Inspection·June 23, 2025

F 0605 Level of Harm - Minimal harm or potential for actual harm Review of Resident #11's physician order dated 05/13/25 to 05/27/25 revealed an order for Hydroxyzine Pamoate one capsule by mouth ever eight hours as needed for anxiety. Review of Resident #11's physician order dated 05/13/25 to 06/05/25 revealed an order to monitor for anxiety related behaviors and document if behaviors were present. Residents Affected - Few Review of Resident #11's CNP note dated 05/12/25 revealed his anxiety was noted, however there was no discussion of cause. Review of Resident #11's progress note dated 05/17/25 revealed Hydroxyzine was administered, there was no indication as to why. Review of Resident #11's progress note dated 05/19/25 revealed Hydroxyzine was administered due to the residents request. Review of Resident #11's CNP note dated 05/19/25 revealed his anxiety was noted, however there was no discussion of cause. Review of Resident #11's progress note dated 05/21/25 revealed Hydroxyzine was administered due to the resident being anxious and decreased stimulation. Review of Resident #11's May 2025 Medication Administration Record (MAR) revealed Hydroxyzine was administered on 05/08/25 as scheduled. It was administered as needed on 05/17/25, 05/18/25, 05/19/25, and 05/21/25. Resident #11's anxiety monitoring indicated no anxiety occurred. Review of Resident #11's progress note dated 06/12/25 revealed an order from the CNP to start the resident on Hydroxyzine 25 mg every eight hours as needed. Review of Resident #11's progress note dated 06/12/25 revealed Hydroxyzine was administered due to increased anxiety. Review of Resident #11's physician order dated 06/12/25 to 06/16/25 revealed an order for Hydroxyzine 25 mg one tablet by mouth every eight hours as needed for anxiety. Review of Resident #11's physician order dated 06/16/25 revealed an order for Hydroxyzine Pamoate one capsule by mouth three times a day for anxiety. Review of Resident #11's physician order dated 06/16/25 revealed an order to monitor for anxiety related behaviors and document if behaviors were present. Review of Resident #11's mini mental score dated 06/02/25 revealed the resident had increased anxiety with shortness of breath. He reported as needed Hydroxyzine was effective when he was anxious. Review of Resident #11's CNP note dated 06/16/25 revealed his anxiety was noted, however there was no discussion of cause. Review of Resident #11's 06/01/25 to 06/17/25 MAR revealed as needed Hydroxyzine was only provided on 06/12/25. Scheduled Hydroxyzine was provided twice on 06/16/25 and three times on 06/17/25. Resident #11's anxiety monitoring indicated no anxiety occurred. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365047 If continuation sheet Page 2 of 12 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 365047 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE First Community Village Healthcare Ctr 1800 Riverside Drive Columbus, OH 43212 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 06/17/25 at 11:00 A.M. and 06/18/25 at 1:17 P.M. with the Director of Nursing (DON) verified the reasoning for Resident #11's anxiety had not been documented until 06/16/25. She reported the anxiety was new to him due to a change in his condition. Resident #11 was anxious due to his shortness of breath; however, she was unable to provide evidence, this or alternate interventions had been discussed with the resident. She additionally verified the nurses were not always documenting the reason for administration of Hydroxyzine. Resident #11's Hydroxyzine was increased to scheduled three times a day despite the fact that he had only used the as needed medication once since 05/20/25. Review of the facility policy 'Psychotropic Medications Policy' dated April 2025, revealed the facility was to ensure residents have not used psychotropic medications unless necessary to treat a specific condition. Efforts were to be made to utilize psychotropic medications at the lowest possible dose to achieve therapeutic dose. 2. Review of the medical record for Resident #10 revealed an admission date of 03/04/24 with diagnoses of altered mental status, anxiety, major depressive disorder, and vascular dementia. Review of the care plan dated 03/04/24 revealed Resident #10 is prescribed anti-anxiety medications related to anxiety and vascular dementia. Interventions include administering non-pharmacological interventions prior to as needed (PRN) medications; nurse practitioner/medical director to perform routine gradual dose reductions (GDR); pharmacy to routinely evaluate medications per policy; and staff to follow up on pharmacy recommendations accordingly. Review of physician orders dated 06/20/24 revealed an order for Buspirone HCl (antianxiety) oral tablet 15 milligrams (mg) three times daily for anxiety, which was an increase