Health inspection·October 17, 2024

F 0641 Ensure each resident receives an accurate assessment. 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, and staff interviews the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This affected three residents (#1, #10, and #17) out of 13 records reviewed. Residents Affected - Few Findings included: 1. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, mood disorder, depression, obsessive-compulsive disorder, insomnia, paranoid schizophrenia, and dementia. The resident resided on the secure unit. a. Review of Resident #1's Preadmission Screening and Resident Review (PASARR) notification dated 01/12/23 revealed Resident #1 met criteria for serious mental illness and would need specialized services. Review of Resident #1's annual Minimum Date Set (MDS) assessment dated [DATE] revealed the resident wasn't considered to have a serious mental illness by the PASARR. Interview on 10/17/24 at 10:04 A.M., with the MDS Nurse #61 and Social Worker (SW) #11 confirmed Resident #1's MDS was marked inaccurate due to the resident did meet criteria for a serious mental illness on the PASARR dated 01/12/23. b. Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 used a physical restraint (physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body) due to he used bed rails daily. Review of Resident #1's bed rail/mattress safety assessment completed by the therapy department dated 03/15/24 revealed the resident enabler bar was used per resident request to increase independency. Interview on 10/15/24 at 10:10 A.M., with Registered Nurse (RN) #4 confirmed there was no residents that had physical restraint at this time on the secure unit. Observation on 10/15/24 at 3:26 P.M., revealed the resident had a enabler bar on the left side of the bed. The resident confirmed the bar was used for positioning and did not prevent him from rising or restraining him. Interview on 10/15/24 at 3:20 P.M. and 10/16/24 at 8:57 A.M. with the Director of Nursing (DON) confirmed Resident #1's MDS was coded inaccurately for physical restraints due to the enabler bar was determined by therapy as not a restraint and was only used to aid the resident in positioning only. The enabler bar did not prevent the resident from rising nor does it restrain him. The DON confirmed the MDS nurse had marked everyone with an enabler bar/bedrail as a physical restraint because that was what the facility was told by Centers of Medicare and Medicaid Services (CMS). 2. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including anxiety, metabolic encephalopathy, atrial fibrillation, hypertension, depression, adult (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 2 of 8 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 10/17/2024 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 0641 failure to thrive, dementia, kidney disease, heart failure, and Alzheimer's. Level of Harm - Minimal harm or potential for actual harm Review of Resident #10 MDS dated [DATE] revealed the resident used a physical restraint (bed rail) daily. Residents Affected - Few Review of Resident #10's bed rail/mattress safety assessment completed by the therapy department and dated 05/24/25 revealed Resident #10's bed rails were not restraints and were used for bed mobility. Review of Resident #10's assessment titled classification of device dated 08/26/24 revealed the resident did not have a device/restraint. Interview on 10/15/24 at 10:10 A.M., with Registered Nurse (RN) #4 confirmed there was no residents that had physical restraint at this time on the secure unit. Observation on 10/15/24 at 3:32 P.M., of Resident #10 revealed the resident had an enabler bar on each side of bed. Interview on 10/15/24 at 3:20 P.M. and 10/16/24 at 8:57 A.M. with the Director of Nursing (DON) confirmed Resident #10's MDS was coded inaccurately for physical restraints due to the enabler bars were assessed and determined not be restraints and were to assist with bed mobility only. 3. Record review revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including diabetes, anemia, bipolar, hypertension, conduct disorder, dementia, depression, restlessness and agitation, hypothyroidism, cirrhosis of the liver, and chronic kidney disease. The resident resided on the secure unit. Review of Resident #17's MDS dated [DATE] revealed the resident used a physical restraint (bed rail) daily. Review of Resident #17's bed rail/mattress assessment dated [DATE] completed by the therapy department revealed the resident's bed rails were required for stand to sit. Observation on 10/15/24 at 3:35 P.M. revealed Resident #17 had a half bed rail on the left side of the bed. The resident was in the dining room with his walker and confirmed the bedrail did not restrict him from any type of movement. Interview on 10/15/24 at 3:20 P.M. and 10/16/24 at 8:57 A.M. with the Director of Nursing (DON) confirmed Resident #17's MDS was coded inaccurately for physical restraints due to the bed rails were assessed and determined not be restraints and were to assist with stand to sit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 3 of 8 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 10/17/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and observation the facility failed to ensure all Pre-admission Screening and Resident Review (PASARR) level II services were implemented and a comprehensive individualized plan of care was completed. This affected one resident (#1) of four reviewed for PASARR. Findings included: Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, mood