Inspection·March 29, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the EMAR for Resident #76 with medication scheduled in the evening hours (8:00 P.M.) administered 02/23/24 and 02/26/24 included documentation by LPN #48 that medication were administered included: Atorvastatin Calcium oral tablet, give 40 mg by mouth at bedtime for hyperlipidemia, Gabapentin oral capsule, give 300 mg by mouth at bedtime for pain, and Sucralfate oral tablet, give 1 gram by mouth four times a day for GERD. 4. Review of the medical record for Resident #94 revealed an initial admission date of 11/03/22 and a re-entry date of 02/02/24. Diagnoses included dementia, hyperlipidemia, depression, and GERD. Review of Resident #94's EMAR for the evening hours (8:00 P.M.) for 02/23/24 and 02/26/24 revealed the following medication was documented by LPN #48 as being administered: Donepezil HCL oral tablet 10 mg, give one tablet by mouth at bedtime for dementia, Pravastatin Sodium oral tablet 20 mg, give one tablet by mouth at bedtime for high cholesterol, and Metformin HCL oral tablet 1000 mg, give one tablet by mouth two times a day for diabetic mellitus. Review of the SRI number 244727 revealed an allegation of neglect. Residents involved included Resident #22, #48, #76, and #94 with no noted ill effects. During a medication audit, it was discovered that a nurse did not administer certain medications as ordered by the physician. The employee was questioned and was terminated from her employment with the facility, additionally the Ohio Board of Nursing was notified. Review of SRI statements revealed that on 02/07/24 the Director of Nursing (DON) was notified by Registered Nurse (RN) #10 of a concern that three residents were stating they were not receiving their medications, in particular their Synthroid (medication used to treat a condition called hypothyroidism or low thyroid). Upon review of the EMAR, all medications were signed off by the assigned nurse, LPN #48 as given. Review of the SRI investigation timeline revealed that on 02/07/24 a statement from a RN #10 regarding concerns for medications being passed on Elm hallway/night shift by a specific nurse LPN #48. On 02/09/24, a resident's treatment on Elm hallway was signed off but not completed by LPN #48. On 02/14/24, Resident #22's ( who resided on Elm hallway) Depakote (a anticonvulsant medication) level received and showed a low result. This prompted medication audits on the cart, as resident's larger Depakote dose is administered on night shift. On 02/22/24, nurse medication administration audit started (night shift scheduled medications selected on 5 different residents on Elm hallway) as this was the first time said nurse worked a shift where medication could be correctly counted and monitored. On 02/23/24, medications were counted and discrepancies were noted but may not have been 100% accurate as medications were filled/received from pharmacy. On 02/26/24 the nurse medication audit continued. On 02/27/24, the medications were counted with discrepancies with LPN #48 and LPN #48 was suspended pending further investigation. Continued review of the facility's SRI investigation revealed Resident #76 did not received Mirtazapine 7.6 mg, Resident #94 did not receive scheduled medication Pravastatin 20 mg and Donepezil 10 mg, Resident #48 did not receive Primidone 100 mg, and Resident #22 did not receive scheduled Depakote 250 mg. All medication was ordered to be administered at 8:00 P.M. and was not administered on 02/23/2024 and 02/26/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365295 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 365295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Elm Health Care Center 370 Tarlton Road Circleville, OH 43113 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 - Some Interview on 03/28/24 with the DON revealed when she was made aware of the concern that medication was not being administered, a medication administration audit and medication cart audit was started. Before the evening shift on 02/23/24 and 02/26/24 the evening medications for noted residents were counted to see how many medication remained, then the next morning a count was completed again and was noted to be the same where if the medication was administered, there should be one missing from the medication card. The DON claimed she personally spoke with LPN #48 who confirmed she did not administer the medication and could not give a clear explanation as to why she did not administer the medication and only claimed she had a lot going on at home. All residents affected by this incident were assessed and the Medical Director completed their own assessment and labs were checked with no negative outcome. LPN #48 was released from her duties and the incident was reported to Ohio Department of Health and Ohio Board of Nursing. Review of the facility policy titled 5 Rights of Medication Use. no date noted revealed When passing medication, make sure we are practicing the 5 Rights', look at the resident's picture/room number, read the drug label (verify x 3) for the correct medication/dose/route against the order in the MAR, check the physician's order is in the chart. Make sure medications are passed at the time they are scheduled to be gives. 5. Review of the medical record for Resident #74 revealed an admission date of 11/19/23. Diagnoses included anxiety, type two diabetes, and cellulitis of the left lower extremity. Review of Resident #74's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental status (BIMS) score of 15 out of 15 indicating an intact cognition for daily decision-making abilities. 