Health inspection·December 6, 2023

F 0694 Level of Harm - Minimal harm or potential for actual harm 2) Review of the medical record for Resident #09 revealed the resident was admitted on [DATE]. Diagnoses included sequelae of cerebral infarction, protein calorie malnutrition, and vascular dementia. Review of the MDS assessment dated [DATE] for Resident #09, revealed the resident had moderate cognitive impairment. Residents Affected - Some Review of the care plan for Resident #09 revealed areas of focus for risk for nutrition and skin integrity. Review of the physician's orders dated 05/08/23, 06/05/23, and 07/08/23 for Resident #09, revealed the resident was ordered to receive nutrition DRIPT intravenous (IV) one-time monthly 1000 mLs of 0.9 % NS at rate of 1000 mLs an hr. with total additive volume of 27.4 mLs of the additive formula: Vitamin C (Ascorbic acid) 5 gms, Vitamin B1 complex (Thiamine) 200 mgs, Vitamin B2 (Riboflavin) 4 mgs, Vitamin B3 (Niacin) 200 mgs, Dexpanthenol 4 mgs, Vitamin B6 Pyridoxine) 4 mgs, Vitamin B5 (Pantothenic Acid) 250 mgs, Vitamin B12 (Methylcobalamin )2 mgs, Magnesium Chloride 1000 mgs, Calcium Chloride 200 mgs, Zinc 10 mgs, Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Vitamin D2 (Calcium Citrate) 250 mgs, BCAA 2 mls via Nutrition IV one time only for micronutrient hydration therapy, hydration, and nutritional wellness secondary to wounds/intake/falls/decline (infusion administration time may vary based on clinic). Review of the MARs for Resident #09 revealed the resident received the ordered infusions on 05/09/23, 06/06/23, and 07/11/23. 3) Review of medical record for Resident #11 revealed the resident was admitted on [DATE]. Diagnoses included Anemia, hypothyroidism, binge eating disorder, Crohn's disease, Vitamin-D deficiency, and Barrett's esophagus with dysplasia. Review of the MDS assessment dated [DATE] for Resident #11 revealed the resident was cognitively intact. Review of the Care Plan for Resident #11 revealed areas of focus for risk for nutrition and skin impairment. Review of the physician's ordered dated 03/07/23, 04/07/23, 05/08/23, 06/05/23, 07/08/23, 08/02/23, 08/10/23, and 08/30/23 for Resident #11 revealed the resident was ordered the Derma infusion protocol for DRIPT IV nurse - DRIPT IV therapy infusion - one time monthly - 1000 mLs of 0.9% NS at 1000 mls/hr. (total additives volume, 20 mls) additive formula: Vitamin C (Ascorbic Acid) 5 gms, Vitamin B1 (Thiamine) 100 mgs, Vitamin B2 (Riboflavin) 2 mgs, Vitamin B3 (Niacin) 100 mgs, Vitamin B5 (Pantothenic Acid) 2 mgs, Vitamin B6 (Pyridoxine) 2 mgs, Vitamin B7 (Biotin) 20 mgs, an amino acid blend (Glutamine 150 mgs, Arginine 500 mg, Ornithine 150mgs, Lysine 250 mgs, Citrulline 250 mgs, and Zinc 10 mgs) one time only for micronutrient hydration therapy for hydration and nutritional wellness secondary to wounds (infusion administration time may vary based on clinic). Review of the MARs revealed Resident #11 received the ordered infusions on 03/09/23, 04/13/23, 05/09/23, 06/06/23, 07/11/23, 08/10/23, and 09/05/23. 4) Review of medical records for Resident #12 revealed an admission date of 08/20/22 and a discharge date of 10/22/23 with diagnoses including traumatic brain injury, non-pressure chronic ulcer of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366288 If continuation sheet Page 2 of 13 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 366288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Nursing Healthcare LLC 3434 State Route 132 Amelia, OH 45102 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 0694 Level of Harm - Minimal harm or potential for actual harm left heel and midfoot, non-pressure chronic ulcer of right heel and midfoot, and pressure ulcer of sacral region stage IV. Review of the MDS assessment dated [DATE] revealed Resident #12 was cognitively intact, exhibited verbal behaviors, and refused care. Residents Affected - Some Review of physician orders revealed orders for Derma Infusion on 03/07/23, 04/10/23, 05/08/23, 06/05/23, 07/08/23, 08/02/23, 08/10/23, and 08/31/23. Review of the physician's ordered dated 03/07/23, 04/07/23, 05/08/23, 06/05/23, 07/08/23, 08/02/23, 08/10/23, and 08/30/23 for Resident #11 revealed the resident was ordered the Derma infusion protocol for DRIPT IV nurse - DRIPT IV therapy infusion - one time monthly - 1000 mLs of 0.9% NS at 1000 mls/hr. (total additive volume of 20 mls) additive formula: Vitamin C (Ascorbic Acid) 5 gms, Vitamin B1 (Thiamine) 100 mgs, Vitamin B2 (Riboflavin) 2 mgs, Vitamin B3 (Niacin) 100 mgs, Vitamin B5 (Pantothenic Acid) 2 mgs, Vitamin B6 (Pyridoxine) 2 mgs, Vitamin B7 (Biotin) 20 mgs, amino acid blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Citrulline 250 mgs, and Zinc 10 mgs) one time only for micronutrient hydration therapy for hydration and nutritional wellness secondary to wounds (infusion administration time may vary based on clinic). Review of MARs revealed Resident #12 received the ordered infusions on 03/09/23, 04/13/23, 05/09/23, 06/06/23, 07/11/23, 08/10/23, and 09/05/23. Interview