Inspection·July 24, 2024

F 0569 • Level of Harm - Minimal harm or potential for actual harm August 2023: $340.00 per day from 08/01/23 to 08/31/23, hair set, tip and shampoo totaling $10579.60 • Residents Affected - Few September 2023: $340.00 per day from 09/01/23 to 09/04/23 totaling $1360.00 The bottom of the ledger indicated there was a credit of $25,514.10. Interview on 07/23/24 at 8:50 A.M. with Executor of Estate (EE) #299 revealed back in 2023, the facility had overcharged Resident #45 while she was a resident in the skilled nursing facility. In January 2024, he identified there was a mistake with Resident #45's accounting due to this overcharging, the facility's corporation had been contacted and a credit was due to Resident #45's estate but the credit had not been received as of the time of the interview. Interview on 07/23/24 starting at 2:20 P.M. with Accounting Manager (AM) #310 and [NAME] Specialist (BS) #309 revealed Resident #45 was a resident here before the facility's corporation came along. Resident #45 had a special life care contract in place which indicated she would be charged $800.00 per month regardless of her level of care. Over Resident #45's time on the facility's campus, she lived in a villa but was admitted to this skilled nursing facility on 05/20/23 where she resided until 09/05/23. At some point (date not known) the facility's corporate billing personnel determined Resident #45 was overcharged while she was in the facility for six months and the money was going to be returned to Resident #45 but neither AM #310 or BS #309 could state if this had actually been done. Phone interview on 07/23/24 at 2:22 P.M. with Corporate Accounts Receivable Director (CARD) #311 with AM #310 and BS #309 present revealed Resident #45 had a specialized contract that dictated she would be charged a set amount per month for care needs. CARD #311 stated around February 2024 there was discussion about a discrepancy between Resident #45's contract and her charges while she had been a resident of the skilled nursing facility. CARD #311 indicated the last correspondence with EE #299 regarding the overpayment had been on 06/28/24 and she was unaware of any further movement with the credit since this date. CARD #311 also shared refunds of resident accounts did not take this long and were usually resolved under 90 days. Review of a financial statement dated 03/31/24 revealed Resident #45's account had a credit of $25,514.10. Review of e-mails between the facility and EE #299 revealed he provided the facility with needed wire transfer information on 06/27/24 at 8:39 P.M. to obtain the overpayment. There were no e-mails after 06/28/24. Follow-up phone interview on 07/24/24 at 10:28 A.M. with CARD #311 confirmed she learned of Resident #45's life care contract in February 2024 and that is when the adjustments to her account were made leading to a credit of $25,514.10. CARD #311 verified there was no evidence the facility's corporation had disbursed the overpayment to Resident #45's estate as of the time of the interview. Review of the facility policy, Resident Personal Funds, revised 04/01/24 revealed upon the discharge, eviction or death of a resident the facility will convey within 30 days the residents' funds and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366289 If continuation sheet Page 2 of 3 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 366289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia at Sumner 970 Sumner Parkway Copley, OH 44321 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 0569 Level of Harm - Minimal harm or potential for actual harm a final account of those funds to the resident or in the case of death, the individual or probate jurisdiction administering the resident's estate in accordance with state law. This deficiency represents noncompliance investigated under Complaint Number OH00154864. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366289 If continuation sheet Page 3 of 3