Health inspection·October 10, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of medical record for Resident #15 revealed an admission date of 05/14/24. Diagnoses included pulmonary embolism (blood clot in lung) without acute cor pulmonale (serious heart condition that develops as a complication of advanced lung disease) , presence of cardiac pacemaker, type two diabetes mellitus with ketoacidosis (complication from having very high blood sugars) without coma, hypo-osmolality (condition of having abnormally low osmolality in the body fluids), hyponatremia (concentration of sodium in blood is abnormally low) , acute ischemic heart disease, and conduction disorder. Review of the physician orders for Resident #15 revealed an order, dated 10/04/24, for DNR Comfort Care. Review of the DNR Comfort Care form for Resident #15, which was signed by the Nurse Practitioner #701 on 10/04/24, revealed neither the box for DNR Comfort Care-Arrest or DNR Comfort Care was checked. Review of the DNR Comfort Care form and interview on 10/08/24 at 2:19 P.M. with LPN #644 revealed LPN #644 confirmed neither box was checked and, she would have to look in the electronic medical record to determine if Resident #15 was a DNR Comfort Care Arrest or DNR Comfort Care. Based on record review and interviews, the facility failed to ensure resident Do Not Resuscitate forms were appropriately filled out for Residents #262 and #15. This finding affected two residents (#262 and #15) out of two residents reviewed for advanced directives. The facility census was 60. Findings include: 1. Review of the medical record revealed Resident #262 was admitted to the facility on [DATE]. Medical diagnoses included acute kidney failure, calculus of kidney, obstructive and reflux uropathy, cognitive communication deficit, peripheral vascular disease, and occlusion and stenosis of bilateral carotid arteries. Review of Resident #262 physician orders revealed an order that stated Do Not Resuscitate Comfort Care Arrest (DNR-CCA) dated 09/18/24. Review of Resident #262's care plan dated 09/19/24 revealed the care plan did not include advanced directives. Review of the Medicare Five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #262 was severely cognitively impaired. Resident #262 was independent with eating, required setup or clean-up assistance with oral hygiene, partial to moderate assistance with upper body dressing and was dependent on staff for toileting hygiene, shower/bathing, lower body dressing and putting on and taking off footwear. Resident #262 had an indwelling urinary catheter and was frequently incontinent of bowel. Review of the DNR (Do Not Resuscitate) Comfort Care form with Licensed Practical Nurse (LPN) #644 on 10/08/24 at 2:19 P.M. revealed the form for Resident #262, which was signed by Nurse Practitioner #701 on 09/18/24, revealed neither the box for DNR Comfort Care-Arrest in which all providers would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 2 of 19 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 10/10/2024 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete treat patient as any other without a DNR order until the point pf cardiac or respiratory arrest at which point all interventions would cease, and the DNR Comfort Care protocol would be implemented or the box for DNR Comfort Care in which following the DNR protocol would be effective immediately. Interview at the time of observation with LPN #644 confirmed neither box was checked, and she would have to look into the electronic medical record to determine if Resident #262 was a DNR Comfort Care Arrest or DNR Comfort Care. Event ID: Facility ID: 366329 If continuation sheet Page 3 of 19 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 10/10/2024 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility policy the facility failed to ensure the physician was notified of daily weight gains of two or more pounds in a day or of blood sugar over 300 per physician order. This affected one resident (#23) of one resident reviewed for daily weights and had the potential to affect nine residents (#1, #4, #6, #13, #16, #20, #35, #43, and #47) who had orders for daily weights. This also affected one resident (#27) out of one resident reviewed for blood sugars and had the potential to affect 12 residents (#1, #2, #10, #16, #17, #21, #24, #27, #45, #47, #52, #164) who received blood glucose monitoring. The facility census was 60. Findings include: 1. Review of the medical record for Resident #27 revealed an admission date of 12/28/20 with diagnoses including diabetes, congestive heart failure, chronic kidney disease, and altered mental status. Review of the care plan dated 12/08/23 revealed Resident #27 had diabetes. Interventions included medication as ordered, blood sugar as ordered and monitor for signs of hypoglycemia and hyperglycemia sign and symptoms. Review of the pharmacy recommendation dated 05/16/24 revealed Consultant Pharmacist #900 recommended to change blood sugar notification to the following: if blood sugar was less than 70 or greater than 300 the nurse was to notify the physician and/or nurse practitioner (NP). NP #701 signed the pharmacy recommendation in agreement. Review of the physician orders for August 2024 and September 2024 revealed Resident #27 had the following order to check his blood sugar twice a day due to diabetes and if less than 70 or above 300 notify the physician and/ or NP. Review of the nursing notes dated from 08/01/24 to 09/20/24 revealed there was no documentation the physician or NP was notified regarding elevated blood sugars as ordered by the physician. