Inspection·December 20, 2024

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some P.M. and 9:00 P.M. The narcotic accountability record revealed clonazepam was signed out on 11/20/24 at 8:00 A.M. with an unrecognizable signature. The MAR did not reveal documentation of clonazepam being administered to Resident #2 on 11/20/24 at 8:00 A.M. 3. Review of the medical record revealed Resident #3 was admitted on [DATE] with diagnoses that included vesicointestinal fistula, chronic kidney disease, pelvic and perineal pain, and acute ischemia of large intestine. The quarterly MDS assessment dated [DATE] revealed Resident #3 was cognitively intact and received opioid medication. Resident #3 was ordered Norco (opioid to treat moderate pain) 10-325 mg three times a day as needed. The narcotic accountability record revealed Norco on 11/26/24 at 6:10 A.M. and 2:00 P.M. were signed out and administered by facility nurses. Further review of the narcotic accountability record revealed after the 2:00 P.M. signature on 11/26/24, unrecognizable signatures signed out Norco on 11/25/24 at 8:00 A.M. and 11/26/24 at 1:00 P.M. The MAR did not reveal documentation of Norco being administered on 11/25/24 at 8:00 A.M. and 11/26/24 at 1:00 P.M. 4. Review of the medical record revealed Resident #4 was admitted [DATE] and discharged [DATE] with diagnoses of abscess of right lower limb, Stage II (partial-thickness skin loss involving the epidermis and dermis) pressure ulcer, lymphedema, and cellulitis. The MDS assessment dated [DATE] revealed Resident #4 had cognitive impairment and received antianxiety and opioid medication. Resident #4 was ordered Percocet (opioid for moderate to severe pain) 5-325 mg every eight hours as needed. A medication card with seven Percocet 5-325 mg arrived at the facility on 11/20/24. Facility nurses administered Percocet on 11/21/24 at 7:33 A.M. and 11/22/24 at 3:25 A.M. The card with the remaining five Percocet and the shift change control count sheet were discovered missing during the investigation. A second medication card of Percocet arrived at the facility on 11/22/24. The narcotic accountability record revealed unrecognizable signatures signed out Percocet on 11/17/24 at 7:15 A.M., 11/18/24 at 10:10 A.M., 11/19/24 at 7:43 P.M., 11/21/24 at 8:35 A.M., 11/21/24 at 8:30 P.M., and 11/22/24 at 8:30 P.M. The MAR did not reveal documentation of Percocet being administered. Resident #4 was not admitted until 11/19/24 and the medication card was not delivered until 11/22/24. 5. Review of the medical record revealed Resident #5 was admitted on [DATE] and readmitted on [DATE] with diagnoses of multiple rib fractures, chronic respiratory failure, anxiety disorder, dementia, sacroiliitis, and spinal stenosis. The MDS assessment dated [DATE] revealed Resident #5 had cognitive impairment and received opioid, antipsychotic, and antianxiety medications. Resident #5 was ordered tramadol (controlled medication for moderate to moderately severe pain) 50 mg three times a day as needed. The narcotic accountability record revealed an unrecognizable signature signed out tramadol on 11/26/24 at 1:00 P.M. The MAR did not reveal tramadol was administered. 6. Review of the medical record revealed Resident #6 was admitted on [DATE] and discharged [DATE] with diagnoses that included fracture of right femur, type two diabetes, and acute pain due to trauma. The MDS assessment dated [DATE] revealed Resident #6 was cognitively intact and received antianxiety, hypnotic, and opioid medication. Resident #6 was ordered tramadol 50 mg every six hours as needed. RN #103 signed the narcotic accountability record on 11/27/24 at 5:00 A.M. The MAR did not reveal tramadol was administered. Interview on 12/20/24 at 10:06 A.M. LPN #101 revealed they discovered the possible drug diversion (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366253 If continuation sheet Page 2 of 5 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 12/20/2024 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 0602 Level of Harm - Minimal harm or potential for actual harm and immediately notified the DON. LPN #101 stated they looked at the cards of medication while RN #103 looked at the narcotic accountability record. LPN #101 stated the drug count was correct. LPN #101 noticed unknown signatures on controlled medications and medications being administered at unusual times. LPN #101 stated she now looked at the book and the cards of medication prior to her shift for any unusual activity and to make sure the count was correct. Residents Affected - Some Interview on 12/20/24 at 1:45 P.M. the DON verified the attending physicians, medical director, board of nursing, pharmacy board, drug enforcement agency, local police, and agency company were notified of the potential drug diversion. RN #103 did not respond to phone calls or text messages. The agency reported RN #103 did not respond to any of their calls. RN #103's demographic information was requested from the agency company. The facility discovered RN #103 had previous nursing board probationary actions against his nursing license that were lifted in 2021 due to theft charges and possession of marijuana charges from 2007 and 2009. The DON also verified