6. Review of the medical record for Resident #128 revealed an admission date of 08/12/22. Diagnoses included muscle weakness, unsteadiness on feet, and depression. Review of Resident #128's quarterly MDS 3.0 assessment dated [DATE] revealed a BIMS score of 15 out of 15 indicating an intact cognition for daily-decision making ability. Review of the facility's SRI dated 03/08/24 revealed an allegation of emotional/verbal abuse allegation noting that a staff member made some inappropriate remarks about a couple of patients to staff. State Tested Nursing Assistant (STNA) #50 intentionally deceived a patient by stating that smoking was canceled so she did not have to get her up. STNA #50 admitted this to a co-worker and asked the co-worker to also deceive the patient and support her story that smoking was canceled. Smoking had not been canceled as weather conditions were appropriate and within the smoking policy guidelines. During the course of the investigation, it was also discovered that in addition to failing to get this patient up, STNA #50 also did not provide incontinence care to another patient who had to wait an extended period of time for someone to help her. These two different residents labeled STNA #50 as having a bad attitude and was snotty STNA #50 is a weekend only staff member and was placed on suspension on 03/08/24 when this incident was brought to the attention of the DON. STNA #50 had not worked since the date of the incident. Interview and statements were obtained from staff working that day who may have had insight into the incident. Additionally, a skin assessment on all patients with a BIMS of 9 or less was completed by the wound nurse and all residents with a BIMS of 10 or above was interviewed. Also, all staff were re-educated regarding the abuse policy. The two nurses initially involved in the complaint were counseled and educated by the administrator on timely reporting of any suspicion of abuse. After the investigation was completed, the facility substantiated the allegation. It was determined by the facility investigator that verbal abuse could not be substantiated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365295 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 365295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Elm Health Care Center 370 Tarlton Road Circleville, OH 43113 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 - Some however it was felt that STNA #50's failure to get a patient up and provide incontinence care to another patient was grounds for termination. The failure to provide the care for patients' needs is substantiated. Review of the resident interview completed on 03/11/24 with Resident #74 revealed the following questions and answers. Has a staff member ever refused to provide care for you? No. Do you feel safe here? Yes. Has anyone ever mistreated you? Yes, refused to change. Review of the resident interview completed on 03/11/24 with Resident #128 revealed the following questions and answers. Has a staff member ever refused to provide care for you? Yes. Do you feel safe here? Yes. Has anyone ever mistreated you? No. Review of a staff statement completed by LPN #68 dated 03/08/24 revealed STNA #50 consistently has a negative attitude with residents, she has left call lights unanswered for 30-45 minutes and when investigated by nurse, both aides were found sitting in the lounge on the hall. STNA #50 has admitted to lying to residents about activities and not taking resident who smoke out so she did not have to get this resident out of bed. Residents have confronted this STNA multiple times on the amount of time it has taken her to answer call lights leaving them soaked in urine and stool for over an hour. She stated to this resident that she has other people to take care of which caused this resident to become agitated. STNA #50 then walked out of the residents room for another 30 plus minutes until the nurse answered the call light and was informed by the resident and got aides from lounge to change the resident. Review of the staff statement completed by Activity Assistant #3 created on 03/08/24 revealed that on Sunday 03/03/24, Activity Assistant was walking inside from taking residents who smoke out for the 9:30 A.M. smoke break and was walking passed STNA #50 and told me that if Resident #128 asks if the resident who smoke went out to smoke at 9:30 A.M. to tell her no. Activity Assistant #3 then asked why and STNA #50 replied because I told her you guys didn't do out to smoke so I didn't have to get her up. Activity Assistant #3 reported what was said to the nurse that day. Review of staff statement created by the DON on 03/08/24 revealed, that the DON interviewed Resident #128 and asked if she was concerned with the care she received at the facility. Resident #128 stated that she sometimes wants to be gotten up for the smoking times and is not always able to get up out of bed. Resident #128 stated that on 03/03/24 that she was not gotten up for the 9:30 A.M. smoking time and that she wanted to. Resident #128 stated that overall, she received good care but that STNA #50 has a bad attitude and does not like to get her up. Review of staff statement created by DON on 03/08/24 revealed, the DON interviewed Resident #74 and asked if she was concerned with the care she received at the facility. Resident #74 stated that she only had had one problem and that was that she did not receive care timely from STNA #50. Resident #74 stated that on the weekend of 03/02/24 and 03/03/24 STNA #50 refused to change her and walked out and after about 40 minutes a nurse came in her room and she reported the issue to the nurse and the nurse provided incontinence care. Review of the staff statement completed by RN #80 dated 03/11/24 revealed On Sunday 03/03/24, RN #80 was the supervisor. Activity Assistant #3 told RN #80 that earlier in the day for the 9:30 A.M. smoke break that STNA #50, the staff member on Elm stated that she told Resident #128 that they weren't going out to smoke so that she didn't have to get her up and laughed. STNA #50 claimed she did not say that and that Resident #128 was asleep. RN #80 revealed she didn't hear anymore about it until (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365295 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 365295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Elm Health Care Center 370 Tarlton Road Circleville, OH 43113 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 - Some Friday 03/15/24 when another staff member stated that after the 3:30 P.M. smoke break on Sunday 03/03/24 STNA #50 refused to assist Resident #128 back into bed and she had an episode of incontinence that was not cleaned up for three hours. Review of the facility's SRI summary of events included: the Administrator was notified on 03/08/24 and initial SRI completed. The alleged employee, STNA #50 was placed on suspension pending investigation. The allegation of abuse was that this employee voiced inappropriate things to staff and purposefully lied to a resident about smoking so that she would not have to get this resident up. During initial reporting, it was noted also that this same aide failed to provide incontinence care to another resident who had to wait and have the service provided by a nurse. Statements from co-workers present at the time of the incident were obtained on 03/08/24. The DON completed interviews with both residents identified on 03/8/24. Both residents indicated they feel safe in the facility but both also reported that the aide in question, STNA #50 was 'snotty' and had a bad attitude. STNA #50 was released from employment for failure to get a patient up and to provide incontinence care. Interview on 03/28/24 at 2:00 P.M. with the DON confirmed STNA #50 was terminated from the facility due to her attitude and failure to provide incontinence care to residents. Review of facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, no date noted revealed Resident have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. The deficient practice was corrected on 03/13/24 when the facility implemented the following corrective actions: • On 02/27/24, LPN #48 was suspended pending further investigation from DON and Administrator. • On 03/01/24, LPN #48 was terminated and was reported to the Ohio Board of Nursing per DON and Administrator. • On 03/01/24, A Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, DON, and MD and the residents who were affected by the failure to administer the medications were reviewed with the facilities response to the incident including but not limited to: Investigation including interviews with alert residents, SRI completion, suspension of employee, termination of employee, Education of nursing staff on Medication administration-provided to QA Committee, Medication Audits, and Our Abuse Policy review with staff. • On 03/04/24, Skin assessments were completed by Wound Nurse #100 on all residents with a BIMS of 9 or less and all residents were interviewed by the DON on timely medication administration and care concerns. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365295 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 365295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Elm Health Care Center 370 Tarlton Road Circleville, OH 43113 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 On 03/04/24, Weekly medication audits 3 times a week for 4 weeks and then monthly x 3 thereafter per the DON. Residents Affected - Some • On 03/04/24, STNA #50 was placed on suspension per the DON and Administrator. • On 03/05/24, Education was done to all licensed nurses on the 5 rights of medication usage/standard for safe medication practices also on abuse timing and reporting per the DON. • On 03/06/24, the Medical Director assessed each affected resident and labs were completed with no concerns. • On 03/06/24, an all staff meeting was held and abuse policy was reviewed at this time per Administrator. • On 03/11/24 and 03/12/24, Residents were assessed and interviewed on feeling safe, being refused care and any mistreatments from staff by the Social Service Designee. • On 03/12/24, Call light audit 3 times a week for 4 weeks then monthly for 2 months to be completed by the DON or designee. • On 03/12/24, Audit on smokers gotten up timely to smoke 3 times a week for 4 weeks then monthly times 2 months by the DON or designee. • On 03/12/24, a mass text message was sent by the Administrator to all staff members regarding abuse and the importance of reporting abuse directly to the supervisor, DON, and Administrator. • On 03/12/24, STNA #50 was terminated by the Administrator. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365295 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 365295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Elm Health Care Center 370 Tarlton Road Circleville, OH 43113 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 On 03/13/24, education continued to all staff on abuse and timely reporting abuse by the DON and designee. This deficiency represents non-compliance investigated under Complaint Number OH00151648. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365295 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 365295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Elm Health Care Center 370 Tarlton Road Circleville, OH 43113 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on self-reported incident (SRI) review, staff interview, and facility policy review, the facility failed to timely report a staff member refusing to provide timely care and assistance out of bed. This affected two (Resident #74 and #128) of the six residents reviewed for timely reporting of incidents. The facility census was 84. Findings include: 1. Review of the medical record for Resident #74 revealed an admission date of 11/19/23. Diagnoses included anxiety, type two diabetes, and cellulitis of the left lower extremity. Review of Resident #74's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental status (BIMS) score of 15 out of 15 indicating an intact cognition for daily decision-making abilities. 