Inspection·January 31, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm On 01/25/22 at 10:28 A.M. observation of Resident #35 from the hallway revealed an indwelling urinary catheter collection bag with visible urine hanging on the side of the bed above the resident's bladder. On 01/26/22 at 2:20 P.M. observation of Resident #35 revealed the resident's indwelling urinary catheter collection bag remained visible from the hallway and hanging above the resident's bladder. Residents Affected - Few On 01/26/22 at 2:40 P.M. interview with Licensed Practical Nurse (LPN) #176 verified the resident's indwelling urinary catheter collection bag was not covered and urine was visible from the hallway by visitors and other residents. Review of the facility policy titled Resident Rights, dated 11/22/16 revealed the resident had the right to be treated with dignity and respect. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 2 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Potential for minimal harm Based on personnel record review, facility policy and procedure review and staff interview the facility failed to develop and implement comprehensive abuse, neglect, exploitation of residents and misappropriation of resident property policies and procedures including checking references as part of the screening process for newly hired staff. This had the potential to affect all 86 residents residing in the facility. Residents Affected - Many Findings include: Review of the employee personnel files revealed no evidence the facility attempted to obtain information from previous employers and/or current employers as part of the required screening process for new employees. The following personnel files were reviewed: Unit Manager #300 who was hired on 12/27/21 Receptionist #131 who was hired on 12/09/21. Dietary Staff #128 who was hired on 10/29/21. State Tested Nursing Aide (STNA) #102 who was hired on 09/07/21. STNA #150 who was hired on 09/07/21. On 01/26/22 at 12:30 P.M. interview with Human Resources #195 confirmed the facility did not have evidence to support reference checks were completed as part of the screening process for all new employees, including documentation of who was called/contacted, dates/times and the response of the reference person when contacted about the new hire. Review of the current facility abuse policy and procedures revealed the policy failed to include checking references as part of the screening process for all new employees as required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 3 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #387, who presented with communication difficulties was able to adequately and effectively communicate needs with staff and staff were able to communicate with resident through the use of an interpreter, communication board or other effective measures. This affected one resident (#387) of three residents reviewed for communication. Residents Affected - Few Findings include: Record review for Resident #387 revealed the resident was admitted to the facility on [DATE] with diagnoses including atherosclerosis of native arteries of right leg with ulceration of other part of foot, COVID-19, pain in unspecified foot, hypertension and type 2 diabetes. Review of the resident's initial nursing assessment, dated 12/29/21 revealed a communication board should be used when communicating with the resident. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/14/22 revealed Resident #387 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13. The MDS noted the resident's resident speech was clear and he was usually understood. Review of the care plan, dated 01/20/22 revealed the resident had communication difficulties related to speaking Korean with some English. Interventions included anticipate and meet needs, encourage resident to continue stating thoughts even if he had difficulty. Focus on a word or phrase that made sense, or respond to the feeling the resident tried to express, provide translator as necessary to communicate with resident (translator is: Google translator), discuss with resident and family concerns or feelings regarding communication difficulty, monitor for confounding problems, decline in cognitive status and mood decline, occupational therapy, physical therapy, nurse to evaluate dexterity/ability to use communication board, writing, using computer for speech. On 01/24/22 at 12:44 P.M. during an interview with Resident #387, the resident was expressing his frustrations about an upcoming appointment he was supposed to attend on this date but that the facility would not allow him to attend due to COVID-19. As the resident was expressing these frustrations, LPN #203 kept interrupting the resident/conversation. The resident was noted to struggle in communication with staff as the resident spoke Korean with limited English and staff could not understand the resident nor could the resident understand staff. As the resident was explaining the importance of his appointment with the surveyor, LPN #203 kept interrupting resident and tried to inform the surveyor the resident wanted his room cleaned and wanted to go back to his formal room. The resident was visibly upset related to the communication with LPN #203. On 01/25/22 at 8:44 A.M. interview via interpreter with Resident #387 revealed he cannot communicate with staff and staff do not communicate with him that much because they do not understand each other. He stated due to staff not understanding him when he speaks, staff mostly ignore him when he calls or they would not help him with what he wanted. Review of the policy titled Limited English Proficiency and Individuals with Hearing Loss, dated 10/31/16 revealed the social services staff at each community would take reasonable steps to ensure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 4 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 0676 Level of Harm - Minimal harm or potential for actual harm that persons with limited English proficiency (LEP) or those who were deaf or hard of hearing have access and an equal opportunity to participate in the facilities services, activities and programs. The policy further revealed language assistance would be provided through use of a competent bilingual interpreter, or through formal arrangements with local organizations, or technology and telephonic interpretation services. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 5 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview the facility failed to ensure Resident #8, who required staff assistance from staff for personal hygiene received timely and adequate assistance with shaving to maintain proper grooming and hygiene. This affected one resident (#8) of four residents reviewed for activities of daily living (ADL) care. Residents Affected - Few Findings include: Review of Resident #8's medical record revealed an admission date of 08/01/18 with diagnoses including dementia with behavioral disturbance, cerebral infarction, chronic kidney disease, peripheral vascular disease, glaucoma, cardiomegaly, diabetes mellitus, anoxic brain damage, hypertension, anemia, chronic obstructive pulmonary disease, major depressive disorder, congestive heart failure and unspecified malignant neoplasm. Review of the plan of care, dated 08/02/18 revealed the resident had a self-care deficit related to dementia, edema, incontinence, hypertension, depression and natural progression of disease process. Interventions included one to two person assist with activities of daily living/care as needed, encourage resident to participate to the fullest extent possible with each interaction and praise all efforts of self care. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/11/22 revealed the resident had clear speech, usually understood others, usually made himself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of five. The resident required extensive assistance of one staff for bed mobility, transfers, ambulation and personal hygiene. Review of the resident's monthly physician's orders for January 2022 revealed no orders related to activities of daily living. On 01/25/22 at 3:24 P.M. Resident #8 was observed to have several days of hair growth to his face. Additional observations on 01/26/22 at 1:20 P.m. and 01/27/22 at 9:50 A.M. revealed the resident remained unshaven. There was no evidence the resident refused to allow staff to shave him. On 01/27/22 at 10:05 A.M. interview with State Tested Nursing Assistant (STNA) #184 revealed Resident #8 was unable to shave himself and indicated staff sometimes shave the resident. At the time of interview, observation of Resident #8 with the STNA verified the resident had several days of facial hair growth at this time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 6 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to complete weekly skin assessments and monitor non-pressure related skin impairment/wounds for Resident #62 and Resident #387. This affected two residents (#62 and #387) of three residents reviewed for non-pressure skin conditions. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #62 revealed the resident was admitted to the facility on [DATE] with diagnoses including gas gangrene, type one diabetes mellitus with diabetic neuropathy, chronic kidney disease stage three, peripheral vascular disease, anemia, acquired absence of left leg below knee, acute osteomyelitis of right ankle and foot, and acquired absence of other right toes. Review of Resident #62's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/04/21 revealed the resident had intact cognition and was at risk of developing pressure ulcers. Review of the plan of care, dated 11/09/21 revealed the resident was at risk for alteration to skin integrity related to gas gangrene foot, osteomyelitis, diabetes, toe amputation, peripheral neuropathy and below knee amputation. Interventions included administering medications and treatments as ordered, encourage adequate nutrition and hydration, weekly skin assessments as tolerated, keep skin clean, dry and odor free as tolerated The plan of care dated 12/10/21 revealed Resident #62 had a recent amputation of his right fourth toe and partial right third toe related to gas gangrene. The care plan noted on 09/08/21 the resident also had toes amputated and had treatments in place. Interventions included checking and documenting on wound daily, elevate bilateral heels as tolerated, encourage compliance with treatments, monitor for bleeding, monitor nutritional status, treatments as ordered. a. Review of the physician's orders for January 2022 revealed Resident #62 had an order for weekly skin assessments to be completed every Thursday. Review of the weekly skin assessments from 11/01/21 to 01/25/22 revealed five assessments were completed on 11/25/21, 01/05/22, 01/06/22, 01/13/22, and 01/21/21. Review of the weekly skin assessment dated [DATE] revealed the resident had a wound on his right toes related to amputation. Review of the weekly skin assessment dated [DATE] revealed the resident had a foot wound, Stage III, it was unspecified which foot it was. Review of the weekly skin assessments dated 01/05/22, 01/06/22, and 01/21/21 revealed nothing related to a right foot wound. b. Review of the non-pressure skin grids from 11/01/21 to 01/25/22 revealed there were assessments completed on seven occasions in this time period, on 11/03/21, 11/17/21, 12/01/21, 12/08/21, and 12/15/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 7 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the skin grid, dated 11/03/21 revealed Resident #62 had a surgical wound to his right toes and top of foot. The wound originated on 08/24/21. At the time the surgical incision to his right toes was 11 centimeters (cm) in length by 12.3 cm width with no depth with a medium amount of drainage, the wound had improved. The resident had surgical amputation of right toes. The resident went back and had the top of his foot amputated. The wound was recently debrided, eschar and slough removed with open area exposing fat layer. Drainage was red and brownish, the margins were well defined, there was no granulation present at that time. Review of the skin grid, dated 11/17/21 revealed Resident #62's surgical wound remained and was measured at 11 cm by 12.3 cm with no depth, with medium amount of drainage. It was reported the wound had declined. However, the physical description of the wound was the same as 11/03/21. Review of the skin grid, dated 12/01/21 revealed Resident #62's surgical wound remained at 11 cm by 12.3 cm with no depth with medium amount of drainage. It was reported the wound had improved. The wound bed was pink with no slough or eschar showing, the resident was set to return to the wound clinic on 12/03/21. Review of the skin grid dated 12/08/21 revealed Resident #62's surgical wound measured at 9 cm by 10.3 cm with unmeasurable amount of drainage. The wound had improved. Review of the skin grid dated 12/15/21 revealed Resident #62's surgical wound remained at 9 cm by 10.3 cm. There was a moderate amount of drainage, with odor. On 01/26/22 at 9:03 A.M. interview with the Director of Nursing (DON) revealed there was no facility documentation (assessment or monitoring) related to Resident #62's wound since 12/15/21. The DON revealed the assessments should have been completed by unit managers weekly but had not been done due to issues with staffing. The DON also confirmed the weekly skin assessments were not addressing the resident had a right foot wound. The DON revealed the resident was seen by at a wound clinic and treatments were being completed even though the weekly skin assessments and wound monitoring was not being completed. 2. Review of Resident #387's medical record revealed the resident was discharged to the hospital on [DATE] and returned on 01/07/22 following bypass surgery. Record review revealed no skin assessment was completed by the facility upon re-admission. Prior to the resident's hospitalization, the most recent skin assessment was completed on 12/29/21. Record review revealed Resident #387 had a care plan, dated 01/17/22 related to risk for alteration in skin integrity related to status post right great toe amputation, popliteal to tibia artery bypass, diabetes mellitus and hypertension. Interventions included weekly skin assessments and keep skin clean, dry and odor free as tolerated. A care plan, dated 01/20/22 revealed Resident #387 had venous stasis/venous insufficiency ulcer to his right great toe related to peripheral vascular disease (PVD), right great toe amputation due to peripheral vascular disease, diabetes mellitus and arthrosclerosis. Interventions included document location of wound, amount of drainage, peri-wound area, pain, edema and circumference measurements weekly, evaluate wound for size, depth and margin, give medication as ordered, monitor for signs and symptoms of infection, treatment as ordered, weight bearing as ordered. On 01/26/22 from 11:26 A.M. to 11:45 A.M. interview with Licensed Practical Nurse (LPN) #112 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 8 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 0684 the Director of Nursing revealed skin assessments should be completed weekly for Resident #387 and verified the lack of skin assessments for the resident from 01/07/22 through 01/26/22. 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: 365421 If continuation sheet Page 9 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 - Actual harm Based on observation, record review, facility policy and procedure review and interview the facility failed to implement interventions to prevent the development of a pressure ulcer for Resident #82. Residents Affected - Few Actual harm occurred on 01/18/22 when Resident #82, who required extensive assistance from two staff for bed mobility and had a known history of pressure ulcers was identified to have an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the coccyx. There was no evidence the facility had adequate interventions in place to prevent the development of the ulcer and to promote healing once the ulcer was identified. The facility failed to ensure the pressure ulcer was timely identified prior to being found as an unstageable pressure ulcer and failed to ensure a comprehensive assessment was completed and interventions were implemented to promote healing when the ulcer was first discovered. This affected one resident (#82) of two residents reviewed for pressure ulcers. Findings include: Review of Resident #82's medical record revealed and admission date of 03/28/18 with diagnoses including multiple sclerosis (MS), dysphagia, glaucoma, arthropathy, vitamin D deficiency, paraplegia, pain, osteoarthritis and gastro-esophageal reflux disease. Review of the plan of care, dated 03/29/18 revealed Resident #82 was at risk for skin breakdown and pressure injury related to MS, weakness, dependence on wheelchair, spastic leg, history of using Baclofen pump, comorbidities, nutritional risks, prefers to have a blanket under him in the wheelchair, history of skin breakdown and impaired dexterity. Interventions included air mattress, encourage/assist with daily hygiene needs as needed, keep area clean, dry and odor free as tolerated, place cube of ice in coffee, report decline in skin condition to physician as needed, treatment to areas as ordered as tolerated and weekly skin assessments as tolerated. The plan of care did not include any interventions related to turning or repositioning for the resident. Review of the resident's physician's orders, revealed an order dated 12/31/18 for moon boots (protective boots) to bilateral lower extremities at all times while in bed, an order dated 12/18/19 for a gel cushion to power wheelchair, an order dated 04/10/20 for a weekly skin assessment every Monday, an order dated 07/07/20 for heels to be floated while in bed, when resident refused to wear mood boots and an order dated 01/08/21 apply skin prep to bilateral heels daily. There was no order for turning and repositioning. Review of the resident's skin risk (Braden Scale) assessment, dated 11/05/21 revealed the resident was at moderate risk for skin breakdown with a score of 14. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/04/22 revealed the resident had clear speech, understood others, made himself understood and had no cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 15. The assessment revealed the resident required extensive assistance from two staff for bed mobility and was dependent on two staff for transfers and toilet use. The assessment revealed the resident was always incontinent of both bowel and bladder. The assessment indicated the resident was at risk for skin breakdown and had no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 10 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 unhealed pressure ulcers. The MDS noted interventions included pressure reducing device to bed/chair and application of ointments/medications other than to feet. Level of Harm - Actual harm Residents Affected - Few Review of a wound evaluation and management summary, completed by Wound Physician #208 dated 01/19/22 (the next day) revealed the resident had an unstageable pressure ulcer to his coccyx measuring 3.3 centimeters (cm) in length by 6.2 cm width with 70% adherent black necrotic tissue, 15% adherent devitalized necrotic tissue and 15% skin. The assessment indicated the unstageable pressure ulcer was debrided to remove narcotic tissue and establish the margins of viable tissue. The wound physician implemented a treatment to cleanse the wound, apply calcium alginate and Santyl, cover with bordered gauze daily for 30 days, off load wound and reposition per facility policy. On 01/20/22 a physician order was written to cleanse coccyx, apply calcium alginate and Santyl and cover with