Inspection·November 21, 2023

F 0600 Level of Harm - Actual harm Residents Affected - Few that transfers a resident from surface such as wheelchair to bed) with two-staff assistance for transfers, and two-staff assistance with toileting. She was unable to ambulate. She was incontinent of bowel and bladder and was to be checked and changed every two hours. Review of the nursing note dated 10/28/23 at 10:08 A.M. and completed by Registered Nurse (RN) #607 revealed he was notified by staff that Resident #42 had bruising to her facial area. She was assessed and had deep purple bruises on her forehead, under her left and right eyes, and on the outside of her left eye. She was confused when asked how it happened and stated, it happened outside the school. Nurse Practitioner (NP) #902 was notified and ordered the resident to be sent to the emergency room (ER) for an evaluation. The Administrator and Resident #42's Power of Attorney (POA) were notified. Review of the After Visit Summary dated 10/28/23 revealed Resident #42 was seen by ER Physician #701 due to fall and closed head injury. The summary report revealed a computed tomography (CT) scan was completed of her cervical spine, facial bones, head, and left hip. She also had a chest and pelvis x-ray. All testing was essentially negative, and he recommended no new orders. Review of the nursing note dated 10/28/23 at 11:08 A.M. and completed by RN #607 revealed he received a call from the hospital, and Resident #42 would be returning to the facility as all x-rays and CT scans were negative. Review of the facility SRI tracking number 240643, dated 10/29/23 revealed the Administrator reported (to the State agency) an injury of unknown source for Resident #42. The report indicated on 10/28/23 at 8:40 A.M. STNA #608 and Agency STNA #609 notified RN #607 that Resident #42 had bruising to her face. RN #607 assessed and noted purple/red bruising to her forehead, under both eyes, and surrounding tissue of her left eye. When interviewed, Resident #42 stated, it happened outside of the school. NP #902 was notified and ordered her to be sent to the hospital for evaluation. The SRI revealed all staff were interviewed that worked from 10/27/23 7:00 A.M. to 10/28/23 at 8:40 A.M. The investigation revealed STNA #700 was assigned to Resident #42 on 10/27/23 from 7:00 A.M. to 7:00 P.M. and had not noticed any bruising. The investigation revealed the Administrator interviewed Agency STNA #611, and she had stated she noticed a bump on Resident #42's forehead and her right eye was purple when she provided her with a bed bath on 10/27/23 at 8:20 P.M. without any other staff assistance. Agency STNA #611 revealed STNA #613 was providing Resident #11 (Resident #42's roommate) a bed bath at the same time, but she had not reported the bruising to STNA #613 or RN #612 (nurse on duty) as she stated, I assumed everyone knew. Agency STNA #611 revealed she checked and changed Resident #42 throughout the rest of the night providing her care without any other staff assistance. The facility investigation concluded that it appeared the resident was turned and repositioned by Agency STNA #611 and hit her face on the half upper side rail. The SRI was substantiated, and Agency STNA #611 was not to return to the facility. As an intervention, the facility padded the residents side rails. Observation on 11/16/23 at 8:57 A.M. revealed Resident #42 had bruising of all different colors (yellow, green, blue, light purple, and dark purple) in the middle of her forehead, under and above her bilateral eyes, and on the outside (temple region) of her left eye. Attempts to interview Resident #42 were unsuccessful due to cognitive ability as she was unable to provide any details regarding how the bruises occurred. She denied pain. Interview on 11/16/23 at 2:20 P.M. with RN #607 revealed on 10/28/23 around breakfast time STNA #609 stated Resident #42 had bruising to her face. He revealed he went and assessed, and she had raccoon eyes as she had bright red to dark red to purple bruising to her bilateral eyes, forehead, and on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 2 of 18 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 366329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hampton Woods Nursing Center, Inc 1525 East Western Reserve Road Poland, OH 44514 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 0600 Level of Harm - Actual harm Residents Affected - Few the outside of her left eye (temple region). He stated he felt they were fresh new bruises by the appearance. He revealed he had not received anything in the report and/or seen anything in her medical record regarding the bruising. He contacted NP #902 who ordered the resident to be sent to the emergency room. He revealed there was no way the resident fell as she would have been unable to get back up unless two staff assisted with a mechanical lift as she was heavy as well as dead weight. He revealed the resident was fully dependent on two staff for her ADL care, including bed mobility, bathing, and toileting as she was difficult to roll over. He revealed he did not feel one person could safely provide ADL care to the resident. Interview on 11/16/23 at 2:38 P.M. with STNA #608 revealed she remembered collecting breakfast trays on 10/28/23 with STNA #609 and noticed Resident #42 had two huge black eyes. She revealed she had purple and black bruises all around both eyes (under and above) and on her forehead. She revealed Resident #42 required two-person assistance with her ADL care as she did not assist with rolling over. Interview on 11/16/23 at 2:49 P.M. with Agency STNA #609 revealed on 10/28/23 at approximately 8:40 A.M. when she went in with STNA #608 to change Resident #42, she noticed the resident had bruising all over her face: both eyes, bridge of her nose, and forehead. She stated she asked Resident #42 what had happened, and she stated she fell going to school but was unable to provide any other information. She stated she reported the bruises to RN #607. She revealed she did not believe the resident fell as two staff would have had to assist her up with a mechanical lift as she does not bear any weight. She stated she required two staff to assist with bed mobility and provide incontinence care as she does not roll herself and would be very hard to do alone. Interview on 11/16/23 at 5:26 P.M. with Agency STNA #611 revealed on 10/27/23 she worked 7:00 P.M. to 7:00 A.M. and the aide she was working with (STNA # 613) stated that Resident #42 and her roommate, Resident #11, were scheduled for bed baths. She stated between 7:00 P.M. and 9:00 P.M. they both went into the room at the same time. She stated STNA #613 completed the bed bath for Resident #11, and she completed the bed bath and incontinence care