disorder, depression, obsessive-compulsive disorder, insomnia, paranoid schizophrenia, and dementia. The resident resided on the secure unit. Review of Resident #1's Preadmission Screening and Resident Review (PASARR) dated 01/12/23 revealed Resident #1 met PASARR inclusion criteria for serious mental illness with the diagnoses of schizoaffective disorder, mood disorder, obsessive-compulsive disorder, insomnia, other systems and signs involving cognitive function and awareness, nicotine dependence, major depression, paranoid schizophrenia, and eating disorder. Recommendation included but not limited to Rehabilitative service a safety plan, behavior management safety plan to decrease inappropriate behaviors and to ensure safety, socialization and recreation activities to decrease isolation, improve mood, and increase peer interaction. The reason for these supports includes: While staying in the nursing home, you should be encouraged to participate in activities you enjoy and to talk with other residents to improve your mood. A behavior management safety plan to ensure your safety and the safety of others helping care for you when feeling easily upset, fearful, or confused. Nutritional consult due to having a history of being diagnosed with an eating disorder where you would choose to not eat and focus on losing weight often noted in your records. Continue with therapy services to improve overall functions and to teach you safety awareness skills for self-care once you are feeling better. Review of Resident #1's PASARR Level II plan of care dated 02/02/18 revealed to follow PASARR recommendations. There was no other intervention listed. Further review of Resident #1's plan of care revealed the resident had behavior problems related to the resident displays aggressive gestures, clenching of fists and sudden changes in mood. Per the resident's sister, resident had been OCD his entire life. He was manipulative with other people including family. The resident avoids others, he will watch form a distance and wait until others clear before leaving his room. Resident self isolates to room. Resident fixates on food/snacks. Difficult to arouse. History of refusing medication when tired. Intervention included to have activities staff to encourage the resident to come out of room for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 4 of 8 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 10/17/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few activities and socialization. Discourage ordering double portions and pop/soda per power of attorneys wishes. Encourage the resident to sleep at night and awake in the morning. If the resident was difficult to arouse form medication, notify the physician. Remind the resident of snack times, orders, meals, and meal choices. Anticipate and meet the residents need to attempt to control the behavior problems. Provide a calm reassurance, redirections or distraction and assess effectiveness. Provide positive reinforcement for appropriate behavior. Confront gently and respectfully when behavior is inappropriate and set limits. Provide a quite environment as needed. Include resident or representative in treatment plan. The resident activity plan of care revealed to invite to activities of interest, offer praise for participation, provide activity calendar, and provide items needed for self-directed activities as needed. Review of the task (completed by State Tested Nurses' Aides) dated 09/17/24 to 10/17/24 revealed the resident had no physical or verbal behaviors. The resident had wandering behaviors seven days. The resident was noted to refuse activities, however watched television in his room. Further review of Resident #1's paper and electronic medical record revealed no evidence of safety plan or behavior management safety plan. Random observation on 10/15/24 from 9:00 A.M. till 3:30 P.M., 09/17/24 8:00 A.M. to 3:00 P.M., the resident was observed in his room in bed. There was no evidence the resident had participated in an activity or left his room. Interview on 10/15/24 at 11:52 A.M., revealed Resident #1 would not stay awake to complete interview. Interview and observation on 10/15/24 at 3:26 PM with Resident #1 revealed the resident was still in bed. The resident reported he didn't go to activities per his choice. The resident reported he had been on the same medication for 23 years and needs bigger medications and he needs medication to help him sleep. The resident confirmed he currently sleeps a lot during the day. Interview on 10/15/24 at 3:32 P.M., with Registered Nurse (RN) #4 confirmed the resident sleeps a lot during the day and doesn't leave his room. The resident overeats and has an obsession with his medications. Interview on 10/17/24 at 8:50 A.M. and 10:51 A.M., with State Tested Nurse's Aide (STNA) #56 confirmed the resident sleeps a lot. The staff tries to encourage the resident to get up in the chair, but as soon as they walk out the door, he puts himself back into bed. The STNA reported the resident only leaves his room when staff were cleaning his room due to his obsessive-compulsive disorder. The resident usually refuses meals but would also ask for double or triple of extra food he likes. The STNA reported she was not aware if the resident had safety plan or a behavior management safety plan. Interview on 10/17/24 at 10:59 A.M., with RN #43 revealed she was not aware the resident had a safety plan or a behavior management safety plan. The RN reported Resident #1 behaviors included isolation and he over eats. Interview