2. Review of the medical record for Resident #128 revealed an admission date of 08/12/22. Diagnoses included muscle weakness, unsteadiness on feet, and depression. Review of Resident #128's quarterly MDS 3.0 assessment dated [DATE] revealed a BIMS score of 15 out of 15 indicating an intact cognition for daily-decision making ability. Review of the facility's SRI dated 03/08/24 revealed an allegation of emotional/verbal abuse allegation noting that a staff member made some inappropriate remarks about a couple of patients to staff. State Tested Nursing Assistant (STNA) #50 intentionally deceived a patient by stating that smoking was canceled so she did not have to get her up. STNA #50 admitted this to a co-worker and asked the co-worker to also deceive the patient and support her story that smoking was canceled. Smoking had not been canceled as weather conditions were appropriate and within the smoking policy guidelines. During the course of the investigation, it was also discovered that in addition to failing to get this patient up, STNA #50 also did not provide incontinence care to another patient who had to wait an extended period of time for someone to help her. These two different residents labeled STNA #50 as having a bad attitude and was snotty STNA #50 is a weekend only staff member and was placed on suspension on 03/08/24 when this incident was brought to the attention of the Director of Nursing (DON). STNA #50 had not worked since the date of the incident. Interview and statements were obtained from staff working that day who may have had insight into the incident. Additionally, a skin assessment on all patients with a BIMS of 9 or less was completed by the wound nurse and all residents with a BIMS of 10 or above was interviewed. Also, all staff were re-educated regarding the abuse policy. The two nurses initially involved in the complaint were counseled and educated by the administrator on timely reporting of any suspicion of abuse. After the investigation was completed, the facility substantiated the allegation. It was determined by the facility investigator that verbal abuse could not be substantiated, however it was felt that STNA #50's failure to get a patient up and provide incontinence care to another patient was grounds for termination. The failure to provide the care for patients' needs is substantiated. Review of the resident interview completed on 03/11/24 with Resident #74 revealed the following (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365295 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 365295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Elm Health Care Center 370 Tarlton Road Circleville, OH 43113 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some questions and answers. Has a staff member ever refused to provide care for you? No. Do you feel safe here? Yes. Has anyone ever mistreated you? Yes, refused to change. Review of the resident interview completed on 03/11/24 with Resident #128 revealed the following questions and answers. Has a staff member ever refused to provide care for you? Yes. Do you feel safe here? Yes. Has anyone ever mistreated you? No. Review of a staff statement completed by Licensed Practical Nurse (LPN) #68 dated 03/08/24 revealed STNA #50 consistently has a negative attitude with residents, she has left call lights unanswered for 30-45 minutes and when investigated by nurse, both aides were found sitting in the lounge on the hall. STNA #50 has admitted to lying to residents about activities and not taking resident who smoke out so she did not have to get this resident out of bed. Residents have confronted this STNA multiple times on the amount of time it has taken her to answer call lights leaving them soaked in urine and stool for over an hour. She stated to this resident that she has other people to take care of which caused this resident to become agitated. STNA #50 then walked out of the residents room for another 30 plus minutes until the nurse answered the call light and was informed by the resident and got aides from lounge to change the resident. Review of the staff statement completed by Activity Assistant #3 created on 03/08/24 revealed that on Sunday 03/03/24, Activity Assistant was walking inside from taking residents who smoke out for the 9:30 A.M. smoke break and was walking passed STNA #50 and told me that if Resident #128 asks if the resident who smoke went out to smoke at 9:30 A.M. to tell her no. Activity Assistant #3 then asked why and STNA #50 replied because I told her you guys didn't do out to smoke so I didn't have to get her up. Activity Assistant #3 reported what was said to the nurse that day. Review of staff statement created by the DON on 03/08/24 revealed, that the DON interviewed Resident #128 and asked if she was concerned with the care she received at the facility. Resident #128 stated that she sometimes wants to be gotten up for the smoking times and is not always able to get up out of bed. Resident #128 stated that on 03/03/24 that she was not gotten up for the 9:30 A.M. smoking time and that she wanted to. Resident #128 stated that overall, she received good care but that STNA #50 has a bad attitude and does not like to get her up. Review of staff statement created by DON on 03/08/24 revealed, the DON interviewed Resident #74 and asked if she was concerned with the care she received at the facility. Resident #74 stated that she only had had one problem and that was that she did not receive care timely from STNA #50. Resident #74 stated that on the weekend of 03/02/24 and 03/03/24 STNA #50 refused to change her and walked out and after