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #27 had impaired cognition. He received insulin. Review of the August 2024 Medication Administration Record (MAR) revealed there was a physician order that Resident #27's blood sugar was to be checked twice a day, and if the blood sugar was less than 70 and/or greater than 300 the facility was to notify the physician and/or NP. The following revealed the blood sugars were either below or above the recommended parameters and the physician or NP should have been notified: 08/01/24 at 4:00 P.M. it was 326, 08/02/24 at 4:00 P.M. it was 341, 08/03/24 at 6:00 A.M. it was 308, 08/06/24 at 4:00 P.M. it was 331, 08/07/24 at 4:00 P.M. it was 320, 08/08/24 at 4:00 P.M. it was 355, 08/11/24 at 4:00 P.M. it was 359. 08/12/24 at 6:00 A.M. it was 344, 08/12/24 at 4:00 P.M. it was 324, 08/13/24 at 4:00 P.M. it was 340, 08/14/24 at 4:00 P.M. it was 348, 08/15/24 at 4:00 P.M. it was 368, 08/17/24 at 4:00 P.M. it was 355, 08/18/24 at 4:00 P.M. it was 316, 08/19/24 at 4:00 P.M. it was 390, 08/20/24 at 4:00 P.M. it was 304, 08/22/24 at 4:00 P.M. it was 398. 08/25/24 at 4:00 P.M. it was 389, 08/28/24 at 4:00 P.M. it was 308, 08/29/24 at 4:00 P.M. 318, and 08/30/24 at 4:00 P.M. it was 364. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 4 of 19 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 10/10/2024 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the September 2024 MAR revealed there was a physician order that Resident #27's blood sugar was to be checked twice a day and if the blood sugar was less than 70 and/or greater than 300 revealed the facility was to notify the physician and/or NP. The following revealed the blood sugars were either below or above the recommended parameters and the physician or NP should have been notified: 09/02/24 at 4:00 P.M. it was 319, 09/04/24 at 4:00 P.M. it was 360, 09/06/24 at 4:00 P.M. it was 415, 09/08/24 at 4:00 P.M. it was 422, 09/09/24 at 4:00 P.M. 335, 09/10/24 at 6:00 A.M. it was 320, 09/11/24 at 4:00 P.M. it was 320, 09/12/24 at 4:00 P.M. it was 399, 09/14/24 at 4:00 P.M. it was 312, 09/16/24 at 4:00 P.M. it was 380, 09/17/24 at 4:00 P.M. it was 366, and 09/20/24 at 4:00 P.M. it was 326. Interview on 10/08/24 at 2:45 P.M. and 4:20 P.M. with the Director of Nursing (DON) verified Resident #27 had an order to notify the physician and/or NP if his blood sugar was less than 70 or if his blood sugar was above 300. She verified that she had reviewed the August 2024 and September 2024 MARs and the nursing notes, and there was no documentation that the physician was notified when Resident #27's blood sugar was above 300. 2. Review of the medical record revealed Resident #23 had an admission date of 02/27/24. Medical diagnoses included acute kidney failure, type two diabetes mellitus, essential atrial fibrillation, and acute on chronic systolic congestive heart failure. Review of quarterly MDS assessment 09/04/24 revealed Resident #23 was moderately cognitively impaired. Resident #23 required supervision or touching assistance with eating, substantial to maximal assistance with oral hygiene, and personal hygiene and was dependent on staff for toileting, upper and lower body dressing. Resident #23 was always incontinent of bowel and bladder. Review of the physician orders for Resident #23 revealed an order dated 07/14/24 for daily weights, notify the physician with a two-pound weight gain in one day or a three to five pound weight gain in one week. Review of the documented daily weights for Resident #23 from 07/14/24 to 10/09/24 revealed resident had a daily weight gain of 5.2 pounds (lbs) from 07/24/25 to 07/25/24, 11lb weight gain from 07/27/24 to 07/28/24, 8.4lbs weight gain from 07/30/24 to 07/31/24, 15.6lbs weight gain from 08/11/24 to 08/12/24, 7.7lbs weight gain from 08/18/24 to 08/19/24, 3.8lbs weight gain from 08/30/24 to 09/01/24 and a 4.2lbs weight gain from 09/11/24 to 09/12/24 with no documentation of physician notification. Interview on 10/09/24 at 12:45 P.M. with Registered Nurse (RN) Campus Director of Nursing #700 confirmed there was no documented evidence that the physician was notified of Resident #23's weight gains on 09/12/24, 09/01/24, 08/19/24, 08/11/24, 07/31/24, 07/28/24, and 07/25/24. Review of the facility policy Diagnostic Testing/Condition Change Reporting, Residents dated 11/22 revealed the physician, resident and/or responsible party are notified when the resident's physical, communicative, psychosocial or functional status changes unexpectedly, return of abnormal lab, radiology or other diagnostic test results, the resident is injured or if treatment is significantly altered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 5 of 19 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 10/10/2024 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on record review, review of the Internet Quality Improvement and Evaluation System (iQIES) Minimum Data Set (MDS) 3.0 Validation Report, staff interview, and facility policy review the facility failed to ensure Resident #19's MDS assessments were submitted in a timely manner. This affected one resident (#19) out of 23 residents reviewed for MDS submission. The facility census was 60. Residents Affected - Few Findings include: Review of medical record for Resident #19 revealed an admission date of 06/23/24. Diagnoses included multiple sclerosis, depressive disorder, primary osteoarthritis, disorder of thyroid, anxiety disorder, essential hypertension (high blood pressure), and atrial fibrillation (irregular heart rhythm). Review of Resident #19's medical record revealed the 08/11/24 quarterly MDS 3.0 assessment had been completed, but there was no indication it had been submitted to the Centers for Medicare and Medicaid (CMS) as required. Review of the IQIES MDS Final Validation Report submitted on 10/08/24 at 3:49 P.M. revealed Resident #19's quarterly MDS assessment, dated 08/11/24, was submitted