Health inspection·June 6, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm mental, or psychosocial status such as a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications. This deficiency represents non-compliance investigated under Complaint Number OH00143042. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365504 If continuation sheet Page 2 of 8 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 06/06/2023 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, interview with Hospice staff, review of the facility's Self-Reported Incidents (SRI), and policy review, the facility failed to timely report an injury of unknown origin to State Survey Agency. This affected one (#90) of one resident reviewed for injury of unknown origin. The facility census was 46. Findings include: Review of Resident #90's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included senile degeneration of brain, adult failure to thrive, and seizures. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 was severely cognitively impaired and had no behaviors. Resident #90 was dependent on staff for ambulation and toileting and required extensive assistance from staff with bed mobility, transfers and dressing. Resident #90 was receiving hospice care. Review of the weekly skin assessment dated [DATE] revealed Resident #90 had no new skin alterations, and no areas of skin abnormality were documented on the assessment. Review of the hospice provider progress note dated 03/05/23 at 10:06 A.M. revealed the facility staff reported Resident #90 with a new onset of right leg pain which started on the evening on 03/04/23. The leg was described as swollen and warm to touch. Resident #90 with Tylenol order in place for pain. Hospice Nurse to visit to assess Resident #90's right leg and any further medication needs for pain control. Review of the weekly skin assessment dated [DATE] revealed bruising and edema to the right lower leg continued. No areas of additional skin abnormality were documented on the assessment. Review of the hospice progress note dated 03/09/23 at 11:25 A.M. revealed the hospice nurse spoke with the Certified Nurse Practitioner (CNP) caring for Resident #90 to update her on the new Tylenol order and a new X-ray was ordered. Review of Physician #630's progress note dated 03/09/23 revealed the hospice nurse called related to Resident #90 needing a right lower leg X-ray related to pain and ecchymosis. Resident #90 was documented as unreliable due to cognition. Resident #90 previously reported as high fall risk due to attempts to get out of bed without requesting help, no record of recent falls of trauma noted found per nursing. Physician #630 documented past medical history did not include diagnoses of osteopenia or osteoporosis. Under the assessment and plan, Physician #630 documented Resident #90 had pain in the right lower leg and the right lower leg had scattered ecchymosis. Resident #90 stated the leg was painful to bend at the knee and bilateral lower extremities had positive dorsi and plantar flexion documented. Physician #630 stated X-ray results were pending. Review of the progress note dated 03/13/23 at 7:26 P.M. revealed the X-ray result to the right hip received with the conclusion of internally fixed right proximal femoral fracture deformity without adverse features. The right knee X-ray findings were an acute non-displaced proximal plateau tibial fracture. Ostopenia was shown on the x-ray results but the facility did not obtain the x-rays until (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365504 If continuation sheet Page 3 of 8 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 06/06/2023 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 03/13/23, this was nine days after the initial injury to Resident #90's leg was found. Level of Harm - Minimal harm or potential for actual harm Review of the facility's SRI dated 03/04/23 to 03/13/23 revealed Resident #90's injury of unknown origin was not reported to the State Survey Agency. Residents Affected - Few Interview with the Director of Nursing (DON) on 05/24/23 at 1:20 P.M. verified the X-ray did not state pathological fracture and verified there was no injury of unknown origin reported to the State Survey Agency. The DON stated the facility felt the fracture was caused by the osteoporosis and osteopenia. Telephone interview on 05/24/23 at 2:29 P.M. with Hospice Case Manager Registered Nurse (HCMRN) #600 revealed the hospice staff had made visits to assess Resident #90's right lower leg. HCMRN #600 stated the leg was documented as swollen with bruising and there was no facility documentation or report of a fall or other injury to Resident #90. HCMRN #600 reported the family declined to have the leg X-rayed at this time but wanted the resident pain to be managed by pain medication. HCMRN #600 stated she made the second after hours visit three days later and the facility staff reported to her the residents was stating she had increased pain in the leg, the leg documentation included that the resident had bruising to the leg, but no documentation of why the resident had bruising. Review of the undated policy titled Abuse, Neglect, Exploitation, and Mistreatment of Residents and Misappropriation of Resident Property revealed the purpose of this policy is to provide a systematic approach to abuse and neglect detection and prevention. It is the responsibility of Associates and volunteers to immediately report all such allegations to the Administrator or designee. The Administrator or designee will report to the Ohio Department of Health (ODH) in accordance with the procedures in this policy. An injury is classified as an Injury of Unknown Source when all the following conditions are met: The source of the injury was not observed by any person; and the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. All incident and allegations of Abuse, Neglect, Exploitation, Mistreatment of a Resident, or Misappropriation of Resident Property and all Injuries of Unknown Source must be reported immediately to the Administrator or designee. The Administrator will ensure that reporters are free from retaliation or reprisal. The Administrator/designee is responsible for ensuring allegations are reported to the state agency immediately. When possible, ODH will be notified by using the online Enhanced Information Dissemination & Collection (EIDC) system. The Community will submit an online Self-Reported Incident form in accordance with ODH's then-current instructions. In the event of an internet outage or similar failure, the Community will temporarily notify the ODH District Office of the allegation via alternative method (e.g., phone), and will then submit the Self-Reported Incident online once service is restored. Only the Administrator or someone specifically designated by the Administrator is authorized to submit a Self-Reported Incident form to ODH. This deficiency represents non-compliance investigated under Complaint Number OH00143042. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365504 If continuation sheet Page 4 of 8 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 06/06/2023 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, review of the facility's Self-Reported Incidents (SRI), interview with Hospice staff, and policy review, the facility failed to report an injury of unknown origin to the State Survey Agency and investigate the injury of unknown origin for a resident. This affected one (#90) of one resident reviewed for injury of unknown origin. The facility census was 46. Residents Affected - Few Findings include: Review of Resident #90's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included senile degeneration of brain, adult failure to thrive, and seizures. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 was severely cognitively impaired and had no behaviors. Resident #90 was dependent on staff for ambulation and toileting and required extensive assistance from staff with bed mobility, transfers and dressing. Resident #90 was receiving hospice care. Review of the weekly skin assessment dated [DATE] revealed Resident #90 had no new skin alterations, and no areas of skin abnormality were documented on the assessment. Review of the hospice provider progress note dated 03/05/23 at 10:06 A.M. revealed the facility staff reported Resident #90 with a new onset of right leg pain which started on the evening on 03/04/23. The leg was described as swollen and warm to touch. Resident #90 with Tylenol order in place for pain. Hospice Nurse to visit to assess Resident #90's right leg and any further medication needs for pain control. Review of the weekly skin assessment dated [DATE] revealed bruising and edema to the right lower leg continued. No areas of additional skin abnormality were documented on the assessment. Review of the hospice progress note dated 03/09/23 at 11:25 A.M. revealed the hospice nurse spoke with the Certified Nurse Practitioner (CNP) caring for Resident #90 to update her on the new Tylenol order and a new X-ray was ordered. Review of Physician #630's progress note dated 03/09/23 revealed the hospice nurse called related to Resident #90 needing a right lower leg X-ray related to pain and ecchymosis. Resident #90 was documented as unreliable due to cognition. Resident #90 previously reported as high fall risk due to attempts to get out of bed without requesting help, no record of recent falls of trauma noted found per nursing. Physician #630 documented past medical history did not include diagnoses of osteopenia or osteoporosis. Under the assessment and plan, Physician #630 documented Resident #90 had pain in the right lower leg and the right lower leg had scattered ecchymosis. Resident #90 stated the leg was painful to bend at the knee and bilateral lower extremities had positive dorsi and plantar flexion documented. Physician #630 stated X-ray results were pending. Review of the progress note dated 03/13/23 at 7:26 P.M. revealed the X-ray result to the right hip received with the conclusion of internally fixed right proximal femoral fracture deformity without adverse features. The right knee X-ray findings were an acute non-displaced proximal plateau tibial fracture. Ostopenia was shown on the x-ray results but the facility did not obtain the x-rays until 03/13/23, this was nine days after the initial injury to Resident #90's leg was found. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365504 If continuation sheet Page 5 of 8 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 06/06/2023 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 The facility was unable to provide the facility's investigation into Resident #90's injury of unknown origin to the State Survey Agency on 05/24/23. Review of the facility's SRI dated 03/04/23 to 03/13/23 revealed Resident #90's injury of unknown origin was not reported to the State Survey Agency. Residents Affected - Few Interview with the Director of Nursing (DON) on 05/24/23 at 1:20 P.M. verified the X-ray did not state pathological fracture and verified there was no injury of unknown origin reported to the State Survey Agency. The DON verified the facility did not complete an investigation of Resident #90's injury of unknown origin because the facility felt the fracture was caused by the osteoporosis and osteopenia. The DON stated Resident #90 had no fall or reported injury. If Resident #90 had a fall, Resident #90 lacked the ability to get herself off the floor and staff would have then been aware of a fall but staff denied helping Resident #90 off the floor. Telephone interview on 05/24/23 at 2:29 P.M. with Hospice Case Manager Registered Nurse (HCMRN) #600 revealed the hospice staff had made visits to assess Resident #90's right lower leg. HCMRN #600 stated the leg was documented as swollen with bruising and there was no facility documentation or report of a fall or other injury to Resident #90. HCMRN #600 reported the family declined to have the leg X-rayed at the initial assessment but wanted the resident's pain to be managed by pain medication. HCMRN #600 stated she made the second visit three days later and the facility staff reported to her the residents