Inspection·December 11, 2024

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few insulin. Interventions included monitoring, recording, and reporting signs and symptoms of malnutrition including significant weight loss, and evaluating and making diet change recommendations as needed. Review of the nutritional assessment dated [DATE] revealed Resident #15 was at risk for malnutrition. The resident's weight was to be maintained with no significant changes and a new order for weekly weights for four weeks was recommended. Review of the weight record revealed Resident #15's weight was obtained on 07/10/24 and was not obtained again until 08/20/24. An interview on 12/05/24 at 11:26 A.M. with Regional Director of Clinical Operations #994 verified the weekly weights for Resident #15 were not obtained per the dietitian recommendations/orders. Review of the facility policy titled, Weight Assessment and Intervention, dated 01/10/23, revealed the multidisciplinary team would strive to prevent, monitor, and intervene for undesirable weight loss for residents. In addition, monthly weights would be completed by the tenth of each month, and weekly weights would be completed on a designated day each week. This deficiency represents non-compliance investigated under Complaint Number OH00159400. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365162 If continuation sheet Page 2 of 10 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 12/11/2024 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 - Some 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 medical record review, resident and staff interview, and review of the facility policy, the facility failed to have sufficient staffing to meet the care needs of all residents. This directly affected three (#4, #15, and #16) of five residents reviewed for staffing and had the potential to affect 18 (#5, #8, #12, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, and #45) additional residents residing on the fourth floor. The facility census was 84. Findings include: 1. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, muscle weakness, need for assistance with personal care, hypertension, chronic kidney disease, anxiety, and depression. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 was cognitively intact. Review of the current physician orders for Resident #4 identified an order dated 09/22/24 for insulin lispro 100 units per milliliter solution with instructions to inject per sliding scale before meals up to 10 units per dose. The resident also had an order dated 10/30/24 for weekly weights for four weeks and then monthly. Review of the medication administration record (MAR) for October 2024 revealed Resident #4's blood glucose level was not documented as obtained before the lunch meal on 10/11/24 and on 10/20/24. Review of the nursing progress notes dated 10/11/24 and timed 5:37 P.M. revealed Resident #4's blood glucose level was not obtained. Review of the nursing progress notes dated 10/20/24 and timed 3:39 P.M. revealed Resident #4's blood glucose level was not obtained. Review of the weight record revealed Resident #4's weight was last obtained on 10/20/24 and was not obtained again until 12/04/24. There was no documentation indicating weekly weights were obtained in accordance with physician orders. Interview on 12/04/24 at 10:44 A.M. with Licensed Practical Nurse (LPN) #970 verified Resident #4's weight not was obtained per physician order between 10/30/24 and 12/04/24. An interview on 12/09/24 at 12:00 P.M. with LPN #802 verified Resident #4's blood glucose level was not obtained as ordered on 10/11/24 and 10/20/24. LPN #802 reported it was due to insufficient staffing. LPN #802 stated by the time they were able to get to Resident #4, the resident's next blood glucose level check was due. LPN #802 also reported staff were often unable to obtain resident weights due to insufficient staffing. Interview on 12/05/24 at 2:10 P.M. with Resident #4 revealed there were not enough staff to meet his needs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365162 If continuation sheet Page 3 of 10 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 12/11/2024 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 - Some 2. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, chronic kidney disease, muscle weakness, and hypertension. Review of the nutritional assessment dated [DATE] revealed Resident #15 was at risk for malnutrition. The resident's weight was to be maintained with no significant changes and a new order for weekly weights for four weeks was recommended. Review of the weight record revealed Resident #15's weight was obtained on 07/10/24 and was not obtained again until 08/20/24. There was no documentation indicating weekly weights were obtained in accordance with physician orders. An interview on 12/05/24 at 11:26 A.M. with Regional Director of Clinical Operations #994 verified the weekly weights for Resident #15 were not obtained per the dietitian recommendations. Interview on 12/04/24 at 11:17 A.M. with LPN #642 stated resident weights were often not obtained due to insufficient staffing. LPN #642 reported weights were often not obtained due to staff attempting to focus on the more immediate needs of the residents. Review of the facility policy titled, Weight Assessment and Intervention, dated 01/10/23, revealed the multidisciplinary team would strive to prevent, monitor, and intervene for undesirable weight loss for residents. In addition, monthly weights would be completed by the tenth of each month, and weekly weights would be completed on a designated day each week. 3. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses included rheumatoid arthritis, pain in right shoulder, pain in left shoulder, chronic pain syndrome, peripheral vascular disease, muscle weakness, need for assistance with personal care, and heart failure. Review of the quarterly MDS assessment dated [DATE] identified Resident #16 was cognitively intact. Review of the plan of care dated 10/23/24 identified Resident #16 had chronic pain related to arthritis and peripheral vascular disease. Interventions included administering pain medication as ordered. Review of the current physician orders for Resident #16 identified an order dated 07/16/24 for Lac-hydrin 12 percent (%) external lotion with instructions to apply to the soles of the feet topically every morning and at bedtime. Further review of the current physician orders for Resident #16 identified an order dated 07/28/24 for the pain medication gabapentin oral capsule 300 milligrams (mg) by mouth every morning and at bedtime for neuropathy, and an order dated 09/18/24 for the narcotic pain medication Ultram oral capsule 50 mg by mouth every morning and at bedtime for pain. Review of the MAR for October 2024 revealed on 10/11/24 the Lac-hydrin lotion was not administered on the mornings of 10/10/24, 10/11/24, 10/20/24, and 10/28/24. Further review of the MAR for October 2024 revealed on 10/11/24 the morning doses of Ultram and gabapentin were not documented as administered and were coded with a 9. In addition, on 10/19/24, the morning dose of gabapentin was not documented as administered and was coded with a 9. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365162 If continuation sheet Page 4 of 10 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 12/11/2024 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 Review of the nursing progress notes dated 10/11/24 and timed 7:09 P.M. revealed Resident #16's Ultram and gabapentin were not administered due to timing. Review of the nursing progress notes dated 10/19/24 and timed 2:43 P.M. revealed Resident #16's gabapentin was not administered due to a time constraint. Residents Affected - Some Interview on 12/04/24 at 12:24 P.M. with Resident #16 revealed the resident did not always receive medications as ordered and often had to wait long periods of time for staff assistance. An interview on 12/09/24 at 12:00 P.M. with LPN #802 verified Resident #16's lotion was not applied as ordered on the above mentioned dates. LPN #802 also confirmed Resident #16's Ultram was not administered as ordered on 10/11/24 and confirmed gabapentin was not administered on 10/11/24 and 10/19/24 as ordered. LPN #802 verified staff were unable to administer medications within the prescribed timeframes due to staffing, and therefore did not administer medications. Review of the facility policy titled, Administering Medications, revised December 2012, revealed medications shall be administered in a safe and timely manner, and as prescribed. In addition, the policy revealed medications must be administered in accordance with the orders, including any required time frame. Review of the facility policy titled, Staffing, revised April 2007, revealed the facility would provide adequate staffing to meet needed care and services for their resident population. This deficiency represents non-compliance investigated under Master Complaint Number OH00159786, Complaint Master Number OH00159769, Complaint Number OH00159718, Complaint Number OH00159400, and Complaint Number OH00159147. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365162 If continuation sheet Page 5 of 10 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 12/11/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to administer medications in accordance with physician orders. This affected two (#6 and #16) of four residents reviewed for medication administration. Findings include. 1. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE]. The resident discharged on 11/05/24. Diagnoses included type II diabetes mellitus, muscle weakness, unspecified age-related cataracts, and heart failure. Review of physician orders identified an order dated 09/27/24 for Olopatadine solution 0.2 percent (%) with instructions to instill one drop in both eyes one time per day for dry eyes. Review of the medication administration record (MAR) for Resident #6 revealed the eye drops were not administered on 09/27/24, 09/28/24, 09/29/24, 09/30/24, 10/01/24, 10/02/24, 10/05/24, 10/06/24, 10/10/24, 10/11/24, and 10/25/24. An interview on 12/09/24 at 2:56 P.M. with Regional Director of Clinical Operations #994 verified staff likely could not locate the eye drops and therefore did not administer them. Regional Director of Clinical Operations #994 verified there was no documentation Resident #6 received eye drops as ordered on the dates listed above. 2. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses included rheumatoid arthritis, pain in right shoulder, pain in left shoulder, chronic pain syndrome, peripheral vascular disease, muscle weakness, need for assistance with personal care, and heart failure. Review of the quarterly Minimum Data Set assessment dated [DATE] identified Resident #16 was cognitively intact. Review of the current physician orders for Resident #16 identified an order dated 07/16/24 for Lac-hydrin 12% external lotion with instructions to apply to the soles of the feet topically every morning and at bedtime. Review of the MAR for October 2024 revealed on 10/11/24 the Lac-hydrin lotion was not administered on the mornings of 10/10/24, 10/11/24, 10/20/24, and 10/28/24. An interview on 12/04/24 at 12:24 P.M. with Resident #16 revealed the resident sometimes did not receive medications including lotion. An interview on 12/09/24 at 12:00 P.M. with Licensed Practical Nurse #802 verified Resident #16's lotion was not applied as ordered on the above mentioned dates. Review of the facility policy titled, Administering Medications, revised December 2012, revealed medications shall be administered in a safe and timely manner, and as prescribed. In addition, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365162 If continuation sheet Page 6 of 10 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 12/11/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm policy revealed medications must be administered in accordance with the orders, including any required time frame. This deficiency represents non-compliance investigated under Complaint Number OH00159718. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365162 If continuation sheet Page 7 of 10 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 12/11/2024 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 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 and staff interview, the facility failed to adequately monitor resident blood glucose levels for sliding scale insulin as ordered. This affected one (#4) of three residents reviewed for insulin administration. The facility census was 84. Residents Affected - Few Findings include: Review of the medical record revealed Resident #4 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, muscle weakness, need for assistance with personal care, hypertension, chronic kidney disease, anxiety, and depression. Review of the current physician orders for Resident #4 identified an order dated 09/22/24 for insulin lispro 100 units per milliliter solution with instructions to inject the insulin per sliding scale before meals up to 10 units per dose. Review of the plan of care dated 10/31/24 revealed Resident #4 had a history of type II diabetes mellitus. Interventions included Accu-checks (blood glucose level monitoring) as ordered, administering medications as ordered, and monitoring blood glucose levels-covering abnormal levels per sliding scale ordered by physician. Review of the medication administration record (MAR) for October 2024 revealed Resident #4's blood glucose level was not documented as obtained before the lunch meal on 10/11/24 and 10/20/24. Review of the nursing progress notes dated 10/11/24 and timed 5:37 P.M. revealed Resident #4's blood glucose level was not obtained. Review of the nursing progress notes dated 10/20/24 and timed 3:39 P.M. revealed Resident #4's blood glucose level was not obtained. An interview on 12/09/24 at 12:00 P.M. with Licensed Practical Nurse #802 verified Resident #4's blood glucose levels were not obtained as ordered on 10/11/24 and 10/20/24 and therefore, there was no way to know how much insulin was supposed to be administered or if the insulin would have not been given. This deficiency represents non-compliance investigated under Complaint Number OH00159718. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365162 If continuation sheet Page 8 of 10 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 12/11/2024 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 0760 Ensure that residents are free from significant medication errors. 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, resident and staff interview, and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one (#16) of four residents reviewed for medication administration. The facility census was 84. Residents Affected - Few Findings include: Review of the medical record revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses included rheumatoid arthritis, pain in right shoulder, pain in left shoulder, chronic pain syndrome, peripheral vascular disease, muscle weakness, need for assistance with personal care, and heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #16 was cognitively intact. Review of the plan of care dated 10/23/24 identified Resident #16 had chronic pain related to arthritis and peripheral vascular disease. Interventions included administering pain medication as ordered. Review of the current physician orders for Resident #16 identified an order dated 07/28/24 for the pain medication gabapentin oral capsule 300 milligrams (mg) by mouth every morning and at bedtime for neuropathy, and an order dated 09/18/24 for the narcotic pain medication Ultram oral capsule 50 mg by mouth every morning and at bedtime for pain. Review of the medication administration record (MAR) for October 2024 revealed on 10/11/24 the morning doses of Ultram and gabapentin were not documented as administered and were coded with a 9. In addition, on 10/19/24, the morning dose of gabapentin was not documented as administered and was coded with a 9. Review of the nursing progress notes dated 10/11/24 and timed 7:09 P.M. revealed Resident #16's Ultram and gabapentin were not administered due to timing. Review of the nursing progress notes dated 10/19/24 and timed 2:43 P.M. revealed Resident #16's gabapentin was not administered due to a time constraint. An interview on 12/04/24 at 12:24 P.M. with Resident #16 revealed the resident did not always receive medications as ordered. An interview on 12/09/24 at 12:00 P.M. with Licensed Practical Nurse (LPN) #802 verified Resident #16's Ultram was not administered as ordered on 10/11/24 and confirmed gabapentin was not administered on 10/11/24 and 10/19/24 as ordered. Review of the facility policy titled, Administering Medications, revised December 2012, revealed medications shall be administered in a safe and timely manner, and as prescribed. In addition, the policy stated medications must be administered in accordance with the orders, including any required time frame. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365162 If continuation sheet Page 9 of 10 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 12/11/2024 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 0760 This deficiency represents non-compliance investigated under Complaint Number OH00159718. 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 10 of 10