Health inspection·February 20, 2020

F 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and review of the facility's policy, the facility failed to obtain proper authorization to establish a personal care needs account for one resident. This affected one (Resident #29) of one resident with a personal care needs account in the facility. The facility census was 41. Residents Affected - Few Finding include: Record review for Resident #29 revealed the resident was admitted to the facility on [DATE]. The resident is cognitively impaired with diagnoses of restlessness, anxiety and psychosis. Review of the authorization and agreement to manage resident funds form, dated 02/19/19, revealed Resident #29 or a resident representative did not authorize the agreement. The form was signed by the Administrator and witnessed by two non-employees of the facility. On 02/19/20 at 10:00 A.M., an interview with the Administrator and Accounts Payable Representative #83 revealed the facility has one personal care needs account. It was for Resident #29 who received the Medicaid benefit. On 02/19/20 at 10:47 A.M., an interview with the Administrator confirmed she signed the document to enable Resident #29's Supplemental Security Income (SSI) to be directly deposited to the facility and to have her $30.00 monthly allowance put into a personal care needs account managed by the facility. The Administrator explained the facility contacted Resident #29's legal guardian and a family member to obtain authorization to open the account. but both parties declined. Review of the policy's undated policy titled 'Resident Funds Accounts Policy and Procedure' revealed all accounts require a signed authorization form in order to open a personal fund/resident trust account. No accounts will be open/have monies deposited without the approved authorization form in hand. The facility must protect and manage resident funds accounts by following the guidelines of the Ohio Department of Health, the Ohio Administrative Code, and Federal Regulation 483.10 (f) (10) (ii). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365504 If continuation sheet Page 2 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Glen Health Services Corp 5155 North High Street Columbus, OH 43214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of the facilities policy, the facility failed to notify the physician of the resident's low blood pressures and holding of the resident's blood pressure medication. This affected one (Resident #18) of 17 residents reviewed for changes in condition. The facility census was 41. Findings include: Review of the medical record for Resident #18 revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction, hypertension, and Alzheimer's disease. Review of the annual Minimum Data Set (MDS) assessment, dated 12/03/19, revealed Resident #18 had moderate cognitive deficits. Review of the physician progress note, dated 09/12/19, revealed Resident #18 had hypertensive disorder, was on Norvasc and Clonidine (for high blood pressure) and the resident's blood pressures trends 120's to 130's. The physician advised the nursing staff to contact the physician if the blood pressure remained elevated. Review of the nurse's electronic medication administration record (EMAR) progress notes, dated 10/02/19, revealed Resident #18's blood pressure was low at 91/52 and Clonidine was held. Subsequent the Clonidine was held on 10/07/19 due to the blood pressure was low at 91/56; on 10/08/19 due to the blood pressure was low at 90/55; on 10/16/19 due to the blood pressure was low at 91/51; on 10/21/19 due to the blood pressure was low at 94/51; on 11/05/19 due to the blood pressure was low at 94/50; on 11/22/19 due to the blood pressure was low at 90/55; and on 12/18/19 due to the blood pressure was low at 90/56. Review of the physician progress note, dated 01/02/20, revealed Resident #18 was seen for hypertensive disorder and her blood pressure trends were 120's to 130's and was receiving Norvasc and Clonidine for hypertension. Nursing was to continue blood pressure management and to contact the physician if the blood pressure remained elevated. No staff concerns were noted. There was no mention of Resident #18's low blood pressures and that nursing staff was holding Clonidine at times due to her low blood pressure. Review of EMAR note, dated 01/06/20, revealed Resident #18's blood pressure was low at 94/58 and Clonidine was held. The Clonidine was subsequently held on 01/22/20 due to the blood pressure was low at 98/55 and on 01/27/20 due to the blood pressure was low at 98/56. Review of the physician progress notes, dated 01/21/20 and 01/29/20, revealed Resident #18 was seen for hypertensive disorder and her blood pressure trends were 120's to 130's and nursing was advised to contact the physician if the blood pressure remained elevated. There was no documentation that Resident #18's blood pressure was running low at times and that nursing was holding her blood pressure medication. Review of the physician progress note, dated 02/11/20, revealed there was no staff concerns reported. Review of the physicians orders, dated 02/2020, revealed an order to monitor the resident's blood pressure daily, give Amlodipine 10 milligrams (mg.) daily for hypertension, and Clonidine 0.1 mg. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365504 If continuation sheet Page 3 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Glen Health Services Corp 5155 North High Street Columbus, OH 43214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 every eight hours for hypertension. Level of Harm - Minimal harm or potential for actual harm Interview on 02/20/20 at 12:59 P.M. with the Director of Nursing (DON) verified Resident #18's medical record did not indicate the physician was ever notified of her low blood pressures and the staff were holding her blood pressure medication. The DON stated he called the physician this date and she verified she was not made aware of Resident #18 having low blood pressures and that staff was holding her blood pressure medication at times. Residents Affected - Few Review of the facilities policy titled Acute Condition Changes Policy, dated 10/2017, revealed the purpose was to assess, recognize, and treat acute condition changes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365504 If continuation sheet Page 4 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Glen Health Services Corp 5155 North High Street Columbus, OH 43214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, and facilities policy review, the facility failed to provide privacy during a pressure ulcer dressing change. This affected one (Resident #8) of four residents reviewed for pressure ulcers. The facility census was 41. Residents Affected - Few Findings include: Review of medical record for Resident #8 revealed an admission date of 05/04/17 with diagnoses