Inspection·December 5, 2023

F 0569 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few emphysema, chronic respiratory failure, dysphagia, cognitive communication deficit, polyneuropathy, peripheral vascular disease, heart failure, anxiety disorder, cardiomyopathy, hypertension, atrial fibrillation, congestive heart failure, atherosclerotic heart disease, schizoaffective disorder, vascular dementia, and occlusion and stenosis of unspecified cerebral artery. Review of the MDS assessment, dated 11/07/23, revealed Resident #19 had a significant cognitive impairment. Review of Resident #19's financial statements, dated 10/01/22 to 09/30/23, revealed his total was above $2000 for the entire time. The totals varied between $3,410.18 and $5,503.92. The facility produces quarterly statements, but after each month, his totals were above $2,000. Spend down notifications were only provided to the resident/representative on 01/03/23, 04/24/23, 07/24/23, and 11/21/23, even though each month from 10/01/22 to 09/30/23 was above $2,000. Interview with Regional Director of Operations #224 on 11/29/23 at 4:11 P.M. confirmed they contact the residents and/or responsible parties to resident finances when they find out they are within $200 of their resident account limit. She confirmed the facility does not have a formal policy regarding spend down notices, but they follow the standard of notifications as soon as the facility knows they are over their limit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 2 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility staff interviews, and facility policy review, the facility failed to ensure resident code status was accurate and consistent throughout medical records for two residents (#8 and #74). The deficient practice affected two residents (#8 and #74) of two residents reviewed for advanced directives. The facility census was 84. Findings include: 1. Review of the medical record for Resident #8 revealed an initial admission date on 08/01/2014 and a readmission date on 03/02/21. Medical diagnoses included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), unspecified protein-calorie malnutrition, emphysema, type II diabetes mellitus, cognitive communication deficit, heart failure, Alzheimer's Disease, and other specified peripheral vascular diseases. Resident #8's code status was listed as Do Not Resuscitate Comfort Care (DNRCC) on the resident's face sheet in the electronic medical record. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 was rarely or never understood. Per the facility staff assessment, Resident #8 had severely impaired cognition. Resident #8 required extensive assistance from one staff member to complete activities of daily living (ADL). Review of the care plan revised 08/26/22 revealed Resident #8 had an advanced directive of DNR-CC initiated on 08/26/22 and cancelled on 11/30/23 due to Resident #8 passing away. Interventions included maintaining communication with the hospice provider, measures will be taken to respect resident and family regarding advanced directives, and respect resident regarding code status decisions. Review of Resident #8's hard chart revealed Resident #8 had a signed order for a code status of Do Not Resuscitate Comfort Care-Arrest (DNRCC-A) dated 11/14 with illegible year. The order was signed by Physician #193. Interview on 11/21/23 at 1:04 P.M. with Registered Nurse (RN) #160 revealed a resident's code status could be confirmed by checking the resident's electronic medical record, the resident's hard chart, or the printed list of residents with their code status that was kept on the medication cart. Interviews on 11/21/23 at 1:17 P.M. with RN #160 and Unit Manager (UM) #109 confirmed Resident #8's electronic medical record showed a code status of DNR-CC, and the resident's hard chart indicated a code status of DNRCC-A. Both facility staff confirmed Resident #8's code statuses did not match in both places. 2. Review of the electronic medical record for Resident #74 revealed an admission date on 06/07/23. Resident #74's code status was listed as DNRCC-A in the electronic medical record. Medical diagnoses included stroke, type II diabetes mellitus, hypokalemia, congestive heart failure, anemia, vascular dementia, and anxiety disorder. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #74 had severely impaired cognition and scored a five out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #74 required assistance ranging from supervision to extensive assistance from one staff to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 3 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 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 0578 complete ADL. Level of Harm - Minimal harm or potential for actual harm Review of the care plan for Resident #74 dated 06/07/23 and revised 09/28/23 revealed Resident #74's advanced directive was DNRCC-A. Interventions included measures will be taken to respect resident and family regarding advanced directives and respect resident regarding code status decisions. Residents Affected - Few Review of the hard chart for Resident #74 revealed a full code status. Interview on 11/21/23 at 1:04 P.M. with RN #160 revealed a resident's code status could be confirmed by checking the resident's electronic medical record, the resident's hard chart, or the printed list of residents with their code status that was kept on the medication cart. Interviews on 11/21/23 at 1:17 P.M. with RN #160 and UM #109 confirmed Resident #74's electronic medical record showed a code status of DNRCC-A and the resident's hard chart indicated a full code status. Both facility staff confirmed Resident #74's code statuses did not match in both places. Review of the facility policy, Advance Directives, revised 12/2016, revealed the policy stated, information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 4 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, financial record review, and staff interview, the facility failed to notify residents/representatives in a timely manner when there was a change in Medicaid benefits. This affected one resident (#3) of four residents reviewed for Medicaid benefits. The facility census was 84. Residents Affected - Few Findings include: Resident #3 was admitted to the facility on [DATE]. Her diagnoses were hemiplegia and hemiparesis, type II diabetes, acute respiratory failure, aphasia, cerebral infarction, vascular dementia, metabolic encephalopathy, peripheral vascular disease, epilepsy, osteoporosis, hydronephrosis, hypertension, hyperlipidemia, and atrial fibrillation. Review of her Minimum Data Set (MDS) assessment, dated 10/15/23, revealed she had a significant cognitive impairment. Review of Resident #3's financial records revealed the facility received notification about her needing to send in documentation and verification for the need of Medicaid services, known as the redetermination. There was no documentation to support the facility took steps to collect the needed documentation and submit it for verification. On 10/31/23, Resident #3 Medicaid insurance benefits ended, and she was transitioned into private pay. There was no documentation to support Resident #3, nor her representatives were notified of these changes in a timely manner. Interview with Business Office Manager (BOM) #2089 on 11/30/23 at approximately 2:30 P.M. confirmed there was no documentation to support notification was made when there was a change to Resident #3's Medicaid benefits. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 5 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. Review of the medical record for Resident #28 revealed an admission date of 10/12/22 with diagnoses of dementia with behavioral disturbance, mood disorder, alcohol abuse, opioid abuse, unspecified psychosis due to substance physiological condition, major depressive disorder, anxiety disorder and developmental disorder of speech and language. Review of the physician orders dated 11/23 revealed Resident #28 received Seroquel (antipsychotic) and duloxetine (antidepressant) medications. Review of the annual MDS assessment, dated 09/05/23, revealed Resident #28 had mild cognitive impairment with physical behaviors towards others. Resident #28 required limited assistance with ADL. Resident #28 had diagnoses of anxiety, depression, psychosis, and dementia. Review of the PASRR dated 06/03/23 revealed Resident #28 had dementia and mood disorder. There were no indications of substance abuse, or serious mental illness as listed in medical record as current diagnoses. Interview on 11/22/23 at 10:00 A.M. with Social Services Director (SSD) #210 and RDO #224 revealed the SSD stated she inputted all non-mental health diagnoses in section D Medical Diagnosis and inputted all mental health diagnoses into section E Indications of Serious Mental Illness. SSD #210 indicated there was not a reason why she was not utilizing the check boxes but confirmed she did not check boxes correctly to indicate the diagnoses. An interview on 11/22/23 at 11:17 A.M. with RDO #224 confirmed the facility did not notify the appropriate state-designated mental health authority for review for resident's PASRR dated 06/03/23. 10. Review of the medical record for Resident #59 revealed an admission date of 01/12/22 with diagnoses including senile degeneration of brain, vascular dementia with behavioral disturbance, schizoaffective disorder, unspecified psychosis, generalized anxiety, and major depressive disorder. Review of the physician orders dated 11/23 revealed Resident #59 received abilify (antipsychotic), fluoxetine hydrochloride (antidepressant), and trazadone (antidepressant). Review of the annual MDS assessment dated [DATE] revealed Resident #59 had severe cognitive impairment, with feelings of depression, little interest, trouble sleeping, and trouble concentrating. Resident #59 required maximal assistance for ADL. Resident #59 had diagnoses of anxiety, depression, and psychotic disorder other than schizophrenia. Review of the PASRR dated 07/24/23 revealed Resident #59 had anxiety/panic disorder, unspecified psychosis and major depressive disorder. There was no indication of vascular dementia, and schizoaffective disorder as listed in the medical record as current diagnoses. Interview on 11/22/23 at 10:00 A.M. with SSD #210 and RDO #224 revealed the SSD stated she inputted all non-mental health diagnoses in section D Medical Diagnosis and inputted all mental health diagnoses into section E Indications of Serious Mental Illness. SSD #210 indicated there was not a reason why she was not utilizing the check boxes but confirmed she did not check boxes correctly to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 6 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 indicate the diagnoses. Level of Harm - Minimal harm or potential for actual harm An interview on 11/22/23 at 11:17 A.M. with RDO #224 confirmed the facility did not notify the appropriate state-designated mental health authority for review for resident's PASRR dated 07/24/23. Residents Affected - Some Review of the facility policy, admission Criteria, revised 12/2016, revealed the policy stated, nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-admission Screening and Resident Review program to the extent practicable. Potential residents with mental disorders or intellectual disabilities will only be admitted if the State mental health agency has determined (through the preadmission screening program) that the individual has a physical or mental condition that requires the level of services provided by the facility. Based on medical record review, staff interview, and facility policy review the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASRR) documents were accurate to resident current conditions and diagnoses. This affected ten residents (#59, #28, #68, #37, #14, #19, #56, #75, #42, and #55) of 13 residents reviewed for PASRR documents. The facility census was 84. Findings include: 1. Resident #14 was admitted to the facility on [DATE]. Her diagnoses were osteomyelitis of vertebra, type II diabetes, chronic obstructive pulmonary disease (COPD), acute respiratory failure, dysphagia, muscle wasting and atrophy, hypokalemia, acute kidney failure, dementia, alcohol abuse, retention of urine, acidosis, bipolar disorder, altered mental status, hypotension, chronic kidney disease (stage III), cognitive communication deficit, schizophrenia, major depressive disorder, insomnia, pressure ulcer left heel, hypertension, anxiety disorder, adjustment disorder, atrial fibrillation, anemia, and gout. Review of her Minimum Data Set (MDS) assessment, dated 10/26/23, revealed she had a significant cognitive impairment. Review of Resident #14 PASRR document, dated 08/25/23, revealed under Section D, the document indicated that she did not have dementia, when she has had that diagnosis since 09/08/23. Then, under section E, her diagnosis of major depressive disorder was not documented. 