from the initial dosage started on 11/27/23. Review of the medication administration record (MAR) from 11/01/24 through 04/30/25 revealed anxiety-related behaviors such as pacing, wandering, disrobing, inappropriate responses to verbal communication, and aggression toward staff or others were not observed or documented during this period. Review of the medication regimen review dated 12/05/24 revealed Resident #10 had been prescribed Buspirone 15 mg since 06/20/24. The pharmacist recommended evaluating the current dose and considering a gradual dose reduction to ensure use of the lowest effective dose. The prescriber selected the option indicating the resident had a good response to treatment and required the current dose for condition stability. It was documented that dose reduction was contraindicated as the benefits outweighed the risks, and reduction could impair the resident ' s function and/or cause psychiatric instability. A request for patient-specific justification was made; however, the prescriber ' s response was disagree, with no further explanation. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed 12/17/24 revealed Resident #10 is cognitively intact and exhibits no behavioral symptoms. Review of psychiatric evaluation dated 01/03/25 revealed Resident #10's mood was documented as good. The resident reported feeling anxious and depressed daily, while staff reported her anxiety was at baseline and she exhibited no behavioral concerns. Review of psychiatric evaluation dated 02/07/25 revealed the resident was re-evaluated for depression, anxiety, insomnia, and dementia with behavioral disturbance. The resident reported her mood was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365047 If continuation sheet Page 3 of 12 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 365047 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE First Community Village Healthcare Ctr 1800 Riverside Drive Columbus, OH 43212 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few very good, denied depression and anxiety, and was at baseline with no new or worsening symptoms. The resident was observed to have no aggression, irritability, or mania. The resident tolerated an increase in Zoloft (antidepressant medication) with improvement in mood. The note indicated a diagnosis of chronic anxiety disorder with baseline symptoms requiring ongoing monitoring. Review of behavior monitoring and interventions from 02/16/25 through 06/06/25 revealed the following documented behaviors: on 02/17/25, Resident #10 was physically aggressive toward others and made threats; on 02/27/25, she was physically aggressive again, accusatory, cursing at others, and agitated; on 06/06/25, she was making disruptive sounds, agitated, refusing care, and screaming; on 06/08/25, she was accusatory toward others, making disruptive sounds, exit-seeking, pacing, and verbalizing persistent false beliefs. Review of the medication regimen review dated 03/05/25 again recommended considering a gradual dose reduction. The same rationale for continuation of the current dose was selected by the prescriber, citing the need for stability and risks associated with dose reduction. No patient-specific justification was provided, and the prescriber again selected disagree without further comment. Interview on 06/17/25 at 2:33 P.M. with the Director of Nursing confirmed the medication regimen reviews did not contain specific rationale explaining why gradual dose reduction was declined on 12/05/24 and 03/05/25. The Director of Nursing also confirmed that the medication administration records used to document anxiety-related behaviors lacked sufficient supporting details to justify refusal of a gradual dose reduction and was inconsistent in documentation. Review of facility policy dated 04/2025 revealed residents receiving psychotropic medications will receive gradual dose reductions and behavioral interventions in an effort to discontinue these drugs. Staff will evaluate the use and effectiveness of any psychotropic medication administered to assist the resident in achieving or maintaining their highest level of overall functioning. Efforts will be made to utilize psychotropic medications at the lowest possible dose to achieve a therapeutic effect. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365047 If continuation sheet Page 4 of 12 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 365047 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE First Community Village Healthcare Ctr 1800 Riverside Drive Columbus, OH 43212 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #54 revealed an admission date of 04/16/25 with no cognitive deficits. Diagnoses included aftercare following surgery on the digestive system, malignant neoplasm colon, and intestinal obstruction, unspecified as to partial versus complete obstruction. Resident #54 discharged from the facility to home on on 04/25/25. Residents Affected - Few Review of Resident #54's Minimum Data Set, dated [DATE] indicated Resident #54 was transferred to the hospital. After surveyor intervention it was modified on 06/17/25 to indicate Resident #54 was discharged home. Interview on 6/17/25 at 10:14 A.M. with the Director of Nursing (DON) confirmed a corrected MDS for Resident #54 was submitted after surveyor intervention on 06/17/25 indicating Resident #54 was not discharged to the hospital as previously recorded, but was discharged home. Based on medical record review and staff interview, the facility failed to complete and maintain accurate resident assessments when significant changes occurred. This affected three (Residents #16, #24, and #54) of 15 resident assessments reviewed. The census was 31. Findings Include: 1. Resident #16 was admitted to the facility on [DATE]. His diagnoses included but were not limited to osteoporosis, spastic hemiplegia, morbid obesity, Type II diabetes, pneumonia, spinal stenosis, coronary atherosclerosis, chronic embolism and thrombosis, chronic kidney disease, cerebral infarction, mood disorder, peripheral vascular disease, anemia, nicotine dependence, acute kidney failure, epilepsy, insomnia, hyperlipidemia, and anxiety disorder. Review of his Minimum Data Set (MDS) assessment, dated 02/06/25, revealed he was cognitively intact and dependent on staff for transfers. Review of Resident #16's MDS assessments revealed his most recent resident assessment was completed on 02/06/25. A quarterly resident assessment was started on 05/09/25, but it had not been completed as of 06/18/25, confirming it was not completed in a timely manner. 2. Resident #24 was admitted to the facility on [DATE]. Her diagnoses were cachexia, unspecified protein calorie malnutrition, encephalopathy, chronic kidney disease, Alzheimer's disease, dementia, chronic respiratory failure, osteoporosis, restlessness and agitation, disorder of thyroid, osteoarthritis, hypo-osmolality and hyponatremia, acute kidney failure, depression, sleep disorder, atherosclerotic heart disease, anxiety disorder, hypertension, muscle weakness, hyperlipidemia, vitamin D deficiency, spinal stenosis, and hypothyroidism. Review of her MDS assessment, dated 02/01/25, revealed she had a significant cognitive impairment. Review of Resident #24's MDS assessments revealed the most recent resident assessment was completed on 02/01/25. A quarterly resident assessment was started on 05/02/25, but it had not been completed as of 06/18/25, confirming it was not completed in a timely manner. Interview with Administrator on 06/18/25 at 2:53 P.M. confirmed the MDS assessments were not done in a timely manner; she confirmed they should have been completed already. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365047 If continuation sheet Page 5 of 12 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 365047 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE First Community Village Healthcare Ctr 1800 Riverside Drive Columbus, OH 43212 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure dressing changes were completed as ordered by the physician. This affected one (Resident #22) out of two residents reviewed for pressure ulcers. The facility census was 31. Residents Affected - Few Findings include: Review of the medical record for Resident #22 revealed an admission date of 04/14/22 with diagnoses including dementia, adult failure to thrive, protein-calorie malnutrition, stage three pressure ulcer of the sacral region, bed confinement status, full incontinence of urine and feces, and muscle contractures. Review of the care plan dated 07/25/22 indicated Resident #22 has a pressure injury of the sacrum related to terminal diagnoses, bed confinement, impaired cognition, and decreased functional mobility. Interventions included administering and completing preventative treatments and dressing changes as ordered, assessing and monitoring wound healing weekly and as needed, following facility policies for skin breakdown prevention and treatment, and hospice nurse oversight of routine dressing changes and wound care orders. Review of the Minimum Data Set (MDS) 3.0 assessment completed on 11/18/24 showed Resident #22 was severely cognitively impaired, required substantial to maximal assistance with bed mobility, was always incontinent of urine and bowel, and had one stage III pressure ulcer (full-thickness skin loss involving damage or necrosis of subcutaneous tissue, which may extend down to, but not through, underlying fascia). Review of the Braden Scale for predicting pressure ulcer risk, dated 12/13/24, revealed Resident #22 was completely limited, very moist, bedfast, immobile, poorly nourished, and at very high risk of pressure ulcers due to friction and shearing. Review of physician orders dated 09/07/24 