including depression, dementia and Alzheimer's disease. Review of the significant change Minimum Data Set (MDS) assessment, dated 02/04/20, revealed she was rarely/never understood and had the presence of a pressure ulcer. Observation on 02/19/20 at 1:26 P.M. of Licensed Practical Nurse (LPN) #48 revealed the LPN performed a treatment and dressing change to Resident #8. LPN #8 was assisted by State Tested Nursing Assistant (STNA) #89. LPN #8 explained the treatment to Resident #8. Resident #8 was lying in bed. LPN #8 and STNA #89 rolled Resident #8 onto her side and exposed her coccyx/buttock area. They did not pull the privacy curtain and her blinds were open to a street outside. She was turned so that her buttocks was in view of the window and door. During the treatment procedure, a mattress delivery guy knocked on the door and opened the door twice to deliver Resident #8 a specialty mattress. Then he quickly excused himself and closed the door. Interview on 02/19/20 at 1:36 P.M. with LPN #48 and STNA #89 verified they did not close the blind to the window or pull the privacy curtain during treatment and care. Review of the facilities policy titled 'Dressing Change,' dated 10/2017, revealed the staff were to explain the procedure to the resident and provide privacy. Review of the facilities policy titled 'Dignity Policy,' dated 10/2017, revealed each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365504 If continuation sheet Page 5 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Glen Health Services Corp 5155 North High Street Columbus, OH 43214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, review of the facility's self-reported incidents and facilities policy review, the facility failed to implement their abuse policy and procedure by not reporting to the State Survey Agency and conducting a thorough investigation for an injury of unknown origin for a resident. This affected one (Resident #7) of two residents reviewed for abuse. The facility census was 41. Residents Affected - Few Findings include: Review of the medical record for Resident #7 revealed an admission date of 01/25/16 with diagnoses including dementia with behavioral disturbance, psychosis, anxiety, depression, and pseudobulbar affect. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/03/20, revealed Resident #7 was rarely understood and displayed physical behavior. Review of the physician orders, dated 02/2020, revealed an order to do weekly skin checks on the resident. Review of weekly skin assessment, dated 01/01/20, revealed Resident #7 had no skin issues noted. The weekly skin assessment, dated 01/08/20, revealed there was a bruise around Resident #7's left eye and right thigh. The weekly skin assessment, dated 01/22/20, revealed old bruises on the left eye and chin area. Review of the nursing progress notes, from 12/12/19 through 02/07/20, revealed there was no documentation of any bruising or any injuries that may have caused bruising. Review of the physician note, dated 01/16/20, revealed Resident #7 was given a baby doll over the weekend to comfort her . She hit herself in the face with the baby doll and suffered left eye and left upper arm and right arm ecchymosis. Review of the facility's self-reported incidents (SRI), from 01/01/20 through 01/22/20, revealed the facility did not submit an SRI involving Resident #7's injury of unknown. Interview on 02/20/20 at 2:14 P.M. with the Administrator verified Resident #7 did have bruising to her left eye and they did an investigation and assumed that it was from a doll that had been given to her because she was constantly moving and hitting out. Interview on 02/20/20 at 2:34 P.M. with the Director of Nursing (DON) stated he was made aware of Resident #7's bruising to her around her eye and stated activities had given her a hard baby doll over the weekend and she was always hitting out and that he assumed it was from the baby doll. He verified they did not do a thorough investigation and did not interview all the staff. He stated he did not take it any further that because he did not feel anyone hurt her and that he called the physician who came in to see her the next day. He stated since the baby doll was hard, he had assumed she had hit her face with the doll. Interview on 02/20/20 at 3:00 P.M. with the Administrator verified she did not have written statements from staff or any investigation to give to survey team on Resident #7's bruising to her left eye. She verified she did not report an injury of unknown source because it was assumed it came from her doll. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365504 If continuation sheet Page 6 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Glen Health Services Corp 5155 North High Street Columbus, OH 43214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 02/20/20 at 3:25 P.M. with Licensed Practical Nurse (LPN) #55 stated she worked the week Resident #7 had bruised left eye and stated they were all baffled at first how that could have happened then they came to the conclusion that it was from a hard baby doll that she had. She stated she hits herself and swings her arms. Review of the facilities 'Reporting Abuse to Facility Management Policy,' dated October 2017, revealed it was the responsibility of employees, facility consultants, attending physician, family members, and visitors to promptly report any incident or suspected incident of neglect, resident abuse, including any injuries of unknown source to facility management. An injury of unknown source is defined as an injury that the source of the injury was not observed by any person or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury and location of the injury. A completed copy of incident reports, documentation forms, witness statements must be provided to the Administrator. An immediate investigation will be made and a copy of the findings of such investigation will be provided to the Administrator. Event ID: Facility ID: 365504 If continuation sheet Page 7 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Glen Health Services Corp 5155 North High Street Columbus, OH 43214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on medical record review, staff interview, review of the facility's self-reported incidents and facilities policy review, the facility failed to report a resident's injury of unknown origin to the State Survey Agency. This affected one (Resident #7) of two residents reviewed for abuse. The facility census was 41. Findings include: Review of the medical record for Resident #7 revealed an admission date of 01/25/16 with diagnoses including dementia with behavioral disturbance, psychosis, anxiety, depression, and pseudobulbar affect. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/03/20, revealed Resident #7 was rarely understood and displayed physical behavior. Review of the physician orders, dated 02/2020, revealed an order to do weekly skin checks on the resident. Review of weekly skin assessment, dated 01/01/20, revealed Resident #7 had no skin issues noted. The weekly skin assessment, dated 01/08/20, revealed there was a bruise around Resident #7's left eye and right thigh. The weekly skin assessment, dated 01/22/20, revealed old bruises on the left eye and chin area. Review of the nursing progress notes, from 12/12/19 through 02/07/20, revealed there was no documentation of any bruising or any injuries that may have caused bruising. Review of the facility's self-reported incidents (SRI), from 01/01/20 through 01/22/20, revealed the facility did not submit an SRI involving Resident #7's injury of unknown. Interview on 02/20/20 at 2:14 P.M. with the Administrator verified Resident #7 did have bruising to her left eye and they did an investigation and assumed that it was from a doll that had been given to her because she was constantly moving and hitting out. Interview on 02/20/20 at 2:34 P.M. with the Director of Nursing (DON) stated he was made aware of Resident #7's bruising to her around her eye and stated activities had given her a hard baby doll over the weekend and she was always hitting out and that he assumed it was from the baby doll. He verified they did not do a thorough investigation and did not interview all the staff. He stated he did not take it any further that because he did not feel anyone hurt her and that he called the physician who came in to see her the next day. He stated since the baby doll was hard, he had assumed she had hit her face with the doll. Interview on 02/20/20 at 3:00 P.M. with the Administrator verified she did not report an injury of unknown source to the State Survey Agency because it was assumed it came from her doll. Review of the facilities 'Reporting Abuse to Facility Management Policy,' dated October 2017, revealed it was the responsibility of employees, facility consultants, attending physician, family members, and visitors to promptly report any incident or suspected incident of neglect, resident abuse, including any injuries of unknown source to facility management. An injury of unknown source is defined as an injury that the source of the injury was not observed by any person or the source of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365504 If continuation sheet Page 8 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Glen Health Services Corp 5155 North High Street Columbus, OH 43214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm injury could not be explained by the resident and the injury is suspicious because of the extent of the injury and location of the injury. A completed copy of incident reports, documentation forms, witness statements must be provided to the Administrator. An immediate investigation will be made and a copy of the findings of such investigation will be provided to the Administrator. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365504 If continuation sheet Page 9 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Glen Health Services Corp 5155 North High Street Columbus, OH 43214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and facilities policy review, the facility failed to conduct a thorough investigation for an injury of unknown origin for a resident. This affected one (Resident #7) of two residents reviewed for abuse. The facility census was 41. Residents Affected - Few Findings include: Review of the medical record for Resident #7 revealed an admission date of 01/25/16 with diagnoses including dementia with behavioral disturbance, psychosis, anxiety, depression, and pseudobulbar affect. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/03/20, revealed Resident #7 was rarely understood and displayed physical behavior. Review of the physician orders, dated 02/2020, revealed an order to do weekly skin checks on the resident. Review of weekly skin assessment, dated 01/01/20, revealed Resident #7 had no skin issues noted. The weekly skin assessment, dated 01/08/20, revealed there was a bruise around Resident #7's left eye and right thigh. The weekly skin assessment, dated 01/22/20, revealed old bruises on the left eye and chin area. Review of the nursing progress notes, from 12/12/19 through 02/07/20, revealed there was no documentation of any bruising or any injuries that may have caused bruising. Review of the physician note, dated 01/16/20, revealed Resident #7 was given a baby doll over the weekend to comfort her . She hit herself in the face with the baby doll and suffered left eye and left upper arm and right arm ecchymosis. Interview on 02/20/20 at 2:14 P.M. with the Administrator verified Resident #7 did have bruising to her left eye and they did an investigation and assumed that it was from a doll that had been given to her because she was constantly moving and hitting out. Interview on 02/20/20 at 2:34 P.M. with the Director of Nursing (DON) stated he was made aware of Resident #7's bruising to her around her eye and stated activities had given her a hard baby doll over the weekend and she was always hitting out and that he assumed it was from the baby doll. He verified they did not do a thorough investigation and did not interview all the staff. He stated he did not take it any further that because he did not feel anyone hurt her and that he called the physician who came in to see her the next day. He stated since the baby doll was hard, he had assumed she had hit her face with the doll. Interview on 02/20/20 at 3:00 P.M. with the Administrator verified she did not have written statements from staff or any investigation to give to survey team on Resident #7's bruising to her left eye. Interview on 02/20/20 at 3:25 P.M. with Licensed Practical Nurse (LPN) #55 stated she worked the week Resident #7 had bruised left eye and stated they were all baffled at first how that could have happened then they came to the conclusion that it was from a hard baby doll that she had. She stated she hits herself and swings her arms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365504 If continuation sheet Page 10 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Glen Health Services Corp 5155 North High Street Columbus, OH 43214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facilities 'Reporting Abuse to Facility Management Policy,' dated October 2017, revealed an injury of unknown source is defined as an injury that the source of the injury was not observed by any person or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury and location of the injury. A completed copy of incident reports, documentation forms, witness statements must be provided to the Administrator. An immediate investigation will be made and a copy of the findings of such investigation will be provided to the Administrator. Event ID: Facility ID: 365504 If continuation sheet Page 11 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Glen Health Services Corp 5155 North High Street Columbus, OH 43214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Potential for minimal harm Based on medical record review and staff interview, the facility failed to conduct resident's Minimum Data Set (MDS) assessments when required and transmit current data to the Centers for Medicare and Medicaid Services (CMS). This affected three residents (Resident #1, #2 and #3) of six residents reviewed for discharges. The facility census was 41. Residents Affected - Some Findings include: 1. Review of medical record for Resident #1 revealed an admission date of 08/22/19 and was discharged from the facility on 10/04/19. Review of the resident's MDS assessments revealed there was no discharge MDS assessment completed. 