with the Administrator and the Director of Nursing (DON) on 11/30/23 at 1:15 P.M. revealed they were unaware if the ancillary provider (DRIPT IV) possessed a Terminal Distributor of Dangerous Drugs (TDDD) license for the State of Ohio. The DON verified that the above listed residents received IV infusions provided by the ancillary provider. Interview with Medical Director (MD) #500 on 11/30/23 at 3:45 P.M. revealed he was told the ancillary provider was a new service vendor brought to the facility to help prevent dehydration, and rehospitalization under the supervision of a physician. MD #500 stated that he was provided information from the facility's corporate management that the outside service was operating under proper local and federal regulations. MD #500 stated no negative reactions were reported to him in connection to the IV infusions. Interview with Representative #405 for the ancillary provider stated they did not have State of Ohio TDDD licensure. He stated they were a Medical Entity, with a Medical Director licensed in the State of Ohio. Every other state in which they provided services did not require a special TDDD license and after about three months of providing services in the Ohio area, they learned Ohio was an exception. He stated they applied for the license and were told they could continue providing services, license approval would take days. He stated an audit was conducted, and the Board of Pharmacy reported them. Simultaneously, the group had decided to stop providing services in Ohio unrelated to the licensure concerns. They rescinded their application for licensure. He stated they provided five specialized infusions that could be specialized based on resident needs. The intervention was created a couple of years ago and found to be beneficial for residents with chronic urinary tract infections (UTI), residents who did not eat or drink well, and/or weight loss concerns. He stated they presented the program to facility ownership. Review of the State of Ohio Terminal Distributor Licensure of Prescriber Practices (https://www.pharmacy.ohio.gov), dated 08/24/23, revealed a TDDD license allows a business entity to purchase, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366288 If continuation sheet Page 3 of 13 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 366288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Nursing Healthcare LLC 3434 State Route 132 Amelia, OH 45102 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some possess, and/or distribute dangerous drugs at specific locations. Terminal distributors of dangerous drugs include, but are not limited to, hospitals, pharmacies, Emergency Medical Services (EMS) organizations, laboratories, nursing homes, and prescriber practices. Distribution includes the administration of drugs on-site to patients as well as providing medications to patients to take away from the facility for later use. Dangerous drugs are defined in the Ohio Revised Code as any drug that meets any of the following: 1. Requires a subscription; 2. Bears on the label a Federal Legend (Rx Only or Caution: Federal law prohibits dispensing without a prescription); 3. Is intended for injection into the human body; or 4. Any drug that is a biological product as defined in section 3715.01 of the Revised Code. Ohio Revised Code (ORC) 4729.51 states that no licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor shall sell dangerous drugs to anyone other than the following: (1) a licensed terminal distributor of dangerous drugs; (2) Any person exempt from licensure as a terminal distributor of dangerous drugs under section 4729.541 of the Revised Code (3) a licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor; or (4) A terminal distributor, manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor that is located in another state, is not engaged in the sale of dangerous drugs within this state, and is actively licensed to engage in the sale of dangerous drugs by the state in which the distributor conducts business. In general, the exemptions to Ohio's TDDD licensure requirements do not apply if the prescriber practice is engaged in drug compounding. Compounding is defined as the preparation, mixing, assembling, packaging, and labeling of one or more drugs. Compounding includes the combining, admixing, diluting, reconstituting, or otherwise altering of a drug or bulk drug substance. The deficiency was corrected on 11/21/23 after the facility implemented the following corrective actions: On 09/22/23, the contract with DRIPT IV cessation was effective. On 09/22/23, all 10 (#02, #03, #04, #08, #09, #10, #11, #12, #16, and #19) residents who remained in the facility, who received IV's from DRIPT IV, were assessed and had no signs or symptoms or adverse effects related to the IV medications. On 11/21/23, all contracts that involve providing medications to the residents were reviewed to ensure the proper TDD licensure is in place and no issues were found. On 11/21/23, education was provided to the governing body (Vice President