2. Resident #42 was admitted to the facility on [DATE]. Her diagnoses were metabolic encephalopathy, cellulitis, chronic respiratory failure with hypoxia, anxiety disorder, bipolar disorder, major depressive disorder, pure hypercholesterolemia, schizoaffective disorder, osteoarthritis of hip, hypertension, and dysphagia. Review of her MDS assessment, dated 09/26/23, revealed she was cognitively intact. Review of Resident #42 updated PASRR document, dated 08/04/23, revealed under Section E, the following diagnoses were missing from being indicated on the document: bipolar disorder, mood disorder, and, major depressive disorder, which were added on 05/03/23. Also, the PASRR document indicated she had other psychotic disorders, but there was no documentation to support her diagnosis. 3. Resident #75 was most recently admitted to the facility on [DATE]. His diagnoses were spinal stenosis, COPD, muscle weakness, Parkinsonism, osteoarthritis, cognitive communication deficit, anxiety disorder, hypertension, peripheral vascular disease, anemia, hyperlipidemia, major depressive disorder, hypothyroidism, bipolar disorder, post-traumatic stress disorder, quadriplegia, polyneuropathy, mood disorder, and cocaine abuse. Review of his MDS assessment, dated 09/24/23, revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 7 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 cognitively intact. Level of Harm - Minimal harm or potential for actual harm Review of Resident #75 PASRR document, dated 07/17/23, revealed under Section D, it indicated he had dementia, which was not accurate. Also, under section E, it was documented that he had no mental health diagnoses. But looking at his medical documentation, he does have the following mental health diagnoses that should have been indicated on the PASRR document: anxiety disorder, major depressive disorder, bipolar disorder, post-traumatic stress disorder, and mood disorder. All these diagnoses were added on 06/20/23. Residents Affected - Some Interview with Social Services Director #210 and Regional Director of Operation #224 on 11/22/23 at 11:07 A.M. and 11:17 A.M. confirmed the above PASRR documents were incorrect and should have been corrected. 4. Review of the medical record for Resident #37 revealed an admission date on 10/06/23. Medical diagnoses included dementia in other diseases classified elsewhere (10/06/23), post-traumatic stress disorder (10/06/23), anxiety disorder (10/06/23), major depressive disorder recurrent (10/06/23), alcohol abuse (10/06/23), and personal history of traumatic brain injury (10/06/23). Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #37 had intact cognition and scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Review of the PASARR dated 10/09/23 revealed the PASRR did not include Resident #37's diagnoses of dementia, post-traumatic stress disorder, major depressive disorder recurrent, or personal history of traumatic brain injury. PASRR indicated Resident #37 had an other psychotic disorder. However, there was no evidence Resident #37 had a medical diagnosis of a psychotic disorder. Interview on 11/22/23 at 11:17 P.M. with the Regional Director of Operations (RDO) #224 confirmed the above medical diagnoses were not included on Resident #37's PASRR. RDO #224 also confirmed there was no evidence Resident #37 had a medical diagnosis of a psychotic disorder. 5. Review of the medical record for Resident #68 revealed an admission date on 11/17/22. Medical diagnoses included schizoaffective disorder (11/17/22), alcohol abuse (11/17/22), bipolar disorder recurrent (11/17/22), anxiety disorder (11/17/22), major depressive disorder recurrent (11/17/22), post-traumatic stress disorder chronic (11/17/22), cannabis abuse (11/17/22), and mood disorder due to known physiological condition (11/17/22). Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #68 had intact cognition and scored a 14 out of 15 on the BIMS assessment. Resident #68 required extensive assistance from one staff to complete Activities of Daily Living (ADL). Review of the PASRR dated 07/20/23 revealed Resident #68's medical diagnoses of anxiety disorder, bipolar disorder recurrent, alcohol abuse and cannabis abuse were not included on the PASRR. The PASRR indicated Resident #68 had a diagnosis of other psychotic disorder. However, there was no evidence the resident had a medical diagnosis of psychotic disorder. Interview on 11/22/23 at 11:17 P.M. with RDO #224 confirmed the above medical diagnoses were not included on Resident #37's PASRR. RDO #224 also confirmed there was no evidence Resident #37 had a medical diagnosis of a psychotic disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 8 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the facility policy, admission Criteria, revised 12/2016, revealed the policy stated, nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-admission Screening and Resident Review program to the extent practicable. Potential residents with mental disorders or intellectual disabilities will only be admitted if the State mental health agency has determined (through the preadmission screening program) that the individual has a physical or mental condition that requires the level of services provided by the facility. 6. Resident #19 was admitted to the facility on [DATE]. Resident #19's diagnoses included Human Immunodeficiency Virus (HIV) disease, type II diabetes mellitus, anxiety, major depressive disorder, schizoaffective disorder, hemiplegia, and hemiparesis. Review of Resident #19's MDS assessment, dated 08/09/23, revealed Resident #19 was moderately cognitively impaired. Review of Resident #19's PASRR document, dated 08/08/23, revealed under Section D, questions one - is there a diagnosis of dementia was checked yes. Question two - list the current diagnoses, all that can be visualized is the Primary diagnoses of HIV. Under section E, schizophrenia, anxiety disorders and Other are checked. No other diagnoses were listed. Review of Resident #19's diagnoses list revealed Resident #19 had the following diagnoses that should have been indicated on the PASRR document: major depressive disorder, and vascular dementia. 11/22/23 11:17 A.M. Interview with RDO #224 confirmed above diagnoses were not included on resident's PASRR dated 08/09/23. 7. Resident #55 was admitted to the facility on [DATE] with diagnoses including encephalopathy, communication deficit, vascular dementia, schizophrenia, Bell's Palsy, epilepsy, major depressive disorder, mood disturbance and anxiety. Resident #55's MDS dated [DATE] revealed she was mildly cognitively impaired. Review of Resident #55's PASRR document, dated 07/27/23, revealed under Section D, questions one - is there a diagnosis of dementia was checked yes. Question two - list the current diagnoses, all that can be visualized is vascular dementia. Under section E, schizophrenia and Other are checked. No other diagnoses were listed. Review of Resident #55's diagnoses list revealed Resident #55 had the following diagnoses that should have been indicated on the PASRR document: major depressive disorder, mood disturbance, and anxiety. Interview on 11/22/23 at 11:17 A.M. with RDO #224 confirmed above diagnoses were not included on resident's PASRR dated 07/27/23. 8. Resident #56 was admitted to the facility on [DATE] with diagnoses that included type II diabetes mellitus with diabetic peripheral neuropathy, cognitive communication deficit, schizophrenia, bipolar disorder, and major depressive disorder. Resident #56's MDS dated [DATE] revealed she was cognitively impaired. Review of Resident #56's PASRR document, dated 07/23/23, revealed under Section D, questions one - is there a diagnosis of dementia was checked yes. Question two - list the current diagnoses, all that can be visualized is Type 2 diabetes mellitus. Under section E, schizophrenia and other are checked. No other diagnoses were listed. Review of Resident #56's diagnoses list revealed Resident #56 had the following diagnoses that should have been indicated on the PASRR document: major depressive disorder and bipolar disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 9 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Interview on 11/22/23 at 11:17 A.M. with RDO #224 confirmed above diagnoses were not included on resident's PASRR dated 07/23/23. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 10 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. Review of the medical record for Resident #28 revealed an admission date of 10/12/22 with diagnoses of dementia with behavioral disturbance, mood disorder, alcohol abuse, opioid abuse, unspecified psychosis due to substance physiological condition, major depressive disorder, anxiety disorder, and developmental disorder of speech and language. Review of the physician orders dated 11/23 revealed Resident #28 received Seroquel (antipsychotic) and duloxetine (antidepressant) medications. Review of the annual MDS assessment dated [DATE] revealed Resident #28 had mild cognitive impairment with physical behaviors towards others. Resident #28 required limited assistance with ADL. Resident #28 had diagnoses of anxiety, depression, psychosis, and dementia. Review of the PASRR dated 06/03/23 revealed Resident #28 had dementia and mood disorder. There were no indications of substance abuse, or serious mental illness as listed in medical record as current diagnoses. Interview on 11/22/23 at 10:00 A.M. with SSD #210 and RDO #224 revealed SSD #210 stated she inputted all non-mental health diagnoses in section D Medical Diagnosis and inputted all mental health diagnoses into section E Indications of Serious Mental Illness. SSD #210 indicated there was not a reason why she was not utilizing the check boxes but confirmed she did not check boxes correctly to indicate the diagnoses. Interview on 11/22/23 at 11:17 A.M. with RDO #224 confirmed Resident #28's diagnoses of psychosis and substance abuse were not included on the resident's PASRR dated 06/03/23. 