Inspection·February 2, 2024

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and a re-entry date of 12/28/2023. Diagnosis included a non-pressure chronic ulcer of the right lower leg, cellulitis, and peripheral vascular disease (PVD) Review of the plan of care dated 09/26/2023 and revised 10/18/2023 revealed Resident #42 had a venous stasis/venous insufficiency ulcer to the right lower leg/shin related to congestive heart failure and PVD. Interventions include to document location of wound, amount of drainage, peri-wound area, pain, edema and circumference measurements as needed. , elevate extremities as needed, give medication as ordered for pain, monitor for signs and symptoms of infection, and complete treatments as ordered. Review of Resident #42's admission MDS 3.0 assessment revealed a BIMS score of 15 indicating an intact cognition for daily decision making abilities. Resident #42 was noted to be free of any skin injuries or pressure wounds including venous ulcers. Review of Resident #42's current physician orders revealed right lower leg cleansed, staples with normal saline, cover with a island dressing daily and as needed for drainage and dislodgement every day. Start 12/29/23. Interview on 01/08/2023 at 9:45 A.M. with the DON confirmed the facility has been using a third out of facility party to complete assessments for residents and the facility staff have been noticing some assessments containing incorrect information include Resident #42 being free of any skin injuries or pressure wounds or ulcers. The DON confirmed Resident #42 was admitted to the facility with a venous ulcer to the right lower leg and this should have been included in her MDS assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 2 of 32 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 02/02/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Pre-admission Screening and Resident Review (PASARR) were accurate regarding resident mental health diagnoses. This affected one (Resident #61) of two residents reviewed for PASARR. The facility census was 83. Findings Include: Review of the medical record for Resident #61 revealed an initial admission date of 09/26/18 with the diagnoses including starvation, psychosis, adult failure to thrive, congestive heart failure (CHF), non-compliance with medical treatment regimen, dementia with behavioral disturbances, delusional disorder, paranoid personality disorder, altered mental status, gastro-esophageal reflux disease (GERD), visual hallucinations, hypertension, vitamin B deficiency, anxiety disorder, restlessness and agitation, glaucoma, auditory hallucinations, constipation and insomnia. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident had anxiety, psychotic disorder and paranoid personality disorder as current diagnoses. Review of Resident #61's PASARR document, dated 09/10/19, revealed under Section D: Indications of Serious Mental Health, did not have anxiety disorder, unspecified psychotic disorder, paranoid personality disorder, unspecified psychosis and delusional disorder. However, according to her current face sheet/diagnoses list, she was diagnosed with anxiety disorder, unspecified psychosis and delusional disorder on 09/26/18 and paranoid personality disorder on 11/13/18. On 01/04/24 at 12:09 P.M., interview with the Administrator verified the facility had not completed a PASARR to reflect the resident's current mental health diagnoses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 3 of 32 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 02/02/2024 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the preadmission screening and record review (PASRR) assessment and referral for level II services were completed. This affected one (Resident #81) of two residents reviewed for PASRR documents. The census was 83. Residents Affected - Few Findings Include: Resident #81 was admitted to the facility on [DATE]. His diagnoses were spinal stenosis, muscle weakness, cervical disc disorder, adjustment disorder with mixed anxiety and depressed mood, generalized anxiety disorder, schizoaffective disorder, osteoarthritis, hypertension, hyperlipidemia, deaf nonspeaking, legal blindness, chronic kidney disease, depression, and insomnia. Review of his Minimum Data Set (MDS) assessment, dated 10/25/23, revealed he had a severe cognitive impairment. Review of Resident #81 PASRR document and determination letter, dated 08/11/23, revealed he was approved for short term nursing stay, starting 08/22/23, for 90 days; which would end on 11/20/23. Review of the remainder of his PASRR documents, there were no other PASRR documents completed until 01/04/24. Also, on the determination letter for the PASRR assessment, dated 08/11/23, revealed Resident #81 was to be referred for level II services. There was no documentation to support this was completed. Interview with Director of Nursing (DON) on 01/04/24 at 1:30 P.M. confirmed there was no additional PASRR documentation in Resident #81 medical record to support a new assessment or that level II services were referred after 08/11/23. She confirmed she provided PASRR documentation, dated 01/04/24, from Social Services Director #251 but there was no additional documentation prior to 01/04/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 4 of 32 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 02/02/2024 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 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the state mental health agency of significant changes in a resident's mental/physical health condition. This affected one (Resident #61) of two Pre-admission Screening and Resident Review (PASARR) documents reviewed. The census was 83. Findings Include: Review of the medical record for Resident #61 revealed an initial admission date of 09/26/18 with the diagnoses including starvation, psychosis, adult failure to thrive, congestive heart failure (CHF), non-compliance with medical treatment regimen, dementia with behavioral disturbances, delusional disorder, paranoid personality disorder, altered mental status, gastro-esophageal reflux disease (GERD), visual hallucinations, hypertension, vitamin B deficiency, anxiety disorder, restlessness and agitation, glaucoma, auditory hallucinations, constipation and insomnia. Review of the significant change MDS assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident had anxiety, psychotic disorder and paranoid personality disorder as current diagnoses. Review of Resident #14 PASARR document, dated 09/10/19, revealed under Section D: Indications of Serious Mental Health, it indicated that she did not have anxiety disorder, unspecified psychotic disorder, paranoid personality disorder, unspecified psychosis and delusional disorder. However, according to her current face sheet/diagnoses list, she was diagnosed with anxiety disorder, unspecified psychosis and delusional disorder on 09/26/18 and paranoid personality disorder on 11/13/18. On 01/04/24 at 12:09 P.M., interview with the Administrator verified the facility had not completed a PASARR to reflect the resident's mental health diagnoses. The facility provided no evidence the state mental health agency was notified of the changes in diagnoses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 5 of 32 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 02/02/2024 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 observation, record review and interview the facility failed to ensure a self-releasing wheelchair seatbelt was only used during transportation to workshop for Resident #1. This affected one resident (Resident #1) of one residents reviewed for transportation devices. Residents Affected - Few Findings Include: Review of Resident #1's medical record revealed Resident #1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #1's admitting diagnoses included intellectual disabilities, type two diabetes, and impaired communication. Further review revealed Resident #1 required assistance from staff for activities of daily living (ADL) tasks. Review of Resident #1's signed physician orders revealed Resident #1 may attend workshop on Mondays and Wednesdays. Further review revealed Resident #1 received transportation to workshop on Mondays and Wednesdays and the resident must be ready 15 minutes prior to pick up time. Review of an email dated 07/12/21 from the administrator for the transport services written to the facility Administrator revealed Resident #1 was required to have a self-releasing seat belt to the wheelchair for transportation purposes. Review of Resident #1's care plan dated 02/16/23 revealed Resident #1 received transportation from a transport company to workshop on Mondays and Wednesdays. Further review revealed care plan dated 09/13/23 Resident #1 uses a self-releasing seatbelt to wheelchair at times, Resident #1 is able to release per self and does not restrict willful movement. Observation on 01/02/24 at 2:32 P.M. revealed an attached self-releasing seatbelt to Resident #1's wheelchair. The seatbelt was latched and loosely laying across Resident #1's thighs. Observation on 01/04/24 at 8:16 A.M. revealed Resident #1 was able to unfasten and refasten the self-releasing wheelchair seatbelt without assistance from staff. Interview on 01/04/24 at 11:56 A.M. with the Administrator revealed Resident #1 was required by transportation services to use a self-releasing seatbelt to the wheelchair for safety during bus transport to the workshop. Interview on 01/08/24 at 9:55 A.M. with the Director of Nursing (DON) revealed Resident #1 was only to be using/wearing the self-releasing seatbelt during transportation to and from the workshop, and that due to Resident #1's cognition, Resident #1 would fasten the self-releasing seatbelt at times when it was not required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 6 of 32 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 02/02/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, interviews and facility policy review, the facility failed to implement adequate skin risk interventions for Resident #32 to prevent the development of a pressure ulcer. Residents Affected - Few Actual harm occurred on 08/24/23 when Resident #32, who was re-admitted to the facility on [DATE] with a displaced subtrochanteric fracture of right the femur with surgical repair and required extensive assistance with bed mobility for turning and repositioning developed a deep tissue injury (DTI) (A purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.) to the right heel. The resident reported