about 40 minutes a nurse came in her room and she reported the issue to the nurse and the nurse provided incontinence care. Review of the staff statement completed by RN #80 dated 03/11/24 revealed On Sunday 03/03/24, RN #80 was the supervisor. Activity Assistant #3 told RN #80 that earlier in the day for the 9:30 A.M. smoke break that STNA #50, the staff member on Elm stated that she told Resident #128 that they weren't going out to smoke so that she didn't have to get her up and laughed. STNA #50 claimed she did not say that and that Resident #128 was asleep. RN #80 revealed she didn't hear anymore about it until Friday 03/15/24 when another staff member stated that after the 3:30 P.M. smoke break on Sunday 03/03/24 STNA #50 refused to assist Resident #128 back into bed and she had an episode of incontinence that was not cleaned up for three hours. Review of the facility's SRI summary of events included: the Administrator was notified on 03/08/24 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365295 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 365295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Elm Health Care Center 370 Tarlton Road Circleville, OH 43113 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and initial SRI completed. The alleged employee, STNA #50 was placed on suspension pending investigation. The allegation of abuse was that this employee voiced inappropriate things to staff and purposefully lied to a resident about smoking so that she would not have to get this resident up. During initial reporting, it was noted also that this same aide failed to provide incontinence care to another resident who had to wait and have the service provided by a nurse. Statements from co-workers present at the time of the incident were obtained on 03/08/24. The DON completed interviews with both residents identified on 03/8/24. Both residents indicated they feel safe in the facility but both also reported that the aide in question, STNA #50 was 'snotty' and had a bad attitude. STNA #50 was released from employment for failure to get a patient up and to provide incontinence care. Interview on 03/28/2024 at 2:00 P.M. with the DON confirmed STNA #50 was terminated from the facility due to her attitude and failure to provide incontinence care to residents. Review of facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, no date noted revealed Facility staff should immediately report all such allegations to the Administrator and to the Ohio Department of Health (ODH) in accordance with the procedure in this policy. The deficient practice was corrected on 03/13/24 when the facility implemented the following corrective actions: • On 02/27/24, LPN #48 was suspended pending further investigation from DON and Administrator. • On 03/01/24, LPN #48 was terminated and was reported to the Ohio Board of Nursing per DON and Administrator. • On 03/01/24, A Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, DON, and MD and the residents who were affected by the failure to administer the medications were reviewed with the facilities response to the incident including but not limited to: Investigation including interviews with alert residents, SRI completion, suspension of employee, termination of employee, Education of nursing staff on Medication administration-provided to QA Committee, Medication Audits, and Our Abuse Policy review with staff. • On 03/04/24, Skin assessments were completed by Wound Nurse #100 on all residents with a BIMS of 9 or less and all residents were interviewed by the DON on timely medication administration and care concerns. • On 03/04/24, Weekly medication audits 3 times a week for 4 weeks and then monthly x 3 thereafter per the DON. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365295 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 365295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Elm Health Care Center 370 Tarlton Road Circleville, OH 43113 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 0609 • Level of Harm - Minimal harm or potential for actual harm On 03/04/24, STNA #50 was placed on suspension per the DON and Administrator. • Residents Affected - Some On 03/05/24, Education was done to all licensed nurses on the 5 rights of medication usage/standard for safe medication practices also on abuse timing and reporting per the DON. • On 03/06/24, the Medical Director assessed each affected resident and labs were completed with no concerns. • On 03/06/24, an all staff meeting was held and abuse policy was reviewed at this time per Administrator. • On 03/11/24 and 03/12/24, Residents were assessed and interviewed on feeling safe, being refused care and any mistreatments from staff by the Social Service Designee. • On 03/12/24, Call light audit 3 times a week for 4 weeks then monthly for 2 months to be completed by the DON or designee. • On 03/12/24, Audit on smokers gotten up timely to smoke 3 times a week for 4 weeks then monthly times 2 months by the DON or designee. • On 03/12/24, a mass text message was sent by the Administrator to all staff members regarding abuse and the importance of reporting abuse directly to the supervisor, DON, and Administrator. • On 03/12/24, STNA #50 was terminated by the Administrator. • On 03/13/24, education continued to all staff on abuse and timely reporting abuse by the DON and designee. This deficiency represents non-compliance identified during investigation for Complaint Number (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365295 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 365295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Elm Health Care Center 370 Tarlton Road Circleville, OH 43113 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 0609 OH00151648. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365295 If continuation sheet Page 12 of 12