of Operations #505, Director of Operations #510, and Director of Clinical Operations #515) to ensure TDD licensure for Ohio is effective before accepting medication into facility/administration of medication. On 11/21/23, to monitor ongoing compliance, the facility will complete audits of any company providing any pharmacy services to ensure that the appropriate TDD licensure is effective in the State of Ohio. Audits will be completed weekly for one month and then monthly for three months. The audits will be taken to the Quality Assurance Performance Improvement (QAPI) review. On 12/06/23 at 10:10 A.M., an interview with the Administrator and the DON, verified education was provided by [NAME] President of Operations (VPO) #505 and confirmed education about verifying sources of medications were compliant with Ohio regulations regarding pharmacy and medications was providing. Review of four Residents (#01, #9, #11, and #12) medical records revealed assessments were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366288 If continuation sheet Page 4 of 13 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 366288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Nursing Healthcare LLC 3434 State Route 132 Amelia, OH 45102 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 0694 completed. Level of Harm - Minimal harm or potential for actual harm This deficiency represents non-compliance investigated under Complaint Number OH00148167. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366288 If continuation sheet Page 5 of 13 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 366288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Nursing Healthcare LLC 3434 State Route 132 Amelia, OH 45102 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, staff interview and contracted entity provider representative interview, the facility failed to ensure medications were obtained from a source with a Terminal Distributor of Dangerous Drugs (TDDD) license (which allows a business entity to purchase, possess, and/or distribute dangerous drugs at a specific location) specific to the State of Ohio. This affected four (#01, #09, #11, and #12) of the four residents reviewed for medications administered by a contracted ancillary provider. This also affected two additional current Residents (#03 and #19) and 16 discharged Residents (#02, #04, #05, #06, #07, #08, #10, #13, #14, #15, #16, #17, #18, #20, #21, and #22) for total of 22 residents. The census was 46. Findings include: 1) Review of the medical record for Resident #01 revealed an admission date of 11/18/19. Diagnoses included Parkinsonism, dementia, and protein calorie malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #01, revealed the resident had moderate cognitive impairment. Review of the Care Plan for Resident #01 revealed areas of resident focus for risks related to hydration, nutrition, and skin integrity. Review of the physician's orders dated 05/08/23, 06/05/23, and 07/08/23 for Resident #01, revealed the resident was ordered to receive nutrition DRIPT (entity who provides intravenous (IV) hydration and vitamin nutrient therapy) IV one-time monthly 1000 milliliters (mLs) of 0.9 percent (%) normal saline (NS) at rate of 1000 mLs an hour (hr.) with total additive volume of 27.4 mLs of the additive formula: Vitamin C (ascorbic acid) 5 grams (gms), Vitamin B1 complex (Thiamine [Thia]) 200 milligrams (mgs), Vitamin B2 (Riboflavin [Ribo]) 4 mgs, Vitamin B3 (Niacin [Nia]) 200 mgs, Dexpanthenol (Dex) 4 mgs, Vitamin B6 (Pyridoxine [Pyr]) 4 mgs, Vitamin B5 (Pantothenic Acid) 250 mgs, Vitamin B12 (Methylcobalamin [Methyl]) 2 mgs, Magnesium Chloride (MagCl) 1000 mgs, Calcium Chloride (CaCl) 200 mgs, Zinc 10 mgs, Glutamine 150 mgs, Arginine (Arg) 500 mgs, Ornithine ([NAME])150 mgs, Lysine ([NAME]) 250 mgs, Vitamin D2 (calcium Citrate) 250 mgs, BCAA 2 mls via Nutrition IV one time only for micronutrient hydration therapy, hydration, and nutritional wellness secondary to wounds/intake/falls/decline (infusion administration time may vary based on clinic). 2) Review of the medical record for Resident #09 revealed the resident was admitted on [DATE]. Diagnoses included sequelae of cerebral infarction, protein calorie malnutrition, and vascular dementia. Review of the MDS assessment dated [DATE] for Resident #09, revealed the resident had moderate cognitive impairment. Review of the care plan for Resident #09 revealed areas of focus for risk for nutrition and skin integrity. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366288 If continuation sheet Page 6 of 13 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 366288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Nursing Healthcare LLC 3434 State Route 132 Amelia, OH 45102 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the physician's orders dated 05/08/23, 06/05/23, and 07/08/23 for Resident #09, revealed the resident was ordered to receive nutrition DRIPT intravenous (IV) one-time monthly 1000 mLs of 0.9 % NS at rate of 1000 mLs an hr. with total additive volume of 27.4 mLs of the additive formula: Vitamin C (Ascorbic acid) 5 gms, Vitamin B1 complex (Thiamine) 200 mgs, Vitamin B2 (Riboflavin) 4 mgs, Vitamin B3 (Niacin) 200 mgs, Dexpanthenol 4 mgs, Vitamin B6 Pyridoxine) 4 mgs, Vitamin B5 (Pantothenic Acid) 250 mgs, Vitamin B12 (Methylcobalamin )2 mgs, Magnesium Chloride 1000 mgs, Calcium Chloride 200 mgs, Zinc 10 mgs, Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Vitamin D2 (Calcium Citrate) 250 mgs, BCAA 2 mls via Nutrition IV one time only for micronutrient hydration therapy, hydration, and nutritional wellness secondary to wounds/intake/falls/decline (infusion administration time may vary based on clinic). Review of the MARs for Resident #09 revealed the resident received the ordered infusions on 05/09/23, 06/06/23, and 07/11/23. 3) Review of medical record for Resident #11 revealed the resident was admitted on [DATE]. Diagnoses included Anemia, hypothyroidism, binge eating disorder, Crohn's disease, Vitamin-D deficiency, and Barrett's esophagus with dysplasia. Review of the MDS assessment dated [DATE] for Resident #11 revealed the resident was cognitively intact. Review of the Care Plan for Resident #11 revealed areas of focus for risk for nutrition and skin impairment. Review of the physician's ordered dated 03/07/23, 04/07/23, 05/08/23, 06/05/23, 07/08/23, 08/02/23, 08/10/23, and 08/30/23 for Resident #11 revealed the resident was ordered the Derma infusion protocol for DRIPT IV nurse - DRIPT IV therapy infusion - one time monthly - 1000 mLs of 0.9% NS at 1000 mls/hr. (total additives volume, 20 mls) additive formula: Vitamin C (Ascorbic Acid) 5 gms, Vitamin B1 (Thiamine) 100 mgs, Vitamin B2 (Riboflavin) 2 mgs, Vitamin B3 (Niacin) 100 mgs, Vitamin B5 (Pantothenic Acid) 2 mgs, Vitamin B6 (Pyridoxine) 2 mgs, Vitamin B7 (Biotin) 20 mgs, an amino acid blend (Glutamine 150 mgs, Arginine 500 mg, Ornithine 150mgs, Lysine 250 mgs, Citrulline 250 mgs, and Zinc 10 mgs) one time only for micronutrient hydration therapy for hydration and nutritional wellness secondary to wounds (infusion administration time may vary based on clinic). Review of the MARs revealed Resident #11 received the ordered infusions on 03/09/23, 04/13/23, 05/09/23, 06/06/23, 07/11/23, 08/10/23, and 09/05/23. 4) Review of medical records for Resident #12 revealed an admission date of 08/20/22 and a discharge date of 10/22/23 with diagnoses including traumatic brain injury, non-pressure chronic ulcer of left heel and midfoot, non-pressure chronic ulcer of right heel and midfoot, and pressure ulcer of sacral region stage IV. Review of the MDS assessment dated [DATE] revealed Resident #12 was cognitively intact, exhibited verbal behaviors, and refused care. Review of physician orders revealed orders for Derma Infusion on 03/07/23, 04/10/23, 05/08/23, 06/05/23, 07/08/23, 08/02/23, 08/10/23, and 08/31/23. Review of the physician's ordered dated 03/07/23, 04/07/23, 05/08/23, 06/05/23, 07/08/23, 08/02/23, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366288 If continuation sheet Page 7 of 13 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 366288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Nursing Healthcare LLC 3434 State Route 132 Amelia, OH 45102 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 08/10/23, and 08/30/23 for Resident #11 revealed the resident was ordered the Derma infusion protocol for DRIPT IV nurse - DRIPT IV therapy infusion - one time monthly - 1000 mLs of 0.9% NS at 1000 mls/hr. (total additive volume of 20 mls) additive formula: Vitamin C (Ascorbic Acid) 5 gms, Vitamin B1 (Thiamine) 100 mgs, Vitamin B2 (Riboflavin) 2 mgs, Vitamin B3 (Niacin) 100 mgs, Vitamin B5 (Pantothenic Acid) 2 mgs, Vitamin B6 (Pyridoxine) 2 mgs, Vitamin B7 (Biotin) 20 mgs, amino acid blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150mgs, Lysine 250 mgs, Citrulline 250 mgs, and Zinc 10 mgs) one time only for micronutrient hydration therapy for hydration and nutritional wellness secondary to wounds (infusion administration time may vary based on clinic). Review of MARs revealed Resident #12 received the ordered infusions on 03/09/23, 04/13/23, 05/09/23, 06/06/23, 07/11/23, 08/10/23, and 09/05/23. Interview with the Administrator and the Director of Nursing (DON) on 11/30/23 at 1:15 P.M. revealed they were unaware if the ancillary provider (DRIPT IV) possessed a Terminal Distributor of Dangerous Drugs (TDDD) license for the State of Ohio. The DON verified that the above listed residents received IV infusions provided by the ancillary provider. Interview with Medical Director (MD) #500 on 11/30/23 at 3:45 P.M. revealed he was told the ancillary provider was a new service vendor brought to the facility to help prevent dehydration, and rehospitalization under the supervision of a physician. MD #500 stated that he was provided information from the facility's corporate management that the outside service was operating under proper local and federal regulations. MD #500 stated no negative reactions were reported to him in connection to the IV infusions. Interview