an increased amount of pain due to the development of the pressure ulcer. In addition, it was the resident's physician who first identified the DTI while on site at the facility on 08/24/23. The facility failed to implement comprehensive and individualized interventions to prevent the development of the pressure ulcer and failed to properly assess, monitor, or implement skin interventions for the DTI until 08/31/23. Findings Include: Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE] with a re-admission of 08/18/23. Resident #32 had diagnoses including encephalopathy, need for assistance with personal care, displaced subtrochanteric fracture of right femur, vitamin D deficiency, major depressive disorder, deaf nonspeaking, type II diabetes, mild intellectual disabilities, secondary malignant neoplasm of the breast, acquired absence of left breast and nipple and anxiety disorder. Review of the plan of care dated 04/04/22 revealed the resident was at risk for an alteration to skin integrity related to encephalopathy, diabetes mellitus, osteoporosis, groin candidiasis and mood boots in bed as tolerated. Interventions included administer medications and treatments as ordered, encourage nutrition/hydration as needed, encourage/assist with daily hygiene as needed, keep skin clean, dry and odor free as tolerated, weekly skin assessment as tolerated and boots/heel protectors while in bed as tolerated was added to the plan of care. Review of the resident's weekly readmission skin assessment dated [DATE], authored by Licensed Practical Nurse (LPN) #191 revealed the resident was re-admitted from an acute care hospital stay to the facility with no pressure ulcers/injuries. Review of the [NAME] scale dated 08/18/23 revealed a score of 10 indicating the resident was at high risk for skin breakdown. Review of the physician progress note dated 08/24/23, authored by Physician #502 revealed the physician was seeing the resident following an emergency room (ER) visit for hypoglycemia. Through interpreter the resident stated, she had a hole in her right heel and had a lot of pain there. Upon examination the resident's right heel was found to be black with eschar. The physician determined the resident had a DTI to the right heel and gave a new order to elevate the heel at that time. Review of the resident's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior section of the MDS revealed the resident had not rejected care. The assessment revealed the resident required extensive assistance from two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 7 of 32 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 02/02/2024 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 staff for bed mobility, transfers, toileting, dressing and personal hygiene and was non-ambulatory. The assessment indicated the resident was always incontinent of both bowel and bladder. The resident was assessed as being at high risk for skin breakdown and had no unhealed pressure ulcer/injuries. The MDS noted the facility implemented the intervention of pressure reducing device to bed and applications of ointments/medications other than to feet. Review of the plan of care dated 08/31/23 revealed the resident had a pressure ulcer to the right heel related to presence of fragile skin, weakness/deconditioning, decreased mobility and moon boots while in bed as tolerated. Interventions included administer medications as ordered, administer treatments as ordered, follow facility policies/protocols for prevention/treatment of skin breakdown, inform family/resident of any new areas of skin breakdown, measure length, width and depth where possible, assess and document status of wound perimeter, wound bed and healing process, report improvements and declines to physician, monitor dressing with rounds to ensure it is intact and adhering, report loose dressing to nurse, monitor nutritional status, serve diet as ordered, monitor intake and record, monitor/document/report to physician as needed changes in skin status and Prostat (liquid protein supplement used to promote wound healing) as ordered. Review of an initial weekly pressure ulcer form dated 08/31/23 revealed this wound was not identified by the facility until 08/31/23 despite the physician identifying the DTI on 08/24/23. The facility now classified the wound as an unstageable pressure ulcer measuring 3.0 centimeters (cm) by 2.0 cm. The wound was described as being black and had no exudate. The facility determined the wound had declined despite the assessment being the initial assessment. The facility implemented a treatment of Betadine daily to the pressure ulcer. Review of Wound Physician (WP) #501's initial progress note dated 09/05/23 revealed the resident had an unstageable DTI measuring 2.2 cm by 2.5 cm. The wound was partial thickness and had no exudate. The wound physician continued the Betadine daily and use of a pressure off-loading boot. Review of WP #501's progress note dated 09/19/23 revealed the wound was now classified as unstageable necrosis measuring 2.0 cm by 2.0 cm by 0.1 cm with 40% thick adherent devitalized necrotic tissue and 60% dermis/subcutaneous tissue. The wound had a moderate amount of serous drainage. The physician determined the wound had improved as evidenced by decreased surface area. The physician changed the treatment to cleanse the wound, apply Mesalt (a salt-impregnated gauze that is used for wound with moderate to heavy drainage, yellow slough, fibrin or infection. The dressing absorbs fluid from the wound and releases sodium chloride which has a cleansing and healing effect. The dressing helps to remove dead tissue and bacteria and prevents further bacterial growth.) and cover with a border gauze island dressing daily and use of pressure off-loading boot. The resident refused debridement of the wound during the visit. Record review revealed WP #501 completed progress notes on 09/26/23, 10/03/23, 10/10/23 10/17/23, 10/24/23 and 10/31/23. Each visit note reflected the resident continued with the unstageable necrosis to the right heel. WP #501 included measurements of the wound, amount of drainage present to the wound and was noted to remove necrotic tissue during the visits. There were no changes made to the wound treatments during this time. Review of the resident's medical record revealed no documented evidence the resident was noncompliant with wound care. Review of the October 2023 Treatment Administration Record (TAR) revealed the treatment to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 8 of 32 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 02/02/2024 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 resident's right heel of cleanse the right heel with normal saline, pat dry, apply Mesalt and cover with dry dressing daily was discontinued on 10/20/23. Further review revealed no evidence the facility initiated a new treatment to the right heel following the discontinuation of the treatment on 10/20/23. Review of the November 2023 TAR revealed the facility re-implemented the treatment on 11/01/23 to cleanse the unstageable necrosis to the right heel with normal saline, apply Mesalt and cover with dry dressing daily following WP #501's visit on 10/31/23. Review of the resident's medical record revealed the resident was seen by WP #501 on 11/07/23, 11/14/23 and 11/21/23 for wound care. Each visit note included the resident continued with the unstageable necrosis to the right heel with measurements and an assessment of the amount of drainage. On 11/07/23 and 11/14/23 the wound physician removed the necrotic tissue and established the margins of viable tissue with permission of the resident. On 11/21/23 the resident refused wound debridement during the visit. The physician made no changes in the treatment to the wound during this time. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior section of the MDS revealed the resident had not rejected any care. The assessment indicated the resident was frequently incontinent of both bowel and bladder. The resident was assessed as being at high risk for skin breakdown and had one unstageable pressure ulcer not present on admission. Review of the resident's medical record revealed the resident was seen by WP #501 for wound care on 11/28/23, 12/05/23, 12/12/23 and 12/19/23 for continued care of the unstageable necrosis pressure ulcer to the right heel. Each visit contained the measurements of the pressure ulcer, presence/amount of drainage. The resident refused wound debridement on 11/28/23. Review of WP #501's progress note dated 12/19/23 revealed the physician classified the right heel pressure injury 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.) on this date. The wound measured 0.5 cm by 0.6 cm by 0.3 cm with the wound being 100% slough tissue. The wound had a moderate amount of serous drainage. The physician made no changes in the treatment to the wound. The wound physician determined the wound had improved as evidence by a decreased surface area. The resident was seen by WP #501 on 12/26/23, 01/02/24, 01/09/24, 01/16/24 and 01/23/24 for continued evaluation and assessment of the Stage IV pressure ulcer to the right heel. WP #501 documented the measurements of the ulcer, amount of drainage noted and whether also if the wound was debrided. The pressure ulcer was debrided during the 01/02/24 and 01/09/24 visits. During the visit on 01/16/24 the wound physician changed the resident's treatment order. A new treatment to apply Betadine daily to the Stage IV pressure ulcer and cover with a border gauze island dressing was ordered. Review of WP #501's progress note dated 01/23/24 revealed the Stage IV pressure injury measured 0.5 cm by 0.3 cm by 0.1 cm with the wound being 100% dermis. The wound had no exudate/drainage. The wound physician documented the wound was at goal and made no changes to the treatment. Observation on 01/25/24 at 9:15 A.M. of the assessment and treatment of the resident's right heel by WP #501 revealed he placed a barrier on the bed, removed the resident's Prevalon boot and measured the wound at 0.5 cm by 0.3 cm with a tan scab covering the wound. The physician then painted the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 9 of 32 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 02/02/2024 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 wound with betadine and covered the wound with an island gauze dressing. Level of Harm - Actual harm Interview on 01/25/24 at 9:23 A.M. with Physician #502 revealed he was unaware the resident had no treatment in place from 10/20/23 to 11/01/23 