2. Review of medical record for Resident #2 revealed an admission date of 09/23/19 and was discharged from the facility on 10/28/19. Review of the resident's MDS assessments revealed there was no discharge MDS assessment completed. 3. Review of medical record for Resident #3 revealed an admission date of 08/23/19 and was discharged from the facility on 10/04/19. Review of the resident's MDS assessments revealed there was no discharge MDS assessment completed. Interview on 02/19/20 at 12:15 P.M. with Registered Nurse (RN) #6 verified Resident #1, #2 and #3 were all discharged from the facility and no discharge MDS assessment were completed and transmitted to CMS as required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365504 If continuation sheet Page 12 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Glen Health Services Corp 5155 North High Street Columbus, OH 43214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** 4. Review of the medical record for Resident #18 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, hypertension, and Alzheimer's disease. Review of the annual Minimum Data Set (MDS) assessment, dated 12/03/19, revealed Resident #18 had moderate cognitive deficits and had had no falls. Review of fall risk assessment note, dated 11/27/19, revealed the resident was at risk for falls and it stated they added the following interventions to the care plan: reorient her to surroundings, introduce self when caring for her, provide incontinence products and assist with changing as needed, assist with placement of call pendant, two person assist for transfers, and administer medications per order. However, there was no evidence the care plan was updated with the interventions listed in the risk assessment. Review of the resident's care plans revealed there was no at risk for falls or injury care planned and fall interventions were not addressed in the care plan. Interview on 02/20/20 at 12:59 P.M. with the Director of Nursing verified Resident #18 did not have a fall risk care plan in place. Review of the facility's policy titled, Care Planning-Interdisciplinary Team, dated 10/2017, revealed the facility's interdisciplinary team was responsible for the development of an individualized comprehensive care plan for each resident. Based on medical record review, staff interview and review of the facility's policy, the facility failed to develop and implement the resident's care plans involving falls and psychotropic, opioid and diuretic medication use. This affected four (Resident #18, #27, #37 and #42) of 17 residents reviewed for care plans. The facility census was 41. Findings include: 1. Review of Resident #27's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, insomnia, and fracture of the left ulna. Review of the Minimum Data Set (MDS) assessment, dated 12/27/19, revealed she had a severe cognitive impairment and required total dependence on staff for transfers and extensive assistance from staff for toilet use. Review of the fall risk assessments, dated 11/27/19, 12/18/19, and 02/07/20, revealed she was at moderate risk for falls. Review of the resident's care plan revealed there was no fall care plan and there were no interventions in place to aide in the prevention of the resident from falling despite the resident being assessed at a moderate risk for falls. Review of Resident #27's current physician orders revealed she was on an opioid 50 milligrams (mg.) every eight hours as needed for pain, a diuretic (Lasix) 20 mg. every day for congestive heart failure, and a psychotropic medication (Trazodone) 50 mg. nightly for insomnia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365504 If continuation sheet Page 13 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Glen Health Services Corp 5155 North High Street Columbus, OH 43214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Further review of Resident #27's care plan revealed it did not a care plan for her opioid, diuretic, or psychotropic medication use. Interview on 02/19/20 at 5:41 P.M. with the Director of Nursing (DON) confirmed Resident #27's care plan lacked a fall care plan and interventions for falls. The DON confirmed she had prior been assessed as being a moderate risk for falls and a care plan should have been initiated at that time. The DON confirmed her care plan lacked the use of opioid, diuretic or psychotropic medications. 2. Review of Resident #42's medical record revealed she was admitted to the facility 11/07/19. Diagnoses included kidney failure and major depressive disorder. Review of the MDS assessment, dated 01/15/20, revealed she was cognitively intact. Review of the physician orders, dated 11/08/19, revealed she was on an antipsychotic (Seroquel) 25 milligrams (mg.) daily and on antidepressants (Wellbutrin) 150 mg. two times a day, and (Fluoxetine) 40 mg. a day. Review of Resident #42's care plan, dated 11/13/19, revealed there was no care plan to address her antipsychotic medication use or antidepressant medication use. Interview on 02/19/20 at 12:39 P.M. with the DON confirmed Resident #42 used antidepressants as well as antipsychotics. The DON confirmed there was no care plan for her psychotropic and antidepressants medication use. The DON confirmed these medications should have been care planned. 3. Record review for Resident #37 revealed she was admitted to the facility on [DATE]. Diagnoses included displaced trimalleolar fracture of the right lower leg, subsequent encounter for closed fracture with routine healing and muscle weakness. Review of the care plan, dated 07/02/19, revealed Resident #37 was at risk with history of falls. An intervention, dated 09/12/19, was for the resident's bed to be kept in the lowest position. Review of the Treatment Administration Record (TAR), dated 02/2019, revealed Resident #37 was scheduled have the bed in the lowest position at all times while the resident was in bed. Observation on 02/18/ 20 at 12:28 P.M. revealed Resident #37 was sitting on side of her bed with a regular mattress, bed at knee level. Observations 02/19/20 at 2:33 P.M. and 3:12 P.M. revealed Resident #37 was sleeping in her bed laying on her left side on top of her regular mattress, head towards the window, and the bed height was at knee level. Interview on 02/19/20 at 3:15 P.M. with Licensed Practical Nurse (LPN) #55 verified Resident #37's bed was not at the lowest position, and it could be lowered. LPN #55 verified the care plan stated the bed was to be in the lowest position. LPN #44 stated when the bed was in the lowest position, it should be almost touching the ground. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365504 If continuation sheet Page 14 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Glen Health Services Corp 5155 North High Street Columbus, OH 43214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical records review, observation, resident and staff interviews and review of the facility's policy, the facility failed to provide appropriate respiratory care and respond timely to notifying licensed nursing staff of an acute change of condition for a resident. The facility also failed to weigh residents daily per physician orders and failed to timely identify and assess a resident's non-pressure related skin breakdown. This affected two (Resident #11 and #37) of 14 residents reviewed for quality of care and affected one (Resident #37) of five residents reviewed for skin conditions. The facility census was 41. Residents Affected - Few Findings include: 1. Review of Resident #11's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, hypertension and asthma. Review of her Minimum Data Set (MDS) assessment, dated 12/10/19, revealed she had a severe cognitive impairment and required extensive assistance from staff with activities of daily living. Review of Resident #11's physician orders, dated 12/16/19, revealed she was to receive two liters of oxygen continuously via nasal cannula every day and night shift for shortness of breath. The physician orders, dated 12/19/19, revealed she was to be weighed daily related to her congestive heart failure. Review of the Medication Administration Record (MAR) for 01/2020 and 02/2020, revealed she was not weighed 10 days in a row from 01/27/20 through 02/05/20 and four days in a row from 02/07/20 through 02/10/20. Review of the progress notes, dated 02/18/20 at 12:41 P.M., revealed the nurse was notified of Resident #11 having shortness of breath. Her blood pressure was 108/47, heart rate 64 and oxygen was 96% on oxygen at two liters per minute. Resident #11 was sent to the emergency room for further evaluation. The progress note, dated 02/19/20 at 10:50 P.M., stated clarification: Resident #11's pulse was 47 beats per minute, not 64. The resident was still in the hospital as of 02/20/20. Observations and interview on 02/18/20 revealed at 11:48 A.M., Resident #11 was in the dining room and stated she was having difficulty breathing. Scheduler #89 (also a state tested nursing aide (STNA)) stated she would get the nurse right away. At 11:50 A.M., Licensed Practical Nurse (LPN) #44 entered the dining room and discovered her oxygen concentrator was plugged in but not set. LPN #44 turned on and set Resident #11's oxygen concentrator. He did not assess or talk the resident. The LPN #44 stated he was fine 'now'. He confirmed her oxygen concentrator was plugged in but was not on or set according to order. At 11:54 A.M., Resident #11 stated she could not breath repeatedly. Scheduler #89 stated she was going to find the nurse. At 11:55 A.M., the resident's food was placed in front of her by a dietary staff member. The resident stated she was not going to eat because she could not breathe. At 11:55 A.M., Scheduler #89 returned to the dining room with portable vital equipment. Resident #11's oxygen was 99 percent and her heart rate percentage and her heart rate remained in the low 50's. The Director of Nursing (DON) instructed Scheduler #89 to remove the resident's nasal cannula and follow him to Resident #11's room so she could be assessed further. The DON ambulated the resident via wheelchair from the dining room to her room without her oxygen on. Resident #11 continued stating (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365504 If continuation sheet Page 15 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Glen Health Services Corp 5155 North High Street Columbus, OH 43214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she could not breathe. Scheduler #89 followed with the oxygen cannula and concentrator. At 12:02 P.M., the DON arrived to Resident #11's room. He stated he did not ambulate the resident with her oxygen on as ordered because he wanted to be able to get her to her room quickly. At 12:03 P.M., the DON began removing extra layers of clothing from Resident #11 in order to take her blood pressure. Her heart rate was 50. At 12:07 P.M., the DON assessed the resident's lung sounds and noted no concerns. At 12:09 P.M., Residents #11's oxygen was at 90 percent and her heart rate was 49. The DON stated Resident #11 needed to go to the hospital because she was, very bradycardic, with a heart rate of 49 and he was concerned about her heart. The DON ordered LPN #44 to call the attending physician and obtain orders to send to the emergency room for evaluation. Interview on 02/18/20 at 12:27 P.M. with DON revealed he thought staff was, overly focused on her oxygen saturation and not thinking about circulatory issues. Subsequent interview on 02/19/20 at 6:12 P.M. with the DON stated Resident #11 was admitted to the hospital with respiratory distress. The DON confirmed Resident #11 was not weighed as ordered from 01/27/20 through 02/05/20 and 02/07/20 through 02/10/20. Interview on 02/18/20 at 12:35 P.M. with LPN #44 again confirmed Resident #11's oxygen was plugged in but not on or set while she was in the dining room. He stated when Scheduler #89 first came to him, she only told him Resident #11's oxygen was not on and needed set. He stated he was not informed she was having difficulty breathing. He stated had he been aware she complained of shortness of breath he would have assessed her oxygen saturation and other vitals. He stated Scheduler #89 came to get him a second time but he was in the middle of passing medications. LPN #44 stated once he arrived to the dining room, the DON was assessing Resident #11. Interview on 02/18/20 at 12:38 P.M. with Scheduler #89 revealed she was also an STNA and worked the floor as needed. Scheduler #89 confirmed the first time she sought LPN #44, she only informed him Resident #11's oxygen was not operating, not that she was complaining of shortness of breath. The scheduler stated she assumed Resident #11 was complaining of shortness of breath because the oxygen was not on and did not think there was any other issue. She stated the second time she went to retrieve LPN #44 he was passing medications so she brought in the vitals equipment. She stated Resident #11's oxygen