to CMS on 10/08/24, which was more than 14 days late. Review of the IQIES MDS Final Validation Report dated 10/08/24 and interview on 10/08/24 at 5:10 P.M. with MDS Coordinator/LPN #621 revealed Resident #19's 08/11/24 MDS assessment was submitted on 10/08/24 and confirmed it had not been submitted within 14 days after the assessment was completed as required. Review of the facility policy titled Minimum Data Set (MDS), dated May 2015, revealed the MDS coordinator would transmit all completed assessments to the appropriate state agency in a timely manner in compliance with federal regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 6 of 19 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 10/10/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #15 revealed an admission date of 05/14/24. Diagnoses included pulmonary embolism (blood clot in lung)without acute cor pulmonale (serious heart condition that develops as a complication of advanced lung disease), presence of cardiac pacemaker, type two diabetes mellitus with ketoacidosis (complication from having very high blood sugars) without coma, hypo-osmolality (condition of having abnormally low osmolality in the body fluids) and hyponatremia (concentration of sodium in blood is abnormally low), acute ischemic heart disease, and conduction disorder. Review of the physician progress note dated 05/13/24 revealed during Resident #15's hospitalization, she was found to have likely chronic obstructive pulmonary disease (COPD), hyponatremia, and concerns for syndrome of inappropriate antidiuretic hormone (SIADH), a condition where the body makes too much antidiuretic hormone which causes water retention, low sodium levels, and fluid overload which is usually treated with a fluid restriction. Review of Resident #15's physician orders revealed an order dated 05/21/24 for fluid restriction 1,200 milliliters (ml) every day and an order dated 10/04/24 for DNR Comfort Care. Review of Resident #15's quarterly Nutrition assessment dated [DATE] revealed the resident continued on a 1200 ml fluid restriction with no identification on how fluids would be dispersed or tracked. Review of the care plan initiated on 05/13/24 revealed Resident #15's code status was not addressed in the care plan. Review of the nutrition care plan created on 05/13/24 revealed Resident #15 was at risk due to having diagnoses of SIADH and fluid overload, being on a diuretic, a mechanically altered diet, and history of weight loss. Interventions listed did not address the fluid restriction. Interview on 10/09/24 at 10:12 A.M. with Dietitian #674 confirmed Resident #15's care plan did not have an intervention addressing the fluid restriction. Interview on 10/10/24 at 8:42 A.M. with MDS Coordinator/LPN #621 confirmed Resident #15's care plan did not address the resident's code status since the facility did not put code status in the care plan. Review of the facility policy Resident Care Plan dated 05/15 revealed the resident care plan is the tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate, and planned to meet the individual needs of the resident consistent with the physician's plan of care. Topics included in care plan but were not limited to problems relating to diagnosis, problems following physician's orders, dietary and nutritional status problems, problems related to preventative care, refusal of care and treatment, problems related to physical deficits and advance directives. Based on record review, interview, and review of the facility policy, the facility failed to ensure comprehensive care plans reflected advanced directives and indwelling urinary catheter use for Resident #262 and advanced directives and fluid restriction for Resident #15. This affected two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 7 of 19 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 10/10/2024 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 0657 residents (#15 and #262) out of 22 residents reviewed for care plans. The facility census was 60. Level of Harm - Minimal harm or potential for actual harm Findings include: Residents Affected - Few 1. Review of the medical record revealed Resident #262 was admitted to the facility on [DATE]. Medical diagnoses included acute kidney failure, calculus of kidney, obstructive and reflux uropathy, cognitive communication deficit, peripheral vascular disease, and occlusion and stenosis of bilateral carotid arteries. Review of the Medicare Five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #262 was severely cognitively impaired. Resident #262 was independent with eating, required setup or clean-up assistance with oral hygiene, partial to moderate assistance with upper body dressing and was dependent on staff for toileting hygiene, shower/bathing, lower body dressing and putting on and taking off footwear. Resident #262 had an indwelling urinary catheter and was frequently incontinent of bowel. Review of Resident #262 physician orders revealed an order that stated Do Not Resuscitate Comfort Care Arrest (DNR-CCA) dated 09/18/24. Further review revealed an order dated 09/18/24 that revealed Resident #262 had an indwelling urinary (Foley) catheter to closed drain and ensure the Foley catheter bag cover was in place. Review of Resident #262's care plan dated 09/19/24 revealed care plan did not include advanced directives or the use of an indwelling urinary catheter. Interview on 10/10/24 at 8:42 A.M. with MDS Licensed Practical Nurse (LPN) #631 stated that they do not put code statuses in the resident's care plans, confirming Resident #262's care plan did not include his code status. MDS LPN #631 further stated that it was not the facility policy to include code statuses in care plans. Interview on 10/10/24 at 8:49 A.M. with Assistant Director of Nursing (ADON) #626 confirmed Resident #262's care plan did not reflect the use of an indwelling urinary catheter. Review of the facility policy Resident Care Plan dated 05/15 revealed the resident care plan is the tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate, and planned to meet the individual needs of the resident consistent with the physician's plan of care. Topics included in care plans but were not limited to problems relating to diagnosis, problems following physician's orders, dietary and nutritional status problems, problems related to preventative care, refusal of care and treatment, problems related to physical deficits and advance directives. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 8 of 19 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 10/10/2024 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 Based on observation, record review, staff interview, and review of the facility policy, the facility failed to ensure Resident #16's medication was not left at bedside unsecured. This affected one resident (#16) out of five residents reviewed for medication administration. The facility census was 60. Residents Affected - Few Findings include: Review of the medical record for Resident #16 revealed an admission date of 05/31/22. Diagnoses included local infection of the skin and subcutaneous (under the skin) tissue, atherosclerotic heart disease, type two diabetes, chronic (congestive) heart failure (CHF), chronic kidney disease, permanent atrial fibrillation (irregular heart rhythm), schizoaffective disorder depressive type (involves both schizophrenia and a mood disorder). Review of Resident #16's physician orders reveal an order dated 09/10/24 for Potassium Chloride Extended Release 20 milliequivalent (mEq) give two tablets by mouth three times a day for health maintenance. Observation and Interview on 10/07/24 at 11:13 A.M. revealed there was a medicine cup with a one white pill sitting on Resident #16's overbed table. Interview at the time of observation with Resident #16 revealed the pill in her cup was her potassium. At the time of observation, Licensed Practical Nurse (LPN) #638 was observed at the medication cart in the common area and was asked to come into the resident's room. Observation and interview on 10/07/24 at 11:13 A.M. with LPN #638 confirmed the potassium pill was left at bedside. She stated due to the commotion of trying to find a multivitamin that had fallen and the resident asking to go to the restroom, she forgot to stay to ensure the medication was taken by the resident. Review of the facility policy titled Medication Administration, dated February 2022, revealed all medications would be administered safely and appropriately and medications would be administered only by licensed nursing personnel or by nursing students under the direct supervision of a licensed nursing instructor and or specific unit nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 9 of 19 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 10/10/2024 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff and resident interviews, medical record review, and facility policy review, the facility failed to track fluids consumed for Resident #15 as ordered by the physician. This affected one resident (#15) out of one resident reviewed for fluid restriction. The facility identified three residents (#15, #17, and #214) with physician's orders for fluid restrictions. The facility census was 60. Residents Affected - Few Findings include: Review of the medical record for Resident #15 revealed an admission date of 05/14/24. Diagnoses included other pulmonary embolism (blood clot in lung) without acute cor pulmonale (serious heart condition that develops as a complication of advanced lung disease), presence of cardiac pacemaker, type two diabetes mellitus with ketoacidosis (complication from having very high blood sugars) without coma, hypo-osmolality (condition of having abnormally low osmolality in the body fluids) and hyponatremia (concentration of sodium in blood is abnormally low), acute ischemic heart disease, and conduction disorder. Review of the physician progress note dated 05/13/24 revealed during Resident #15's hospitalization she was found to have likely chronic obstructive pulmonary disease (COPD), hyponatremia, and concerns for syndrome of inappropriate antidiuretic hormone (SIADH), a condition where the body makes too much antidiuretic hormone which causes water retention, low sodium levels, and fluid overload which is usually treated with a fluid restriction. Review of the nutrition care plan created on 05/13/24 revealed Resident #15 was at risk due to having diagnoses of SIADH and fluid overload, being on a diuretic, a mechanically altered diet, and history of weight loss. Interventions listed did not address the fluid restriction. Review of Resident #15's physician orders revealed an order dated 05/21/24 for fluid restriction 1,200 milliliters (ml) every day. Review of Resident #15's quarterly nutrition assessment, dated 08/27/24, revealed the resident continued a 1200 ml fluid restriction with no identification on how fluids would be dispersed or tracked. Review of the September 2024 and October 2024 Medication Administration Record (MAR) revealed nurses were acknowledging Resident #15 was on a 1200 ml fluid restriction, but there was documentation in the MAR on how the fluids were being dispersed or how much fluid the resident was consuming daily. Observation on 10/08/24 at 5:41 P.M. revealed Resident #15 received orange Jello with whipped topping for dessert. Interview on 10/08/24 at 5:43 P.M. with Registered Nurse (RN) #640 confirmed Resident #15 received the Jello and stated she shouldn't have received the Jello since she was on