Health inspection·December 31, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of the safety data sheets, and policy review, the facility failed to ensure the resident environment was free of accident hazards. This affected four (#01, #16, #26 and #54) out of four residents reviewed and had the potential to affect all seven (#01, #16, #26, #33, #51, #54 and #64) independently mobile residents who reside in the memory care unit. The facility census was 64.Findings include-Based on observation, interview, review of the safety data sheets, and policy review, the facility failed to ensure the resident environment was free of accident hazards. This affected four (#01, #16, #26 and #54) out of four residents reviewed and had the potential to affect all seven (#01, #16, #26, #33, #51, #54 and #64) independently mobile residents who reside in the memory care unit. The facility census was 64.Findings Include:1. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included anxiety disorder, dementia in other diseases classified elsewhere, severe with other behavioral disturbance, major depressive disorder, attention-deficit hyperactivity disorder, hallucinations, and post-traumatic stress disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 had severe cognitive impairment, supervision with eating, substantial assistance with toileting, dependent with bathing, and partial assistance with personal hygiene. 2. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses included Alzheimer ' s disease with late onset, dementia, anxiety disorder, and adult failure to thrive. Review of the most recent MDS 3.0 assessment revealed Resident #16 had severe cognitive impairment, supervision with eating, dependent with toileting, dependent with bathing, and supervision with personal hygiene. 3. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia, vascular dementia, depression, amnesia, and cerebral infarction. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #26 had moderately impaired cognition, supervision with eating, independent with toileting, supervision with bathing, and independent with personal hygiene. 4. Review of the medical record Resident #54 was admitted to the facility on [DATE]. Diagnosis included Alzheimer ' s disease, unspecified dementia, other symptoms and signs involving cognitive functions and awareness, and personal history of other diseases of the nervous system and sense organs. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #54 had severe cognitive impairment, supervision with eating, independent with toileting, dependent with bathing, and supervision with personal hygiene. Observation and interview on 12/31/25 at 10:30 A.M. the State Tested Nurse Aide (STNA) #50 verified the central bathing door was unlocked with one large jug of soap with no lid and five razors sitting on the table directly inside the door. The STNA #50 verified the door was unlocked due to being broken and the medication room unlocked as well. Interview on 12/31/25 at 10:35 A.M. Licensed Practical Nurse (LPN) #36 verified the medication room door was unlocked with items in the cabinets included the following:Five insulin syringes with needlesFive razorsOne tub of Clorox wipes 75 countAcetaminophen (pain reliever) 325 milligrams (mg) two full bottles One bottle of vitamin D3 50 micrograms (mcg) 250 tabletsOne bottle of cimetidine (acid reducer) 200 mg 60 tab bottle Six bottles of acetic acid irrigation 500 milliliters (ml) in eachTwo jugs of drug busterTwo bottles of hand sanitizer LPN #36 verified the medication room door had been unlocked for about one hour. Review of the safety data sheet (SDS) for drug buster dated 10/10/14 identifies the hazard of eye damage/irritation, skin sensitization, skin corrosion/irritation. Review of the SDS for Clorox commercial solutions dated 06/02/20 states handle in accordance with good industrial hygiene and safety practice. Review of the SDS for germ-x hand sanitizer dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366417 If continuation sheet Page 2 of 6 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 12/31/2025 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 01/16/15 identifies the hazard of flammable liquid and vapor. Review of the SDS for Lysol dated 07/30/21 identifies the hazard flammable aerosol, causes eye irritation. Review of the SDS for body wash dated 01/07/15 identifies storage as keep out of reach of children, store in a dry, well-ventilated place away from incompatible materials. Review of the SDS for Refresh tears dated 11/07/23 states handle in accordance with good industrial hygiene and safety practice. Review of the SDS for Ear Wax Remover dated 07/28/14 identifies the hazard causes serious eye irritation. Review of the policy titled, Medication Storage, dated 11/01/23 all drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. Review of the policy titled, Dementia Care, dated 11/01/23 care and services will be person-centered and reflect each resident ' s individual goals while maximizing the resident ' s dignity, autonomy, privacy, socialization, independence, choice, and safety. Event ID: Facility ID: 366417 If continuation sheet Page 3 of 6 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 12/31/2025 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)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and policy review, the facility failed to adequately monitor the administration of warfarin. This affected one (#56) of five residents reviewed for unnecessary medications. The facility census was 64.Findings include-Based on medical record review, interview, and policy review, the facility failed to adequately monitor the administration of warfarin. This affected one (#56) of five residents reviewed for unnecessary medications. The facility census was 64.Findings Include:Review of the medical record revealed Resident #56 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease late onset, epilepsy, major depressive disorder, peripheral vascular disease, chronic embolism and thrombosis of unspecified vein, and essential hypertension.