saturation was within normal limits and that her heart rate was around 54 and any heart rate below 60 was considered a concern. She did not ask for more assistance at that time because she was waiting for a nurse to come to the dining room to assess her. Scheduler #89 stated she was not worried about the heart rate because Resident #11 was only complaining of shortness of breath and her oxygen saturations were normal. Review of the facility's policy titled, Acute Condition Changes, dated October 2017, revealed staff would assess, recognize, and treat acute condition changes. The policy stated direct care staff, including nursing assistants, would be trained in recognizing subtle but significant changes in the resident and how to communicate those changes to the nurse. Review of a facility policy titled, Oxygen Administration, dated October 2017, revealed the facility would safely provide oxygen administration. The policy stated staff would assemble oxygen equipment and supplies as needed. Before administering oxygen, and while the resident was receiving oxygen therapy, to assess for the following: cyanosis, difficulty breathing, vital signs, lung sounds, and oxygen saturation. The eighth step of oxygen administration was to turn on the oxygen. The tenth step was to adjust the oxygen delivery devise so that it was comfortable for the resident and the proper flow of oxygen was being administered. Staff should observe the resident upon setup and periodically thereafter to be sure the oxygen was being tolerated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365504 If continuation sheet Page 16 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Glen Health Services Corp 5155 North High Street Columbus, OH 43214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Record review for Resident #37 revealed the resident was admitted to the facility on [DATE]. Diagnoses included displaced trimalleolar fracture of right lower leg, subsequent encounter for closed fracture with routine healing, type two diabetes mellitus without complications and chronic kidney disease. Review of the quarterly Minimum Date Set (MDS) assessment, dated 01/08/20, revealed the resident required limited assistance with one-person physical assistance with personal hygiene and bathing. She was identified to be at risk for pressure ulcers. Review of the care plan, dated 07/02/19, revealed the resident was at risk for impaired skin integrity to rule out bowel incontinence, chronic kidney disease, diabetes mellitus, diuretic use, generalized muscle weakness, impaired cognition, impaired mobility, urinary incontinence and BiPap use. Interventions included skin assessments weekly and as needed. Review of the podiatry progress note, dated 01/05/20, revealed this was the initial exam. The resident had type two diabetes mellitus with painful callus to her right foot and toenails that were dystrophic. A callus plantar to the right foot with seven toenails yellow and thick. Treatment included to debride the nails to the bed and debride callus. Review of the physician visit summary, dated 01/07/20, revealed the skin was warm, dry and no rashes. Review of the weekly skin assessment, dated 01/11/20 revealed there were no new skin issues at this time. She remained with mild redness under the abdominal fold, and to continue with the treatment order. The skin assessment, dated 02/08/20, revealed no new skin issues noted with fading bruises to her abdomen from insulin injection. Review of the progress notes, from 01/02/20 to 02/19/20, revealed no issues or concerns with the resident's right foot. Review of the non-pressure skin condition record, dated 02/20/20, revealed the resident had an area to the right third toe measuring 0.7 centimeter (cm.) in length by 0.7 cm. in width by 0.1 cm. in depth and an area to the right second toe measuring 1.0 cm. in length by 1.5 cm. in width by 0.1 cm. in depth. Observation and interview on 02/18/20 at 11:59 A.M. with Resident #37 revealed she has a dime sized area to her right bottom toe. It was flaky around the edges and has a black spot in the middle the size of an eraser top. She stated the same issue was starting on the third toe of the right foot with dry flaky skin. Her nails were yellow and thick in consistency. She saw the podiatrist in the facility some time back and was supposed to have a follow up appointment but was unsure when that is. She reports the podiatrist looked at the second right toe and did trim her nails and something else but was unsure. She further states she was supposed to wear her shoes, but the two spots on her toes were so sensitive, it made it hard to wear so she was wearing house slippers. Interview on 02/20/20 at 10:15 A.M. with the Director of Nursing (DON) revealed he was unaware of Resident #37 having any issues with her toes on the right foot. He reported she was diabetic. Observation on 02/20/20 at 10:54 A.M. with DON, Campus Nurse Manager and Resident #37 revealed the DON and Campus Nurse Manager examined the area to Resident #37 toes on the right foot. The DON educated the resident to not touch her toes with her hands. The DON asked if the resident's shoes were fitting properly and the resident informed the DON that it hurts to wear her shoes. She was only able (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365504 If continuation sheet Page 17 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Glen Health Services Corp 5155 North High Street Columbus, OH 43214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete to wear shoes for about 20 minutes, so she has been wearing house slippers. The DON educated the resident on the importance of wearing proper fitting shoes as this could cause this issue. The DON reported there was a lack of blood flow to her feet noted by the black discoloration to the center of the area. The DON recommended to the Campus Nurse Manager to pad and protect the area. He encouraged the resident not to wear her shoes and to wear non-skid socks. Campus Nurse Manager report she would add Resident #37 to the wound doctor list for next week. Event ID: Facility ID: 365504 If continuation sheet Page 18 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Glen Health Services Corp 5155 North High Street Columbus, OH 43214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interviews, the facility failed to ensure residents were wearing splints as ordered. This affected one (Resident #19) of two residents reviewed for activities of daily living and positioning. The facility census was 41. Findings include: Review of the medical record for Resident #19 revealed the resident was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebrovascular disease affecting left non dominant hand, cognitive deficits and vascular dementia. Review of the quarterly Minimum Date Set (MDS) assessment, dated 12/03/19, revealed the resident had severe cognitive