Health inspection·September 28, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, medical record review, review of shower sheets, and facility policy review, the facility failed to ensure one resident's (Resident #85) hair was washed and one resident's (Resident #88) unwanted facial hair was removed. This affected two (Residents #85 and #88) of eight residents reviewed for activities of daily living (ADLs). The facility census was 116. Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #85 revealed an initial admission date on 03/22/21 and a readmission date on 04/09/21. Medical diagnoses included chronic obstructive pulmonary disease (COPD), Type II diabetes mellitus with polyneuropathy, stroke, essential hypertension (high blood pressure), colostomy status, fibromyalgia, other chronic pain, major depressive disorder, anxiety disorder, and drug induced subacute dyskinesia (abnormal movements). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #85 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #85 required extensive assistance to total dependence from one to two staff to complete Activities of Daily Living (ADLs). Resident #85 required total dependence on staff for bathing. Review of the progress notes dated from 07/01/23 to 09/27/23 revealed no evidence Resident #85 refused to have her hair washed. Review of the care plan revised 09/25/23 revealed Resident #85 had an ADL self-care performance deficit. Interventions included one to two staff assistance with bathing and to provide a sponge bath when a full bath or shower cannot be tolerated. There was no indication Resident #85 refused to have her hair washed in the care plan. Observations on 09/26/23 at 9:53 A.M. and 09/27/23 at 12:25 P.M. of Resident #85 in her room revealed the resident's hair appeared greasy with visible white flakes on her scalp near the resident's hair line. Interview on 09/26/23 at 9:53 A.M. with Resident #85 revealed she received bed baths. Resident #85 stated she would like to have her hair washed. The resident stated she had not had her hair washed in a couple of weeks. Interview on 09/27/23 at 5:42 P.M. with the Assistant Director of Nursing (ADON) #507 revealed if a resident received a full bed bath, the resident's hair should be washed unless the resident refuses. ADON #507 stated if the resident refused, it should be documented on a shower sheet. Review of shower sheets dated from July 2023 through September 2023 revealed the most recent shower sheet was dated 09/19/23 (approximately nine days ago). The shower sheet did not include whether or not the resident had her hair washed. The shower sheet did not indicate Resident #85 had refused any personal hygiene care. Review of the bathing task for the last 30 days revealed Resident #85 had showers scheduled two times a week. The task indicated the amount of assistance required to complete the task and stated, excludes washing hair or back. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365436 If continuation sheet Page 2 of 26 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 09/28/23 at 1:27 P.M. with the Administrator confirmed there were no additional shower sheets after 09/19/23 found for Resident #85. The Administrator confirmed there was no evidence on the shower sheet or in the bathing task that showed evidence Resident #85 had her hair washed. 2) Review of Resident #88's medical record revealed the resident was admitted to the facility on [DATE] with the admitting diagnosis including dementia, type II diabetes mellitus, depression, anxiety, dysphagia, and weakness. Further review revealed Resident #88 had impaired cognition and impaired hearing. Review of Resident #88 quarterly [NAME] Data Set (MDS) dated [DATE] revealed in Section G Functional Status the resident required extensive assistance from staff for bed mobility, transfers, toileting, dressing, personal hygiene, and bathing. Review of Resident #88 care plan dated 09/23/22 revealed the resident required assistance from staff to complete Activities of Daily Living (ADL) tasks including personal hygiene and bathing. Review of Resident #88 shower documentation sheets dated 06/10/23 to 09/26/23 revealed documentation reflecting Resident #88 received a bed bath for each shower day and Resident #88 was assisted in removing facial hair two times out of the 26 times Resident #88 was bathed between 06/10/23 and 09/26/23. Observations on 09/25/23 at 10:15 A.M. and again at 2:50 P.M. revealed Resident #88 had a moderate amount of facial hair visible. Interview on 09/25/23 at 11:15 A.M. with Resident #88's brother revealed the expectation of Resident #88's family is for him to be clean shaved and free of facial hair. Resident #88's brother stated, I have brought in a very good electric razor for the staff to use, but they don't seem to use it. Observations on 09/26/23 at 8:15 A.M. and again at 3:30 P.M. revealed Resident #88 continued to have a moderate amount of facial hair visible. Interview on 09/27/23 at 8:30 A.M. with Resident #88 revealed he would like to be clean shaved and free of facial hair at least daily. Observation on 09/27/23 at 8:45 A.M. revealed Resident #88 continued with a moderate amount of facial hair visible. Interview on 09/27/23 at 8:50 A.M. with State Tested Nursing Assistance (STNA) #508 revealed, Resident #88 receives his showers on Monday and Thursdays, and we do shave him during the shower or bed bath. We put that on the shower sheets. STNA #508 confirmed Resident #88 had moderate facial hair visible. Review of the facility policy titled Activities of Daily Living (ADL), Supporting dated 03/2018 revealed, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365436 If continuation sheet Page 3 of 26 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to have weekend activities and daily independent activities available. This affected two residents (#41 and #62) of two residents reviewed for activities. The facility census was 116. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #41 revealed an admission date of 02/02/17 with diagnoses including dementia, type II diabetes, dysphagia, psychotic disorder with delusions, moderate protein-calorie malnutrition, and memory deficit following cerebral infarction. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #41 was rarely or never understood. Review of the plan of care dated 07/27/23 revealed Resident #41 required structured activities due to diagnoses, need for verbal or tactile cueing, and need for assistance for mobility. Interventions included involving the resident in daily facility routine, reminding, and encouraging to attend activities of interest, providing leisure supplies needed to facilitate interests, providing assistance in wheelchair to activities, praising all efforts and encouraging family support. Review of the quarterly activities assessment dated [DATE] revealed Resident #41 was a passive to active observer depending on the day due to dementia. The resident was able to verbalize pleasant and unpleasant stimuli, tires easily through some activities. She enjoyed activities such as music, sing-along, and sensory. Review of her activities documentation for September 2023 revealed she had only done one weekend activity on 09/16/23 when she passively watched a movie. She had not participated in watching television or listening to the radio since 09/15/23. Review of the activities calendar revealed catholic mass was the only activity offered on Sundays. Observation on 09/25/23 at 10:35 A.M., 11:32 A.M. 2:50 P.M. and 4:21 P.M., on 09/26/23 at 9:16 A.M. and 2:30 P.M., and on 09/27/23 at 10:57 A.M. revealed Resident #41 in her chair the common area lounge, no television, music, or other entertainment was provided. Interview on 09/27/23 at 11:00 A.M. with Unit Manager #531 verified Resident #41 was in the common area with no source of entertainment. She reported she was unsure what was done to entertain the residents sitting in the common area. Interview on 09/27/23 at 11:00 A.M. with Activities Staff #535 revealed she did try to turn on music for the residents in the common area or move them to the area in front of the television, but she did not think she had done it in the last couple of days. She additionally verified it was something the nursing staff could do for residents as well. Interview on 09/27/23 at 11:15 A.M. and 09/28/23 at 9:40 A.M. with Activities Director #525 revealed activity staff worked every other weekend. On days the activity staff was not present they had mass and independent activities. She reported for cognitively impaired residents the nurse aides would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365436 If continuation sheet Page 4 of 26 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facilitate activities including games, reading to them, and music. She reported the nurse aides did not document this and verified the activities documentation showed only one weekend activity for Resident #41. 