Health inspection·September 28, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Review of the policy labeled, Catheter Care, dated 10/01/22, revealed the policy was to ensure residents with indwelling catheters received appropriate catheter care and maintained their dignity and privacy when indwelling catheters were in use. The policy revealed privacy bags would be available and catheter drainage bags would be always covered. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365306 If continuation sheet Page 2 of 8 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 365306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madison Health Care 7600 S Ridge Rd Madison, OH 44057 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 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to obtain witnessed authorizations to manage resident funds. This affected three residents (#48, #67 and #98) of eight records reviewed for personal fund accounts. Residents Affected - Few Findings include: Review of Resident #48's medical record revealed an admission date of 02/22/23. Review of the undated authorization and agreement form to handle resident funds revealed Resident #48's power-of-attorney signed the form and the form did not contain a witness signature as required. Review of Resident #67's medical record revealed an admission date of 06/25/21. Review of the undated authorization and agreement form to handle resident funds revealed Resident #67 signed the form and the form did not contain a witness signature as required. Review of Resident #98's medical record revealed an admission date of 08/17/22. Review of the undated authorization and agreement form to handle resident funds revealed Resident #98's representative payee signed the form and the form did not contain a witness signature as required. Interview on 09/28/23 at 9:24 A.M. with Business Office Manger #504 confirmed the authorization and agreement forms to handle resident funds were not witnessed as required for Residents #48, #67 and #98. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365306 If continuation sheet Page 3 of 8 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 365306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madison Health Care 7600 S Ridge Rd Madison, OH 44057 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure Resident #28 wore hand splints as recommended per therapy and/or the physician order. This affected one resident (#28) of one resident reviewed for range of motion (ROM). The facility census was 102. Findings include: Review of the medical record for Resident #28 revealed an admission date of 07/26/19 with diagnoses including sequela of cerebrovascular disease, contracture, and cerebral palsy. The resident was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #28 was moderately cognitively impaired. The assessment indicated the resident required the extensive assistance of two people for bed mobility and dressing. The resident was totally dependent on two people for transfers, toilet use, and personal hygiene and dependent on one person for locomotion. Review of physician orders for Resident #28 for September 2023 revealed no order for hand splints. Review of the discontinued orders for Resident #28 revealed an order for resting hand splints with finger separators while sleeping/during nighttime to decrease further risk for hand contractures. The order started 02/17/23 and was discontinued when the resident was discharged to the hospital. Review of the plan of care for Resident #28 dated 09/18/18 and last revised 05/09/23 revealed the resident was at risk for decline in ROM related to the effects of cerebral palsy and contractures. Interventions included bilateral hand splints as tolerated. Observations of Resident #28 on 09/25/23 at 1:05 P.M., 09/27/23 at 10:38 A.M. and on 09/28/23 at 10:09 A.M. revealed the resident was not wearing hand splints. Interview on 09/25/23 at 1:05 P.M. with Resident #28 stated he hadn't worn hand splints in about a month. Interview on 09/27/23 at 4:10 P.M. with Licensed Practical Nurse (LPN) #505 and MDS Coordinator #424, revealed they did not know a reason why the splints would have been discontinued. Therapy would have been the ones who made the recommendation. Interview on 09/28/23 at 10:05 A.M. with the Director of Rehab #540 stated the splints were not recommended to be discontinued. The order had inadvertently not been restarted when Resident #28 returned from the hospital on [DATE]. Interview and observation on 09/28/23 at 10:33 A.M. with STNA #423 verified hand splints were not on the resident. Interview on 09/28/23 at 11:47 A.M. the Director of Nursing (DON) verified the order had not been restarted when the resident returned from the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365306 If continuation sheet Page 4 of 8 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 365306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madison Health Care 7600 S Ridge Rd Madison, OH 44057 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Many Based on record review and interview, the facility failed to employ a registered nurse (RN) for at least eight consecutive hours daily who was not acting in the capacity of the Director of Nursing. This had the potential to affect all 102 residents residing in the facility. Findings include: Review of the facility posted staffing information for January 2023 revealed on 01/02/23 there was no RN on duty for at least eight hours who was not acting in the capacity of the Director of Nursing. Review of the facility posted staffing information for August 2023 revealed on 08/11/23 there was no RN on duty for at least eight hours who was not the acting in the capacity of the Director of Nursing, and on 08/19/23 there was no RN on duty in the facility. Interview on 09/27/23 at 2:16 P.M. with Scheduler and State Tested Nursing Assistant (STNA) #422 verified on 01/02/23, 08/11/23, and 08/19/23 there was no RN on duty for at least eight hours who was not acting in the capacity of the Director of Nursing. The deficient practice was corrected on 08/24/23 when the facility implemented the following corrective actions: Administrator, Human Resources, Assistant Director of Nursing and Scheduler were educated by the Regional Director of Clinical Operations regarding the regulation, clinical management back up plan coverage, and daily staffing meeting on 08/23/23. Audits were established and initiated by the Administrator/Designee on 08/23/23 and completed three to five times weekly for four weeks thereafter to ensure an RN was scheduled seven days weekly eight hours daily. Results were reviewed by the quality assurance committee to determine further need for action. This deficiency represents non-compliance investigated under Complaint Number OH00146162. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365306 If continuation sheet Page 5 of 8 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 365306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madison Health Care 7600 S Ridge Rd Madison, OH 44057 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 0851 Level of Harm - Minimal harm or potential for actual harm Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on record review and interview, the facility failed to submit payroll-based journal (PBJ) data quarterly as required. This had the potential to affect all 102 residents residing in the facility. Residents Affected - Many Findings include: Review of the PBJ staffing data report dated 09/15/23 revealed the facility failed to submit PBJ data for the second quarter of the federal fiscal year 2023. Review of the facility provided PBJ validation reports for the federal fiscal year 2023 revealed there was no evidence the PBJ data for the second quarter was submitted. Interview on 09/28/23 at 11:34 A.M. with Regional Administrative Director #539 verified there was no PBJ data submitted in the second quarter of the federal fiscal year 2023 as required. This deficiency represents non-compliance investigated under Complaint Number OH00146162. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365306 If continuation sheet Page 6 of 8 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 365306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madison Health Care 7600 S Ridge Rd Madison, OH 44057 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review the facility failed to ensure infection control standards were followed during dining including a resident feeding another resident utilizing the same utensil that he was using to eat with. This affected two residents (#15 and #57) out of four residents reviewed for nutrition/ hydration and had the potential to affect 35 residents (#1, #2, #3, #4, #5, #9, #12, #14, #16, #18, #19, #20, #24, #25, #29, #31, #34, #35, #40, #44, #50, #52, #57, #59, #60, #68, #75, #77, #80, #90, #91, #92, #95 #97, and #99) residing on the secured units four and five. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 01/13/14 with diagnoses including intellectual disability, alcohol-induced persisting dementia, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had impaired cognition as his Brief Interview for Mental Status (BIMS) score was a four. He required supervision and set up help with eating. Review of the September 2023 Physician Orders revealed Resident #15 had an order for a mechanical soft diet and was to be supervised at all meals due to dysphagia (difficulty in swallowing). Review of the care plan dated 09/05/23 revealed Resident #15 was at risk for alteration in his nutrition related to texture altered diet. Interventions included providing his diet as ordered, and monitoring for changes in his mood, behavior, and cognition which impacted his intakes. 2. Review of medical record for Resident #57 revealed an admission date of 02/09/21 with diagnoses including schizophrenia, alcohol dependence with alcohol induced persisting dementia, dysphagia, nephrogenic diabetes insipidus, and seizures. Review of the September 2023 Physician Orders revealed Resident #57 had an order for mechanical soft diet, and food in bowls. Review of the Medicare Five-Day MDS assessment dated [DATE] revealed Resident #57 had impaired cognition. She required extensive assistance from one staff member with eating. Review of the care plan dated 09/12/23 revealed Resident #57 was at risk for alterations in her nutrition and/ or hydration status related to textured altered diet, significant weight loss, and inadequate oral intake. Interventions included assist with feeding as needed. Observation on 09/26/23 at 12:25 P.M. revealed Resident #15 was sitting at the dining room table next to Resident #57 on the secured unit four and five. Resident #15 received his lunch tray and began to eat his meal with a plastic spoon. Resident #57 then reached out towards Resident #15 attempting to grab the food on his tray. Resident #15 then took his plastic spoon that he had been eating with and retrieved a spoonful of mashed potatoes from his plate, blew on the mashed potatoes appearing to cool the mashed potatoes and then proceeded to feed the spoonful to Resident #57. Resident #15 then proceeded with the same spoon and took a bite of his food and then proceeded to take another spoonful of mashed potatoes blow on it again and feed another bite to Resident #57. Staff continued to pass trays and were not observing Resident #15 feed Resident #57 using the same spoon he was eating (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365306 If continuation sheet Page 7 of 8 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 365306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madison Health Care 7600 S Ridge Rd Madison, OH 44057 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few from. Dietitian #444 walked past, and this surveyor asked him to observe, and he observed Resident #15 take a bite of his food and then proceed for a third time to take a spoonful of mashed potatoes, blow on the mashed potatoes, and then feed the spoonful of mashed potatoes to Resident #57. Dietitian #444 then notified the nurse in the dining room of the concern. Interview on 09/26/23 at 12:30 P.M. with Dietitian #444 verified Resident #15 was feeding Resident #57 food off his tray using the same spoon that he was eating with. Review of the facility policy labeled, Meal Supervision and Assistance, dated November 2017, revealed the resident would be prepared a well-balanced meal in a calm environment, location of his or her preference and with adequate supervision and assistance to prevent accidents, and provide adequate nutrition. The policy did not include anything in regard to monitoring of other residents attempting to feed other residents including in regards to infection control. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365306 If continuation sheet Page 8 of 8