to the right heel. Residents Affected - Few Interview on 01/25/24 at 12:13 P.M. with the Director of Nursing (DON) verified the resident had inadequate skin interventions in place to prevent the DTI and the resident's pressure injury was not assessed, monitored or interventions implemented when identified on 08/24/23. The DON verified the resident's medical record had no documented evidence the resident refused skin interventions. The DON verified the resident went without a treatment from 10/20/23 to 10/31/23 when WP #501 identified the resident had no treatment in place. Observation on 01/29/24 at 2:30 P.M. of Resident #32 revealed she was laying in bed with the head of her bed elevated. The resident was observed with no heel protectors/boot in place as physician ordered. Registered Nurse (RN) #182 verified the resident's physician ordered heel protection was not in place at the time of the observation. However, review of the resident's January 2024 Treatment Administration Record (TAR) revealed the boot was initialed as being in place by RN #182. Review of the facility policy titled, Pressure Injury/Ulcer Prevention, last revised 06/14/23 revealed a resident who entered the facility without pressure injury or ulcers should not develop pressure injury/ulcers and/or other non-pressure ulcers, unless the resident's clinical condition demonstrates that they were unavoidable. The facility would implement individualized interventions to attempt to stabilize, reduce or remove underlying risk factors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 10 of 32 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 02/02/2024 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, hospital records review, Hoyer Lift user manual review and facility policy review, the facility failed to ensure Resident #87 was transferred in a safe manner using a mechanical (Hoyer) lift (a mechanical device with a sling used to transfer residents from one place to another). Actual Harm occurred on 10/18/23 when Resident #87, who was dependent on two staff for transfers using a Hoyer lift, sustained a fall out of the lift resulting in a hospitalization and diagnosis of cervicalgia (pain in the neck and shoulders that varies in intensity, and may feel achy or like an electric shock from the neck to the arm) with an order for a cervical collar to be worn at all times for four weeks. The fall occurred as a result of the legs of the lift not being in proper position to accommodate a shift in the resident's weight during the transfer. This affected one resident (Resident #87) of five residents reviewed for accidents. The facility census was 83. Findings Include: Review of the medical record for Resident #87 revealed an initial admission date of 09/28/23 with diagnoses including displaced trimalleolar fracture of the left lower leg, generalized muscle weakness, spinal stenosis, osteoarthritis, chronic pain, anxiety disorder, anemia, obstructive sleep apnea, chronic pain syndrome, severe morbid obesity, and diabetes mellitus. Review of the plan of care dated 09/28/23 revealed the resident had a self-care deficit related to fracture, diabetes mellitus, edema, morbid obesity, congestive heart failure, self transfers when weak and self limiting behaviors. Interventions included one to two assists with activities of daily living (ADL), encourage resident to discuss self care deficit as needed, encourage resident to participate to the fullest extent possible as needed, Hoyer lift for transfers, therapy referral as needed, side rails for positioning and weight bearing as tolerated. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The resident was dependent on staff for toileting, bathing and ambulation was not attempted. Review of the progress note dated 10/18/23 at 3:55 P.M., revealed at approximately 3:00 P.M. the resident was being transferred from her wheelchair to bed via Hoyer lift by two staff members and while being guided into her bed, the Hoyer lift shifted to the left which caused the resident to be repositioned on the floor. The resident complained of pain to back, hips and head. The resident was transported to a local acute care hospital at approximately 3:45 P.M. via emergency medical services (EMS). Further review of the medical record revealed the resident did not return to the facility. Review of the staff statement by State Tested Nursing Assistant (STNA) #224 dated 10/18/23 revealed at approximately 3:00 P.M. the STNA and Certified Occupational Therapy Assistant (COTA) #400 were transferring the resident from her wheelchair to her bed using a Hoyer lift. The STNA documented she was monitoring the controls while the COTA guided the resident into bed when suddenly the Hoyer shifted to the left and the resident fell to the ground. The Hoyer lift was removed and the aide summoned the nurse on duty. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 11 of 32 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 02/02/2024 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 0689 Level of Harm - Actual harm Residents Affected - Few Review of the staff statement of COTA #400 dated 10/18/23 revealed at approximately 3:00 P.M. the COTA and STNA #224 were transferring the resident from her wheelchair to the bed utilizing a Hoyer lift. The COTA was guiding the resident while the STNA monitored the controls when suddenly the Hoyer shifted to the right and the resident fell three feet to the floor. The Hoyer was removed and the STNA went to summons a nurse. The COTA documented she stayed with the resident. Review of the typed document titled, Root Cause Analysis, dated 10/18/23 revealed the resident was being transferred from her wheelchair to bed after being showered using the bariatric Hoyer lift. The Hoyer lift pad was wet. The State Tested Nursing Assistant (STNA) maneuvered the Hoyer lift to the bed. The COTA used the handles on the Hoyer pad to turn the resident, to better position her, over the bed prior to lowering the resident to the bed. This caused the lift to tip which resulted in the resident landing on the floor on her buttocks. The resident was taken to the hospital for an evaluation. The facility determined the resident shifted in the Hoyer lift causing it to tip and the resident fell to the floor. The facility implemented a three person assist with this resident in Hoyer transfers. On 01/04/24 at 2:40 P.M., interview with the Director of Nursing DON revealed the resident was admitted to the acute care hospital for observation and then discharged home. On 01/04/24 at 4:18 P.M., interview with COTA #400 revealed she and STNA #224 were transferring the resident from her wheelchair to bed following a shower. She said they were transferring her back into bed and STNA #224 was doing the controls while she was moving the resident. She said there was a sudden shift and the Hoyer topped over. She revealed the Hoyer legs were opened at one point but they had to be closed to get them under the bed. On 01/08/24 at 1:22 P.M., interview with STNA #224 revealed COTA #400 gave the resident a shower and she assisted with transferring the resident. STNA #224 revealed she was maneuvering the Hoyer lift and COTA #400 was moving the sling. She said COTA #400 told her to close the legs and when she closed the legs, the Hoyer fell over. Multiple attempts were made to contact Resident #87 by phone but no return call was provided. Review of the hospital summary provided by the facility for a hospitalization from 10/21/23 to 10/24/23 revealed the resident presented on 10/18/23 with a fall from a Hoyer lift. Further review revealed the resident had cervicalgia and the plan was for the resident to wear a cervical collar at all times for four weeks. Review of the user manual for the Hoyer lift, provided by the facility, revealed the legs of the lift must be in the maximum open position and the shifter handle locked in place for optimum stability and safety. Review of the facility policy titled, Safe Resident Handling and Transfers Guidelines, last revised 02/07/23, revealed residents require safe handling with transfers to prevent risk to them and to employees. Staff will perform lifts/transfers based on the manufacturer's instructions for use of the device. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 12 of 32 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 02/02/2024 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 - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, hospital record review, staff, physician and Registered Dietician (RD) interview, review of the Ohio Board of Dietetics (OBD) Standards of Practice in Nutrition Care, contract reviews, and facility policy review, the facility failed to ensure Resident #32, who was identified at nutritional risk, was provided a comprehensive and individualized nutritional plan to include monitoring weights and nutritional status, physician and dietitian notification for weight loss and implementation of nutrition interventions to prevent severe weight loss. This resulted in Immediate Jeopardy and actual harm for Resident #32, who experienced severe weight loss from 09/07/23 to 10/04/23 when she lost 19.9 pounds, representing a weight loss of 10.05% in one month (September to October 2023); 6.5% from October to November and 6.0% from November to December 2023 with a total weight loss over this time period of 21.6 % of her body weight (a 43 pound weight loss) due to the facility repeated and systemic failures to assess and address the resident's nutritional status and to implement pertinent interventions based on such an assessment resulting in continued significant/severe weight loss and functional decline. The resident was admitted to the hospital on [DATE] and returned to the facility on [DATE], continuing to lose weight. Residents Affected - Few Additionally, a concern that did not rise to an Immediate Jeopardy occurred when the facility failed to monitor weights per physician orders and notify the physician and/or dietician of weight loss for Resident #49. This affected two residents (#32 and #49) of 11 residents reviewed for nutrition. The facility census was 83. On 01/25/24 at 3:35 P.M., the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on 10/04/23 when Resident #32 experienced a severe weight loss of 19.9 pounds/10.05% of her body weight in a one month period of time (September to October 2023); 6.5% from October to November 2023 and 6.0% from November to December 2023 with a total weight loss over this time period of 21.6 % of the resident's body weight (43 pounds) with the weight