Health inspection·December 20, 2023

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and staff and resident interviews, the facility failed to ensure incontinence care was provided to the residents in a timely manner. This affected two (Resident #39 and #87) of three residents reviewed for incontinence care. The facility census was 90. Findings include: 1. Review of the medical record for Resident #39 revealed the resident was admitted on [DATE]. Diagnoses included heart failure, peripheral vascular disease, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had intact cognition. Resident #39 required partial to maximum assistance from two staff for toileting. Interview and observation on 12/14/23 at 10:55 A.M. with Resident #39 revealed she had had a bowel movement (BM) and had been soaked all morning. Resident #39 stated no staff had been in her room to assist her this morning and she had an accident. Her whole bed will need to be changed. At 11:00 A.M., State Tested Nursing Aide (STNA) #306 came in the room to assist Resident #39 with incontinence care. Interview on 12/14/23 at 12:13 P.M. with STNA #306 stated there were not enough staff to get work done timely. STNA #306 stated 11:00 A.M. was the first time she could make it into Resident #39's room to get her cleaned up. STNA #306 stated she started at 6:30 A.M. STNA #306 verified that Resident #39 was saturated with urine and had a BM and required a whole bed change. Interview on 12/14/23 at 10:47 A.M. with Resident #27 revealed she had to wait for three hours yesterday for the bed pan and she waited two hours last night for two hours to use the bedpan. 2. Review of the medical record for Resident #87 revealed the resident was admitted to the facility on [DATE]. Diagnoses included heart failure, respiratory failure, and malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #87 was dependent on staff for toileting. Interview and observation on 12/19/23 at 9:35 A.M. with Resident #87 revealed she had to wait a long time to get assistance with the bed pan. Resident #87 was on the bed pan at this time. State Tested Nursing Aide (STNA) #319 went into Resident #87's room and Resident #87 stated she would need five more minutes. STNA #319 stated she would come back at 9:45 A.M. At 10:00 A.M., Resident #87 put her call light on due STNA #319 did not return. At 10:05 A.M., Resident #87 started yelling for assistance. At 10:10 A.M., STNA #318 came in Resident #87's room and asked what she needed. Resident #87 stated she has been waiting to be taken off the bed pan. Interview on 12/19/23 at 10:15 A.M. with STNA #318 stated she came in at 9:00 A.M. and STNA #319 had been there by herself from 6:30 A.M. to 9:00 A.M. for 27 residents. STNA #318 verified 35 minutes was too long for a resident to have to wait to get off the bed pan. STNA #318 stated aides have to work short all the time and resident care suffers. There was no way staff can meet the residents' needs timely. This deficiency represents non-compliance investigated under Master Complaint Number OH00149250, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365162 If continuation sheet Page 2 of 5 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 365162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesleyan Village 807 West Ave Elyria, OH 44035 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 0690 Complaint Number OH00148839, Complaint Number OH00148571, and Complaint Number OH00148553. 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: 365162 If continuation sheet Page 3 of 5 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 365162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesleyan Village 807 West Ave Elyria, OH 44035 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interviews and resident interviews the facility to ensure there was enough staff was available to meet resident needs timely. This affected three (Resident #27, #39 and #87) of five residents reviewed for staffing This had the potential to affect all 90 residents residing in the facility. Findings include: Review of the facility staffing schedules and posted staffing information from 12/01/23 through 12/14/23 revealed on 12/07/23 and 12/08/23 revealed there was only one state tested nursing aide (STNA) on third shift for the fourth floor (27 residents). On 12/09/23 and 12/12/23, there was one STNA on the fourth floor for three hours. Interview on 12/20/23 at 4:09 A.M. with Scheduler #319 verified on 12/07/23 and 12/08/23, there were only four STNAs in the building on third shift and there was only one STNA on the fourth floor for 27 residents. Scheduler #319 verified on 12/18/23, there was one STNA on the fourth floor from 3:00 P.M. to 6:30 P.M. and on 12/19/23 there was only one STNA on the fourth floor from 6:30 A.M. to 9:00 A.M. Scheduler #319 stated at times if the facility needs