed she was scheduled to take three showers a week, but sometimes does not want to take all three showers. Resident #35 revealed the facility had been restricting the phone and going outside for months now when she refused a shower. Interview on 09/04/19 at 9:47 A.M. with STNA #50 confirmed Resident #35 could not make phone calls if she did not take a shower. STNA #50 revealed when she came in for first shift, third shift notified her if Resident #35 can have her phone calls or not. STNA #50 revealed Resident #35 could get an attitude about not being able to use the phone and stated it was unfair that she could not make (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 3 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 phone calls. Level of Harm - Minimal harm or potential for actual harm Interview on 09/04/19 at 10:14 A.M. with Licensed Practical Nurse (LPN) #44 revealed Resident #35's guardian had set restrictions in the past, but she was unaware of any phone restrictions related to the resident not taking a shower. LPN #44 revealed with the right approach, she can get the resident to take a shower. Residents Affected - Few Interview on 09/04/19 at 10:22 A.M. with RN #8 (the acting director of nursing) revealed at times Resident #35 had certain restrictions but at the present time there was not a plan to restrict any privileges. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 4 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 0606 Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Level of Harm - Minimal harm or potential for actual harm Based on review of personnel files, staff interview, and review of the facility abuse policy the facility failed to ensure 19 staff members were checked against the State Nurse Aide Registry (NAR) prior to employment to ensure the employee did not have a finding entered in the State NAR concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. This had the potential to affect all 42 residents currently residing in the facility. Residents Affected - Many Findings include: Review of personnel list and personnel files revealed the non-licensed staff including; Laundry Aide (LA) #15, LA #17, Housekeeping Aide (HA) #18, Environmental Director (ED) #20, Dietary Director (DD) #22, Dietary Aide (DA) #24, Activities Aide (AA) #25, admission Director (AD) #26, Dietary [NAME] (DC) #27, DC #30, DC #33 and DC #40, Activities Director (AD) #28, DA #31, HA #37, AA #38, DA #41, Medical records (MR) #46, and HA #52 had not been checked against the State NAR. Interview on 09/04/19 at 10:00 A.M., with Registered Nurse (RN) #53 verified she had no documented evidence the above non-licensed staff were checked against the State NAR to ensure the employee did not have a finding entered in the State NAR concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. Review of the facility Abuse, Neglect, Misappropriation, and Exploitation policy originated dated 11/16 revealed the facility would undertake background checks of all employees and to retain on file applicable record of current employees regarding such checks. The facility would do the following prior to hiring a new employee: 1a. Check with the Ohio NAR and any other nurse assistant registries that the facility had reason to believe contain information on an individual, prior to using the individual as a nursing assistant. b. Check with all applicable licensing and certification authorities to ensure that employees hold the requisite license and/or certification status to perform their job function and do not have a disciplinary action in effect against his or her professional license by state licensure agency because of a finding of abuse, neglect, exploitation or misappropriation of resident property; c. Conduct a criminal background check d. Verify that the applicant was not excluded from any Federally-funded health care programs. 2. All potential employees certify as part of the employment application process that they had not been convicted of an offense or otherwise have been found guilty of an offense that would preclude employment in a nursing facility. 3. It is the ongoing obligation of all employees to alter the facility of any convictions or findings that would disqualify them form continued employment with the facility under Ohio or Federal law, or the facilities policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 5 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review the facility failed to ensure their policy and procedure relative to abuse prevention was implemented regarding timely reporting of an injury of unknown origin for Resident #41. This affected one (Resident #41) of two residents reviewed for abuse. Additionally, based on review of personnel files, staff interview, and review of the facility abuse policy the facility failed to ensure 19 staff members were checked against the State Nurse Aide Registry (NAR) prior to employment to ensure the employee did not have a finding entered in the State NAR concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. Residents Affected - Some Findings include: Resident #41 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's disease, age related physical debility, chronic pain, lack of coordination, major depressive disorder, restlessness and agitation, and anxiety disorder. Review of Resident #41's Health Status Note on 01/06/19 at 11:29 A.M., authored by Registered Nurse (RN) #51, revealed the nurse noticed a bruise on the top of the resident's left hand, about softball-sized. State Tested Nursing Assistant (STNA) #10 stated the bruise was first noticed by staff during change of shift report on this morning around 6:00 A.M. STNA #5 stated the resident's left hand appeared swollen and reddened during change of shift report this morning around 6:00 A.M. Witness statements were collected, and the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were notified. Review of the the facility incident report for Resident #41's injury on 01/06/19, revealed the injury was first discovered on 01/06/19 at 6:00 A.M. and was not reported to the Director of Nursing (DON) until 11:29 A.M. Registered Nurse (RN) #49's handwritten witness statement dated 01/06/19 revealed at shift change (6:00 A.M.) nurse aides reported that Resident #41's left hand was reddened. There was no evidence RN #49 reported Resident #41's injury to the DON or Administrator for further investigation. Review of STNA #10's and STNA #5's handwritten witness statements confirmed Resident #41's left hand injury was reported at shift change at 6:00 A.M. Review of RN #60's handwritten witness statement dated 01/06/19 revealed around 11:30 A.M. the nurse noticed a bruise/discoloration to Resident #41's left hand. Resident #41's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed her cognition was severely impaired, she had hallucination and delusions, had physical and verbal behavior directed towards others, and required two person extensive assistance with bed mobility, transfers, dressing, and toileting. Interview with Resident #41's family member revealed on 01/06/19 Resident #41's left hand was completely bruised and swollen, and the facility was unable to give an explanation of the injury. Interview on 09/05/19 at 8:09 A.M. with RN #8 (acting DON) revealed RN #49 was made aware of Resident #41's left hand injury on 01/06/19 at 6:00 A.M. and did not report the incident. RN #8 verified per the facility abuse prevention policy, RN #49 should have reported the injury to administrative (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 6 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 0607 staff immediately. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy, titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, revised 11/28/16, revealed facility staff should immediately report all such allegation to the Director of Nursing, Administrator and to the Ohio Department of Health in accordance with the procedures in this policy. When a resident is injured as a result of the alleged or suspected incident, immediately action should be taken to treat the resident, including reporting all incidents immediately to the Administrator of designee. Residents Affected - Some Review of personnel list and personnel files revealed the non-licensed staff including; Laundry Aide (LA) #15, LA #17, Housekeeping Aide (HA) #18, Environmental Director (ED) #20, Dietary Director (DD) #22, Dietary Aide (DA) #24, Activities Aide (AA) #25, admission Director (AD) #26, Dietary [NAME] (DC) #27, DC #30, DC #33 and DC #40, Activities Director (AD) #28, DA #31, HA #37, AA #38, DA #41, Medical records (MR) #46, and HA #52 had not been checked against the State NAR. Interview on 09/04/19 at 10:00 A.M., with Registered Nurse (RN) #53 verified she had no documented evidence the above non-licensed staff were checked against the State NAR to ensure the employee did not have a finding entered in the State NAR concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. Review of the facility Abuse, Neglect, Misappropriation, and Exploitation policy originated dated 11/16 revealed the facility would undertake background checks of all employees and to retain on file applicable record of current employees regarding such checks. The facility would do the following prior to hiring a new employee: 1a. Check with the Ohio NAR and any other nurse assistant registries that the facility had reason to believe contain information on an individual, prior to using the individual as a nursing assistant. b. Check with all applicable licensing and certification authorities to ensure that employees hold the requisite license and/or certification status to perform their job function and do not have a disciplinary action in effect against his or her professional license by state licensure agency because of a finding of abuse, neglect, exploitation or misappropriation of resident property; c. Conduct a criminal background check d. Verify that the applicant was not excluded from any Federally-funded health care programs. 2. All potential employees certify as part of the employment application process that they had not been convicted of an offense or otherwise have been found guilty of an offense that would preclude employment in a nursing facility. 