loss not being comprehensively addressed and monitored ultimately leading to the resident being given the diagnoses of malnutrition related to poor intake and a subsequent admission to the hospital. The Immediate Jeopardy was removed on 01/29/24 when the facility implemented the following corrective actions: On 01/23/24 Resident #32 was transferred to the hospital for evaluation and treatment related to pneumonia, urinary tract infection (UTI), sepsis, diverticulitis, abdominal pain and nausea/vomiting. The resident was re-admitted to the facility on [DATE]. The facility implemented a plan for the resident to be encouraged and assisted to attend the assist dining room for lunch and dinner to encourage increase intake of meals. Resident #32's supplement order was modified to include the percentage of intake of the supplement by the Director of Nursing (DON) on 01/25/24. The resident's plan of care was updated on 01/25/24 to review the weight loss. Registered Dietician (RD) #500 reviewed the resident and recommended to continue the supplements as ordered. Resident #32 was started on an appetite stimulant (Remeron) on 01/26/24. On 01/29/24 Dietary Manager (DM) #115 updated Resident #32's food likes and dislikes and on 01/30/24 Resident #32's house supplement was discontinued and an order for mighty shakes three times a day was added. On 01/25/24 at 4:30 P.M. DON and Unit Managers #176 and #213 began in-person re-education for all direct care staff regarding the facility's weight loss policy and procedure. The direct care staff would be educated on the process for documenting the percentage of food intake at meals and the need (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 13 of 32 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 02/02/2024 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 - Immediate jeopardy to resident health or safety Residents Affected - Few to notify the nurse and/or dietician when there was a decrease in a meal or supplement intake that may need to be addressed. The direct care staff would document supplement intakes on the Medication Administration Record (MAR) via supplementary documentation. The direct care staff would document meal intakes on the point of care (POC) charting. Direct care staff would not be permitted to work until they have received the education. As of 01/26/24 there were 7 Registered Nurses (RN), 12 Licensed Practical Nurses (LPN), and 20 State Tested Nursing Assistant (STNA) who were educated. The clinical management team would be present at shift change to ensure staff did not work prior to being educated. The facility has 13 staff members RN #166, LPN #126, #283, #321 and STNA #122, #124, #168, #211, #259, #311, #320, #340 and #343 out of the country who would not be permitted to work until the education was provided by the clinical management team. On 01/25/24, the facility re-implemented their Weight Change policy. The policy included how to respond to weight loss and significant weight loss and how it should be communicated to the Interdisciplinary Team (IDT), Physician #502, and responsible party. Direct care staff would obtain the weight; if a significant change was identified, they would notify the unit manager assigned to their hallway; that Unit Manager would initiate the standing orders, and contact the physician and dietician for recommendations. On 01/26/24, the DON and Unit Manager #176 reviewed the weights of 82 residents in the facility for undesired significant changes. Seven residents, Resident #1, #9, #31, #42, #46, #57 and #76 triggered for a greater than 5 pound (lb) weight loss. For any residents who were triggered for weight loss during this review, the diet tech and physician were notified by the unit manager or designee (on 1/26/2024 at 11:41 A.M.). The Diet Tech and physician assessed the residents and recommendations were received by 1/27/2024. All residents who triggered were interviewed and/or family interviewed. Moving forward the care conference form has been updated to review nutrition as a systemic approach to address the individual needs of each resident. All residents who triggered to have an undesired weight loss would be reviewed by the IDT team, DON, Unit Manager #176, #213, Licensed Social Worker (LSW) #251, Administrator, Licensed Nursing Home Administrator (LNHA) #110, during the weekly risk meeting. The new weight review would be added to the weekly risk meeting beginning 1/29/2024. Standing orders for house supplements were in place for residents triggering for an undesired weight loss as recommended by the physicians on 1/26/2024. The Unit Managers #176 and #213 would enter the order during the daily IDT meeting. The RD/DR would also be part of the weekly meeting and updates would also be provided at that time. On 01/26/24 supplement orders for Residents #3, #5, #7, #9, #12, #14, #16, #17, #18, #19, #23, #24, #30, #32, 335, #36, #37, #39, #40, #42, #45, #47, #48, #52, #53, #54, #56, #57, #58, #59, #60, #64, #70, #72, #73, #76, #81 and #84 were modified by Unit Manager #176 to track intake percentages for residents who were at risk for weight loss. The documentation would be located in the resident's MAR under supplementary documentation. The facility implemented a plan for the IDT Team to review food intakes for all residents during the weekly risk meeting beginning 01/29/24. On 01/26/24, an ad hoc Quality Assessment Performance Improvement (QAPI) meeting was held with Physician #501, the Administrator, the DON, Regional Registered Dietician (RRD) #503, Unit Manager #176, LNHA #110, Registered Nurse (RN) #508 and RN #510, to discuss the plan of action. The facility also reviewed the re-implemented weight policy for any changes. On 01/29/24 at 12:00 P.M., the Administrator, DON, and RD #500 discussed alternative supplement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 14 of 32 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 02/02/2024 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 - Immediate jeopardy to resident health or safety options (if the resident prefers a different supplement than the one as part of the standing orders). The Dietician/Diet Tech would be attending the communities risk management meeting beginning the week of 01/29/2024 and weekly, thereafter. On 01/29/24 at 12:25 P.M. Resident #32 was interviewed for updated preferences In addition, the resident food committee meets the first Friday of each month to review the menu and add preferences. Residents Affected - Few The facility implemented a plan for the DON/designee to audit 10 resident records three times a week to ensure that meal and supplement intakes were being documented, weights were being obtained in accordance with the plan of care, weight changes were being reported to the IDT and physician as appropriate, and interventions were implemented related to weight changes. The audits would begin on 01/29/24 and continue for 12 weeks. Although the Immediate Jeopardy was removed on 01/29/24, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Include: Review of Resident #32's medical record revealed an admission date of 03/28/22 with a re-admission date of 08/18/23. The resident's diagnoses included encephalopathy, need for assistance with personal care, displaced subtrochanteric fracture of right femur, vitamin D deficiency, major depressive disorder, deaf and nonspeaking, type II diabetes, mild intellectual disabilities, secondary malignant neoplasm of the breast, acquired absence of left breast and nipple and anxiety disorder. Review of the resident is at risk for altered nutrition/hydration related to diagnoses encephalopathy, diabetes mellitus, developmental disabilities (DD), vitamin D deficiency, depression, anxiety, history of need for therapeutic diet, usually good by mouth intakes, abnormal labs, body mass index (BMI) indicates obesity and refuses weights occasionally plan of care, dated 04/04/22, revealed interventions which included to educate resident/representative regarding nutritional needs and requirements, modify diet as appropriate according to resident's food tolerance and preferences, monitor for alteration in chewing or swallowing status, alert physician and speech therapy (ST) as needed, provide diet as ordered, encourage intakes of diet and fluids, assist with meals as needed, provide medications as ordered, report to physician any signs/symptoms of dysphagia (swallowing difficulty) report to physician as needed any signs/symptoms of malnutrition, report the physician any signs/symptoms of dehydration, weights as ordered. The care plan also reflected the following weight documentation: On 10/12/23 significant weight loss at one week/30/90/180 days, 11/02/23 significant weight loss at 30/90/180 days, 11/28/23 significant weight loss with varied meals and abnormal labs, 01/15/24 significant weight loss at 90 and 180 days. Review of the resident's re-admission initial nursing assessment dated [DATE], authored by Licensed Practical Nurse (LPN) #191, revealed the resident required set-up, supervision with meals, was non-weight bearing to the right leg and required two staff members with bed mobility and transfers. Review of the medical record revealed no re-admission weight and the first documented weight following the resident's re-admission was obtained on 08/25/23 at 202.7 pounds. Review of the resident's meal percentage intakes for August 2023 revealed the facility failed to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 15 of 32 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 02/02/2024 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 - Immediate jeopardy to resident health or safety Residents Affected - Few document the resident's meal intakes on the following days: 08/06/23, 08/07/23, 08/10/23 for lunch and dinner, 08/14/23, 08/19/23, 08/20/23, 08/21/23, and 08/24/23 for the dinner meal. Review of the resident's weights revealed from 08/25/23 (202.7 pounds) to 09/07/23 (197.9 pounds) the resident had a weight loss of 4.8 pounds or (2.37%) weight loss in 13 days. Review of the resident's meal percentage intakes for September 2023 revealed the facility failed to document the resident's meal intakes on the following days: 09/03/23, 09/04/23 for the dinner meal, 09/07/23, 09/08/23, 09/09/23, 09/17/23, 09/18/23, 09/22/23, 09/25/23, 09/27/23, 09/29/23 and 09/30/23. Review of the resident's weights revealed from 09/07/23 (197.9 pounds) to 10/04/23 (178.0 pounds) the resident had a weight loss of 19.9 pounds or (10.05 %) weight loss in one month. Review of the resident's progress notes revealed