gauze island dressing every shift. However, review of the treatment administration record revealed no treatment was completed for the pressure ulcer on 01/20/22. On 01/24/22 the treatment frequency was increased to twice a day. Review of the resident's care plans revealed no plan of care addressing the unstageable pressure ulcer to the resident's coccyx. On 01/24/22 at 9:36 A.M. Resident #82 was observed in bed. The resident was not observed to have an air mattress in place at the time of the observation. On 01/24/22 at 2:53 P.M. interview with Resident #82 revealed he was a quadriplegic and had little feeling to his coccyx area. The resident revealed he needed staff assistance to turn completely over in bed. On 01/25/22 at 1:15 P.M. the resident was also observed in bed with no air mattress in place. Review of the wound evaluation and management summary, dated 01/26/22 and completed by Wound Physician #208 revealed the wound was classified as a Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer measuring 3.3 cm in length by 5.2 cm width with 3.0 cm depth with 70% thick adherent devitalized necrotic tissue, 10% slough, 10% muscle and 10% skin. The treatment was changed and a new treatment to cleanse the wound, apply Dakins' solution, calcium alginate with sliver and cover with sponge gauze twice daily for 30 days was initiated. On 01/26/22 at 1:08 P.M. Licensed Practical Nurse (LPN) #176 and LPN #210 (the wound nurse) were observed to complete the resident's coccyx pressure ulcer. At the time of the observation, the wound was observed with blackish tissue and yellowish strings of tissue. LPN #210 cleansed the wound with normal saline (NS) and 4X4 gauze and then washed her hands. She then packed the wound with Maxorb with calcium alginate silver and covered with foam dressing. The resident was noted to have a bolster mattress on his bed. At time time of the observation, interview with LPN #210 revealed Maxorb was used as the facility had not yet received the Dakins' solution. LPN #210 verified the resident did not have an air mattress (as previously care planned) at the time of this observation. On 01/25/22 at 1:11 P.M. interview with Director of Nursing (DON) verified an initial assessment of the pressure ulcer was not completed at the time the ulcer was first identified on 01/18/22. On 01/25/22 at 1:20 P.M. interview with LPN #210 revealed she was verbally notified of the resident's wound on 01/18/22. The LPN revealed she had examined the wound on that date but failed to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 11 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 - Actual harm Residents Affected - Few document an assessment of the wound or implement a treatment. The LPN revealed she felt the wound was at least a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister) because the wound was a bluish, gray with yellow in the wound. During the interview, the LPN verified a wound that was bluish/gray/yellow in color was not consistent with a State II pressure ulcer but rather possibly a deep tissue injury (intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue). In addition, LPN #210 verified the resident required staff assistance with bed mobility and turning and repositioning and there was no evidence this had been provided for the resident to assist in pressure ulcer prevention. The lack of turning and repositioning along with the lack of an air mattress placed the resident at increased risk and likely contributed to the development of the unstageable/Stage IV pressure ulcer. On 01/25/22 at 2:59 P.M. interview with the Director of Nursing verified no plan of care had been initiated to address the resident's actual skin breakdown/pressure ulcer to the coccyx. On 01/26/22 11:53 AM interview with Wound Physician (WP) #208 revealed the wound was debrided to a Stage IV on 01/26/22. WP #208 said the wound was never a Stage II pressure ulcer and indicated staff should have noticed the wound prior to the discovery date. Review of the facility policy titled Pressure Ulcer Care Special Considerations, dated 2016 revealed comprehensive skin assessments were to be completed on admission, daily on the unit and upon discharge from the unit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 12 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 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 observation, record review, facility policy and procedure review and staff interview the facility failed to ensure Resident #35's indwelling urinary catheter was properly positioned to prevent backflow of urine and possible urinary tract infections and failed to provide catheter and perineal care in a manner to decrease the risk of urinary tract infections. The facility also failed to ensure a urinalysis and culture and sensitivity were obtained timely as ordered for Resident #42 who was symptomatic of a urinary tract infection. This affected one resident (#35) of one resident reviewed for indwelling urinary catheter use and one resident (#42) of five residents reviewed for infections. The facility identified two residents with indwelling urinary catheters. Findings include: 1. Review of Resident #35's medical record revealed an initial admission date of 03/19/18 with the latest readmission of 05/29/19. Resident #35 had diagnoses including congestive heart failure, personal history of COVID-19, dementia, ataxia, dysphagia, degenerative disc of lumbar region, anemia, urinary retention, urinary tract infection (UTI), scoliosis, hypertension, major depressive disorder, osteoporosis, osteoarthritis, benign prostatic hyperplasia (BPH) and deafness. Review of the plan of care, dated 03/20/18 revealed the resident had a suprapubic catheter related to BPH with lower urinary tract symptoms, bladder spasms and had minimal urinary output. Interventions included catheter care with rounds and as needed, empty and report output to nursing every shift, irrigate catheter with 60 milliliters (ml) sterile water daily and as needed, position catheter bag and tubing below the level of the bladder and away from the entrance room door, monitor and document intake and output as facility policy, monitor for signs/symptoms on urination and frequency, report to physician for signs/symptoms of UTI, check tubing for kinks each shift, monitor/document for pain/discomfort due to catheter, provide incontinence care with rounds and as needed and refer to urologist as needed. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/05/22 revealed the resident's hearing was highly impaired, the resident had no speech, understands others, made himself understand and had severe cognitive impairment. The resident required extensive assistance of two staff for bed mobility, was dependent on two staff for transfers and toilet use and required limited assistance with eating. The assessment indicated the resident had an indwelling urinary catheter and was always incontinent of bowel. Review of the resident's monthly physician's orders for January 2022 revealed an order, dated 06/26/19 for suprapubic catheter 20 FR with 30 ml balloon for obstructive uropathy, an order dated 07/15/19 to irrigate suprapubic tube with 60 ml sterile water until catheter free of debris, an order dated 09/02/19 to change suprapubic every 28 days, an order dated 02/18/20 to change suprapubic 20 FR 30 ml catheter as needed, an order dated 04/23/21 to cleanse suprapubic site with normal saline, pat dry, apply triple antibiotic ointment and cover with drain sponge every shift and an order dated, 08/25/21 to monitor suprapubic output every shift, change suprapubic catheter bag as needed when blocked/unable to flow freely and suprapubic catheter care every shift. a. On 01/25/22 at 10:28 A.M. observation of Resident #35 from the hallway revealed an indwelling urinary catheter collection bag with visible urine hanging on the side of the bed above the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 13 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 bladder. Level of Harm - Minimal harm or potential for actual harm On 01/26/22 at 2:20 P.M. observation of Resident #35 revealed the resident's indwelling urinary catheter collection bag remained visible from the hallway and hanging above the resident's bladder. Residents Affected - Few On 01/26/22 at 2:20 P.M. interview with State Tested Nursing Assistant (STNA) #102 verified the resident's indwelling urinary catheter collection bag was improperly positioned above the resident's bladder. Review of the facility policy titled Catheter Care, dated 2016 revealed keep the catheter bag and drainage tubing free from kinks to allow the free flow of urine, and keep the drainage bag below the level of the resident's bladder to prevent backflow of urine into the bladder, which increased the risk of a UTI. b. On 01/26/22 at 2:20 P.M. State Tested Nursing Assistant (STNA) #102 was observed providing catheter care for Resident #35. The STNA entered the resident's room and sanitized his hands upon entry into the room. The STNA obtained a basin of warm water and placed it on the resident's bedside table. The STNA was unable to locate any soap to provide catheter care. The STNA then removed his gloves, exited the room and then returned with a clear plastic cup with soap. At the time of the observation, the resident's urinary collection bag was observed to be positioned at the resident's bladder level and without a privacy cover. The resident's suprapubic catheter stoma site was covered with a split sponge. The STNA applied double gloved, applied soap to the washcloth and began to cleanse the resident's penis and groin area with the washcloth without washing from front to back. The STNA also used the same area of the washcloth to wash the resident's penis and groin area. The STNA then placed the soiled washcloth back into the basin of soapy water. He then assisted the resident to turn onto his left side. The STNA removed the soiled