for Resident #42. She revealed the resident required a complete linen change during the bed bath. She verified she did not ask STNA #613 for assistance in providing the care as she completed it by herself. She stated she had never received information in report that Resident #42 required two staff assist with her ADL care and was not aware of the facility had resident care cards indicating the type of care the residents required. She stated during Resident #42's bed bath she had noticed a bruise to the middle of her forehead and underneath one of her eyes (was not sure which eye). She revealed she asked Resident #42 what happened, and she stated, she rolled out of bed. She revealed STNA #613 was on the other side of the room, and she told her about the bruise and what Resident #42 said. She revealed she told a nurse but was not sure of the nurse's name. She revealed the next day a man from the facility (unsure who) contacted her, and she told him that Resident #42 stated she rolled out of bed. She revealed throughout the night she checked and changed Resident #42, and each time she did not have any assistance. Interview on 11/16/23 at 3:33 P.M. with RN #612 revealed she worked on 10/27/23 from 7:00 A.M. to 11:30 P.M. and completed several assessments approximately every four hours on Residents #42 as she had COVID-19. She revealed she last checked her at approximately 9:30 P.M. and that Resident #42 did not have any bruising to her face. She stated Agency STNA #611 never reported to her that Resident #42 had bruising to her forehead and/or her eye. She also never reported that Resident #42 stated that she rolled out of bed. Interview on 11/16/23 at 4:50 P.M. with STNA #613 revealed on 10/27/23 from 4:00 P.M. to 10:00 P.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 3 of 18 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 366329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hampton Woods Nursing Center, Inc 1525 East Western Reserve Road Poland, OH 44514 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 0600 Level of Harm - Actual harm Residents Affected - Few Resident #42 and her roommate (Resident #11) were scheduled for bed baths. She stated she and Agency STNA #611 went into the room together, and Agency STNA #611 gave Resident #42 a bed bath at the same time she gave Resident #11 a bed bath. She stated she had not seen Resident #42 as the curtain was pulled, but she did not hear anything that appeared unusual. She stated she did not assist Agency STNA #611 with the bed bath, changing of linens, incontinence care, and/or turning Resident #42. She revealed Agency STNA #611 never told her anything about Resident #42 having bruising to her face and/or the resident stating that she rolled out of bed. Interview on 11/16/23 at 2:17 P.M. with the Administrator and Director of Nursing (DON) verified Resident #42 required two-person assistance with bed mobility, incontinence care, and bed baths. They stated staff were to check the resident care cards for what assistance a resident needed and verified Resident #42's care card stated she required two-staff assistance for the above ADL. They stated through the investigation it was determined beginning the evening of 10/27/23 Agency STNA #611 provided Resident #42 a bed bath, changed her linen, and provided incontinence care without any other staff assistance. They revealed that was the reason they concluded that the bruising to Resident #42's face most likely occurred; from Agency STNA #611 turning the resident into the side rail. They revealed as an intervention they padded the resident's half side rails. They revealed they did not feel Resident #42 fell as she was pretty heavy (her weight was 160 pounds), and she required a mechanical lift with two persons assist to transfer her. They also revealed they believed if she had fallen, she would have had bruises and/or injuries on other parts of her body, not only on her face. They stated Agency STNA #611 also verified throughout the rest of the night that she checked and changed Resident #42 also using only one person assist. Observation on 11/19/23 at 9:25 P.M. revealed Licensed Practical Nurse (LPN) #615 and STNA #617 transferred Resident #42 with a mechanical lift from her wheelchair to her bed to provide incontinence care. Resident #42 was totally dependent on the staff to roll her side to side as she did not assist. They both confirmed that they would not be able to complete her care by themselves as they stated, she was very heavy and fully dependent on care. Interview on 11/19/23 at 10:40 A.M. with Administrator revealed he had contacted Agency STNA #611 on 10/28/23 at approximately 1:00 P.M. as part of the investigation and Agency STNA #611 had stated during the bed bath she had noticed bruising to Resident #42 forehead and small purple mark by her right eye. He revealed he asked her if she reported the bruising, and she stated she had not stating, she assumed everyone knew. He revealed Agency STNA #611 had never told him that Resident #42 had stated she rolled out of bed. Interview on 11/19/23 at 12:58 P.M. with Resident #11 (Resident #42's roommate) revealed she did not know what happened to Resident #42 as she just knew one day her face was all bruised up. She denied seeing or hearing anything. Review of the facility policy labeled Activities of Daily Living, dated June 2015, revealed the purpose of the policy was to provide assistance as necessary. The policy revealed all resident functional status would be assessed and supervised as needed to assist in achieving and maintaining maximum functional ability. Review of the facility policy labeled Abuse, Alleged and/ or Actual, Neglect and Misappropriation, dated September 2016, revealed the purpose of the policy was to assure residents right to be free of verbal, physical, sexual, and mistreatment. The policy stated no employee and/or agency serving the residents would knowing abuse, mistreat, or neglect any resident of the facility. The policy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 4 of 18 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 366329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hampton Woods Nursing Center, Inc 1525 East Western Reserve Road Poland, OH 44514 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 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete revealed neglect was the reckless failing to provide a resident with treatment, care, goods, or services necessary to maintain the health and safety of the resident when the failure results in serious physical harm to the resident. This deficiency represents non-compliance investigated under Self-Reported Incident, Control Number OH00147913. Event ID: Facility ID: 366329 If continuation sheet Page 5 of 18 