Health inspection·July 29, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review and facility policy review, the facility failed to ensure the call light was in reach for Resident #03. This affected one resident (#03) of four residents reviewed for call light accessibility. The facility census was 117.Findings included:Review of the medical record revealed Resident #03 was admitted to facility on 12/14/2024. Pertinent diagnoses included metabolic encephalopathy, adult failure to thrive, heart failure, major depressive disorder.Review of the Minimum Data Set (MDS) 3.0 dated 04/25/25 for Resident #03 revealed she was dependent on staff for toileting, rolling left to right, sit to lying and lying to sitting on side of bed.Review of care plan focus for Resident #03 dated 04/10/25 revealed Resident #03 was at increased risk for falls and intervention suggested was for staff to be sure resident's call light was within reach.Observation and interview on 07/22/25 at 2:22 P.M. of Resident #03 in bed with call light behind the resident, out of sight and out of reach. Resident #03 confirmed she was unable to see or reach the call light.Observation and interview on 07/22/25 at 2:44 P.M. the call light continued to be out of reach for Resident #03. Certified Nursing Assistant (CNA) #226 said the call light should be clipped nearby the resident so that she could reach it. She confirmed it was not within reach of the resident and moved it in place.Observation and interview on 07/23/2025 at 8:28 AM. Resident #03 sitting up in bed eating breakfast. Call light was not within her reach. A family friend was assisting resident. The friend confirmed call light was not in reach and moved it where resident could reach. Review of facility policy titled, Call Lights: Accessibility and Timely Response dated 10/21/24 revealed staff will ensure the call light is within reach of resident and secured, as needed.This deficiency represents non compliance investigated under Complaint Number OH001386198. Residents Affected - Few Page 1 of 52 365436 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review and facility policy review, the facility failed to ensure private medical record information for Resident #03 was not visible to facility visitors. This affected one resident (#03) of four residents reviewed for privacy concerns. The facility census was 117.Findings include:Review of the medical record revealed Resident #03 was admitted to facility on 12/14/2024. Pertinent diagnoses included metabolic encephalopathy, adult failure to thrive, heart failure, major depressive disorder, hyperthyroidism and ileostomy status.Observation on 07/21/25 at 9:35 A.M. on the outside door to room of Resident #03 a sign which said, Synthroid - take whole- no crushing it - 4 hours before breakfast. Place bottom of ostomy bag towards right wall, not over crotch.Observation and interview on 07/22/2025 at 2:45 P.M. the sign remained on outside of door of Resident #03. Certified Nursing Assistant (CNA) #226 confirmed the sign was on the door, confirmed she knew it was HIPAA violation and said the sign had been there since she started in February. CNA #226 said she did not want to be the one who removed it.Interview on 07/22/2025 at 2:50 P.M. with Licensed Practical Nurse (LPN) #385 confirmed the sign on door was a privacy violation. He said the sister had put it up and that he thought a physician had even expressed concern to the sister regarding the sign. He said he didn't know if he had personally ever said anything to the sister but was hopeful that it would be removed now that it was noticed by a surveyor.Observation and interview on 07/23/25 at 8:00 A.M. with LPN #385 who confirmed the sign was no longer on the outside of the door. He said he brought up the privacy concern to the sister of Resident #03 and she had moved the sign to the inside of the resident's room. The sign was on the hand-sanitizing dispenser inside the resident's room.Review of the facility policy titled, Confidentiality of Personal and Medical Records, dated 05/12/25 revealed paper notes or reminders with resident's personal or medical information shall not be unattended or viewable by unauthorized persons. Residents Affected - Few 365436 Page 2 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interviews and facility policy review, the facility failed to ensure an appropriate diagnosis for the use of antipsychotic medications and to identify target behaviors and monitor the target behaviors for the use of antipsychotic medications. This affected five residents (#12, #45, #71, #93 and #106) of five residents reviewed for unnecessary medications. The facility census was 117.Findings Include: 1. Review of the medical record for Resident #45 revealed an initial admission date of 02/23/25 with the diagnoses including but not limited to diabetes mellitus, chronic kidney disease, dependence on wheelchair, dementia, idiopathic peripheral autonomic neuropathy, atrial fibrillation, hypertension, restless leg syndrome, major depressive disorder, constipation, overactive bladder, insomnia and gastro-esophageal reflux disease. Review of the plan of care dated 02/24/25 revealed the resident used an psychotropic medication (Trazadone) related to depression. Interventions included administer medications as ordered by physician, monitor for side effects, discuss with physician, family regarding ongoing need for use of medication review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy, evaluate for psychotropic related risks every shift and as needed, provide non-pharmacological interventions and report any changes in condition to primary care provider. Further review of the plan of care revealed no identified target behaviors to monitor for the use of the medication Trazadone. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident had no indicators of depression and displayed no behaviors. Review of the resident's monthly physician orders for July 2025 identified orders dated 02/23/25 monitor for Depression, for signs & symptoms of feeling of hopelessness, loss of interest in socializing or hobbies, new onset neglecting person care, skipping meals, new onset slowed movement, loss of self-worth, sadness, insomnia, negative statements, tearfulness, feeling despair, unexplained or aggravated aches and pains, target behaviors of: (fill in). If present document and notify Nursing Supervisor every shift and 02/24/25 Trazadone 150 milligrams (mg) by mouth daily at bedtime for depression. Review of the medical record revealed no documented evidence the facility identified targeted behaviors or monitored the resident for behaviors for the use of the antipsychotropic medication Trazadone. On 07/28/2025 at 10:28 A.M., an interview with the Director of Nursing (DON) verified the resident had no identified targeted behaviors or monitoring for the use of the antipsychotropic medication Trazadone. 2. Review of the medical record for Resident #93 revealed an initial admission date of 03/28/25 with the diagnoses including but not limited to cerebrovascular disease, myelodysplastic syndrome, dementia with psychotic disturbance, congestive heart failure, chronic kidney failure, diabetes mellitus, anemia, emphysema, peripheral venous insufficiency, major depressive disorder, secondary and 365436 Page 3 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some unspecified malignant neoplasm of intra-abdominal lymph nodes, hypothyroidism, hyperlipidemia, calculus of gallbladder, macular degeneration and hypertension. Review of the plan of care dated 05/01/25 revealed the resident was at risk for behaviors associated with cognitive decline, takes clean clothes out of drawer and mixes them up with dirty clothes, makes it look as though there are more dirty clothes than it actually is, she packs up items in her room, attempts to leave, exit seeking at times. Interventions included evaluate for medication side effects, give medication as ordered, monitor/document behavior every shift and as needed, provide non-pharmacological interventions, report change in condition to primary care provider and staff to observe when the resident is pulling clean clothes out of drawer and redirect when applicable. Review of the plan of care dated 06/18/25 revealed the resident utilizes psychotropic medications Seroquel due to dementia with psychotic features and depression. Interventions included administer psychotropic medications as ordered by physician, monitor for side effects and effectiveness every shift, discuss with physician, family regarding ongoing need for use of medication, review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy, document evaluation any signs/symptoms identified, evaluate for psychotropic related risks every shift and as needed, monitor/document/report as any adverse reactions of psychotropic medications and monitor/record occurrence of for target behavior symptoms and document per facility protocol. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident had indicators of depression and displayed no behaviors. The assessment indicated non-Alzheimer's dementia and depression was a current diagnosis. The MDS indicated psychotic disorder was not a diagnosis. Review of the resident's April 2025 MAR revealed the resident was receiving Seroquel 50 mg by mouth twice daily for behaviors. The order was discontinued on 04/24/25 and written as Seroquel 50 mg by mouth twice daily related to unspecified dementia with psychotic disturbance. Review of the pharmacy recommendation dated 04/16/25 revealed the pharmacist recommended an acceptable diagnosis for the antipsychotic medication Seroquel 50 mg by mouth twice daily. The physician addressed on 04/22/25 and added the diagnoses dementia with psychotic behavior. Review of the resident's physician orders for July 2025 identified orders dated 06/24/25 monitor for antipsychotic medication potential side effects, 04/24/25 Seroquel 50 milligrams (mg) by mouth twice daily for unspecified dementia with psychotic disturbance. Review of the medical record revealed the no identified target behaviors, behavior monitoring or diagnosis to support the use of the antipsychotic medication Seroquel. On 07/28/2025 at 10:28 A.M., an interview with the Director of Nursing (DON) verified the resident had no identified targeted behaviors, behavior monitoring or diagnosis to support the use of the medication Seroquel. 3. Resident #12 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] after a weeklong hospitalization. On 07/24/25 at 8:46 A.M., a review of the medical record via the electronic charting system Point Click Care (PCC) revealed Resident #12 had a primary ICD admitting diagnosis F28 which was listed as, other psychotic disorder not due to a substance or known physiological condition with a start date of 05/07/24 and entry date of 05/09/25. Additional 365436 Page 4 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some diagnoses included spinal stenosis; unspecified dementia, unspecified severity, with other behavioral disturbance; unspecified mood (affective disorder); adjustment disorder, dementia in other disease classified elsewhere, severe, with agitation; major depressive disorder and generalized anxiety disorder. Review of the Minimum Data Set (MDS) 3.0 dated 04/29/25 revealed on that date, prior to his hospitalization, Resident #12 had primary diagnosis of Spinal Stenosis. Review of the Minimum Data Set (MDS) 3.0 dated 05/14/25 revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 9 (moderately cognitively impaired). Review of the functional status assessment revealed Resident #12 needed set up or clean-up assistance for eating and upper body dressing, partial to moderate assistance with toileting, showering, lower body dressing and walking. Review of the change in condition (CIC) progress note entry made 04/29/25 at 10:36 P.M. for Resident #12 revealed Resident #12 was sent to the hospital for agitation and psychosis. Review of the hospital after visit summary from Resident #12's hospital stay from 04/30/25-05/07/25 revealed a new prescription of Olanzapine (an anti-psychotic). Review of pharmacy review note to attending provider for Resident #12 dated 05/20/25 revealed the resident received Olanzapine 2.5 mg BID (twice daily) for anxiety. The pharmacist asked if the antipsychotic order could be updated to an accepted diagnosis for use. The pharmacist also suggested if the resident did not require Olanzapine, could an attempt to discontinue it be made. On the document, the provider noted they would update to dementia with behaviors. Interview on 07/29/25 at 8:53 A.M. with Consulting Pharmacist #555 confirmed that he looks at the facility list of diagnoses and the physician notes when he is making recommendations regarding an anti-psychotic medication. Consulting pharmacist #555 said he would recommend a different frequency for gradual dose reduction (GDR) for residents who had dementia in addition a diagnosis of Schizophrenia or Bipolar disorder due to the increased risks. He confirmed that Olanzapine was off label (not approved by the Food and Drug Administration) for a resident who had dementia without a co-occurring diagnosis of Schizophrenia or Bipolar Diagnosis. Interview on 07/28/25 at 09:40 A.M. with Certified Nurse Practitioner (CNP) #412 confirmed she understood there was a black box warning regarding the medication for residents with dementia, however, she felt he had a better quality of life. She said if they stopped the medicine, she thought he would be manic again. Interview on 07/28/25 at 2:54 P.M. with facility medical director confirmed that Resident #12 did not have a psychotic disorder as was noted in the medical record when Resident #12 returned from hospital. She noted the Olanzapine was for his behaviors. Interview on 07/23/25 at 10:55 A.M. with Resident #12 in his room who said he felt no one visited him and he felt ignored. Interview on 07/23/25 at 12:26 P.M. with Activity Director #259 who said the resident has little to no involvement in activities aside from attending Mass. She said she did remember when he came to an activity to dance but doesn't do that anymore and attributed it to him being a fall risk. 365436 Page 5 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 07/23/25 at 3:12 P.M. with Licensed Practical Nurse (LPN) #385 who stated resident had not had any behaviors or acting out in about three months. Interview on 07/23/25 at 5:26 P.M. with the CEO who is also a Sister. She said that Resident #12 comes to Mass every day. She said he had behavioral issues with anger outbursts almost daily or weekly but they hadn't happened in three months. She did say he hasn't struck out at other residents in probably six months. She said people visits the resident but he forgets. She agreed that he seemed very sad although did not attribute this to his medication. Interview on 07/24/25 at 09:55 A.M. with the Administrator who said resident had not had behaviors since he had returned from hospitalization in early May. Review of Olanzapine label dated 03/2025 revealed a warning that elderly patients with dementia-related psychosis treated with antipsychotic drugs are at increased risk of death. Olanzapine is not approved for the treatment of patients with dementia-related psychosis. 4. Review of the medical record for Resident #71 revealed an admission date of 02/17/23 with diagnoses including severe dementia with behavioral disturbance, Alzheimer's disease, anxiety and major depressive disorder. Review of care plan dated 06/22/25 for Resident #71 documented use of psychotropic medications. Interventions included administering medications as ordered, evaluating behavioral responses, discussing continued need with the physician and family, offering non-pharmacological interventions and reporting changes in condition. Review of the admission Minimum Data Set (MDS) 3.0 assessment completed on 06/26/25 for Resident #71 showed the resident had severe cognitive impairment, with symptoms of inattention, disorganized thinking and physical/verbal behaviors toward others. Active psychiatric conditions included anxiety and depression. Review of an updated care plan dated 07/01/25 for Resident #71 identified aggressive behaviors such as throwing objects and inappropriate language. Interventions included medication administration, monitoring for side effects and effectiveness, anticipating needs, and documenting behavior patterns and possible triggers. Review of physician orders dated 06/30/25 for Resident #71 revealed olanzapine 5 milligrams (mg) at bedtime for behaviors. Review of behavior monitoring documentation from 07/12/25 to 07/28/25 for Resident #71 revealed one behavioral incident on 07/18/25 involving grabbing and disruptive sounds. No other behavioral concerns were noted during this period. Review of additional orders dated 07/16/25 for Resident #71 showed Depakote 250 mg delayed-release tablets was initiated at bedtime for dementia with agitation. Review of a psychiatric progress note dated 07/21/25 stated Resident #71 was increasingly confused and agitated, with episodes of falling to the floor and combativeness. The psychiatrist recommended continuing the current medication regimen and increasing social support engagement. Interview on 07/28/25 at 2:57 P.M. with the Director of Nursing confirmed Depakote and Zyprexa were 365436 Page 6 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0605 not being used in accordance with their approved indications and were being used off-label. Level of Harm - Minimal harm or potential for actual harm Review of Depakote (anticonvulsant) FDA labeling dated 01/2025 showed approved uses for treatment of bipolar disorder (mania), seizure therapy, and migraine prophylaxis. Residents Affected - Some Review of Zyprexa (atypical antipsychotic) FDA labeling dated 01/2025 showed approved uses for treatment of schizophrenia, bipolar disorder, and treatment-resistant depression in adults. 