2. Review of the medical record for Resident #62 revealed an admission date of 05/11/22 with diagnoses including dementia, chronic kidney disease stage three, adjustment disorder, type II diabetes mellitus, anxiety disorder, age-related nuclear cataract, and need for assistance with personal care. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #62 had severely impaired cognition. She was totally dependent for locomotion. Review of the plan of care dated 01/03/23 revealed Resident #62 pursued independent leisure activities and group activities. She required reminders and wheelchair assistance when attending activities and required prompting and reminders due to dementia. Interventions included encouraging active participation, encouraging family support, encouraging and reminding of activities of interest, providing and reviewing activity calendar, providing leisure as needed to facilitate interests including music, television, and spiritual materials. Review of the quarterly activities assessment dated [DATE] revealed Resident #62 took part in group activities. She would join in for music, bingo, drumming and fitness, nails, and movies. She could be quiet and passive but would become involved with prompting. Review of Resident #62's activity participation for September 2023 revealed Resident #62 only completed activities on the weekend on one day, 09/02/23. Review of the activities calendar revealed catholic mass was the only activity offered on Sundays. Observation on 09/25/23 at 10:38 A.M., 11:30 A.M., and 4:21 P.M. and on 09/27/23 at 10:57 A.M. revealed Resident #62 was seated in her wheelchair in the common area lounge, no television, music, or other entertainment being provided. Resident #62 was not positioned near the table where independent activities were present. Interview on 09/27/23 at 11:00 A.M. with Unit Manager #531 verified Resident #62 was in the common area with no source of entertainment. She reported she was unsure what was done to entertain the residents sitting in the common area. Interview on 09/27/23 at 11:00 A.M. with Activities Staff #535 revealed she did try to turn on music for the residents in the common area or move them to the area in front of the television, but she did not think she had done it in the last couple of days. She additionally verified it was something the nursing staff could do for residents as well. Interview on 09/27/23 at 11:15 A.M. and 09/28/23 at 9:40 A.M. with Activities Director #525 revealed activity staff worked every other weekend. On days the activity staff was not present they had mass and independent activities. She reported for cognitively impaired residents the nurse aides would facilitate activities including games, reading to them, and music. She reported the nurse aides did not document this and verified the activities documentation showed only one weekend of activity for Resident #62. Activities Director #525 verified Resident #62 could look through activity booklets and complete puzzles independently but would need assistance to get to these activities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365436 If continuation sheet Page 5 of 26 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 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 0679 Level of Harm - Minimal harm or potential for actual harm Review of the activities policy dated 03/01/23 revealed activities could occur at any time and were not limited to formal activities, they could include other staff members, volunteers, visitors, and families. Activities were to include indoor and outdoor activities, religious programs, exercise programs, social activities, in-room activities, individualized activities, and educational programs. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365436 If continuation sheet Page 6 of 26 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 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 medical record review, staff interview, review of pharmacy delivery receipts, and facility policy review, the facility failed to ensure hospice notes were kept on-site and readily available to staff for one resident (Resident #89). The facility failed to administer as needed (PRN) blood pressure medication as ordered to one resident (Resident #67). The facility failed to timely treat tardive dyskinesia (involuntary, repetitive movements often caused by long-term use of some psychiatric medications) for one resident (Resident #85). This affected one (Resident #89) of two residents reviewed for hospice services and two (Residents #67 and #85) of five residents reviewed for medications. The facility census was 116. Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #89 revealed an original admission date on 06/17/22 and a readmission date on 07/13/23. Diagnoses included Parkinson's Disease, dementia, pneumonia (07/14/23), esophageal obstruction (07/14/23), type II diabetes mellitus without complications, heart disease, and encounter for palliative care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #89 has impaired cognition and scored six out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #89 required extensive assistance to total dependence on one to two staff to complete Activities of Daily Living (ADLs). Resident #89 received hospice services. Review of the care plan revised on 07/24/23 revealed Resident #89 had a terminal prognosis related to Parkinson's Disease and received hospice services. Interventions included work cooperatively with hospice team to ensure the resident's needs were met. There were no hospice notes for Resident #89 in the medical record. Interview on 09/27/23 at 7:20 A.M. with the Administrator confirmed no hospice notes for Resident #89 were found on-site at the facility. Interviews on 09/27/23 at 5:26 P.M. and 5:39 P.M. with Licensed Practical Nurse (LPN) #559 and the Assistant Director of Nursing (ADON) revealed no hospice notes for Resident #89 could be found on-site in the facility. LPN #559 and the ADON were not able to locate a binder at the nurse's station where additional hospice binders were found. The ADON stated she was not able to find any hospice notes for Resident #89 on any other unit either. The ADON confirmed the Social Services Director (SSD) #547 was contacting the provider to request the hospice notes be sent to the facility. Review of the facility policy, Coordination of Hospice Services, revised 03/01/23, revealed the policy stated, when a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable physical, mental, and psychosocial well-being. Furthermore, the facility will communicate with hospice and identify, communicate, follow and document all interventions put into place by hospice and the facility. 