Resident #1 had two Oxycodone that were unaccounted for. Resident #2 had one clonazepam unaccounted for. Resident #3 had two Norco unaccounted for. Resident #4 had 11 Percocet unaccounted for. Resident #5 had one dose tramadol 50 mg unaccounted for. Resident #6 had one dose of tramadol unaccounted for. The DON also stated agency staff were not being used at this time. If the facility needed to use agency staff in the future, the nurse's licenses would be checked by the facility before the nurse could cover a shift. The Inventory Control of Controlled Substances policy and procedure revised on 08/01/24 revealed the facility should ensure incoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk of abuse of diversion at the change of each shift and document the results on a Controlled Substance Count Verification/Shift Count Sheet. The total number of controlled medications on hand and number of doses remaining in the packages should be reconciled. The facility should ensure its staff immediately report suspected theft or loss of controlled substances to their supervisor/manager. The facility should ensure the appropriate facility personnel confirm the discrepancy and follow facility policy and applicable law regarding documentation of the incident. The Abuse, Neglect and Exploitation policy revised 07/11/24 revealed misappropriation is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of resident's belongings or money without the resident's consent. If the facility enters into a contract for the use of temporary (agency) employees, then it will generally require the organization providing such employees to conduct the background checks and to certify that it will not provide any temporary employees that do not have the requisite licensure or certification. The deficiency was corrected on 11/28/24 when the facility implemented the following corrective actions: • On 11/27/24 the DON completed narcotic accountability records and narcotic counts on all medication carts. • On 11/27/24 Residents #1, #2, #3, #4, and #6 were interviewed about pain management and updated pain observations were completed by DON/Licensed Nurse. Resident #5 was at the hospital on [DATE]. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366253 If continuation sheet Page 3 of 5 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 12/20/2024 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 0602 On 11/27/24 head-to-toe observations were completed by DON/Licensed Nurse for Residents #1, #2, #3, #4, and #6 to ensure there was no physical abuse. Level of Harm - Minimal harm or potential for actual harm • Residents Affected - Some On 11/27/24 the attending physician/medical director were notified by the DON of potential drug diversion. • On 11/27/24 the Licensed Nursing Home Administrator (LNHA) initiated a SRI to the Ohio Department of Health. • On 11/27/24 the LNHA made phone calls to RN #103 and the agency company. • On 11/27/24 the DON spoke with the agency company and requested RN #103 have a drug screen completed. • On 11/27/24 the LNHA reviewed random employee files for two LPN's and three RNs, and no negative findings were discovered. • On 11/27/24 the DON contacted the local police department. • On 11/27/24 the DON sent an email to Consultant Pharmacist about the allegation of misappropriation of narcotic mediation. • On 11/27/24 the 27 residents that were able to be interviewed were interviewed about pain management and medication being administered. No negative findings were discovered. • On 11/27/24 the 14 residents that were not able to be interviewed had head-to-toe skin observations completed. No negative findings were discovered. • On 11/27/24 all 41 residents had pain assessments completed by a licensed nurse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366253 If continuation sheet Page 4 of 5 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 12/20/2024 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 0602 • Level of Harm - Minimal harm or potential for actual harm On 11/27/24 the LNHA and DON educated all 54 staff on Abuse, Neglect, and Misappropriation. • Residents Affected - Some On 11/27/24 the DON/designee educated all 12 licensed nurses (five LPN's and seven RN's) on Drug Diversion and narcotic accountability. • On 11/27/24 an in-service for nurses revealed the nurse was to look at the card of controlled medication and the narcotic accountability sheet when narcotics were being counted at shift change. • On 11/27/24 an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with the medical director in attendance. • The DON/designee will complete a narcotic count on each medication cart three times a week for four weeks and then monthly for two months. • The DON/designee will audit completed narcotic accountability records three times a week for four weeks and then monthly for two months to ensure any as needed controlled medications administered are documented properly on the MAR and the resident validates (if able) the receipt of the medication. This deficiency represents non-compliance investigated under Self-Reported Incident, Control Number OH00160410. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366253 If continuation sheet Page 5 of 5