5. Resident #126 was admitted on [DATE] with diagnoses that included Alzheimer's disease. Her diagnoses were silent for bipolar disease or schizophrenia. Review of Resident #126's physician orders revealed that she was to have Quetiapine Fumarate, an atypical antipsychotic medication, oral tablet 25 milligrams (mg) one tablet daily. Review of Resident #126's Medication Administration Record (MAR) for July 2025 revealed that she was receiving Quetiapine Fumarate as ordered. Review of Resident #126's care plan dated 07/16/25 revealed that she had impaired cognitive function related to dementia. Interventions included administering medications as ordered. Review of Resident #126's care plan dated 07/16/25 revealed that she had a mood problem related to dementia. A goal was to have an improved mood state through the review date. Interventions included administering medications as ordered. Interview with the Director of Nursing on 07/24/25 at 9:40 A.M. confirmed that Resident #126 did not have the appropriate diagnosis to justify the use of Quetiapine Fumarate. Review of a facility policy titled, Use of Psychotropic Medication, dated 02/05/25 revealed that psychotropic medications should only be received by residents when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms. For psychotropic medications, without explanation as to why the practitioner has determined that other treatments have been deemed clinically contraindicated, the indication for its use is inadequate. Adequate indication means that the medication administered is consistent with manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence-based review of articles that are published in medical and/or pharmacy journals. Review of the Centers for Medicare and Medicaid Atypical Antipsychotics Approved Indications and Dosages for Use in Adults indicates that olanzapine is indicated in schizophrenia, quatiapine is indicated for bipolar I disorder, bipolar mania, bipolar depressive episodes, and schizophrenia. 365436 Page 7 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident medical record, family interview, staff interviews, dentist interview, review of facility self-reported incident investigation, review of hospital notes, and review of facility policies, the facility failed to complete a thorough investigation of an injury of unknown origin. This affected one resident (Resident #48) that was reviewed for abuse. The facility census was 117 residents. Findings include: Review of Resident #48's medical record revealed that Resident #48 was admitted to the facility on [DATE] and had diagnoses that included cerebral infarction, anxiety disorder and unspecified dementia with mood disturbance. Review of Resident #48's comprehensive admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that she had modified independence for daily decision making. She was assessed as needing touch assistance for transfers and touch assist for rolling from lying on her back to left and right side. Review of Resident #48's activities of daily living (ADL) care plan dated 06/06/25 revealed that she had a self-care performance deficit. An intervention listed was that for bed mobility, she required substantial and dependent assistance from one to two staff members. She also required substantial to dependent assistance for transfers. Review of Resident #48's fall care plan dated 06/06/25 and revised on 07/04/25 revealed that Resident #48 was at an increased risk for falls related to a history of falls and a diagnosis of arthritis with unsteady gait. An intervention added on 07/16/25 included to have the bed in the lowest position while resident was in bed. Review of a progress note authored by Nurse Practitioner #410 on 06/30/25 indicated that her skin was warm and dry. The progress note indicated that Resident #48 was being treated for a urinary tract infection. Review of a progress note authored by Nurse Practitioner #410 on 07/01/25 revealed that she was asked to assess Resident #48 after a recent injury and questionable fall. Resident #48 was assessed as having a traumatic injury which was unclear due to Resident #48 being a poor historian and it was unwitnessed. A hip and rib X-ray was ordered. The plan included to decrease the dosage of Zoloft due to recent falls. Resident #48's skin was noted to have a bruise to her right temporal. Review of nursing progress note dated 07/01/25 revealed that Resident #48 was having complaints of pain to her right rib area. Review of nursing notes on 07/01/25 revealed that social services was notified of family request for dental service due to missing teeth. Review of progress note authored by Physician #408 on 07/02/25 revealed that Resident #48 was being seen due to an unwitnessed fall. The physician note addressed rib pain and that the X-rays were negative for any fractures. There was an injury of Resident #48's head, which was unwitnessed, but noted to be likely due to a fall. Physician #408 noted bruising to her temple as well as two cracked/ missing teeth and bruising to her right lower ribs. The physician notes noted a fall and stated, unwitnessed fall with likely head strike, given right temple bruise and dental injuries noted above. Continue fall precautions and safety measures. Broken teeth not found. Her skin was noted to be warm, dry, and a visible quarter sized bruise to her right temple, mildly tender. Review of nursing progress notes dated 07/02/25 indicated that the Nurse Practitioner #410 has ordered for Resident #48 to be sent to the hospital for a CT scan. Review of the hospital notes for Resident #48 on 07/03/25 revealed that on the morning of 07/01/25, Resident #48's daughter visited the facility where Resident #48 resides and noticed that Resident #48 had several teeth missing, bruising to the right side of her face, and right sided rib pain. The facility denies knowledge of her falling. ST imaging showed a traumatic right subarachnoid hemorrhage. Her physical exam on 07/03/25 showed right forehead bruising and tenderness to right chest wall. The injury assessment concluded that Resident #48 had acute traumatic pain and acute traumatic right temporal subarachnoid hemorrhage. An interview with the Resident Representative and Power of Attorney for Resident #48 on 07/21/25 at 9:58 A.M. Residents Affected - Few 365436 Page 8 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed that on 07/01/25, family had found Resident #48 to be missing three teeth, a bruise on her face, and complaining of rib pain. The interview revealed that family had been with Resident #48 on the evening of 06/30/25 and Resident #48 did not have those signs and symptoms at that time and date. Review of self-reported incident (SRI) #262287 revealed that Resident #48 was found with a bruise on her temple, rib pain and two teeth missing. There was no conclusion marked on the self-reported incident. The investigation by the facility revealed that Resident #48 was not found on the floor and that the daughter thinks that she fell and broke a tooth. The Director of Nursing noted in her investigation that she felt that the bruising on the right side of her forehead was due to a previous fall that was investigated on 06/22/25. The oral examination was assessed as having a broken tooth in the front and broken teeth to the side that appeared to look as if the tooth had crumbled. Further review of SRI #262287 revealed that the nursing staff that had been working on the evening of 06/30/25 and morning of 07/01/25 were all interviewed, staff was educated on abuse. An interview with the Director of Nursing (DON) on 07/23/25 at 3:37 P.M. revealed that she came to the conclusion that Resident #48 did not fall because there was no swelling or bruising, no bleeding and that no teeth were found. The DON stated that they did not come to a conclusion on how Resident #48 possibly sustained her injuries, but the DON stated that there was no evidence that she fell. The DON also stated that no fall intervention or fall prevention education was given to staff members during the course of the SRI investigation process. Review of Resident #48's medical record on 07/23/25 revealed that she had seen the dentist for an oral examination. Interview with Dentist #414, who examined Resident #48 on 07/23/25, including dental X-rays, on 07/23/25 at 10:45 A.M. revealed that the injury to Resident #48's front teeth was likely caused by acute blunt force trauma, such as which would happen in the course of a fall. Dentist #414 indicated that the bone underneath in Resident #48's jaw was intact and showed no signs of deterioration. Review of the undated facility policy titled Fall Prevention Program revealed that when any resident experiences a fall, the facility will document all assessments and actions. Review of the facility policy titled, Prevention, Identification, Investigation and Reporting of Abuse, Neglect, Mistreatment or Exploitation of a Resident effective 02/28/23 revealed that the facility will take all necessary corrective actions depending on the results of the investigation. The facility will analyze the injury of unknown source occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. The Administrator will review that the investigation is complete. The investigatory results will be delegated to the DON, Director of Social Work or the Director of Human Resources so that he/she can inform the Resident, if appropriate, the Legal Representative, and the staff member involved. The investigation results will be given to the QAA committee to conduct root cause analysis to see what changes, if any, are needed to policies and procedures to prevent further occurrences or to determine corrective actions and follow up. 365436 Page 9 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of facility policy, the facility failed to perform oral assessments on a resident. This affected one resident out (Resident #58) out of twenty nine residents reviewed. The facility census was 117 residents. Findings include: Review of the medical record for Resident # 58 revealed that Resident #58 was admitted to the facility on [DATE] with diagnoses that include chronic pain, Alzheimer's disease and chronic kidney disease stage 3. Review of Resident #58's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 11 out of 15, which suggested moderate cognitive impairment. The resident was assessed to require substantial/maximal assistance with oral hygiene and personal hygiene, bed mobility and transfers. She was assessed as having no dental concerns. Review of Resident #58's nursing quarterly assessments on 03/01/25 and 05/02/25 revealed that the nurse did not assess her oral and dental status. Interview with Resident #58's daughter on 07/21/25 at 2:13 P.M. revealed that she had informed the facility about her mother's dentures fitting improperly and rubbing against her gums. Interview with MDS Licensed Practical Nurse #307 on 07/28/25 at 11:03 A.M. confirmed that the facility had not assessed Resident #58's oral status since at least 03/01/25. Review of the facility policy titled, Dental Services, dated 03/04/25 revealed that the dental needs of each resident are identified through physical assessment. The oral and dental status shall be documented according to physical and MDS assessment findings. 365436 Page 10 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure documented diagnoses were accurate for Resident #12. This affected one resident (#12) out of five residents reviewed. Facility census was 117.Findings include:Review of the medical record for Resident #12 revealed resident was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] after a weeklong hospitalization. On 07/24/25 at 8:46 A.M., a review of the medical record via the electronic charting system Point Click Care (PCC) revealed Resident #12 had a primary ICD admitting diagnosis F28 which was listed as, other psychotic disorder not due to a substance or known physiological condition with a start date of 05/07/24 and entry date of 05/09/25. Additional diagnoses included spinal stenosis; unspecified dementia, unspecified severity, with other behavioral disturbance; unspecified mood (affective disorder); adjustment disorder, dementia in other disease classified elsewhere, severe, with agitation; major depressive disorder and generalized anxiety disorder.Review of the Minimum Data Set (MDS) 3.0 dated 05/14/25 revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 9 (moderately cognitively impaired) out of 15. Review of the functional status assessment revealed Resident #12 needed set up or clean-up assistance for eating and upper body dressing, partial to moderate assistance with toileting, showering, lower body dressing and walking. Further review of the 05/14/25 MDS section I revealed the ICD coded primary diagnosis was F28 which corresponded to the primary diagnosis listed in the Point Click Care (PCC) charting system: Other psychotic disorder not due to a substance or known physiological condition. Additionally, I5950 was checked, indicating Resident #12 had a Psychotic Disorder (other than schizophrenia). Section I8000 listed F28 with Other psych disorder not due to a sub or known physical condition written in.Interview on 07/24/25 from 11:47 A.M. to 12:11 P.M. with MDS Registered Nurse (RN) #358 confirmed she was the one who entered new diagnoses into electronic medical record when Resident #12 returned from hospitalization. She also confirmed she completed the MDS documentation. She said she obtained the diagnoses from the hospital documentation. She was unable to find the source within the hospital documentation of the F28 Other psychotic disorder diagnosis at that time and the interview was ended for her to have time to find the documentation.Interviews on 07/24/25 between 4:00 P.M. and 5:00 P.M. with facility Administrator, who provided a single page printout from Resident #12's hospitalization with the phrase Other psychiatric disorder highlighted. He said that this is where the primary diagnosis came from. When surveyor pointed out that other psychiatric disorder was not identical to other psychotic disorder he agreed they were not the same. He left and returned and relayed that he had confirmed with the MDS nurse that she had entered in both the start date and the diagnosis incorrectly.Record review on 07/24/25 at 5:14 P.M. of diagnoses listing in Point Click Care (PCC) for Resident #12 revealed a primary diagnosis of unspecified dementia, unspecified severity, with other behavioral disturbance. The diagnosis of Other Psychotic Disorder was struck out and noted to be incorrect documentation.Record review of psychotropic consent form dated 05/08/25 and 06/19/25 revealed that F28 was written in with Psychotic Disorder as one of the diagnoses to justify the resident's anti-psychotic disorder. It was noted on the form that verbal consent was obtained from the emergency contact for Resident #12.Interview on 07/28/25 at 11:36 A.M. with the Director of Nursing (DON) confirmed that the F28 other psychotic disorder had been entered into PCC and MDS incorrectly and that an MDS correction had been filed. She confirmed that the nurse who initially completed the psychotropic consent document signed on 05/08/25 and 06/19/25 document no longer working at the facility, however, they would normally speak to the diagnoses, so it is likely that this erroneous diagnosis was shared with Resident #12's emergency contact on those prior dates. The DON said they recently Residents Affected - Few 365436 Page 11 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0641 Level of Harm - Minimal harm or potential for actual harm had obtained another consent for changes in medications, and she noted F28 was no longer listed on the consent form but she could not say whether the emergency contact had been notified that F28 was a false diagnosis. She said she would make sure he was informed. Residents Affected - Few 365436 Page 12 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 staff interview, record review and facility policy review, the facility failed to ensure accurate coordination with the Pre-admission Screening and Resident Review (PASARR) process by submitting an incorrect list of mental health diagnoses. This affected four (Resident #6, #12, #79 and #90) out of five residents reviewed for PASARR. The facility census was 117. Findings include:1. Review of the Pre-admission Screening and Resident Review (PASRR) identification screen dated 05/13/25 for Resident #9 completed by facility staff noted no mental health diagnoses. Review of the medical record for Resident #9 revealed an admission date of 05/17/25 with diagnoses including schizophrenia, mood disorder due to known physiological condition with depressive features, delusional disorder, and generalized anxiety disorder. Review of the care plan dated 05/19/25 revealed Resident #9 had a mood problem related to diagnoses of insomnia, dementia, and depression. Interventions included administering medications as ordered, monitoring and documenting for side effects, and monitoring mood to determine needs. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 was cognitively intact, exhibited no mood or behavior problems, and had active psychiatric/mood diagnoses of anxiety, depression, psychotic disorder, and schizophrenia. Review of a PASRR identification screen dated 07/23/25 completed by Social Services Director (SSD) #255 revealed mental health diagnoses of schizophrenia, mood disorder, delusional disorder, panic or other severe anxiety disorder, insomnia, and depression. Interview on 07/24/25 at 11:50 A.M. with Social Services Director (SSD) #255 stated that the PASRR completed on 05/13/25 did not reflect several mental health diagnoses that were documented at the time of admission on [DATE]. These diagnoses included schizophrenia, mood disorder due to known physiological condition with depressive features, delusional disorder, and generalized anxiety disorder. SSD #255 confirmed these diagnoses should have been submitted promptly to the Department of Aging through an updated PASRR in accordance with facility policy. SSD acknowledged that the PASRR was not updated until 07/23/25, following a request from the surveyor. 2. Review of the medical record for Resident #79 revealed an admission date of 08/04/23 with diagnoses of depression (08/03/23) and major depressive disorder (11/04/24). Review of the Pre-admission Screening and Resident Review (PASRR) identification screen dated 11/01/24 revealed no documented mental health diagnoses. Review of the care plan dated 11/05/24 revealed Resident #79 had a diagnosis of depression. Interventions included administering medications, discussing any concerns with the resident, and monitoring for additional signs and symptoms of depression. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] showed Resident #79 was moderately cognitively impaired and had an active psychiatric/mood diagnosis of depression. Review of a PASRR identification screen dated 02/04/25 completed by Social services Director (SSD) 365436 Page 13 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0644 #255 listed a diagnosis of mood disorder. Level of Harm - Minimal harm or potential for actual harm Interview on 07/24/25 at 11:50 A.M. with SSD #255 stated that Resident #79 was diagnosed with major depressive disorder on 11/04/24. SSD confirmed that this diagnosis was not reflected in the PASRR completed on 11/01/24 and acknowledged that, per facility policy, an updated PASRR should have been submitted to the Department of Aging to reflect this change. SSD confirmed that the PASRR was not revised until 02/04/25 to reflect the updated diagnosis. Residents Affected - Some 3. Review of the medical record for Resident #6 revealed an admission date of 05/05/23 with diagnoses dated 05/05/23 of bipolar disorder, anxiety and insomnia, and schizoaffective disorder – bipolar type dated 09/12/23 and unspecified mood (affective) disorder dated 07/26/24. Review of the Pre-admission Screening and Resident Review (PASRR) identification screen dated 05/25/23 listed mental health diagnoses of panic or other severe anxiety disorder and personality disorder. Review of the care plan dated 10/07/23 revealed Resident #6 had a potential for mood problems related to bipolar disorder, mood disorder, anxiety, depression, insomnia, hallucinations, and schizoaffective disorder. Interventions included administering medications as ordered, initiating referrals as needed, consulting behavioral health services as necessary, and monitoring for issues related to the resident's diagnoses. Review of the Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was moderately cognitively impaired and had active psychiatric/mood diagnoses of anxiety and bipolar disorder. Review of a PASRR identification screen dated 07/23/25 completed by SSD #255 listed diagnoses including mood disorder, other psychotic disorder, insomnia, depression, anxiety, bipolar disorder, schizoaffective disorder, hallucinations, and mood affective disorder. Interview on 07/24/25 at 11:50 A.M. with SSD #255 acknowledged that the PASRR completed on 05/25/23 for Resident #6 did not reflect multiple mental health diagnoses that were added after that date. These included schizoaffective disorder, bipolar type (added 09/12/23); unspecified mood (affective) disorder (added 07/26/24); as well as bipolar disorder, anxiety, and insomnia (all added on 05/05/23). SSD #255 confirmed that an updated PASRR including these diagnoses was not submitted to the Department of Aging until 07/23/25, after it was requested by the surveyor. Review of Resident assessment- coordination with PASARR program dated 09/18/24 revealed the facility coordinates assessments with the preadmission screening and resident review (PASARR) program to ensure individuals with a mental disorder, intellectual disability or related condition receives care and services, a resident who experiences a significant change in status will be referred promptly to the state mental health board for resident review, those changes include a resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder. 4. Resident #12 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] after a weeklong hospitalization. On 07/24/25 at 8:46 A.M., a review of the medical record via the electronic charting system Point Click Care (PCC) revealed Resident #12 had a primary ICD admitting diagnosis F28 which was listed as, other psychotic disorder not due to a substance or known physiological condition with a start date of 05/07/24 and entry date of 05/09/25. Additional 365436 Page 14 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some diagnoses included spinal stenosis; unspecified dementia, unspecified severity, with other behavioral disturbance; unspecified mood (affective disorder); adjustment disorder, dementia in other disease classified elsewhere, severe, with agitation; major depressive disorder and generalized anxiety disorder. Review of the Minimum Data Set (MDS) 3.0 dated 05/14/25 revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 9 (moderately cognitively impaired). Review of the functional status assessment revealed Resident #12 needed set up or clean-up assistance for eating and upper body dressing, partial to moderate assistance with toileting, showering, lower body dressing and walking. Review of the change in condition (CIC) progress note entry made 04/29/25 at 10:36 P.M. for Resident #12 revealed Resident #12 was sent to the hospital for agitation and psychosis. Review of psychiatric note dated 05/12/25 for Resident #12 indicated while the resident was hospitalized , he was brought to the ED (emergency department) for combativeness and enroute received ketamine 150 IM (intramuscular) and at the ED he was kept on a wrist restraint and received 10 milligrams (mg) Geodon (antipsychotic). Review of facility medical record documentation for Resident #12 revealed the most recent PASRR (Preadmission Screening and Resident Review) on file was one that had been completed 09/09/20. The document listed that resident #12 had a mood disorder and no other mental health diagnoses. Interview on 07/24/25 at 09:02 A.M. with SSD #255 confirmed she had not completed an updated PASRR to include his documented diagnosis of psychotic disorder, his hospitalization for psychosis or his ongoing psychiatric case management. She confirmed she also did not notify the Department of Aging of the additional indications of serious mental illness. Review of facility policy titled, Resident Assessment-Coordination with PASARR Program dated 09/18/24 revealed that residents should receive a PASRR level I screening prior to admission. If the resident has a negative Level I screen, admission may processed unless a possible serious mental disorder or intellectual disability arises later. If there is a positive Level I screen, this necessitates a comprehensive evaluation by the appropriate state-designated authority and this screening cannot be completed by the facility. If a resident was not screened prior to admission due to an exception (readmitted from a hospital) and remains in facility longer than 30 days, the facility must screen the individual using the State's Level I screening process and refer any resident who has or may have a serious mental disorder to the appropriate state-designated authority for Level II PASARR evaluation and determination. This screening should be completed within 40 calendar days of admission. 365436 Page 15 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

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 interview and record review, the facility failed to ensure accurate Preadmission screening and resident review (PASRR) Level I screenings for residents with qualifying mental health diagnoses. This affected one (Resident #90) out of five residents reviewed for PASRR screenings accuracy. The facility census was 117. Findings include:Review of Preadmission screening and resident review (PASRR) identification screen dated 05/12/25 for Resident #90 revealed diagnosis of dementia however no active mental health disorders listed. Review of the medical record for Resident #90 revealed an admission date of 05/14/25 with diagnoses of dementia, bipolar disorder, and history of mental and behavioral disorders. Review of care plan dated 05/16/25 revealed Resident #90 has a mood problem interventions include administer medications as ordered, educate family and resident of treatment and monitor/record mood concerns or changes. Review of admission Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] revealed Resident #90 has active psychiatric/mood disorder of bipolar. Interview on 07/24/25 at 11:50 A.M. with Social Services Director #255 confirmed that the PASRR completed at admission on [DATE] did not accurately reflect Resident #90's active mental health diagnoses. The diagnoses of bipolar disorder and a history of mental and behavioral disorders were omitted. SSD #255 stated that an updated PASRR was completed on 07/23/25 to include the correct diagnoses.Review of resident assessment - coordination with PASARR program policy dated 09/18/24 revealed all residents will be screened for serious mental disorders or intellectual disabilities and related conditions and an initial pre-screening is completed prior to admission. Residents Affected - Few 365436 Page 16 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 record review, facility policy review, and staff interview, the facility failed to ensure the state mental health authority was notified of updated and accurate mental health diagnoses. This affected four (Resident #6, #12, #79 and #90) out of five residents reviewed for Pre-admission Screening and Resident Review (PASRR). The facility census was 117. Findings include: 1.Review of the medical record for Resident #9 revealed an admission date of 05/17/25 with diagnoses including schizophrenia, mood disorder due to known physiological condition with depressive features, delusional disorder, and generalized anxiety disorder. Review of the Pre-admission Screening and Resident Review (PASRR) identification screen dated 05/13/25 for Resident #9 completed by facility staff noted no mental health diagnoses. Review of the care plan dated 05/19/25 documented Resident #9 had a mood problem related to diagnoses of insomnia, dementia, and depression. Interventions included administering medications as ordered, monitoring and documenting for side effects, and recording mood to determine needs. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] showed Resident #9 was cognitively intact and had active psychiatric/mood diagnoses of anxiety, depression, psychotic disorder, and schizophrenia. Review of the Pre-admission Screening and Resident Review (PASRR) dated 05/13/25, completed prior to admission, showed no identified mental health diagnoses. A subsequent PASRR dated 07/23/25 completed by Social Services Director (SSD) #255 included the resident's mental health diagnoses: schizophrenia, mood disorder, delusional disorder, panic or other severe anxiety disorder, insomnia, and depression. Interview on 07/24/25 at 11:50 A.M. with SSD #255 confirmed that the diagnoses documented on 05/17/25—including schizophrenia, mood disorder due to known physiological condition with depressive features, delusional disorder, and generalized anxiety disorder—were not reflected in the PASRR completed prior to admission. SSD stated the PASRR should have been updated and submitted to the Department of Aging promptly, and acknowledged this was not done until 07/23/25, after the surveyor requested the most recent PASRR record. 2. Review of the medical record for Resident #79 revealed an admission date of 08/04/23 with diagnoses of depression (08/03/23) and major depressive disorder (11/04/24). Review of the care plan dated 11/05/24 documented Resident #79 had a diagnosis of depression. Interventions included administering medications, discussing any concerns with the resident, and monitoring for signs and symptoms of depression. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] showed Resident #79 was moderately cognitively impaired and had an active psychiatric/mood diagnosis of depression. Review of the Pre-admission Screening and Resident Review (PASRR) dated 11/01/24 showed no documented mental health diagnoses. A subsequent PASRR dated 02/04/25 completed by SSD #255 reflected a 365436 Page 17 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0646 diagnosis of mood disorder. Level of Harm - Minimal harm or potential for actual harm Interview on 07/24/25 at 11:50 A.M. with SSD #255 confirmed that the resident's diagnosis of major depressive disorder was added on 11/04/24 and should have been included in a revised PASRR. SSD acknowledged that an updated PASRR was not submitted to the Department of Aging until 07/23/25, after it was requested by the surveyor. Residents Affected - Some 3. Review of the medical record for Resident #6 revealed an admission date of 05/05/23 with diagnoses dated 05/05/23 of bipolar disorder, anxiety and insomnia, and schizoaffective disorder – bipolar type dated 09/12/23 and unspecified mood (affective) disorder dated 07/26/24. Review of the care plan dated 10/07/23 documented Resident #6 had the potential for mood problems related to bipolar disorder, mood disorder, anxiety, depression, insomnia, hallucinations, and schizoaffective disorder. Interventions included administering medications as ordered, initiating referrals and behavioral health consults as needed, and monitoring for changes related to these diagnoses. Review of the Minimum Data Set (MDS) 3.0 annual assessment dated [DATE] showed Resident #6 was moderately cognitively impaired and had active psychiatric/mood diagnoses of anxiety and bipolar disorder. Review of the Pre-admission Screening and Resident Review (PASRR) dated 05/25/23 identified mental health diagnoses of panic or other severe anxiety disorder and personality disorder. A revised PASRR dated 07/23/25 completed by SSD #255 reflected updated mental health diagnoses of mood disorder, other psychotic disorder, insomnia, depression, anxiety, bipolar disorder, schizoaffective disorder, hallucinations, and mood affective disorder. Review of Quarterly Minimum Data Set (3.0) completed 06/05/25 revealed Resident #6 is cognitively intact and has active psychiatric/mood disorders of anxiety, bipolar and schizophrenia. Interview on 07/24/25 at 11:50 A.M. with SSD #255 confirmed that the PASRR completed on 05/25/23 did not reflect multiple mental health diagnoses that had been added to the resident's record after that date, including schizoaffective disorder, bipolar type (09/12/23), unspecified mood (affective) disorder (07/26/24), bipolar disorder, anxiety, and insomnia (all 05/05/23). SSD stated that a revised PASRR should have been submitted to the Department of Aging and acknowledged it was not done until 07/23/25, after the surveyor requested the most recent PASRR record. 4. Resident #12 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] after a weeklong hospitalization. On 07/24/25 at 8:46 A.M., a review of the medical record via the electronic charting system Point Click Care (PCC) revealed Resident #12 had a primary ICD admitting diagnosis F28 which was listed as, other psychotic disorder not due to a substance or known physiological condition with a start date of 05/07/24 and entry date of 05/09/25. Additional diagnoses included spinal stenosis; unspecified dementia, unspecified severity, with other behavioral disturbance; unspecified mood (affective disorder); adjustment disorder, dementia in other disease classified elsewhere, severe, with agitation; major depressive disorder and generalized anxiety disorder. Review of the Minimum Data Set (MDS) 3.0 dated 05/14/25 revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 9 (moderately cognitively impaired). Review of the functional status assessment revealed Resident #12 needed set up or clean-up assistance for eating and upper body 365436 Page 18 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0646 dressing, partial to moderate assistance with toileting, showering, lower body dressing and walking. Level of Harm - Minimal harm or potential for actual harm Review of the change in condition (CIC) progress note entry made 04/29/25 at 10:36 P.M. for Resident #12 revealed Resident #12 was sent to the hospital for agitation and psychosis. Residents Affected - Some Review of psychiatric note dated 05/12/25 for Resident #12 indicated while the resident was hospitalized , he was brought to the ED (emergency department) for combativeness and enroute received ketamine 150 IM (intramuscular) and at the ED he was kept on a wrist restraint and received 10 milligrams (mg) Geodon (antipsychotic). Review of facility medical record documentation for Resident #12 revealed the most recent PASARR (Preadmission screening and resident review) on file was one that had been completed 09/09/20. The document listed that resident #12 had a mood disorder and no other mental health diagnoses. Review of facility Minimum Data Set (MDS) documentation dated 06/04/25 revealed Resident #12 was discharged from skilled services on this date. Interview on 07/24/25 at 09:02 A.M. with SSD #255 confirmed she had not completed an updated PASRR to include his documented diagnosis of psychotic disorder, his hospitalization for psychosis or his ongoing psychiatric case management. She confirmed she also did not notify the Department of Aging of the additional indications of serious mental illness. SSD #255 indicated she thought she had more time to file a PASRR after a change of condition. Review of facility policy titled, Resident Assessment-Coordination with PASARR Program dated 09/18/24 revealed that any level II resident who experiences a significant change in status will be referred promptly to the state mental health or intellectual disability authority for additional resident review. 