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #56 had severely impaired cognition, required supervision with eating, dependent with toileting, and dependent with bathing.Review of Resident #56 provider order dated 04/14/25 revealed warfarin (a blood thinning medication) sodium oral tablet five milligrams (mg) give one tablet by mouth in the evening related to chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity. Collect a prothrombin time/international normalized ratio (PT/INR) weekly on Monday.Review of Resident #56's laboratory results for PT/INR were 11/17/25 PT 24.4 and INR 2.3 with progress note Nurse Practitioner (NP) aware, orders for this visit, please continue coumadin five mg daily and repeat INR in one week.Review of Resident #56 lab results for PT/INR were 12/03/25 PT 24.2 and INR 2.3. Review of Resident #56 lab results for PT/INR were 12/19/25 PT 36.8 and INR 3.5 with progress note, orders for this visit, hold coumadin dose tonight times one and repeat PT/INR tomorrow and notify of results.Review of Resident #56 lab results for PT/INR were 12/23/25 PT 14.7 and INR 1.4.Review of Resident #56 lab results for PT/INR were 12/29/25 PT 23.2 and INR 2.2.Review of Resident #56 medical record revealed no PT/INR for 11/24/25, 12/01/25, 12/08/25, 12/15/25, 12/20/25 and 12/22/25.Review of Resident #56 progress note dated 12/26/25 revealed the patient was seen for an acute care visit for decreased INR. The patient was on long-term Coumadin therapy for chronic embolism and thrombosis. The most recent INR was 1.4, which was below the target range. INR recheck was planned, but no new results were available yet. Please keep Coumadin at five mg daily and check if the INR lab was actually done. Weekly Monday INR checks were needed for safe monitoring.Review of Resident #56 care plan dated 07/22/24 revealed currently prescribed an anticoagulation medication therapy with the intervention of will monitor PT/INR. Interview on 12/30/25 at 7:55 A.M. with the Director of Nursing (DON) verified no PT/INR for Resident #56 was completed on the following dates: 11/24/25, 12/01/25, 12/08/25, 12/15/25, 12/20/25 and 12/22/25 and was unsure as to why the labs were missed, the nurses should not administer the dose of warfarin with no PT/INR lab results.Interview on 12/30/25 at 8:26 A.M. with the Nurse Practitioner (NP) #80 verified the PT/INR for Resident #56 was missed a few times in the last month and she was currently working with the DON to come up with a resolution as the PT/INR was important to have drawn to monitor for a therapeutic level of warfarin. The NP #80 additionally verified she stressed to the DON that Resident #56 needed the PT/INR drawn every Monday.Review of the policy titled, High Risk Medications Anticoagulants, dated 02/05/25 reads routine labs, including baseline and subsequent labs, shall be ordered for each resident requiring anticoagulant medication. Results shall be communicated to the physician in a timely manner. Review of the policy titled, Coumadin Monitoring, dated 06/22 it reads Coumadin will be administered in the evening to ensure lab results are received and reported prior to administering the dose on the date of the lab draws. Review of the policy titled, Laboratory Services and Reporting, dated 11/29/23, reads the facility must provide or obtain laboratory services to meet the Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366417 If continuation sheet Page 4 of 6 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 12/31/2025 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)

F 0757 needs of its residents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366417 If continuation sheet Page 5 of 6 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 12/31/2025 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and policy review, the facility failed to ensure laundry was stored to prevent the spread of infection. This had the potential to affect all 64 residents who reside in the facility. The facility census was 64.Findings Included:Based on observation, interview and policy review, the facility failed to ensure laundry was stored to prevent the spread of infection. This had the potential to affect all 64 residents who reside in the facility. The facility census was 64.Findings Included:Observation on 12/31/25 at 8:35 A.M. with the Environmental Manager (EM) #39 of the 300 hall central bath with a linen cart with four shelves filled with linens, towels, washcloths, and other miscellaneous items had a front flap that was opened up and on top of the cart, leaving all of the items on the cart exposed. The bathtub was about one foot from the cart. Interview on 12/31/25 at the time of the observation the EM #39 stated the cover was constantly up and the items were exposed when housekeeping goes in multiple times per day in all of the central bath rooms. Continued observation revealed the 200 hall central bath room with a linen cart designed the same as the 300 hall central bath with the linen cart flap open and on top with items on top of the flap. The cart was about two feet from the bathtub. Continued observation of the 100 hall central bath with a linen cart the same design as the 200 and 300 hall central baths with the flap open with items on the top of the flap. The EM #39 verified the flaps were all up and not covering the items on the cart and could be exposed to bacteria from the bathtub. Review of the policy titled, Handling Clean Linen, dated 11/01/23 clean linen shall be delivered to resident care units on covered linen carts with covers down. Nothing shall be kept on top of linen carts. Only rolls of bags used for linen transport may be kept on the carts, in the designated pockets only. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366417 If continuation sheet Page 6 of 6