10. Review of the medical record for Resident #59 revealed an admission date of 01/12/22 with diagnoses including senile degeneration of brain, vascular dementia with behavioral disturbance, schizoaffective disorder, unspecified psychosis, generalized anxiety, and major depressive disorder. Review of the physician orders dated 11/23 revealed Resident #59 received abilify (antipsychotic), fluoxetine hydrochloride (antidepressant), and trazadone (antidepressant). Review of the annual MDS assessment dated [DATE] revealed Resident #59 had severe cognitive impairment, with feelings of depression, little interest, trouble sleeping, and trouble concentrating. Resident #59 required maximal assistance for ADL. Resident #59 had diagnoses of anxiety, depression, and psychotic disorder other than schizophrenia. Review of the PASRR dated 07/24/23 revealed Resident #59 had anxiety/panic disorder, unspecified psychosis, and major depressive disorder. There was no indication of vascular dementia and schizoaffective disorder as listed in the medical record as current diagnoses. Interview on 11/22/23 at 10:00 A.M. with SSD #210 and RDO #224 revealed SSD #210 stated she inputted all non-mental health diagnoses in section D Medical Diagnosis and inputted all mental health diagnoses into section E Indications of Serious Mental Illness. SSD #210 indicated there was no reason why she was not utilizing the check boxes but confirmed she did not check boxes correctly to indicate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 11 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0646 the diagnoses. Level of Harm - Minimal harm or potential for actual harm Interview on 11/22/23 at 11:17 A.M. with RDO #224 confirmed Resident #59 diagnoses of schizoaffective disorder and vascular dementia were not included on the resident's PASRR dated 07/24/23. Residents Affected - Some Based on medical record review, staff interview, and facility policy review the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected ten residents (#59, #28, #68, #37, #14, #19, #56, #75, #42, and #55) of 13 residents reviewed for Pre-admission Screening and Resident Review (PASRR) documents. The facility census was 84. Findings include: 1. Resident #14 was admitted to the facility on [DATE]. Her diagnoses were osteomyelitis of vertebra, type II diabetes, chronic obstructive pulmonary disease (COPD), acute respiratory failure, dysphagia, muscle wasting and atrophy, hypokalemia, acute kidney failure, dementia, alcohol abuse, retention of urine, acidosis, bipolar disorder, altered mental status, hypotension, chronic kidney disease (stage III), cognitive communication deficit, schizophrenia, major depressive disorder, insomnia, pressure ulcer left heel, hypertension, anxiety disorder, adjustment disorder, atrial fibrillation, anemia, and gout. Review of her Minimum Data Set (MDS) assessment, dated 10/26/23, revealed she had a significant cognitive impairment. Review of Resident #14's PASRR document, dated 08/25/23, revealed under Section D, the document indicated that she did not have dementia, when she has had that diagnosis since 09/08/23. Then, under section E, her diagnosis of major depressive disorder was not documented. There was no documented evidence to support these significant mental health changes were communicated to the state mental health agency. 2. Resident #42 was admitted to the facility on [DATE]. Her diagnoses were metabolic encephalopathy, cellulitis, chronic respiratory failure with hypoxia, anxiety disorder, bipolar disorder, major depressive disorder, pure hypercholesterolemia, schizoaffective disorder, osteoarthritis of hip, hypertension, and dysphagia. Review of her MDS assessment, dated 09/26/23, revealed she was cognitively intact. Review of Resident #42's updated PASRR document, dated 08/04/23, revealed under Section E, the following diagnoses were missing from being indicated on the document: bipolar disorder, mood disorder, and, major depressive disorder, which were added on 05/03/23. Also, the PASRR document indicated she had other psychotic disorders, but there was no documentation to support she had this diagnosis. There was no documented evidence to support these significant mental health changes were communicated to the state mental health agency. 3. Resident #75 was most recently admitted to the facility on [DATE]. His diagnoses were spinal stenosis, COPD, muscle weakness, Parkinsonism, osteoarthritis, cognitive communication deficit, anxiety disorder, hypertension, peripheral vascular disease, anemia, hyperlipidemia, major depressive disorder, hypothyroidism, bipolar disorder, post-traumatic stress disorder, quadriplegia, polyneuropathy, mood disorder, and cocaine abuse. Review of his MDS assessment, dated 09/24/23, revealed he was cognitively intact. Review of Resident #75's PASRR document, dated 07/17/23, revealed under Section D, it indicated he had dementia, which was not accurate. Also, under section E, it was documented that he had no mental (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 12 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0646 Level of Harm - Minimal harm or potential for actual harm health diagnoses. But looking at his medical documentation, he does have the following mental health diagnoses that should have been indicated on the PASRR document: anxiety disorder, major depressive disorder, bipolar disorder, post-traumatic stress disorder, and mood disorder. All these diagnoses were added on 06/20/23. There was no documented evidence to support these significant mental health changes were communicated to the state mental health agency. Residents Affected - Some Interview with Social Services Director (SSD) #210 and Regional Director of Operation (RDO) #224 on 11/22/23 at 11:07 A.M. and 11:17 A.M. confirmed the above PASRR documents were incorrect and should have been corrected. They also confirmed there was no documented evidence to support the significant changes to the resident's mental health diagnoses were communicated to the state mental health agency. 4. Review of the medical record for Resident #37 revealed an admission date on 10/06/23. Medical diagnoses included dementia in other diseases classified elsewhere (10/06/23), post-traumatic stress disorder (10/06/23), anxiety disorder (10/06/23), major depressive disorder recurrent (10/06/23), alcohol abuse (10/06/23), and personal history of traumatic brain injury (10/06/23). Review of the admission MDS assessment dated [DATE] revealed Resident #37 had intact cognition and scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Review of the PASRR dated 10/09/23 revealed the PASRR did not include Resident #37's diagnoses of dementia, post-traumatic stress disorder, major depressive disorder recurrent or personal history of traumatic brain injury. The PASRR indicated Resident #37 had an other psychotic disorder. However, there was no documented evidence Resident #37 had a medical diagnosis of a psychotic disorder. There was no evidence the state mental health agency had been properly notified of all of Resident #37's mental health diagnoses. Interview on 11/22/23 at 11:17 P.M. with RDO #224 confirmed the above medical diagnoses were not included on Resident #37's PASRR. RDO #224 also confirmed there was no documented evidence Resident #37 had a medical diagnosis of a psychotic disorder. RDO #224 confirmed there was no documented evidence the state mental health agency was properly notified of all of Resident #37's mental health diagnoses. 5. Review of the medical record for Resident #68 revealed an admission date on 11/17/22. Medical diagnoses included schizoaffective disorder (11/17/22), alcohol abuse (11/17/22), bipolar disorder recurrent (11/17/22), anxiety disorder (11/17/22), major depressive disorder recurrent (11/17/22), post-traumatic stress disorder chronic (11/17/22), cannabis abuse (11/17/22), and mood disorder due to known physiological condition (11/17/22). Review of the quarterly MDS assessment dated [DATE] revealed Resident #68 had intact cognition and scored a 14 out of 15 on the BIMS assessment. Resident #68 required extensive assistance from one staff member to complete activities of daily living (ADL). Review of the PASRR dated 07/20/23 revealed Resident #68's medical diagnoses of anxiety disorder, bipolar disorder recurrent, alcohol abuse, and cannabis abuse were not included on the PASRR. The PASRR indicated Resident #68 had a diagnosis of other psychotic disorder. However, there was no evidence the resident had a medical diagnosis of psychotic disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 13 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some There was no evidence the state mental health agency had been notified of all of Resident #68's mental health diagnoses. Interview on 11/22/23 at 11:17 P.M. with RDO #224 confirmed the above medical diagnoses were not included on Resident #37's PASRR. RDO #224 also confirmed there was no evidence Resident #37 had a medical diagnosis of a psychotic disorder. RDO #224 confirmed there was no documented evidence the state mental health agency had been properly notified of all of Resident #68's mental health diagnoses. Review of the facility policy, admission Criteria, revised 12/2016, revealed the policy stated, nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-admission Screening and Resident Review program to the extent practicable. Potential residents with mental disorders or intellectual disabilities will only be admitted if the State mental health agency has determined (through the preadmission screening program) that the individual has a physical or mental condition that requires the level of services provided by the facility. 6. Resident #19 was admitted to the facility on 08/2720. Resident #19's diagnoses included human immunodeficiency virus (HIV) disease, type II diabetes mellitus, anxiety, major depressive disorder, schizoaffective disorder, hemiplegia and hemiparesis. Review of Resident #19's MDS assessment, dated 08/09/23, revealed Resident #19 was moderately cognitively impaired. Review of Resident #19's PASRR document, dated 08/08/23, revealed under Section D, questions one - is there a diagnosis of dementia was checked yes. Question two - list the current diagnoses, all that can be visualized is the primary diagnoses of HIV. Under section E, schizophrenia, anxiety disorders and other were checked. No other diagnoses were listed. Review of Resident #19's diagnoses list revealed Resident #19 had the following diagnoses that should have been indicated on the PASRR document: major depressive disorder and vascular dementia. Interview on 11/22/23 at 11:17 A.M. with RDO #224 confirmed above diagnoses were not included on resident's PASRR dated 08/09/23. 7. Resident #55 was admitted to the facility on [DATE] with diagnoses including encephalopathy, communication deficit, vascular dementia, schizophrenia, Bell's palsy, epilepsy, major depressive disorder, mood disturbance, and anxiety. Resident #55's MDS dated [DATE] revealed she was mildly cognitively impaired. Review of Resident #55's PASRR document, dated 07/27/23, revealed under Section D, questions one - is there a diagnosis of dementia was checked yes. Question two - list the current diagnoses, all that could be visualized was vascular dementia. Under section E, schizophrenia and other were checked. No other diagnoses were listed. Review of Resident #55's diagnoses list revealed Resident #55 had the following diagnoses that should have been indicated on the PASRR document: major depressive disorder, mood disturbance, and anxiety. Interview on 11/22/23 at 11:17 A.M. with RDO #224 confirmed above diagnoses were not included on resident's PASRR dated 07/27/23. 