washcloth from the basin and began washing the resident's rectal area and buttocks without wiping from front to back. Dark brown stool was observed on the washcloth. STNA #102 then walked to the resident's roommates side of the room and obtained the roommate's trash can and sat it down beside the resident's bed. The STNA removed the trash out of the trash can and placed it in the resident's trash can. He then removed a set of gloves and applied barrier cream to the resident's buttocks. The STNA then assisted the resident onto his back and applied barrier cream to the resident's groin and placed a disposable brief on the resident. The STNA then dumped the soap water, washed his hands and obtained a new pan of water. STNA #102 then double gloved, placed the cup of soap into the water and swirled the cup around. He then began washing the resident's indwelling urinary catheter with a soapy washcloth moving up and down the tube several time, using the same area of the washcloth. The STNA then lifted the split sponge up and cleansed the resident's skin/stoma site using the same area of the cloth and indicated the nurse was responsible to change the suprapubic catheter dressing. The STNA then dried the indwelling urinary catheter with a dry cloth moving the cloth up and down. Interview with the STNA at the time of the observation confirmed the catheter and perineal care was not completed in a sanitary manner and increased the risk of urinary tract infection for the resident. The STNA verified his actions contaminated the indwelling urinary catheter at the time of the observation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 14 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of the medical record for Resident #42 revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia, COVID-19 and diabetes mellitus type 2. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/24/21 revealed Resident #42 had severely impaired cognition, required extensive assistance from one staff for toileting and was occasionally incontinent of urine. Review of a nurse's note, dated 01/18/22 at 7:20 P.M. revealed Resident #42 had complaints of lower back pain and increased frequency to void. Review of a physician's order, dated 01/19/22 at 4:54 P.M. revealed an order for a urinalysis and culture and sensitivity laboratory test for Resident #42. Review of the medical record revealed the urinalysis and culture and sensitivity were not completed for Resident #42. On 01/27/22 at 9:08 A.M. interview with the Director of Nursing verified the urinalysis and culture and sensitivity had not been completed as ordered for Resident #42 as of this date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 15 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of Resident #35's medical record revealed an initial admission date of 03/19/18 with the latest readmission of 05/29/19. Resident #35 had diagnoses including congestive heart failure, personal history of COVID-19, dementia, ataxia, dysphagia, degenerative disc of lumbar region, anemia, urinary retention, urinary tract infection (UTI), scoliosis, hypertension, major depressive disorder, osteoporosis, osteoarthritis, benign prostatic hyperplasia and deafness. Residents Affected - Some Review of the resident's plan of care, dated 03/19/18 revealed the resident had potential for nutrition/hydration problem related to aspiration, abdominal pain, anemia, ataxia, deaf, narcolepsy, osteoporosis, scoliosis, congestive heart failure, poor fluid/meal intakes and significant weight loss. Interventions included to administer medications as ordered, collaborate with Hospice as needed, provide/serve diet as ordered, provide supplement as ordered, report to physician as needed signs/symptoms of dysphagia/dehydration, weigh as ordered and indicated the resident required extensive staff assist for eating. The care plan did not include information about providing beverages to the resident for independent consumption or indicate the resident was not permitted to have beverages available to him. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/05/22 revealed the resident's hearing was highly impaired, the resident had no speech, understands others, made himself understand and had severe cognitive impairment. The resident required extensive assistance of two staff with bed mobility, was dependent on two staff for transfers and toilet use and required limited assistance from staff for eating. The assessment indicated the resident had an indwelling urinary catheter and was always incontinent of bowel. The assessment indicated the resident had not been treated for a UTI in the past 30 days. The resident had received antibiotic medication. Review of the resident's monthly physician's orders for January 2022 revealed an order, dated 08/19/20 for a regular diet with thin liquids, an order dated, 09/04/19 for a magic cup (a nutritional supplement) twice daily and an order dated, 06/09/21 for a 2.0 supplement daily. On 01/25/22 at 10:24 A.M. interview with unidentified family members revealed the resident doesn't always have water at the bedside and they had brought the issue to the facility's attention on several occasions. On 01/26/22 at 12:48 P.M. a Styrofoam cup half full of warm water was observed sitting on the resident's night stand out of his reach. On 01/26/22 at 12:49 P.M. interview with State Tested Nursing Assistant (STNA) #145 revealed the resident's water was not kept at his bedside due to him spilling or throwing the cup of water. On 01/26/22 at 2:20 P.M. observation revealed Resident #35 had no fluids at the bedside accessible to him. On 01/27/22 at 10:07 A.M. observation of the resident revealed the resident had no water at the bedside. This observation was verified with Licensed Practical Nurse #184 at the time it was made. Review of the facility policy titled, Hydration dated 12/17/18 revealed staff would offer fluids between meals. The policy did not include the delivery or accessibility of beverages for resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 16 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 0692 independent consumption. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure residents were weighed or re-weighed timely to identify/confirm weight loss or significant weight changes and/or failed to provide fluids to Resident #35 who needed/requested them. This affected four residents (#50, #75, #34 and #387) of seven residents reviewed for nutrition and one resident (#35) of two residents reviewed for hydration. Residents Affected - Some Findings include: 1. Resident #50 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, muscle weakness, difficulty in walking, sensorineural hearing loss, hypertension, obesity, hyperlipidemia, lymphedema, atherosclerotic heart disease, iron deficiency, atrial fibrillation, major depressive disorder, type II diabetes, anemia, hypothyroidism. Review of the Minimum Data Set (MDS) 3.0 assessment, section C, dated 12/07/21 revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Review of Resident #50's weights revealed the following: On 01/05/21 the resident weighed 288.5 pounds, on 01/12/21 the resident weighed 278 pounds, on 01/19/21 the resident weighed 280 pounds, on 02/16/21 the resident weighed 292 pounds, on 05/24/21 the resident weighed 295.25 pounds, on 07/12/21 the resident weighed 307 pounds, on 08/14/21 the resident weighed 296 pounds, on 10/04/21 the resident weighed 305 pounds, on 11/01/21 the resident weighed 309.5 pounds and on 01/25/22 the resident 299.5 pounds. Record review revealed a lack of timely re-weights following the months with significant weight changed noted. Review of the nutritional notes, dated January 2021 to January 2022 revealed when there was a significant weight change (five pounds gained/lost, or percentage of weight change met the industry standard for significant change), there was no physician notification of the significant weight change. According to Resident #50's nutritional care plan, it mentioned Resident #50 would refuse weights, but there was no documentation to support she refused any weights that were attempted (monthly/routine or re-weight attempts). Also within her care plan, it indicated the the facility would complete weights as ordered, and to report significant weight changes to the physician. There were no monthly/routine weights taken when it should have been on 01/26/21 (4th weekly weight upon admission), March 2021, April 2021, June 2021, September 2021 or December 2021. On 01/27/22 at 12:20 P.M. interview with Diet Technician (DT) #205 revealed she expected re-weights to be done within one or two days after a significant weight change had been identified. The nursing staff (aides and nurses) were to complete the weights as ordered/needed. The nursing staff would then enter the residents' weights in the electronic medical records. DT #205 revealed she would look at resident weights at least once a week as she did not expect the nursing staff to look to determine if there was a significant weight change. DT #205 revealed re-weights were a problem in this facility; they were not being done as expected/needed. DT #205 revealed she made nutritional recommendations as needed and expected the nursing staff (nurses) to report to the physician and nurse practitioner when there was a change in a resident's nutritional status or when nutritional orders were recommended by her. The DT indicated this notification was to be documented in the resident's electronic medical record by the nurse. DT #205 verified the significant weight changes identified for Resident #50 had not been communicated to the physician and that re-weights had not been obtained as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 17 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 0692 required. Level of Harm - Minimal harm or potential for actual harm 2. Resident #75 was admitted to the facility in 2012 (official date not available per medical records). with diagnoses including hypoglycemia, unsteadiness on feet, cerebrovascular disease, dysphagia, lack of coordination, paranoia schizophrenia, chronic obstructive pulmonary disease, deafness, atherosclerotic heart disease, type II diabetes, hypertensive retinopathy, age related nuclear cataract, anemia, constipation, nicotine dependence, hyperlipidemia, intellectual disabilities, and hypertension. Residents Affected - Some Review of the MDS 3.0 assessment, section C, dated 01/01/22 revealed the resident had cognitive impairment with a BIMS score of one. Review of Resident #75's weights revealed the following: On 07/07/21 the resident weighed 178 pounds, on 08/07/21 the resident weighed 163.5 pounds, on 09/14/21 the resident weighed 156 pounds, on 10/20/21 the resident weighed 147 pounds, on 11/07/21 the resident weighed 142 pounds, on 11/09/21 the resident weighed 142.5 pounds, on 12/07/21 the resident weighed 137 pounds and on 12/16/21 the resident weighed 136.5 pounds. There was no documentation to support a re-weight was taken after significant weight changes on 08/07/21, 09/14/21 or 12/07/21. Also, there was no documentation to support the physician was notified after each significant change occurred (other than one instance on 09/23/21). Overall, there was a 25.6% weight decrease from July 2021 to January 2022. According to Resident #75 nutritional care plan, the physician was to be notified when there was a significant weight loss. On 01/27/22 at 12:20 P.M. interview with Diet Technician (DT) #205 revealed she expected re-weights to be done within one or two days after a significant weight change had been identified. The nursing staff (aides and nurses) were to complete the weights as ordered/needed. The nursing staff would then enter the residents' weights in the electronic medical records. DT #205 revealed she would look at resident weights at least once a week as she did not expect the nursing staff to look to determine if there was a significant weight change. DT #205 revealed re-weights were a problem in this facility; they were not being done as expected/needed. DT #205 revealed she made nutritional recommendations as needed and expected the nursing staff (nurses) to report to the physician and nurse practitioner when there was a change in a resident's nutritional status or when nutritional orders were recommended by her. The DT indicated this notification was to be documented in the resident's electronic medical record by the nurse. DT #205 verified re-weights had not been obtained as required for Resident #75. Review of facility Weight Change policy, dated March 2018 revealed the procedures would be followed to ensure consistent monitoring and documentation or resident weight and implementation of dietary plan of correction with significant changes. A significant weight loss was defined as 5% weight loss in one month, 7.5% in three months or 10% in six months. Monthly weights were to be obtained by the 10th of each month. Recheck weights were to be obtained for a five pound loss or gain if a resident weighed over 100 pounds. A five pound weight gain or loss for a resident who weighed more than 100 pounds would be reported to the dietitian and the physician. Weights would be taken once a week for four weeks for all new admissions and readmissions. 3. Review of Resident #387's medical record revealed a documented weight of 123 pounds on a hospital discharge document, dated 12/21/21. Record review revealed no weight was obtained by the facility upon re-admission and the first documented weight for the resident was not obtained until 01/26/22, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 18 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 0692 which noted the resident to weigh 115 pounds (seated in a wheelchair). Level of Harm - Minimal harm or potential for actual harm A plan of care, dated 01/17/22 revealed the resident had a nutritional/hydration problem related to diet restrictions, blood loss/anemia, right great toe amputation, popliteal to tibial artery bypass, diabetes mellitus, constipation and gastroesophageal reflux disease. Interventions included administer medications as ordered, assist with meals as needed, encourage intakes of diet/fluids, monitor for changes in diet tolerances as needed, monitor record and report to physician signs and symptoms of malnutrition, emaciation, muscle wasting or significant weight loss (three pounds in one week, more than five percent in one month, more than 7.5 percent in three months or more than ten percent in six months. Residents Affected - Some On 01/25/22 at 8:53 A.M. interview with Resident #387 revealed he believed he had lost weight since being in the facility. On 01/26/22 at 11:36 A.M. interview with Licensed Practical Nurse (LPN) #112 verified Resident #387 had not been weighed as required following his re-admission. Review of facility policy titled Weight Change policy, dated 03/2018 revealed residents should have a weight upon admission and daily for three additional days then weekly for four weeks and then monthly. The policy indicated (monthly) weights should be obtained in the first ten days of the month. 4. Review of the medical record for Resident #34 revealed an admission date of 08/02/21 with diagnoses including hemiplegia and hemiparesis following cerebral infarction (CVA) affecting right side side, muscle weakness, swelling of the neck, jaw pain, seizures, dysphagia, deaf non-speaking, kidney failure, depression and cognitive communication deficit. Review of Resident #34's weight log revealed on 08/03/21 (admission) the resident weighed 156 pounds. On 08/10/21 the resident weighed 155 pounds and on 08/24/21 the resident weighed 146.5 pounds. Review of the progress note, dated 08/27/21 by the dietician revealed Resident #34 had weight loss triggering a weight warning with fair intakes for meals. The resident was already on two types of supplements and consuming supplements well. Resident #34 had a six pound weight loss in the first month at the facility. The dietician recommended liberalizing the resident's diet and increasing the 2.0 supplement to routine instead of when less than 50% of meals were consumed. A progress note, dated 08/31/21 revealed the resident refused being weighed. A progress note, dated 09/16/21 revealed resident meal intakes were around 50-100%, and monthly weights had not been obtained so the dietician requested a weight be obtained. A progress note, dated 10/31/21 revealed the resident refused to be weighed on this date but on 10/19/21 the resident weighed 144 pounds. Review of the plan of care, dated 11/22/21 revealed Resident #34 had a nutritional problem related to CVA and dysphagia with a need for a mechanically altered diet and meal intakes of 25-75% with a need for a nutritional supplement. Interventions included to monitor and document signs of pocketing, choking, coughing, drooling or refusing to eat, report signs of malnutrition to the physician as needed for weight loss of three pounds in one week, loss of five percent in one month, 7.5 percent in three months or ten percent in six months. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #34 was cognitively impaired and required extensive assistance from one staff member for activities of daily living and extensive assist of two staff members for transfers. The assessment revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 19 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident had no documented swallowing disorders and was not documented as having a significant weight loss. On 11/30/21 the resident weighed 136.5 pounds. Review of the physician's order, dated 12/04/21 revealed an order for a re-weight on this date. Record review revealed no evidence this weight was obtained. A physician's order, dated 12/17/21 revealed an order to obtain a re-weight for two days. A dietary progress note, dated 12/19/21 revealed the resident's weight was unable to be obtained during day shift and was passed on to night shift. A progress note from the dietician revealed the resident's re-weight on 12/20/21 was 137 pounds and on 12/30/21 the resident weighed 137 pounds. On 01/26/22 at 10:35 A.M. interview with LPN #112 revealed the STNA staff were to obtain resident weights weekly or monthly depending on the physician order. The LPN revealed her expectation would be for staff to inform her if a resident refused to be weighed and she would speak with the resident to educate them on the necessity of obtaining the weight and then would expect staff to try again at a later time or on another day. If a resident had a weight change of three or five pounds, staff should follow the facility policy and complete a re-weight and if the weight gain or loss was confirmed the physician should be contacted. During the interview, the LPN revealed she was not aware of any residents missing weights, but then confirmed after reviewing the chart for Resident #34 that several weights had been missed for the resident outside of her refusals. The LPN revealed the facility had used agency staff recently and was unsure for the reason in communication breakdowns with residents not receiving weights as ordered. On 01/26/22 at 3:45 P.M. interview with the Director of Nursing confirmed Resident #34 was missing weights. The DON confirmed Resident #34 was not weighed daily upon admission, weekly or monthly as ordered. The DON revealed getting weights was an ongoing issue at the facility and typically the dietician would inform management staff of missing weights who would then go and get the resident weighted. On 01/27/22 at 12:20 P.M. interview with Diet Technician (DT) #205 revealed she expected re-weights to be done within one or two days after a significant weight change had been identified. The nursing staff (aides and nurses) were to complete the weights as ordered/needed. The nursing staff would then enter the residents' weights in the electronic medical records. DT #205 revealed she would look at resident weights at least once a week as she did not expect the nursing staff to look to determine if there was a significant weight change. DT #205 revealed re-weights were a problem in this facility; they were not being done as expected/needed. DT #205 revealed she made nutritional recommendations as needed and expected the nursing staff (nurses) to report to the physician and nurse practitioner when there was a change in a resident's nutritional status or when nutritional orders were recommended by her. The DT indicated this notification was to be documented in the resident's electronic medical record by the nurse. Review of facility policy titled Weight Change policy, dated 03/2018 revealed residents should have a weight upon admission and daily for three additional days then weekly for four weeks and then monthly. The policy indicated (monthly) weights should be obtained in the first ten days of the month. The policy revealed residents with a three pound (if under 100 pounds) and five pounds (if over 100 pounds) weight gain or loss should have a reweigh and if confirmed the dietician and physician (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 20 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 0692 should be notified. 