a fluid restriction. Interview on 10/09/24 at 9:18 A.M. with State Tested Nursing Assistant (STNA) #653 revealed she has never been told what residents are allowed to have while on a fluid restriction, but she would only give one drink with a meal. She stated for residents that had a physician's order for a fluid restriction, it would depend on the type of soup if they were allowed soup, but she knew they couldn't (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 10 of 19 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 10/10/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have Jello. She stated she had never been told how much fluid a resident could have with a meal when they were on a fluid restriction. Interview on 10/09/24 at 9:20 A.M. with STNA #655 revealed a paper comes up with the beverage cart tells them what residents were on a fluid restriction and the amount of fluids allowed in a 24 hour period. She stated she was never told how much fluid a resident was allowed when they were on a fluid restriction, but she stated one cup was 800 (ml) (one cup is 240 ml). Interview and observation on 10/09/24 at 10:02 A.M. with Registered Nurse (RN) #640 revealed the fluid restriction was broken down on a form kept on the nurse's cart. The form stated how the fluids would be dispersed when a resident was on a fluid restriction. There was a separate form for each resident on a fluid restriction. Observation of the notebook on the nurse's cart with RN #640, where the fluid restriction forms were kept, revealed there was no form for Resident #15's fluid restriction. Interview at the time of observation with RN #640 confirmed there was no form in the notebook on how fluids would be dispersed for the resident's 1200 ml fluid restriction. He confirmed there was no documentation in the medical record on how much the resident was consuming, and he had no way of knowing how much fluid the resident was consuming. Interview on 10/09/24 at 10:12 A.M. with Dietitian #674 stated there was supposed to be a fluid restriction breakdown on the nurse's cart but confirmed there was no documentation in the medical record on how much fluid was to be consumed for residents on a fluid restriction. Interview on 10/09/24 at 12:00 P.M. with Resident #15 revealed she had never been educated on the fluid restriction. She stated all she knows is that she is allowed to have one drink per meal and some water with her pills. She didn't know how much water she was allowed, and she didn't know what else she should be limiting while being on a fluid restriction. Review of the facility policy titled Fluid Restriction Policy, updated 04/12/16, revealed the purpose of the fluid restriction was to prevent fluid overload in patients at risk and to manage symptoms and improve overall health outcomes. The dietitian or designee would provide breakdown of fluids at med passes and meals. Nursing would then place the breakdown in the treatment book, track daily, and document if not being followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 11 of 19 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 10/10/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and review of the facility policy, the facility failed to ensure masks or pipes for the nebulizer (a machine that turns liquid medication into a fine mist) were covered when not in use for Resident #16 and #35. This affected two residents (#16 and #35) out of three residents reviewed for respiratory care. The facility identified 16 residents (#3, # 9, #10, #16, #20, #35, #39, #42, #44, #45, #50, #163, #164, #214, #215, #263) who used nebulizers. The facility census was 60. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 05/31/22. Diagnoses included chronic diastolic (congestive) heart failure (CHF), schizoaffective disorder-depressive type, other disorders of the lung, and depression. Review of the quarterly [NAME] Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively intact, required partial/moderate assistance from staff for most activities of daily living, including transfers, and supervision or touch assistance from staff for wheelchair mobility. Review of Resident #16's physician orders revealed an order dated 08/17/24 for one application of albuterol sulfate (a bronchodilator which helps to relax the muscles around the lungs to help improve breathing function) inhalation nebulization solution (2.5 milligram (mg)/three milliliters (ml)) 0.083 percent to be inhaled orally via nebulizer every six hours as needed for shortness of breath. Review of the October 2024 Medication Administration Record (MAR) revealed Resident #16 hadn't received any as needed albuterol sulfate treatments for shortness of breath. Review of the care plan initiated on 09/08/23 revealed Resident #16 had altered respiratory function related to CHF and history of pneumonia. Interventions included oxygen per physician orders, aerosol treatment per physician orders, monitor and report any significant changes to the physician, monitor and report to nurse/physician any signs or symptoms or respiratory distress, changes in breathing, respiratory rate, restlessness, chills, or fever, promote comfortable sleeping position by elevating head of bed as needed. Observation and interview on 10/09/24 at 2:35 P.M. with Registered Nurse (RN) #640 confirmed Resident #16's nebulizer pipe was uncovered and was sitting on the resident's bedside table. He stated it should be covered when not in use and could not answer why it was not covered. 