8. Resident #56 was admitted to the facility on [DATE] with diagnoses including type II diabetes mellitus with diabetic peripheral neuropathy, cognitive communication deficit, schizophrenia, bipolar disorder, and major depressive disorder. Resident #56's MDS dated [DATE] revealed she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 14 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0646 cognitively impaired. Level of Harm - Minimal harm or potential for actual harm Review of Resident #56's PASRR document, dated 07/23/23, revealed under Section D, questions one - is there a diagnosis of dementia was checked yes. Question two - list the current diagnoses, all that could be visualized was type II diabetes mellitus. Under section E, schizophrenia and other were checked. No other diagnoses were listed. Review of Resident #56's diagnoses list revealed Resident #56 had the following diagnoses that should have been indicated on the PASRR document: major depressive disorder and bipolar disorder. Residents Affected - Some Interview on 11/22/23 at 11:17 A.M. with RDO #224 confirmed above diagnoses were not included on resident's PASRR dated 07/23/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 15 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 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 - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interviews with facility staff, review of laboratory test results, review of hospital records, and review of facility policies, the facility failed to provide timely, adequate, and necessary care and treatment to Resident #74 following laboratory notification of a critically low potassium level. This resulted in Immediate Jeopardy and Actual Harm on 09/08/23 when a Basic Metabolic Panel (BMP) laboratory blood test showed a critically low potassium level of 2.7 milliequivalents (meq)/hour (hr) (normal 3.5 to 5.3 meq/hr), and the facility failed to notify the physician or provide treatment until 09/15/23. On 09/15/23 Resident #74 was assessed to be dehydrated and had increased confusion which had worsened over the previous week. From 09/15/23 to 09/19/23 the facility failed to ensure physician orders related to a fluid bolus were clarified and failed to ensure nursing staff adequately monitored the resident. On 09/19/23 the resident was transferred to the hospital and treated for ventricular tachycardia (VT) requiring one electric shock treatment before a return of spontaneous circulation (ROSC) was received as well as treatment for hypokalemia (low potassium). The resident was hospitalized until 09/22/23 and then admitted to Hospice care services on 09/27/23. Residents Affected - Few Additionally, a concern that did not rise to an Immediate Jeopardy occurred when facility staff failed to timely notify the physician or accurately address abnormal laboratory testing for Resident #19, #24 and #34. This affected four residents (#19, #24, #34, and #74) of four residents reviewed for laboratory services, physician notification, and quality of care. The facility census was 84. On 11/28/23 at 4:10 P.M., the Administrator, Regional Director of Operations #224, Corporate Director of Nursing (CDON) #102, Director of Nursing (DON), [NAME] President of Clinical Services #230, and [NAME] President of Operations #231 were notified Immediate Jeopardy began on 09/08/23 at 2:55 P.M. when a critically low potassium level of 2.7 for Resident #74 was received and the facility failed to notify Physician #191 of the critical lab results or provide treatment until 09/15/23 (one week later). Additionally, on 09/15/23 the facility failed to ensure a complete physician's order was obtained for a bolus of fluids to treat Resident #74's dehydration. The facility failed to monitor Resident #74 every two hours as their policy stated while the resident received the fluids. The facility failed to develop and implement a comprehensive care plan for Resident #74 that addressed the resident's risk for low potassium levels. The resident required hospital treatment/intervention after being transferred from the facility to the hospital on [DATE]. The Immediate Jeopardy was removed on 11/29/23 when the facility completed the following actions: On 09/19/23 at 9:00 A.M., an order was received to send Resident #74 to the hospital after reassessment due to altered mental status (AMS), lethargy and elevated blood pressure of 174/94. The resident was re-admitted to the facility on [DATE] at 5:43 P.M. On 11/27/23 at 11:00 A.M. the facility subcutaneous (SQ) infusion policy was reviewed by [NAME] President of Clinical Services #230, [NAME] President of Operations ##231, Regional Director of Operations #224, and CDON #103 with no changes made to policy. On 11/28/23 at 5:00 P.M., a whole house audit for any resident with any change in condition in the last seven days was completed to ensure care plans were in place and address specific interventions by the Minimum Data Set (MDS) Nurse Director #212. MDS Nurse Director #212 also audited all current residents with chronic clinical condition history to ensure care plans reflected monitoring. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 16 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 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 - Immediate jeopardy to resident health or safety Residents Affected - Few On 11/28/23 at 5:00 P.M., a whole house audit was completed to ensure labs drawn in the last seven days had physician notifications for any critical results by CDON #103. On 11/28/23 at 5:00 P.M., a whole house audit was completed to ensure any changes in condition in the last seven days had physician notification by CDON #103. On 11/28/23 at 5:10 P.M., nursing management was educated on Change of Condition, Lab Services, and Notification per facility policy by CDON #103. Nursing managers included: ADON #105, DON, and Unit Manager #109. On 11/28/23 at 5:44 P.M., an Ad Hoc Quality Assessment Performance Improvement (QAPI) meeting was conducted with the Administrator, ADON #105, CDON #103, Human Resources Director #204, Dietary Director #207, and Physician #191 (Medical Director), Therapy Director #225, Business Office Manager (BOM) #209, Housekeeping Director #232, MDS Nurse Director #212, Unit Manager #109, and Activities Director #214. The Immediate Jeopardy Notification was reviewed, policies on Change of Condition, Lab Services, and Notification were reviewed. Also, audits were implemented, and a plan for weekly QAPI to take place. Policies were reviewed at this time with no changes made. The facility would also hold weekly QAPl meetings times four weeks. On 11/28/23 at 6:22 P.M., a whole house education was completed to all nurses (20 LPNs and seven RNs) by the DON, ADON #105, and Unit Manager #109. Change of Condition, Lab Services, and Notification were reviewed. At the time of the training, the facility identified they used no agency staff, and no current employees were on leave. On 11/28/23, audits began and would be conducted five times weekly by the DON/designee to ensure any critical lab values had physician notification promptly times four weeks then weekly thereafter for eight weeks. On 11/28/23, audits began and would be conducted five times weekly by the DON/designee to ensure any change in condition is reassessed 24 hours after the initial change in condition with physician notification, the care plan is updated after the initial change in condition, and that physician notification is completed with any discrepancies from reassessment and orders obtained if appropriate times four weeks, then weekly thereafter for eight weeks. On 11/29/23 at 5:50 P.M., whole house education was completed to nursing managers including the ADON, Unit Manager (UM) #109, MDS Nurse Director #212, and the DON by CDON #103 related to infusion orders that included the SQ infusion policy and chronic clinical history care planning. Infusion education was to cover all forms of possible infusions. On 11/29/23 at 6:32 P.M., whole house education was completed for all nurses (20 LPNs and seven RNs) by ADON #105, the DON, and Unit Manager (UM) #109 over infusion orders, SQ infusion policy, and chronic clinical history care planning. The facility has no agency nurses or staff on leave at the time of the training. For all newly hired nurses, the facility would complete education during orientation. The infusion education covered all forms of possible infusions. On 11/29/23, audits were started and would be conducted five times weekly by the DON/designee to ensure any infusion orders had the correct rate, dose, amount, and time along with assessments of sites while infusions run times four weeks, then weekly thereafter for eight weeks. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 17 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 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 - Immediate jeopardy to resident health or safety Residents Affected - Few All audits would be discussed/reviewed through QAPI weekly times four weeks. Any discrepancies will be addressed at that time. Although the Immediate Jeopardy was removed on 11/29/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: 1.Review of the medical record for Resident #74 revealed an admission date of 06/07/23 with medical diagnoses including cerebral infarction (stroke), type II diabetes mellitus, generalized muscle weakness, difficulty in walking, vascular dementia with behavioral disturbance, other abnormalities of gait and mobility, essential primary hypertension (high blood pressure), hypokalemia (added on 09/22/23) (low potassium level), paroxysmal atrial fibrillation, syncope and collapse, cardiac arrhythmia (added on 09/22/23), and congestive heart failure (added on 09/22/23). Review of Resident #74's laboratory testing result history from 03/15/22 through 10/27/23 revealed Resident #74's potassium levels ranged from 3.1 to 5.2 milliequivalents (meq)/hour (hr). The normal range for potassium level is 3.5 to 5.3 meq/hr. Review of the plan of care, dated 06/07/23 revealed Resident #74's risk for hypokalemia (low potassium levels) was not addressed in the resident's care plan. A diagnosis of hypokalemia was added to the care plan for cardiovascular status on 09/22/23. However, there were no specific interventions related to the hypokalemia diagnosis added to the care plan. Review of Physician #191's progress note dated 09/07/23 revealed the physician visited Resident #74 for a scheduled surveillance visit. Physician #191 was notified Resident #74 had experienced two falls that week and diarrhea for four days. Resident #74's blood glucose levels, blood pressures, and neurological checks were within normal limits. Physician #191 ordered orthostatic blood pressures, a Clostridium difficile (C. Diff) test, complete blood count (CBC) and basic metabolic panel (BMP) laboratory tests. Review of the corresponding physician's orders for September 2023 revealed on 09/07/23 orders for a CBC, BMP, and urinalysis (UA) laboratory tests. Review of the laboratory test results dated 09/08/23 revealed Resident #74 had a renal critically low (RCL) potassium level of 2.7 milliequivalents (meq)/hour (hr). Test results also show hypoglycemia with a low glucose level of 58, and a high creatinine level of 1.6 (normal range was listed as 0.6 to 1.2). The results were reported (from the lab to the facility) on 09/08/23 at 2:55 P.M. Review of the progress notes revealed there was no documented evidence the physician was notified of the critical lab results for Resident #74. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #74 had severely impaired cognition with a score of five out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #74 required supervision from one staff to complete bed mobility and limited assistance from one staff to complete transfers. Resident #74 required extensive assistance from one staff to complete dressing, toileting, and personal hygiene tasks. Resident #74 had not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 18 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 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 experienced any falls and did not receive any special services, including hospice services. Level of Harm - Immediate jeopardy to resident health or safety Review of Physician #191's untimed progress note dated 09/15/23 (seven days after the laboratory results were obtained) revealed Resident #74 was seen for follow-up of abnormal lab results. Resident #74 was noted with dehydration, acute injury of the kidney most likely in setting of low perfusion (reduced peripheral blood flow) and dehydration, hypokalemia (low potassium level) with critically low potassium level of 2.7, worsened anemia without an obvious source of bleeding, and high creatinine level. Physician #191 ordered a STAT (immediate) CBC, BMP, and UA along with a potassium supplement (on 09/15/23). Physician #191 confirmed the facility did not notify her of Resident #74's critical lab results (on 09/08/23). Physician #191 was informed by the nurse at the time of the visit that Resident #74 had not had diarrhea during the shift but was unable to state when it had improved. Resident #74 had poor intakes for some time. Unit Manager (UM) #111 notified Physician #191 Resident #74 had been more confused than normal for over one week. The nurse notified Physician #191 later in the day (on 09/15/23) that the laboratory testing (ordered on this date) could not be completed as attempts to obtain blood from the resident were unsuccessful. Physician #191 ordered a subcutaneous (SQ) bolus of 500 milliliters (mL) of normal saline (NS) with labs to be repeated once fluids were administered. Physician #191 noted having a lengthy conversation with ADON #105, CDON #103, and UM #111 related to proper notification protocols of abnormal lab results. Residents Affected - Few Review of additional physician's orders dated September 2023 revealed Resident #74 had an order for STAT CBC and BMP laboratory tests one time only for altered mental status dated 09/15/23 at 6:30 P.M. The tests were ordered by Physician #191 and had an end date on 09/16/23 at 6:29 P.M. Resident #74 had a physician's order for 500 mL of 0.9% NS bolus one time only for hydration dated 09/15/23. The order did not indicate a rate, end date, or end time. The order was made by Physician #191. Resident #74 had an order for Potassium Chloride Extended Release 20 meq with instructions to give two tablets one time only for hypokalemia (administer a total of 40 meq). The order was dated 09/15/23. Review of the progress note dated 09/15/23 at 6:23 P.M. by LPN #226 revealed a lab technician arrived to draw STAT CBC and BMP labs but was not able to obtain. Physician #191 was notified and gave orders to administer 500 mL bolus of 0.9% NS and 40 meq of potassium one time. Repeat STAT CBC and BMP after administration of fluids. The note did not specify a rate for the bolus or an end date or time. Review of the progress note dated 09/15/23 at 6:24 P.M. by LPN #226 revealed the nurse placed a SQ IV in Resident #74's lower left quadrant of her abdomen. Resident #74 tolerated the placement well. The IV line was patent and running. The note indicated LPN #226 would continue to monitor. Review of the Medication Administration Record (MAR) dated September 2023 revealed Resident #74 received potassium supplement and IV fluids as ordered. The bolus was signed off on the MAR on 09/15/23 at 09:16 P.M. by LPN #155. The STAT CBC and BMP lab order was signed off on 09/15/23 at 9:22 P.M. by LPN #155. Review of the lab results dated 09/16/23 revealed Resident #74 had a low potassium level of 3.0 millimoles per liter (mmol/L). The results were faxed to the facility on [DATE] at 7:45 P.M. There were no additional progress notes entered on Resident #74 until 09/17/23 at 11:32 A.M. (approximately 41 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 19 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 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 hours after the IV line was placed). Level of Harm - Immediate jeopardy to resident health or safety Review of the progress note dated 09/17/23 at 11:32 A.M. (approximately 16 hours after the results were faxed to the facility) by LPN #176 revealed lab results were received and the on-call physician was notified. A new order for potassium 40 meq was received with instructions to administer twice daily for three days. LPN #176 would continue to monitor. Residents Affected - Few Review of the physician orders dated September 2023 revealed Resident #74 had an order for potassium oral tablet with instructions to give 40 meq twice daily for supplement for three days until 09/20/23. The order was dated 09/17/23. Review of the MAR dated September 2023 revealed Resident #74 received the potassium supplement at 8:00 P.M. on 09/17/23 and on 09/18/23 at 8:00 A.M. and 8:00 P.M. Resident #74 was out of the facility on 09/19/23 at 8:00 A.M. The potassium was marked as administered on 09/19/23 at 8:00 P.M. but Resident #74 was out of the center on 09/20/23 at 8:00 A.M. according to the MAR. Review of the progress note dated 09/19/23 at 9:00 A.M. by RN #160 revealed Resident #74 was found lying down in bed very lethargic, unable to sit or stand. Resident #74 was not able to eat or drink breakfast. Resident #74's blood pressure was (elevated/hypertensive) 174/94, pulse was 71, respiratory rate was 20, and oxygen saturation was 95%. The nurse practitioner was notified and ordered Resident #74 to be sent to the emergency department. The DON and resident's family were notified. Resident #74 was hospitalized from [DATE] to 09/22/23. Resident #74's payer source was changed to a Hospice payer on 09/27/23. Review of the progress note dated 09/22/23 at 9:17 P.M. revealed Resident #74 returned to the facility from the hospital on [DATE] at 4:45 P.M. Review of hospital records dated 09/22/23 revealed Resident #74 was treated for an elevated troponin level (a protein released into the bloodstream during a heart attack and a sign of some damage to the heart), tachycardia (fast heart rate) with frequent premature ventricular contractions (PVCs), ventricular tachycardia (a condition caused by faulty heart signaling that triggers a fast heart rate in the lower heart chambers), hypertension, hypokalemia, and hypomagnesemia. Resident #74's blood pressure was 180/65 while lying down. Upon admission on [DATE], Resident #74 had a low potassium level of 3.3 and critically high troponin levels of 251 initially and 128 upon repeat. Review of the after-visit summary (AVS) dated 09/22/23 revealed Resident #74 was treated for ventricular tachycardia (VT) felt to be electrolyte related. Resident #74 experienced VT arrest with return of spontaneous circulation (ROSC) following a single defibrillation. Treatment for hypokalemia and hypomagnesemia (low magnesium level) included replacing electrolytes, maintaining potassium level above four, and maintaining a magnesium level over two. At discharge, Resident #74 would continue potassium and magnesium supplements. Review of the progress note dated 09/27/23 at 4:06 P.M. revealed Resident #74 was accepted to Hospice and palliative care. Interview on 11/22/23 at 5:15 P.M. with Regional Director of Operations #224 and Corporate Director of Nursing (CDON) #103 confirmed Resident #74's physician was not notified of the critical lab results that were received on 09/08/23 until 09/15/23 (one week later). CDON #103 stated Resident #74 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 20 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 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 - Immediate jeopardy to resident health or safety Residents Affected - Few received a potassium supplement and IV fluids on 09/15/23. Resident #74 was sent to the hospital on [DATE] for a change in condition. CDON #103 confirmed Resident #74 experienced VT in the hospital and confirmed the resident was treated for heart issues and low potassium. Interview via telephone on 11/27/23 at 10:02 A.M. with LPN #176 revealed she worked at the facility on the weekends and was familiar with Resident #74. LPN #176 stated if a resident had an order to receive SQ IV fluids, the order should include a rate and time frame for it to infuse over. If the order did not include these instructions, the nurse should clarify the order (with the physician). LPN #176 also stated the resident should be monitored while the fluids were administered to ensure the line was patent and flowing and that the resident was tolerating the treatment. The observations of the resident should be documented in the medical record. Interview via telephone on 11/27/23 at 11:44 A.M. with Physician #191 confirmed the facility failed to notify her of Resident #74's critical lab results on 09/08/23. Physician #191 stated she was at the facility for a regular visit on 09/15/23 and Resident #74 was not on her schedule to be seen that day. When she arrived on-site, she happened to find and reviewed Resident #74's lab results. At that time, Physician #191 decided to see Resident #74 on 09/15/23 to follow up. Physician #191 stated there were concerns Resident #74 was dehydrated based on the resident's appearance. The resident appeared dehydrated and had dry lips. Physician #191 stated she was told the DON would be available to monitor the bolus while the fluids were being administered. Physician #191 confirmed she could not confirm the rate at which the nurse was ordered to administer the fluids. Physician #191 stated the rate was determined based on the resident's weight and other factors. Physician #191 stated the bolus should have been administered at a rate less than 70 mL/hr. Physician #191 confirmed MedOne (the physician's group) received notification of the lab results completed on 09/16/23 on 09/17/23 at 11:41 A.M. Physician #191 stated she had considered sending Resident #74 to the hospital on [DATE] but the nursing staff reported the resident had been at baseline, looked okay, and vital signs were within normal limits. Physician #191 decided to treat Resident #74 at the facility. Physician #191 reported if a resident had low potassium levels, she would want to replace it as soon as possible because there would be concern for the resident's heart health. Interview on 11/27/23 at 2:13 P.M. with CDON #103 confirmed there was no documented evidence in the medical Resident #74 had been monitored every two hours. There was no documented evidence of any observations completed on Resident #74 except on 09/15/23 at 6:23 P.M. when the nurse placed the line for the SQ IV fluids and 09/15/23 at 9:16 P.M. when the night shift nurse signed off on the MAR. Interview via email on 11/27/23 at 5:40 P.M. with CDON #103 confirmed Resident #74's abnormal lab results were faxed to the facility on [DATE] at 7:45 P.M. and there was no documented evidence the physician was notified until 09/17/23 at approximately 11:30 A.M. Interview on 11/28/23 at 10:47 A.M. with LPN #226 confirmed she was the nurse who started the SQ IV fluids for Resident #74 on 09/15/23 ordered by Physician #191. LPN #226 confirmed Physician #191 did not provide a rate at which the fluids should have been administered. LPN #226 confirmed Resident #74 should have been observed/monitored at least every two hours to make sure the line was still in place, running without any issues, and the resident was tolerating the infusion without any adverse effects. LPN #226 stated she thought it was an open line. LPN #226 stated the nursing staff should notify the physician of any lab results regardless of whether the results were abnormal. Interview on 11/28/23 at 4:00 P.M. with CDON #103 confirmed Resident #74's care plan did not address the resident's risk for low potassium levels