with the Administrator on 12/06/23 at 10:20 A.M. revealed [NAME] President of Operations (VPO) #505 from the facility's corporate office notified them to stop administration of IV infusions from the ancillary provider (DRIPT IV) on 09/22/23. They were not made aware of any concerns related to the TDDD Ohio licensure for the ancillary provider. Interview with Representative #405 for the ancillary provider stated they did not have State of Ohio TDDD licensure. He stated they were a Medical Entity, with a Medical Director licensed in the State of Ohio. Every other state in which they provided services did not require a special TDDD license and after about three months of providing services in the Ohio area, they learned Ohio was an exception. He stated they applied for the license and were told they could continue providing services, license approval would take days. He stated an audit was conducted, and the Board of Pharmacy reported them. Simultaneously, the group had decided to stop providing services in Ohio unrelated to the licensure concerns. They rescinded their application for licensure. He stated they provided five specialized infusions that could be specialized based on resident needs. The intervention was created a couple of years ago and found to be beneficial for residents with chronic urinary tract infections (UTI), residents who did not eat or drink well, and/or weight loss concerns. He stated they presented the program to facility ownership. Review of the State of Ohio Terminal Distributor Licensure of Prescriber Practices (https://www.pharmacy.ohio.gov), dated 08/24/23, revealed a TDDD license allows a business entity to purchase, possess, and/or distribute dangerous drugs at specific locations. Terminal distributors of dangerous drugs include, but are not limited to, hospitals, pharmacies, Emergency Medical Services (EMS) organizations, laboratories, nursing homes, and prescriber practices. Distribution includes the administration of drugs on-site to patients as well as providing medications to patients to take away from the facility for later use. Dangerous drugs are defined in the Ohio Revised Code as any drug that meets (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366288 If continuation sheet Page 8 of 13 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 366288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Nursing Healthcare LLC 3434 State Route 132 Amelia, OH 45102 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some any of the following: 1. Requires a subscription; 2. Bears on the label a Federal Legend (Rx Only or Caution: Federal law prohibits dispensing without a prescription); 3. Is intended for injection into the human body; or 4. Any drug that is a biological product as defined in section 3715.01 of the Revised Code. Ohio Revised Code (ORC) 4729.51 states that no licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor shall sell dangerous drugs to anyone other than the following: (1) a licensed terminal distributor of dangerous drugs; (2) Any person exempt from licensure as a terminal distributor of dangerous drugs under section 4729.541 of the Revised Code (3) a licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor; or (4) A terminal distributor, manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor that is located in another state, is not engaged in the sale of dangerous drugs within this state, and is actively licensed to engage in the sale of dangerous drugs by the state in which the distributor conducts business. In general, the exemptions to Ohio's TDDD licensure requirements do not apply if the prescriber practice is engaged in drug compounding. Compounding is defined as the preparation, mixing, assembling, packaging, and labeling of one or more drugs. Compounding includes the combining, admixing, diluting, reconstituting, or otherwise altering of a drug or bulk drug substance. The deficiency was corrected on 11/21/23 after the facility implemented the following corrective actions. On 09/22/23, the contract with DRIPT IV cessation was effective. On 09/22/23, all 10 (#02, #03, #04, #08, #09, #10, #11, #12, #16, and #19) residents who remained in the facility, who received IV's from DRIPT IV, were assessed and had no signs or symptoms or adverse effects related to the IV medications. On 11/21/23, all contracts that involve providing medications to the residents were reviewed to ensure the proper TDD licensure is in place and no issues were found. On 11/21/23, education was provided to the governing body (Vice President of Operations #505, Director of Operations #510, and Director of Clinical Operations #515) to ensure TDD licensure for Ohio is effective before accepting medication into facility/administration of medication. On 11/21/23, to monitor ongoing compliance, the facility will complete audits of any company providing any pharmacy services to ensure that the appropriate TDD licensure is effective in the State of Ohio. Audits will be completed weekly for one month and then monthly for three months. The audits will be taken to the Quality Assurance Performance Improvement (QAPI) review. On 12/06/23 at 10:10 A.M., an interview with the Administrator and the DON, verified education was provided by [NAME] President of Operations (VPO) #505 and confirmed education about verifying sources of medications were compliant with Ohio regulations regarding pharmacy and medications was providing. Review of four Residents (#01, #9, #11, and #12) medical records revealed assessments were completed. This deficiency represents non-compliance investigated under Complaint Number OH00148167. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366288 If continuation sheet Page 9 of 13 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 366288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Nursing Healthcare LLC 3434 State Route 132 Amelia, OH 45102 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 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, review of facility policy, and interview the facility failed to ensure a contracted entity had appropriate State of Ohio required credentials for provision of services for residents. This affected four (#01, #09, #11, and #12) of the four residents reviewed for medications administered by a contracted ancillary provider. This also affected two additional current Residents (#03 and #19) and 16 discharged Residents (#02, #04, #05, #06, #07, #08, #10, #13, #14, #15, #16, #17, #18, #20, #21, and #22) for total of 22 residents. The facility census was 46. Findings include: 1) Review of the medical record for Resident #01 revealed an admission date of 11/18/19. Diagnoses included Parkinsonism, dementia, and protein calorie malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #01, revealed the resident had moderate cognitive impairment. Review of the Care Plan for Resident #01 revealed areas of resident focus for risks related to hydration, nutrition, and skin integrity. Review of the physician's orders dated 05/08/23, 06/05/23, and 07/08/23 for Resident #01, revealed the resident was ordered to receive nutrition DRIPT IV (entity who provides intravenous [IV] hydration and vitamin nutrient therapy) via IV one-time monthly 1000 milliliters (mLs) of 0.9 percent (%) normal saline (NS) at rate of 1000 mLs an hour (hr.) with total additive volume of 27.4 mLs of the additive formula: Vitamin C (ascorbic acid) 5 grams (gms), Vitamin B1 complex (Thiamine [Thia]) 200 milligrams (mgs), Vitamin B2 (Riboflavin [Ribo]) 4 mgs, Vitamin B3 (Niacin [Nia]) 200 mgs, Dexpanthenol (Dex) 4 mgs, Vitamin B6 (Pyridoxine [Pyr]) 4 mgs, Vitamin B5 (Pantothenic Acid) 250 mgs, Vitamin B12 (Methylcobalamin [Methyl]) 2 mgs, Magnesium Chloride (MagCl) 1000 mgs, Calcium Chloride (CaCl) 200 mgs, Zinc 10 mgs, Glutamine 150 mgs, Arginine (Arg) 500 mgs, Ornithine ([NAME])150 mgs, Lysine ([NAME]) 250 mgs, Vitamin D2 (calcium Citrate) 250 mgs, BCAA 2 mls via Nutrition IV one time only for micronutrient hydration therapy, hydration, and nutritional wellness secondary to wounds/intake/falls/decline (infusion administration time may vary based on clinic). Review of Medication Administration Records (MARs) revealed Resident #01 received ordered Nutrition IV infusions on 05/09/23, 06/06/23, and 07/11/23. 2) Review of the medical record for Resident #09 revealed the resident was admitted on [DATE]. Diagnoses included sequelae of cerebral infarction, protein calorie malnutrition, and vascular dementia. Review of the MDS assessment dated [DATE] for Resident #09, revealed the resident had moderate cognitive impairment. Review of the care plan for Resident #09 revealed areas of focus for risk for nutrition and skin integrity. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366288 If continuation sheet Page 10 of 13 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 366288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Nursing Healthcare LLC 3434 State Route 132 Amelia, OH 45102 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 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the physician's orders dated 05/08/23, 06/05/23, and 07/08/23 for Resident #09, revealed the resident was ordered to receive nutrition DRIPT intravenous (IV) one-time monthly 1000 mLs of 0.9 % NS at rate of 1000 mLs an hr. with total additive volume of 27.4 mLs of the additive formula: Vitamin C (Ascorbic acid) 5 gms, Vitamin B1 complex (Thiamine) 200 mgs, Vitamin B2 (Riboflavin) 4 mgs, Vitamin B3 (Niacin) 200 mgs, Dexpanthenol 4 mgs, Vitamin B6 Pyridoxine) 4 mgs, Vitamin B5 (Pantothenic Acid) 250 mgs, Vitamin B12 (Methylcobalamin )2 mgs, Magnesium Chloride 1000 mgs, Calcium Chloride 200 mgs, Zinc 10 mgs, Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150 mgs, Lysine 250 mgs, Vitamin D2 (Calcium Citrate) 250 mgs, BCAA 2 mls via Nutrition IV one time only for micronutrient hydration therapy, hydration, and nutritional wellness secondary to wounds/intake/falls/decline (infusion administration time may vary based on clinic). Review of the MARs for Resident #09 revealed the resident received the ordered infusions on 05/09/23, 06/06/23, and 07/11/23. 