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 366329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hampton Woods Nursing Center, Inc 1525 East Western Reserve Road Poland, OH 44514 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, facility policy and procedure review, self-reported incident (SRI) review, and facility investigation review the facility failed to ensure an injury of unknown origin resulting in serious bodily injury for Resident #42 was timely reported to the State agency, within two hours and failed to ensure law enforcement was notified. This affected one resident (#42) of one resident reviewed for abuse. The facility census was 62. Findings include: Review of the medical record for Resident #42 revealed an admission date of 03/03/16 with diagnoses including Alzheimer's disease, psychotic disturbance, and diabetes. Review of the care plan dated 03/10/16 revealed Resident #42 had an activities of daily living (ADL) self-care performance deficit related to weakness, decreased mobility, and alteration in cognition. Interventions included bed mobility and transfer with staff assistance (refer to resident care card). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Resident #42 rejected care one to three days during the seven-day assessment reference period. She was dependent on staff ADL including rolling left and right, transfers, and toileting. She was always incontinent of bowel and bladder. Review of the resident care card dated 10/23/23 revealed Resident #42 was oriented to self only. She required a turn schedule with two-staff assistance for bed mobility, a mechanical lift with two-staff assistance for transfers, and two-staff assistance with toileting. She was unable to ambulate. She was incontinent of bowel and bladder and was to be checked and changed every two hours. Review of the nursing note dated 10/28/23 at 10:08 A.M. and completed by Registered Nurse (RN) #607 revealed he was notified by staff that Resident #42 had bruising to her facial area. She was assessed and had deep purple bruises on her forehead, under her left and right eyes, and on the outside of her left eye (temple area). She was confused, and when asked how it happened, she stated, it happened outside the school. Nurse Practitioner (NP) #902 was notified and ordered the resident to be sent to the emergency room (ER) for an evaluation. The Administrator and Resident #42's Power of Attorney (POA) were notified. Review of the after-visit summary from the ER dated 10/28/23 revealed Resident #42 was seen by ER Physician #701 due to fall and closed head injury. The summary report revealed a computed tomography (CT) scan was completed of her cervical spine, facial bones, head, and left hip. She also had a chest and pelvis x-ray. All testing was essentially negative, and he recommended no new orders. Review of facility SRI tracking number 240643 as created on 10/29/23 at 6:05 A.M. for injury of unknown source and submitted by the Administrator revealed on 10/28/23 at 8:40 A.M. State Tested Nurse Aide (STNA) #608 and Agency STNA #609 notified RN #607 Resident #42 had bruising to her face. RN #607 assessed the resident and noted purple/red bruising to her forehead, under both eyes, and surrounding tissue of her left eye. When interviewed, Resident #42 stated, it happened outside of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 6 of 18 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 366329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hampton Woods Nursing Center, Inc 1525 East Western Reserve Road Poland, OH 44514 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few school. NP #902 was notified and ordered her to be sent to the hospital for evaluation. The SRI revealed all staff were interviewed who worked from 10/27/23 7:00 A.M. to 10/28/23 at 8:40 A.M. The investigation revealed STNA #700 was assigned to Resident #42 on 10/27/23 from 7:00 A.M. to 7:00 P.M. and had not noticed any bruising. The investigation revealed the Administrator interviewed Agency STNA #611, and she had stated she noticed a bump on Resident #42's forehead and her right eye was purple when she provided her with a bed bath on 10/27/23 at 8:20 P.M. without any other staff assistance. Agency STNA #611 revealed STNA #613 was providing a bed bath at the same time to Resident #11 (Resident #42's roommate) but had not reported the bruising to STNA #613 or RN #612 (nurse on duty) as she stated, I assumed everyone knew. Agency STNA #611 revealed she checked and changed Resident #42 throughout the rest of the night providing her care without any other staff assistance. The facility investigation concluded that it appeared the resident was turned and repositioned by Agency STNA #611 and hit her face on the half upper side rail. The SRI was substantiated, and Agency STNA #611 was not to return to the facility. As an intervention, Resident #42's top half side rails were padded. The SRI indicated that law enforcement was not notified. Observation on 11/16/23 at 8:57 A.M. revealed Resident #42 had bruising of all different colors (yellow, green, blue, light purple, and dark purple) in the middle of her forehead, under and above her bilateral eyes and on the outside (temple region) of her left eye. Attempts to interview Resident #42 were unsuccessful due to the resident's cognitive ability as she was unable to provide any details regarding how the bruises occurred. She denied pain. Interview on 11/16/23 at 2:20 P.M. with RN #607 revealed on 10/28/23 around breakfast time STNA #609 stated Resident #42 had bruising to her face. He revealed he went and assessed, and she had raccoon eyes as she had bright red to dark red to purple bruising to her bilateral eyes, forehead, and on the outside of her left eye (temple region). He stated he felt they were fresh new bruises by the appearance. He revealed he had not received anything in the report and/or seen anything in her medical record regarding the bruising. He contacted NP #902 who ordered the resident to be sent to the emergency room. He revealed there was no way that she fell as she would have been unable to get back up unless two staff assisted with a mechanical lift as she was heavy as well as dead weight. He revealed she was fully dependent on two staff for her ADL, including bed mobility, bathing, and toileting as she was difficult to roll over. He revealed he did not feel one person could safely provide her ADL. Interview on 11/16/23 at 2:38 P.M. with STNA #608 revealed she remembered collecting breakfast trays on 10/28/23 with STNA #609 and noticed Resident #42 had two huge black eyes. She revealed she had purple and black bruises all around both eyes (under and above) and on her forehead. She revealed Resident #42 required two-person assistance with her