until Resident #74 returned from the hospital on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 21 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 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 [DATE] with that diagnosis. Level of Harm - Immediate jeopardy to resident health or safety Interviews on 11/29/23 at 3:40 P.M. with RN #160 and Assistant Director of Nursing (ADON) #105 confirmed the physician should be notified immediately upon receipt of any lab results regardless of if the results were normal or abnormal. Both nurses confirmed this had always been the facility's process for the nursing staff. Both nurses confirmed all notifications should be documented in the electronic medical record. Residents Affected - Few Review of the facility policy, Lab and Diagnostic Test Results-Clinical Protocol, revised 09/2012, revealed nursing staff would consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: the result was something that should be conveyed to a physician regardless of other circumstances (the abnormal result is problematic regardless of any other factors), the resident's clinical status was unclear or worsening. Furthermore, if the resident had signs and symptoms of acute illness or condition change and he/she was not stable or improving, the nurse would notify the physician promptly to discuss the situation. Facility staff should document information about when, how, and to whom the information was provided and the response in the Progress Notes section of the medical record and not on the lab results report. Review of the facility policy, Guidelines for Reporting Abnormal Test Results to Physicians, revised 02/2014, revealed for a chemistry test, immediate notification should be completed if potassium level was less than 3.0. Review of the undated facility policy, Hypodermoclysis revealed hypodermoclysis was subcutaneous administration of fluid to correct dehydration. Infusion sites would be observed at least every two hours for redness, swelling, leaking, or discomfort. Document date and time of procedure, site assessment, patient response to procedure and/or medication, and patient teaching on appropriate nursing document. Review of the facility policy, Change in a Resident's condition or Status, revised 12/2016, revealed the nurse would notify the resident's Attending Physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition or need to alter the resident's medical treatment significantly. A significant change of condition was a major decline or improvement in the resident's status that would not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. Review of the facility policy, Care Plans, Comprehensive Person-Centered, revised 12/2016, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. The comprehensive, person-centered care plan would include measurable objectives and timeframes, describe the services that were to be furnished to attain or maintain the resident's highest physical, mental and psychosocial well-being, describe services that would otherwise be provided for the above, but were not provided due to the resident exercising his or her rights, including the right to refuse treatment, include the resident's stated goals upon admission and desired outcomes, incorporate identified problem areas, incorporate risk factors associated with identified problems, identify the professional services that are responsible for each element of care, and reflect currently recognized standards of practice for problem areas and conditions. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 22 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the facility policy, Medication Orders, revised 11/2014, related to intravenous orders included when recording orders for IV solutions, specify the type of solution, rate of flow, and volume to be infused. Example: 1000 cc D5W I.V. at 50 cc/hr. Discontinue when infused. 2. Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including human immunodeficiency virus (HIV) disease, atrial fibrillation, type two diabetes mellitus with neuropathy, cardiomyopathy, peripheral vascular disease, anxiety disorder, major depressive disorder, and pulmonary embolism without acute cor pulmonale. Review of Resident #19's quarterly MDS assessment dated [DATE] revealed Resident #19 was cognitively impaired with a BIMS score of an eight out of 15 and required extensive assistance for mobility and general personal care. Resident #19 was on medication to thin the blood that put Resident #19 at risk for bruising and bleeding. Resident #19 was listed on the facility's quality improvement monitoring log indicating Resident #19 had lab work drawn on 10/09/23 and the physician was notified of results on 10/09/23 at 7:30 P.M. Resident # 19's electronic medical record indicated Resident #19 had a PT (prothrombin time)/INR (international normalized ratio) test results called to the physician 10/12/23 at 4:25 P.M. and 10/19/23 at 11:37 A.M. Resident #19's paper chart has a PT/INR listed as drawn 10/13/23 at 11:11 A.M. and resulted 10/13/23 at 6:21 P.M., with results listed as high outside the normal range, and a hand written note stating the physician was notified with no documented evidence of the date or time the notification occurred. Interview on 11/20/23 at 1:00 P.M. with Regional Director of Operations #224 confirmed the lab audit contained inconsistent information and the paper chart for Resident #19 was missing information. Review of the facility document Guidelines for Reporting Abnormal Test Results to Physician, revision date of 02/2014, revealed any PT/INR outside the therapeutic range requires immediate notification. Any results in the normal range are non-emergent and should be reported on the next office day. 3. Record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, type two diabetes mellitus with neuropathy, peripheral vascular disease, vascular dementia, and a history of falls. Review of Resident #24's quarterly MDS dated [DATE] revealed Resident #24 mildly cognitively impaired with a BIMS score of 11 out of 15. Resident #24 was on medication to thin the blood that put Resident #24 at risk for bruising and bleeding. Resident #24 was listed on the facility's quality improvement monitoring log reflecting Resident #24 had lab work drawn on 10/13/23 and the physician was notified of results on 10/13/23 at 7:00 P.M. with results listed as highly outside the normal range. Resident #24's electronic medical record indicated Resident #19 had a PT/INR test results called to the physician 10/12/23 at 4:25 P.M. and 10/19/23 at 11:37 A.M. Resident #19's paper chart had a PT/INR listed as drawn 10/13/23 at 11:11 A.M. and resulted 10/13/23 at 6:21 P.M. with a handwritten note stating physician notified 10/13/23 with no documented evidence of the time the notification occurred. Interview on 11/20/23 at 1:00 P.M. with Regional Director of Operations #224 confirmed the lab audit contained inconsistent information and the paper chart for Resident #24 was missing information. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 23 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the facility document Guidelines for Reporting Abnormal Test Results to Physician, revision date of 02/2014, revealed any PT/INR outside the therapeutic range requires immediate notification. Any results in the normal range are non-emergent and should be reported on the next office day. 4. Record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, type two diabetes mellitus with neuropathy, congestive heart failure, cardiomyopathy, and peripheral vascular disease. Review of the annual MDS dated [DATE] revealed Resident #34 was cognitively intact with a BIMS score of 12 out of 15 and required supervision for mobility, general activities of daily living, and personal care. Resident #34 was on medication to thin the blood that put Resident #34 at risk for bruising and bleeding. Resident #34 was listed on the facility's quality improvement monitoring log stating Resident #34 had lab work drawn on 09/27/23 and the physician was notified of results on 09/28/23 at 1:00 A.M. Resident # 34's electronic medical record indicates Resident #34 had a PT/INR test results called to the physician 09/28/23 at 12:23 P.M. Review of Resident #34's paper chart revealed a PT/INR listed as drawn 09/27/23 at 8:26 P.M. and resulted 09/27/23 at 9:50 P.M. with no documented evidence of the time the notification occurred. Interview on 11/20/23 at 1:00 P.M. with Regional Director of Operations #224 confirmed the lab audit contained inconsistent information, and the paper chart for Resident #34 was missing information. Interview on 11/29/23 at 3:30 P.M. with Regional Director of Nursing #103 revealed not all notification of lab work reported to the physician was in the electronic medical record. The nurses may also document notification in the paper chart. Review of the facility document Guidelines for Reporting Abnormal Test Results to Physician, revision date of 02/2014, revealed any PT/INR outside the therapeutic range requires immediate notification. Any results in the normal range are non-emergent and should be reported on the next office day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 24 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 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 observation, interview, record review, and facility policy review the facility failed to complete thorough neurological checks for Resident #8 after a fall. This affected one resident (#8) of two residents reviewed for accidents. The facility census was 84. Findings include: Review of the medical record for Resident #8 revealed an admission date of 08/01/14 with diagnoses including chronic obstructive pulmonary disease (COPD), peripheral vascular disorder (PVD), age related nuclear cataract bilateral, age-related macular degeneration, congestive heart failure, Alzheimer's disease, and cardiac arrhythmias. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had severe cognitive impairment with hallucinations and delusions. Resident #8 required extensive assistance of one person for bed mobility, toileting, and personal hygiene and extensive assistance of two persons for transfers. Resident #8 had an unsteady balance and gait and was incontinent of bowel and bladder. Resident #8 was short of breath with exertion and had one fall with no injury. Review of the plan of care dated 06/17/18 at risk for falls related to Alzheimer's dementia, chronic obstructive pulmonary disorder, congestive heart failure, impaired gait and balance, impaired vision, poor trunk support, and respiratory failure. The goal stated Resident #8 would be free from injury from falls. Interventions included to anticipate and meet the resident's needs, keep call light in reach, encourage the resident to use the call light and ask for assistance as needed, reclining Broda chair, mat at bedside, hospital bed with bolsters, and therapy to evaluate and treat as needed. Review of the nursing progress note for 01/09/23 revealed Resident #8 was sitting up in a Broda chair in the dining/common area. Resident #8 used his trunk control and fell forward out of the chair. The immediate intervention was staff education on reclining the chair and positioning the resident in the Broda chair. After reviewing the Broda chair, the resident received a new Broda chair that was fitted for his size. Review of the neurological check flowsheet revealed on 01/09/23 from 11:45 A.M. through 01/10/23 at 6:30 A.M. there was no documentation of pupil response, motor functions, or pain response. An observation on 11/28/23 at 10:07 A.M. revealed Resident #8 was lying in bed with eyes closed. The following fall precautions were in place: hospital bed with bolsters, mat to the floor at bedside, call light in reach, and a Broda chair at bedside. An interview on 11/29/23 at 2:19 P.M. with Licensed Practical Nurse (LPN) #175 revealed neurological checks would be completed if a resident fell and hit their head or an unwitnessed fall. LPN #175vstated neurological checks included vital signs, pain, pupil reaction to light, level of consciousness, and strength in hands, arms, and legs. Interview on 11/30/23 at 9:30 A.M. with Regional Nurse #103 confirmed the neurological check assessments for Resident #8 on 01/09/23 were not completed. The assessments were missing pupil response, motor functions, and pain response. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 25 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 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 Review of the facility policy Neurological Assessment, dated 9/10, indicated when assessing neurological status always include frequent vital signs, with particular attention paid to widening pulse pressure. The nurse should determine residents' orientation to time, place, and person, patterns of speech, and speech clarity, check pupil reactions, determine motor ability, and document on the form. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 26 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, financial record review, and staff interview, the facility failed to provide an adequate plan to spend down resident finances when it was above the Medicaid allowable limit. This affected three residents (#2, #3, and #19) of four resident's financial records reviewed. Also, the facility failed to provide adequate social services to ensure residents didn't lose their Medicaid benefits. This affected one resident (#3) of four resident's financial records reviewed. The facility census was 84. Residents Affected - Few Findings Include: 1. Resident #2 was admitted to the facility on [DATE]. His diagnoses were chronic respiratory failure, type II diabetes, morbid obesity. unspecified focal traumatic brain injury, cognitive communication deficit, chronic kidney disease, peripheral vascular disease, hypertension, hyperlipidemia, insomnia, thrombocytopenia, dementia, congestive heart failure, tachycardia, and anxiety disorder. Review of his Minimum Data Set (MDS) assessment, dated 09/30/23, revealed he had a significant cognitive impairment. Review of Resident #2's financial statements, dated 10/01/22 to 09/30/23, revealed his total was above $2000 for the entire time. The totals varied between $2,096.49 and $3,552.39. The facility produces quarterly statements, but after each month, his totals were above $2,000. The facility provided a spend down notification to this resident/representative on 01/03/23, 04/24/23, 07/24/23, and 11/21/23. On each spend-down notice, it stated, this letter is to notify you that your current Resident Fund balance is within $200 or exceeding what is allowable under Medical Assistance. Please contact your social worker within the next seven days to discuss ways to assure continuance of Medicaid benefits. Review of her medical and financial records found no plan devised by the facility to assist with spending his money down, which placed Resident #2 at risk for losing his Medicaid benefits. 2. Resident #3 was admitted to the facility on [DATE]. Her diagnoses were hemiplegia and hemiparesis, type II diabetes, acute respiratory failure, aphasia, cerebral infarction, vascular dementia, metabolic encephalopathy, peripheral vascular disease, epilepsy, osteoporosis, hydronephrosis, hypertension, hyperlipidemia, and atrial fibrillation. Review of her MDS assessment, dated 10/15/23, revealed she had a significant cognitive impairment. Review of Resident #3's financial statements, dated 10/01/22 to 09/30/23, revealed her total was above $2000 for the entire time. The totals varied between $2,310.53 and $4,518.75. The facility produces quarterly statements, but after each month, her totals were above $2,000. The facility provided a spend-down notification to this resident/representative on 01/03/23, 04/24/23, and 07/24/23. On each spend-down notice, it stated, this letter is to notify you that your current Resident Fund balance is within $200 or exceeding what is allowable under Medical Assistance. Please contact your social worker within the next seven days to discuss ways to assure continuance of Medicaid benefits. Review of her medical and financial records found no plan devised by the facility to assist with spending his money down, which places Resident #3 at risk for losing his Medicaid benefits. 3. Resident #19 was admitted to the facility on [DATE]. His diagnoses were human immunodeficiency virus, type II diabetes, hemiplegia and hemiparesis, chronic obstructive pulmonary disease, emphysema, chronic respiratory failure, dysphagia, cognitive communication deficit, polyneuropathy, peripheral vascular disease, heart failure, anxiety disorder, cardiomyopathy, hypertension, atrial (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 27 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 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 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few fibrillation, congestive heart failure, atherosclerotic heart disease, schizoaffective disorder, vascular dementia, and occlusion and stenosis of unspecified cerebral artery. Review of his MDS assessment, dated 11/07/23, revealed he had a significant cognitive impairment. Review of Resident #19 financial statements, dated 10/01/22 to 09/30/23, revealed his total was above $2000 for the entire time. The totals varied between $3,410.18 and $5,503.92. The facility produces quarterly statements, but after each month, his totals were above $2,000. On each spend-down notice, it stated, this letter is to notify you that your current Resident Fund balance is within $200 or exceeding what is allowable under Medical Assistance. Please contact your social worker within the next seven days to discuss ways to assure continuance of Medicaid benefits. Review of her medical and financial records found no plan devised by the facility to assist with spending his money down, which places Resident #19 at risk for losing his Medicaid benefits. Interview with Regional Director of Operations (RDO) #224 on 11/29/23 at 4:11 P.M. confirmed they contact the residents and/or responsible parties to resident finances when they find out they are within $200 of their resident account limit. She confirmed the facility does not have a formal policy regarding spend down notices, but they follow the standard of notifications as soon as the facility knows they are over their limit. She also confirmed there is no documented plan to assist the residents with spending down their money as the spend down notice indicates. 4. Review of Resident #3 financial records revealed the facility received notification about her needing to send in documentation and verification for the need of Medicaid services, known as the redetermination. There was no documentation to support the facility took steps to collect the needed documentation and submit it for verification. On 10/31/23, Resident #3's Medicaid insurance benefits ended, and she was transitioned into private pay. There was no documentation to support the facility collected the documentation and/or contacted the local Medicaid office to assist with keeping her Medicaid benefits. Documentation supported that the facility was Resident #3's representative payee. Interview with state Medicaid official on 11/28/29 at approximately 10:45 A.M. revealed they have not received any information from Resident #3's family/representatives, nor her nursing facility to maintain her Medicaid benefits. He stated on 09/11/23, they sent a letter to the nursing facility to indicate there were documents they needed to make the redetermination. They never received anything from any of the parties involved. By 09/28/23, they had not received any documentation, so on 09/29/23, they sent a letter to the same parties stating that Resident #3's Medicaid benefits would be discontinued on 10/31/23 pending an appeal. He confirmed even after this letter was sent about her benefits being discontinued, they have not received any communication to support restarting Resident #3's Medicaid benefits. Interview with local Medicaid official on 11/28/23 at approximately 1:45 P.M. confirmed there was no documentation to support communication from the facility or Resident #3's representatives about maintaining/restarting Resident #3's Medicaid benefits. Interview with Business Office Manager (BOM) #2089 on 11/30/23 at 1:00 P.M. confirmed there was no documentation to support communication with the local/state Medicaid office to maintain Resident #3 Medicaid benefits. She confirmed they received the letter about Medicaid needing documentation to continue her Medicaid benefits, but they did not provide them, which led to Resident #3's Medicaid benefits discontinuing. She confirmed Resident #3 is not private pay, and they have deducted $1,713 from her resident trust account to pay for her November cost of care. When her Medicaid benefits are started again, they will reimburse her this money, after Medicaid provides back payment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 28 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to adequately address the pharmacy recommendations and have proper diagnosis for medications for Resident #28 and did not write contraindication for recommendations to decrease a medication for Resident #20. This affected two residents (#28 and #20) of five residents reviewed for unnecessary medications. The facility census was 84. Findings include: 1. Review of the medical record for Resident #20 revealed an admission date of 01/06/18 with diagnoses including type II diabetes mellitus, epilepsy, congestive heart failure, anxiety disorder, bipolar disorder, and post-traumatic stress disorder. Review of the current physician orders dated 11/23 revealed Resident #20 received clonazepam (antianxiety) 0.5 milligrams (mg) by mouth daily for major depressive disorder, buspirone hydrochloride (antianxiety) 7.5 mg by mouth two times per day for anxiety, aripiprazole 5 mg by mouth daily for insomnia related to schizoaffective disorder, and duloxetine hydrochloride sprinkle 60 mg by mouth two times daily for major depressive disorder. Review of the quarterly modification Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was alert and oriented with no cognitive impairment. Resident #20 had verbal behaviors directed towards others. Resident #20 required extensive assistance with activities of daily living. Resident #20 had diagnoses of anxiety, depression, bipolar disorder, schizophrenia, and post-traumatic stress disorder. Resident #20 received antianxiety, antidepressant, and antipsychotic medications. The antipsychotic medications were reviewed on routine basis with no Gradual Dose Reduction (GDR) and no physician documentation. Review of the Medication Regime Review (MRR) for Resident #20 revealed the review was completed monthly. The pharmacy recommendation dated 07/26/23 revealed the antidepressant medication duloxetine 60 mg by mouth two times daily was ordered following an acute phase. The pharmacist recommended decreasing the dose as a trial dose. The physician noted to continue this antidepressant therapy dose and the reduction was contraindicated. However, the physician did not document reason why the recommendation was contraindicated. An interview on 11/29/23 at 2:15 P.M. with Regional Nurse #103 confirmed the physician did not document the reason a reduction of antidepressant medication was contraindicated. Regional Nurse #103 also confirmed the medication clonazepam was an antianxiety medication and Resident #20 received the medication for diagnosis of major depressive disorder. The facility did not provide a policy for Pharmacy Recommendations. 