Health inspection·August 11, 2025

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. Based on record review, facility staff interview and facility policy review, the facility failed to ensure allegations of abuse were reported in a timely manner. This had the potential to affect 62 of 62 residents. Findings included:Review of a self-reported incident (SRI) dated 03/31/25 revealed on 03/29/25 at about 11:30 A.M., a visitor to the facility was heard speaking loudly to Resident #13 and #32, telling them they could not sit at the table they were at and it belonged to her mother and her friends. The visitor told Residents #13 and #32 no one likely them and they had been told before not to sit at this table. Licensed Practical Nurse (LPN) #101 immediately intervened and addressed the visitor who immediately reported the incident to the weekend manager and called the Administrator. After documentation from the weekend was reviewed, it was determined the incident was more than a visitor being rude. Review of a statement by Resident #1 dated 03/31/25 revealed she was sitting at a table when a family member came in and in a loud voice said, we're going to put the tables together and I think you should move. Resident #1 said she couldn't remember if anything else was said but acknowledged this was not the first time that person told her to move. Resident #1 stated she was upset and didn't want to go back to the dining room, and wondered how that person would feel if someone treated their mother like that. Resident #1 was teary-eyed during the interview. Review of a statement by Resident #2 dated 03/31/25 revealed a family member yelled at her and Resident #1 wanting them to move from a table. Resident #2 stated she was mad and didn't like the drama. Review of a witness statement dated 04/01/25 by Activities Staff (AS) #110 revealed she witnessed a family member tell Resident #1 she could not sit at the table she had already been sitting at. AS #110 stated it was very loud and upset Resident #1 who stated she felt bullied. Review of a statement dated 04/01/25 by Staff #113 revealed she walked into the dining room to help residents get set up for lunch, Resident #1 was sitting at a table and a family member started yelling at her and saying, you can't sit here, other people are sitting here, and you don't belong here. The family kept repeating those sentences. A nurse intervened and the family denied saying anything wrong. Review of a statement dated 04/01/25 by Registered Nurse (RN) #132 revealed a family member brings in treats for certain residents to the dining room and once told a resident who didn't eat her treat she could not get one next time. Review of a statement dated 04/01/25 by Certified Nursing Assistant (CNA) #121 revealed a family member brings in food for residents who sit at the same table, some get the food and some do not get the food, leaving some residents feeling left out. The family tried to tell residents where they could or could not sit and has made residents move, has been rude, and has made residents not want to eat in the dining room. Review of a statement dated 04/01/25 by CNA #125 revealed a family member tells residents where they can and can't sit while in the dining area, has been asked not to move the tables together and continues to do so. Residents were beginning to refuse to come to the dining room due to the family member being present. Review of a statement dated 04/03/25 at 12:08 P.M. by CNA #120 revealed she was walking to the dining room to speak to the nurse, and (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 366417 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 08/11/2025 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)