deficits, had upper extremity impairment on once side, and received splint assistance. Review of the care plan revealed the resident required assistance with activities of daily living due to limited mobility, impaired cognitive skills, cerebral vascular accident, and incontinence. Intervention included to be assisted with brace daily. Review of the physical therapy order, dated 10/25/19, revealed the resident was to wear a left hand splint and a left elbow splint two hours on two hours off every day. Review of the physician orders, dated 02/2020, revealed the resident was to wear a left hand splint during the day and remove at hours of sleep. The physician orders were silent for any elbow splint. Observation on 02/18/20 at 11:17 A.M. of Resident #19 revealed she was up in the activities room and there was no hand or elbow splint in place. Subsequent observation on 02/18/20 at 11:22 A.M. of Resident #19's room and left hand and wrist splint was located on the night stand. Interview on 02/18/20 at 11:32 A.M. with Licensed Practical Nurse (LPN) #44 verified Resident #19 was supposed to be wearing a left hand and elbow splint. Observation on 02/18/20 at 12:02 P.M. revealed the resident remained with no splints in place. Subsequent observation on 02/19/20 at 8:14 A.M. and at 10:17 A.M. revealed Resident #19 was wearing her left hand splint and was not wearing the left elbow splint. The left elbow splint was on top of the night stand and was visibly soiled. Interview on 02/19/20 at 10:19 A.M. with State Tested Nursing Assistant (STNA) #31 verified Resident #19 was to be wearing a left hand and a elbow splint. She stated the left elbow splint was from therapy and she verified it was the resident was not wearing it and it was soiled and she took it to laundry. She stated she was to wear her left hand splint during the day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365504 If continuation sheet Page 19 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Glen Health Services Corp 5155 North High Street Columbus, OH 43214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of the facility's policy, the facility failed to provide timely assistance with toileting to prevent the resident from falling. This caused actual physical harm to Resident #27 when she self-toileted herself since the staff didn't answer her call light timely resulting in the resident falling, sustaining a fracture to her left wrist. This affected one (Resident #27) of one resident reviewed for accidents. The facility identified 26 residents at risk for falls. Findings include: Review of Resident #27's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, insomnia, and fracture of the left ulna. Review of the Minimum Data Set (MDS) assessment, dated 12/27/19, revealed she had a severe cognitive impairment and required total dependence on staff for transfers and extensive assistance from staff for toilet use. Review of the fall risk assessments, dated 11/27/19, 12/18/19, and 02/07/20, revealed she was at moderate risk for falls. Review of the resident's care plan revealed there was no fall care plan and there were no interventions in place to aide in the prevention of the resident from falling despite the resident being assessed at a moderate risk for falls. Review of a progress note, dated 02/07/20, revealed Resident #27 was noted to be sitting on the floor in the bathroom in front of her wheelchair. Her right hand was holding the rail and the left arm was on the wheelchair. She had on non-skid footwear and there was adequate light. The progress note indicated Resident #27 stated she wanted to use the bathroom but could not transfer herself. A head-to-toe assessment was completed, and no visible injuries were noted. She was able to move all extremities. She was assisted with a mechanical lift to the bed by three staff members. Resident #27 denied pain. She was educated to call for help with transfers so the staff could assist her. Review of an incident report, dated 02/07/20, revealed on 02/07/20, Resident #27 was noted to be on the floor in her bathroom in front of her wheelchair. Her right hand was on the rail while the left hand was on the wheelchair. She stated she wanted to use the bathroom but could not transfer herself. The report indicated she was educated to call for help with transfers so staff can assist her. It documented Resident #27 self-transferred to the toilet because she was waiting too long for staff to answer her call light and could no longer hold her bladder. The report stated Resident #27 had, waited too long due to mealtime congestion and was to be scheduled for toileting after meals. Review of a physician's order, dated 02/08/20, revealed the staff were to assist Resident #27 to the bathroom after each meal three times a day for post fall intervention. Review of the nursing note, dated 02/10/20 at 9:26 A.M., revealed Resident #27's daughter notified the nurse that Resident #27 had been complaining of left wrist pain since falling on 02/07/20. The nurse assessed Resident #27. The left wrist was swollen and sore to touch. The note stated her wrist was painful when she tried to hold onto the lift. A new order was obtained for an x-ray of the left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365504 If continuation sheet Page 20 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Glen Health Services Corp 5155 North High Street Columbus, OH 43214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm wrist. A nursing progress note, dated 02/10/20 at 11:04 A.M., revealed the x-ray of Resident #27's wrist revealed a fracture of the distal shaft of the radius. An order was received to send the resident to the emergency room for evaluation and splinting of the fracture. A nursing note, dated 02/10/20 at 6:51 P.M., revealed Resident #27 returned to the facility with a new soft cast to her left lower arm. Residents Affected - Few Interview on 02/19/20 at 5:41 P.M. with the Director of Nursing (DON) confirmed Resident #27's care plan lacked a plan and interventions for falls. The DON confirmed she had prior been assessed as being a moderate risk for falls and that a care plan should have been initiated at that time. The DON confirmed a physician order dated 02/08/20 revealed the staff should assist Resident #27 to the toilet after meals. DON confirmed Resident #27 was severely cognitively impaired and nursing was educating her to use her call light and this was not an effective or appropriate intervention. The DON further confirmed Resident #27 had been waiting with her call light on to use the bathroom for an estimated 30 minutes because staff were assisting with the meal service. He stated an intervention for scheduled toileting after meals was supposed to be implemented but it was not. Review of the facility's policy titled, Accidents and Incidents, dated 10/2017, revealed all accidents involving the residents