365436 Page 19 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility failed to ensure care plans reflected resident care needs. This affected three residents (#12, #45, and #114) out of four reviewed for care plans. The facility census was 117.1.Review of the medical record for Resident #12 revealed resident was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] after a weeklong hospitalization. On 07/24/25 at 8:46 A.M., a review of the medical record via the electronic charting system Point Click Care (PCC) revealed Resident #12 had a primary ICD admitting diagnosis F28 which was listed as, other psychotic disorder not due to a substance or known physiological condition with a start date of 05/07/24 and entry date of 05/09/25. Additional diagnoses included spinal stenosis; unspecified dementia, unspecified severity, with other behavioral disturbance; unspecified mood (affective disorder); adjustment disorder, dementia in other disease classified elsewhere, severe, with agitation; major depressive disorder and generalized anxiety disorder. Review of the Minimum Data Set (MDS) 3.0 dated 04/29/25 revealed on that date, prior to his hospitalization, Resident #12 had primary diagnosis of Spinal Stenosis. Review of the diagnosis list on 07/28/25 revealed Resident #12 had primary diagnosis of unspecified dementia, unspecified severity, with other behavioral disturbance. Review of the Minimum Data Set (MDS) 3.0 dated 05/14/25 revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 9 (moderately cognitively impaired). Review of the functional status assessment revealed Resident #12 needed set up or clean-up assistance for eating and upper body dressing, partial to moderate assistance with toileting, showering, lower body dressing and walking. Review of the progress note on 04/25/25 at 3:12 A.M. revealed Resident #12 walked out of his room towards the elevator. Per note, resident was agitated and refused to listen and exited the building. The staff member had to call supervisor and security for assistance to retrieve resident. Review of the progress note dated 04/27/25 at 01:21 A.M. revealed Resident #12 went outside followed by a nurse. The note entails that Resident #12 proceeded to run outside stating he would not fall. Review of the Elopement Assessment for Resident #12 dated 04/27/25 revealed Resident #12 was at high risk for elopement and/or wandering. Review of the Care Plan for Resident #12 on 07/12/25 revealed no focus on ensuring Resident #12 does not wander or elope. Review of psychiatric note dated 05/12/25 revealed Resident #12 has been using his walker but still struggles with agitation, following directions and being safe. Interview on 7/28/25 at 9:40 A.M. with Certified Nurse Practitioner (CNP) #412 who stated that if Resident 12's medication recently changed and she noted that Resident #12 was skipping and happy again and she worried he might be found in the road again. She confirmed he goes to Mass on his own. Interview on 07/28/25 at 9:37 A.M. with Licensed Practical Nurse (LPN) #385 confirmed Resident #12 goes to Mass on his own without being accompanied. He said Resident #12 goes downstairs to work on 365436 Page 20 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0656 jigsaw puzzle and confirmed that if Resident #12 left the building after that, he would not know. Level of Harm - Minimal harm or potential for actual harm Interview with Director of Nursing (DON) on 07/28/25 at 11:36 A.M. confirmed the 04/27/25 wandering assessment was the most recent assessment for the resident. She said the resident never tried to elope. She confirmed the care plan did not have plan for elopement. She noted due to Resident #12 being a fall risk, he should be accompanied by staff when he left the floor. She said that he should tell someone if he wants to go downstairs. She admitted that may not be the most practical intervention for a resident with primary diagnosis of dementia. Residents Affected - Few Review of facility policy titled, Elopement and Wandering Residents revealed The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. 2. Review of the medical record for Resident #45 revealed an initial admission date of 02/23/25 with the diagnoses including but not limited to diabetes mellitus, chronic kidney disease, dependence on wheelchair, dementia, idiopathic peripheral autonomic neuropathy, atrial fibrillation, hypertension, restless leg syndrome, major depressive disorder, constipation, overactive bladder, insomnia and gastro-esophageal reflux disease. Review of the plan of care dated 02/24/25 revealed the resident uses psychotropic medications (Trazadone) related to depression. Interventions included administer medications as ordered by physician, monitor for side effects, discuss with physician, family regarding ongoing need for use of medication review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy, elevate for psychotropic related risks every shift and as needed, provide non-pharmacological interventions and report any changes in condition to primary care provider. Further review of the plan of care revealed no targeted behaviors to be monitored. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident had no indicators of depression and displayed no behaviors. The assessment indicated depression was a current diagnosis. Review of the resident's monthly physician orders for July 2025 identified orders dated 02/24/25 Trazadone 150 milligrams (mg) by mouth daily at bedtime for depression. On 07/23/25 at 3:00 P.M., an interview with MDS Coordinator #307 verified the resident's plan of care had no identified targeted behaviors. 3. Review of the medical record for Resident #114 revealed an initial admission date of 10/18/24 with the diagnoses including but not limited to diabetes mellitus, dementia, hypertension, hyperlipidemia, anxiety disorder, glaucoma and long term use of insulin. Review of the resident's admission assessment dated [DATE] revealed the resident was continent of both bowel and bladder. Review of the resident's plan of care revealed no care plan addressing the resident's bowel and bladder incontinence. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the 365436 Page 21 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0656 Level of Harm - Minimal harm or potential for actual harm resident had a severe cognitive deficit. The assessment indicated the resident was frequently incontinent of both bowel and bladder. On 07/23/25 at 3:00 P.M., an interview with MDS Coordinator #307 verified the resident has no plan of care addressing the resident's bowel and bladder incontinence. Residents Affected - Few 365436 Page 22 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, record review and facility policy review, the facility failed to ensure shaving needs were completed for two residents (#79 and #120) who required assistance with needs for personal care. Four residents were reviewed for activities of daily living. The facility census was 117.Findings include: Residents Affected - Few 1.Review of the medical record for Resident #120, revealed an admission date of 05/18/18. Diagnoses included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, vascular dementia, weakness and need for assistance personal care. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of rarely/never understood. The resident was assessed to require partial/moderate assistance with bed mobility and transfers with substantial/maximal assistance with shower/bathe self and toilet hygiene. Review of the active plan of care revealed Resident #120 had no interventions for shaving her facial hair as well as no refusals of care for receiving assistance with activities of daily living. Further review of the medical record for Resident #120 from 06/25/25 through 07/22/25 revealed only two refusals for assistance with activities of daily living including shaving her facial hair on shower days dated 07/02/25 and 07/16/25. No other refusals were noted. Observation on 07/21/25 at 2:01 P.M. of Resident #120 revealed her in a wheelchair at the nurse's station with facial hair noted. Observation on 07/22/25 at 8:39 A.M. of Resident #120 revealed her in the wheelchair at the nurse's station with facial hair noted. Concurrent interview with Certified Nurse Aide #250 verified Resident #120 had facial hair and stated, usually on shower days we shave the resident's facial hair if needed. 2. Review of the medical record for Resident #79 revealed an admission date of 08/04/23 with diagnoses of metabolic encephalopathy, hemiplegia and hemiparesis, cognitive communication deficit, need for assistance with personal care, weakness, depression and osteoarthritis. Review of care plan dated 11/05/24 revealed Resident #79 has an activities of daily living self care performance deficit with interventions to provide partial assistance with bathing and personal hygiene. Review of quarterly Minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #79 has a memory problem, requires modified independence with daily decision making, exhibits no behavior of refusal of care and requires partial/moderate assistance with personal hygiene (including shaving). Review of shaving task from 06/30/25 through 07/28/25 revealed shaving services were received on 06/30/25, 07/10/25 and 07/21/25. Additionally documentation of refusal of this task was noted on 07/14/25. 365436 Page 23 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0676 Observation on 07/21/2025 at 10:03 A.M. revealed Resident #79 was laying in bed facial hair was present on both lower chin and upper lip approximately .5 inch in length. Level of Harm - Minimal harm or potential for actual harm Observation on 07/21/2025 at 1:29 P.M. revealed facial hair remained. Residents Affected - Few Observation on 07/22/2025 at 7:42 A.M. revealed facial hair remained. Observation on 07/23/25 at 10:20 A.M. revealed facial hair remained. Interview on 07/24/25 at 10:20 A.M. with State Tested Nursing Assistant #313 (STNA) confirmed presence of long facial hair which should be removed as resident requested, STNA confirmed the assigned nursing assistant would be notified of the residents request. STNA #313 confirmed shaving needs should be offered with bathing services as well as if additional need arise. Interview on 07/24/25 at 4:25 P.M. with the administrator confirmed facial hair should be removed upon resident request. Review of the facility titled Activities of Daily Living (ADLs) no date revealed care and services will be provided for the following activities of daily living including but not limited to bathing, dressing, grooming and oral care. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 365436 Page 24 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

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 medical record review, interview and facility policy review, the facility failed to develop an individualized activity program to meet one resident (#45) needs. This affected one (Resident #45) of two residents reviewed for activities. The facility census was 117.Findings Include:Review of the medical record for Resident #45 revealed an initial admission date of 02/23/25 with the diagnoses including but not limited to diabetes mellitus, chronic kidney disease, dependence on wheelchair, dementia, idiopathic peripheral autonomic neuropathy, atrial fibrillation, hypertension, restless leg syndrome, major depressive disorder, constipation, overactive bladder, insomnia and gastro-esophageal reflux disease. Review of the plan of care dated 02/25/25 revealed the resident was a new long term care resident who pursues independent leisure activities, may benefit from groups for social and recreational needs, assimilation to new surroundings, glasses worn for reading and may require wheelchair assistance when attending group activities. Interventions included encourage active participation. Involve in daily facility routine to assimilate to new surroundings, encourage and promote family and friends support via social visits, provide and review activity calendar, provide leisure supplies as needed to facilitate interests; books, current events, cd player and cd's and spiritual material and provide wheelchair when attending group activities. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated it was very important to the resident to be able to do her favorite activities and for her family and friends to be involved in decisions. On 07/21/2025 at 11:22 A.M., an interview with the resident revealed her only concern with the facility was not being able to visit with her husband who resides in the assisted living (AL) across campus. The resident revealed the only time she was able to visit with her husband was when her family brought him to the facility. The resident expressed she had asked the facility to assist with visits with her husband with no arrangements being made. On 07/24/2025 at 8:50 A.M., interview with Activity Director (AD) #259 revealed the AD stated the facility did not have the staff to do individual resident activities and the resident's husband lives at the AL facility across the campus. She said it would be hard to coordinate getting the resident there because they only have the AD and two activity assistants for the entire building and transport staff are out doing transports. On 07/24/2025 at 4:26 P.M., an interview with the Administrator revealed the AD did not give the right answer and if the resident would like to visit her husband, then the arrangements should have been made when requested. Review of the facility policy titled, Activities, dated 02/04/25 revealed it was the policy of the facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility sponsored group, individual and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental and psychosocial well-being. Activities will encourage both independence and interaction within the community. Residents Affected - Few 365436 Page 25 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

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, interview, record review, and facility policy review, the facility failed to ensure proper skin monitoring for Residents #79, #95, and #58; failed to remove medication patches as ordered for Resident #50; failed to ensure Geri sleeves and related care plans were implemented for Resident #58; and failed to monitor and implement dental care recommendations following the extraction of seven teeth for Resident #49. These failures affected five (Residents #79, #95, #58, #50, and #49) out of 26 residents reviewed for quality of care. The facility census was 117.Findings include: Residents Affected - Some 1. Review of the medical record for Resident #50 revealed an admission date of 02/28/25 with diagnoses of morbid obesity, type two diabetes mellitus, mixed hyperlipidemia, shortness of breath and hypertension. Review of physician order dated 03/01/25 revealed clonidine transdermal patch weekly 0.3 milligrams per 24 hours. Apply one patch every seven days for hypertension and remove prior to application of new patch. Review of medication administration record revealed on 07/12/25 clonidine patch was removed and placed, and on 07/19/25 clonidine patch was removed and placed. Review of physician order dated 07/12/25 revealed lidocaine external patch 5 percent to be applied to back topically one time a day for back pain for seven days and removed every 12 hours. Review of medication administration record revealed on 07/19/25 lidocaine external patch 5 percent was documented as removed at 8:59 A.M. Observation of Resident #50 on 07/24/25 at 1:50 P.M. during interview with family revealed a round patch located on the resident's left upper chest. Family noted they were unsure what the patch was for. The patch was dated 07/12/25. Observation of Resident #50 on 07/24/25 at 1:55 P.M. with Licensed Practical Nurse (LPN) #279 confirmed presence of a round patch on the resident's left upper chest, dated 07/12/25. Review of medication administration record revealed on 07/24/25 a new order was received to remove clonidine patch and apply a new one for seven days. Interview on 07/24/25 at 2:10 P.M. with LPN #279 and Nurse Manager #266 confirmed the patch on Resident #50's chest was a clonidine transdermal patch, ordered to be removed weekly. Observation of Resident #50 on 07/24/25 at 2:44 P.M. with LPN #279 confirmed no additional clonidine patches were located on the resident's chest, upper extremities, shoulders, or back as documented on the medication administration record as given on 07/19/25. However, a lidocaine patch dated 07/19/25 was found on the resident's right lower backside. LPN #279 confirmed the patch should have been removed per physician order on 07/19/25. Additionally, the patch should have been identified and removed during routine care before observation on 07/24/25. Review of federal drug administration drug labeling dated 02/02/23 revealed Catapres TTS (clonidine transdermal system) provides continuous systemic delivery of clonidine for seven days at an 365436 Page 26 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some approximately constant rate. Application of a new system to a fresh skin site at weekly intervals maintains therapeutic plasma concentration of clonidine. 