2. Review of the medical record for Resident #35 revealed an admission date of 10/19/22. Diagnoses included acute and chronic respiratory failure, congestive diastolic (congestive) heart failure (CHF), chronic obstructive pulmonary disease (COPD), anxiety disorder, depression, and bipolar disorder. Review of Resident #35's physician orders revealed an order dated 09/24/24 for three ml to be inhaled four times a day for shortness of breath or wheezing of Ipratropium-Albuterol Inhalation Solution (respiratory inhalant combination) 0.5-2.5(3) mg/3 ml. Review of the October 2024 MAR for Resident #35 revealed Resident #35 received Ipratropium-Albuterol inhalation solution via a nebulizer machine three to four times a day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 12 of 19 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 10/10/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the quarterly MDS dated [DATE] revealed Resident #35 was moderately impaired cognitively, required substantial/maximum staff assistance for personal hygiene, chair to bed transfer, and mobility of her wheelchair, was dependent on staff for toileting hygiene, shower/bathe self, and shower transfers. Review of the care plan initiated on 09/08/23 which indicated Resident #35 had altered respiratory function related to CHF and COPD. Interventions included oxygen per physician orders, aerosol treatment per physician orders, monitor and report any significant changes to the physician, monitor and report to nurse/physician any signs or symptoms or respiratory distress, changes in breathing, respiratory rate, restlessness, chills, or fever, promote comfortable sleeping position by elevating head of bed as needed. Observation and interview on 10/09/24 at 2:35 P.M. with RN #640 confirmed Resident #35's nebulizer mask was uncovered and was sitting on the resident's bedside table. He stated it should be covered when not in use and could not answer why it was not covered. Interview on 10/09/24 at 2:41 P.M. with Admission/Infection Control RN #627 confirmed nebulizer pipes and masks should be rinsed, air dried after use, and then covered. Review of the facility policy titled Oral and Nasal Inhalations Administration Procedure effective dated 06/02/15 revealed before the next treatment, dissemble and clean the medicine chamber, adapter, mouthpiece or mask, and lid with soap and water, rinse thoroughly. Lay all pieces on a towel: cover with towel and air dry. Store in a clean plastic bag. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 13 of 19 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 10/10/2024 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, and review of facility mealtimes, the facility failed to ensure residents were offered a snack as required when there was greater than 14 hours between dinner and breakfast. This had the potential to affect all residents except for one resident (#44) identified by the facility as receiving nothing by mouth. The facility census was 60. Findings include: Interview on 10/08/24 at 11:52 A.M. with Resident #15 revealed the staff only bring snacks if you ask for them, and he gets hungry some nights. Interview on 10/08/24 at 11:54 A.M. with Resident #16 revealed she gets hungry at night, and the staff don't come around to ask if we want snacks. Observations during dinner time on 10/08/24 revealed Resident #6 received dinner at approximately 5:03 P.M. and breakfast on 10/09/24 at approximately 8:15 A.M., which was approximately 15 hours from dinner to breakfast, Review of undated facility document titled Hampton Woods Mealtimes revealed there were 15 hours between dinner and breakfast as evidenced by: Breakfast 1. [NAME] unit (400 rooms) 7:30 A.M. 2. Montauk unit (300 room) unit 7:50 A.M. 3. Bridge unit (100 rooms) 8:10 A.M. 4. [NAME] unit (200 rooms) 8:30 A.M. Lunch 1. [NAME] unit 11:30 A.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 14 of 19 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 10/10/2024 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 0809 2. Level of Harm - Minimal harm or potential for actual harm Montauk unit 11:50 A.M. 3. Residents Affected - Many Bridge unit 12:10 P.M. 4. [NAME] unit 12:30 P.M. Dinner 1. [NAME] unit 4:30 P.M. 2. Montauk unit 4:50 P.M. 3. Bridge unit 5:10 P.M. 4. [NAME] unit 5:30 P.M. Interview on 10/09/24 at 5:10 A.M. with State Tested Nurse Aide (STNA) #703 revealed snacks were upon request. Interview on 10/09/24 at 5:16 A.M. with STNA #672 revealed snacks were upon request. Interview on 10/09/24 at 5:20 A.M. with STNA #703 and STNA #668 revealed snacks were provided upon request. Interview on 10/09/24 at 5:40 A.M. with STNA #705 revealed snacks were provided upon request. Interview on 10/09/24 at 10:12 A.M. with Dietitian #674 confirmed there was greater than 14 hours between dinner and lunch, and all residents were not being offered a substantial snack by staff. She confirmed the residents had not voted to have meals greater than 14 hours. She stated logistically with the kitchen also feeding the assisted living and the rehab unit, it was hard to feed everyone 14 hours or less between dinner and breakfast. She stated residents could receive snacks if they asked for them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 15 of 19 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 10/10/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on record review and interview, the facility failed to ensure the Tuberculosis (TB) Risk Assessment was completed in an accurate manner. This had the potential to affect all residents who resided in the facility. The facility census was 60. Findings include: Review of the facility provided TB Risk Assessment revealed the assessment was completed on 01/2023. On 10/08/24 at 10:15 A.M. the Administrator was made aware that the TB Risk assessment provided was dated 01/2023 and was asked to provide an updated TB Risk Assessment. Review of updated facility provided TB Risk Assessment revealed a completion date of 01/2024. Interview on 10/08/24 at 