2. Review of the medical record for Resident #67 revealed an original admission on [DATE] and a readmission date on 12/14/19. Medical diagnoses included end stage renal disease, dependence on renal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365436 If continuation sheet Page 7 of 26 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dialysis, essential hypertension (high blood pressure), hypotension (low blood pressure), major depressive disorder recurrent, and seizures. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #67 had intact cognition and scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #67 required extensive assistance to total dependence on one staff to complete Activities of Daily Living (ADLs). Review of the current physician orders dated September 2023 revealed Resident #67 had an order for Midodrine Hydrochloride (HCl) oral tablet 2.5 milligrams (mg) with instructions to give one tablet by mouth every eight hours as needed for low blood pressure under 100/80. The order was dated 06/17/23. Review of Resident #67's blood pressure readings from July 2023 through September 2023 revealed Resident #67 had a blood pressure under 100/80 on the following dates: 07/04/23, 07/11/23, 07/20/23, 07/25/23, 08/01/23, 08/15/23 twice, 08/29/23, and 09/23/23. Review of the Medication Administration Records (MARs) dated July 2023, August 2023, and September 2023 revealed Midodrine HCl medication was not administered at all in any of the three months reviewed. Review of the care plan revised 07/30/23 revealed Resident #67 had hypertension. Interventions included administer medications as ordered and monitor for side effects and effectiveness. Resident #67 has had a history of hypotension. Interventions included administer medications as ordered and monitor for side effects and effectiveness. Interview on 09/27/23 at 6:19 P.M. with Licensed Practical Nurse (LPN) #559 confirmed Resident #67 had an active order to administer Midodrine HCL as needed for a blood pressure reading under 100/80. LPN #559 reviewed the MARs for Resident #67 and confirmed the Midodrine medication has not been administered at all to the resident. LPN #559 reviewed Resident #67's blood pressure readings and confirmed the resident had blood pressure readings under 100/80. LPN #559 checked the medication cart and confirmed the medication was not in the medication cart for Resident #67. Review of the facility policy, Physician Services, dated 03/01/23, revealed the policy stated, a physician or non-physician practitioner must provide orders for the resident's intermediate care needs. 3. Review of the medical record for Resident #85 revealed an initial admission date on 03/22/21 and a readmission date on 04/09/21. Medical diagnoses included chronic obstructive pulmonary disease (COPD), Type II diabetes mellitus with polyneuropathy, stroke, essential hypertension (high blood pressure), colostomy status, fibromyalgia, other chronic pain, spondylosis without myelopathy or radiculopathy lumbosacral region, major depressive disorder, anxiety disorder, and drug induced subacute dyskinesia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #85 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #85 required extensive assistance to total dependence from one to two staff to complete Activities of Daily Living (ADLs). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365436 If continuation sheet Page 8 of 26 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Review of the Medication Administration Record (MAR) dated July 2023 revealed Resident #85 had an order for Austedo Extended Release (XR) 24 hour 12 milligrams (mg) with instructions to give one tablet by mouth one time daily for tardive dyskinesia. The order was dated to start on 07/27/23. The medication was not administered on 07/27/23, 07/29/23, or 07/31/23. The medication was marked as administered on 07/28/23 and 07/30/23. Residents Affected - Few Review of the Pharmacy Non-Control Packing Slip dated 07/31/23 at 12:48 P.M. revealed Resident #85's Austedo medication was delivered. Review of the progress notes and electronic medication administration record (e-MAR) notes dated from 07/25/23 through 08/01/23 revealed on 07/26/23 at 2:49 P.M., a new order was received from the psychiatric physician to add Austedo medication for Resident #85. On 07/27/23 at 5:49 P.M., 07/29/23 at 10:16 A.M., and 07/31/23 at 10:13 A.M., the Austedo medication was noted to be on order and the facility was awaiting delivery. There was no evidence the physician was notified of the delayed delivery of the medication to the facility. Review of the psychiatrist note dated 07/26/23 revealed Resident #89 complained of having abnormal tongue movements that may be due to tardive dyskinesia. The psychiatrist noted to add Austedo medication for tardive dyskinesia. Interview on 09/28/23 at 1:27 P.M. with the Administrator confirmed Resident #85's Austedo medication was not delivered to the facility until 07/31/23. The Administrator confirmed Resident #85's MAR was inaccurate on 07/28/23 and 07/30/23 because the facility did not have the medication to administer to the resident. The Administrator stated the facility would be changing pharmacies next month due to ongoing issues with deliveries. The Administrator confirmed Resident #85 had a delay in treatment of tardive dyskinesia from 07/27/23 through 07/31/23 (five days). The Administrator also confirmed there was not any evidence that physician had been notified of the delayed delivery/delayed initiation of treatment. Review of the facility policy, Nursing Service: Notification of Changes, revised 11/13/19, revealed the policy stated, the facility shall promptly notify the resident, consult with the resident's physician, and notify, the resident representative when there are changes in the resident's condition or status. Review of the facility policy, Physician Services, dated 03/01/23, revealed the policy stated, a physician or non-physician practitioner must provide orders for the resident's intermediate care needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365436 If continuation sheet Page 9 of 26 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure pressure reducing interventions were in place for Resident #41. This affected one resident (#41) of two residents reviewed for pressure ulcers. The facility census was 116. Residents Affected - Few Findings include: Review of the medical record for Resident #41 revealed an admission date of 02/02/17 with diagnoses including dementia, type two diabetes, dysphagia, psychotic disorder with delusions, moderate protein-calorie malnutrition, and memory deficit following cerebral infarction. Review of the physician order dated 05/10/23 revealed Resident #41 was to be encouraged to lay down after meals due to wounds on the sacrum. Review of the Medication Administration Record (MAR) for September 2023 revealed this was marked as completed on 09/25/23, 09/26/23, and 09/27/23. Review of the plan of care dated 05/12/23 revealed Resident #41 was at risk for development of pressure injuries and other skin impairments related to weakness, impaired mobility, diagnoses, and incontinence. Interventions included encouraging Resident #41 to lay down after meals, monitoring any skin impairments, and documenting the condition of the skin. Review of the physician order dated 07/12/23 revealed Resident #41 was to receive barrier cream for preventative staff was to continue to encourage the resident to lay down after meals. Review of the Review of the Medication Administration Record (MAR) for September 2023 revealed this was marked as completed on 09/25/23, 09/26/23, and 09/27/23. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #41 was rarely or never understood. Resident #41 was at risk for pressure ulcers. Observation on 09/25/23 at 10:35 A.M., 11:32 A.M. 2:50 P.M. and 4:21 P.M., on 09/26/23 at 9:16 A.M. and 2:30 P.M., on 09/27/23 at 10:57 A.M. revealed Resident #41 up in her wheelchair in the common area. Interview on 09/27/23 at 11:01 A.M. with Unit Manager #531 verified Resident #41 was up in her chair while the orders stated she should be in her bed after meals for preventative measures. The resident did not have a current pressure ulcer. Interview on 09/27/23 at 11:05 A.M. with State Tested Nursing Aide (STNA) #650 revealed staff laid the resident down after lunch and usually she stayed in bed for the rest of the day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365436 If continuation sheet Page 10 of 26 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and policy review the facility failed to complete assessments for continuation of an appropriate restorative program. This affected two residents (Resident #43 and Resident #74) of two residents reviewed for Restorative Therapy. The facility census was 116. Findings include: Review of Resident #74 medical record revealed the resident was admitted to the facility on [DATE] with the following diagnosis including Alzheimer's disease, hemiplegia to the right side, psychosis, seizures, and weakness. A further review revealed Resident #74 was cognitively impaired and required assistance from staff for Activities of Daily Living (ADL) tasks. Review of Resident #74 assessments revealed the last Restorative Therapy Assessments was completed on 08/05/19. Review of Resident #74 physician orders revealed an order dated 08/15/22 for a Restorative ambulation therapy program to ambulate up to 135 feet with Resident #74 pushing the wheelchair with assist of a staff member six to seven days per week. Review of Resident #74 quarterly [NAME] Data Set (MDS) dated [DATE] Section O Special Treatments, Procedures, and Programs revealed Resident #74 participated in a restorative ambulation program two days during the seven days look back period. Review of Resident #74 Point Click Care task documentation revealed during the past 30 days from 08/30/23 to 09/27/23 Resident #74 refused to participate in the Restorative ambulation program nine times, Resident #74 was not available two times, for 16 days the documentation reflected not applicable and on 09/14/23 and 09/23/23 Resident #74 participated in the Restorative ambulation program for 15 minutes. Observations on 09/25/23 at 10:30 A.M. and again at 2:45 P.M. revealed Resident #74 was not participating in the Restorative ambulation program. Observations on 09/26/23 at 9:10 A.M. and again at 1:30 P.M. revealed Resident #74 was not participating in the Restorative ambulation program. Interview on 09/27/23 at 8:15 A.M. with [NAME] Data Set (MDS) Registered Nurse (RN) #605 confirmed there were no further Restorative Therapy Assessments completed after the date of 08/05/19. MDS RN #605 stated the assessments should be completed every 90 days or three months to assess the effectiveness of the restorative programs for the residents that have written restorative programs. The floor staff should be doing the programs with the residents, and the facility did not have a specific Restorative aide. 2. Review of Resident #43's medical record revealed an original admission date of 02/01/21. Diagnoses included dementia and hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365436 If continuation sheet Page 11 of 26 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Review of an occupational therapy evaluation and plan of treatment with a certification period between 01/19/23 and 02/17/23 revealed Resident #43 was discharged from therapy on 02/09/23. The treatment administration plan indicated a restorative plan for bilateral upper extremities exercise program was put in place on 06/09/22. The orders indicated the restorative program was discontinued on 04/10/23. A documented reason for discontinuing treatment was not given. Residents Affected - Few Further review of Resident #43's medical record revealed no documentation indicating why the restorative program ended on 04/10/23. Interview on 09/28/23 at 12:58 P.M. with Administrator #563 verified the facility did not have a documented assessment that discontinued the restorative program. Review of the facility policy titled, Restorative Nursing Services dated 07/2017 revealed, Residents will receive restorative nursing care as needed to help promote optimal safety and independence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365436 If continuation sheet Page 12 of 26 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 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 - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and facility policy review, the facility failed to conduct a thorough investigation following a choking episode for one resident (Resident #89). This affected one (Resident #89) of three residents reviewed for accidents. The facility census was 116. Findings Include: Review of the medical record for Resident #89 revealed an original admission date on 06/17/22 and a readmission date on 07/13/23. Diagnoses included Parkinson's Disease, dementia, pneumonia (07/14/23), esophageal obstruction (07/14/23), type II diabetes mellitus without complications, heart disease, and encounter for palliative care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #89 has impaired cognition and scored six out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #89 required extensive assistance to total dependence on one to two staff to complete Activities of Daily Living (ADLs). Resident #89 received hospice services. Resident #89 did not have any known chewing or swallowing concerns and was not on a special diet at the time of the assessment. Review of the progress note dated 05/27/23 at 12:41 P.M. (documented as a late entry note on 06/01/23) revealed Resident #89 was noted choking at lunch time. The Heimlich maneuver was performed and the resident was encouraged to cough. Resident #89 was able to cough out a piece of meat. The resident was encouraged to eat gently and not talk while eating. The responsible party was aware. On 06/01/23 at 8:10 A.M., Resident #89's diet was downgraded to mechanical soft with ground meats due to choking per the hospice Certified Nurse Practitioner (CNP). On 07/08/23 at 12:00 P.M., Resident #89 was assisted to the dining room for lunch. The resident started choking on a piece of finely chopped meat. The Heimlich maneuver was performed. Resident #89 was responsive with a lot of salivation and drooling noted. Resident #89 complained his throat was closing and the resident's daughter called 911. The resident was transported to the hospital where he received treatment for aspiration pneumonia. Review of the hospice note dated 06/02/23 revealed Resident #89's family and facility staff notified the hospice Registered Nurse (RN) that the resident had difficulty swallowing and had a choking incident times two. Resident #89 was provided the Heimlich maneuver during one of the episodes. After collaboration with the family, facility, and attending physician, new orders were received to downgrade Resident #89's diet to mechanical soft with ground meats. The orders were left with the Assistant Director of Nursing (ADON). Review of the hospital documents from the 07/08/23 admission revealed the resident returned from the hospital on a puree diet with honey thickened liquids. Review of the medical record revealed the resident remained on the hospital ordered diet and no additional concerns had been identified regarding swallowing or choking episodes. Review of the care plan, revised 09/23/23, revealed Resident #89 had potential for a nutritional problem related to need for a therapeutic diet. Interventions included to honor hospice plans of care, provide and serve diet as ordered, and provide and serve supplements as ordered. There was no mention of Resident #89's risk of choking or choking incident in the care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365436 If continuation sheet Page 13 of 26 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 