Inspection·January 19, 2023

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. Based on interview and record review the facility failed to hold quarterly plan of care meetings for Resident #24 for the developement of and updates to the plan of care for Resident #24. This affected one out of one resident reviewed for care conferences. The facility census was 41. Findings include: Review of Resident #24's medical record revealed an admission date 01/14/22. Diagnoses included hallucinations, weakness, hypertension, and chronic obstructive pulmonary disease (COPD). Review of Resident #24's quarterly Minimum Data Set 3.0 assessment, dated 10/19/22, revealed the resident had intact cogitation. Interview on 01/17/23 at 8:56 A.M. Resident #24 revealed she doesn't believe she has had a care conference meeting and hasn't participated in her care planning. Review of a yearly look back of care conferences from admission through 01/2022 revealed Resident #24's last care conference was on 05/19/22. Interview on 01/17/23 at 3:25 P.M. the Administrator confirmed Resident #24's last care conference was on 05/19/22. She continued it was her expectation care conferences were to be done quarterly. Review of the facility policy, Comprehensive Care Planning Policy, dated 07/19/19, revealed the facility will invite the resident and complete a care conference every 90 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366253 If continuation sheet Page 2 of 7 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 366253 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amberwood Manor 245 South Broadway New Philadelphia, OH 44663 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, interview, and policy and procedure review, the facility failed to follow the bowel protocol when Resident #9 went five days without a bowel movement. This affected one Resident (#9) out of five Residents reviewed for bowel elimination. The facility also failed to notify the physician when Resident #26 gained three to five pounds in one day. This affected one Resident (#26) out of six Residents reviewed for weights. The facility census was 41. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #9 was admitted on [DATE] with diagnoses that included type two diabetes mellitus, chronic kidney disease, and acute/chronic respiratory failure. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 was cognitively intact. The resident required extensive assistance of one for bed mobility and total dependence of one for toilet use. Resident #9 was always continent of bowel. Review of the documentation for bowel movements revealed Resident #9 did not have a bowel movement on 01/12/23, 01/13/23, 01/14/23, 01/15/23, and 01/16/23. Resident #9 had an order in place for magnesium hydroxide suspension 30 milliliters (ml) by mouth every 24 hours as needed for constipation. Review of the Medication Administration Record (MAR) revealed no evidence of magnesium hydroxide being administered to Resident #9 to treat the lack of bowel movements from 01/12/23 to 01/16/23. Review of the Bowel Tracking policy and procedure dated 02/26/20 revealed the nursing assistant would document the residents bowel activity on the bowel activity tracking document. If a resident did not have a bowel movement, then the space would be marked as none. The Director of Nursing (DON) was responsible for ensuring a daily auditing process was in place to identify residents who have not had a bowel movement in three day (72 hours). If the resident had not had a bowel movement for three full days (72 hours), the nurse would initiate the facility bowel protocol per standing orders for constipation. Review of standing orders for the facility dated 06/13/22 revealed constipation orders included: magnesium hydroxide 30 ml by mouth every day as needed, bisacodyl suppository 10 milligram (mg) every day as needed, and sodium/bisphosphate/sodium phosphate enema once a day if magnesium hydroxide was ineffective. Interview on 01/18/23 at 2:42 P.M. DON verified there was no evidence of Resident #9 being administered magnesium hydroxide suspension, bisacodyl suppository, or sodium/bisphosphate/sodium phosphate enema per the standing orders and bowel protocol. 2. Review of medical record revealed Resident #26 was admitted on [DATE] and 01/06/21 with diagnoses including but not limited to type two diabetes, mellitus, Alzheimer's disease, atherosclerotic heart disease, and bradycardia. The comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #26 had cognitive impairment. The resident required extensive assistance of one for bed mobility and transfers. Review of physician orders revealed Resident #26 had an order in place for daily weights in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366253 If continuation sheet Page 3 of 7 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 366253 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amberwood Manor 245 South Broadway New Philadelphia, OH 44663 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few morning for heart failure. The physician was to be notified if there was a three pound gain in one day or five pound gain in one week. On 12/14/22 Resident #26 weighed 213 pounds. On 12/15/22 Resident #26 weighed 218 pounds. Review of the medical record revealed no evidence of the physician being notified Resident #26 had a weight gain of five pounds in one day. On 12/23/22 Resident #26 weighed 213 pounds. On 12/24/22 Resident #26 weighed 216 pounds. Review of the medical record revealed no evidence of the physician being notified Resident #26 had a weight gain of three pounds in one day. On 01/02/23 Resident #26 weighed 218 pounds. On 01/03/23 Resident #26 weighed 222 pounds. Review of the medical record revealed no evidence of the physician being notified Resident #26 had a weight gain of four pounds in one day. Interview on 01/18/23 at 1:12 P.M. DON verified the physician was not notified on 12/15/22, 12/24/22, and 01/03/23 as ordered, when