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: 365421 If continuation sheet Page 21 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on record review, facility policy and procedure review and interview the facility failed to review or complete pharmacy recommendations in a timely manner for Resident #38, Resident #54 and Resident #72. This affected three residents (#38, #54 and #72) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of the medical record for Resident #38 revealed an admission date of 12/20/17 with diagnoses including moderate protein-calorie malnutrition, deaf non-speaking, unspecified dementia without behavioral disturbance, dysphagia, chronic kidney disease, unspecified open-angle glaucoma, hyperlipidemia, hypertension, cerebral infarction, major depression, unspecified psychosis not due to a substance or known physiological condition. Review of a pharmacist recommendation, dated 07/20/21 revealed a recommendation for a review of a gradual dose reduction (GDR) related to the resident receiving antipsychotic medications, including Abilify 2.5 milligrams (mg), Citalopram 10 mg, Mirtazapine 15 mg and Trazodone 25 mg. Review of the medical record revealed no evidence this recommendation was addressed by the physician or the certified nurse practitioner (CNP). Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 11/18/21 revealed the resident had severely impaired cognition. On 01/26/22 at 10:14 A.M. interview with the Director of Nursing (DON) confirmed the pharmacy recommendation on 07/20/21 had not been addressed. The DON was unable to explain why the recommendation had not been addressed as she stated the CNP was in the facility every day. On 01/26/22 at 12:57 P.M. interview with CNP #209 revealed she went through pharmacy recommendations as she reviewed residents. She reported when she addressed pharmacy recommendations she signed them and gave them to the unit manager. There was no information as to why the recommendation for Resident #38, from July 2021 had not been addressed. Review of the facility policy titled Medication Regimen Review, reviewed January 2018 revealed pharmacy recommendations were to be acted upon and documented by the facility personnel or prescriber. 2. Review of the medical record for Resident #72 revealed an admission date of 07/18/01 with diagnoses including paraplegia, gastro-esophageal reflux disease, hyperlipidemia, deaf non-speaking, atherosclerotic heart disease, peripheral vascular disease, heart failure, borderline personality disorder, spinal stenosis, major depressive disorder, type two diabetes mellitus. Review of a pharmacy recommendation, dated 03/31/21 revealed a recommendation to check Resident #72's B12 with his routine labs in April 2021 due to the resident receiving the medication Metformin 100 mg twice a day. The CNP agreed with the recommendation and noted such on the recommendation form. However, there was no evidence the lab work for the B12 was ordered or completed following the recommendation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 22 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the pharmacy recommendation, dated 07/20/21 revealed a recommendation to review for a possible GDR related to the use of the resident's antidepressant medication, Duloxetine 30 mg daily. The pharmacist requested documentation to ensure the risks versus benefits had been considered. Review of the medical record revealed no evidence this recommendation had been reviewed by the physician or CNP. Review of a pharmacy recommendation, dated 08/19/21 revealed the pharmacist recommended considering a dose reduction for the resident's Pantoprazole 20 mg daily as the resident had been receiving it since July 2021. Review of the medical record revealed no evidence this recommendation was reviewed by the physician or CNP. Review of a pharmacy recommendation, dated 09/28/21 revealed the resident had orders to crush medications and was ordered three different extended-release tablet/medications. The pharmacist recommended considering switching each medication with an alternative. She recommended instead of Glipizide extended-release to use Glipizide regular release, instead of Isosorbide Mononitrate extended-release to use Isosorbide Dinitrate and instead of Protonix delayed release use Protonix packets or change to Prilosec. Review of the medical record revealed no evidence this recommendation was reviewed by the physician or CNP. Review of a pharmacy recommendation, dated 10/27/21 revealed the resident had two active orders in point click care (the electronic medical record) for Acrabose 100 mg every 24 hours. The pharmacist recommended the facility clarify dosing and noted Acrabose was recommended to be given at mealtime with first bite of meal for efficacy. Review of the medical record revealed no evidence this recommendation was reviewed by the physician or CNP. On 01/26/22 at 10:14 A.M. with the DON confirmed the above pharmacy recommendations for Resident #72 were not addressed. The DON was unable to explain why the recommendations had not been addressed as she stated the CNP was in the facility every day. On 01/26/22 at 12:57 P.M. interview with CNP #209 revealed she went through pharmacy recommendations as she reviewed residents. She reported when she addressed pharmacy recommendations she signed them and gave them to the unit manager. There was no information as to why the recommendations for Resident #72 as noted above had not been addressed. Interview on 01/26/22 at 12:57 P.M. with CNP #209 revealed she went through pharmacy recommendations as she reviewed residents. She reported when she addressed pharmacy recommendations, she signed them and gave them to the unit manager. Review of the facility policy titled Medication Regimen Review, reviewed January 2018 revealed pharmacy recommendations were to be acted upon and documented by the facility personnel or prescriber. 3. Review of the medical record for Resident #54 revealed an admission date of 08/16/21 with diagnoses including chronic obstructive pulmonary disease, depression, emphysema, osteoarthritis, foot drop and anxiety. Review of the physician's orders revealed an order, dated 09/03/21 for Lorazepam (Ativan) 0.5 mg one tablet every four hours as needed (PRN), an order dated 08/19/21 for Aspirin Tablet chewable 81 mg once a day, an order dated 09/09/21 for Lipitor (Atorvastatin Calcium) 40 mg one tablet daily at bedtime and an order dated 08/16/21 for Mirtazapine 7.5 mg once daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 23 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 0756 Level of Harm - Minimal harm or potential for actual harm Review of a pharmacy recommendation, dated 11/23/21 revealed Resident #54 had an order for the anti-anxiety medication, Lorazepam for more than 14 days without a reasoning or an end date. A second recommendation was made on 11/23/21 for lab work (CBC, CMP, TSH and lipids) due to the resident receiving the medications Aspirin, Atorvastatin, and Mirtazapine and having no laboratory testing on file. Record review revealed neither pharmacy recommendation had been addressed/acted on Residents Affected - Few On 01/26/22 at 3:36 P.M. interview with the DON revealed the facility has no evidence the pharmacy recommendations were seen by the physician and no evidence the recommendations had been addressed. The DON revealed no laboratory testing had been ordered or obtained as recommended (CBC, CMP, TSH or lipids) and Resident #54 continued to have an Ativan PRN order. On 01/27/22 at 12:18 P.M. interview with Physician #206 revealed pharmacy recommendations had not been reviewed recently. The physician revealed the facility was supposed to bundle any pharmacy recommendations for him or the CNP to review when onsite. Physician #206 revealed Resident #54' PRN Ativan order had been overlooked and should have been discontinued. During the interview, the physician sent a message his CNP who also confirmed no recent pharmacy recommendations had been addressed for Resident #54. Review of facility policy titled Medication Regimen Review, dated 01/2018, revealed recommendations were to be reported to the DON and the prescriber and if needed the Medial Director and Administrator. The policy revealed recommendations were acted upon and documented by the facility. The prescriber accepted and acted upon suggestions or rejects and provides rationale for disagreeing, if their was potential for harm and the prescriber does not concur, the DON or pharmacist should contact the medical director, or the DON could address or document recommendations