2. Review of the medical record for Resident #28 revealed an admission date of 10/05/22 with diagnoses including dementia with behavioral disturbance, chronic obstructive pulmonary disorder, mood disorder, alcohol abuse, opioid abuse, unspecified psychosis due to substance physiological condition, major depressive disorder, anxiety disorder, epilepsy, chronic pain syndrome, and developmental disorder of speech and language. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 29 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the current physician orders dated 11/23 revealed Resident #28 received Seroquel (antipsychotic) for psychosis, divalproex sodium for seizure disorder, and duloxetine hydrochloride for depression. Review of the annual MDS assessment dated [DATE] revealed Resident #28 had mild cognitive impairment with verbal and physical behaviors directed towards others. Resident #28 required limited assistance with activities of daily living. Resident #28 had diagnoses of dementia with behavioral disturbance, mood disorder, unspecified psychosis, major depressive disorder, anxiety disorder, epilepsy, and developmental disorder of speech and language. Resident #28 received antipsychotic, antianxiety, and antidepressant medications. The antipsychotic mediations were reviewed on a routine basis with no GDR and no physician documentation. Review of the monthly pharmacy MRR for Resident #28 revealed on 04/24/23, 05/23/23, 07/26/23, and 08/01/23 the pharmacist recommended a serum valproic acid level every six months and serum ammonia level one time. The pharmacy recommendation dated 07/26/23 was not signed by the physician. Review of the lab results provided by the facility revealed Resident #28 did not have a valproic acid level drawn as recommended until 10/12/23. The results were within normal limits. Resident #28 had an ammonia level drawn monthly per recommendations. An interview on 11/29/23 at 2:15 P.M. with the Regional Nurse #103 confirmed the physician did not sign pharmacy recommendations and did not order the recommended lab valproic acid level. The facility did not provide a policy for Pharmacy Recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 30 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to obtain proper parameters for as needed pain medications. This affected one Residents (#11) of five residents reviewed for unnecessary medications. The facility census was 84. Residents Affected - Few Findings include: Resident #11 was admitted to the facility on [DATE]. Her diagnoses were type II diabetes, unspecified protein calorie malnutrition, cognitive communication deficit, muscle wasting and atrophy, muscle weakness, peripheral vascular disease, hyperlipidemia, hypothyroidism, anemia, nicotine dependence, paraplegia, depression, polyneuropathy, cachexia, hypertension, and chronic kidney disease (stage IV). Review of the Minimum Data Set (MDS) assessment, dated 10/23/23, revealed Resident #11 was cognitively intact. Review of Resident #11's medical records revealed her current physician orders included Percocet 10-325 milligrams (mg) every eight hours as needed for pain, Acetaminophen 325 mg every six hours as needed for mild pain, and Methadone five mg every six hours as needed for severe pain (which was changed from as needed for pain on 11/14/23). Review of her Medication Administration Record (MAR) revealed she was administered Acetaminophen on 11/21/23 for a pain level of three and Methadone for a pain level of three, zero, and two on dates 11/17/23, 11/18/23, and 11/22/23 respectively. Also, she was administered Percocet for pain level four on the following dates: 11/16/23, 11/17/23, 11/22/23, and 11/23/23, but she was also given Methadone for pain level four on the following dates: 11/15/23, 11/16/23, and 11/23/23. There were no progress notes or other medical documentation to support the justification for using different as needed pain medications for the same (or less) level of pain. Interview with Corporate Director of Nursing (DON) #103 on 11/28/23 at 10:10 A.M. confirmed there should be clear parameters for all as needed pain medications. She confirmed multiple as needed pain medications were given for the same pain level and there was no direction on which medication should be given. Interview with Assistant Director of Nursing (ADON) #105 on 11/28/23 at 10:27 A.M. confirmed Resident #11 was someone who they would take direction from, as to which pain medication she wanted to take. He confirmed there were times that Resident #11 had the same level of pain, but different pain medication was administered due to her desire for a certain pain medication at that time. Review of the facility Administering Pain Medication policy, dated October 2010, revealed pain management defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Standardized pain assessment tools, as indicated per facility protocol, are to be used. Five-point (or 10 point) pain intensity scale with word modifiers, Wong-Baker FACES Pain Rating Scale and/or pain assessment form and pain flow sheet should be used. Pain medication is to be administered as ordered. Document the following in the resident's medical records: results of the pain assessment, medication, dose, route of administration, and results of the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 31 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, resident medical records, staff interview, and facility policy review, the facility failed to ensure pureed food was maintained in a manner that met the resident's health and safety needs. This affected two residents (#8 and #235) of two residents who had orders for puree diets. The facility census was 84. Findings include: Observation on 11/27/23 from 11:25 A.M. to 11:35 A.M. revealed [NAME] #202 placed approximately five scoops of chicken and noodles in the blender to make it pureed texture. After blending for approximately 45 seconds, she obtained the proper texture. She started to pour the pureed texture chicken and noodles back into the pan that had regular textured chicken and noodles, which still had full pieces of chicken and noodles in the pan. As she lifted the blending pan to pour the pureed food back into the original pan, the surveyor stopped her so the two textured food items would not be mixed. Review of Resident #8 and Resident #235's medical records confirmed both were on a puree texture diet order. Interview with [NAME] #202 on 11/27/23 at approximately 11:35 A.M. confirmed she did not see the regular textured food items in the original pan, prior to attempting to pour the pureed food into it. She confirmed after looking in the pan, there were chunks of regular food in there, which would have made the pureed food not servable. She confirmed she did not ask for another clean pan prior to attempting to pour the pureed food in the original pain. Review of the undated facility Pureed Food Preparation policy and guidelines revealed the facility will prepare pureed foods in a manner that sustains nutritional value and taste. The foods will be pureed to assure the desired consistency. All kitchen staff working on 11/27/23 were educated on this policy. Review of the undated facility Dysphagia Diets policy revealed dysphagia pureed diet is consisted of pureed, homogenous, and cohesive foods. Foods should be pudding like. No coarse textures, raw fruits or vegetables, nuts, and so forth are allowed. Handwritten into this policy, it stated, when you puree a food item, place it in a new, clean pan so there are no chunks in it. All kitchen staff working on 11/27/23 were educated on this policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 32 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain accurate medical records. This affected one resident (#37) of 27 residents medical records reviewed. The facility census was 84. Findings include: Resident #37 was admitted to the facility on [DATE]. His diagnoses were chronic obstructive pulmonary disease (COPD), chronic bronchitis, dysphagia, muscle wasting and atrophy, muscle weakness, nicotine dependence, hypomagnesemia, hypocalcemia, hypocalcemia, dementia, post-traumatic stress disorder (PTSD), age related physical debility, anxiety disorder, major depressive disorder, adult failure to thrive, hypokalemia, acute kidney failure, hypertension, pneumonia, hyperlipidemia, toxic encephalopathy, and hypo-osmolality and hyponatremia. Review of his Minimum Data Set (MDS) assessment, dated 10/13/23, revealed he was cognitively intact. Review of Resident #37 medical records revealed he had dental appointment records, dated 11/10/23, that were not actually his records. The dental vendor put Resident #37 name on the dental records, and the facility scanned them into his electronic medical records. But, upon further review, Resident #37 never went to the dentist; the records were meant for Resident #26, who has the same last name. The document was not fully reviewed prior to it being put into Resident #37's medical records to determine that it was not accurate. Interview with Corporate Director of Nursing (CDON) #103 on 11/29/23 at 2:57 P.M. and 3:10 P.M. confirmed the dental records were meant to be for Resident #26; not for Resident #37. She is unsure how the dental company put another resident's name on the dental records, and how the facility missed that the records were meant for Resident #26. She confirmed with Resident #37 that he has not had any dental appointments since being admitted to the facility. This deficiency represents non-compliance investigated under Complaint Number OH00148113. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 33 of 34 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 365572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastland Rehabilitation and Nursing Center 2425 Kimberly Parkway East Columbus, OH 43232 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, review of the manufacturers guidelines, and facility policy review the facility failed to follow proper infection control procedures regarding cleaning a glucometer. This had the potential to affect two residents (#2 and #235) on the 300-memory care hall that received fingerstick blood sugars using the glucometer. The facility census was 84. Residents Affected - Few Findings include: During the medication administration observation on 11/27/23 at 11:45 A.M. Licensed Practical Nurse (LPN)#164 obtained fingerstick blood sugar for Resident #235. After the procedure, LPN #164 cleaned the glucometer with a Micro-Kill bleach wipe by wiping it off and placing on the medication cart. LPN #164 stated she kept the glucometer wet for a few seconds (did not monitor the time). LPN #164 reviewed the instructions on the container of Micro-Kill bleach wipes that stated to kill viruses or bacteria keep the glucometer wet with the Micro-Kill bleach wipe for 30 seconds and let air dry. LPN #164 confirmed she did not keep the glucometer wet for 30 seconds. LPN #164 stated she did not have another fingerstick at this time to complete. Review of the residents on the 300-hall revealed there was not any residents with a blood borne pathogen illness. Review of the facility policy titled Obtaining a Fingerstick Glucose level dated 10/11 indicated the nurse would clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standard practices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365572 If continuation sheet Page 34 of 34