on 10/17/24 at 11:14 A.M., with the Director of Nursing (DON) and Activity's Director (AD) #9 confirmed the resident refused activities frequently. The AD reported the activities staff just (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 5 of 8 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 10/17/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few document refusal and the staff doesn't do anything else to encourage the resident from isolating himself to his room or to attend activities. The AD confirmed the only activity the Resident had engaged in was watching television; however, the AD reported the resident does like to window shop on the computer, but she doesn't have any documentation to support the window shopping occurred or when. The facility did not have a comprehensive individualized plan of care to meet the resident social/activities needs per the PASARR level II recommendations. Interview on 10/17/24 at 10:55 A.M. with the Director of Nursing (DON) confirmed the resident did not have a safety plan or a comprehensive behavioral management safety plan per the PASARR level II recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 6 of 8 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 10/17/2024 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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, staff interview, and policy review the facility failed to ensure Pre-admission Screening and Resident Review (PASARR) assessments were completed accurately upon admission to the facility. This affected one resident (#37) of four residents reviewed for PASARR. Residents Affected - Few Findings include: Medical record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, intermittent explosive disorder, bipolar, and generalized anxiety disorder. Review of Resident #37's admission orders dated 07/12/24 revealed the resident was ordered Mirtazapine 15 milligrams (mg) 1.5 tablets at bedtime for depression, Rivastigmine 6 mg twice a day for dementia, Ativan 1 mg every four hours as needed for anxiety/agitation and Risperdal 0.5 mg twice a day for dementia. Review of Resident #37's PASARR dated 07/12/24 revealed the resident was marked for mental disorder. The box was checked for other for mental disorder and depression was typed in on the line. There was documented evidence the resident had intermittent explosive disorder, bipolar, and generalized anxiety disorder. The medication section indicated the resident medication included anti-psychotics and anti-anxiety. There was no documented evidence the resident was on an anti-depressant. Interview on 10/15/24 at 11:01 A.M., with Social Worker (SW) #11 confirmed the PASARR was inaccurate on admission and did not include intermittent explosive disorder, bipolar, and generalized anxiety disorder nor the anti-depressant medication. Review of the Pre-admission Screening and Resident review policy (dated 04/2017 and reviewed and revised 2024) revealed a resident review was required for any nursing facility resident with a serious mental illness or intellectual developmental disability who had experienced a change in mental diagnoses or psychotropic medication. Nursing facilities were required to complete the 3622 accurately and submit it to the if indication of serious mental illness and or developmental disabilities are present. The system allows the NF to complete the form and submit it directly to the department for further review. A resident review was required for any resident had experienced a significant change in condition (mental diagnosis or psychotropic medication). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 7 of 8 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 10/17/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure Resident #3's oxygen therapy was set to the correct liters per minute. This affected one resident ( #3) of one resident reviewed for oxygen therapy. The facility census was 42. Residents Affected - Few Findings include: Review of the medical record for Resident #3 revealed an admission date of 09/04/15. Diagnoses included asthma, chronic obstructive pulmonary disease (COPD), morbid obesity, and chronic respiratory failure with hypoxia. Review of Resident #3's October 2024 physician orders revealed an order dated 07/31/24 to have oxygen at two to five liters per minute via nasal cannula continuously. Review of Resident #3's Comprehensive care plan dated 08/20/24 revealed the resident is at risk for altered respiratory status and difficulty breathing related to shortness of breath. Interventions included to administer medication as ordered, observe need for oxygen therapy, change in respiratory rate or pattern, mental status changes, and oxygen (therapy) at two to five liters a minute to maintain saturation at greater than 90 percent as needed. Observation on 10/15/24 at 11:31 A.M. revealed Resident #3 to be in sitting in her room receiving oxygen therapy. The resident's oxygen set at 10 liters via nasal cannula. Observation on 10/16/24 at 8:53 A.M. revealed Resident #3 to be laying in her bed receiving oxygen therapy via nasal cannula. The oxygen was set at 10 liters. Interview on 10/16/24 at 8:53 A.M. Registered Nurse (RN) #22 confirmed Resident #3's oxygen was incorrectly placed on 10 liters. She verified the order was for the resident to have her oxygen set at two to five liters a minute. At the time of the observation and interview, RN #22 turned down the resident's oxygen at this time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366249 If continuation sheet Page 8 of 8