not requiring a physician order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 24 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on record review and interview the facility failed to ensure an as needed (PRN) psychoactive medication for Resident #54 was limited to 14 days or continued only with an evaluation by the physician or certified nurse practitioner (CNP) for the appropriateness of continued use. This affected one resident (#54) of five residents reviewed for unnecessary medication use. Findings include: Review of the medical record for Resident #54 revealed an admission date of 08/16/21 with diagnoses including chronic obstructive pulmonary disease, depression, emphysema, osteoarthritis, foot drop and anxiety. Review of physician's orders revealed an order, dated 09/03/21 for the psychoactive, anti-anxiety medication Lorazepam (Ativan) 0.5 milligrams (mg) one tablet every four hours as needed (PRN). A pharmacy recommendation, dated 11/23/21 identified the resident had a PRN order for Lorazepam medication for more than 14 days without a reasoning or an end date. The pharmacy recommendation to discontinue the medication or provide a reason/rationale for continued use was not addressed by the physician or certified nurse practitioner. Review of a Minimum Data Set (MDS) 3.0 assessment, dated 12/14/21 revealed Resident #54 had mild cognitive impairment and required supervision and set up assistance from staff for mobility and transfers. Review of the plan of care, dated 01/05/22 revealed Resident #54 had a behavior problem related to anxiety and depression with aggressions and refusals for care. Interventions included anticipating needs for resident and encouraging resident to express feelings appropriately. The care plan revealed the resident received anti-anxiety medications with interventions including attempting gradual dose reduction as clinically indicated. On 01/26/22 at 3:36 P.M. interview with the Director of Nursing (DON) verified Resident #54 had a current PRN order for Ativan (originally ordered on 09/03/21) with no updated reasoning or end date. The DON verified the pharmacist had made a recommendation related to the order in November 2021 but the recommendation had not been addressed by the physician or CNP. On 01/27/22 at 12:18 P.M. interview with Physician #206 revealed Resident #54's PRN Ativan order had been overlooked and should have been discontinued. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 25 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to maintain a medication error rate of less than five percent. The facility medication error rate was calculated to be 5.88 percent and included two medication errors of 34 medication administration opportunities. This affected one resident (#387) of seven residents observed for medication administration. Residents Affected - Few Findings include: Record review for Resident #387 revealed the resident was admitted to the facility on [DATE] with diagnoses including atherosclerosis of native arteries of right leg with ulceration of other part of foot, COVID-19, pain in unspecified foot, hypertension and type 2 diabetes mellitus. Review of the physician's orders, dated 12/30/21, revealed an order for Humalog solution 100 unit (insulin Lispro (Human) to be given before meals (for diabetes) per sliding scale. If the resident's blood sugar was 151 to 200 give one unit, for blood sugar 201 to 250 give two units for blood sugar 251 to 300 give three units, for blood sugar 301 to 400 give four units. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/14/22, revealed Resident #387 was cognitively intact and required set up supervision assistance from staff for transfers, mobility and toileting. Review of the physician's orders, revealed an order dated 01/17/22 for Fiasp Flex Touch Solution Pen injector 100 unit/ml (insulin Aspart inject) 10 units subcutaneously before meals for diabetes. Review of the care plan, dated 01/20/22 revealed resident is at risk for complications. Interventions included diabetes medication as ordered by the physician, monitor/document/report to physician as needed for signs and symptoms of hyperglycemia and hypoglycemia. On 01/26/22 at 8:30 A.M. Licensed Practical Nurse (LPN) #112 was observed during medication administration. The LPN was observed to check Resident #387 blood sugar which was 219. LPN #112 proceeded to prep the Fiasp touch solution pen injector and set the dial to 13 units and then administered 13 units of insulin to the resident subcutaneously. Continued observation revealed the LPN did not administer the Humalog per sliding scale as ordered. Review of the medication administration record (MAR) for January 2022 revealed to administer 10 units of Fiasp Flex Touch solution subcutaneously before meals and Humalog solution, inject per sliding scale subcutaneously before meals for diabetes. On 01/26/22 at 9:20 A.M. interview with LPN #112 confirmed she should have administered 10 units of the Fiasp insulin and should have administered Humalog per sliding scale as ordered. The LPN revealed she had a discussion with Physician #205 the day before to change the resident's insulin orders and thought the physician had changed the order but she had not checked the orders to make sure she was giving the right dose. Review of the facility policy titled Medication Administration-general guidelines, dated November 2018 revealed medications were administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The policy further revealed to follow (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 26 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 0759 the five rights, right resident, right drug, right dose, right route and right time were applied for each medication being administered. 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: 365421 If continuation sheet Page 27 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, facility policy and procedure review and interview facility failed to properly store food items in the dry storage, refrigerator and freezer locations to prevent contamination, spoilage or food borne illness. This had the potential to affect all 86 residents residing in the facility. Findings include: On 01/24/22 at 10:22 A.M. observation of the facility kitchen revealed in the dry storage area there was a large bag of dried noodles that had previously been opened that was tied and undated. There was an opened bag of butterscotch baking chips undated, bags of dry spiral pasta and elbow noodles that were open and undated, two bags of gravy mix were that were undated and a container with instant mash potatoes had a secured lid on it with no date. On 01/24/22 at 10:32 A.M. observation of the walk in refrigerator revealed a block of butter was uncovered and undated, three packs of yellow and white cheese slices were wrapped up and undated. A bag of shredded cheese was opened and undated and a large plastic tub with a lid on it was unlabeled and undated. A tray of lunch meat and cheese sandwiches were undated as well as three egg salad sandwiches which were wrapped up but not dated. A large metal bin filled with thawing frozen green beans and large chunks of butter was covered but not dated. On top of the frozen there were green beans in a Styrofoam to-go box filled with leftover pork dinner from a recent dinner that was undated. On 01/24/22 at 10:39 A.M. observation of the walk in freezer revealed ice cream had been scooped into serving cups and were uncovered and undated. Bags of raw chicken, meatballs, cubed ham, and waffles were opened and tied to seal but were also undated. At the time of the observations, interview with Kitchen Manager #201 confirmed the above food items were undated and indicated they would need to be thrown away. The kitchen manager revealed staff were supposed to use stickers, but many times the stickers fall off. Review of facility policy titled Food Storage, dated 2019 revealed the food in the dry storage, refrigerator and freezer should be sealed and labeled with the date it was opened. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 28 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 Based on observation, facility census review, review of the Centers for Disease and Prevention (CDC) guidance, facility policy and procedure review and interview the facility failed to ensure N95 masks were worn properly/correctly by staff working on the facility COVID-19 unit to prevent the spread of COVID-19 in the facility. This affected two staff (Licensed Practical Nurse (LPN) #203 and State Tested Nursing Assistant (STNA) #116 who were assigned to care for the 11 residents who resided on the COVID-19 unit and had the potential to affect all 86 residents residing in the facility as these staff could also work in other (non-COVID) areas of the facility. Residents Affected - Many Findings include: On 01/24/22 review of the facility census and observation of the facility revealed a designated COVID-19 unit with a census of 11 residents on the unit who were in isolation for COVID-19. On 01/24/22 at 12:30 P.M. LPN #203 was observed on the COVID-19 unit wearing an N95 mask over top of a surgical mask. The lower elastic strap of the N95 mask was hanging below LPN #203's chin. LPN #203 was observed entering and exiting resident rooms. On 01/24/22 at 12:34 P.M. interview with LPN #203 verified she was wearing a surgical mask under the N95 mask. LPN #203 also verified she did not place the lower strap of the N95 around her neck and below her ears. LPN #203 stated it was easier to breath when she wore the surgical mask under the N95 and did not put the lower strap of the N95 mask around her neck. LPN #203 revealed she was an agency nurse and was the dedicated nurse for the COVID-19 unit on this date but indicated she could work off the unit if needed at another time/date. On 01/25/22 at 1:15 P.M. STNA #116 was observed on the COVID-19 unit wearing an