3. It is the ongoing obligation of all employees to alter the facility of any convictions or findings that would disqualify them form continued employment with the facility under Ohio or Federal law, or the facilities policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 7 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to ensure an injury of unknown origin was reported timely for Resident #41. This affected one (Resident #41) of two residents reviewed for abuse. Findings include: Resident #41 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's disease, age related physical debility, chronic pain, lack of coordination, major depressive disorder, restlessness and agitation, and anxiety disorder. Review of Resident #41's Health Status Note on 01/06/19 at 11:29 A.M., authored by Registered Nurse (RN) #51, revealed the nurse noticed a bruise on the top of the resident's left hand, about softball-sized. State Tested Nursing Assistant (STNA) #10 stated the bruise was first noticed by staff during change of shift report on this morning around 6:00 A.M. STNA #5 stated the resident's left hand appeared swollen and reddened during change of shift report this morning around 6:00 A.M. Witness statements were collected, and the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were notified. Review of the the facility incident report for Resident #41's injury on 01/06/19, revealed the injury was first discovered on 01/06/19 at 6:00 A.M. and was not reported to the Director of Nursing (DON) until 11:29 A.M. Registered Nurse (RN) #49's handwritten witness statement dated 01/06/19 revealed at shift change (6:00 A.M.) nurse aides reported that Resident #41's left hand was reddened. There was no evidence RN #49 reported Resident #41's injury to the DON or Administrator for further investigation. Review of STNA #10's and STNA #5's handwritten witness statements confirmed Resident #41's left hand injury was reported at shift change at 6:00 A.M. Interview on 09/05/19 at 8:09 A.M. with RN #8 (acting DON) confirmed RN #49 was made aware of Resident #41's left hand injury on 01/06/19 at 6:00 A.M. and did not report the incident. Review of the facility policy, titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, revised 11/28/16, revealed facility staff should immediately report all such allegation to the Director of Nursing, Administrator and to the Ohio Department of Health in accordance with the procedures in this policy. When a resident is injured as a result of the alleged or suspected incident, immediately action should be taken to treat the resident, including reporting all incidents immediately to the Administrator of designee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 8 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 0610 Respond appropriately to all alleged violations. 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, interview and policy review, the facility failed to ensure a thorough investigation for injuries of unknown origin for Resident #41. This affected one (Resident #41) of two residents reviewed for abuse. Residents Affected - Few Findings include: Resident #41 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's disease, age related physical debility, chronic pain, lack of coordination, major depressive disorder, restlessness and agitation, and anxiety disorder. Resident #41's active comprehensive care plan for activities of daily living (ADL) revealed a self-care deficit due to impaired cognition, she was known to become combative during ADL care, and will strike out and become verbally aggressive. Care planned interventions included giving the resident space when she became combative and re-approach when appropriate and safe. Resident #41's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed her cognition was severely impaired, she had hallucination and delusions, had physical and verbal behavior directed towards others, and required two person extensive assistance with bed mobility, transfers, dressing, and toileting. 1. Review of Resident #41's Health Status Note on 01/06/19 at 11:29 A.M., authored by Registered Nurse (RN) #51, revealed the nurse noticed a bruise on the top of the resident's left hand, about softball-sized. Review of the facility incident report for Resident #41's injury on 01/06/19, revealed witness statements were obtained. RN #49 indicated Resident #41's hand was not reddened when she passed medication at 5:30 A.M. STNA #10's and STNA #5's handwritten witness statements confirmed Resident #41's left hand injury was reported at shift change at 6:00 A.M. The investigation contained no evidence staff were interviewed about any care or observation of the resident from 5:30 A.M. to 6:00 A.M. Interview on 09/05/19 at 8:09 A.M. with RN #8 (acting DON) confirmed the facility did not interview staff about what occurred from 5:30 A.M. to 6:00 A.M. to help determine the cause of Resident #41's left hand injury. 2. Resident #41's Health Status Note dated 08/29/19 at 4:15 P.M., authored by Licensed Practical Nurse (LPN) #4, revealed the resident was assisted with toileting, and complained of her thumb hurting shortly after. The resident's thumb was assessed with no swelling or bruising noted and resident was bending her thumb. Staff were interviewed and stated the resident was physically harming them. STNA #19 had a left thumb nail broken and a bruise to the right wrist. Resident #41 showed no signs of distress and the facility would continue to monitor. Resident #41's Health Status Note, dated 08/29/19 at 6:44 P.M. revealed the daughter was informed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 9 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 0610 of the resident's complaint of her thumb hurting and was insisting on an X-ray of the thumb. Level of Harm - Minimal harm or potential for actual harm Resident #41's Health Status Note dated 08/29/19 at 7:08 P.M. revealed Hospice was called and made aware of the daughter's request for an X-ray of the resident's right thumb Residents Affected - Few Review of the facility history of incident reports for Resident #41 revealed no incident report was completed for Resident #41's injury to her right hand, and no evidence was found the right-hand injury was investigated. Observation on 09/04/19 at 3:00 P.M. of Resident #41 revealed a purplish discoloration of her right hand and thumb area. Interview with a family member revealed on 08/29/19 she discovered Resident #41's right hand was swollen and the resident stated her hand hurt. The family member asked LPN #4 about the resident's hand, and LPN #4 indicated the resident complained about her hand earlier but she did not see anything. The Family member said an X-ray was done that showed tissue damage, but no fracture Interview on 09/05/19 at 10:27 A.M. with RN #8 (acting DON) confirmed the facility did not complete an incident report and did not investigate Resident #41's right hand injury on 08/29/19. RN #8 revealed they thought the injury probably happened when the resident hit her right hand on a sit to stand lift during toileting but confirmed there were no witness statements obtained and no investigation was completed. Review of the facility policy, titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, revised 11/28/16, revealed once the Director of Nursing and/or Administrator are notified, an investigation of the allegation violation will be conducted. The person investigating the incident should interview all witnesses. Witnesses generally include anyone who came in close contact with the resident the day of the incident, including other residents, family members, and employees. For injuries of unknown source, the investigation may generally involve talking with both the shift on duty when the injury was discovered and prior shifts as well. The investigation should be documented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 10 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #33's comprehensive fall risk plan of care was revised to include all fall interventions. This affected one resident (#33) of four residents reviewed for falls. Findings include: Medical record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, contractures, and the absence of the right and left legs below the knee. Review of the physician's orders, dated October 2019 revealed an order for a fall mat to the right side of the bed for safety and an order for the bed to be in the low position, except during care. Record review revealed a current plan of care, dated August 2019 indicating Resident #33 was at risk for injuries from falls. However, the physician ordered interventions for the bed to be in low position and for a fall mat were not included on the care plan. On 11/06/19 at 9:02 A.M., Resident #33 was observed laying in bed with his eyes closed, his bed was not in the lowest position and his floor mat was not laying along the right side of his bed, but at the foot of his bed, past the bedside table. During a follow up observation on 11/06/19 at 10:29 A.M., Resident #33 was observed resting with his eyes closed. The resident's bed was not in the lowest position and the fall mat was not laying along the right side of his bed, but laying near the foot of the bed. On 11/06/19 at 2:05 P.M. interview with the Director of Nursing (DON) verified Resident #33's care plan had not been revised to include the physician ordered fall interventions including the use of a fall mat and for the bed to be placed in the lowest position. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 11 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Resident #29 received assistance with meals and Resident #4 received nail care. This affected two of three residents received for activities of daily living (ADL). Residents Affected - Few Findings include: 1. Resident #29 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's dementia. Review of the quarterly MDS 3.0 dated 07/19/19 revealed the resident was not interviewable. Review of the current care plan revealed it was not specific to the resident's need for assistance during meals. Further review of the [NAME], a quick reference for the nurse aides, revealed the resident needed encouragement to eat and assistance with meals. Review of the occupational therapy Discharge summary dated [DATE] revealed the resident required moderate to maximum assistance for feeding. On 09/03/19 observation during the lunch meal at 12:00 P.M. revealed the resident was sitting at a table without any staff. His mechanical soft meal was delivered and he picked up his apple pie with his fingers, ate the apple pie and then tried to pick up the main entree with his fingers multiple times. He was unsuccessful and he then gave up and did not eat anymore. At 12:48 P.M., State Tested Nurse Aide (STNA) #2 approached the table and attempted to hand the resident his fork but the resident was not able to grab and hold it. STNA #2 had to put the fork in the resident's hand. The resident was not able to use the fork to feed himself. STNA #2 then fed the resident a bite of his mechanical soft meatloaf which the resident ate. Upon request the temperature of the foods were taken by [NAME] #30. At 12:51 P.M., the meatloaf was 78 degrees, the mixed vegetables were 60 degrees and the mashed potatoes were 80 degrees. This was verified by [NAME] #30 at the time each temperature was taken utilizing the facility thermometer. The plate was re-heated and STNA #2 fed the resident his meal. On 09/03/19 at 1:01 P.M., interview with STNA #2 indicated the wife would feed Resident #29 when she was there, otherwise the resident was not assisted and then verified the resident was not able to feed himself. On 09/06/19 at 11:00 A.M., interview with Registered Nurse (RN) #8 verified the above concerns and stated the resident did need to be moved to the assist/feed table when the wife was not thee to feed him. 2. Resident #4 was admitted to the facility on [DATE] with diagnoses including brain cancer and cerebral infarct with left sided hemiplegia. Review of the quarterly MDS 3.0 dated 07/25/19 revealed the resident was cognitively intact but needed extensive assistance with ADL's including grooming and hygiene. On 09/03/19 at 3:45 P.M., the resident was observed being taken to the shower room for a shower. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 12 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 09/03/19 at 4:25 P.M., interview with Resident #4 revealed he had a shower today, but no one had cut or cleaned his fingernails in a long time, and they were dirty and needed cut. The resident verified he was not able to clean or cut his finger nails. On 09/03/19 at 4:30 P.M., interview with STNA #10 verified the residents nails were dirty and long and needed cut. She stated nail care should be done as needed on shower days and verified it was not done today with the residents shower. Event ID: Facility ID: 366249 If continuation sheet Page 13 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to timely follow up on gastric symptoms. This affected one (Resident #3) of six reviewed for unnecessary medications. Residents Affected - Few Findings included: Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including dysphagia, constipation, parkinsonism, Alzheimer's disease, bipolar disorder, schizophrenia, moderate protein-calorie malnutrition, and anemia. Review of Resident #3's current medication list revealed she was on Ranitidine 150 milligrams (mg) for indigestion, Miralax daily for constipation, and Compazine (antiemetic/antipsychotic) 5 mg before meals for nausea and vomiting. Review of Resident #3's progress notes dated 07/20/19 revealed the resident had a brown-colored liquid emesis. There was no evidence the physician was contacted/notified. On 09/01/19 the resident had a large, yellow-colored projectile emesis. Her lunch was held, and the physician was updated. Interview on 09/06/19 at 9:42 A.M., with Registered Nurse (RN) #8 confirmed she spoke to the physician today after speaking to this surveyor to follow-up with concerns related to the resident's projectile emesis on 09/01/19. The physician was not aware of nor notified the resident had projectile emesis on 07/20/19. The physician ordered an ultra sound of the gall bladder, a gastrology consult, discontinued Compazine and started Zofran 4 mg every six hours as needed for nausea and vomiting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 14 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interview, and policy review the facility failed to accurately assess, treat, and develop a plan of care for a pressure ulcer. This affected one (Resident #33) of one reviewed for pressure ulcers. Residents Affected - Few Finding include: Record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including diabetes, heart disease, pressure ulcers, chronic pain, anxiety, Alzheimer's disease, hallucinations, chronic kidney disease, Parkinson's disease, anemia, mood disorder, bipolar, depression, venous insufficiency, respiratory failure, contractures, absence of right and left leg below the knee, and edema. 1. Review of Resident #33's skin/pressure ulcer assessments dated 07/29/19 to 09/02/19 revealed: -07/29/19 moisture associated skin Damage (MASD) was acquired to the left buttocks measuring 5.5 centimeters (cm) by 3.0 cm by 0.0 cm. Medi honey (debriding agent) was ordered to treat the area. -08/05/19 MASD continued to the left buttock measuring 3.0 cm by 1.5 cm by 0.0 cm. Medi honey treatment was continued. -08/12/19 MASD continued to the left buttocks measuring 1.0 cm by 1.0 cm by 0.1 cm. Medi honey was continued to treat the area. -08/19/19 MASD continued to the left buttocks measuring 1.7 cm by 1.9 cm by 0.0 cm. The area had worsened. The wound bed was covered with 50% slough (white/yellow dead tissue that adheres to the ulcer bed). The treatment was changed to Calcium Alginate (AG) (debriding and fluid absorbing dressing). There was no evidence the area was identified and staged as a pressure ulcer. -08/26/19 The MASD area was changed to a stage II pressure ulcer (partial thickness loss of the dermis without slough) measuring 1.1 cm by 1.0 cm by 0.1 cm area. The wound bed was covered with 20% slough. Calcium AG was continued to treat the area. -09/02/19 The area was a Stage II pressure ulcer measuring 1.0 cm by 0.8 cm by 0.1 cm. Calcium AG was continued to treat the area. 2. Review of the 08/2019 treatment administration records (TAR) revealed no evidence a treatment was administered from 08/07/19 to 08/20/19 to the left buttocks. On 08/21/19 the treatment was changed to Calcium AG and covered with foam dressing daily. 3. Observation on 09/05/19 at 4:22 P.M., of Resident #33's pressure ulcer dressing change revealed the resident had a foam dressing intact to the left buttocks dated 09/04/19. The nurse removed the intact dressing and there was no evidence the Calcium AG was present per orders. The wound bed was covered with 100% white slough. Findings were confirmed during the observation with Registered Nurse (RN) #34. Interview on 09/06/19 at 9:34 A.M., with RN #8 confirmed Resident #33's skin/pressure assessments (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 15 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few were inaccurate. She confirmed the assessment completed on 08/19/19 should have identified the area was a pressure ulcer and no longer MASD. The assessment completed on 08/26/19 indicated the area was a stage II pressure ulcer with slough present. RN #8 confirmed by definition a stage II pressure ulcer would not have slough. The assessment dated [DATE] continued to indicate a stage II pressure ulcer with slough. RN #8 confirmed there was no documented evidence that treatments were administered to the left buttock's skin/pressure ulcer from 08/07/19 to 08/20/19 and she provided education to the nurse that performed the dressing change on 09/04/19 that did not apply the Calcium AG to the wound per orders. 4. Review of Resident #33's quarterly Minimum Data Set (MDS) 3.0 dated 08/15/19 revealed the resident had one or more unhealed pressure ulcers and had one stage II pressure. Review of Resident #33's plan of care revealed no evidence of a plan of care for pressure ulcers. Interview on 09/06/19 at 10:56 A.M., with Licensed Practical Nurse (LPN) #44 confirmed the MDS dated [DATE] was inaccurate due to the resident did not have pressure during the seven day look back period and he did not have a pressure ulcer plan of care. Review of the pressure treatment policy dated 09/13 revealed a stage II pressure ulcer was partial thickness loss of the dermis without slough. Cleanse the wound with ordered cleanser and apply the dressing and secure the dressing per orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 16 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Resident #7 had antithrombolitic compression stockings (TED) and setopress compression bandage wrap dressings in place as ordered. This affected one of two residents reviewed for compression stockings. Residents Affected - Few Findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses which included morbid obesity, muscle wasting, chronic obstructive pulmonary disease and diabetes mellitus. The resident did not get out of bed. Review of the physician order dated 08/30/19 revealed to apply TED stockings, an antithrombolic compression stocking used to guard against or prevent further progression of venous disorders. Then apply setopress wraps, a compression bandage, over the TED stockings bilaterally from the toes to the knees. These were to be put on the in morning and removed each night. On 09/03/19 at 11:50 A.M., 3:27 P.M. and 6:40 P.M., the resident was observed in bed without anything on her lower extremities. On 09/03/19 at 6:41 P.M., interview with Registered Nurse (RN) #34 verified the resident did not have on the TED stockings or setopress wraps as ordered. On 09/04/19 at 8:35 A.M., 10:42 A.M. and 11:40 A.M., the resident was observed in bed without anything on her lower extremities. On 09/04/19 at 1:54 P.M., the resident was observed in bed with TED stockings on both lower extremities. On 09/04/19 at 1:55 P.M., interview with Licensed Practical Nurse (LPN) #4 verified the resident did not have on the setopress wraps as ordered. On 09/05/19 at 7:36 A.M., 8:05 A.M. and 9:00 A.M., the resident was observed in bed without anything on her lower extremities. On 09/06/19 at 10:20 A.M., the resident was observed in bed without anything on her lower extremities. On 09/06/19 at 11:05 A.M., interview with RN #8 verified the above. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 17 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 observation, interview and record review the facility failed to ensure residents were assessed for restorative nursing programs and the programs were initiated, implemented, monitored, and delivered as planned for Residents #4, #29, #3 and #23 to maintain function and/or prevent further decline. This affected four of five residents reviewed for restorative services. Findings include: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses which included brain cancer and cerebral infarct with left sided hemiplegia. The resident was cognitively intact but dependent of staff for ADL's. The resident was discharged from occupational therapy (OT) on 08/06/19 with recommendations for the restorative nursing program to provide active range of motion (AROM) to the right and left upper extremities (UE) and grooming at the sink while seated in the wheelchair. Review of the current restorative program book revealed there was no evidence the resident was receiving restorative nursing services. On 09/03/19 at 9:55 A.M., interview with the resident revealed the staff did not perform ROM to his arms. He revealed he received therapy in August but it was stopped and he had not received therapy since. On 09/03/19 at 12:19 P.M., interview with STNA #36 revealed she was not aware the resident was on any restorative programs. On 09/03/19 at 3:00 P.M., interview with STNA #2 revealed the floor STNAs completed restorative programs and she was not aware the resident was on any restorative programs including splinting, braces and/or ROM. On 09/03/19 at 6:35 P.M., interview with STNA #4 revealed the floor STNA completed restorative programs and she was not aware the resident was on any restorative programs including splinting, braces and/or ROM. On 09/03/19 at 6:37 P.M., interview with STNA #29 revealed therapy did the restorative programs. On 09/04/19 at 9:40 A.M., interview with COTA #56 revealed Resident #4 received OT from 06/02/19 until 08/06/19 and he showed improvement and met his goals. The resident was referred to restorative nursing on 08/06/19 including ROM of bilateral upper and lower extremities. On 09/06/19 at 11:05 A.M., interview with Registered Nurse (RN) #8 verified the resident was not receiving any restorative nursing programs. 