was stating she had increased pain in the leg, the leg documentation included the resident had bruising to the leg, but no documentation of why the resident had bruising. Review of the undated policy titled Abuse, Neglect, Exploitation, and Mistreatment of Residents and Misappropriation of Resident Property revealed this Community will not tolerate abuse, neglect, exploitation and mistreatment of its Residents or the misappropriation of Resident property and will take necessary steps to provide protections for the health, welfare and rights of each Resident residing in the Community. An injury is classified as an Injury of Unknown Source when all the following conditions are met: the source of the injury was not observed by any person; and the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. All alleged violations involving Abuse, Neglect, Exploitation or Mistreatment of a Resident, or Misappropriation of Resident Property, including Injuries of Unknown Source will be investigated in accordance with this procedure. Once the Administrator and Ohio Department of Health (ODH) are notified, an investigation of the allegation/violation will be conducted by the Administrator/Designee. The focus of the investigation should be to determine if abuse, neglect, exploitation, mistreatment and/or misappropriation of Resident property has occurred, the extent, and cause. The investigation must be completed within five working days, unless there are special circumstances causing the investigation to continue beyond 5 working days (e.g., quantifying amounts misappropriated if accountant needs more time. Evidence of the investigation should be documented. The person investigating the incident should generally take the following actions: a. Interview and obtain or document statements from the Resident, the accused, and all witnesses. Witnesses generally include anyone who: witnessed or heard the incident; came in close contact with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365504 If continuation sheet Page 6 of 8 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 06/06/2023 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 the Resident the day of the incident (including other Residents, family members); and employees who worked closely with the accused employee(s) and/or alleged victim the day of the incident. b. If there are no direct witnesses, then the interviews may be expanded, for example, to cover all employees on the unit, or, as appropriate, the shift. For Injuries of Unknown Source, the investigation may generally involve talking with both the shift on duty when the injury was discovered and prior shifts as well. c. Interviews may also be conducted with Residents who reside on the same unit and/or have similar care needs as the alleged victim. d. Examine the alleged victim for signs of injury, including a physical examination or psychosocial assessment if needed. e. Obtain all medical reports and statements from physicians and/or hospitals if applicable. f. Review the Resident's records. This violation represents non-compliance investigated under Complaint Number OH00143042. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365504 If continuation sheet Page 7 of 8 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 06/06/2023 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 - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews, and policy review, the facility failed to ensure fall interventions were in place for a resident at risk for falls and who had a history of falling. This affected one (#100) of three residents reviewed for falls. The facility census was 46. Findings include: Review of Resident #100's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included syncope, dementia, weakness, and osteoporosis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 had severe cognitive impairment and required extensive assistance from staff for bed mobility, toileting, and transfers. Resident #100 had a fall since admission to the facility and had a fall prior to admission. Review of the care plan revealed Resident #100 was at risk for falls. Interventions included a dropped wheelchair seat and dycem to the wheelchair and a reclining chair. Review of the progress note dated 04/02/23 at 5:54 P.M. revealed the nurse was called to Resident #100's room by a State Tested Nursing Assistant (STNA) and Resident #100 was found lying on the floor beside the reclining chair. Resident #100 was assessed and no injuries were noted, vital signs were normal and neurological checks were initiated. The intervention for the fall was to provide dycem to the wheelchair and reclining chair. Review of Resident #100's physician orders dated 04/03/23 revealed an order for dycem to the reclining chair and wheelchair at all times. Observation of Resident #100 on 06/06/23 at 11:30 A.M. revealed the resident was sitting in his wheelchair and no dycem was observed in the wheelchair. Interview on 06/06/23 at 11:30 A.M. with Activities Worker #590 verified Resident #100 did not have any dycem to his wheelchair. Observation and interview of Resident #100 with the Director of Nursing (DON) on 06/06/23 at 11:40 A.M. verified Resident #100's wheelchair seat was dropped, but no dycem was in the wheelchair. The DON verified Resident #100 should have dycem in the wheelchair and verified it was not present. Review of the undated policy titled Resident Falls revealed to ensure the safety of our residents through assessments, monitoring, supervision, and assistance to prevent the occurrence of falls. The Nurse Manager or designee will complete the Fall Risk Assessment. Based on the results of the assessment, the nurse will determine what factor places the resident at the greatest risk and select an appropriate intervention to prevent a fall. A care plan will be written that identifies the risk factor and provides a list of appropriate interventions. This deficiency represents non-compliance investigated under Complaint Number OH00143042. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365504 If continuation sheet Page 8 of 8