ADL as she does not assist with rolling over. Interview on 11/16/23 at 2:49 P.M. with Agency STNA #609 revealed on 10/28/23 at approximately 8:40 A.M. when she went in with STNA #608 to change Resident #42, she noticed the resident had bruising all over her face: both eyes, bridge of her nose, and forehead. She stated she asked Resident #42 what had happened, and she stated she fell going to school but was unable to provide any other information. She stated she reported the bruises to RN #607. She revealed she did not believe she fell as two staff would have had to assist her up with a mechanical lift as she does not bear any weight. She stated she required two staff to assist with bed mobility and provide incontinence care as she does not roll herself and would be very hard to do alone. Interview on 11/16/23 at 5:26 P.M. with Agency STNA #611 revealed on 10/27/23 she worked 7:00 P.M. to 7:00 A.M. and the aide she was working with (STNA # 613) stated that Resident #42 and her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 7 of 18 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 366329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hampton Woods Nursing Center, Inc 1525 East Western Reserve Road Poland, OH 44514 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few roommate, Resident #11, were scheduled for bed baths. She stated at between 7:00 P.M. and 9:00 P.M. they both went into the room at the same time. She stated STNA #613 completed the bed bath for Resident #11, and she completed the bed bath and incontinence care for Resident #42's. She revealed she required a complete linen change during the bed bath. She verified that she did not ask STNA #613 for assistance in providing the care as she completed it by herself. She stated she had never received information in report that Resident #42 required two staff assist with her ADL and was not aware of the facility had resident care cards indicating the type of care the residents required. She stated during Resident #42's bed bath she had noticed a bruise to the middle of her forehead and underneath one of her eyes (was not sure which eye). She revealed she asked Resident #42 what happened, and she stated, she rolled out of bed. She revealed STNA #613 was on the other side of the room, and she told her about the bruise and what Resident #42 said. She revealed she told a nurse but was not sure of the nurse's name. She revealed the next day a man from the facility (unsure who) contacted her, and she told him that Resident #42 stated she rolled out of bed. She revealed throughout the night she checked and changed Resident #42, and each time she did not have any assistance. She denied at any time Resident #42 bumping her head on the side rail during her care. Interview on 11/16/23 at 3:33 P.M. with RN #612 revealed she worked on 10/27/23 from 7:00 A.M. to 11:30 P.M. and completed several assessments approximately every four hours on Residents #42 as she had COVID-19. She revealed she last checked her at approximately 9:30 P.M. and that Resident #42 did not have any bruising to her face. She stated Agency STNA #611 never reported to her that Resident #42 had bruising to her forehead and/or her eye. She also never reported that Resident #42 stated that she rolled out of bed. Interview on 11/16/23 at 4:50 P.M. with STNA #613 revealed on 10/27/23 from 4:00 P.M. to 10:00 P.M. Resident #42 and her roommate (Resident #11) were scheduled for bed baths. She stated she and Agency STNA #611 went into the room together, and Agency STNA #611 gave Resident #42 a bed bath at the same time she gave Resident #11 a bed bath. She stated she had not seen Resident #42 as the curtain was pulled, but she did not hear anything that appeared unusual. She stated she did not assist Agency STNA #611 with the bed bath, changing of linens, incontinence care, and/or turning Resident #42. She revealed Agency STNA #611 never told her anything about Resident #42 having bruising to her face and/or the resident stating that she rolled out of bed. Interview on 11/19/23 at 10:40 A.M. with Administrator revealed he had contacted Agency STNA #611 on 10/28/23 at approximately 1:00 P.M. as part of the investigation and that Agency STNA #611 had stated during the bed bath she had noticed bruising to Resident #42 forehead and small purple mark by her right eye. He revealed he asked her if she reported the bruising and she had stated she had not and she stated she, assumed everyone knew. He revealed Agency STNA #611 had never told him that Resident #42 had stated she rolled out of bed. Interview on 11/16/23 at 2:17 P.M. with the Administrator and Director of Nursing (DON) verified Resident #42 required two-person assistance with bed mobility, incontinence care, and bed baths. They stated staff were to check the resident care cards for what assistance a resident needed and verified Resident #42's care card stated she required two-staff assistance for the above ADL. They stated through the investigation it was determined the evening of 10/27/23 Agency STNA #611 provided Resident #42 a bed bath, changed her linen, and provided incontinence care without any assistance. They revealed that was the reason they concluded that the bruising to Resident #42's face most likely occurred from Agency STNA #611 turning her into the side rail. They revealed as an intervention they padded her half side rails. They revealed they did not feel Resident #42 fell as she was pretty heavy as her weight was 160 pounds, and she required a mechanical lift with two persons assist to transfer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 8 of 18 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 366329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hampton Woods Nursing Center, Inc 1525 East Western Reserve Road Poland, OH 44514 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 0609 Level of Harm - Minimal harm or potential for actual harm her. They also revealed they believed if she had fallen, she would have had bruises and/ or injuries on other parts of her body, not only on her face. They stated Agency STNA #611 also verified throughout the rest of the night that she checked and changed Resident #42 also using only one person assist. They verified they had not reported the incident to the local law enforcement and/or submitted the SRI to the State agency within two hours. Residents Affected - Few Interview on 11/19/23 at 12:58 P.M. with Resident #11 (Resident #42's roommate) revealed she did not know what happened to Resident #42 as she just knew one day her face was all bruised up. She denied seeing or hearing anything. Review of the facility policy labeled Abuse, Alleged and/ or Actual, Neglect and Misappropriation, dated September 2016, revealed the purpose of the policy was to assure residents right to be free of verbal, physical, sexual, and mistreatment. The policy revealed the facility would report to proper authorities as per policy. The policy revealed any injury of unknown origin involving any resident would be investigated as possible abuse. The policy did not include to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury. The policy also did not include instances where an alleged violation of abuse, neglect, misappropriation of resident property and exploitation would be reasonable suspicion of a crime. The policy also did not include in these cases, the facility was obligated to report the reasonable suspicion of a crime to the local law enforcement. This deficiency represents non-compliance investigated under Self-Reported Incident, Control Number OH00147913. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 9 of 18 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 366329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hampton Woods Nursing Center, Inc 1525 East Western Reserve Road Poland, OH 44514 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 interview, record review, and review of the facility policy the facility failed to obtain daily weights as ordered. This affected two residents (#39 and #58) out of three residents reviewed for daily weights. This had the potential to affect eight residents (#7, #13, #16, #19, #25, #39, #48, and #58) who had orders for daily weights. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #39 revealed an admission date of 07/20/23 with diagnoses including congestive heart failure (CHF), diabetes, hypertension, and acute kidney failure. Review of the care plan dated 07/21/23 revealed Resident #39 had an alteration in nutrition related to CHF. Interventions included obtaining a daily weight, monitoring her appetite and weight, and diet as ordered. Review of the Medicare Five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had impaired cognition. Her weight was 194 pounds with no weight loss. Review of the October 2023 and November 2023 physician's orders revealed Resident #39 had an order for a daily weight to be completed every night shift due to acute CHF. Review of the October 2023 Treatment Administration Record (TAR) revealed Resident #39 had an order dated 08/31/23 to have a daily weight in the morning and to call the cardiac clinic if there was a five-pound weight gain in one week. The TAR was blank from 10/10/23 to 10/19/23. Review of the weight summary dated from 10/10/23 to 10/19/23 revealed on 10/10/23 Resident #39's weight was 189 pounds and on 10/19/23 her weight was also 189.9 pounds. There were no weights recorded from 10/11/23 to 10/18/23. Review of the nutritional risk assessment dated [DATE] and completed by Dietitian #606 revealed Resident #39 had a diagnosis of CHF and was recently diuresed (an increased excretion of urine by means at times of medication) at the hospital. She was to be weighed daily. Interview on 11/19/23 at 11:35 A.M. with the Director of Nursing (DON) verified Resident #39 had an order for a daily weight to be completed, and there was no documented evidence daily weights were completed from 10/11/23 to 10/18/23. 2. Review of the medical record for Resident #58 revealed an admission date of 11/08/23 with diagnoses including atherosclerotic heart disease, hypertension, cerebral infarction, and presence of coronary bypass graft. Review of the after-visit summary from the hospital dated 11/08/23 revealed Resident #58's discharge instructions after open heart surgery included obtain a weight every morning and call the surgeon if a weight gain of three or more pounds overnight or five pounds in a week as this may be a sign of fluid retention. Review of the November 2023 Physician orders revealed Resident #58 had an order dated 11/09/23 for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 10 of 18 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 366329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hampton Woods Nursing Center, Inc 1525 East Western Reserve Road Poland, OH 44514 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 a daily weight to be completed in the morning and notify the physician if weight gain of three pounds in one day. Review of the November 2023 TAR revealed on 11/09/23 Resident #58 had an order to have a daily weight completed in the morning and notify the physician of weight gain of three or more pounds in a day. The TAR revealed on 11/09/23, 11/10/23, 11/12/23, 11/13/23, 11/15/23, 11/16/23, and 11/18/23 the TAR was blank. The TAR revealed on 11/10/23 and 11/14/23 the TAR was signed off, but no weight was recorded. The only two weights recorded on the MAR from 11/09/23 to 11/19/23 were on 11/17/23 and his weight was 191.2 and on 11/19/23 his weight was 191.4. Review of the care plan dated 11/09/23 revealed Resident #58 had an alteration in nutrition with diagnoses of coronary artery bypass graft (CABG) (a surgical procedure used to treat coronary heart disease by diverting blood around narrowed or clogged parts of the major arteries to improve blood flow and oxygen supply to the heart), and hypertension. Interventions included daily weight, diet as ordered, monitor appetite, and weight and notify physician of significant problems. Review of the nutritional risk assessment dated [DATE] and completed by Dietitian Tech #621 revealed Resident #58 was status post CABG surgical procedure and had an order for a daily weight to be monitored. Review of the weight summary dated from 11/09/23 to 11/19/23 revealed Resident #58 had the following weights completed: 11/09/23 his weight was 189 pounds, 11/14/23 his weight was 191.6, 11/17/23 his weight was 191.2 pounds, and on 11/19/23 his weight was 191.4. He was missing daily weights for 11/10/23, 11/11/23, 11/12/23, 11/13/23, 11/15/23, 11/16/23, and 11/18/23. Review of the Medicare Five-Day MDS assessment dated [DATE] revealed Resident #58 had intact cognition. Interview on 11/19/23 at 12:14 P.M. with Resident #58 revealed that he was to be weighed daily due to having recent heart surgery, but sometimes it did not happen as the staff just did not obtain it. Interview on 11/19/23 at 11:35 A.M. with the DON verified Resident #58's weight was not completed daily as ordered as there was no weight completed on the following days: 11/10/23, 11/11/23, 11/12/23, 11/13/23, 11/15/23, 11/16/23, and 11/18/23. Interview on 11/16/23 at 11:28 A.M. with Dietitian #606 revealed that it had been an issue at the facility with daily weights being completed. She stated residents, including Resident #39 and Resident #58, who had orders for daily weights were not obtained as ordered. Review of the undated facility policy labeled Weight and Height Measurements revealed residents were to be weighted on admission and monthly unless otherwise ordered by nursing order or the attending physician when the following conditions existed including renal failure and onset of CHF. This deficiency represents non-compliance investigated under Complaint Number OH0000147676. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 11 of 18 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 366329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hampton Woods Nursing Center, Inc 1525 East Western Reserve Road Poland, OH 44514 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility policy and interview the facility failed to ensure timely assessments were completed and adequate interventions were implemented to prevent the development of a pressure ulcer for Resident #14. Residents Affected - Few Actual Harm occurred on 10/03/23 when Resident #14, who was totally dependent on staff for activities of daily living (ADL) including bed mobility, toileting, and transfers was found to have an unstageable (full thickness tissue loss in which the actual depth of the ulcer was obscured by slough/ dead skin) pressure ulcer to his left gluteal (buttock) area. There was no documented evidence of adequate intervention(s) or monitoring to prevent the development of this wound or to ensure the pressure ulcer was identified prior to being unstageable. This affected one resident (#14) of two residents reviewed for pressure ulcers. The facility census was 62. Findings include: Review of the medical record for Resident #14 revealed an admission date of 06/28/23 with diagnoses including osteomyelitis of vertebra sacral region, cerebral infarction, congestive heart failure, and diabetes. Review of the care plan dated 06/29/23 revealed Resident #14 had the potential for and/or actual skin breakdown related to decreased mobility, incontinence, friction, and diabetes. Interventions included keeping the resident's skin clean and dry, positioning him properly using devices such as pillows as needed, pressure reducing device to bed and wheelchair, and preventing skin to skin contact as much as possible. Review of the care plan dated 07/05/23 revealed Resident #14 had a self-care deficit in ADL related to weakness, decreased mobility, and cerebral vascular accident. Interventions included assisting with all transfers, assisting with bed mobility, and anticipating and meeting all needs in a timely manner. Review of the Braden scale for predicting pressure sore risk dated 09/14/23 and completed by Licensed Practical Nurse (LPN) #620 revealed Resident #14 was at risk for developing pressure ulcers because he was chair fast, very limited with mobility, and had a problem with friction and shearing. Review of the resident care card dated 09/14/23 revealed Resident #14 required two-staff assistance and was on a turn schedule for bed mobility, two-staff assistance with a mechanical lift for transfers, and two-staff assistance with toileting. Review of the significant change Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #14 had impaired cognition. He was totally dependent on two staff with bed mobility, transfers, and toileting. He was unable to ambulate. He was at risk for pressure ulcers. Review of the weekly skin assessment dated [DATE] and completed by Assistant Director of Nursing (ADON)/ LPN/ Wound Nurse #620 revealed no new areas of concern, including Resident #14's left gluteal area. Review of nursing note dated 10/02/23 at 8:03 P.M. and completed by LPN #615 revealed he found a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 12 of 18 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 366329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hampton Woods Nursing Center, Inc 1525 East Western Reserve Road Poland, OH 44514 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 0686 new area on Resident #15's left buttock and compromised tissue on his hip. The note revealed new orders were in place. There was no other description of the wound including stage and/or measurements. Level of Harm - Actual harm Residents Affected - Few Review of the provider consultation dated 10/03/23 revealed Wound Nurse Practitioner (NP) #901 consulted, and Resident #14 had a new pressure wound to his left gluteal area which was in-house acquired. The wound was classified as unstageable and measured 7.0 centimeters (cm) in length by and 11.0 cm in width. The wound had a moderate amount of serosanguinous (thin and watery fluid that is pink in color due to the presence of small amounts of blood) drainage. The wound contained 20 percent (%) slough and 10 percent deep tissue injury (an injury to the soft tissue under the skin due to pressure and was usually over a boney prominence). She ordered a treatment for the area. Review of the skin grid dated 10/03/23 and completed by ADON/ LPN/ Wound Nurse #620 revealed Resident #14's left gluteal area originated as a facility acquired unstageable pressure ulcer on 10/03/23. The wound measured 7.0 cm in length by 11.0 cm in width, and the wound contained slough. Review of the November 2023 physician's orders revealed Resident #14 had an order dated 10/03/23 to cleanse the lower left buttock wound with normal saline, apply Medihoney (promotes a moist wound environment that aids and supports autolytic debridement), calcium alginate (dressing for moderately to heavily draining wounds), and cover with a dressing twice a day and as needed. Review of the skin grid dated 11/14/23 and completed by ADON/ LPN/ Wound Nurse #620 revealed Resident #14's left gluteal unstageable pressure ulcer continued and measured one cm in length, 7.5 cm in width and 0.1 cm in depth. The wound bed contained slough. Review of the provider consultation dated 11/14/23 revealed Wound NP #901 consulted, and the unstageable pressure ulcer was now classified as a Stage three (involved full-thickness skin loss potentially extending into the subcutaneous tissue layer) and measured a 1.0 cm in length by 7.5 cm in width by 0.1 cm in depth. The wound continued to have moderate serosanguinous drainage with 10% percent slough. The wound was debrided to remove the slough at the bedside, and Resident #14 tolerated the procedure well. Interview on 11/19/23 at 10:30 A.M. with the Director of Nursing (DON) and ADON/ LPN/ Wound Nurse #620 revealed Resident #14's wound to his left gluteal area was noted per nursing notes on 10/02/23 by LPN #615 but there was no description including stage and/or measurements of the wound. They verified the first measurements and staging of the wound was on 10/03/23 identified as facility acquired unstageable pressure ulcer that contained 20% slough per Wound NP #901's assessment on 10/03/23. They verified Resident #14 required total dependence from staff for his ADL, including for bed mobility, transfers, and toileting. Observation of the wound care on 11/19/23 at 1:06 P.M. completed by LPN #601 and LPN #615 revealed Resident #14 continued to have a pressure ulcer to his left gluteal area. LPN #615 described the wound as having small amount of white slough to the center of the wound bed with blanchable healthy skin surrounding the wound. The treatment was completed as ordered. Interview on 11/19/23 at 1:29 P.M. with LPN #615 as he was the nurse who first found the wound on 10/02/23 revealed he had to be honest stating, it had been a hot minute since the wound was found and could not recall and/or describe how the wound looked when he found it. He verified he did not include a description, and/or measurements in the nursing notes and/or on another assessment form. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 13 of 18 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 366329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hampton Woods Nursing Center, Inc 1525 East Western Reserve Road Poland, OH 44514 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 0686 Level of Harm - Actual harm Residents Affected - Few Review of the facility policy labeled Pressure Ulcers identification and Suggested Treatment Protocols, dated June 2015, revealed pressure ulcers would be identified and treatments would be ordered for proper healing of the wound. Review of the facility policy labeled Pressure Ulcers, Prevention and Care of, dated June 2015, revealed the purpose of the policy was to prevent impairment in the skin integrity. The protocol would be followed when a resident had a decubitus ulcer or was at high risk for developing an ulcer including care to prevent the alteration in skin integrity in all residents. This deficiency represents non-compliance investigated under Complaint Number OH00147676. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 14 of 18 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 366329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hampton Woods Nursing Center, Inc 1525 East Western Reserve Road Poland, OH 44514 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record review, and facility policy review the facility failed to ensure Resident #39 was free from significant medication errors. This affected one resident (#39) out of two residents reviewed for insulin administration. This had the potential to affect 15 residents (#12, #13, #14, #16, #17, #23, #27, #29, #31, #35, #39, #43, #46, #48, and #52) with orders for insulin. In addition, the facility did not ensure Resident #39 was not administered two glucagon kits (a subcutaneous injection that worked by triggering the liver to release stored sugar to raise the blood sugar) without a physician order affecting one resident (#39) out of three residents reviewed for medication administration. The facility census was 62. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #39 revealed an admission date of 07/20/23 with diagnoses including diabetes, acute kidney failure, and congestive heart failure (CHF). Review of the care plan dated 07/21/23 revealed Resident #39 had alteration in nutrition due to diabetes. Interventions included diet per order and encourage completion of meals. There was nothing in her care plan related to checking her blood sugars and/or administering her insulin. Review of the Medicare Five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had impaired cognition and received seven days of insulin injections. Review of the November 2023 physician's orders revealed Resident #39 had an order for Insulin lispro (a fast-acting insulin that should be given 15 minutes before a meal) 100 units per milliliter (ml) inject six units subcutaneously (SQ) with meals and insulin lispro injection solution inject per sliding scale SQ with meals due to diabetes. Observation on 11/16/23 at 9:04 A.M. revealed Resident #39's breakfast tray was on her bedside table off to the side of the room with a clothing protector over it appearing as she had completed her breakfast. Interview on 11/16/23 at 9:04 A.M. with Private Caregiver #603 in Resident #39's room revealed she comes in every Tuesday and Thursday from 8:00 A.M. to 3:00 P.M. to assist in caring for Resident #39. She revealed Resident #39 received her breakfast tray approximately between 8:30 A.M. to 8:45 A.M. and was finished. She revealed a nurse had not been in to check her blood sugar and/or administer her insulin while she was there. She revealed rarely do the nurses administer her insulin before and/or when she received her tray as this had been a concern as they always come in after she was finished with her meal. Observation of medication administration on 11/16/23 at 9:13 A.M. of Licensed Practical Nurse (LPN) #604 revealed she had taken Resident #39's blood sugar at approximately 8:20 A.M. and it was 220 requiring sliding scale coverage. She revealed she did not administer her insulin (lispro) routine or sliding scale order as the insulin was on the other side in another medication cart and that she needed to retrieve it. She retrieved the insulin and administered insulin lispro six units SQ per her routine order that was scheduled for 8:00 A.M. as well as her insulin lispro per her sliding scale to administer three units for blood sugar between 201 and 225 that was also scheduled at 8:00 A.M. with meals. She administered a total of nine units of lispro insulin to the right side of her abdomen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 15 of 18 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 366329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hampton Woods Nursing Center, Inc 1525 East Western Reserve Road Poland, OH 44514 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on 11/16/23 at 9:47 A.M. LPN #604 then proceeded to sign off the other medication that she had administered and verified that she had already signed off the lispro insulin as given previously when she had obtained the blood sugar but had not given the insulin. She verified that she had documented a blood sugar check of 207 not 220 as she had previously told this surveyor. She revealed she had obtained her blood sugar twice, once at 8:15 A.M. that was 207 and then she took it again at approximately 8:45 A.M. and at that time her blood sugar was 220. She verified she should not have signed off her insulin as given until after it was given. She also verified that the lispro insulin was given at 9:47 A.M. and that the order was scheduled for 8:00 A.M. and was to be given with meals. She verified she had already completed her breakfast when she administered her insulin. Interview on 11/16/23 at 10:59 A.M. with the Director of Nursing (DON) revealed LPN #604 told her that she had signed off the insulin as being given when she obtained her blood sugar but had not given the insulin. She verified the expectation of the nurse was not to sign off a medication until after the medication was administered. She also verified that Resident #39's insulin lispro was scheduled to be given with meals and this morning was scheduled for 8:00 A.M. She verified that giving the insulin at 9:47 A.M. was not following the physician's order. 