2. Resident #29 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's dementia and falls. The resident had bilateral knee contractures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 18 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 Review of the restorative nursing program referral from skilled therapy dated 01/31/19 revealed to provide static standing for 15 minutes with bilateral support and two-person assistance for safety for lower extremity strengthening. May ambulate the resident for short distances as able with two-person assistance as needed. Review of the restorative program progress note dated 06/29/19 revealed the resident continued on the restorative program for static standing with two-person assist. Review of the quarterly MDS 3.0 dated 07/19/19 revealed the resident was not interviewable. The resident needed extensive assistance from staff with activities of daily living (ADL). The resident had bilateral lower extremity contractures. The resident was not steady with surface to surface transfers. Review of the range of motion assessment dated [DATE] revealed the resident had moderate contractures of his bilateral lower extremities. Review of the August and September 2019 documentation grids indicated the resident was able to stand for 10 to 15 minutes according to the restorative program. On 09/03/19 at 12:19 P.M., interview with STNA #36 revealed she was not aware the resident was on any restorative programs. On 09/03/19 at 3:00 P.M., interview with STNA #2 revealed the floor STNAs completed restorative programs and she was not aware the resident was on any restorative programs. Observation on 09/03/19 at 6:23 P.M. revealed STNAs #5 and #29 attempted to pivot transfer Resident #29 from the wheelchair into his bed. The resident was not able to assist in the transfer and when he was lifted up by his pants, his right foot crossed over his left foot and the resident was dragged to the bed. The resident was not able to bear any weight. On 09/03/19 at 6:25 P.M., interview with STNAs #5 and #29 verified the resident was not able to stand or bear any weight when transferred and due to contractures in his legs. When lifted the resident's right foot always crossed over the left foot and the resident could not assist in the pivot transfers. They reported Resident #29 had been that way for a while, but they could not recall how long. The STNAs verified the resident would not be able to stand at all and he was not on any restorative programs. On 09/03/19 at 6:35 P.M., interview with STNA #4 revealed the floor STNAs completed restorative programs and she was not aware the resident was on any restorative programs. On 09/03/19 at 6:37 P.M., interview with STNA #29 revealed therapy did the restorative programs. On 09/05/19 at 2:35 P.M., interview with RN #8 verified Resident #29's restorative program was not being implemented or updated to reflect the resident was not able to bear weight at this time despite the aides documenting static standing for 15 minutes was being completed. 3. Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including parkinsonism, Alzheimer's disease, bipolar disorder, depression, epilepsy, schizophrenia, osteoporosis, and contractures of the right and left hip, knee, and ankles. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 19 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 Observation of Resident #3 on 09/03/19 at 10:52 A.M. 10:44 A.M., 10:52 A.M., 11:28 A.M., 3:01 P.M., on 09/04/19 at 1:22 P.M., and on 09/05/19 at 11:14 P.M., revealed the resident had her legs drawn up into her abdominal/pelvic area and her head was tilted to the right. The resident had a neck pillow in place, however, it was not correctly applied around the base of the neck. There was no evidence of splints to the lower extremities. Residents Affected - Some Review of Resident #3's active care plan revealed to perform active range of motion (AROM) and passive range of motion (PROM) to contracted joints as indicated and/or ordered. Observe the resident's response to range of motion exercise and pain tolerance. If the resident complains of pain, stop ROM exercise and reattempt at a later time. Review of Resident #3's nurse aide documentation under the task tab revealed no evidence AROM/PROM was being performed. Review of the restorative book revealed no evidence the resident was receiving restorative ROM. Review of Resident #3's physical therapy discharge note dated 05/16/19 revealed the resident was to have bilateral knee neuro extension braces and a restorative nursing program. Nursing staff educated on gentle motion and stretches and on positioning techniques. Review of Resident #3's MDS 3.0 dated 08/27/19 revealed the resident did not receive restorative services and had limited ROM of both lower extremities. Interview on 09/04/19 at 3:08 P.M. and 09/05/19 at 1:22 P.M., with RN #8 revealed she was responsible for the restorative nursing program and knew there were problems with the program. She confirmed Resident #3 was not on a restorative program nor was there evidence the resident was provided AROM or PROM per the plan of care. She reported she would write an order and implement a ROM program for the resident. She also reported if there was no order it would not transfer over to the nurse aide task tab to alert them to perform range of motion task. RN #8 was not aware of any braces to the knees for Resident #3. Interview on 09/05/19 at 10:35 AM with COTA #56 who was the therapy manager Resident #3 was seen by physical therapy from 05/06/19 to 05/21/19 for contracture management and improved positioning. The therapist discharge recommendation was for bilateral knee neruo extension braces and restorative nursing program. The braces were originally denied by insurance on 06/27/19 due to the brace company not being an approved provider. COTA #56 reported she started on 08/19/19 and found the denial letter laying on her desk. She followed up with the insurance provider on 08/20/19 because in the first paragraph of the denial letter it said the company was not a provider, however in the second paragraph it listed the company as one of the three approved providers. The braces were still at the facility, but she could not issue the braces to the resident because they were not paid for. The resident was screened yesterday (after concerns were brought to the facility's attention) by OT for new onset of decreased postural alignment, decreased skin integrity, joint instability, decreased neuromotor control and reduced functional activity tolerance indicating the need for a RNP (restorative nursing program). The resident demonstrated a new cervical contracture and her head was tilting to one side. There was no evidence the lower extremities were evaluated to ensure there was no decline in her lower extremity contractures. She would complete a physical therapy screen for the resident today. Observation of Resident #3 on 09/05/19 at 11:14 A.M., and interview with STNA #19 revealed the resident's knees had been contracted for some time and even when she was in bed her legs were drawn up (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 20 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 toward her abdomen. STNA #19 confirmed she had not been performing ROM and it was not on the STNA task list to alert them to do it. Interview with 09/05/19 at 2:35 P.M., with the regional director of physical therapy (RDPT) #57 revealed the therapy department just had physical therapy assess the resident and she did not have any major declines in her lower extremity contractors, however they were going to pick her back up today to apply the braces that were originally ordered in 05/16/19. 4. Record review revealed Resident #23 was admitted [DATE] with diagnoses including dementia, contractures of the left knee and of the left and right ankles. Observation of Resident #23 on 09/03/19 at 12:05 P.M., revealed no evidence of splints. Review of Resident #23's active care plan revealed to perform AROM/PROM to contracted joints as indicated and/or as ordered. Observe the resident's response to ROM, and pain tolerance. If the resident complained of pain, stop ROM and reattempt at a later time. Review of Resident #23's nurse aide documentation under the task tab revealed no evidence AROM/PROM was being performed. Review of the restorative book revealed no evidence the resident was receiving restorative ROM. Interview on 09/04/19 at 3:08 P.M. and 09/05/19 at 1:22 P.M., with RN #8 confirmed the resident was not on a restorative program nor was there evidence the resident was provided AROM or PROM per the plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 21 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 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** 2. Resident #29 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's dementia and falls. Residents Affected - Some Review of the quarterly MDS 3.0 dated 07/19/19 revealed the resident was not interviewable. The resident needed extensive assistance of two or more staff for transfers. Review of the current care plan revealed it was not specific to the resident and did not include many of the implemented fall interventions. The care plan did indicate for the resident to wear proper footware. Review of the fall investigation dated 11/01/18 at 2:15 P.M., revealed the resident was found sitting on the floor in front of the recliner. The new interventions listed were hipsters at all times, and dycem (a non skid material used to prevent residents from sliding out of the wheelchair) to the recliner and the wheelchair. Review of the fall investigation dated 11/03/18 at 2:09 A.M., revealed the resident was found sitting on the floor in front of the wheelchair beside his bed. There was no evidence the dycem or hipsters were in place at the time of the fall. The new intervention was to not leave the resident unattended while in the wheelchair. Review of the orders initiated 11/16/18 revealed the resident needed to wear hipsters at all times. Review of the fall investigation dated 12/25/18 at 6:30 P.M., revealed the resident was observed leaning forward in his wheelchair and then found on the floor in front of the wheelchair. There was no evidence the dycem or hipsters were in place. The new intervention was to apply a brace to maintain posture and have therapy assess the resident for positioning. Review of the fall investigtion dated 04/19/19 at 6:30 P.M., revealed the resident was found on the floor in the dining room unattended. There was no evidence the dycem, hipsters or brace were in place. The new intervention was for a busy board and staff were educated to not leave the resident alone. There was no documented evidence of the education. Review of the nurses note dated 05/02/19 revealed the resident was leaning over his knees and attempted to stand up from his wheelchair. Review of the nurse note date 07/20/19 revealed the resident leaned forward in his wheelchair and forcefully grasped the lower bar on the wheelchair that extended downward below the arm rest. Review of the investigation dated on 07/28/19 at 4:00 P.M. revealed the resident was just outside of the room and was observed to fall out of the wheelchair. There was no evidence the dycem, hipsters, brace or busy board were in place. The new intervention was was for 30 minute checks. There was no evidence the 30 minute checks were completed. Review of the September 2019 treatment administration record (TAR) indicated the only intervention that was monitored were the hipsters. On 09/03/19 during the day and on 09/04/19 during the night it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 22 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 was documented the resident had hipsters on despite verified observations of the hipsters not being in place. On 09/03/19 at 11:40 A.M. and 12:17 P.M., the resident was observed sleeping and leaning far forward in the wheelchair. The resident's head was almost touching his knees. Residents Affected - Some On 09/03/19 at 12:18 P.M., interview