Health inspection·April 29, 2021

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** Based on record review and resident and staff interviews, the facility failed to hold initial care planning conferences for new admissions to the facility. This affected one (#27) of one resident sampled for care planning conferences. The facility census was 40 residents. Findings include: Record review for Resident #27 revealed the resident was admitted to the facility on [DATE]. Diagnoses included low back pain, hyperlipidemia, osteoarthritis, hypothyroidism, seizures, anxiety disorder, hypokalemia, history of falls, obesity, insomnia, weakness, depressive episodes, and edema. Review of the admission Minimum Data Set (MDS) assessment, dated 03/03/21 revealed Resident #27 was assessed with no cognitive deficit. The record was silent for an initial care planning conference. Interview on 04/26/21 at 1:50 P.M., with Resident #27 revealed the facility had not invited the resident to attend care conference after admission to the facility. Interview on 04/29/21 at 9:44 A.M. with Social Service (SS) #50 revealed an understanding that care conferences were done every three months after admission and confirmed a care conference was not completed upon admission for Resident #27. SS #50 stated she does an admission note but not a care conference and was not instructed to complete an admission care conference on new residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366417 If continuation sheet Page 2 of 9 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 366417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copper Knoll Health & Rehab LLC 201 Courthouse Parkway Washingtn C H, OH 43160 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, review of the facility's policy and staff interviews, the facility failed to ensure activities were provided to meet the needs of Resident #25. This affected one (Resident #25) of three residents reviewed for activities. This had the potential to affect all seven residents (Resident #1, #3, #8, #11, #25, #32, and #33) residing on the memory care unit. The facility census was 40. Residents Affected - Some Findings include: Review of the medical record for Resident #25 revealed an admission date of 08/24/19. Diagnoses included Alzheimer's disease and aphasia. Review of the five-day Minimum Data Set (MDS) assessment, dated 02/22/21, revealed Resident #25 was unable to complete the interview for the brief interview for mental status assessment. Review of the annual MDS assessment dated [DATE] revealed it was very important for Resident #25 to have books, newspapers, and magazines to read, listen to music she likes, do things with groups of people, do her favorite activities, go outside when the weather was nice, and participate in religious services/practices. It was somewhat important for Resident #25 to keep up with the news. Review of Resident #25's comprehensive care plan revealed a problem of Resident #25 spends most of the time alone or watching television and had little or no involvement in activity programs with interventions including to introduce to other residents with similar interests/disabilities/limitations, invite to scheduled activities, offer a variety of activity types and locations, offer to assist/escort resident to activity functions, remind resident that they may leave activities at any time and are not required to stay for the entire activity, and resident likes to have her hair brushed due to it calming her. Review of the Resident #25's activity attendance records dated April 2020, revealed she was not marked as attending or refusing any activities on 04/01/21, 04/05/21, 04/06/21, 04/11/21, 04/14/21, 04/16/21, 04/17/21, 04/18/21, 04/20/21, 04/21/21, and 04/26/21. Review of the facility's April 2021 activity calendar revealed no structured activities were scheduled on 04/01/21 through 04/11/21 as well as on 04/17/21, 04/18/21, and 04/25/21. Observations of Resident #25 on 04/26/21 at 11:10 A.M., 12:16 P.M., 3:00 P.M., and 3:51 P.M., all revealed Resident #25 was in her room laying in her bed. On 04/27/21 at 3:35 P.M. and 4:16 P.M., she was laying in bed with the television on. On 04/28/21 at 9:43 A.M., she was laying in bed in her room. On 04/28/21 at 1:37 P.M., she was seated in her wheelchair in the common area with the television on. On 04/28/21 at 2:55 P.M., Resident #25 was in her wheelchair in the common area and the television was on. On 04/28/21 at 4:00 P.M., Resident #25 was in her wheelchair in the corner of the common area. The television was observed to be on however Resident #25 was not observed to be able to see the television from where she was seated. Interview with State Tested Nurse Aide (STNA) #54 on 04/28/21 at 5:26 P.M. revealed the STNAs were currently responsible for activities on the memory care unit. She stated there has been minimal structured activities on the memory care unit since the activities staff resigned several