2. Review of the medical record for Resident #79 revealed an admission date of 08/04/23 with diagnoses of metabolic encephalopathy, type two diabetes mellitus, obesity, hemiplegia and hemiparesis, chronic kidney disease stage four, atherosclerotic heart disease, peripheral vascular disease and tachycardia. Review of physician orders dated 11/05/24 revealed ace wraps to bilateral lower extremities on in the morning and off at night time. This treatment is scheduled to be completed at 8:00 A.M. daily. Review of quarterly Minimum Data Set (MDS) 3.0 assessment completed 05/13/25 revealed Resident #79 requires partial or moderate assistance with lower body dressing and has active diagnoses of coronary artery disease, heart failure, hypertension and peripheral vascular disease. Review of care plan dated 05/20/25 revealed Resident #79 has congestive heart failure (CHF) with interventions to monitor lungs, give cardiac medications as ordered, and monitor for signs and symptoms of CHF including edema, shortness of breath, distended neck veins, weight gain and abnormal vital signs. Observation on 07/23/25 at 8:49 A.M., 10:20 A.M., and 11:27 A.M. of Resident #79 revealed ace wraps to bilateral lower extremities were not in place. Resident #79 voiced agreement to placement of the wraps during all observations. Interview on 07/23/25 at 10:23 A.M. with LPN #235 confirmed the ace wraps were not yet in place and they would be applied as soon as possible. Review of treatment administration record dated 07/23/25 at 12:04 P.M. revealed application of ace wraps to bilateral extremities had not occurred for the day. 3. Review of the medical record for Resident #58, revealed an admission date of 09/12/23. Diagnoses included but were not limited to chronic pain, Alzheimer's disease, and chronic kidney disease stage 3. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 11 out of 15 suggested moderate cognitive impairment. The resident was assessed to require substantial/maximal assistance with toilet hygiene, shower/bathe self, mobility and transfers. Review of the active care plan for Resident #58 revealed to have a potential/actual impairment to skin integrity with an intervention including but not limited to weekly treatment documentation to include measurement of each area of the skins breakdown's width, length, depth and type of tissue and exudate and any other notable changes or observations. Review of the progress note dated 07/09/25 at 5:45 A.M. for Resident #58 revealed a new skin issue measuring 0.1 centimeters (cm) by 0.2 cm located on the sacrum. Further review of the progress note dated 07/09/25 at 1:00 P.M. for this resident revealed the Interdisciplinary team discussed the area and noted it to be an abscess. 365436 Page 27 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0684 Level of Harm - Minimal harm or potential for actual harm Review of the weekly skin check dated 07/16/25 for Resident #58 revealed no assessment of the abscess of the sacrum. Review of the weekly skin check dated 07/23/25 for Resident #58 revealed no assessment of the abscess of the sacrum. Residents Affected - Some Interview on 07/28/25 at 12:40 P.M. with the Director of Nursing verified Resident #58's abscess to the sacrum obtained on 07/09/25 did not have weekly documentation assessments and should have to monitor it. 4. Review of the medical record for Resident #95, revealed an admission date of 8/9/24. Diagnoses included but were not limited to cerebral infarction, cognitive communication deficit, other abnormalities of gait and mobility, and dementia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident is rarely/never understood. The resident was assessed to require total dependence with toilet hygiene, shower/bathe self, bed mobility and transfers. Review of the active plan of care for Resident #95 revealed none for the prevention/treatment of potential skin integrity issues. Review of the active physician order dated 01/22/25 for Resident #95 revealed apply Geri sleeves to legs in the AM and remove in the PM as tolerated. Review of the medical record for Resident #95 for 01/22/25 through 07/28/25 revealed no refusals to wear the Geri sleeves to the bilateral legs. Review of the weekly skin assessment dated [DATE] for Resident #95 revealed a right later lower leg skin tear that measured 0.5 cm X 0.6cm. Review of the weekly skin assessments dated 07/11/25, 07/18/25 and 07/25/25 for Resident #95 revealed no assessment to monitor the left lower leg skin tear. Observation on 07/21/25 at 10:05 A.M. of Resident #95 revealed no Geri sleeves to bilateral legs. Observation on 07/28/25 at 11:34 A.M. of Resident #95 revealed no Geri sleeves to bilateral legs. Interview on 07/28/25 at 11:34 A.M. with LPN #279 verified Resident #95 did not have Geri sleeves to bilateral legs. Interview on 07/28/25 at 12:03 P.M. with the DON verified Resident #95 did not have weekly documentations for the right lower leg skin tear acquired on 07/04/25 and did not have a plan of care for the prevention/treatment of potential skin issues. Review of the facility policy titled Skin Integrity-Skin Tears no date revealed for monitoring, the Registered Nurses and Licensed Practical Nurses will participate in the management of skin tears and medical conditions by following physician orders, assessment of the residents, and reporting changes in condition to the residents physicians. 365436 Page 28 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. Review of the closed medical record for Resident #49 revealed an initial admission date of 01/02/25 with the diagnoses including but not limited to dementia with psychotic disturbances, dysphagia, cerebrovascular accident with left sided hemiplegia, gastro-esophageal reflux disease, hypertension, congestive heart failure, insomnia, major depressive disorder, presence of cardiac pacemaker, hyperlipidemia, anemia, constipation, chronic pain, atrial fibrillation and hypothyroidism. The resident expired on 07/08/25 at the facility. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the dental progress note dated 05/07/25 revealed the dentist recommended the resident to have seven teeth extracted (#21 through #27). The resident's tongue, mucosa, lips and gums were within normal limits. Review of the progress note dated 06/10/25 at 12:26 P.M. revealed the resident returned from having a tooth extraction procedure. The resident was not to use straws and have soft foods and liquids. A new order was received for Tylenol 500 milligrams (mg) and Ibuprofen 800 mg by mouth three times a day for even days. The resident was to keep the head of her bed elevated. Review of the resident's dental extraction instructions dated 06/10/25 revealed the following recommendations, apply an ice bag to the area of swelling for 30 minutes and remove for 20 minutes, continue this cycle until swelling subsides. After 24 hours is tis okay to gently rinse mouth with a warm saltwater solution after meals. Review of the progress note dated 06/16/25 at 6:23 P.M. revealed the resident was observed having bruises to her chin post tooth extraction. Review of the medical record revealed no documented evidence the resident's seven tooth extraction cites were monitored for complications or signs/symptoms of infection. On 07/22/2025 at 2:12 P.M., an interview with the Director of Nursing (DON) verified there was no documented evidence the resident was monitored for complications or signs/symptoms of infection. This deficiency represents non-compliance investigated under Complaint Number OH001386198. 365436 Page 29 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

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 interview, observation, and record reviews, the facility failed to ensure air mattress bed settings were appropriate and ordered for four (Residents #2, #8, #53 and #70) of four residents who were at risk for developing pressure ulcers. The facility census was 117.Findings include:1. Review of the medical record for Resident #2, revealed an admission date of 11/1/22 . Diagnoses included but were not limited to dementia, weakness, need for assistance for personal care, and lack of coordination. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of not assessed with memory problem with short term and long term memory. The resident was assessed to require total dependence with toilet hygiene, shower/bathe self, bed mobility, and transfers. this resident was also assessed to be at risk for pressure ulcers.Review of the active care pian for Resident #2 revealed her to have a potential for developing pressure injuries due related to weakness, incontinence, risk for malnutrition and dementia with an intervention not including a low air loss mattress.Review of the active physician order dated 04/09/25 for Resident #2 revealed a low air loss mattress; check placement and function every day and night shift. Review of the Braden Scale for Predicting Pressure Sore Risk dated 05/12/25 for Resident #2 revealed a score of 13.0 on a scale of, 6 (high risk) to 23 (no risk), which indicated Resident #2 to be at moderate risk for skin breakdown.Review of the medical record for Resident #2 revealed a date of 07/06/25 with a weight of 103.4 pounds. Observation on 07/21/25 at 2:14 P.M. of Resident #2 revealed her to be in bed with her low air loss mattress set to firm (over 250 pounds). Observation on 07/28/25 at 10:11 A.M. of Resident #2 revealed her to be in bed with her low air loss mattress set to firm (over 250 pounds). Interview on 07/28/25 at 10:12 A.M. with Licensed Practical Nurse (LPN) #279 verified Resident #2's low air loss mattress was set to firm (over 250 pounds) and the resident was to only weigh 103.4 pounds. Also verified she is not sure how to adjust/set the low air loss mattress when it gets turned off and does not know where to find the appropriate settings. Interview on 07/28/25 at 10:27 A.M. with the Director of Nursing verified Resident #2's low air loss mattress order did not contain appropriate settings for the floor nurses to follow and that type of bed should be set to their weight unless other indicated by the physician in the order.2. Review of the medical record for Resident #8, revealed an admission date of 08/05/23. Diagnoses included but were not limited to depression, weakness, generalized anxiety disorder, with a new diagnosis of contracture to the right elbow on 6/20/24. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 08 out of 15 suggested severe cognitive impairment. The resident was assessed to require total dependence on toilet hygiene, shower/bathe self, bed mobility and transfers. This resident was also assessed to be at risk for developing pressure ulcers.Review of the active care plan for Resident #8 revealed her to have a protentional for developing pressure injuries related to weakness, lack of coordination, general bedbound status and history of pressure injury to the coccyx with an intervention not including a low air loss mattress. Review of the active physician order dated 04/29/25 for Resident #8 revealed a low air loss mattress to bed; check placement and function every day and night shift. Review of the Braden Scale for Predicting Pressure Sore Risk dated 05/22/25 for Resident #8 revealed a score of 10.0 on a scale of, 6 (high risk) to 23 (no risk), which indicated Resident #8 to be at high risk for skin breakdown.Review of the medical record for Resident #8 revealed a date of 7/20/25 weight of 116.2 pounds. Observation on 07/21/25 at 10:42 A.M. of Resident #2 revealed her to be in bed with her low air loss mattress set to 60 pounds. Observation on 07/28/25 at 9:34 A.M. of Resident #2 revealed her to bed in bed with her low air loss mattress set to 60 pounds. Residents Affected - Some 365436 Page 30 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 07/28/25 at 10:04 A.M. with LPN #233 verified Resident #8's low air loss mattress was set to 60 pounds, and the resident was recently weighed at 116.2 pounds. Also verified the company sets up the settings and does not know where to find appropriate settings from the physician. 3. Review of the medical record for Resident #53, revealed an admission date of 10/01/24. Diagnoses included but were not limited to hypertensive heart disease without heart failure, muscle weakness, dementia, bipolar disorder, and dyspnea. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 01 out of 15 suggested severe cognitive impairment. The resident was assessed to require total dependence on toilet hygiene, shower/bathe self, bed mobility, and transfers. This resident was also assessed to be at risk for pressure ulcers. Review of the active care plan for Resident #53 revealed her have no care plan for the potential of the development of pressure injuries. Review of the active physician order dated 04/29/25 for Resident #53 revealed a low air loss mattress to bed' check placement and function every day and night shift. Review of the Braden Scale for Predicting Pressure Sore Risk dated 05/28/25 for Resident #53 revealed a score of 10.0 on a scale of, 6 (high risk) to 23 (no risk), which indicated Resident #53 to be at moderate risk for skin breakdown.Review of the medical record for Resident #53 revealed a date of 07/07/25 with a weight of 139.6 pounds. Observation on 07/21/25 at 2:05 P.M. of Resident #53 revealed her to be in bed with the low air loss mattress set to 240 pounds.Observation on 07/28/25 at 9:31 A.M. revealed Resident #53 to her to bed in bed with the low air loss mattress set to 240 pounds.Interview on 07/28/25 at 9:59 A.M. with LPN #233 verified Resident #53's low air loss mattress was set to 240 pounds with the resident currently weighing at 139.6 pounds. 4. Review of the medical record for Resident #70, revealed an admission date of 03/09/23. Diagnoses included but were not limited to adult failure to thrive, anxiety disorder, need for assistance with personal care, muscle weakness and muscle wasting and atrophy. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 07 out of 15 suggested severe cognitive impairment. The resident was assessed to require toilet hygiene, shower/bathe self, bed mobility and transfers. This resident was also assessed to be at risk for pressure ulcers.Review of the active care plan for Resident #70 revealed to have the protentional for developing pressure injuries related to weakness, chronic debility, cognitive impairment and incontinence with an intervention including but not limited to a low air loss mattress. Review of the active physician order dated 02/14/25 for Resident #70 revealed an air mattress to bed' check placement and function every day and night shift. Review of the Braden Scale for Predicting Pressure Sore Risk dated 04/28/25 for Resident #8 revealed a score of 14.0 on a scale of, 6 (high risk) to 23 (no risk), which indicated Resident #8 to be at moderate risk for skin breakdown.Review of the medical record for Resident #70 revealed a date of 07/18/25 with a weight of 113 pounds. Observation on 07/21/25 at 10:34 A.M. of Resident #70 revealed the resident to be in bed with the low air loss mattress set between 250-280 pounds. Observation on 07/28/25 at 9:33 A.M. of Resident #70 revealed the resident to be in bed and with the low air loss mattress set to 250 pounds. Interview on 07/28/25 at 10:01 A.M. with LPN #233 verified Resident #70s low air loss mattress was set to 250 pounds, with the residents current weight being 113 pounds. 365436 Page 31 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