11:45 A.M. with the Director of Nursing (DON) revealed the updated TB Risk Assessment was completed on 10/07/24. The DON further stated when she had gone through the state readiness binder to ensure everything was completed, she found that there was not an up-to-date TB Risk Assessment. The DON stated that was when she completed the TB Risk Assessment and dated it as completed 01/2024 when it was actually completed on 10/07/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 16 of 19 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 10/10/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation, record review, review of the memorandum, QSO-24-08-NH, entitled Enhanced Barrier Precautions in Nursing Homes and review of facility policy, the facility failed to ensure enhanced barrier precautions (EBP) were utilized during high contact resident care. This affected three residents (#54, #164, and #262) out of five residents observed for EBP. This had the potential to affect 22 residents (#1, #2, #3, #4, #7, #16, #21, #22, #27, #33, #37, #42, #44, #46, #54, #162, #164, #212, #214, #213, #262, and #264) who had orders for enhanced barriers. The facility census was 60. Residents Affected - Few Findings included: 1. Review of the medical record for Resident #164 revealed an admission date of 03/11/24 with diagnoses including hypertension, neoplasm of the kidney, hydronephrosis (swelling of one or both kidneys due to urine build up), diabetes, neuromuscular dysfunction of the bladder, presence of nephrostomy and percutaneous endoscopic gastrostomy (PEG) tube. Review of the undated care plan revealed Resident #164 had a self-care deficit with activities of daily living (ADL) related to decreased mobility, weakness, and amputation. Interventions included assistance with all bed mobility/transfers and anticipate the resident's needs in a timely manner. Review of the undated care plan revealed Resident #164 was incontinent of bowel and had an indwelling urinary catheter due to neurogenic bladder. Interventions included catheter care per the policy, assess and report any signs of impaired catheter integrity, and monitor and report any signs of infection. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #164 had impaired cognition and was dependent on staff for ADL including: toileting hygiene, dressing, rolling left and right (bed mobility), and transfers. She was always incontinent of bowel and bladder. Review of the October 2024 physician orders revealed Resident #164 had an order to cleanse around her nephrostomy tube insertion site and apply abdominal (ABD) pad with tape every day shift and as needed, hospice care, cleanse around PEG tube with normal saline and apply split sponge gauze every shift, EBP due to PEG tube, and EBP due to nephrostomy tube. Observation on 10/08/24 at 9:51 A.M. revealed Registered Nurse (RN) #800 entered Resident #164's room with her morning medications to administer orally as ordered. There was no signage on Resident #164's door that she was on EBP. After administering her medications, Hospice RN #801 entered the room and they both (RN #800 and Hospice RN #801) donned gloves but no other enhanced barriers including gowns and proceeded to provide high contact care including: rolling Resident #164 left and right as Resident #164 was dependent on staff on bed mobility, provided incontinence care as she was incontinent of bowel movement, and changed her nephrostomy tube dressing to her right lower back. Interview on 10/08/24 at 11:30 A.M. with RN #800 was asked how she determined which residents were on EBP due to no signage on the entry of the doors revealed if a resident had a urinary catheter or open area requiring a dressing then they needed to wear enhanced barriers. She revealed staff went by a purple magnet in the upper corner of the door frame as she pointed to the presence of the magnet to Resident 164's door frame that indicated she was on EBP. She verified she had not donned a gown during Resident #164's high contact care including bed mobility, incontinence care, and changing of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 17 of 19 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 10/10/2024 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 0880 her nephrostomy tube dressing because she forgot to. Level of Harm - Minimal harm or potential for actual harm Interview on 10/08/24 at 11:30 A.M. with Hospice RN #801 revealed that when she entered facilities, there was usually a sign on the entry door that indicated they were on any special precautions but verified Resident #164 was to be on EBP, and they should have worn a gown during her care. Residents Affected - Few 2. Review of the medical record for Resident #54 revealed she had an admission date of 07/27/24 with diagnoses including Alzheimer's disease, urinary retention, acute cystitis with hematuria (blood in urine), and rheumatoid arthritis. Review of Medicare five-day MDS assessment dated [DATE] revealed Resident #54 had impaired cognition. She was dependent on staff for ADL, including toileting hygiene, dressing, rolling left and right (bed mobility), and transfers. She was always incontinent with bowel and bladder. Review of the October 2024 physician orders revealed Resident #54 had an order dated 10/07/24 for EBP, indwelling urinary catheter due to obstructive and reflux uropathy and indwelling urinary catheter care twice a day. Review of the care plan dated 10/07/24 revealed Resident #54 had an indwelling urinary catheter due to urinary retention and she was frequently incontinent of bowel. Interventions included catheter care per policy, assess and report any signs of impaired catheter integrity, and monitor and report any signs of infection. Observation on 10/08/24 at 3:51 P.M. of