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 - Minimal harm or potential for actual harm Residents Affected - Few Interview on 09/27/23 at 5:48 P.M. with the Assistant Director of Nursing (ADON) revealed Resident #89 was sent to the hospital in July 2023. The ADON was unsure why Resident #89 was sent to the hospital. The ADON was not aware of any previous accidents or choking episodes for Resident #89. Interview on 09/27/23 at 6:40 P.M. with Licensed Practical Nurse (LPN) #559 revealed she was aware Resident #89 had a couple of choking episodes at the facility. LPN #559 stated she was not working when the incidents occurred so she did not know what happened. Interview on 09/28/23 at 3:09 P.M. with the Director of Nursing (DON) revealed she was off from work when the choking incident occurred with Resident #89. The DON stated she was notified of the incident on 06/01/23 by the floor nurse that Resident #89 had two choking episodes. The facility was not informed by the family until 06/01/23 and not when the incidents had happened. The DON stated she was not sure if the incident occurred in the resident's room or in the dining room. The DON was not sure if there were any staff present when the episodes occurred or if the resident's family were the only witnesses to the episodes. Interview via email on 09/28/23 at 3:15 P.M. with the Administrator confirmed she was not able to provide evidence of a thorough investigation of Resident #89's choking incidents. Review of the facility policy, Accidents and Supervision, dated 03/16/23, revealed the policy stated, the resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: identifying hazards and risks, evaluating and analyzing hazards and risks, implementing interventions to reduce hazards and risks, and monitoring effectiveness and modifying interventions when necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365436 If continuation sheet Page 14 of 26 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure physician orders were in place for an indwelling urinary catheter. This affected one resident (Resident #361) of one residents reviewed for indwelling urinary catheter. The facility census was 116. Findings include: Review of Resident #361 medical record revealed the resident was admitted to the facility on [DATE] with the admitting diagnoses including rectal cancer, encephalopathy, weakness, hallucinations, urinary tract infection, and high blood pressure. Further review revealed Resident #361 had intact cognition and required assistance from staff for Activities of Daily Living (ADL) tasks. Review of Resident #361 admission and current physician orders revealed no indication for the use of the indwelling urinary catheter and no orders for the care and/or maintenance of the resident's indwelling urinary catheter. Review of Resident #361 care plan dated 09/08/23 revealed Resident #361 had an indwelling urinary catheter and staff were to perform care as required for the use of an indwelling urinary catheter. Review of Resident #361 admission [NAME] Data Set (MDS) dated [DATE] revealed Section H - Bladder and Bowel marked for the presence of an indwelling urinary catheter. Review of Resident #361 Point Click Care tasks revealed there were no tasks implemented to reflect the necessary care of an indwelling urinary catheter. Observation on 09/25/23 at 9:15 A.M. revealed Resident #361 had an indwelling catheter in place with the drainage bag covered for privacy. Interview on 09/25/23 at 2:28 P.M. with Licensed Practical Nurse (LPN) #587 confirmed there were no orders for the resident's indwelling urinary catheter. Review of the facility policy titled Physician Services dated 03/01/23 revealed, A physician shall write the order admitting the resident to the facility. In addition, a physician or non-physician practitioner (NPP), meaning a physician's assistant, nurse practitioner or clinical nurse specialist, must provide orders for the resident's intermediate care needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365436 If continuation sheet Page 15 of 26 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #85 revealed an initial admission date on 03/22/21 and a readmission date on 04/09/21. Medical diagnoses included chronic obstructive pulmonary disease (COPD), Type II Diabetes Mellitus with polyneuropathy, stroke, essential hypertension (high blood pressure), colostomy status, fibromyalgia, other chronic pain, spondylosis without myelopathy or radiculopathy lumbosacral region, major depressive disorder, anxiety disorder, and drug induced subacute dyskinesia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #85 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #85 required extensive assistance to total dependence from one to two staff to complete Activities of Daily Living (ADLs). Resident #85 received daily antianxiety, antidepressant, anticoagulant, antibiotic, and diuretic medications. Resident #85 received opioid medication six out of seven days during the review period. Review of the pharmacy recommendations dated 01/10/23, 02/07/23, and 03/09/23 revealed the physician disagreed with each recommendation but did not provide a detailed explanation why the medications should be continued. The physician listed therapeutic on three of the recommendations and continue all on the fourth recommendation reviewed. Interview on 09/28/23 at 1:27 P.M. with Administrator confirmed the physician did not provide a detailed explanation related to why pharmacy recommendations were declined for Resident #85. Review of the facility policy, Medication Therapy, revised 04/2007, revealed the policy stated, each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks. Medication use shall be consistent with an individual's condition, prognosis, values, wishes, and responses to such treatments. All medication orders will be supported by appropriate care processes and practices. All decisions related to medications shall include appropriate elements of the care process, such as: adequately detailed assessment, review of causes of symptoms, consideration of the clinical relevance of symptoms and abnormal diagnostic test results, and each resident's wishes, values, goals, condition, and prognosis. Upon or shortly after admission, and periodically thereafter, the staff and practitioner (assisted by the consultant pharmacist) will review an individual's current medication regimen, to identify whether: there is a clear indication for treating that individual with the medication, the dosage is appropriate, the frequency of administration and duration of use are appropriate, and potential or suspected side effects are present. Based on record review, observation and interviews the facility failed to ensure pharmacy recommendations were dated and appropriate rationale was provided regarding gradual dose reductions. This affected three residents (Resident #43, #74 and #85) of five residents reviewed for unnecessary medications. The facility census was 116. Findings include: 1. Review of Resident #74 medical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses including Alzheimer's disease, hemiplegia to the right side, psychosis, seizures, and weakness. A further review revealed Resident #74 was cognitively impaired and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365436 If continuation sheet Page 16 of 26 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 required assistance from staff for Activities of Daily Living (ADL) tasks. Level of Harm - Minimal harm or potential for actual harm Review of Resident #74 physician orders revealed the resident received anti-anxiety medication lorazepam 0.5 milligrams (mg) daily for anxiety, anti-psychotic medication perphenazine 2 mg at bedtime for psychosis, and anti-seizure medication levetiracetam 100mg per milliliter (ml) give 5 ml every twelve hours for seizures. Residents Affected - Some Review