3) Review of medical record for Resident #11 revealed the resident was admitted on [DATE]. Diagnoses included Anemia, hypothyroidism, binge eating disorder, Crohn's disease, Vitamin-D deficiency, and Barrett's esophagus with dysplasia. Review of the MDS assessment dated [DATE] for Resident #11 revealed the resident was cognitively intact. Review of the Care Plan for Resident #11 revealed areas of focus for risk for nutrition and skin impairment. Review of the physician's ordered dated 03/07/23, 04/07/23, 05/08/23, 06/05/23, 07/08/23, 08/02/23, 08/10/23, and 08/30/23 for Resident #11 revealed the resident was ordered the Derma infusion protocol for DRIPT IV nurse - DRIPT IV therapy infusion - one time monthly - 1000 mLs of 0.9% NS at 1000 mls/hr. (total additives volume, 20 mls) additive formula: Vitamin C (Ascorbic Acid) 5 gms, Vitamin B1 (Thiamine) 100 mgs, Vitamin B2 (Riboflavin) 2 mgs, Vitamin B3 (Niacin) 100 mgs, Vitamin B5 (Pantothenic Acid) 2 mgs, Vitamin B6 (Pyridoxine) 2 mgs, Vitamin B7 (Biotin) 20 mgs, an amino acid blend (Glutamine 150 mgs, Arginine 500 mg, Ornithine 150mgs, Lysine 250 mgs, Citrulline 250 mgs, and Zinc 10 mgs) one time only for micronutrient hydration therapy for hydration and nutritional wellness secondary to wounds (infusion administration time may vary based on clinic). Review of the MARs revealed Resident #11 received the ordered infusions on 03/09/23, 04/13/23, 05/09/23, 06/06/23, 07/11/23, 08/10/23, and 09/05/23. 4) Review of medical records for Resident #12 revealed an admission date of 08/20/22 and a discharge date of 10/22/23 with diagnoses including traumatic brain injury, non-pressure chronic ulcer of left heel and midfoot, non-pressure chronic ulcer of right heel and midfoot, and pressure ulcer of sacral region stage IV. Review of the MDS assessment dated [DATE] revealed Resident #12 was cognitively intact, exhibited verbal behaviors, and refused care. Review of physician orders revealed orders for Derma Infusion on 03/07/23, 04/10/23, 05/08/23, 06/05/23, 07/08/23, 08/02/23, 08/10/23, and 08/31/23. Review of the physician's ordered dated 03/07/23, 04/07/23, 05/08/23, 06/05/23, 07/08/23, 08/02/23, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366288 If continuation sheet Page 11 of 13 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 366288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Nursing Healthcare LLC 3434 State Route 132 Amelia, OH 45102 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 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 08/10/23, and 08/30/23 for Resident #11 revealed the resident was ordered the Derma infusion protocol for DRIPT IV nurse - DRIPT IV therapy infusion - one time monthly - 1000 mLs of 0.9% NS at 1000 mls/hr. (total additive volume of 20 mls) additive formula: Vitamin C (Ascorbic Acid) 5 gms, Vitamin B1 (Thiamine) 100 mgs, Vitamin B2 (Riboflavin) 2 mgs, Vitamin B3 (Niacin) 100 mgs, Vitamin B5 (Pantothenic Acid) 2 mgs, Vitamin B6 (Pyridoxine) 2 mgs, Vitamin B7 (Biotin) 20 mgs, amino acid blend (Glutamine 150 mgs, Arginine 500 mgs, Ornithine 150mgs, Lysine 250 mgs, Citrulline 250 mgs, and Zinc 10 mgs) one time only for micronutrient hydration therapy for hydration and nutritional wellness secondary to wounds (infusion administration time may vary based on clinic). Review of MARs revealed Resident #12 received the ordered infusions on 03/09/23, 04/13/23, 05/09/23, 06/06/23, 07/11/23, 08/10/23, and 09/05/23. Interview with the Administrator and the Director of Nursing (DON) on 11/30/23 at 1:15 P.M. revealed they were unaware if the ancillary provider (DRIPT IV) possessed a Terminal Distributor of Dangerous Drugs (TDDD) license for the State of Ohio. The DON verified that the above listed residents received IV infusions provided by the ancillary provider. Interview with Medical Director (MD) #500 on 11/30/23 at 3:45 P.M. revealed he was told the ancillary provider was a new service vendor brought to the facility to help prevent dehydration, and rehospitalization under the supervision of a physician. MD #500 stated that he was provided information from the facility's corporate management that the outside service was operating under proper local and federal regulations. MD #500 stated no negative reactions were reported to him in connection to the IV infusions. Interview with the Administrator on 12/06/23 at 10:20 A.M. revealed [NAME] President of Operations (VPO) #505 from the facility's corporate office notified them to stop administration of IV infusions from the ancillary provider (DRIPT IV) on 09/22/23. They were not made aware of any concerns related to the TDDD Ohio licensure for the ancillary provider. Interview with Representative #405 for the ancillary provider stated they did not have State of Ohio TDDD licensure. He stated they were a Medical Entity, with a Medical Director licensed in the State of Ohio. Every other state in which they provided services did not require a special TDDD license and after about three months of providing services in the Ohio area, they