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 interview, observation, and record review, the facility failed to ensure treatment for a contracture and plan of care was in place for one Resident (#95) of one that was reviewed for position and mobility. The facility census was 117.Findings include:Review of the medical record for Resident #95, revealed an admission date of 08/09/24. Diagnoses included but were not limited to cerebral infarction, cognitive communication deficit, other abnormalities of gait and mobility, and dementia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of the resident is rarely/never understood. The resident was assessed to require total dependence on toilet hygiene, shower/bathe self, bed mobility and transfers. Review of the active plan of care for Resident #95 revealed none for care and treatment of the contracture to her left hand. Review of the hospice note dated 01/14/25 for Resident #95 revealed a contracture to the left hand upon admission assessment. Review of the active physician order dated 02/13/25 for Resident #95 revealed to apply left hand brace to the arm as tolerated and off at night. Review of the medical record from dates 02/13/25 through 07/28/25 for Resident #95 revealed no refusal documentation from the resident to wear the left-hand brace daily. Observation on 07/21/25 at 10:05 A.M. of Resident #95 revealed the resident to be up in the wheelchair in the common area with no left arm brace on.Observation on 07/28/25 at 11:34 A.M. of Resident #95 revealed the resident to be up in the wheelchair in the common area with no left arm brace on.Interview on 07/28/25 at 11:34 A.M. with Licensed Practical Nurse #279 verified Resident #95 did not have her left arm brace on.Interview on 07/28/25 at 5:40 P.M. with the Assistant Director of Nursing verified for Resident #95 had no plan of care for the left-hand contracture and no documentation of refusals. 365436 Page 32 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 review of resident medical records, observations, staff interviews and review of company policies, the facility failed to provide supervision with dining for residents that were identified as choking risks. This affected two residents (Resident #4 and 18) out of thirty three residents that the facility identified as at risk for choking. The facility also failed to ensure that transfers were completed as required for Resident #116 and that the call light cord wiring was not exposed for Resident #79. These affected two residents (Resident #79 and #116) out of six residents that were reviewed for accidents. The facility census was 117 residents.Findings include:1. Review of Resident #18's medical record revealed that he was admitted to the facility on [DATE] and had diagnoses that included vascular dementia, multiple sclerosis and postural kyphosis. Review of Resident #18's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that he was cognitively intact. Review of dietary progress note on 07/09/25 revealed that Resident #18 had mild to moderate oral phase dysphagia and suspected moderate to severe pharyngeal dysphagia. Review of Resident #18's dysphagia care plan dated 01/06/21 and revised on 11/14/24 revealed that Resident #18 had dysphagia. Some interventions included instructing and reminding Resident #18 to eat in an upright position, to eat slowly and to chew each bite thoroughly, and to monitor for signs of dysphagia such as pocketing, choking, coughing, drooling, holding food in mouth and appearing concerns during meals. Review of Resident #18's activities of daily (ADL) living care plan dated 09/19/24 and revised on 07/14/25 revealed that Resident #18 was at risk for a decline in his ADL status due to weakness. An intervention for eating included that he was at continued risk for aspiration and therefore will need to be supervised during meals. Review of Resident #18's speech therapy evaluation and plan of treatment for dysphagia dated 07/09/25 revealed that he had a history of dysphagia with multiple courses of speech therapy including modified barium swallow studies with the identification of aspiration. He was permitted to have a pureed diet texture with nectar thickened liquids for quality of life in lieu of having a modified barium swallow study or pursuing an alternative means of nutrition support. Observation of the fourth-floor dining room on 07/21/25 from 5:40 P.M. to 5:46 P.M. revealed that no licensed nursing staff was present in the dining room. Observation revealed that there were seven residents that were unattended in the dining room, including Resident #18, who was observed to be drooling and coughing after he ate food. Interview with Certified Nursing Aide (CNA) #253 on 07/21/25 at 5:46 P.M. confirmed that the residents had been left unattended in the dining room and that the residents needed to be supervised while dining in the dining room. 2. Review of Resident #4's medical record revealed that he was admitted to the facility on [DATE] and that his diagnoses included dementia and dysphagia. 365436 Page 33 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #4's physician orders revealed that he was to have a pureed diet with this liquids via straw and that regular bananas were permitted. His physician orders revealed that he was on aspiration precautions. Observation of the second floor dining room on 07/22/25 from 5:15 P.M. to 5:16 P.M. revealed that three residents were feeding themselves in the dining room without a licensed nursing staff member in the dining room. The residents included Resident #4, #29, and #66. Interview with CNA # 241 on 07/22/25 at 5:16 P.M. confirmed that there had been no licensed nursing staff in the dining room for a period of time and that some of the residents in the dining room needed supervision while eating. 3. Review of the medical record for Resident #116 revealed an initial admission date of 06/01/21 with the diagnoses including but not limited to polyosteoarthritis, zoster, atrial fibrillation, chronic kidney disease, anemia, congestive heart failure, asthma, dry eye syndrome, myopia, presbyopia, constipation, abdominal aortic aneurysm, seasonal allergic allergies, hyperlipidemia, aortic valve stenosis, overactive bladder, insomnia, presence of cardiac pacemaker, peripheral vascular disease, hypertension and obstructive sleep apnea. Review of the plan of care dated 06/01/21 revealed the resident was at risk for falls related to weakness, difficulty walking, history of falling and incontinence. Interventions included anticipate and meet needs, be sure call light is within reach and encourage resident to use it for assistance as needed, ensure resident is wearing appropriate nonskid footwear when ambulating or mobilizing in wheelchair, Offer frequent assistance with toileting/incontinence care, sign posted in bathroom to remind resident to lock wheelchair breaks before transferring, staff education for most recent fall and therapy to evaluate for appropriate use of sit to stand and therapy recommends use of Hoyer lift at time of evaluation. Review of the plan of care dated 08/04/21 and last revised on 03/10/25 revealed the resident had impaired self-transfer related to weakness. Interventions included make sure resident wears non-skid footwear when up, praise for efforts and success, provide verbal cues and physical assistance as needed, reassess quarterly and as needed, restorative transfer program from wheelchair to toilet and back with assist of one staff, for at least 15 minutes, six to seven days a week. Review of the resident's fall risk assessment dated [DATE] revealed a score of 16 indicated the resident was at increased risk for falls. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident was dependent on staff for transfers. The assessment indicated the resident had not had any falls since prior assessment. Review of the medical record revealed no documented evidence the facility's therapy department evaluated the resident for the use of the sit to stand lift to ensure the resident's safety. Review of the progress note dated 04/15/25 at 11:46 P.M. revealed an aide reported to the nurse the resident slid off the sit to stand lift to the floor when being transferred to bed. The resident reported a 5/10 pain level, with zero being no pain and 10 being the worst pain possible to her left shoulder. The resident was administered as needed Tylenol. The resident's range of motion (ROM) was within normal limits for all extremities. The resident sustained a scratch to her right arm measuring 365436 Page 34 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 0.5 centimeters (cm). The wound was cleansed and covered with a Band-Aid. The resident's physician and power of attorney (POA) was notified of the incident. Review of the incident/accident interview form dated 04/15/25 at 9:55 P.M. revealed while the Certified Nursing Assistant (CNA) as transferring the resident from a shower chair to her bed with the sit to stand lift, the resident let go of the handles and her knees buckled causing her to slide to the floor. The CNA went and retrieved assistance to lift the resident into bed. On 07/24/2025 at 12:27 P.M., interview with the Director of Nursing (DON) verified the CNA was utilizing the sit to stand lift with only one assist and all mechanical lifts should be used with two assists. Review of the facility policy titled, Safe Resident Handling/Transfers, dated 12/17/24 revealed it was the facility's policy to ensure the residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employee safe in accordance with current standards and guidelines. The interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs, taking in account other factors as well. Two staff members must be utilized when transferring residents with a mechanical lift. 4. Review of the medical record for Resident #79 revealed an admission date of 08/04/23 with diagnoses of need for assistance with personal care, cognitive communication deficit, metabolic encephalopathy, and transient cerebral ischemic attack. Review of care plan dated 01/13/25 revealed Resident #79 has impaired cognitive and thought process related to dementia, resulting in difficulty making decisions, long term memory loss, short term memory loss, and cognitive communication deficit. Interventions include asking yes or no questions to determine the resident's needs. Review of Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #79 has a memory problem and requires modified independence for daily decision making, has no impairment of upper or lower extremities, and requires partial or moderate assistance with bed mobility. Observation on 07/21/25 at 10:03 A.M. revealed Resident #79 was lying in bed with exposed call light wiring approximately two inches outside the wall. The cord was found behind the headboard, wrapped around the bed railing. Observation on 07/21/25 at 1:29 P.M. revealed the call light cord wiring remained exposed. Observation on 07/22/25 at 7:42 A.M. revealed the call light cord wiring remained exposed. Observation on 07/22/25 at 7:46 A.M. with Registered Nurse (RN) #345 revealed he believed the cord had been pulled out earlier in the morning. He entered the room and reconnected the cord, stating it was an easy fix staff had not identified. Review of call light policy dated 10/21/24 revealed staff will report problems with the call light or call system immediately to the supervisor or maintenance director and provide immediate or alternative solutions until the problem can be remedied. 365436 Page 35 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure nutritional supplements were provided as ordered by the physician for one (Resident #48) of four residents reviewed for nutritional support. The facility also failed to obtain weekly weights as ordered for two (Residents #9 and #13) of four residents reviewed for nutritional support. The facility census was 117. Findings include:1. Review of the medical record for Resident #13 revealed an admission date of 09/17/21 with diagnoses of Alzheimer's disease, vascular dementia, weakness, muscle wasting and atrophy, type two diabetes mellitus, and abnormal weight loss. Residents Affected - Few Review of care plan dated 09/21/21 revealed Resident #13 has a potential nutritional problem related to dementia, hypertension, alcohol dependence, variable oral intake, unintentional weight loss, and use of an appetite stimulant. Interventions include obtaining and monitoring lab and diagnostic work as ordered, obtaining weights as ordered, providing and serving supplements as ordered, monitoring intakes, and referring to the registered dietitian to evaluate and recommend dietary changes as needed. Review of physician order dated 02/01/25 revealed weekly weights are to be obtained on either Saturday or Sunday. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 05/16/25 revealed Resident #13 is moderately cognitively impaired, dependent on staff for transfers, and has no documented history of previous weight loss. Review of the weight summary from 05/01/25 through 07/20/25 revealed weights were documented on 05/01/25 (132.8 pounds), 05/11/25 (138.2 pounds), 05/25/25 (138.0 pounds), 06/05/25 (133.2 pounds), 06/08/25 (142.0 pounds), 06/15/25 (141.4 pounds), 06/29/25 (142.0 pounds), 07/02/25 (136.5 pounds), 07/13/25 (145.2 pounds), and 07/20/25 (143.4 pounds). Review showed no weights were documented during the weeks of 05/18/25, 06/01/25, 06/22/25, and 07/09/25. Review of the Mini Nutritional assessment dated [DATE] revealed the resident is at risk for malnutrition due to mobility needs and diagnoses of severe dementia and depression. Interview conducted on 07/28/25 at 10:16 A.M. with a Certified Nursing Assistant (CNA) confirmed CNAs are responsible for obtaining weekly weights. The CNA stated residents requiring weekly weights are listed on a paper that includes previous weight values. The CNA added that if a large weight change is noted, staff should notify the nurse and reweigh the resident to confirm the change. Interview conducted on 07/28/25 at 1:14 P.M. with Dietitian #363 confirmed Resident #13 had no documented weights during the weeks of 05/18/25, 06/01/25, 06/22/25, and 07/09/25. The dietitian further confirmed a five and a half pound weight change occurred between 06/29/25 and 07/02/25, and per facility policy, staff should have reweighed the resident when a large weight change was identified. 2. Review of the medical record for Resident #9 revealed an admission date of 05/17/25 with diagnoses of protein-calorie malnutrition, weakness, mood disorder with depressive features, and arthritis. Review of physician order dated 05/18/25 indicated weekly weights were to be obtained on either Saturday or Sunday. 365436 Page 36 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0692 Level of Harm - Minimal harm or potential for actual harm Review of the weight summary for Resident #9 from 05/17/25 through 07/20/25 revealed weights documented on 05/17/25 (110.8 pounds), 05/18/25 (110.8 pounds), 05/19/25 (111.2 pounds), 06/05/25 (105.0 pounds), 06/08/25 (101.2 pounds), 06/15/25 (100.4 pounds), 07/02/25 (100.7 pounds), 07/13/25 (99.4 pounds), and 07/20/25 (100.8 pounds). No weights were documented during the weeks of 05/26/25 and 06/23/25. Residents Affected - Few Review of care plan dated 06/12/25 revealed Resident #9 had significant weight loss over the prior month. Interventions included changing supplements to eight ounces of Ensure Plus, adding a high-supplement snack, and scheduling fortified donuts, ice cream, or pudding with some meals. Review of dietary note dated 06/12/25 confirmed supplement change to Ensure Plus and addition of fortified snacks due to weight loss of 10 pounds (9%) and continued weight weekly weight monitoring. Review of care plan dated 07/23/25 revealed continued weight loss since admission two months prior, leading to increased frequency of meal enhancements. Review of significant weight change assessment dated [DATE] revealed Resident #9 exhibited unplanned weight loss of 12 pounds (10.8%) since admission. Oral intake was 25–75%, with Ensure Plus intake at 100%. Scheduled snacks included ice cream, pudding, and fortified donuts. Interventions were updated to increase frequency of ice cream and pudding with meals and to continue weekly weights for close monitoring. Interview with Certified Nursing Assistant on 07/28/25 revealed staff are responsible for obtaining weekly weights and reweighing residents with large weight changes. Interview conducted on 07/28/25 at 1:14 P.M. with Dietitian #363 confirmed Resident #9 had missed weights on the weeks of 05/26/25 and 06/23/25 despite physician orders, and it was pertinent to obtain weights weekly due to history of weight loss. 3. Resident #48 was admitted on [DATE] with diagnoses that included wedge compression fracture, unspecified dementia with mood disturbance and dysphagia. Review of Resident #48's comprehensive admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that she had a memory problem and that she was assessed as having modified independence for daily decision making. Review of Resident #48's Nutrition assessment completed on 06/08/25 revealed that she was at risk for malnutrition and that a nutritional shake was recommended once daily for added nutritional support. Review of Resident #48's nutrition care plan dated 06/10/25 revealed that Resident #48 had a potential nutritional problem related to being underweight for height and dementia diagnosis. An intervention added on 06/08/25 was to provide and serve supplements as ordered. Review of Resident #48's physician orders revealed that on 06/10/25, there were orders for Resident #48 to receive a shake 4 ounces twice daily at 10:00 A.M. and 4:00 P.M. Interview with the Power of Attorney for Resident #48 on 07/21/25 at 9:58 A.M. revealed that Resident #48's family stayed with Resident #48 around the clock and that Resident #48 did not receive nutrition shakes between meals per her orders. 365436 Page 37 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Continuous observation of Resident #48's room on 07/24/25 from 9:26 A.M. through 11:45 A.M. revealed that no nutrition shakes were delivered to Resident #48. Interview with Unit Manager Licensed Practical Nurse #209 on 07/24/25 at 11:47 A.M. confirmed that Resident #48 did not receive her nutrition shake on 07/24/25 at 10:00 A.M. as ordered. The interview further revealed that the nutrition shakes should be delivered within one hour of the scheduled/ ordered time frame. 365436 Page 38 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, observations, staff interview, and review of facility policy, the facility failed to administer an enteral feeding per physician's orders. The facility also did not date the enteral formula container with the hang date and/or time. This affected one (Resident #72) out of two residents reviewed for tube feedings. The facility census was 117 residents. Findings include: Resident #72 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, dysphagia, hemiplegia and hemiparesis and gastrostomy status. Review of Resident #72's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that his cognitive skills for daily decision making were moderately impaired. He was assessed as being dependent for his oral hygiene, personal hygiene and for sit to stand positioning. He was assessed as being substantial to maximal assistance for bed mobility. He was assessed as having a feeding tube and receiving 51% or more of his total calories from his tube feeding. Review of Resident #72's physician orders dated 07/03/25 revealed that he was to have Jevity 1.5 infuse continuously through his feeding tube at a rate of 60 milliliters per hour. Observation of Resident #72's tube feeding on 07/21/25 at 11:08 A.M. and on 07/22/25 at 7:50 A.M. revealed that Nepro 1.8 formula was infusing at a rate of 70 milliliters per hour. The enteral tube feeding container was not dated. Interview on 07/22/25 at 8:22 A.M. with Unit Manager Licensed Practical Nurse #209 confirmed that Resident #72 was receiving the incorrect formula at the incorrect rate, and that the tube feeding was not dated. Review of the facility policy titled, Care and Treatment of Feeding Tubes dated 08/01/24 revealed that feeding tubes will be utilized according to physician orders. 