of Resident #74 quarterly [NAME] Data Set (MDS) dated [DATE] active diagnosis Section I revealed psychosis was marked. Further review revealed medication Section N revealed anti-psychotic medication was received during the seven days look back period. Review of Resident #74 assessments revealed Abnormal Involuntary Movements Scale (AIMS) assessments completed on 11/10/22 and 05/10/23. Review of the past year's pharmacy Medication Regimen Review (MRR) dated 09/01/23, 07/01/23, 06/01/23, 04/03/23, 03/02/23, 02/02/23, 12/02/22, 11/07/22 and 10/05/22 revealed no recommendations for the physician to address. Further review of MRR dated 01/05/23 with recommendations for a Gradual Dose Reduction (GDR) signed and dated by the physician on 02/03/23, MRR dated 05/02/23 with recommendations for GDR signed and dated by the physician on 05/24/23 and MRR dated 08/01/23 with recommendations for GDR signed the physician with no date to reflect when the physician reviewed and signed the recommendations. Interview on 09/26/23 at 3:15 P.M. with the Director of Nursing (DON) confirmed the omission of the date reflecting the physician's review of the MRR dated 08/01/23. The DON shared the physician should be dating those when they are reviewed and the nurse should be verifying the physician has signed and dated the MRR recommendations. 2. Review of the medical record for Resident #43 revealed an admission date of 02/01/21. Diagnoses included dementia, major depressive disorder, cerebral infarction, anxiety disorder, insomnia, and hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. a. Review of the pharmacy recommendations dated 02/02/23 revealed Resident #43 was on Trazadone 50 milligrams (mg) and Lexapro 20mg. The pharmacist requested the physician consider a trial discontinuation of Trazodone and continue Lexapro 20mg. The physician declined, signed, and dated the recommendations on 02/07/23. However, the physician response was documented as Therapeutic. Interview on 09/27/23 at 4:11 P.M. with Administrator #563 verified the 02/02/23 physicians note for the Gradual Dose Reduction says therapeutic. Review of a facility provided policy titled Documentation in the medical record, dated 09/19/23, stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365436 If continuation sheet Page 17 of 26 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Principals of documentation include, but are not limited to: Avoid generalizations and vague phrases or Level of Harm - Minimal harm or potential for actual harm expressions. b. Review of the pharmacy recommendations dated 08/01/23 revealed Resident #43 was on Lexapro 20 Residents Affected - Some milligrams (mg), 1 pill by mouth each day and Trazadone 50 mg, 1 pill by mouth at bedtime. The pharmacist requested the physician consider a dosage reduction for Lexapro from 20 mg to 10 mg. The physician declined and did not provide rationale why the recommendation was declined and did not date the form. Interview on 09/27/23 at 4:11 P.M. with Administrator #563 revealed the 08/01/23 Pharmacy Recommendation is not dated and there is no rationale why the recommendation was declined on the form. Administrator #563 said they do not have documentation of any response or when it was reviewed and signed. She said all reviewed progress notes would be uploaded to the electronic medical record. She explained that if it's not in the system then it's not there. Review of a facility provided policy titled Medication Therapy, dated April 2007, stated The Medical Director and Consultant Pharmacist shall collaborate to address issues of medication prescribing and monitoring with the practitioners and staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365436 If continuation sheet Page 18 of 26 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of medication administration records, and facility policy review, the facility failed to attempt a variety of non-pharmacological interventions and did not include parameters for administering as needed (PRN) pain medications to one resident (Resident #85). The facility also failed to ensure appropriate monitoring for antipsychotic medication side effects was completed. This affected two residents (Resident #5 and #85) of five residents reviewed for unnecessary medications. The facility census was 116. Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #85 revealed an initial admission date on 03/22/21 and a readmission date on 04/09/21. Medical diagnoses included chronic obstructive pulmonary disease (COPD), Type II diabetes mellitus with polyneuropathy, stroke, essential hypertension (high blood pressure), colostomy status, fibromyalgia, other chronic pain, spondylosis without myelopathy or radiculopathy lumbosacral region, major depressive disorder, anxiety disorder, and drug induced subacute dyskinesia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #85 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #85 required extensive assistance to total dependence from one to two staff to complete Activities of Daily Living (ADLs). Resident #85 received daily antianxiety, antidepressant, anticoagulant, antibiotic, and diuretic medications. Resident #85 received opioid medication six out of seven days during the review period. Review of the physician orders dated September 2023 revealed Resident #85 had an order for Acetaminophen Oral Tablet 325 milligrams (mg) with instructions to give two tablets by mouth every eight hours as needed for sore throat. The order was dated 07/17/23. Resident #85 also had an order for Oxycodone Hydrochloride (HCl) 5 mg tablet with instructions to give two tablets by mouth every four hours as needed for pain. The order was dated 12/28/21. Neither order included parameters. Review of the Medication Administration Record (MAR) dated August 2023 revealed PRN Acetaminophen was administered on 08/10/23, 08/26/23, and 08/28/23 for pain levels of six, two, and four respectively. PRN Oxycodone medication was administered daily, with administration twice a day on several occasions. Pain levels ranged from zero to nine. The only non-pharmacological intervention attempted with Resident #85 was repositioning. Review of the MAR dated September 2023 revealed PRN Acetaminophen was not administered at all this month. PRN Oxycodone medication was administered daily except on 09/21/23. Pain levels ranged from zero to nine. The only non-pharmacological intervention attempted with Resident #85 was repositioning. Interview on 09/28/23 at 7:29 A.M. with the Director of Nursing (DON) revealed the staff were expected to attempt as many as possible non-pharmacological interventions with a resident prior to administering pain medications. The DON confirmed the staff should attempt to complete more than just one or the same non-pharmacological intervention with the resident prior to administering pain medications. The DON was not sure where the staff would find what non-pharmacological interventions should be attempted with each resident. The DON stated Resident #85 was aware of what pain medications had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365436 If continuation sheet Page 19 of 26 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few been ordered for her and will ask for an Oxycodone tablet for pain so the staff would give it to her. The DON confirmed the staff should not administer PRN Oxycodone medication for a pain level of zero or two. The DON agreed to follow up with the physician regarding adding parameters to PRN pain medications. An interview via email on 09/28/23 at 10:45 A.M. with the Administrator revealed Resident #85's physician refused to add parameters to pain medications due to not having any concerns. Review of the facility policy, Medication Therapy, revised 04/2007, revealed the policy stated, medication use shall be consistent with an individual's condition, prognosis, values, wishes, and responses to such treatments. All medication orders will be supported by appropriate care processes and practices. 2. Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE] with the admitting diagnoses including dementia, spinal stenosis, dysphagia, weakness, psychosis, and high blood pressure. Further review revealed Resident #5 had impaired cognition and required extensive assistance from staff. Review of Resident #5 physician orders revealed the anti-psychotic medication olanzapine 5 milligrams (mg) daily for dementia and psychosis. Review of Resident #5 quarterly [NAME] Data Set (MDS) dated [DATE] Section I revealed Resident #5 active diagnosis included dementia and psychosis. Further review revealed Section N revealed Resident #5 received anti-psychotic medication during the seven days look back period. Review of Resident #5 care plan dated 08/11/23 revealed Resident #5 received anti-psychotic medication and had aggressive behaviors toward staff. Review of Resident #5's admission assessments dated 04/21/23 revealed no completed Abnormal Involuntary Movement Scale (AIMS) assessment, which is used to assess tardive dyskinesia, a condition affecting the nervous system often caused by the use of psychiatric medications. Interview on 09/27/23 at 1:44 P.M. with MDS Registered Nurse (RN) #605 confirmed the omission of a completed AIMS assessment on admission for Resident #5. MDS-RN #605 stated AIMS assessments should be completed upon admission and at least every six months after admissions. Resident #5 had not been assessed for involuntary movements since admission to the facility. Review of the facility policy titled Medication Therapy dated 04/2007 revealed, All decisions related to medications shall include appropriate elements of the care process, such as: adequately detailed assessment; review of causes of symptoms; consideration of the clinical relevance of symptoms and abnormal diagnostic test results. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365436 If continuation sheet Page 20 of 26 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, observation, and staff interview the facility failed to ensure one resident (#71) with a documented lactose intolerance received food free from dairy products containing lactose. This affected one resident (#71) out of one resident reviewed for food allergies or food intolerances. The facility census was 116. Findings include: Review of the medical record for Resident #71 revealed the resident was admitted on [DATE] with diagnoses that included osteomyelitis of left foot and ankle, type 2 diabetes mellitus, acute kidney failure, acquired absence of right leg below knee, osteoarthritis, hypertension, and congestive heart failure. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #71 was cognitively intact and independent for eating. On 09/26/23 at 9:12 A.M. interview with Resident #71 revealed she had some food allergies and was lactose intolerant. Resident #71 shared her menu had her allergies and lactose intolerance listed but she was often served foods she should not eat. On 09/27/23 at 8:35 A.M. observation and interview with Resident #71, revealed Resident #71 pointed out her menu clearly stated she was lactose intolerant, and she was sent a breakfast sandwich with cheese. On 09/27/23 at 8:40 A.M. interview with Licensed Practical Nurse (LPN) #590 confirmed the resident had a breakfast sandwich with cheese on her breakfast tray and the resident was lactose intolerant. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365436 If continuation sheet Page 21 of 26 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and review of facility policy, the facility failed to ensure the satellite kitchens were maintained in a sanitary manner. This had the potential to affect 113 of 113 residents who consumed food from the kitchen. Findings include: Observation on 09/27/23 from 2:05 P.M. to 2:20 P.M. of the satellite kitchens revealed the following concerns: a. Observation of the second-floor kitchen revealed three food carts that had a buildup of food debris and splatters. Additionally, in the refrigerator there was a stack of cheese wrapped in plastic wrap. The cheese was poorly wrapped, the plastic wrap was wet with an unidentifiable substance, and was not labeled or dated. b. Observation of the third-floor kitchen revealed two food carts with a buildup of food debris and splatter. Additionally, observation of the steam table revealed the wells had a build up of calcium and food debris. The water in the steam table was brown. c. Observation of the fourth-floor kitchen (which was additionally observed during meal service at 11:30 A.M.) revealed two food carts with a buildup of food debris and splatter. Additionally, observation of the steam table revealed the wells had a build up of calcium and food debris. Interview on 09/27/23 from 2:05 P.M. to 2:20 P.M. with Dietary Director #572 verified the observations. Review of the policy titled Sanitation Inspection dated 08/01/23 revealed all food service areas were to be kept clean and sanitary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365436 If continuation sheet Page 22 of 26 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the medical record for Resident #85 revealed an initial admission date on 03/22/21 and a readmission date on 04/09/21. Medical diagnoses included chronic obstructive pulmonary disease (COPD), Type II diabetes mellitus with polyneuropathy, stroke, essential hypertension (high blood pressure), colostomy status, fibromyalgia, other chronic pain, spondylosis without myelopathy or radiculopathy lumbosacral region, major depressive disorder, anxiety disorder, and drug induced subacute dyskinesia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #85 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #85 required extensive assistance to total dependence from one to two staff to complete Activities of Daily Living (ADLs). Review of the Medication Administration Record (MAR) dated July 2023 revealed Resident #85 had an order for Austedo Extended Release (XR) 24 hour 12 milligrams (mg) with instructions to give one tablet by mouth one time daily for tardive dyskinesia. The order was dated to start on 07/27/23. The medication was marked as administered on 07/28/23 and 07/30/23 according to the Medication Administration Record. Review of the Pharmacy Non-Control Packing Slip dated 07/31/23 at 12:48 P.M. revealed Resident #85's Austedo medication was delivered. Review of the progress notes and electronic medication administration record (e-MAR) notes dated from 07/25/23 through 08/01/23 revealed on 07/26/23 at 2:49 P.M., a new order was received from the psychiatric physician to add Austedo medication for Resident #85. On 07/27/23 at 5:49 P.M., 07/29/23 at 10:16 A.M., and 07/31/23 at 10:13 A.M., the Austedo medication was noted to be on order and the facility was awaiting delivery. Interview on 09/28/23 at 1:27 P.M. with the Administrator confirmed Resident #85's Austedo medication was not delivered to the facility until 07/31/23. The Administrator confirmed Resident #85's MAR was inaccurate on 07/28/23 and 07/30/23 because the facility did not have the medication to administer to the resident. Review of the facility policy, Documentation in the Medical Record, dated 09/19/23, revealed the policy stated, each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through accurate and timely documentation. Documentation should be completed at the time of service. Documentation was to be factual, objective and resident centered. Based on interview and record review the facility failed to maintain complete and accurate medical records. This affected five residents (#23, #88, #71, #66, and #85) of 24 resident records reviewed. The facility census was 116. Findings include: 1. Review of the medical record for Resident #66 revealed an admission date of 05/27/22 with diagnoses including chronic