Certified Nursing Assistant (CNA) #649 and CNA #661 revealed they entered Resident #54's room to provide care. There was no signage on the outside of her room that indicated Resident #54 was on EBP. Both performed hand hygiene and donned gloves but no other personal protective equipment (PPE) such as a gown. They proceeded to provide high contact care including indwelling urinary catheter care, turning in bed as she was totally dependent on staff rolling left and right, provided incontinence care as she was incontinent of bowel movement, and assisting Resident #54 out of bed with the use of a mechanical lift to her wheelchair. Interview on 10/08/24 at 4:05 P.M. with CNA #649 and CNA #661 verified they had not worn appropriate PPE including gowns during the above care. CNA #661 stated, oh my goodness, I completely forgot as she revealed there was no sign on the outside of the door to remind staff that a resident was on EBP. CNA #649 revealed staff were to go by the small purple magnet in the corner of the doorframe indicating a resident was on EBP as he pointed to the magnet to the top corner of Resident #54's doorframe. CNA #649 revealed often they get caught up in providing care and forget to look. They verified Resident #54 was to be on EBP as she had an indwelling urinary catheter, and they should have worn gowns during her care. Interview on 10/09/24 at 2:30 P.M. with Admission/ RN/ Infection Control #627 revealed EBP were required for any high contact care including for residents with wounds, indwelling catheter, nephrostomy tubes, intravenous catheters besides peripheral access, and PEG tubes. She revealed all residents on EBP were identified with a purple magnet to the upper corner of the doorframe as the facility was trying to provide dignity and not call attention to residents on EBP as often then there is a stigma as to what was wrong with that person. She verified in the incidents observed that staff should have worn appropriate PPE, including gowns when providing high contact care especially with indwelling urinary catheter care, and nephrostomy tube dressing change. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 18 of 19 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 10/10/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Review of the memorandum, QSO-24-08-NH, entitled Enhanced Barrier Precautions in Nursing Homes, dated 03/20/24, by the Centers for Medicare & Medicaid Services, Department of Health & Human Services revealed EBP were indicated for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a multidrug-resistant organism (MDRO). The effective date for implementation of EBP under the guidelines was 04/01/24. Residents Affected - Few Review of the facility policy labeled, Enhanced Barrier Precautions (EBP) dated April 2024 revealed the purpose of the policy was to follow the most current recommendation of the center of the disease control (CDC) and the prevention of transmitting MDRO from one resident to another. The policy revealed EBP would be followed to prevent the transfer of MDRO during high contact care activities for residents. This was applicable to include people with indwelling medical devices including urinary catheters, central vascular lines, tracheostomies, enteral feeding tubes, wound drains, and persons with chronic wounds. 3. Review of the medical record revealed Resident #262 was admitted to the facility on [DATE]. Medical diagnoses included acute kidney failure, calculus of kidney, obstructive and reflux uropathy, cognitive communication deficit, peripheral vascular disease, and occlusion and stenosis of bilateral carotid arteries. Review of the Medicare Five Day MDS assessment dated [DATE] revealed Resident #262 was severely cognitively impaired. Resident #262 was independent with eating, required setup or clean-up assistance with oral hygiene, partial to moderate assistance with upper body dressing and was dependent on staff for toileting hygiene, shower/bathing, lower body dressing and putting on and taking off footwear. Resident #262 had an indwelling urinary catheter and was frequently incontinent of bowel. Review of Resident #262's physician orders revealed an order dated 09/19/24 for EBP due to indwelling urinary (Foley) catheter and deep tissue injury (DTI) to the left heel (A purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue). Observation on 10/07/24 at 12:01 P.M. of Resident #262 room revealed no evidence of an EBP sign indicating the need to wear PPE during hands on care. Observation on 10/09/24 1:12 P.M. of indwelling urinary catheter care for Resident #262 revealed State Tested Nurse Aide (STNA) #654 and STNA #666 knocked on door, entered resident room, performed hand hygiene and put on clean gloves. STNA #654 and STNA #666 started providing catheter care for Resident #262 with gloves being the only PPE that was worn. Once catheter care was completed, STNA #654 and STNA #666 removed their soiled gloves and performed hand hygiene. Interview on 10/09/24 at 1:20 P.M. with STNA #654 and STNA #666 confirmed the only PPE they used during catheter care was gloves. STNA #654 and STNA #666 confirmed that Resident #262 was in EBP and that they should have also worn gowns during catheter care. Interview on 10/09/24 at 2:30 P.M. with Infection Control Registered Nurse (RN) #627 stated residents who have PEG tubes, surgical wounds, Foley catheters, and peripherally inserted central catheter (PICC) were placed in EBP. Those residents identified as needing EBP get a small purple magnet above their door that identifies that they are in EBP. During care such as catheter care, wound care, turning and repositioning staff would wear designated PPE. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366329 If continuation sheet Page 19 of 19