365436 Page 39 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 the nebulizer medication delivery system as stored in a manner to prevent contamination. This affected one (Resident #116) of one resident reviewed for respiratory care. The facility census was 117.Findings Include:Review of the medical record for Resident #116 revealed an initial admission date of 06/01/21 with the diagnoses including but not limited to polyosteoarthritis, zoster, atrial fibrillation, chronic kidney disease, anemia, congestive heart failure, asthma, dry eye syndrome, myopia, presbyopia, constipation, abdominal aortic aneurysm, seasonal allergic allergies, hyperlipidemia, aortic valve stenosis, overactive bladder, insomnia, presence of cardiac pacemaker, peripheral vascular disease, hypertension and obstructive sleep apnea. Review of the plan of care dated 06/02/21 revealed the resident experienced and was at risk for respiratory insufficiency related to asthma, obstructive sleep apnea, seasonal allergies, history of shortness of breath while lying flat, congestive heart failure, cough and had a history of COVID-19. Interventions included administer medications as ordered, monitor for side effects and effectiveness, be sure call light is within reach and encourage resident to use it for assistance as needed, elevate head of bed as needed, encourage resident to take frequent rest breaks if experiencing shortness of breath with exertion, monitor/document/report as needed any significant change in condition, obtain oxygen saturation level as ordered, notify physician of significant abnormalities and position to facilitate optimum breathing patterns as tolerated. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. On 07/21/25 at 12:16 P.M., observation of the resident's nebulizer revealed the nebulizer machine was sitting on the floor with the nebulizer medication delivery system in a torn and tattered plastic bag. The nebulizer medication delivery system had no date on the system. On 07/22/25 at 9:10 A.M., observation of the resident's nebulizer revealed the nebulizer machine was sitting on the resident's recliner with the nebulizer medication delivery system in a torn and tattered plastic bag. The nebulizer medication delivery system continued to have no date on the system. On 07/22/25 at 9:12 A.M., an interview with Licensed Practical Nurse (LPN) #230 verified the nebulizer was stored inappropriate and the nebulizer medication delivery system remained in a torn and tattered plastic bag with no date identifying when the nebulizer medication delivery system was last changed. The LPN revealed the facility contracted company changed the tubing weekly, however verified the nebulizer medication delivery system looked older than one week. Residents Affected - Few 365436 Page 40 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0697 Provide safe, appropriate pain management 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 closed record review, interview and facility policy review, the facility failed to ensure long-acting narcotic pain medication was available for administration. This affected one resident (Resident #15) out of five residents reviewed for pain. The facility census was 117. Findings include:Review of the closed medical record for Resident #15 revealed an initial admission date of 6/02/25 with the diagnoses including but not limited to dementia, weakness, need for assistance with personal care, dependence on wheelchair, history of falling, pain in right hip, anemia, chronic kidney disease, hypertension, hyperlipidemia, depression, anxiety disorder, obesity and low back pain. The resident was discharged home on [DATE]. Review of the resident's admission pain assessment dated [DATE] revealed the resident denied any pain. Review of the plan of care dated 06/03/25 revealed the resident was at risk for alteration in comfort. Interventions included complete pain evaluation upon admission and as needed, give pain medications as ordered, monitor/document effectiveness of all pain interventions, provide appropriate non-pharmacological measures and report unrelieved pain and condition changes to primary care provider. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident had no indicators of depression and displayed no behaviors. The assessment indicated the resident received scheduled pain medication, receives as needed pain medication and non-pharmacological interventions. The resident indicated she had pain frequently at a level of seven out of 10 with zero being no pain and 10 being the worst pain possible. Review of the resident's discharged physician orders identified orders dated 06/02/25 pain evaluation every shift, Lidocaine External Patch 4% apply to affected area topically daily for pain, 6/03/25 Acetaminophen 975 milligrams (mg) by mouth three times day, 06/04/25 Acetaminophen 325 mg by mouth every six hours as needed for pain, Oxycodone 5 mg give one half tablet (2.5 mg) by mouth every four hours as needed for pain, 07/07/25 Oxycontin Extended Release (ER) 12 hour abuse-deterrent 10 mg by mouth every 12 hours for mild to severe pain. Review of the resident's June 2025 Medication Administration Record (MAR) revealed the resident was not given the scheduled Oxycontin ER 10 mg by mouth on 06/02/25 at 6:00 P.M., 06/03/25 at 6:00 P.M., 06/05/25 at 6:00 P.M., and on 06/06/25 at 8:30 A.M. Further review of the resident's July 2025 MAR revealed the Oxycontin ER 10 mg by mouth every 12 hours was scheduled at 8:30 A.M. and 6:00 P.M. leaving only nine and one-half hours between the doses of medication instead of 12 hours as physician ordered. On 07/28/25 at 3:00 P.M., an interview with the Director of Nursing (DON) verified the facility had no documented evidence the resident received the physician ordered medication Oxycontin ER 10 mg as physician ordered. Review of the facility policy titled, Pain Management, dated 02/05/25 revealed the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences. Opioid treatment for acute pain, subacute pain and chronic pain will be prescribed and dosed in accordance with current professional standards of practice and manufactures' guidelines to optimize their effectiveness and minimize their adverse consequences. This deficiency represents non-compliance investigated under Complaint Number OH001386198. Residents Affected - Few 365436 Page 41 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

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 observation, record review, interview and facility policy review, the facility failed to ensure pain management monitoring, evaluations and indication for usage for residents. This affected four (Resident #58, #9, #50 and #13) out of five residents reviewed for pain. The facility also failed to ensure Dexcom (continuous glucose monitoring system) was not expired, this affected one (Resident #114) out of one reviewed for insulin usage. The facility census was 117. Findings include:1.Review of the medical record for Resident #9 revealed an admission date of [DATE] with diagnoses including fracture of the left patella, weakness, age-related osteoporosis, and pain in the left leg. Residents Affected - Some Review of care plan dated [DATE] identified Resident #9 is at risk for alteration in comfort related to arthritis and left patella fracture. Interventions include completing a comprehensive pain evaluation, administering pain medications as ordered, monitoring and documenting the effectiveness of pain interventions, providing appropriate non-pharmacological measures and reporting unrelieved pain or changes in condition to the physician. Review of the admission Minimum Data Set (MDS) 3.0 dated [DATE] revealed Resident #9 is cognitively intact. Review of physician's order dated [DATE] revealed an order for tramadol 50 milligrams (mg) oral tablet, one tablet by mouth every six hours for pain. Review of pain assessment tool dated [DATE] showed Resident #9's pain management regimen includes medication with a goal to remain pain-free. Review of the Medication Administration Record (MAR) for Resident #9 from [DATE] through [DATE] showed tramadol 50 mg was administered a total of 64 times with resident's documented pain level at 0 out of 10 at the time of administration. Specifically, tramadol was administered on: [DATE] at 12:00 P.M. and 6:00 P.M. [DATE] at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. [DATE] at 12:00 A.M., 6:00 A.M. and 12:00 P.M. [DATE] at 12:00 A.M. [DATE] at 12:00 A.M. and 6:00 A.M. [DATE] at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. [DATE] at 12:00 A.M. and 6:00 A.M. [DATE] and [DATE] at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. [DATE] at 12:00 A.M., 12:00 P.M. and 6:00 P.M. [DATE] at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. [DATE] at 6:00 A.M., 12:00 P.M. and 6:00 P.M. [DATE] at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. [DATE] and [DATE] at 12:00 P.M. and 6:00 P.M. [DATE] at 12:00 A.M., 6:00 A.M. and 6:00 P.M. [DATE] at 6:00 P.M. [DATE] at 12:00 A.M. and 6:00 A.M. [DATE] at 12:00 A.M. [DATE] at 12:00 P.M. and 6:00 P.M. [DATE] at 12:00 A.M., 6:00 A.M. and 12:00 P.M. [DATE] at 12:00 A.M., 12:00 P.M. and 6:00 P.M. [DATE] at 12:00 A.M. [DATE] at 12:00 P.M. and 6:00 P.M. [DATE] at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M.; and [DATE] at 12:00 A.M. 2. Review of the medical record for Resident #13 revealed an admission date of [DATE] with diagnoses of Alzheimer's disease, dementia, displaced fracture of the second cervical vertebra, constipation, and malignant neoplasm of the breast. Review of care plan dated [DATE] revealed Resident #13 has the potential for alteration in comfort related to a history of breast cancer, generalized pain, headache, cervicalgia, and skin impairment. Interventions included administering pain medication as ordered, nursing staff to perform pain 365436 Page 42 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0757 Level of Harm - Minimal harm or potential for actual harm evaluations, providing appropriate non-pharmacological measures, and reporting unrelieved pain or changes in condition to the physician. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 is moderately cognitively impaired and receives a high-risk medication (opioid). Residents Affected - Some Review of pain interview dated [DATE] revealed Resident #13 reported occasional pain. The resident stated the pain rarely interfered with sleep and day-to-day activities. Review of physician's order dated [DATE] prescribed hydrocodone-acetaminophen 10-325 mg, one tablet by mouth twice daily for neck pain. Review of the Medication Administration Record (MAR) from [DATE] through [DATE] revealed hydrocodone-acetaminophen 10-325 mg was administered a total of 22 times, despite the resident's documented pain level being 0 out of 10 at the time of administration. Specifically, the medication was administered on: [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. 365436 Page 43 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0757 [DATE] at 8:30 A.M. and 6:00 P.M. Level of Harm - Minimal harm or potential for actual harm [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. Residents Affected - Some [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. and 6:00 P.M. [DATE] at 8:30 A.M. Interview conducted on [DATE] at 2:44 P.M. with the Director of Nursing confirmed administration of narcotic medication at a pain level of 0 out of 10 is not acceptable according to nursing standards of practice, confirmed the presence on Resident #13 medical record in the month of July. In addition, nursing staff should be consistently evaluating and documenting the resident's pain level prior to administration and reassessing after medication administration to determine effectiveness. 3. Review of the medical record for Resident #58, revealed an admission date of [DATE]. Diagnoses included but were not limited to chronic pain, Alzheimer's disease, and chronic kidney disease stage 3. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 11 out of 15 suggested moderate cognitive impairment. The resident was assessed to require substantial/maximal assistance with toilet hygiene, shower/bathe self, mobility and transfers. Review of the active plan of care revised [DATE] for Resident #58 revealed her to be at risk for alteration in comfort related to chronic pain with interventions including but not limited to give pain medications as ordered. Review of the physician order dated [DATE] for Resident #58 revealed a pain medication for Acetaminophen tablet 325milligrams (mg) give two tablets by mouth every four hours as needed for pain. Further review of the physician orders for this resident revealed a pain medication dated [DATE] for Hydrocodone-Acetaminophen oral tablet 5mg /325mg, give one tablet by mouth every 12 hours as needed for pain. Interview on [DATE] at 12:40 P.M. with the Director of Nursing verified Resident #58 had two pain medications ordered for as needed, both not containing pain parameters with a pain scale for appropriate administration. 365436 Page 44 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of facility Pain Management Policy dated [DATE] revealed the facility must ensure that pain management is provided to resident who require such services, consistent with professional standards of practice, comprehensive person-centered care plan, and the residents goals and preferences. Additionally staff should reassess and adjust the medication dose to optimize the residents pain relief while monitoring the effectiveness of the medication and work to minimize or manage side effects. Pharmacological interventions will follow a systemic approach for selecting medications and doses to treat pain. Use lower doses of medication initially and titrate slowly upward until comfort is achieved. 4. Review of the medical record for Resident #114 revealed an initial admission date of [DATE] with the diagnoses including but not limited to diabetes mellitus, dementia, hypertension, hyperlipidemia, anxiety disorder, glaucoma and long-term use of insulin. Review of the plan of care dated [DATE] revealed the resident had diabetes mellitus with other complications. Interventions included check all of body for breaks in skin and treat promptly as ordered by doctor, diabetes medication as ordered by doctor, monitor/document for side effects and effectiveness, dietary consult for nutritional regimen and ongoing monitoring, encourage resident to practice good general health practices. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident received daily insulin injections and received hypoglycemic medications. Review of the resident's monthly physician orders for [DATE] identified orders dated [DATE] Dexcom 7 sensor apply to upper arm topically every day shift every 14 days. Review of the resident's [DATE] Medication Administration Record (MAR) revealed the resident's Dexcome7 sensor was in place for 14 instead of the 10 days as designed. Review of the Decom7 instruction booklet located in the medication administration cart indicated the sensor was good for only 10 days with a 12-hour grace period. On [DATE] at 11:22 A.M., an interview with Registered Nurse (RN) #216 verified the Decom7 sensor was good for only 10 days with a 12-hour grace period and the facility was using the sensor for 14 days. 365436 Page 45 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and facility policy review, the facility failed to ensure a medication error rate was below 5%. This affected two (Resident #6 and #48) out of four residents observed during medication administration. 27 opportunities of medication administration were observed and 2 of the 27 medications were not administered in accordance with physician's orders, resulting in a medication error rate of 7.41%. The facility census was 117.Findings include: 1. Review of the medical record for Resident #48 revealed an admission date of 06/05/25 with diagnoses of encephalopathy, hyperlipidemia, cerebral infarction and hypercholesterolemia.Review care plan dated 06/06/25 indicated Resident #48 has altered cardiovascular status related to hypertension and cardiomegaly. Interventions include assessing for chest pain and shortness of breath, monitoring lung sounds and reporting changes, and monitoring, documenting, and reporting any signs or symptoms of coronary artery disease.Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48 has memory impairment and is moderately impaired in making daily decisions.Review of physician's order dated 07/17/25 prescribed Metoprolol Succinate Extended Release 25 mg, one tablet daily for hypertension.On 07/23/25 at 8:49 A.M., an observation of morning medication administration was conducted with Registered Nurse Evening Supervisor (RN SP) #386. Resident #48 was scheduled to receive the following medications:Sertraline HCl 100 mg, once daily for depressionAcetaminophen 325 mg, two tablets twice dailyBuspirone HCl 7.5 mg, one tablet twice dailyBudesonide ER 9 mg, one tablet dailyLevetiracetam ER 500 mg, one tablet twice dailyMetoprolol Succinate ER 25 mg, one tablet dailyOlmesartan Medoxomil 40 mg, one tablet dailyAspirin Chewable 81 mg, one tablet daily as a blood thinnerRN SP #386 removed all medications from their individual packaging and placed them into a medication cup. She then discarded all packaging into the trash, with the Metoprolol Succinate 25 mg tablet observed remaining inside an opened pill packet in the corner of the packaging in the trash. After Resident #48 received the medications, the packaging with the Metoprolol tablet 25 mg was retrieved from the top layer of the trash and shown to RN SP #386. She confirmed she had not noticed the tablet remained in the packaging and stated she could not confirm whether the resident received the Metoprolol as intended.Interview conducted on 07/23/25 at 12:19 P.M. with the Director of Nursing (DON) confirmed the physician had been notified of the potential missed dose. The resident's blood pressure was to be monitored, and the physician was consulted regarding whether a replacement dose should be administered. The DON confirmed that RN SP #386 was unable to verify administration of the Metoprolol tablet during the morning medication pass. 2. Review of the medical record for Resident #6 revealed an admission date of 05/05/23 with diagnoses including weakness, muscle wasting and atrophy, chronic pain, and osteoporosis.Review of care plan dated 09/15/23 indicated that Resident #6 has the potential for alteration in comfort related to generalized pain, a history of vertebral fracture, hernia, osteoarthritis, and chronic pain. Interventions included administering medications as ordered, providing appropriate non-pharmacological measures, nursing pain evaluations, and reporting unrelieved pain to the physician.Review of quarterly Minimum Data Set (MDS) 3.0 assessment completed on 03/06/25 identified Resident #6 as cognitively intact.Review of Physician orders dated 07/08/25 included the application of lidocaine 4% external patches to bilateral shoulders topically at bedtime for pain, with instructions to remove them in the morning.Review of the Medication Administration Record (MAR) for 07/23/25 included instructions to remove the lidocaine patches at 9:00 A.M.Observation of medication administration was conducted on 07/23/25 at 8:23 A.M. with Licensed Practical Nurse (LPN) #235. During this observation, Resident #6 was administered the following medications:Furosemide 20 mg tablet, once dailyPravastatin Sodium 10 mg tablet, once Residents Affected - Few 365436 Page 46 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dailyEliquis 2.5 mg tablet, twice dailySenna 8.6 mg tablet, once dailySertraline 50 mg tablet, once dailyArtificial Tears Ophthalmic Solution 1%, applied to bilateral eyesPolyethylene Glycol 3350 (Miralax) powder, once dailyLidocaine External Patches 4%, two patches applied to bilateral shouldersResident #6 took oral medications without issue. LPN #235 then applied two lidocaine patches to the resident's bilateral shoulders and administered eye drops to both eyes. No concerns were noted from the resident during the entirety of the administration.Interview conducted on 07/23/25 at 10:23 A.M. with LPN #235 confirmed per physician orders, the lidocaine patches were to be removed in the morning, not applied. LPN #235 stated there were no lidocaine patches present on Resident #6 at the time of administration and acknowledged the patches should have been removed rather than newly applied.Review of medication administration policy dated 04/09/25 revealed ensure the six rights of medication administration are followed including right resident, right drug, right dosage, right route, right time and right documentation. This deficiency represents non-compliance investigated under Complaint Number OH001386198. 365436 Page 47 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interview and review of facility policy, the facility failed to store food in a safe and sanitary method. This had the potential to affect 116 residents who ate food from the kitchen. The facility identified one resident (Resident #72) who did not eat food from the kitchen. The facility census was 117 residents.Findings include: Observation of the kitchen on 07/21/25 from 8:18 A.M. to 8:35 A.M. revealed that in the dry storage area, there was an opened undated box of elbow macaroni, an opened undated package of spaghetti, and an opened one-gallon container of soy sauce that was undated. Observation of the kitchen on 07/21/25 from 8:18 A.M. to 8:35 A.M. revealed that in the freezer there was an opened unlabeled and undated container of french fries. Observation of the kitchen on 07/21/25 from 8:18 A.M. to 8:35 A.M. revealed that in the walk in refrigerator, there was an uncovered bun rack that contained three uncovered sheet pans full of diced potatoes and two sheets of uncovered raw burger patties. Observation of the fans in the walk-in refrigerator revealed that the fans were covered in a brown fuzzy substance resembling dust, and the fans were blowing in the direction of the uncovered bun rack containing the potatoes and burger patties. Interview with [NAME] #360 on 07/21/25 at 8:29 A.M. confirmed that the box of elbow macaroni, the package of spaghetti and the container of soy sauce were open and undated, that the freezer contained an unlabeled and undated opened bag of french fries, and that the walk-in refrigerator had an uncovered bun rack containing two sheets of raw burger patties and three sheets of diced potatoes. [NAME] #360 also confirmed that the fan appeared to be dusty and blowing onto the uncovered food items. Review of the facility policy titled, Food and Supply Storage: Labeling and Dating, dated 02/11/25 revealed that all food used in food preparation shall be stored in such a manner to prevent contamination and maintain the safety and wholesomeness of the food. All foods in the walk-in refrigerator, freezer and pantry should be properly labeled and include a produced on or opened date. All foods are to be securely covered, labeled and dated. 365436 Page 48 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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** Based on closed record review, interview and facility policy review, the facility failed to ensure the transfer was documented in the resident's medical record. This affected one resident (#49) of three residents reviewed. The facility census was 117.Findings Include:Review of the closed medical record for Resident #49 revealed an initial admission date of [DATE] with the diagnoses including but not limited to dementia with psychotic disturbances, dysphagia, cerebrovascular accident with left sided hemiplegia, gastro-esophageal reflux disease, hypertension, congestive heart failure, insomnia, major depressive disorder, presence of cardiac pacemaker, hyperlipidemia, anemia, constipation, chronic pain, atrial fibrillation and hypothyroidism. The resident expired on [DATE] at the facility. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the resident's change in condition evaluation dated [DATE] revealed the resident had abnormal vital signs. The resident's blood pressure was 77/39, pulse 67, respirations 20, temperature of 98.6 and oxygen saturation rate of 87% with shortness of breath. The assessment indicated the resident was a full code. Under the area of summarization of observations, evaluations and recommendations revealed the resident was noted with low oxygen saturation rate and hypotension. An as needed nebulizer treatment was administered with no effect. The resident's physician was notified, and an order was obtained to send the resident to the local emergency room (ER) for an evaluation. Review of the resident's Transfer Notice-Ohio form dated [DATE] revealed the facility's Ombudsman was notified of the resident being discharged from the facility due to the resident's urgent medical needs. Further review of the medical record revealed no document evidence of the disposition of the resident's transfer. On [DATE] at 2:12 P.M., an interview the Director of Nursing (DON) verified the medical record contained no documentation of the resident being transferred to the local ED or transfer documentation. Review of the facility policy titled, Transfer and Discharge, dated [DATE] revealed the facility will obtain a physician's order for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis. For a transfer to another provider, ensure necessary information (contact information of the practitioner who was responsible for the care of the resident, resident representative information, advanced directives, all information necessary to meet the resident's needs, all special instructions and/or precautions for ongoing care and the resident's comprehensive care plan goals. Document assessment findings and other relevant information regarding the transfer in the medical record. 365436 Page 49 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident medical record, observations, staff interview, CDC website review, and review of facility policies, the facility failed to serve food in a safe and sanitary manner. This had the potential to affect 116 out of 117 residents who ate food from the kitchen. The facility identified one resident (Resident #72) as not eating food from the kitchen. The facility also failed to thoroughly perform legionella surveillance. This had the potential to affect all 117 residents residing in the facility. The facility also failed to provide designated disposal bins for used personal protective equipment in a resident's room when the resident was under contact precautions. This affected one resident (#125) out of three residents (#48, #72 and #125) reviewed for transmission-based precautions. The facility census was 117.Findings include:1. Observation of food lunch service on 07/23/25 from 11:55 A.M. to 12:40 P.M. revealed that while recording temperatures of the food in the steam wells, Dietary Aide # 382 was observed sticking the thermometer into the mashed potatoes and also into the chicken. The plastic body of the digital thermometer (beyond the metal probe) was plastic and was observed to be resting on and in the food products that were being temped. The plastic body of the digital thermometer was not sanitized between food items.Interview with Dietary Director #340 on 07/23/25 at 12:49 P.M. confirmed that the body of the digital thermometer had been observed resting on and in the chicken and mashed potatoes and had not been sanitized between taking the temperature of the two food items. 2. Review of the Legionella infection control surveillance revealed that the facility could not produce evidence of regular flushing of pipes for the rooms in the facility, nor could they produce evidence of cleaning shower heads and faucets.Interview with the Administrator on 07/28/25 at 2:58 P.M. revealed that the facility does not keep flush logs to show ongoing prevention of Legionella.Review of the facility's Legionella water management program revealed that the control measures that the facility will take include to flush the pipes of the low use areas, and to disinfect the shower heads. Review of the procedure titled Visual inspection of the water system revealed that the shower heads will be checked for leaks and corrosion on a monthly basis. Review of the procedure titled Flushing of low use piping in the Legionella Control plan revealed that the facility will flush cold and hot water piping for a minimum of five minutes if the room has a less that fourteen day vacancy period and that if a room is vacated for over fourteen days, the aerators, hoses, shower heads and sprayers will be removed and disinfected. The cold and hot water piping and outlets will be flushed for a minimum of ten minutes. All flushing shall be completed with the same day, preferably a four hour period if possible.3. Review of the medical record for Resident #125 revealed that he was admitted on [DATE] with diagnoses that included chronic kidney disease stage 4, adult failure to thrive and enterocolitis.Review of Resident #125's treatment administration record for July 2025 revealed that he had enhanced barrier precautions in place, which included wearing a glove and gown with dressing, bathing, transferring, changing lines, toileting and ostomy care.Review of Resident #125's physician orders dated 07/17/25 revealed that he was on contact precautions for possible clostridium difficile, an infectious bacteria that can cause diarrhea and damage to the colon.Observation of Resident #125's door on 07/23/25 at 8:44 A.M. revealed that he had a contact precautions sign on his door and personal protective equipment (PPE) outside of his door. Observation of Resident #125's ostomy care on 07/23/25 from 8:44 A.M. to 8:50 A.M. revealed that Registered Nurse (RN) #386 donned PPE appropriately per protocol. At the end of the ostomy care, there was not a designated bin for RN #386 to dispose of her contaminated PPE in.Interview with RN #386 on 07/23/25 at 8:51 A.M. confirmed that there was not a designated bin to dispose of contaminated PPE in within Resident #125's room.Review of the facility policy titled Residents Affected - Many 365436 Page 50 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0880 Level of Harm - Minimal harm or potential for actual harm Infection Prevention and Control Program dated 06/11/25 revealed that a resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines.Review of a document on the CDC website titled Donning and Doffing PPE: Proper Wearing, Removal, and Disposal recommends disposing of all PPE in appropriate waste containers.1. 2. Residents Affected - Many 365436 Page 51 of 52 365436 07/29/2025 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to maintain a clean, sanitary, and homelike environment in multiple resident areas. This affected one (Resident #50) out of six residents reviewed for environmental concerns. Additionally the facility failed to maintain the cleanliness of common areas this had the potential to affect 40 residents (#40, #14, #58, #2, #41, #93, #85, #24, #95, #13, #75, #114, #115, #99, #30, #80, #97, #10, #89, #49, #131, #6, #73, #69, #104, #86, #1, #51, #76, #71, #26, #9, #62, #34, #21, #60, #79, #50, #64, and #74) identified using the affected areas. The facility census was 117. Findings include:1. Review of the medical record for Resident #50 revealed an admission date of 02/28/25 with diagnoses of type two diabetes mellitus, severe protein-calorie malnutrition, morbid obesity, gastro-esophageal reflux disease and gastrostomy status. Review of care plan dated 03/03/25 revealed Resident #50 has potential nutritional problem related to need to mechanically altered diet, need for tube feed due to inadequate oral intake and need for appetite stimulant. Interventions include monitor speech therapy recommendations, monitor weight and labs as ordered, provide supplement and diet as ordered and registered dietician to evaluate and make changes as needed.Review of physician orders dated 05/16/25 revealed enteral feed order for feeding Osmolite 1.2 at 50 milliliters per hour to start at 6:00 P.M. and end at 6:00 A.M.Review of quarterly minimum data set (MDS) 3.0 assessment completed 06/06/25 revealed Resident #50 is cognitively intact, is dependent on staff for all activities of daily living and receives tube feeding and mechanically altered diet. On 07/23/25 at 11:20 A.M., six dried brown spots resembling splattered tube feeding formula were observed on the legs of the tube feeding pole.Observation on 07/24/25 at 8:42 A.M., and 1:55 P.M. revealed the dried brown residue remained. Observation on 07/28/25 at 10:20 A.M., of Resident #50's room with Licensed Practical Nurse (LPN) #370 confirmed the dried brown residue was present on the pole legs, along with a large puddle of dried formula on the floor beneath the pole stated she had not previously noticed the spill or buildup on the pole and left to notify housekeeping. LPN #370 confirmed spills should be cleaned up immediately or as soon as it is identified by staff. 2. Observation on 07/21/25 at 10:22 A.M. of the hallway near Resident #79's room revealed splatter marks on two walls. The first wall, directly outside the resident's room, had mixed brown and orange splatters with visible water staining around the droplets. The second wall, located perpendicular to the room on the left, had brown drip marks running down the wall.Observation on 07/22/25 at 2:28 P.M. with Nurse Manager #266 and Registered Nurse #210 confirmed the presence of carpet staining and wall splatter in the hallway.3. Observation on 07/22/25 at 7:48 A.M. of the wall directly across from the memory care nurses' station, near the walkway to the bathroom and laundry room, revealed various splattered colors and drips along the wall surface.Observation on 07/22/25 at 2:36 P.M. with Certified Nursing Assistant (CNA) #312 confirmed the presence of splatter marks behind the medication cart, stating she had not noticed them prior but would notify housekeeping.Interview on 07/22/25 at 2:42 P.M. with Environmental Services Director #321 revealed he was unaware of any cleanliness issues in the building. He acknowledged that nursing staff can clean minor spills or housekeeping concerns as needed, and he also stated he was unaware the hallway carpets required cleaning outside of Resident #79's room and walls requiring cleaning on the floor.Review of safe and homelike environment policy dated 07/22/25 revealed housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. 365436 Page 52 of 52