obstructive pulmonary disease, cerebral infarction, bipolar disorder, anxiety (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365436 If continuation sheet Page 23 of 26 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 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 0842 disorder, dysphagia, dementia, and fibromyalgia. Level of Harm - Minimal harm or potential for actual harm Review of the quarterly MDS dated [DATE] revealed Resident #66 had severely impaired cognition. She was totally dependent for bathing. Residents Affected - Some Review of the plan of care dated 06/27/22 revealed Resident #66 had an activity of daily living self-care performance deficit related to weakness, abnormal gait, dementia. Resident #66 had noted fluctuations with level of assistance. Interventions included fluctuations with level of assistance, preferring to stay in bed most days, extensive to dependent with staff assistance for dressing, and one staff assistance for bathing. Review of the shower documentation provided on 09/27/23 at 12:25 PM by the Administrator revealed a shower sheet dated 09/30/23 indicating a shower had been completed. This form was signed by a nurse aide and a nurse. Interview on 09/27/23 at 3:23 P.M. with the Administrator verified the shower sheet was dated for the future and filled out as if it had been completed. 2. Review of the medical record for Resident #23 revealed an admission date of 12/13/21 with diagnoses including Parkinson's disease, chronic obstructive pulmonary disease, epilepsy, dysphagia, dementia, depression, schizoaffective disorder, delusional disorder, and aphasia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 had severely impaired cognition. She was totally dependent on two staff for bathing. Review of the plan of care dated 12/22/21 revealed Resident #23 had an activity of daily living self-care performance deficit and fluctuating levels of assistance needs related to weakness, right sided hemiplegia, dementia, and Parkinson's disease. Interventions included one to two staff assistance for bathing and dressing, and oral care offered and encouraged twice a day and as needed. Review of the shower documentation provided on 09/27/23 at 12:25 PM by the Administrator revealed a shower sheet dated 09/28/23 indicating a bed bath had been completed. This form was signed by a nurse aide and a nurse. Interview on 09/27/23 at 3:23 P.M. with the Administrator verified the shower sheet was dated for the future and filled out as if it had been completed. 4. Review of the medical record for Resident #71 revealed an admission date of 06/20/23 with diagnoses including osteomyelitis of left foot and ankle, type 2 diabetes mellitus, acquired absence of right leg below the knee, osteoarthritis, and congestive heart failure. Review of the admission minimum data set (MDS) dated [DATE] revealed that Resident #71 was cognitively intact, required extensive assistance for mobility, and was on regularly scheduled pain medication and as needed pain medication and continued to have occasional pain that prevented sleep. Review of Weekly Wound Documentation for August and September 2023 revealed the anatomical location of Resident #71's wounds were the right heel and the top of the left foot. The narrative description for Resident #71's wounds were diabetic pressure ulcers of the left heel and the top of the left foot. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365436 If continuation sheet Page 24 of 26 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the Weekly Skin Assessment for Resident #71 revealed that on 08/10/23 Resident #71 had a diabetic pressure ulcer on the right heel, on 08/24/23 Resident #71 had a right below the knee amputation and a diabetic pressure ulcer on the right heel, and on 08/31/23 Resident #71 had diabetic pressure ulcers on the top of the left foot and on the right heel. On 09/27/23 at 3:30 P.M. interview with the director of nursing confirmed the weekly skin assessments and weekly wounds assessment documentation contained conflicting and inaccurate statements. 3. Review of Resident #88 medical record revealed Resident #88 was admitted to the facility on [DATE] with the admitting diagnosis including dementia, type II diabetes mellitus, depression, anxiety, dysphagia, and weakness. Further review revealed Resident #88 had impaired cognition and impaired hearing. Review of Resident #88 quarterly [NAME] Data Set (MDS) dated [DATE] revealed in Section G Functional Status revealed Resident #88 required extensive assistance from staff for bed mobility, transfers, toileting, dressing, personal hygiene, and bathing. Review of Resident #88 care plan dated 09/23/22 revealed Resident #88 required assistance from staff to complete Activities of Daily Living (ADL) tasks including personal hygiene and bathing. Review of Resident #88's shower documentation sheets dated 06/10/23 to 09/26/23 revealed documentation reflecting Resident #88 received a bed bath for each shower day and Resident #88 was assisted in removing facial hair two times out of the 26 times Resident #88 was bathed between 06/10/23 and 09/26/23. Further review of Resident #88 shower documentation sheets revealed out of 26 completed shower documentation sheets there were 14 shower documentation sheets that were signed by a licensed nurse but there was no evidence these 14 shower documentation sheets had been signed or initialed by a State Tested Nursing Assistance (STNA). Interview on 09/27/23 at 2:49 P.M. with STNA #508 revealed the STNAs are to sign the shower sheets when the shower is complete. Then the nurse will sign the shower sheets and they go in a binder for the unit manager to gather at the end of the week. Interview on 09/27/23 at 3:00 P.M. with the Unit Manager #552 confirmed the absence of STNA signatures or initials on 14 out 26 completed shower documentation sheets dated 06/10/23 to 09/26/23 for Resident #88. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365436 If continuation sheet Page 25 of 26 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 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 maintain accurate resident influenza and pneumonia immunization records. This affected two residents (Resident #88 and Resident #361) out of five residents reviewed for accurate immunization documentation. The census was 116. Residents Affected - Few 1. Review of Resident #88 medical record revealed Resident #88 was admitted to the facility on [DATE] with the admitting diagnosis including dementia, type two diabetes mellitus, depression, anxiety, dysphagia, and weakness. Further review revealed Resident #88 had impaired cognition and impaired hearing. Review of Resident #88 immunization record revealed there was no current influenza vaccine received date or a signed refusal consent by Resident #88 or Power of Attorney (POA) for Resident #88. 2. Review of Resident #361 medical record revealed Resident #361 was admitted to the facility on [DATE] with the admitting diagnoses including rectal cancer, encephalopathy, weakness, hallucinations, urinary tract infection, and high blood pressure. Further review revealed Resident #361 had intact cognition and required assistance from staff for Activities of Daily Living (ADL) tasks. Review of Resident #361 immunization record revealed Resident #361 had received a Pneumococcal vaccine prior to admission to the facility, there was no date reflecting when Resident #361 received the vaccine. Further review revealed no current received dates for an influenza vaccine and there were no signed refusal consents by Resident #361 or POA for Resident #361. Interview on 09/28/23 at 2:46 P.M. with the Administrator confirmed the lack of accurate dates for Resident #88 and Resident #361's immunization records for influenza and pneumonia vaccines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365436 If continuation sheet Page 26 of 26