Inspection·December 20, 2023

F 0600 every six hours as needed when requested. Level of Harm - Minimal harm or potential for actual harm Review of the Self-Reported Incident and facility investigation dated 12/09/23 revealed the facility substantiated an allegation of misappropriation of narcotics by Licensed Practical Nurse (LPN) #710 affecting Resident #25 and Resident #38. LPN #710 was indefinitely suspended on 12/09/23 pending results of the investigation and the local police were notified. The incident was reported to the Ohio Board of Nursing on 12/11/23. The local police department determined there was sufficient information to issue a warrant for LPN #710. LPN #710's employment was terminated on 12/11/23. The DON determined 85 doses of oxycodone were taken by LPN #710 from Resident #25 and #38 who were interviewed by the DON and stated they did not miss any doses of their oxycodone and were medicated for pain upon request. Residents Affected - Few Review of the Ohio Department of Health Bureau of Regulatory Operations Misappropriation Final Investigation, dated 12/21/23, revealed LPN #210 confessed to misappropriation of the oxycodone belonging to Resident #25 and #38. Interviews conducted on 12/20/23 at 12:57 P.M. and 1:00 P.M. with Residents #25 and #38 revealed they did not miss any doses of their pain medications and the facility replaced stolen medications at no cost to them. They stated they had no adverse effects related to the incident. Interview on 12/20/23 at 1:25 P.M. with the Director of Nursing (DON) revealed she was notified by the oncoming day shift nurse the narcotic count was wrong on 12/09/23 with multiple narcotic count sheets missing and the associated cards for Residents #25 and #38. The DON stated LPN #710 was identified by nursing staff as the nurse on duty the night of 12/08/23. When the DON questioned LPN #710 about the missing narcotics, she stated she accidentally threw them away. LPN #710 was immediately suspended, and an investigation was started. A drug test was completed on LPN #710 and the two other nurses in the building and all tests came back negative. All three nurses were asked to write statements as to what happened and how many narcotic sheets and cards were there on 12/08/23 and 12/09/23. LPN #710 was asked to not leave the facility due to additional questions needed to be answered and the police were involved and would need to speak with her. LPN #710 left the facility. The DON stated the police were able to contact LPN #710 and she stated she threw them away by accident. The DON and other administrative staff searched all trash cans and dumpsters and there were no medications found. The DON stated when the Ohio Department of Health Abuse, Neglect and Misappropriation investigator arrived on Monday 12/18/23 they reviewed text messages sent to the DON and LPN #710 stated she realized she had taken the narcotic card count sheets home when she found them in her bag. She also texted she was an addict and taking Suboxone. She had run out of the Suboxone and started to get sick. She panicked and should have been honest about everything, but she was scared and didn't want to get arrested. The DON and the Administrator substantiated the Self-Reported Incident (SRI) for misappropriation. The deficient practice was corrected on 12/09/23 when the facility implemented the following corrective actions: • On 12/09/23 LPN #710 was indefinitely suspended pending results of the investigation, and the local police were notified of the alleged misappropriation. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366479 If continuation sheet Page 2 of 4 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 366479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Timberland Ridge Nursing & Rehabilitation 3558 Ridgewood Road Fairlawn, OH 44333 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/09/23 the facility DON reviewed the narcotic shift-to-shift count process with no changes made. The DON also made observations of shift-to-shift narcotic counts with no concerns identified. • On 12/09/23 all medication carts and medication rooms, including contingency controlled substance supply, were audited by the DON to ensure all controlled substances were accounted for. All residents on the [NAME] Hall were interviewed and/or assessed to see if there were any concerns with the medication administration, and there were no concerns identified. All other residents in the facility who received controlled substances were interviewed and assessed with no concerns identified. All nurses were interviewed by the DON to see if they had any concerns with controlled substances, and there were no concerns reported. • On 12/09/2023 all 112 facility staff members were educated by the Administrator and designee on the facility abuse policy. All facility nurses were educated on the narcotic shift-to-shift count process by the DON and designee. • On 12/11/23 LPN #710 was reported to the Ohio Board of Nursing and her employment at the facility was terminated. • On 12/11/23 an ad hoc quality assurance committee meeting was held with the medical director to discuss the SRI and the controlled substance action plan. Those attending included the DON, assistant DON, the Administrator, pharmacy and the Medical Director. • On 12/13/2023 the DON and designee began conducting audits/observations three times per week for two weeks randomly of two shift-to-shift count process to ensure there were no concerns with the process. • On 12/13/2023 the DON and designee began random audits three times per week for two weeks on two random medication storage areas to ensure all controlled substances were accounted for. • On 12/13/2023 the DON and designee began audits three times per week for two weeks of three random residents who receive controlled substances for interviews and assessments to see if they had any concerns with administration of their controlled substances. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366479 If continuation sheet Page 3 of 4 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 366479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Timberland Ridge Nursing & Rehabilitation 3558 Ridgewood Road Fairlawn, OH 44333 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Any identified concerns will be reviewed by the interdisciplinary team (IDT) and reeducation will be completed. The DON will be responsible for ongoing compliance. There were no further incidents of residents experiencing misappropriation from 12/09/23 through the date of this survey on 12/20/23. Residents Affected - Few This deficiency was an incidental finding during the investigation of Complaint Number OH00149191. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366479 If continuation sheet Page 4 of 4