would be investigated and reported to the Administrator. The policy stated the facility would investigate and generate a report related to the accident/incident and the report would be reviewed by the Safety Committee for trends related to the accident or safety hazards in the facility and to analyze individual resident vulnerabilities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365504 If continuation sheet Page 21 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Glen Health Services Corp 5155 North High Street Columbus, OH 43214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of the facility's policy, the facility failed to have supporting diagnoses for residents who were on psychotropic drugs. This affected two (Resident #13 and #42) of six residents reviewed for unnecessary medications. The facility census was 41. Findings include: 1. Review of Resident #13's medical record revealed he was admitted to the facility 11/08/19. At the time of admission, diagnoses included atrial fibrillation, dysphagia, and hypothyroidism. Review of the Minimum Data Set (MDS) assessment, dated 11/27/19, revealed he had a severe cognitive impairment and his diagnoses did not include dementia with behavioral disturbance. Review of the care plan, dated 11/12/19, revealed it lacked evidence of a diagnoses of dementia with behavioral disturbance or evidence of any exhibited behaviors Review of the physician orders, dated 01/16/20, revealed an order for an antipsychotic medication (Olanzapine) five milligrams (mg.) at bedtime. Further review of the medical record including nursing and state tested nursing aide (STNA) documentation as well as physician progress notes revealed no behaviors were noted. Review of a physician recommendation form, dated 01/28/20, revealed Resident #13 was receiving an antipsychotic and did not have an active diagnosis to support therapy. The recommendation requested the physician to evaluate and update the record accordingly. The physician commented to add a diagnosis of dementia with behavioral symptoms. On 02/04/20, Resident #13 received a new diagnosis of dementia with behavioral disturbance. Interview on 02/19/20 at 4:21 P.M. with Director of Nursing (DON) confirmed Resident #13 received the diagnoses of dementia with behavioral disturbance after a medication regimen review and subsequent recommendation from the consulting pharmacist revealed Resident #13 did not have a diagnosis that warranted the use of an antipsychotic medication. The DON confirmed based on his review of Resident #13's medical record, there were no behaviors documented for Resident #13. The DON stated he did not know why the antipsychotic was prescribed initially as there was no indication for its use in Resident #13's medial record. The DON confirmed Resident #13 did not have a specific, documented condition or behaviors that warranted the use of an antipsychotic medication. 2. Review of Resident #42's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included atrial fibrillation and major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 01/15/20, revealed she was cognitively intact and received an antipsychotic medication seven of the seven days in the review period. The MDS assessment further revealed she received antipsychotics on a routine basis and no gradual dose reduction (GDR) had been attempted. Review of the physician orders revealed an order for an antipsychotic (Seroquel) 25 milligrams (mg.) at bedtime for paranoia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365504 If continuation sheet Page 22 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365504 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Glen Health Services Corp 5155 North High Street Columbus, OH 43214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Review of a form titled, Physician Recommendation Form, dated 11/13/19, revealed Resident #42 was receiving an antipsychotic medication and did not have an active diagnosis to support therapy. The recommendation stated to evaluate and update her record accordingly. The physician neither agreed nor disagreed, checked the box marked, other, and wrote he would like Resident #42's Psychiatrist to manage her psychiatric medications. Residents Affected - Few Review of a handwritten psychiatry note, dated 11/14/19, revealed Resident #42's psychiatrist visited Resident #42 for behaviors of refusing care, cursing at staff and pulling staffs' hair. No diagnoses were listed on the psychiatry note. Further review of Resident #42's medical record lacked evidence of any psychiatric diagnoses other than major depressive disorder. Review of the care plan, nursing and state-tested nursing assistant (STNA) documentation lacked evidence of a diagnosis or behaviors that warranted the use of an antipsychotic medication. The only behavior documented in Resident #42's entire medical record including nursing and STNA documentation as well as physician progress notes was wandering on first shift 01/21/20. Interview on 02/19/20 at 3:20 P.M. with the Director of Nursing (DON) confirmed Resident #42's medical record lacked evidence her attending physician nor psychiatrist addressed the physician recommendation form, dated 11/13/19. The DON confirmed Resident #42's attending physician wrote that her psychiatrist would manage her psychiatric medications and deferred decisions to him. The DON confirmed no physician gave Resident #42 a diagnoses for her prescribed antipsychotic medication. Review of the facility's policy titled, Antipsychotic Medication Use, dated October 2017, revealed residents would only receive antipsychotic medications when necessary to treat specific conditions for which they were indicated. The policy stated antipsychotic medications shall generally be used only for the following conditions documented in the record: schizophrenia, schizo-affective disorder, schizophrenia, delusional disorder, mood disorders (bipolar disorder, depression with psychotic features), psychosis, Tourette's disorder, Huntington Disease, hiccups, and nausea associated with cancer. The policy further revealed diagnoses alone did not warrant the use of antipsychotic medications. In addition to the above criteria, antipsychotic medications would generally only be considered if the behavioral symptoms presented a danger to the resident or others; and the symptoms were identified as being due to mania or psychosis; or behavioral interventions had been attempted and included in the plan or care. Further review it stated antipsychotic medications would not be used if the only symptoms were one or more of the following: wandering; poor self-care; restlessness; impaired memory; mild anxiety; insomnia; inattention or indifference to surroundings; sadness or crying; fidgeting; nervousness; or uncooperativeness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365504 If continuation sheet Page 23 of 23