learned Ohio was an exception. He stated they applied for the license and were told they could continue providing services, license approval would take days. He stated an audit was conducted, and the Board of Pharmacy reported them. Simultaneously, the group had decided to stop providing services in Ohio unrelated to the licensure concerns. They rescinded their application for licensure. He stated they provided five specialized infusions that could be specialized based on resident needs. The intervention was created a couple of years ago and found to be beneficial for residents with chronic urinary tract infections (UTI), residents who did not eat or drink well, and/or weight loss concerns. He stated they presented the program to facility ownership. Review of the State of Ohio Terminal Distributor Licensure of Prescriber Practices (https://www.pharmacy.ohio.gov), dated 08/24/23, revealed a TDDD license allows a business entity to purchase, possess, and/or distribute dangerous drugs at specific locations. Terminal distributors of dangerous drugs include, but are not limited to, hospitals, pharmacies, Emergency Medical Services (EMS) organizations, laboratories, nursing homes, and prescriber practices. Distribution includes the administration of drugs on-site to patients as well as providing medications to patients to take away from the facility for later use. Dangerous drugs are defined in the Ohio Revised Code as any drug that meets (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366288 If continuation sheet Page 12 of 13 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 366288 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Nursing Healthcare LLC 3434 State Route 132 Amelia, OH 45102 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 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some any of the following: 1. Requires a subscription; 2. Bears on the label a Federal Legend (Rx Only or Caution: Federal law prohibits dispensing without a prescription); 3. Is intended for injection into the human body; or 4. Any drug that is a biological product as defined in section 3715.01 of the Revised Code. Ohio Revised Code (ORC) 4729.51 states that no licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor shall sell dangerous drugs to anyone other than the following: (1) a licensed terminal distributor of dangerous drugs; (2) Any person exempt from licensure as a terminal distributor of dangerous drugs under section 4729.541 of the Revised Code (3) a licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor; or (4) A terminal distributor, manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor that is located in another state, is not engaged in the sale of dangerous drugs within this state, and is actively licensed to engage in the sale of dangerous drugs by the state in which the distributor conducts business. In general, the exemptions to Ohio's TDDD licensure requirements do not apply if the prescriber practice is engaged in drug compounding. Compounding is defined as the preparation, mixing, assembling, packaging, and labeling of one or more drugs. Compounding includes the combining, admixing, diluting, reconstituting, or otherwise altering of a drug or bulk drug substance. The deficiency was corrected on 11/21/23 after the facility implemented the following corrective actions. On 09/22/23, the contract with DRIPT IV cessation was effective. On 09/22/23, all 10 (#02, #03, #04, #08, #09, #10, #11, #12, #16, and #19) residents who remained in the facility, who received IV's from DRIPT IV, were assessed and had no signs or symptoms or adverse effects related to the IV medications. On 11/21/23, all contracts that involve providing medications to the residents were reviewed to ensure the proper TDD licensure is in place and no issues were found. On 11/21/23, education was provided to the governing body (Vice President of Operations #505, Director of Operations #510, and Director of Clinical Operations #515) to ensure TDD licensure for Ohio is effective before accepting medication into facility/administration of medication. On 11/21/23, to monitor ongoing compliance, the facility will complete audits of any company providing any pharmacy services to ensure that the appropriate TDD licensure is effective in the State of Ohio. Audits will be completed weekly for one month and then monthly for three months. The audits will be taken to the Quality Assurance Performance Improvement (QAPI) review. On 12/06/23 at 10:10 A.M., an interview with the Administrator and the DON, verified education was provided by [NAME] President of Operations (VPO) #505 and confirmed education about verifying sources of medications were compliant with Ohio regulations regarding pharmacy and medications was providing. Review of four Residents (#01, #9, #11, and #12) medical records revealed assessments were completed. This deficiency represents non-compliance investigated under Complaint Number OH00148167. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366288 If continuation sheet Page 13 of 13