Resident #26 had a weight gain of three pounds or more in one day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366253 If continuation sheet Page 4 of 7 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 366253 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amberwood Manor 245 South Broadway New Philadelphia, OH 44663 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 - Few 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. Based on observation, family interview, medical record review and staff interview the facility failed to provide care and services to prevent worsening of identified joint contractures. This affected one Resident (#11) of one Resident reviewed for range of motion services. The facility census was 41. Findings include: Observation of Resident #11 on 01/17/23 at 8:30 A.M. and again at 3:40 P.M. identified contractures to the bilateral elbows and bilateral wrists. No evidence of any splint or brace device was observed in place at this time. Interview with Resident #11's power of attorney (POA) on 01/17/23 at 2:40 P.M. revealed Resident #11 had impaired movement to multiple joints for several years. Resident #11's POA was unaware of any services provided for the residents joint movement limitation other than some therapy at times. Review of Resident #11's medical record revealed an admission date of 03/28/11 with admission diagnoses that included contractures, traumatic brain injury and hypertension. Review of a restorative nursing assessment completed on 06/27/22 identified multiple joint contractures to the neck, bilateral elbows, bilateral wrists, bilateral hips, bilateral knees and bilateral ankles. Further review of the restorative nursing assessment found no evidence of a joint contracture management program provided. Review of MDS 3.0 assessments with reference dates of 10/02/22 and 01/02/23 revealed no evidence of any restorative nursing programs for joint contracture management. Review of Resident #11's care plans revealed no evidence of any care plan related to joint contracture or joint contracture management program. Interview with State Tested Nurse Aide (STNA) #126 on 01/17/23 at 3:45 P.M. revealed no knowledge of any type of services provided for Resident #11 related to joint contracture management, including range of motion of splint/brace device use. Interview with the Director of Nursing on 01/18/23 at 9:55 A.M. verified there were no services in place for Resident #11 related to joint contracture management, including range of motion of splint/brace device use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366253 If continuation sheet Page 5 of 7 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 366253 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amberwood Manor 245 South Broadway New Philadelphia, OH 44663 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to provide a proper indication for Resident # 32's Depakote use. This affected one Resident (#32) out of five Residents reviewed for unnecessary medications. The facility census was 41. Residents Affected - Few Findings include: Review of Resident #32's medical record revealed an admission date of 09/02/22. Diagnoses included diabetes mellitus type two, atrial fibrillation, hypertension, obesity, and congestive heart failure. Continued review revealed the resident did not have a diagnosis of a seizure disorder or a psychiatric disorder. Review of Resident #32's Minimum Data Set 3.0 assessment, dated 01/07/23, revealed the resident had impaired cogitation. Review of Resident #32's admission orders revealed orders for Divalproex Sodium (Depakote) tablet Delayed Release (DR) 500 milligrams (mg) by mouth at bedtime for behaviors and Divalproex Sodium DR 250 MG by mouth two times a day for behaviors. Review of the resident's most recent physician's orders, dated 01/2023, revealed current orders for Depakote Sprinkles Capsule DR Sprinkle 125 mg with instructions to give two capsules by mouth three times a day for behaviors. Interview on 01/18/23 at 1:35 P.M. the Director of Nursing (DON) confirmed Resident #32 was admitted on the medication Depakote for behaviors without a known psychiatric diagnosis or and the DON verified he was currently taking the medication for behaviors. She reported when looking back at his hospital information she found the correct rational for his Depakote use was for a history of seizures which she did not know the resident had seizures. She reported she would change the indication to a seizure disorder and add a care plan for the management of his disorder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366253 If continuation sheet Page 6 of 7 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 366253 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amberwood Manor 245 South Broadway New Philadelphia, OH 44663 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Based on medical record review and staff interview, the facility failed to ensure physician ordered laboratory testing was obtained and completed as ordered. This affected one Resident (#21) of five Residents reviewed for medication use. The facility census was 41. Findings include: Review of Resident #21's medical record revealed an admission date of 09/08/22 with admission diagnoses that included pneumonia, chronic obstructive pulmonary disease, diabetes mellitus and hypothyroidism. Further review of the medical record revealed on 09/20/22 the physician ordered the following laboratory testing including base metabolic profile (BMP), hemoglobin A1c, (HgbA1c), complete blood count (CBC) and thyroid stimulating hormone level (TSH). Review of the medical record found no evidence the laboratory testing was completed and obtained as ordered. Interview with the Director of Nursing on 01/18/23 at 9:50 A.M. verified the ordered laboratory testing was not completed and obtained for Resident #21 as ordered by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366253 If continuation sheet Page 7 of 7