months ago. STNA #54 stated she tries to complete activities with residents however it was hard to complete structured activities when there was no activities staff. The quality and quantity of activities on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366417 If continuation sheet Page 3 of 9 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 366417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copper Knoll Health & Rehab LLC 201 Courthouse Parkway Washingtn C H, OH 43160 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some memory care unit has declined over the past several months since the activities staff resigned. STNA #54 stated she tries to give residents coloring books or puzzles as well as do their nails for activities. She stated carnival day was scheduled for 04/28/21 however Resident #25 did not attend carnival day due to staff only being able to take a few of the residents from the memory care unit. The STNAs were unable to complete all of the activities with the residents on the memory care unit due to having to provide care to them. The residents on the memory care unit used to participate in more activities when the facility had designated activities staff. Interview with Physical Therapy Assistant #75 on 04/29/21 at 2:40 P.M. revealed she has been assisting with activities on the memory care unit. She verified there were no structured activities on the memory care unit due to residents with different cognition levels. Prior to the COVID-19 pandemic when there was more activities staff, there were more structured activities on the memory care unit. She stated Resident #25 enjoyed playing with the knob board and fake cat, as well as having her nails/hair done. Review of the facility's census and room number roster revealed Resident #1, #3, #8, #11, #25, #32, and #33 resided on the memory care unit. Review of the facility's undated policy titled Activity Policy and Procedure revealed the activity department will be responsible for planning, implementation, and scheduling of activity programs, encouraging and stimulating residents to have a fuller and richer life, plan programs based on resident needs, interests and abilities, and offer in-room self directed activities as well as one to one visits to residents that choose not to attend group activities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366417 If continuation sheet Page 4 of 9 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 366417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copper Knoll Health & Rehab LLC 201 Courthouse Parkway Washingtn C H, OH 43160 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. Based on observation, review of manufacturer's recommendations and staff interview, the facility failed to dispose of outdated insulin and failed to date open vials of insulin with the date when opened. This affected one (#11) of eight residents identified by the facility who receive insulin. The facility census was 40 residents. Findings include: On 04/29/21 at 10:09 A.M., an observation in the Fall unit medication cart with Licensed Practical Nurse (LPN) #56 revealed an open vial of Lantus insulin with a date when opened of 03/08/21, and two open vials of Lantus insulin with no date when opened for Resident #11. On 04/29/21 at 10:09 A.M., an interview with LPN #56 confirmed the findings and verified the open vials of Lantus insulin should be disposed of after 28 days after opened and all opened vials of insulin should have the date when opened noted on the vial. Review of the manufacturers's recommendations for Lantus insulin revealed the Lantus insulin must be discarded 28 days after opened. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366417 If continuation sheet Page 5 of 9 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 366417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copper Knoll Health & Rehab LLC 201 Courthouse Parkway Washingtn C H, OH 43160 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, record review, and review of the facility's policy, the facility failed to ensure resident foods in the unit refrigerators were dated and/or labeled and thickened water was not expired. This had the potential to affect 39 of 40 residents who receive food from the kitchen (Resident #26 received nothing by mouth). Findings include: 1. Observation of the 200 hall unit refrigerator on 04/29/21 at 2:21 P.M. revealed two eggs in a bag in the refrigerator with no name or date. Interview with Minimum Data Set (MDS) Nurse #3 on 04/29/21 at 2:21 P.M. verified the two eggs had no name or date. 2. Observation of the Fall hall unit refrigerator on 04/29/21 at 2:25 P.M. revealed four white castle sandwiches with no name or date and a partially used container of lemon flavored nectar consistency water with an open date of 01/12/21. Observation of the lemon flavored nectar consistency water packaging revealed the product was to be used within seven days of opening. Interview