no documented evidence Registered Dietician (RD) #500 or Physician #502 were notified of the significant weight loss of 19.9 pounds or 10.05 % in one month until 10/16/23. Further review revealed RD #500 recommended to add house supplement 2.0 240 milliliters (ml) daily and notify the physician or Certified Nurse Practitioner (CNP) of the significant weight loss. The RD was to continue to monitor weight trend and follow up as needed. Review of the resident's physician orders revealed the house supplement 240 ml by mouth daily recommendation from RD #500 was not implemented by the facility until 10/27/23. Review of the resident's weights from 10/04/23 (178 pounds) to 11/01/23 (166.5 pounds) revealed the resident had a significant weight loss of 11.5 pounds or 6.5 % of her total body weight loss in 28 days. Further review of the medical record revealed no documented evidence that the physician was notified of the significant weight loss. Review of the resident's meal percentage intakes for October 2023 revealed the facility failed to document the resident's meal intakes on the following days: 10/05/23, 10/06/23, 10/09/23, 10/13/23, 10/14/23, 10/16/23, 10/17/23, 10/19/23, 10/20/23, 10/21/23, 10/23/23, 10/25/23, 10/26/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23 and 10/31/23. Review of the Medication Administration Record (MAR) for October 2023 revealed the facility failed to document the percentage of the house supplement consumed. Review of the resident's weights from 11/01/23 (166.5 pounds) to 12/14/23 (156.5 pounds) revealed the resident had a significant weight loss of 10 pounds or 6% weight loss. Review of the weight change note dated 11/02/23 at 12:48 P.M., authored by RD #500, revealed the resident had a significant weight loss at 30/90/180 days and continued with a pressure ulcer to the right heel. The resident continued to receive a regular diet and had no recent meal intakes to review. The resident was receiving house supplement of 240 milliliters (ml) by mouth daily and 30 ml protein supplement twice daily. The note documented all supplements were accepted well. The RD recommended to increase the house supplement to 240 ml twice daily and continue to monitor weights weekly. Review of the medical record revealed the resident's weights were not obtained on 11/08/23 and 11/15/23 as physician ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 16 of 32 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 02/02/2024 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior section of the assessment revealed the resident had not rejected care. The assessment indicated the resident's weight was 161 pounds and she had a significant weight loss and was not on a prescribed weight loos regimen. Review of the dietary progress note dated 11/29/23, authored by RD #500 revealed the resident continued to have a significant weight loss of 7% in 30 days, 21% in 90 days and 21% in 180 days. The RD recommended to increase the house supplement to 240 ml three times a day, obtain weekly weights as physician ordered and notify the physician and/or CNP of the continued weight loss. Review of the physician's progress note dated 11/30/23, authored by Physician #502, revealed the physician was seeing the resident for unintentional weight loss. Following the review of the medical record the resident had lost approximately 40 pounds in the past six months. The physician gave orders to encourage by mouth intake, increase house supplement to 240 ml to three times a day and obtain weight weekly. Further review revealed the physician ordered a chest x-ray, calcium (CA) laboratory test, carcinoembryonic antigen (CEA) (a type of tumor marker used to monitor for cancer) laboratory test, complete metabolic panel laboratory and stool for guaiac three times (test used to detect blood in stool). Review of the medical record revealed no evidence the CEA, CA or the stool for guaiac three times had been obtained. Review of the resident's meal percentages intakes for November 2023 revealed the facility failed to document the resident's meal intakes on the following days: 11/02/23, 11/05/23, 11/06/23, 11/07/23 and 11/08/23. Review of the MAR for November 2023 revealed the facility failed to document the percentage of the house supplement consumed. Review of the medical record revealed the resident's weights were not obtained on 11/30/23 and 12/07/23 as physician ordered. Review of the resident's weight for 12/14/23 (156.5 pounds) revealed the resident had lost another four pounds or 2.5% weight loss in 22 days continuing the resident's weight loss trend. The medical record contained no documented evidence that the resident's physician or RD were notified of the continued weight loss. Review of the resident's weights revealed the physician ordered weight was not obtained on 12/21/23. Review of the physician progress note dated 12/21/23, authored by Physician #502, revealed the physician reviewed the resident's labs and the complete metabolic panel (CMP) supported the diagnoses of malnutrition with an Albumin low at 2.4 and protein low at 4.6. Further review of the physician progress note revealed the physician again ordered the labs CA, CEA and stool for guaiac three times due to them not being previously obtained. Review of the resident's weights revealed the physician ordered weight was not obtained on 01/04/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 17 of 32 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 02/02/2024 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 - Immediate jeopardy to resident health or safety Review of the resident's weight revealed on 01/11/24 the resident's weight was 152.6 pounds indicating another 3.4 pound or 2.18% weight loss continuing the weight loss trend. Review of the dietary progress note dated 01/15/24 at 10:44 A.M., authored by RD #500 revealed the resident had no significant weight loss in the past 30 days however, the resident had an 11% weight loss in the past 90 days and 25% weight loss in the past 180 days. Residents Affected - Few Review of the resident's weights revealed no weight was obtained on 01/18/24 as ordered by the physician. Review of the MAR for January 2024 revealed the facility failed to document the percentage of house supplements consumed. Review of the resident's meal percentage intakes for January 2024 revealed the facility failed to document the resident's meal intakes on the following days: 01/19/24 and 01/20/24. The facility did not identify the resident's weight loss as a severe weight loss. Review of the Centers for Medicare and Medicaid guidance under the intent for 4383.25 (g) revealed the suggested parameters for evaluating the significance of unplanned and undesired weight loss defined severe weight loss as greater than five percent lost in one month; greater than 7.5% in three months and greater than 10% in six months. Observation on 01/23/24 at 12:40 P.M. revealed the resident was offered her lunch meal tray. The resident communicated via sign language to Licensed Practical Nurse (LPN) #219 that she wanted her meal. The resident was served her meal, in a disposable container, which consisted of an oven fried pork chop, buttered parsley noodles, veggie blend, a slice of wheat bread, a slice of crème pie and tea for beverage. A bowl of chicken noodle soup was also on the tray, in a disposable bowl. The resident consumed 75% of her pork chop and bread and began using sign language to communicate that she was sick to her stomach. Interview on 01/23/24 at 12:43 P.M. with LPN #219 revealed the resident had complaints of nausea for the past few days. The LPN shared she had administered Zofran (an anti-nausea medication) to the resident, but she continued to complain of nausea. She revealed the resident was independent with eating and had just recently stopped eating. The LPN revealed the resident only takes sips of the physician ordered supplement but refused it the majority of time. She stated she had not communicated to the physician or the management team the resident's refusal of the supplement or the resident's decreased appetite. Interview on 01/23/24 at 12:56 P.M. with the Director of Nursing (DON) verified the lack of an individualized nutritional plan to include monitoring weights and nutritional status, physician and dietitian notification for weight loss and implementation of nutrition interventions to prevent severe weight loss for Resident #32. Interview on 01/23/24 at 1:06 P.M. with RD #500 revealed she was aware of the significant weight loss the resident had experienced. The RD verified the resident's meal percentages were not documented consistently, the percentage of nutritional supplement consumed was not documented and weekly weights were not obtained. The RD revealed it was difficult to determine if interventions implemented were appropriate due to the lack of charting. The RD stated she would expect her recommendations to be implemented within three days of receiving. The RD verified she was never told the resident refused (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 18 of 32 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 02/02/2024 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 - Immediate jeopardy to resident health or safety to be weighed or refused supplements. Lastly, the RD shared she had no additional interventions to implement and was waiting for the physician to implement an appetite stimulant. Interview on 01/23/24 at 4:10 P.M. with the DON verified the physician ordered lab tests CA, CEA and guaiac stools three times were not obtained when ordered on 11/30/23 and again on 12/16/23. The DON also verified this was not communicated with the physician. Residents Affected - Few Further review of the medical record revealed the resident was transferred to the hospital on [DATE] due to vomiting and was admitted with sepsis due to unspecified organism, pneumonia of the right lower lobe due to infectious organism, nausea and vomiting, pain of upper abdomen, fecal impaction and acute urinary tract infection. Review of the hospital documentation dated 01/24/24 provided by the facility revealed the resident was admitted to the local acute care hospital after being transferred from the facility for the final diagnoses of sepsis due to unspecified organism, pneumonia of right lower lobe due to infectious organism, nausea and vomiting, pain of upper abdomen, fecal impaction, and acute urinary tract infection. Further review revealed the resident's weight on 01/24/24 (in the hospital) was 149 pounds continuing the weight loss