with STNA #36 verified the resident was leaning far forward in the wheelchair and he did not fit properly in the wheelchair. On 09/03/19 observations between 3:05 P.M. and 3:50 P.M., revealed Resident #29 was sleeping and leaning forward in the wheelchair holding onto the hand rail with his left hand. Three separate times staff attempted to reposition the resident and after a minute the resident returned to leaning forward with his head close to his knees. On 09/03/19 at 6:23 P.M., the resident was observed being transferred from his wheelchair into bed by STNA #5 and #29. There was no dycem on the seat of the wheelchair. On 09/03/19 at 6:25 P.M., interview with STNA #5 and #29 verified the resident did not have a dycem nor did they ever place a dycem in the seat of the wheelchair. They did not know the resident was suppose to have a dycem in his wheelchair. On 09/05/19 at 8:20 A.M., interview with RN #8 verified the resident should always have on hipsters except when providing incontinence care. On 09/05/19 at 8:40 A.M., the resident was observed in bed without hipsters on. The resident was then transferred into his wheelchair by STNA #3 and #10. There was no dycem in the seat of the wheelchair. On 09/05/19 at 8:45 A.M., interview with STNA #3 and #10 verified Resident #229 did not have on his hipsters and when transferred into the wheelchair there was no dycem in the seat of the wheelchair. The STNAs did not know the resident was to have a dycem in the seat of the wheelchair. On 09/05/19 at 9:45 A.M., interview with RN #8 verified the above concerns with falls for Resident #29 and no evidence the interventions were in place including the most recently added intervention for 30 minute checks. 3. Resident #29 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's dementia and falls. Review of the quarterly MDS 3.0 dated 07/19/19 revealed the resident was not interviewable. The resident needed extensive assistance of two or more staff for transfers. Review of the current care plan revealed it was not specific to the resident but did indicated to wear proper footware. On 09/03/19 at 6:23 P.M., the resident was in his wheelchair. STNA #5 removed his non skid socks. STNAs #5 and #29 proceeded to pivot transfer the resident from the wheelchair into his bed. The resident was in his bare feet, the wheels of the wheelchair were not locked and a gait belt was not used. The resident was not able to assist in the transfer and when he was lifted up by his pants his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 23 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 right foot crossed over his left foot and the resident was dragged to the bed. Level of Harm - Minimal harm or potential for actual harm On 09/03/19 at 6:25 P.M., interview with STNAs #5 and #29 verified they should have locked the wheels of the wheelchair, should have had non skid footwear on and should have used a gait belt but did not. STNA #5 verified the resident was not able to bear any weight when transferred and due to contractures the right foot always crossed over the left foot. The resident could not assist in the pivot transfers. Residents Affected - Some On 09/05/19 at 4:05 P.M., interview with RN #53 verified the facility did not have a policy related to pivot transfers but the expectation was for staff to lock the wheels of the wheelchair, use a gait belt and ensure the resident wore non skid footwear. RN #53 reported the STNAs participated in competency training to ensure proper transfers but she was not able to locate any documented evidence of such for STNA #5 or #29. Based on record review, observation, interview, and policy review the facility failed to ensure fall interventions were in-place per plan of care, fall care plans were revised, residents were transferred properly, and resident smoking was supervised. This affected two (Resident #29 and #31) of two residents reviewed for falls and 10 (Residents #12, #19, #8, #26, #342, #30, #15, #18, #6 and #34) of 11 residents identified by the facility as smokers. The facility census was 42. Findings include: 1. Record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including fracture of the neck of the left femur, history of transient ischemic attack, lack of coordination, difficulty in walking, muscle weakness, osteoarthritis of the knee, right leg pain, abnormalities of gait and mobility, contractures of the right ankle and left knee, syncope and collapse, and a history of falls. Review of Resident #31's fall plan of care revealed a self-releasing seat belt to the chair/wheelchair for safety, keep the bed in low position, keep the call light in reach, and assist the resident with wearing proper footwear. There was no evidence of anti-tippers to the wheelchair. Observation of Resident #31 on 09/03/19 at 2:44 P.M., revealed the resident was resting in bed. Interview revealed the resident was slightly confused and he reported he fallen recently fracturing his leg and hip. The resident had plain white socks on at the time of the observation. There was no evidence of a self-releasing seat belt to chair/wheelchair. There were anti-tippers on his wheelchair. Observation on 09/04/19 at 12:39 PM with Registered Nurse (RN) #53 confirmed the resident was wearing plain white socks instead of gripper (non-slip) socks. Resident #31 indicated he had several pairs in his drawer. RN #53 applied the gripper socks. RN #53 confirmed the resident's bed was not in low position and, there was no self-releasing seat belt, but there were antitippers on the wheelchair. Interview on 09/04/19 at 2:17 P.M., with RN #54 verified the resident's fall plan of care was not revised to reflect current fall interventions. The low bed and self-releasing seat belt were discontinued, and the anti-tippers should be added to the plan of care. Review of the fall and fall risk policy dated 03/18 revealed the staff would implement a resident-centered fall prevention plan of care to reduce risk factor of falls for each resident at risk or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 24 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with history of falls. Staff would identify and implement relevant intervention to try to minimize serious consequences of falling. 4. Resident #12 was admitted on [DATE] and his Smoking Evaluation, dated 07/19/19, revealed the resident must wear a smoking apron at all times while smoking and required the use of a cigarette holder. Resident #12's active comprehensive care plan for being at risk for injury due to smoking, revealed he needed supervision when smoking. 5. Resident #19 was admitted on [DATE] and his Smoking Evaluation, dated 08/06/19, revealed he must be supervised by staff, volunteer, or family member at all times. 6. Resident #8 was admitted on [DATE] and his Smoking Evaluation, dated 07/12/19, revealed he must be supervised by staff, volunteer, or family member at all times. 7. Resident #26 was admitted on [DATE] and her Smoking Evaluation, dated 07/11/19, revealed she must be supervised by staff, volunteer, or family member at all times. 8. Resident #342 was admitted on [DATE] and her Smoking Evaluation, dated 08/12/19, revealed she must be supervised by staff, volunteer, or family member at all times. 9. Resident #30 was admitted on [DATE] and his Smoking Evaluation, dated 07/07/19, revealed he must be supervised by staff, volunteer, or family member at all times. 10. Resident #15 was admitted on [DATE] and her Smoking Evaluation, dated 09/01/19, revealed she must be supervised by staff, volunteer, or family member at all times. 11. Resident #18 was admitted on [DATE] and her Smoking Evaluation, dated 06/21/19, revealed she must be supervised by staff, volunteer, or family member at all times. 12. Resident #6 was admitted on [DATE] and his Smoking Evaluation, dated 09/04/19, revealed he must be supervised by staff, volunteer, or family member at all times. 13. Resident #34 was admitted on [DATE] and her Smoking Evaluation, dated 09/04/19, revealed the must be supervised by staff, volunteer, or family member at all times. Observation on 09/03/19 at 3:19 P.M. revealed STNA #48 was supervising Resident #22, Resident #12, Resident #19, Resident #8, Resident #26, Resident #342, Resident #30, Resident #15, Resident #18, Resident #6, and Resident #34 who were smoking in the designated smoking area. The smoking area was located outside off of the secured unit. Residents who did not reside on the secured unit were escorted in to the unit by staff. Observation on 09/03/19 at 3:42 P.M. revealed STNA #48 left seven residents smoking unsupervised, while she assisted Resident #22 resident back to her unit. STNA #48 returned within the minute but left again to assist Resident #12 back to his unit, leaving six resident unsupervised. STNA #48 returned right away and at 3:44 P.M. left one resident (Resident #15) smoking unsupervised. Residents that were ambulatory let themselves back in the building after they were finished smoking. At 3:45 P.M. STNA #48 came back outside and notified the Resident #15 that should would be back. At 3:46 P.M. she came back to supervise Resident #15 until she was done smoking. Interview at this time with STNA #48 confirmed she left the residents unsupervised to help residents back to their unit when done (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 25 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 smoking. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy, titled Smoking Policy - Residents, revised July 2017, revealed residents will be evaluated on admission and quarterly to determine a residents ability to smoke safely with or without supervision per a completed Safe Smoking Evaluation. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 26 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 0711 Level of Harm - Minimal harm or potential for actual harm Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident #4 was admitted to the facility on [DATE] with diagnoses which included brain cancer. Residents Affected - Many Review of the residents medical record for 2019 revealed there were no physician progress notes in the electronic or paper chart. Further review revealed the only evidence the physician saw the resident were the nursing notes dated 06/20/19 and 08/08/19 which stated the physician was here. On 09/05/19 at 11:00 A.M., interview with Registered Nurse (RN) #55 verified there were no physician progress notes completed for 2019. 7. Resident #5 was admitted to the facility on [DATE] with diagnoses which included schizophrenia, depression and difficulty walking. Review of the residents medical record for 2019 revealed there were no physician progress notes in the electronic or paper chart. Further review revealed the only evidence the physician saw the resident were the nursing notes dated 04/18/19, 06/06/19 and 08/08/19 which stated the physician was here. On 09/05/19 at 11:00 A.M., interview with Registered Nurse (RN) #55 verified there were no physician progress notes completed for 2019. 