2. Review of medical record for Resident #39 revealed an admission date of 07/20/23 with diagnoses including diabetes, acute kidney failure, and CHF. Review of the October 2023 physician's orders and Medication Administration Record (MAR) for October 2023 revealed Resident #39 had an order dated 08/04/23 for glucose oral gel 40 percent give 15 grams by mouth as needed for hypoglycemia. The MAR revealed on 10/27/23 that the glucose oral gel was not signed off as administered as noted as given per the medication incident report and nursing notes. There was no order for Resident #39 to receive a glucagon kit (glucagon injection requiring a physician's order). Review of nursing note dated 10/27/23 at 10:41 P.M. completed by Registered Nurse (RN) #612 revealed Primary Care Physician (PCP) #900 was in to see Resident #39 and requested Resident #39 be sent to the hospital because her blood sugar was 58 despite soda with sugar, orange juice, peanut butter crackers, and the oral glycogen gel was ineffective. There was no mention in the nursing notes that glucagon kits were administered times two. Review of the medication incident report dated 10/27/23 at 10:39 P.M. revealed RN #612 administered glucose oral gel times one dose and when that was ineffective, she administered glucagon kit times two with no order for the doses. She borrowed the glucagon kits from other residents that they were prescribed for. The report revealed RN #612 stated when the glucose oral gel was ineffective, she made an emergency decision to give two glucagon kits despite knowing there was no physician order for the medication. The report revealed PCP #900 was in the facility at the time, but that RN #612 never bothered to get the orders from him to use the glucagon kits. The report revealed the final disposition of the facility investigation was RN #612 was given disciplinary action for working outside her scope of practice and was terminated from her employment. Interview on 11/16/23 at 2:17 P.M. with the Administrator and Director of Nursing revealed on 10/27/23 RN #612 administered Resident #39 two glucagon kits without a physician order. They revealed she used kits that belonged to other residents for Resident #39 and verified she failed to get a physician order despite PCP #900 being in the facility. They verified they terminated her employment as they felt RN #612 worked outside her scope of practice and even if they felt a resident could benefit from a certain medication, they were to call the physician for the order and/or if an emergency ask (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 16 of 18 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 366329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hampton Woods Nursing Center, Inc 1525 East Western Reserve Road Poland, OH 44514 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 0760 another nurse for assistance to call. Level of Harm - Minimal harm or potential for actual harm Review of the undated policy labeled Medication Administration revealed the purpose of the policy was to ensure all medications were administered safely. The policy revealed whenever medications were administered the mode, frequency, timing, and route of administration was consistent with the prescription or order. Residents Affected - Few Review of the facility policy labeled Insulin Injection Administration Procedures, dated 06/02/15, revealed the procedure to be followed included: check prescribers' order, compare medication label with medication administration record including medication expiration date, and documented the administration on the MAR including site of administration and dosage given if using sliding scale. This deficiency represents non-compliance investigated under Complaint Number OH00147676. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 17 of 18 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 366329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hampton Woods Nursing Center, Inc 1525 East Western Reserve Road Poland, OH 44514 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record review, and pharmacy guidelines review the facility failed to ensure Resident #39's insulin was not expired upon administration. This affected one resident (#39) out of two residents reviewed for insulin administration. This had the potential to affect 15 residents (#12, #13, #14, #16, #17, #23, #27, #29, #31, #35, #39, #43, #46, #48, and #52) with orders for insulin. Findings include: Review of the medical record for Resident #39 revealed an admission date of [DATE] with diagnoses including diabetes, acute kidney failure, and congestive heart failure (CHF). Review of the care plan dated [DATE] revealed Resident #39 had alteration in nutrition due to diabetes. Interventions included diet per order and encourage completion of meals. There was nothing in her care plan related to the administration of her insulin. Review of the Medicare Five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had impaired cognition and received seven days of insulin injections during the seven-day assessment reference period. Review of the [DATE] physician's orders revealed Resident #39 had an order insulin glargine (Lantus) inject 22 units subcutaneously (SQ) in the morning due to diabetes. Observation of medication administration revealed Licensed Practical Nurse (LPN) #604 administered Resident #39 her Lantus insulin as ordered on [DATE] at 9:46 A.M. to the left side of her abdomen. The insulin was labeled that it was opened on [DATE]. Interview on [DATE] at 9:48 A.M. with LPN #604 revealed that she thought Lantus was good after being opened for three months. She verified that the Lantus was labeled and that it was opened on [DATE]. Interview on [DATE] at 10:59 A.M. with the Director of Nursing verified Lantus was only good for 28 days after being opened and that LPN #604 administered Resident #39 her Lantus with a date as opened as [DATE] (37 days). Review of the untitled and undated pharmacy guidelines regarding medication expiration once opened revealed the policy of dating all vials once opened must be always reinforced. The guideline revealed Lantus was to be used within 28 days after the first dose. This deficiency represents non-compliance investigated under Complaint Number OH00147676. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 18 of 18