trend. In addition, review of the hospital documentation revealed a bedside modified barium swallow (an x-ray test that takes pictures of the patient's mouth and throat while he or she swallows various foods and liquids) was completed. The resident displayed mild to moderate dysphagia due to impaired cognition, impulsiveness and overall disorganized bolus (a ball-like mixture of food and saliva that forms in the mouth during the process of chewing) formation. Recommendations were made for thickened liquids and an altered diet texture. When the resident returned to the facility on [DATE], the resident had a new diet order for mechanical soft (restricts difficult to chew foods) and nectar thickened liquids (the fluid consistency is altered to the consistency of nectar and aides in swallowing of those with difficulty swallowing). Interview on 01/25/24 at 9:23 A.M. with Physician #502 revealed the resident was given the diagnoses of malnutrition based on the CMP laboratory results and the weight loss. He revealed the facility had not notified him of the resident's trending weight loss, decreased oral intake, decreased and/or refusal of supplements and labs not being completed as he had ordered. Review of the nursing progress notes dated 01/25/24 at 6:29 P.M. revealed the resident would have new medications including a 10-day course of Cefdinir (antibiotic), insulin changes and the resident was oriented to her room and call light. Medications were confirmed with the nurse practitioner (unidentified) at the time of her re-admission from the hospital. Review of the Ohio Board of Dietetics (OBD) Standards of Practice in Nutrition Care, effective 11/30/19 revealed the licensee monitors and evaluates indicators and outcomes data directly related to the nutrition diagnosis, goals and intervention strategies to determine the progress made in achieving desired outcomes of nutrition care and whether planned interventions should be continued or revised. Nutrition monitoring and evaluation is the fourth step of the nutrition care process. Monitoring specifically refers to the review and measurement of the patient / client / group's status at a scheduled (preplanned) follow-up point with regard to the nutrition diagnosis, intervention plans / goals and outcomes, whereas evaluation is the systematic comparison of current findings with previous status, intervention goals, or a reference standard. Monitoring and evaluation use selected outcome indicators (markers) that are relevant to the patient / client / group's defined needs, nutrition (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 19 of 32 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 02/02/2024 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 diagnosis, nutrition goals, and disease state. Level of Harm - Immediate jeopardy to resident health or safety Review of the facility's contract with the RD, dated 01/24/20 included that RD would formulate nutritional assessments and care plans on all new admissions, make resident visitations, observe eating in rooms and dining areas, and monitor weight, skin, and hydration management programs. Residents Affected - Few Review of the Medical Director (MD) Agreement dated 07/12/21 revealed the MD shall be responsible for the implementation of resident care policies and the coordination of medical care in the facility, overall coordination of physician services in the skilled nursing facility and wellness program. Maintains effective liaison with attending physicians and provides guidance to them regarding the implementation of facility patient care and documentation policies. Review of facility Weight Change policy, dated March 2018, revealed a significant weight loss was defined as five percent in one month, 7.5 percent in three months, and 10 percent in six months. Recheck weights were to be obtained for a five-pound loss or gain if resident weights over 100 pounds and a three-pound gain or loss on a resident weighing less than 100 pounds. A five-pound gain or loss on a resident weighing 100 pounds or more and three-pound gain or loss on a resident weighing less than 100 pounds would be reported to the dietician and physician. 2. Resident #49 was admitted to the facility on [DATE] with diagnoses including displaced intertrochanteric fracture of right femur, muscle weakness, acute respiratory failure with hypoxia, pressure ulcer of sacral region, urinary tract infection, dysphagia, congestive heart failure, encephalopathy, chronic obstructive pulmonary disease, dementia, attention deficit hyperactivity disorder, Alzheimer's disease, chronic kidney disease, atherosclerotic heart disease, depression, hypertension, anemia, and deaf nonspeaking. Review of his Minimum Data Set (MDS) assessment, dated 11/14/23, revealed the resident had a mild cognitive impairment. Review of Resident #49's weights revealed the following: On 07/11/23 (188 pounds), 08/14/23 (187.8 pounds), and 11/05/23 (175 pounds). No weight was obtained in December 2023 and no re-weights were obtained to verify the resident's weight loss. The resident's next weight was on 12/05/23, there was no documentation that a re-weight was taken in a timely manner to verify the weight loss. Review of Resident #49's physician orders revealed he was to be weighed once per month which by documentation was not occurring. Interview with the DON on 01/08/24 at 11:30 A.M. revealed staff were to notify the physician when the dietitian looked at the weights/nutritional status and made a new order. She confirmed staff do not notify the dietitian or physician when they take weights, and they had not been responsible to report significant changes; but rather the dietitian reviews this routinely. She confirmed the facility weight change policy was to notify the physician and dietitian when there was a change of five pounds or more. Review of facility Weight Change policy, dated March 2018, revealed a significant weight loss was defined as five percent in one month, 7.5 percent in three months, and 10 percent in six months. Recheck weights were to be obtained for a five-pound loss or gain if resident weights over 100 pounds (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 20 of 32 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 02/02/2024 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 - Immediate jeopardy to resident health or safety and a three-pound gain or loss on a resident weighing less than 100 pounds. A five-pound gain or loss on a resident weighing 100 pounds or more and three-pound gain or loss on a resident weighing less than 100 pounds would be reported to the dietician and physician. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 21 of 32 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 02/02/2024 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and facility policy review, the facility failed to provide adequate pain management for Resident #32 following an unwitnessed fall with pain to the right hip. Residents Affected - Few Actual harm occurred on 07/31/23 when Resident #32 who was noted to have chronic hip pain and received scheduled Tylenol, was found on the floor screaming and pointing to her right leg at 4:30 A.M. The resident was assisted back into bed and continued to scream and point to her right leg for an additional two hours before Physician #502 was notified and an order was obtained for an x-ray. Additionally, the resident rated her pain as 7 out of 10 (zero being no pain and 10 being the worst pain possible) and was not given any pain medication until her scheduled Tylenol at 8:00 A.M. Subsequently the resident was assessed to have a displaced subtrochanteric fracture of right femur, leading to a transfer to a local acute care hospital on [DATE] at 2:15 P.M. and a surgical repair of the displaced subtrochanteric fracture of the right femur was required. This affected one resident (#32) of four residents reviewed for falls. The facility census was 83. Findings Include: Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE] with a re-admission on [DATE]. Resident #32 had diagnoses including encephalopathy, need for assistance with personal care, displaced subtrochanteric fracture of right femur, vitamin D deficiency, major depressive disorder, deaf nonspeaking, type II diabetes, mild intellectual disabilities, secondary malignant neoplasm of the breast, acquired absence of left breast and nipple and anxiety disorder. Review of the resident's physician orders revealed an order, dated 03/02/22 for Tylenol Extra Strength 500 milligrams (mg) with the special instructions to give two tablets by mouth three times a day for chronic hip pain. Review of the plan of care dated 04/04/22 revealed the resident had potential for pain related to rhabdomyolysis, cervical disc disease, osteoporosis and diabetes mellitus. Interventions included to administer medications as ordered, inform the physician if pain was not relieved or uncontrolled pain as needed, offer non-pharmacological pain interventions as tolerated and therapy referrals. Review of the resident's comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior section of the MDS revealed the resident had not rejected care. The assessment revealed the resident required extensive assistance from one staff for bed mobility, transfers, toileting, dressing and personal hygiene and was non-ambulatory. The assessment indicated the resident was always incontinent of bladder and frequently incontinent of bowel. The assessment indicated the resident received scheduled pain medication and had no pain during the pain interview. Review of the nurse's note dated 07/31/23 at 4:30 A.M., authored by Licensed Practical Nurse (LPN) #191 revealed the resident was found lying on the floor on her back. A head-to-toe assessment was completed, vital signs were within normal limits, no bodily injury was noted, and the resident demonstrated pain by screaming and pointing to her right leg. The resident was assisted back to bed with her call light within reach. The on-call Certified Nurse Practitioner (CNP) was notified and no new orders were obtained at that time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 22 of 32 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 02/02/2024 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 0697 Level of Harm - Actual harm Residents Affected - Few Review of the nurse's note dated 07/31/23 at 6:37 A.M., authored by LPN #191 revealed the LPN documented again the resident being found on the floor and the resident demonstrated pain by screaming and pointing to right leg. The