N95 mask with the lower strap of the mask hanging below her chin. STNA #116 was observed entering and exiting resident rooms. On 01/25/22 at 1:22 P.M. interview with STNA #116 verified the lower strap of the N95 mask was not properly secured around her neck. STNA #116 revealed the mask was too tight if the lower strap was around her neck. The STNA revealed she provided care for residents both on the COVID-19 unit and off the COVID-19 unit. Review of the CDC general procedures for properly putting on a disposable respirator (N95) revealed anything that was between the respirator and a persons face would make the respirator less effective. When putting a respirator on correctly, the top strap would go over the persons head, resting high at the top of the back of the persons head. The bottom strap would be positioned around the neck and below the ears. Review of the facility policy titled COVID+ Residents: Screening and Management, revised 07/26/21 revealed staff caring for residents who were COVID positive should have full personal protective equipment (PPE), including face shield/goggles, N95 respirator, isolation gown, and gloves. PPE must be donned (applied) correctly before entering the resident area/room. The PPE must remain in place and be worn correctly for the duration of work. According to the CDC, Types of Masks and Respirators, dated 01/21/22 revealed a mask should fit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 29 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 closely to the persons face without any gaps along the edges. A mask would be less effective if it was worn improperly. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 30 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview, review of Food and Drug Administration (FDA) Residents Affected - Some information, review of a HealthDay News Study and facility policy and procedure review, the facility failed to provide adequate justification for the use of antibiotics as a preventative measure for COVID-19. This affected six residents (#14, #33, #35, #49, #57 and #67) of six residents prescribed antibiotics. Findings include: Review of Resident #14, #33, #35, #49, #57 and #67's medical records, dated from 12/30/21 to 01/14/22 revealed the residents were treated with Azithromax (an antibiotic medication used to treat infection) or Cipro (an antibiotic medication used to treat infection) after testing positive for COVID-19. On 01/25/22 at 1:11 P.M. interview with the Director of Nursing (DON) confirmed the residents were prescribed antibiotics after testing positive for COVID-19. The DON failed to provide any other evidence these residents met any type of criteria for the antibiotic use. Review of information on the FDA website (https://www.fda.gov) revealed the following FDA response to the question, Are antibiotics effective in preventing or treating COVID-19? No. Antibiotics do not work against viruses; they only work on bacterial infections. Antibiotics do not prevent or treat COVID-19, because COVID-19 is caused by a virus, not bacteria. Some patients with COVID-19 may also develop a bacterial infection, such as pneumonia. In that case, a health care professional may treat the bacterial infection with an antibiotic. In addition, an article from HealthDay News, dated 08/04/20 revealed the following: Early in the U.S. coronavirus pandemic, many people landing in the hospital may have been given unnecessary antibiotics, a new study suggests. The findings come from one of the hard-hit hospitals in New York City, the initial epicenter of the U.S. pandemic. Researchers there found that of COVID-19 patients admitted between March and May, just over 70% were given antibiotics. That's despite the fact that COVID-19 is caused by a virus, and very few of those patients actually had a coexisting bacterial infection. Antibiotics kill bacteria, but are useless against viral infections such as the common cold, the flu and COVID-19. Review of the facility policy titled, Antibiotic Stewardship Policy & Procedures, dated 03/05/18 revealed it was the facility policy to maintain an Antibiotic Stewardship Program with the mission of promoting the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 31 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On 01/27/22 from 11:00 A.M. to 11:05 A.M. an environmental tour of the 200 hallway was conducted with the Administrator. The following concerns were observed and verified with the Administrator at the time of the observations: The bathroom wall in room [ROOM NUMBER] beside the commode had exposed and missing drywall. There were rust stains around the commode was well as black stains on the floor. The bathroom in room [ROOM NUMBER] had cracked tile on the floor, rust stains around the commode as well as black stains on the floor. The floor under a fall mat in room [ROOM NUMBER] had a red wet liquid under the mat that had been present since initial observations on 01/26/22. Based on observation, record review and interview the facility failed to maintain a safe, functional and sanitary environment for all residents. The facility also failed to maintain resident equipment in good repair for Resident #67 and Resident #38. This affected two residents (#38 and #67) and three of the four hallways in the facility. The facility census was 86. Findings include: 1. Review of Resident #67's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including altered mental status, blindness, deafness, and hemiplegia and hemiparesis affecting right dominant side. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/05/22 revealed Resident #67 had severe cognitive impairment and used a wheelchair as a mobility device. On 01/25/22 at 8:17 A.M. observation of Resident #67's wheelchair revealed the vinyl-like material was cracked and peeling to the bilateral armrests on the wheelchair. On 01/27/22 at 11:10 A.M. interview with the Administrator verified the vinyl-like material was cracked and peeling to the bilateral armrests on Resident #67's wheelchair. 2. Review of the medical record for Resident #38 revealed an admission date of 12/20/17 with diagnoses including moderate protein-calorie malnutrition, deaf non-speaking, unspecified dementia without behavioral disturbance, dysphagia, chronic kidney disease, unspecified open-angle glaucoma, hyperlipidemia, hypertension, cerebral infarction, major depression, unspecified psychosis not due to a substance or known physiological condition. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. On 01/25/22 at 10:15 A.M., 12:40 P.M., 2:58 P.M. and 3:24 P.M. Resident #38's wheelchair was observed to be dirty. The sides of his wheelchair were covered in what looked to be dried food and liquids. The cushion the resident was sitting on had multiple stains that also appeared to be dried food (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 32 of 33 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 365421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inniswood Health and Rehabilitation 1150 Colony Drive Westerville, OH 43081 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 0921 and liquids. Level of Harm - Minimal harm or potential for actual harm On 01/25/22 at 3:27 P.M. interview with Licensed Practical Nurse (LPN) #112 confirmed Resident #38's wheelchair needed cleaned. LPN# 112 was unsure how often the wheelchair was cleaned, however, she thought night shift was responsible for the cleaning. Residents Affected - Some On 01/27/22 at 9:02 A.M. with the Director of Nursing (DON) revealed the resident's wheelchair was to be cleaned every Wednesday. However, she reported wheelchairs should be cleaned as needed when noticeably soiled. Review of undated Daily Cleaning Duties-Both Shifts revealed Resident #38's wheelchair was to be cleaned on Wednesdays. 3. On 01/24/22 at 11:56 A.M. and on 01/27/22 at 9:55 A.M. observation of room [ROOM NUMBER] revealed a rust ring about 0.5 inches thick around the bottom of the toilet in the bathroom. The rust was extending from the toilet down the lines of the tiles. There was a circle on the floor to the left of the toilet that was a dirty gray color and a similar circular indent on the wall to the left of the toilet, making it appear as if something had been removed. On 01/26/22 at 9:55 A.M. a tour with Maintenance Director (MD) #158 confirmed the observation of room [ROOM NUMBER]'s bathroom. MD #158 revealed the rust was something housekeeping should be able to clean. He revealed the spots on the floor and wall were from a handrail that had been removed as the current residents did not need it 4. Observation on 01/24/22 at 12:15 P.M. and on 01/25/22 from 10:10 A.M. to 10:20 A.M. of the dining room on the 400 hall revealed the walls were not maintained in an appropriate manner. Observation revealed a chair rail around the room that was painted brown, the paint was chipped off in most locations throughout the room. On the wall between the chair rail and the baseboard there were black scuffs, and multiple spots where the paint had chipped, additionally, in one location there was a hole measuring about two inches by five inches exposing the dry wall underneath. The baseboard was also painted brown and was chipped in most locations. On 01/26/22 at 9:55 A.M. a tour with Maintenance Director #158 confirmed there were multiple scuffs, scratches, and missing paint in the dining room. He did not know the last time the dining room had been painted and he had been in the facility for three years. 6. On 01/25/22 at 8:25 A.M. observation of room [ROOM NUMBER] revealed a dent and hole the size of a tennis ball on the wall behind the resident's bed. On 01/27/22 at 9:55 A.M. interview with Maintenance Director (MD) #158 confirmed there was a hole in the wall. MD #158 revealed he was unaware of this hole and revealed staff should have reported this problem to him and had not. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 33 of 33