8. Resident #7 was admitted to the facility on [DATE] with diagnoses which included morbid obesity and muscle wasting. Review of the residents medical record for 2019 revealed there were no physician progress notes in the electronic or paper chart. Further review revealed the only evidence the physician saw the resident were the nursing notes dated 06/06/19 and and 08/08/19 which stated the physician was here. On 09/05/19 at 11:00 A.M., interview with Registered Nurse (RN) #55 verified there were no physician progress notes completed for 2019 for Residents #4, #5 or #7. 9. Resident #29 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's dementia. Review of the residents medical record for 2019 revealed there were no physician progress notes in the electronic or paper chart. Further review revealed the only evidence the physician saw the resident were the nursing notes dated 01/03/19, 04/18/19 and 08/08/19 which stated the physician was here. On 09/05/19 at 11:00 A.M., interview with Registered Nurse (RN) #55 verified there were no physician progress notes completed for 2019. 10. Resident #39 was admitted to the facility on [DATE] with diagnosis of multiple sclerosis. Review of the residents medical record for 2019 revealed there were no physician progress notes in the electronic or paper chart. Further review revealed the only evidence the physician saw the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 27 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 0711 resident were the nursing notes dated 01/03/19 and 08/08/19 which stated the physician was here. Level of Harm - Minimal harm or potential for actual harm On 09/05/19 at 11:00 A.M., interview with Registered Nurse (RN) #55 verified there were no physician progress notes completed for 2019. Residents Affected - Many On 09/05/19 at 9:30 A.M., interview with Physician #60 revealed when he came to the facility the Director of Nursing (DON) would have a spread sheet with a synopsis and/or concerns about each resident he would visit that day. He took notes on the spread sheet as needed but did not document anything in the medical record. Physician #60 verified there were no physician progress notes in the medical record for 2019. Based on record review and interview the physician failed to document, sign, and date each physician visit. This affected 11 (Residents #3, #4, #5, #7, #8, #11, #23, #29, #31, #33, and #39) of 19 resident records reviewed and had the potential to affect all residents currently residing in the facility. The census was 42. Findings include: 1. Record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including diabetes, heart disease, pressure ulcers, chronic pain, anxiety, insomnia, hypercholesterolemia, Alzheimer's , hallucination, chronic kidney disease, Parkinson's, hyperparathyroidism, anemia, mood disorder, bipolar, depression, conduct disorder, glaucoma, venous insufficiency, respiratory failure, contractures, absence of right and left leg below knee, and edema. There was no evidence of a signed or dated physician note from 01/2019 to 09/2019. The nurse documented the physician had seen the resident on 01/03/19 and 04/18/19 in the nursing progress notes. 2. Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbances, insomnia, anxiety, depression, mood disorder, contractures, hyperlipidemia, hypothyroidism, contractures, and Alzheimer's. There was no evidence of a signed or dated physician note from 01/2019 to 09/2019. The nurse documented the physician had seen the resident on 01/03/19 and 04/18/19 in the nursing progress notes. 3. Record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including left femur fracture, heart disease, osteoarthritis, schizophrenia, dementia, contractures, hyperlipemia, and peripheral vascular disease. There was no evidence of a signed or dated physician note from 01/2019 to 09/2019. The nurse documented the physician had seen the resident on 01/03/19, 04/18/19, and 08/08/19 in the nursing progress notes. 4. Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including parkinsonism, Alzheimer's, bipolar, depression, adult failure to thrive, epilepsy, schizophrenia, dysphagia, hypokalemia, dementia, contracture, and anemia. There was no evidence of a signed or dated physician note from 01/2019 to 09/2019. The nurse documented the physician had seen the resident on 01/03/19 and 08/08/19. 5. Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including emphysema, pain, anxiety, cachexia, heart disease, history of leukemia, pulmonary disease, and protein calorie malnutrition. There was no evidence of a signed or dated physician not from 04/2019 to 09/2019. The nurse documented the physician had seen the resident on 04/18/19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 28 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 09/05/19 at 9:59 A.M. and 2:29 P.M., with Registered Nurse (RN) #55 confirmed the physician had not been completing signed and dated progress notes in the electronic or paper medical records. The physician was just provided written education on documentation and frequency of visits. The RN confirmed the above findings. 11. Resident #8 was admitted on [DATE] with diagnoses including but not limited to bipolar disorder, anxiety disorder, and schizoaffective disorder, major depressive disorder, edema, glaucoma, hypertension, kidney and ureter disorders, chest pain, hyperlipidemia, and type two diabetes. Review of Resident #8's medical record revealed the last physician visit progress note was documented 05/30/19. Interview on 09/04/19 at 2:51 P.M. with Registered Nurse (RN) #8 (acting director of nursing) confirmed Resident #8's physician was not documenting his visits with the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 29 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident #4 was admitted to the facility on [DATE] with diagnoses which included brain cancer. Residents Affected - Many Review of the residents medical record for 2019 revealed there were no physician progress notes nor physician assistant, nurse practitioner or clinical nurse specialist notes in the electronic or paper chart. Further review revealed the only evidence the physician saw the resident were the nursing notes dated 06/20/19 and 08/08/19 which stated the physician was here. 7. Resident #5 was admitted to the facility on [DATE] with diagnoses which included schizophrenia, depression and difficulty walking. Review of the residents medical record for 2019 revealed there were no physician progress notes nor physician assistant, nurse practitioner or clinical nurse specialist notes in the electronic or paper chart. Further review revealed the only evidence the physician saw the resident were the nursing notes dated 04/18/19, 06/06/19 and 08/08/19 which stated the physician was here. 8. Resident #7 was admitted to the facility on [DATE] with diagnoses which included morbid obesity and muscle wasting. Review of the residents medical record for 2019 revealed there were no physician progress notes nor physician assistant, nurse practitioner or clinical nurse specialist notes in the electronic or paper chair. Further review revealed the only evidence the physician saw the resident were the nursing notes dated 06/06/19 and and 08/08/19 which stated the physician was here. 9. Resident #29 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's dementia. Review of the residents medical record for 2019 revealed there were no physician progress notes nor physician assistant, nurse practitioner or clinical nurse specialist notes in the electronic or paper chart. Further review revealed the only evidence the physician saw the resident were the nursing notes dated 01/03/19, 04/18/19 and 08/08/19 which stated the physician was here. 10. Resident #39 was admitted to the facility on [DATE] with diagnosis of multiple sclerosis. Review of the residents medical record for 2019 revealed there were no physician progress notes nor physician assistant, nurse practitioner or clinical nurse specialist notes in the electronic or paper chart. Further review revealed the only evidence the physician saw the resident were the nursing notes dated 01/03/19 and 08/08/19 which stated the physician was here. On 09/05/19 at 11:00 A.M., interview with Registered Nurse (RN) #55 verified there were no physician progress notes completed for 2019 and a lack of evidence the residents were seen by the physician every 60 days. On 09/05/19 at 9:30 A.M., interview with physician #60 revealed when he came to the facility the director of nursing (DON) would have a spread sheet with a synopsis and/or concerns about each resident he would visit that day. He took notes on the spread sheet as needed but did not document anything in the medical record. Physician #60 verified there were no physician progress notes in the medical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 30 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 0712 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many record for 2019 nor did he have a physician assistant, nurse practitioner or clinical nurse specialist completing monthly progress notes. 11. Resident #8 was admitted on [DATE] with diagnoses including but not limited to bipolar disorder, anxiety disorder, and schizoaffective disorder, major depressive disorder, edema, glaucoma, hypertension, kidney and ureter disorders, chest pain, hyperlipidemia, and type two diabetes. Review of Resident #8's medical record revealed the last physician visit progress note was documented 05/30/19. Interview on 09/04/19 at 2:51 P.M. with Registered Nurse (RN) #8 (acting director of nursing) confirmed Resident #8's physician was not documenting his visits with the resident and there was a lack of evidence the resident was seen every 60 days by the physician. Based on record review and interview the physician failed to ensure physician visits were provided timely and at the required frequency for all residents. This affected 11 (Resident #3, #4, #5, #7, #8, #11, #23, #29, #31, #33, and #39) of 19 resident records reviewed and had the potential to affect all residents currently residing in the facility. The facility census was 42. Findings include: 1. Record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including diabetes, heart disease, pressure ulcers, chronic pain, anxiety, insomnia, hypercholesterolemia, Alzheimer's , hallucination, chronic kidney disease, Parkinson's, hyperparathyroidism, anemia, mood disorder, bipolar, depression, conduct disorder, glaucoma, venous insufficiency, respiratory failure, contractures, absence of right and left leg below knee, and edema. There was no evidence of a signed or dated physician note from 01/2019 to 09/2019. The nurse documented the physician had seen the resident on 01/03/19 and 04/18/19 in the nursing progress notes. There was no evidence the physician visited the resident every 60 days. 2. Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbances, insomnia, anxiety, depression, mood disorder, contractures, hyperlipidemia, hypothyroidism, contractures, and Alzheimer's. There was no evidence of a signed or dated physician note from 01/2019 to 09/2019. The nurse documented the physician had seen the resident on 01/03/19 and 04/18/19 in the nursing progress notes. There was no evidence the physician visited the resident every 60 days. 3. Record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including left femur fracture, heart disease, osteoarthritis, schizophrenia, dementia, contractures, hyperlipemia, and peripheral vascular disease. There was no evidence of a signed or dated physician note from 01/2019 to 09/2019. The nurse documented the physician had seen the resident on 01/03/19, 04/18/19, and 08/08/19 in the nursing progress notes. There was no evidence the physician had visited the resident every 60 days. 4. Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including parkinsonism, Alzheimer's, bipolar, depression, adult failure to thrive, epilepsy, schizophrenia, dysphagia, hypokalemia, dementia, contracture, and anemia. There was no evidence of a signed or dated physician note from 01/2019 to 09/2019. The nurse documented the physician had seen the resident on 01/03/19 and 08/08/19. There was no evidence the physician had visited the resident every 60 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 31 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 0712 Level of Harm - Minimal harm or potential for actual harm 5. Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including emphysema, pain, anxiety, cachexia, heart disease, history of leukemia, pulmonary disease, and protein calorie malnutrition. There was no evidence of a signed or dated physician not from 04/2019 to 09/2019. The nurse documented the physician had seen the resident on 04/18/19. There was no evidence the physician had visited the resident every 30 days for the first 90 days after admission. Residents Affected - Many Interview on 09/05/19 at 9:59 A.M. and 2:29 P.M., with Registered Nurse (RN) #55 confirmed the physician had not been completing signed and dated progress notes in the electronic or paper medical records nor providing frequency of visits per the regulation. The physician was just provided written education on documentation and frequency of visits. The RN confirmed lack of evidence the physician visited the resident every 60 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 32 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a non-pharmacological interdisciplinary approach with a behavior modification plan was in place for Resident #5's behaviors. This affected one of one residents reviewed for behavior modification. Findings include: 1. Resident #5 was admitted to the facility on [DATE] with diagnoses which included schizophrenia, depression and difficulty walking. Review of the 03/08/19 quarterly minimum data set (MDS) 3.0 revealed the resident was cognitively intact and had behaviors including verbal and other behavioral symptoms one to three days and rejection of care four to six days during the reference period. Review of the current care plan, initiated 03/13/19, revealed the resident was disruptive, socially inappropriate, refused care, threw objects in his room and out into hallway and yelling out at staff. Goals included the resident would demonstrate fewer episodes of verbally and/or physically abusive behaviors and would voice anger and/or frustration through appropriate channels. There were no individualized interventions to allow the resident to achieve the goals set. Interventions included anticipate needs, provide calm reassurance, redirection with distractions while assessing effectiveness and include the resident in his care. Review of the nurse note dated 05/19/19 revealed the resident was verbally aggressive towards staff several times and had thrown things into the hallway off and on during the shift. Review of the nurse note dated 05/20/19 revealed on 05/17/19 the resident was in a verbal altercation with another resident and attempted to hit the resident, who was sitting on the other side of the dining room, with his silverware. Review of the physician's order initiated 05/20/19 revealed to serve all meals with plastic ware. Review of the nurse practitioner progress note dated 05/30/19 revealed the resident was pleasant and cooperative at the visit but staff reported the resident was mean and rude to staff with an increase in mood lability. The resident was also easily agitated. The resident was started on Depakote sprinkles, a mood stabilizer, three times a day for a new diagnosis of intermittent explosive disorder. Review of the 06/04/19 quarterly minimum data set (MDS) 3.0 revealed the resident was cognitively intact and had physical, other behavior symptoms and rejected care one to three days during the reference period. Review of the nurse note dated 07/16/19 revealed the STNA noticed the right arm of the resident's wheelchair was broken. When asked about the arm, the resident pulled the arm out of the wheelchair and threw it across the dining room. Review of the nurse note dated 07/21/19 revealed the resident threw a piece of ham across the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 33 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 0740 dining room because he did not like ham. Level of Harm - Minimal harm or potential for actual harm On 09/03/19 at 9:55 A.M., interview with the resident revealed he did not like having to eat off of plastic ware for meals and did not know why he had to. The resident indicated he ate most of his meals in his room but denied throwing things. Residents Affected - Few On 09/03/19 at 12:10 P.M., the resident was observed eating in his room with plastic ware. On 09/04/19 at 2:15 P.M., interview with Registered Nurse (RN) #8 revealed the resident ate most of his meals in his room or in the breezeway. She verified the resident threw silverware during a meal on 05/19/19 and after that he was not permitted to have regular silverware. RN #8 verified the resident had not thrown any of the plastic silver ware since ordered on 05/20/19 but there had not been any attempts to re-introduce the regular dinner ware to the resident. The resident continued to eat off of plastic dinner ware despite the resident not liking it. RN #8 verified there was no evidence the facility attempted to figure out the root cause of the resident throwing things nor was there any evidence of interventions to attempt to control the behavior except for removing the regular dinner ware. RN #8 stated the resident threw a wash cloth and Styrofoam cup into the hall from his room but they did not attempt to figure out why. On 09/05/19 at 9:30 A.M., interview Physician #60 revealed he was aware of the resident's behaviors of throwing things into the hall and being mean to staff. He stated the resident had periodic behaviors of isolating himself in his room. He was aware the psychiatric nurse practitioner started the resident on a mood stabilizer but he had not communicated with her nor was he aware of any non-pharmalogical behavior modifications plan in place for the resident. On 09/05/19 at 10:45 A.M., interview with RN #34 revealed back in May 2019 the resident threw his silverware in the dinning room but she did not believe he threw them at anyone specific. She verified it had not happened again but there was no evidence of discussion of allowing the resident to resume eating off of regular dinner ware. She verified the resident usually ate his meals in his room. On 09/05/19 at 1:00 P.M., phone interview with Clinical Nurse Practitioner (CNP) #61 revealed she was provided a resident list on each of her visits to see any residents with any concerns. She verified she initiated a mood stabilizer for the resident in May 2019 because the staff stated he was mean and rude to them. She verified she had not seen the resident since despite starting a new medication but would expect the medication would calm his mood and behaviors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 34 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure residents received the lowest effective dose of psychotropic/sedative medication to prevent sedation/lethargy. This affected one (Resident #3) of six reviewed for unnecessary medications. Findings include: Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including dysphagia, constipation, parkinsonism, Alzheimer's, bipolar, schizophrenia, adult failure to thrive, moderate protein-calorie malnutrition, and anemia. There was no evidence of a signed or dated physician note from 01/2019 to 09/2019. The nurse documented the physician had seen the resident on 01/03/19 and 08/08/19. There was no evidence the physician had visited the resident every 60 days. Review of Resident #3's current medication list revealed the resident was receiving the following scheduled medication that could induce sedation/lethargy; Melatonin 9 milligrams (mg) at bedtime for insomnia, Compazine (antipsychotic/antiemetic) 5 mg before meals for nausea and vomiting, Remeron (antidepressant) 15 mg at bedtime, Haldol (antipsychotic) 5 mg twice daily, Seroquel (antipsychotic) 200 mg twice daily, Baclofen (muscle relaxer) 10 mg three times daily, and Vistaril 25 mg three times daily for anxiety. Review of the pharmacy recommendations dated 01/09/19 and 07/11/19 revealed the pharmacist made recommendations for gradual dose reduction (GDR) for Seroquel and Remeron (the resident had been on each for over a year) and on 06/25/19 and 07/11/19 for Haldol and Compazine. The psychiatric nurse practitioner declined the above recommendation; however, she did not include resident specific rational for declining the GDR. There was no documented evidence the physician had reviewed the pharmacist recommendation. There was no documented evidence of GDR in the last year for the Seroquel and Remeron. Observation on 09/03/19 from 10:44 A.M. to 3:01 P.M., revealed the resident was lethargic and hard to arouse. During lunch staff had to shake resident to get her to respond to assist her with her lunch meal. Additional observation throughout the day on 09/04/19 and 09/05/19 revealed the resident was either asleep in the hallway by nurses' station in her chair or was in her room asleep. Interview on 09/06/19 at 9:42 A.M., with Registered Nurse (RN) #8 confirmed the resident was receiving several medications that could cause sedation/lethargy. The RN verified the resident had been very lethargic lately and she had notified the physician last night after the surveyor reported concerns to the corporate nurse. The physician reviewed the resident's medication and he\discontinued the scheduled Compazine and started Zofran as needed, discontinued the scheduled Vistaril, decreased the Melatonin to 6 mg, and decreased the Haldol to 2.5 mg in the morning and 5 mg at night. RN #8 verified the lack of evidence for GDR for Remeron and Seroquel and/or rational for declining. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 35 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including hyperlipidemia, type two diabetes, morbid obesity, heart disease, and antipsychotic therapy. There was no evidence a lipid panel was collected from 04/01/19 to 09/06/19. The hemoglobin A1C was collected on 07/31/19. Residents Affected - Few Review of Resident #33 pharmacy recommendation dated 04/18/19 revealed the pharmacist made a recommendation to order a lipid panel and hemoglobin A1C to monitor antipsychotic therapy. The physician agreed to order laboratory testing every three months. On 05/17/19 the pharmacist recommended the same request as 04/18/19. The physician responded the consultant needed to review labs before making monthly recommendations. On 06/13/19 the pharmacist reported the hemoglobin A1C was obtained, however, the lipid panel was not drawn per orders on 04/18/19. The physician did not address the recommendation on 06/13/19. On 08/27/19 the pharmacist made the same recommendation as 06/13/19 regarding the lipid panel. Interview on 09/06/19 at 10:12 A.M., with Registered Nurse (RN) #8 confirmed the lipid panel was not obtained per orders and the pharmacy recommendation. Based on record review and interview, the facility failed to ensure laboratory tests were completed as ordered for Resident #8 and Resident #33. This affected two (Resident #8 and Resident #33) of five residents reviewed for unnecessary medications. Findings include: 1. Resident #8 was admitted on [DATE] with diagnoses including bipolar disorder, anxiety disorder, schizoaffective disorder, and major depressive disorder. Resident #8's physician orders revealed he received Depakote, 500 milligrams, three tablets by mouth, for mood stabilization. Resident #8's physician orders revealed on 09/14/17 he was ordered laboratory testing for valproic acid (Depakote) levels on the fourteenth day of every month. Review of Resident #8's laboratory results since March 2019 revealed valproic acid level results were found for March, June, July, or August 2019. Interview on 09/04/19 at 2:51 P.M. with Registered Nurse #8 confirmed laboratory testing for Resident #8's valproic acid levels were not completed as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 36 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Resident #39, who needed teeth extracted, was provided the service timely. This affected one of one resident reviewed for dental services. Residents Affected - Few Findings include: Resident #39 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis. Review of the dental visit dated 08/27/18 revealed the resident had poor oral hygiene, a build up of plaque, loose and decaying teeth and teeth numbers 14 and 19 needed extracted. There was no evidence this was completed. Review of the significant change minimum data set (MDS) 3.0 dated 08/08/19 revealed the resident was cognitively intact but was totally dependent on staff for activities of daily living including brushing her teeth. On 09/06/19 at 9:10 A.M., interview with the Licensed Practical Nurse (LPN) #3 revealed the facility needed to get approval for the teeth extraction from Medicaid and the authorization paperwork was never submitted until June 2019. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 37 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on record review, review of personnel files and policy review the facility failed to ensure administration was effective in regards to checking of non-licensed staff against the nurse aide registry, frequency of physician visits and physician documentation, and thorough implementation of an antibiotic stewardship program. This had the potential to affect all 42 residents currently residing in the facility. Residents Affected - Many Findings include: 1. Review of personnel list and personnel files revealed the non-licensed (Laundry aide (LA) #15, LA #17, Housekeeping aide (HA) #18, Environmental Director (ED) #20, Dietary Director (DA) #22, Dietary Aide (DA) #24, Activities Aide (AA) #25, admission Director (AD) #26, Dietary [NAME] (DC) #27, DC #30, DC #33 and DC 40, Activities Director (AD) #28, DA #31, HA #37, AA #38, DA #41, Medical records (MR) #46, and HA #52 had not been checked against the State NAR. Interview on 09/04/19 at 10:00 A.M., with Registered Nurse (RN) #53 verified she had no documented evidence the above non-licensed staff were checked against the State NAR to ensure the employee did not have a finding entered the State NAR concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. The RN reported she had sent emails to all the facility's after the deficient practice was cited at a sister facility, however it still was not completed. 2. Record review revealed no evidence Residents #3, #4, #5, #7, #8, #11, #23, #29, #31, #33 and #39 were seen by the physician every 30 days for the first 90 days after admission and every 60 days thereafter as required. There was no evidence of a signed or dated physician progress notes. Interview on 09/05/19 at 9:59 A.M. and 2:29 P.M., with Registered Nurse (RN) #55 confirmed the physician had not been completing signed and dated progress notes in the electronic or paper medical records nor providing frequency of visits every 30 days for the first 90 days after admission and every 60 days thereafter as required. On 09/05/19 at 11:00 A.M., interview with Registered Nurse (RN) #55 verified there were no physician progress notes completed for 2019 and a lack of evidence the residents were seen by the physician every 60 days. On 09/05/19 at 9:30 A.M., interview with physician #60 revealed when he came to the facility the director of nursing (DON) would have a spread sheet with a synopsis and/or concerns about each resident he would visit that day. He took notes on the spread sheet as needed but did not document anything in the medical record. Physician #60 verified there were no physician progress notes in the medical record for 2019 nor did he have a physician assistant, nurse practitioner or clinical nurse specialist completing monthly progress notes. 3. Review of the facility infection control program revealed no evidence from May 2019 through July 2019 that the facility had antibiograms for antibiotic susceptibility review or that the consulting pharmacist attended infection prevention and control meetings to help guide antibiotic use. Interview on 09/05/19 at 10:00 A.M. with Registered Nurse (RN) #8 (Infection Preventionist), revealed the facility had not completed antibiograms for review and the consulting pharmacist has not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 38 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 0835 attended any meetings to review antibiotic use. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy, titled Antibiotic Stewardship - Staff and Clinician Training and Roles, dated November 2017, revealed the Infection Preventionist (IP) will monitor over time and report to the Infection Prevention and Control Committee (IPCC) the antibiotic susceptibility patterns (antibiogram data for specific timeframe). The Consultant Pharmacist (CP) will review the microbiology culture date (antibiogram) and share with the provider's to help guide antibiotic selection. The CP will provide the facility with the most current medication formulary, and participate in IPCC meetings on a regular basis. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 39 of 40 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 366249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunnyslope Nursing Home 102 Boyce Drive Bowerston, OH 44695 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to thoroughly implement an antibiotic stewardship program. This had the potential to affect all 42 residents currently residing in the facility. Residents Affected - Many Findings include: Review of the facility infection control program revealed no evidence from May 2019 through July 2019 that the facility had antibiograms for antibiotic susceptibility review or that the consulting pharmacist attended infection prevention and control meetings to help guide antibiotic use. Interview on 09/05/19 at 10:00 A.M. with Registered Nurse (RN) #8 (Infection Preventionist), revealed the facility had not completed antibiograms for review and the consulting pharmacist has not attended any meetings to review antibiotic use. Review of the facility policy, titled Antibiotic Stewardship - Staff and Clinician Training and Roles, dated November 2017, revealed the Infection Preventionist (IP) will monitor over time and report to the Infection Prevention and Control Committee (IPCC) the antibiotic susceptibility patterns (antibiogram data for specific timeframe). The Consultant Pharmacist (CP) will review the microbiology culture date (antibiogram) and share with the provider's to help guide antibiotic selection. The CP will provide the facility with the most current medication formulary, and participate in IPCC meetings on a regular basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 40 of 40

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Citations

32 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0610GeneralS&S Dpotential for harm
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
0561GeneralS&S Dpotential for harm
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
0606GeneralS&S Fpotential for harm
F606 - The facility must—
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
0607GeneralS&S Epotential for harm
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
0609GeneralS&S Dpotential for harm
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
0657GeneralS&S Dpotential for harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
0677GeneralS&S Dpotential for harm
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0686GeneralS&S Dpotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0687GeneralS&S Dpotential for harm
F687 - Foot care
Provide appropriate foot care.
0688GeneralS&S Epotential for harm
F688 - Mobility
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.
0689GeneralS&S Epotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0711GeneralS&S Fpotential for harm
F711 - Physician Visits
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
0712GeneralS&S Fpotential for harm
F712 - Frequency of physician visits
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
0740GeneralS&S Dpotential for harm
F740 - Behavioral health services
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
0770GeneralS&S Dpotential for harm
F770 - Laboratory Services
Provide timely, quality laboratory services/tests to meet the needs of residents.
0791GeneralS&S Dpotential for harm
F791 - Dental Services
Provide or obtain dental services for each resident.
0835GeneralS&S Fpotential for harm
F835 - Administration
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
0881GeneralS&S Fpotential for harm
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
0037GeneralS&S Fpotential for harm
Establish staff and initial training requirements.
0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
0346GeneralS&S Fpotential for harm
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
0355GeneralS&S Fpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
0374GeneralS&S Epotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
0541GeneralS&S Epotential for harm
Install properly constructed and protected linen or trash chutes.
0761GeneralS&S Fpotential for harm
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
0918GeneralS&S Fpotential for harm
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
0920GeneralS&S Epotential for harm
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.

FAQ · About this visit

Common questions about this visit

What happened during the September 6, 2019 survey of SUNNYSLOPE NURSING HOME?

This was a inspection survey of SUNNYSLOPE NURSING HOME on September 6, 2019. The surveyor cited 32 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at SUNNYSLOPE NURSING HOME on September 6, 2019?

Yes, 32 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Respond appropriately to all alleged violations."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 8, 2026. If you believe any information is inaccurate, report it here.

Inspection·September 6, 2019