CNP was notified of the continued pain and ordered an x-ray. Review of the pain assessment dated [DATE] at 6:40 A.M., authored by LPN #191 revealed the LPN documented the resident had no pain, despite the resident screaming out and pointing to her leg per the entry in the nursing note. Review of the pain assessment dated [DATE] at 8:18 A.M., authored by LPN #515 revealed the resident voiced pain almost constant interfering with sleep and day to day activities at a level of seven out of 10. Review of the resident's July 2023 Medication Administration Record (MAR) revealed the resident was administered her scheduled Tylenol Extra Strength 500 milligrams (mg) for the pain level of 7 out of 10 on 07/31/23 at 8:00 A.M. Review of the medical record revealed no documented evidence the resident's pain was reassessed following the administration of the scheduled analgesic Tylenol Extra Strength due at 8:00 A.M. for effectiveness. Review of the July 2023 MAR revealed the resident was again administered Tylenol Extra Strength 500 mg, two tablets on 07/31/23 at 12:00 P.M. for a pain level of five out of 10. Review of the medical record revealed no documented evidence the resident's pain was reassessed following the administration of the scheduled analgesic Tylenol extra strength due at 12:00 P.M. for effectiveness. Review of the progress note dated 07/31/23 at 12:25 P.M., authored by LPN #515 revealed x-ray results were called to the physician group and they requested the results be faxed to their office. The facility was awaiting new orders. Review of the progress note dated 07/31/23 at 2:14 P.M., authored by LPN #515 revealed a new order was obtained from the resident's physician to send the resident out to the emergency room (ER) due to the x-ray results. Review of the progress note dated 07/31/23 at 5:02 P.M., authored by LPN #219 revealed the local acute care hospital called requesting a consent to perform a nerve block. The facility attempted to call the resident's spouse with no answer. Review of the late entry Intradisciplinary team (IDT) note dated 08/23/23 at 3:15 P.M. for 08/01/23 at 3:15 P.M., authored by the Director of Nursing (DON) revealed Resident #32 was found on the floor writhing in pain. The resident was moved to the bed and physician was called. The resident was sent to the hospital due to x-ray results showing the resident's hip was broken. The resident was given visual reminders to call for assistance when she wanted to get out of bed. Review of the medical record revealed no documented evidence the facility provided effective pain management for the resident's complaints of right hip pain following the unwitnessed fall resulting in the displaced subtrochanteric fracture of right femur requiring surgical repair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 23 of 32 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 02/02/2024 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 0697 Level of Harm - Actual harm Interview on 01/25/24 at 9:23 A.M. with Physician #502 revealed he would have expected the resident's pain to be reassessed within an hour of the administration of the medication (routine) Tylenol and if the resident's pain was not controlled, the staff should have called for a new order for a stronger pain medication. This order for Tylenol had been in place since 2022. Residents Affected - Few Interview on 01/25/24 at 2:49 P.M., interview with the DON verified the resident's pain was not controlled with the use of the scheduled Tylenol and reassessments of the resident's pain were not completed. The DON revealed the facility did not have a policy for pain management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 24 of 32 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 02/02/2024 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 follow a physician ordered fluid restriction for Resident #55, who received hemodialysis to promote optimal cardiac and renal outcomes for the resident. The facility also failed to ensure dialysis communication forms were accessible to facility staff for review and reference. This affected one resident (#55) of one resident reviewed for hemodialysis/hydration. The facility census was 83. Residents Affected - Few Findings Include: Review of the medical record for Resident #55 revealed an initial admission date of 03/24/23 and a re-entry date of 11/10/2023. Diagnosis included end stage renal disease, dependence on renal dialysis, and heart disease. Review of the plan of care dated 03/27/23 and revised 12/22/23 revealed Resident #55 had a potential for nutritional and/or hydration problem related to type two diabetes, end stage renal disease/hemodialysis, coronary artery disease, depression, anxiety, cerebral infarction, need for therapeutic diet with fluctuating anticipated usually good intake, on a fluid restriction, and resident refuses to follow fluid. Interventions included to administer medication as ordered, coordinate care with renal dietitian at dialysis, explain and reinforce importance of following diet recommendations, fluid restriction as ordered, and monitor weight as ordered. Review of Resident #55's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was receiving dialysis services and was independent for all activities of daily living (ADL) care. a. Review of Resident #55's physician orders revealed outpatient dialysis on Monday, Wednesday and Friday. The resident also had an order, written 05/15/23 for a 1.2 liter (1,200 milliliter) fluid restriction per day. Review of Resident #55's fluid intake for the last 30 days revealed the following: On 12/12/2023 the resident had 2296 ml/day On 12/14/2023 the resident had 1640 ml/day On 12/16/2023 the resident had 1560 ml/day On 12/17/2023 the resident had 2100 ml/day On 12/19/2023 the resident had 1620 ml/day On 12/21/2023 the resident had 1440 ml/day On 12/23/2023 the resident had 1560 ml/day On 12/26/2023 the resident had 1740 ml/day (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 25 of 32 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 02/02/2024 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 0698 On 12/28/2023 the resident had 1440 ml/day Level of Harm - Minimal harm or potential for actual harm On 12/30/2023 the resident had 1440 ml/day On 01/01/2024 the resident had 1360 ml/day Residents Affected - Few On 01/02/2024 the resident had 1440 ml/day On 01/03/2024 the resident had 1920 ml/day On 01/04/2024 the resident had 1620 ml/day On 01/05/2024 the resident had 1560 ml/day Interview on 01/08/2024 at 10:30 A.M. with the Director of Nursing (DON) confirmed the resident's medical record reflected a greater than 1200 ml's of fluid some days and Resident #55 was not supposed to take in more than 1200 ml's of fluid daily due to his heart failure and end stage renal disease. The DON believed Resident #55 was known to be non-compliant with this fluid restriction but verified there was not documentation to reflect this non-compliance. b. Review of Resident #55's physician orders revealed the following outpatient dialysis on Monday, Wednesday and Friday and dialysis communication form to be sent with guest with every dialysis visit and put back in communication book upon return. If returned without it (the communication form) call the dialysis center to have it faxed. Review of Resident #55's dialysis communication forms revealed only forms from 04/01/2023 through 08/07/2023 were available and provided by the facility. Interview on 01/08/2024 at 10:30 A.M. with the Director of Nursing (DON) revealed the communication forms provided where the only forms the facility had on site and had contacted the dialysis center for the other forms to be faxed over. The DON alert and orient and when he returns from his dialysis treatments, sometimes he will forget to give the form to his nurse or will just throw it away. Interview on 01/08/2024 at 1:40 P.M. with Licensed Practical Nurse (LPN) #176 confirmed there was an order in Resident #55's medical record for the dialysis communication form to be placed in the communication book when the resident returned from dialysis treatments. If this form is not provided to the facility, then the nurse is to call the dialysis center and have it faxed over. LPN #176 confirmed the last few months of dialysis communication forms were not currently at the facility for review and this had not been addressed until requested during this survey process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 26 of 32 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 02/02/2024 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure medication monitoring was completed for the use of antipsychotic medications. This affected one resident (Residents #70) of five residents reviewed for unnecessary medications. The facility census was 83. Findings include: Review of Resident #70's medical record revealed the resident was admitted to the facility on [DATE] with admitting diagnoses including depression, hallucinations, schizophrenia, and high blood pressure. Further review revealed Resident #70 required staff assistance for Activities of Daily Living (ADL) task completion and medication administration. Review of Resident #70's signed physician orders revealed an order dated 04/21/21 for the use of the antipsychotic medication Risperdal one milligram (mg) given daily at bedtime related to schizophrenia. Review of Resident #70's Medication Administration Record (MAR) dated December 2023 revealed Risperdal was administered per physician order. Review of Resident #70's quarterly Minimum Data Set (MDS) dated [DATE] revealed in section I Active Diagnoses, the psychotic diagnosis was marked, and in section N Medications, the use of an antipsychotic medication was marked with the last Gradual Dose Reduction (GDR) on 10/18/23 as being contraindicated for Resident #70. Review of Resident #70's care plan dated 04/21/21 revealed Resident #70 was to be monitored for side effects and adverse reactions due to the use of psychotropic medications for the management of schizophrenia. Review of Resident #70's assessment listing for the assessment titled Abnormal Involuntary Movement Scale (AIMS) revealed Resident #70 had an assessment completed on admission dated 04/22/21. Further review revealed Resident #70 had completed AIMS assessments for the following dates: 05/11/22, and 02/26/23. Interview on 01/03/23 at 1:59 P.M. with the Director of Nursing (DON) revealed the staff nurses, the unit managers, or the DON will complete the resident assessments required for the scheduled MDS. The AIMS assessments are required on admission and then every six months following admission. The DON confirmed Resident #70's last completed AIMS assessment dated [DATE], and Resident #70's AIMS assessments were not completed as required for monitoring of antipsychotic medication side effects and adverse reactions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 27 of 32 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 02/02/2024 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and facility policy review, the facility failed to ensure one resident's (#32) physician ordered laboratory tests were completed as ordered. This affected one of 11 residents reviewed for nutrition. The facility census was 83. Residents Affected - Few Findings Include: Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE] with the latest readmission of 08/18/23. Her diagnoses included encephalopathy, need for assistance with personal care, displaced subtrochanteric fracture of right femur, vitamin D deficiency, major depressive disorder, deaf nonspeaking, type II diabetes, mild intellectual disabilities, secondary malignant neoplasm of the breast, acquired absence of left breast and nipple and anxiety disorder. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the physician progress note dated 11/30/23, authored by Physician #502 revealed the physician was seeing the resident for unintentional weight loss. Following the review of the medical record the resident had lost approximately 40 pounds in the past six months. The physician gave orders for a chest x-ray, calcium (CA), carcinoembryonic antigen (CEA) (a type of tumor marker used to monitor for cancer), complete metabolic panel (CMP) and stool for guaiac three times (test used to detect blood in stool). Review of the medical record revealed no documented evidence the physician ordered laboratory tests CEA, CA and guaiac stools were completed. Review of the physician progress note dated 12/21/23, authored by Physician #502 revealed the physician again ordered the labs CA, CEA and stool for guaiac three times due to not being obtained. Review of the medical record revealed no documented evidence the physician ordered laboratory tests were completed. Interview on 01/25/23 at 9:23 A.M. with Physician #502 revealed he was not made aware the laboratory tests were not completed until 01/25/23, when he arrived at the facility. Interview on 01/23/24 at 4:10 P.M. with the DON verified the physician ordered lab tests CA, CEA and guaiac stools three times were not obtained when ordered on 11/30/23 and again on 12/16/23. Review of the facility policy titled, Laboratory Services and Reporting, dated 04/27/22 revealed the facility must provide or obtain laboratory services when ordered by a practitioner in accordance with state law. The facility provides or obtains laboratory services to meet the needs of residents. The facility is responsible for the timeliness of the services. If needed the facility will assist the residents in making transportation arrangements to an from the laboratory if necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 28 of 32 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 02/02/2024 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 - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interviews, the facility failed to ensure residents were not served food past the use-by date. This had the potential to affect 82 of 82 residents who receive food from the facility kitchen. One resident (Resident #23) receives nothing by mouth. The census was 83. Findings include: Observation in the facility kitchen on 01/02/24 from 8:39 A.M. to 9:23 A.M. revealed 102 cartons of 1% milk in the walk-in refrigerator that had a use by date of 01/01/24. Interview with Director of Dietary #115 on 01/02/24 at 9:14 A.M. confirmed the milk was past the use by date, and stated she thought the facility had a seven day look back policy on milk. Director of Dietary #115 confirmed the intent to use the milk past the use- by date. Interview with Director of Dietary #115 on 01/04/24 at 2:30 P.M. confirmed the facility did not have a policy for a look-back period on milk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 29 of 32 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 02/02/2024 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain hospice documentation on-site for resident care. This affected one resident (Resident #2) of one resident reviewed for hospice services. The facility census was 83. Findings Include: Resident #2 was admitted to the facility on [DATE]. Her diagnoses were chronic kidney disease, diabetes, hypertension, hyperkalemia, depression, anxiety disorder, lumbar spina bifida, acquired absence of right and left leg above knee, and glaucoma. Review of her minimum data set (MDS) assessment, dated 12/14/23, revealed she had a significant cognitive impairment. Review of Resident #2's medical records revealed the facility had no hospice notes or orders on site for her. The hospice notes provided to the survey team on 01/08/24 had a fax date of 01/08/24, indicating all the hospice notes were sent to the facility on that day. Interview with Licensed Practical Nurse (LPN) #176 on 01/08/24 at 1:07 P.M. confirmed the facility did not have any hospice documentation for Resident #2 until it was sent to the facility via fax on 01/08/24. Review of facility Hospice Agreement, dated 05/10/21, revealed communication will be documented between the nursing facility and hospice through physician orders, nurses' notes, interdisciplinary plan of care (IPOC) and plan of care (POC) to ensure the needs of the resident are addressed and met 24 hours per day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 30 of 32 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 02/02/2024 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 provide evidence of education and administration of pneumonia immunizations. This affected two residents (Resident #35 and #84) of five residents reviewed for immunizations. The facility census was 83. Residents Affected - Few 1. Review of Resident #35's medical record revealed Resident #35 was admitted to the facility on [DATE] with admitting diagnoses including asthma, chronic obstructive pulmonary disease (COPD), depression, high blood pressure, and chronic venous ulcer to lower left leg. Resident #35 required assistance from staff for activities of daily living (ADL) tasks. Review of Resident #35's immunization record revealed Resident #35 declined the Covid-19 immunization, the influenza immunization, and the annual Tuberculosis health questionnaire on 10/04/23. Interview on 01/08/24 at 11:30 A.M. with the Director of Nursing (DON) revealed the facility did not have information on when Resident #35 would have received any previous pneumonia immunizations. The DON confirmed Resident #35 did not have any updated pneumonia immunizations and Resident #35 did not receive any pneumonia immunization education while being a resident at the facility. 2. Review of Resident #84's medical record revealed Resident #84 was initially admitted to the facility on [DATE] and was re-admitted to the facility on [DATE] with diagnoses including fracture of left femur, weakness, deafness, anxiety, and depression. Further review revealed Resident #84 required assistance from staff for activities of daily living (ADL) tasks. Review of Resident #84 immunization record revealed Resident #84 received the influenza immunization and influenza education on 10/04/23. Interview on 01/08/24 at 11:30 A.M. with the DON revealed Resident #84 had recently admitted to the facility. The facility did not have information for Resident #84 receiving any previous pneumonia immunizations. The DON confirmed Resident #84 had not received the pneumonia immunization or the pneumonia immunization education while being a resident at the facility. Review of the facility policy titled, Pneumococcal Immunizations revised 09/01/21 revealed, It is the policy of this United Church Home to minimize the risk of the residents acquiring or experiencing complications from pneumococcal pneumonia by ensuring that each resident receive the pneumococcal vaccination unless the vaccine is medically contraindicated, or the resident refuses the vaccine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 31 of 32 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 02/02/2024 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and staff interview the facility failed to maintain effective pest management. This had the potential to affect all 83 residents. Residents Affected - Many Findings include: Observation on 01/02/24 at 8:39 A.M. in the kitchen under the dishwasher revealed two live cockroaches. Director of Dietary #115 verified the cockroaches at the time of the discovery, and verbalized seeing cockroaches occasionally. Observation on 01/02/24 at 10:26 A.M. in Resident #17 room revealed two live cockroaches on Resident #17's bathroom counter where one toothbrush was laying uncovered. Director of Maintenance #269 verified the pests at the time of the discovery. Interview on 01/02/24 at 10:26 A.M. with Director of Maintenance #269 confirmed they have had an outbreak of cockroaches in the kitchen, 200's and 300's hall. Observation on 01/02/24 at 10:35 A.M. in Resident #10 room revealed one live cockroach on the bathroom counter. State Tested Nursing Assistant (STNA) #128 verified the pests at the time of discovery, stating the pests were everywhere. Observation on 01/04/24 at 10:21 A.M. of the water refill cart in the 300's hall revealed a cockroach on the cart under an opened sleeve of cups. This was confirmed with STNA #326 at the time of the observation. Review of Resident Council minutes from 07/07/23 revealed a resident complaint of bugs in a resident care area. Review of service inspection reports with the pest control company revealed the following: On 08/28/23 Roach cleanout . in kitchen area. treat 10 rooms for roaches. On 09/25/23 treated kitchen for cockroaches and fly activity. Four rooms were treated between the 200 and 300 halls and high activity was noted in the light above a resident's bed on 200 hall. On 11/01/23 Baited for cockroach activity in kitchen On 12/08/23 Treated three rooms on 200 hall and every other room of the 300 hallway, for cockroach activity. On 01/02/24 Treated 200 hallway for cockroach activity. This deficiency represents non-compliance investigated under Complaint Number OH00149587. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365421 If continuation sheet Page 32 of 32