with MDS Nurse #3 on 04/29/21 at 2:25 P.M. verified Fall hall unit refrigerator had four white castle sandwiches with no name or date and verified the lemon flavored nectar consistency water was partially opened, had an open date of 01/12/21, and was to be used within seven days of opening. Review of the facility's list of residents and their diets revealed Resident #26 was on a nothing by mouth diet and the only resident who didn't receive food from the kitchen. Review of the facility's policy titled Resident Food Storage and Handling, last revised November 2017, revealed the resident food will be kept for five days from the label date and then discarded except: condiment-type foods will be kept for two months/60 days, and non-perishable drinks and frozen foods will be kept for one month/30 days. Any food or beverage that is not labeled with resident name and dated will be discarded immediately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366417 If continuation sheet Page 6 of 9 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 366417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copper Knoll Health & Rehab LLC 201 Courthouse Parkway Washingtn C H, OH 43160 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 - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review for Resident #27 revealed the resident was admitted to the facility on [DATE]. Diagnoses included low back pain, history of motor vehicle accident with severe back injuries, and osteoarthritis. Review of the admission Minimum Data Set (MDS) assessment, dated 03/03/21 revealed the resident was cognitively intact and was on a scheduled pain regimen and was in constant pain. Review of the physician order sheet, dated 03/2021 and 04/2021, revealed an order, dated 02/24/21, for Morphine Sulfate IR (immediate release) (narcotic used to treat moderate to severe pain) 15 milligrams (mg.) one tablet every twelve hours as needed for moderate pain. Review of the resident's narcotic sign out sheet and the resident's medication administration record (MAR) revealed they did not correspond on the following dates and times: On 03/10/21, the narcotic sign out sheet revealed two doses were signed out on 03/10/21 at 6:30 A.M. and 6:30 P.M. but the MAR were not marked as administered on 03/10/21. On 04/02/21, the Morphine Sulphate IR was signed out at 1:00 P.M., but the MAR record was silent for the 1:00 P.M. dose marked as given. On 04/03/21, the narcotic sign out sheet revealed two doses of Morphine Sulfate IR 15 mg. were signed out at 1:00 A.M. and at 2:30 P.M., but the MAR revealed three doses were marked as administered on 04/03/21 at 1:00 A.M., at 1:00 P.M. and at 2:30 P.M. On 04/07/21 the Morphine Sulphate IR was signed out at 4:30 A.M. on the narcotic sign out sheet, but the MAR record was silent for the 4:30 A.M. dose marked as administered. On 04/08/21, the Morphine Sulphate IR was signed out at 10:00 P.M. on the narcotic sign out sheet, but the MAR record was silent for the 10:00 P.M. dose marked as administered. On 04/09/21, the narcotic sign out sheet revealed two doses were signed out at 10:00 A.M. and at 10:00 P.M., but the MAR had three doses marked as administered at 10:00 A.M., 10:00 P.M., and at 2:00 P.M. On 04/012/21, the Morphine Sulphate IR was signed out at 3:30 A.M. on the narcotic sign out sheet, but the MAR record was silent for the 3:30 A.M. dose marked as administered. On 04/17/21, the Morphine Sulphate IR was signed out at 6:45 P.M. on the narcotic sign out sheet, but the MAR record was silent for the 6:45 P.M. dose marked as administered. On 04/24/21, the Morphine Sulphate IR was signed out at 3:00 A.M. on the narcotic sign out sheet, but the MAR record was silent for the 3:00 A.M. dose marked as administered. Interview on 04/29/21 at 9:01 A.M. with the Director of Nursing (DON) revealed the facility did a quality assurance performance improvement (QAPI) plan on signing out narcotics three or four months ago. The DON confirmed Resident #27's signed out narcotics where not documented accurately on the MAR as administered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366417 If continuation sheet Page 7 of 9 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 366417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copper Knoll Health & Rehab LLC 201 Courthouse Parkway Washingtn C H, OH 43160 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 Based on record review, review of the facility's policy, and staff interview, the facility failed to accurately document resident supplements and administration of a resident's narcotics. This affected two (Resident #3 and #22) of four residents reviewed for nutrition and one (Resident #27) of five residents for unnecessary medications. The facility census was 40. Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #3 revealed an admission date of 08/12/19 with diagnoses including dementia and dysphagia. Review of the active physician orders revealed an order dated 08/15/19 for a magic cup (high calorie nutritional supplement) twice a day with lunch and dinner. Review of the April 2021 medication administration records (MAR) revealed Resident #3 received a magic cup with lunch and dinner until 04/23/21 when it was crossed out and marked as discontinued. There was no documentation of Resident #3 receiving the magic cup twice a day after it was crossed out and marked discontinued on 04/23/21. Review of the physician orders revealed an order dated 01/15/21 for Two Cal supplement (high calorie nutritional supplement) 240 milliliters three times a day. Review of the physician orders revealed an order dated 04/22/21 for Two Cal 240 milliliters to be increased to four times a day. Review of the April 2021 MAR revealed Resident #3 was ordered Two Cal 240 milliliters four times a day however there were only three slots available each day for documentation of administration of the Two Cal and Resident #3 was only documented as having received it three times a day from 04/23/21 through 04/28/21. Interview with Registered Dietitian (RD) #76 on 04/29/21 at 1:05 P.M. revealed Resident #3 received Magic Cup twice daily with lunch and dinner and it was never discontinued. She verified Resident #3 was ordered Two Cal 240 milliliters four times a day and received it four times a day. RD #76 stated she does not know why the fourth slot for the Two Cal 240 milliliters was not added to the MAR on 04/23/21 when it was increased. Interview with the Director of Nursing (DON) on 04/29/21 at 1:58 P.M. revealed Resident #3 received Two Cal 240 milliliters four times a day since it was increased on 04/23/21. The staff forgot to add the fourth slot in order to document the administration of the additional 240 milliliters of Two Cal. The DON verified Resident #3 has been receiving magic cup twice daily with lunch and dinner despite it having been marked discontinued on 04/23/21. 2. Review of the medical record for Resident #22 revealed an admission date of 05/17/19 with diagnoses including depression and chronic obstructive pulmonary disease. Review of the February 2021 physician orders revealed Resident #22 was ordered Magic Cup twice a day and Mighty Shakes (high calorie nutritional supplement) two shakes with each meal. The physician orders for March 2021 revealed no order for Magic Cup twice a day or Mighty Shake two shakes with each meal. The physician orders for April 2021 revealed an order dated 04/14/21 for Magic Cup twice a day and there was no order for Mighty Shake two shakes with each meal. There were no physician orders to discontinue the Magic Cup or Mighty Shakes despite they were not on the MAR for March 2021 and during part of April 2021. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366417 If continuation sheet Page 8 of 9 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 366417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copper Knoll Health & Rehab LLC 201 Courthouse Parkway Washingtn C H, OH 43160 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 There was no documentation of Resident #22 having been ordered or received Magic Cup twice a day or Mighty shake two shakes with each meal for March 2021 MAR. There was no documentation of Resident #22 having been ordered or received Mighty shake two shakes with each meal for April 2021 MAR. Resident #22 was re-ordered Magic Cup twice a day on 04/14/21 and was documented as receiving it twice a day from 04/15/21 through 04/27/21. Residents Affected - Few Interview with RD #76 on 04/29/21 at 1:05 P.M. revealed Resident #22 was receiving Mighty Shakes two shakes with each meal and Magic Cup twice a day due to weight loss. Resident #22 received the supplements despite them not being ordered in the physician orders or documented on the March 2021 MAR or April 2021 MAR prior to 04/14/21. Interview with the DON on 04/29/21 at 1:58 P.M. revealed Resident #22 received Mighty Shakes two shakes with each meal and Magic Cup twice a day between 03/01/21 and 04/14/21. The DON verified Resident #22's Mighty Shakes and Magic Cups were not documented on the MAR between 03/01/21 and 04/14/21 and his physician orders list between 03/01/21 and 04/14/21 do not include the orders for Mighty shake two shakes with each meal and Magic Cup twice a day despite Resident #22 having received both. The DON further verified the April 2021 MAR still does not document Resident #22 having received his Mighty Shake two shakes with each meal despite having received them. Review of the facility's undated policy titled Nursing Standards of Practice revealed documentation guidelines pertinent to good clinical record practice will be followed by all individuals who document in the patient's/resident's record. A complete health picture of the patient/resident must be available to all disciplines contributing to patient/resident care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366417 If continuation sheet Page 9 of 9