staff, she will have to pull staff from the assistant living for the healthcare side. 1. Review of the medical record for Resident #27 revealed the resident was admitted to the facility on [DATE]. Diagnoses included depression and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had intact cognition. Resident #27 required substantial/maximum assistance from staff with toileting and dressing and required assistance from staff with bed mobility. Interview and observation on 12/14/23 at 10:47 A.M. with Resident #27 revealed she had to wait for three hours on 12/13/23 for the bed pan and she waited two hours again at night for her call light to be answered. Resident #27 turned her call light on at 9:48 A.M. and Resident #27 stated to see how long it would take for her call light to be answered. At 10:52 A.M., STNA #304 answered the call light. (Call light was not answered for 64 minutes.) Interview on 12/14/23 at 11:22 A.M. with STNA #304 revealed there was not enough staff to answer call lights timely. STNA #304 stated she has been trying to get to all of the residents timely but was unable to. STNA #304 verified she had not got to Resident #27's call light until 10:52 A.M. Interview on 12/14/23 at 12:01 P.M. with Unit Nurse Manager #305 stated call lights should be answered within 10 minutes. LPN #305 verified that 64 minutes was too long for a call light to be going off and be unanswered. 2. Review of the medical record for Resident #39 revealed the resident was admitted on [DATE]. Diagnoses included heart failure, peripheral vascular disease, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had intact cognition. Resident #39 required partial to maximum assistance from two staff for toileting. Interview and observation on 12/14/23 at 10:55 A.M. with Resident #39 revealed she had had a bowel (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365162 If continuation sheet Page 4 of 5 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 365162 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesleyan Village 807 West Ave Elyria, OH 44035 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many movement (BM) and had been soaked all morning. Resident #39 stated no staff had been in her room to assist her this morning and she had an accident. Her whole bed will need to be changed. At 11:00 A.M., STNA #306 came in the room to assist Resident #39 with incontinence care. Interview on 12/14/23 at 12:13 P.M. with STNA #306 stated there were not enough staff to get work done timely. STNA #306 stated 11:00 A.M. was the first time she could make it into Resident #39's room to get her cleaned up. STNA #306 stated she started at 6:30 A.M. STNA #306 verified that Resident #39 was saturated with urine and had a BM and required a whole bed change. Interview on 12/14/23 at 10:47 A.M. with Resident #27 revealed she had to wait for three hours yesterday for the bed pan and she waited two hours last night for two hours to use the bedpan. 3. Review of the medical record for Resident #87 revealed the resident was admitted to the facility on [DATE]. Diagnoses included heart failure, respiratory failure, and malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #87 was dependent on staff for toileting. Interview and observation on 12/19/23 at 9:35 A.M. with Resident #87 revealed she had to wait a long time to get assistance with the bed pan. Resident #87 was on the bed pan at this time. STNA #319 went into Resident #87's room and Resident #87 stated she would need five more minutes. STNA #319 stated she would come back at 9:45 A.M. At 10:00 A.M., Resident #87 put her call light on due STNA #319 did not return. At 10:05 A.M., Resident #87 started yelling for assistance. At 10:10 A.M., STNA #318 came in Resident #87's room and asked what she needed. Resident #87 stated she has been waiting to be taken off the bed pan. Interview on 12/19/23 at 10:15 A.M. with STNA #318 stated she came in at 9:00 A.M. and STNA #319 had been there by herself from 6:30 A.M. to 9:00 A.M. for 27 residents. STNA #318 verified 35 minutes was too long for a resident to have to wait to get off the bed pan. STNA #318 stated aides have to work short all the time and resident care suffers. There was no way staff can meet the residents' needs timely. Interview on 12/18/23 at 5:45 A.M. with STNA #311 stated she works night shift, and she was the only aide working the whole unit of 43 residents with a trainee. STNA #312 stated residents do not receive the care they need. STNA #311 stated the resident were lucky if the staff can get to all the residents in the shift. This deficiency represents non-compliance investigated under Master Complaint Number OH00149250, Complaint Number OH00148839, Complaint Number OH00148571, and Complaint Number OH00148553. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365162 If continuation sheet Page 5 of 5