revealed staff were required to cleanse sacral pressure ulcer with wound cleanser, pat dry, apply calcium alginate to pack the entire wound bed, followed by application of a sacral Allevyn dressing. Review of the Treatment Administration Record (TAR) from 02/01/25 through 02/28/25 revealed missed treatments on 02/02/25 and 02/08/25. Review of skin and wound evaluation dated 02/06/25 noted Resident #22 had a stage III pressure ulcer on the sacrum measuring 0.6 cm by 2.1 cm, with a depth of 2.0 cm by 0.2 cm undermining and 1.2 cm tunneling. The wound showed 100% granulation, no signs of infection or odor, moderate bloody drainage, and was noted as stable. Review of skin and wound evaluation dated 02/13/25 showed the same ulcer measuring 1.6 cm by 3.7 cm, with a depth of 1.2 cm. There was no undermining or tunneling. The wound was 100% granulated, free of infection or odor, had moderate bloody drainage, and was noted as improving. Interview on 06/17/25 at 11:20 A.M. with the Assistant Director of Nursing (#120) confirmed Resident #22 had missed treatments on 02/02/25 and 02/08/25, and no documentation supported completion of these treatments by nursing staff or hospice providers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365047 If continuation sheet Page 6 of 12 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 365047 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE First Community Village Healthcare Ctr 1800 Riverside Drive Columbus, OH 43212 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 0686 Level of Harm - Minimal harm or potential for actual harm Review of skin care and wound management policy dated 01/2024 revealed residents with pressure injuries will receive necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection and prevent new injuries from developing. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365047 If continuation sheet Page 7 of 12 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 365047 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE First Community Village Healthcare Ctr 1800 Riverside Drive Columbus, OH 43212 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of facility incident report and investigative documents, resident and staff interview, and facility policy review, the facility failed to ensure a resident was safely transferred by a mechanical lift. This resulted in Actual Harm on 01/30/25 when staff attempted to transfer Resident #16 from the bed to his wheelchair with the mechanical lift and due to poor staff transferring techniques, Resident #16 was dropped to the floor. Resident #16 was sent to the hospital and returned to the facility with the following injuries: right knee posterior cruciate ligament (PCL) avulsion fracture, right Lateral Compression (LC) 1 pelvic ring injury, sacrum fracture, and Thoracic (T)9 distraction fracture (a fracture caused by a flexion-distraction injury during a rapid deceleration event). This affected one resident (#16) of three residents reviewed for accidents/falls. The facility census was 31. Findings Include: Resident #16 was admitted to the facility on [DATE] with diagnoses including, but were not limited to, osteoporosis, spastic hemiplegia, morbid obesity, type II diabetes, pneumonia, spinal stenosis, coronary atherosclerosis, chronic embolism and thrombosis, chronic kidney disease, cerebral infarction, mood disorder, peripheral vascular disease, anemia, nicotine dependence, acute kidney failure, epilepsy, insomnia, hyperlipidemia, and anxiety disorder. Review of the resident's Minimum Data Set (MDS) assessment, dated 02/06/25, revealed the resident was cognitively intact and dependent on staff for transfers. Review of Resident #16's care plan, dated 01/30/25, revealed Resident #16 had an activity of daily living (ADL) deficit. An intervention, within this care plan, revealed the resident needed two-person total assistance for all transfers due to having to use a mechanical lift. Review of Resident #16's Incident Report and Progress Notes, dated 01/30/25 to 02/03/25, confirmed Resident #16 was being transferred from his bed to his wheelchair via mechanical lift on 01/30/25 by Certified Nursing Assistant (CNA) #127 and CNA #400. During the transfer, CNA #400 adjusted the resident's feet and the lift pad, while the resident was suspended in the air. CNA #400 lifted one side of the lift pad while Resident #16 was in it, the pad/resident became unbalanced, and one hook of the pad came loose from the mechanical lift. The mechanical lift became unbalanced and tipped forward, which caused Resident #16 to fall out of the lift to the ground. Nursing staff were immediately called to his room to assess him for injuries; Emergency Medical Services (EMS) were called, and Resident #16 was sent to the hospital. In review of the findings, the facility confirmed CNA #400 should not have lifted Resident #16 mechanical lift pad while the resident was suspended in the air. The facility further confirmed this action contributed to the lift being unbalanced and tipping over, which caused Resident #16 to fall. Interview with the Administrator on 06/17/25 at 11:06 A.M. confirmed Resident #16 fell while he was being transferred by staff in his mechanical lift. She stated, based on the investigation that was completed, CNA #127 and CNA #400 put Resident #16's lift pad in place to prepare him for transfer. She stated one CNA was maneuvering his pad/body from the front of him (by his feet/legs), and the other CNA was on the back, maneuvering the actual lift. She stated CNA #400 lifted Resident #16's lift (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365047 If continuation sheet Page 8 of 12 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 365047 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE First Community Village Healthcare Ctr 1800 Riverside Drive Columbus, OH 43212 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 - Actual harm Residents Affected - Few pad to assist him in his wheelchair. She confirmed the mechanical lift pad came unhooked from the machine, the machine became unbalanced, and it tipped over, causing an injury to Resident #16 when he fell out of the lift to the floor. She confirmed the facility completed the investigation, and started a plan of correction for this situation, which included educational training to all nursing staff, auditing all resident medical records of those that used mechanical lifts, and on-going monitoring. Interview with Resident #16 on 06/18/25 at 9:59 A.M. stated the aides who were transferring him were moving too fast when moving him from his bed to his wheelchair in the mechanical lift. He stated he was off-center in the lift/pad, and the CNAs tried to adjust him while he was suspended in the air, and the machine started to tip. One of the CNAs tried to hold him up, but one side of the pad came off the machine, and he fell to the ground. He confirmed it was very painful, and after going to the hospital, it was confirmed he had fractures. Review of facility's mechanical lift manual, undated, revealed the facility is to follow all the procedures to ensure a resident transfer is completed safely. After the resident has been safely placed in the mechanical lift pad and raised from the bed, staff is to stand behind the resident and hold onto the center handle located on the back of the sling. When the resident is nearly seated, gently pull up on the center handle to ensure the resident will be seated in an upright position. The deficient practice was corrected on 02/12/25, when the facility implemented the following corrective actions: On 01/30/25, Director of Nursing (DON) or designee assessed all residents who use a mechanical lift for injuries, no injuries were identified. On 01/30/25, DON or designee audited all mechanical lift pads for safety and functionality. None had to be discarded. The facility also had enough lift pads in varying sizes to meet the needs of each resident who utilized a mechanical lift. On 01/30/25, DON or designee audited all residents who utilize a mechanical lift. Mechanical lift assessments and care plans were reviewed, and updates were made as necessary. On 01/30/25, the Administrator completed a Quality Assurance Performance Improvement (QAPI) meeting to review the fall, determine the root cause, and develop a plan of action to reduce the likelihood of an accident similar to this occurring again. From 01/30/25 to 02/10/25, DON or designee educated all nursing staff. The education included operating a mechanical lift with two staff at all times, proper use of mechanical lifts, and the overall lateral transfer system usage. The following nursing staff were interviewed on 06/17/25 and 06/18/25, and confirmed they received education and were aware of the proper procedures to follow regarding mechanical lifts: DON, ADON #120, CNA #117, CNA #142, and CNA #153. From 02/03/25 to 02/12/25, DON ensured all nursing staff received and passed competency training regarding the proper assessment of mechanical lift pads and properly transferring a resident with the mechanical lift. Starting 01/31/25, nursing managers/designees assessed mechanical lift pads to ensure the correct size was being used and monitored/observed actual resident transfers via mechanical lift at least (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365047 If continuation sheet Page 9 of 12 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 365047 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE First Community Village Healthcare Ctr 1800 Riverside Drive Columbus, OH 43212 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 - Actual harm three times weekly for four weeks through March 2025 and then discussed at the June 2025 QAPI meeting. Audits were completed on the following dates: 01/31/25, 02/03/25, 02/05/25, 02/07/25, 02/10/25, 02/12/25, 02/14/25, 02/17/25, 02/19/25, 02/21/25, 02/24/25, 02/26/25, 02/28/25, 03/03/25, and 03/10/25 with no negative findings. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365047 If continuation sheet Page 10 of 12 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 365047 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE First Community Village Healthcare Ctr 1800 Riverside Drive Columbus, OH 43212 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 and staff interview, the facility failed to provide parameters for as needed pain medication. This affected one (Resident #16) of five residents reviewed for unnecessary medications. The census was 31. Residents Affected - Few Findings Include: Resident #16 was admitted to the facility on [DATE]. His diagnoses included but were not limited to osteoporosis, spastic hemiplegia, morbid obesity, Type II diabetes, pneumonia, spinal stenosis, coronary atherosclerosis, chronic embolism and thrombosis, chronic kidney disease, cerebral infarction, mood disorder, peripheral vascular disease, anemia, nicotine dependence, acute kidney failure, epilepsy, insomnia, hyperlipidemia, and anxiety disorder. Review of his Minimum Data Set (MDS) assessment, dated 02/06/25, revealed he was cognitively intact and dependent on staff for transfers. Review of Resident #16's physician orders, dated September 2024 to June 2025, revealed an order for Acetaminophen (analgesic) 325 milligrams (mg), two tablets every four hours as needed for pain. Also, there was an order for Oxycodone (opioid) five mg every four hours as needed for pain. Neither the Acetaminophen or the Oxycodone medications had parameters as to which pain medication should be given and what pain level each medication should be given at. Review of Resident #16 medication administration record (MAR), dated January 2025 to June 2025, revealed the following as needed pain medications were administered: in February 2025, Acetaminophen was administered zero times and Oxycodone was administered a total of 10 times for pain levels between two to nine. In March 2025, Acetaminophen was administered one time for pain level five and Oxycodone was administered a total of 31 times for pain levels between zero and eight. In April 2025, Acetaminophen was administered zero times and Oxycodone was administered 23 times for pain levels between four and eight. In May 2025, Acetaminophen was administered zero times and Oxycodone was administered 36 times for pain levels between three and eight. For June 2025, Acetaminophen was administered two times for pain levels four and five, and Oxycodone was administered 18 times for pain levels between four and eight. Interview with Registered Nurse (RN) #141 on 06/17/25 at 3:59 P.M. stated he will judge a residents pain level based on what they state their level of pain is, and why the resident is in the facility (surgery, chronic pain, etc.) as to which pain medication he will administer. He will verify with physician or Director of Nursing (DON) if a resident has two as needed pain medications, to ensure the resident is supposed to have them. Once verified, he will use his nursing judgement as to which pain medication to offer/administer. He confirmed there are not always parameters for the as needed pain medications, which is why he will use nursing judgement on which pain medication to administer. Interview with Director of Nursing (DON) and Administrator on 06/18/25 at 9:06 A.M. confirmed there should be parameters on the as needed pain medication orders. They stated Resident #16 is able to tell the nurse which medication he would want, but they confirmed as needed pain medications should be given at certain pain levels. They confirmed the pain levels for Resident #16, and the medications administered, were inconsistent. Review of facility Pain Management policy, dated April 2025, revealed the facility is committed to recognizing, assessing, treating, and documenting pain management to promote the comfort and quality (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365047 If continuation sheet Page 11 of 12 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 365047 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE First Community Village Healthcare Ctr 1800 Riverside Drive Columbus, OH 43212 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 0697 Level of Harm - Minimal harm or potential for actual harm of life for all residents. Pain will be addressed through evidenced based practices, resident centered care, and interdisciplinary care. For pain management, the facility will following physician orders for pain medications and administered PRN medications as indicated. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365047 If continuation sheet Page 12 of 12