Inspection·June 6, 2022

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on medical record review and staff interview, the facility failed to complete an updated Preadmission Screening and Resident Review for a resident with a newly evident or possible serious mental disorder. This affected one (Resident #49) out of one resident reviewed for Preadmission Screening and Resident Review. The facility census was 71. Findings include: Medical record review for Resident #49 revealed an admission date of 09/17/16. Diagnoses included type two diabetes mellitus, hypokalemia, major depressive disorder, cerebral infarction, and essential hypertension. Resident #49 had a diagnosis of Schizoaffective disorder, depressive type added on 11/18/21. Review of the Preadmission Screening and Resident Review (PASRR) Result Notice dated 06/01/22 revealed a referral was made for a level II evaluation. Review of the medical record for Resident #49 revealed no evidence of a new PASRR having been completed prior to 06/01/22 since Resident #49's new diagnosis of Schizoaffective disorder, depressive type on 11/18/21. Interview on 06/01/22 at 3:09 P.M. Social Services Director (SSD) #59 revealed the SSD was a newer employee and Resident #49's diagnosis of Schizoaffective disorder, depressive type was determined several months prior to her hire date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 2 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 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 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview, policy review, and review of a job description, the facility failed to implement an effective and timely discharge planning process. This affected one (Resident #43) of two residents reviewed for discharge. The facility census was 71. Residents Affected - Few Findings include: Review of the medical record for Resident #43 revealed an admission date of 03/13/22. Diagnoses included asthma, diabetes type two, COVID-19, guillain-barre syndrome, and respiratory failure with hypoxia. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #43 was cognitively intact and required extensive assist of two staff for bed mobility and transfers. Review of the care plan dated 04/01/22 revealed Resident #43 was anticipated as a short term stay at the facility with discharge anticipated back home to the community with services and HME (home medical equipment) needed with interventions to document all discharge planning, and document all interactions with resident and family regarding discharge plans. The care plan revealed Resident #43 had an activities of daily living (ADL) self care deficit with interventions including transfer assist with mechanical lift (hoyer) and assist of two staff for transfers. Review of the physician order dated 04/19/22 revealed an order for a bipap with instructions to specify the type of mask was over the nose with humidifier with oxygen at four liters per minute with pressure settings of 14/10. Review of the progress note dated 03/14/22 from social services revealed Resident #43 was assessed for discharge needs and was reported to have all HME needed for discharge planning. Review of the progress note dated 03/30/22 revealed Resident #43's bipap machine had issues and did not stay on all the time, and the equipment company was contacted to request a new machine. Review of another progress note dated 03/30/22 revealed Resident #43 was found to be pale with jerking movements and revealed she was not feeling right. Staff found the bipap did not work correctly and a new bipap was started and the residents oxygen stabilized to 90-92%. Review of the progress note dated 04/18/22 from social services revealed Resident #43 returned from the hospital and social services would assist in coordinating discharge. Review of the progress note dated 05/25/22 revealed social services met with Resident #43 to discuss discharge planning. Therapy services were ending on 05/26/22 and Resident #43 requested discharge on [DATE]. The progress note revealed Resident #43 had all needed HME and a hoyer lift was ordered through the equipment company. Review of the progress note dated 05/31/22 from social services revealed Resident #43 had ordered a new bipap machine which had not yet been delivered and social services was coordinating copayment with the equipment company for the hoyer. Social services also documented issues with home health referrals and finding an accepting agency after the agency of choice declined. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 3 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 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 0660 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the progress note dated 06/01/22 (four days after anticipated discharge), revealed the equipment company, which Resident #43 ordered her bipap through, revealed it would take four to six weeks until delivery. Social Services found an alternative option for a monthly rental and presented it to Resident #43. Review of the progress note dated 06/02/22 revealed Social Services Designee (SSD) #17 met with Resident #43 to discuss discharge planning and Resident #43 was agreeable to rent the CPAP box device and was assisted in ordering the device. Shipping for the device should take an estimated 48 hours. Interview on 05/31/22 at 3:00 P.M. with Resident #43 revealed she had concerns about the coordination of her discharge. Resident #43 revealed she had been ready for discharge and was supposed to discharge on [DATE] but revealed there was no update on when she would be able to discharge. Resident #43 revealed there was an issue with getting medical equipment which was the reason for her discharge delay. Interview on 06/01/22 at 2:11 P.M. with SSD #17 revealed she starts discharge planning upon admission and should follow the resident for the entirety of their admission to coordinate discharge plans. SSD #17 revealed Resident #43 was asked at admission and revealed she had several items of medical equipment already in her possession. SSD #17 revealed she met with therapy weekly and they should informed her of Resident #43's needs at discharge. SSD #17 revealed she was not informed Resident #43 needed to use a hoyer. SSD #17 confirmed Resident #43 was admitted under private pay and therapy had a scheduled end date of 05/26/22 and she met with Resident #43 on 05/25/22, and began a home health referral to Resident #43's preferred company and looked into ordering a hoyer lift for home. SSD #17 revealed she was not aware Resident #43's bipap machine was broken and needed to be ordered. SSD #17 revealed she found out when Resident #43 told SSD #17 she contacted an oxygen company herself on 05/25/22 since she needed a bipap at discharge. SSD #17 confirmed she had not spoken with the oxygen company regarding Resident #43's request since the referral was made on 05/25/22. Interview on 06/01/22 at 2:58 P.M. with SSD #17 revealed she called the oxygen company Resident #43 placed an order with, and was informed the delivery could take four to six weeks for the new bipap to be delivered. She contacted another company that would be able to rent a CPAP Box for a monthly fee. SSD #17 planned to present this option to Resident #43 for review. Review of policy titled Discharge Summary and Plan, dated 12/2016, revealed when the facility anticipates a resident's discharge to a private residence, a post discharge plan will be developed which will assist the resident to adjust to the new living environment. The policy revealed the discharge plan will be developed by the interdisciplinary team and include the resident and family and should include arrangements for follow up care and services. The discharge plan will be reevaluated based on changes in the resident's condition or needs prior to discharge and should be documented in the medical record. Review of the job description of the social services designee revealed the social services designee should follow facility policies to meet the needs of the residents, develop one on one professional relationships with residents and families, assess, plan, and document discharge needs in accordance with the facility policy, act as a liaison with health and community agencies, consistently work cooperatively with residents, resident representatives, facility staff, consultants, and ancillary services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 4 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to provide adequate assistance with eating. This affected one (Resident #36) out of four residents reviewed for nutrition. The facility census was 71. Residents Affected - Few Findings include: Review of Resident #36's medical record revealed admission to the facility occurred on 07/23/20. Resident #36 had medical diagnoses including dementia, high blood pressure, and coronary artery disease. Review of Resident #36's most recent quarterly assessment dated [DATE] revealed Resident #36 had severe cognitive impairment. Review of Resident #36's speech therapy discharge instructions dated 04/13/22 revealed Resident #36 required concrete one step directions. Observation of Resident #36's lunch meal on 05/31/22 at 12:26 P.M. revealed Resident #36 was in bed with her lunch tray. Resident #36 was not provided any assistance including opening her milk carton. The observation revealed Resident #36 ate no food and drank half of a nutritional shake before her tray was removed. Resident #36 was observed to have no teeth or dentures. Observation on 06/01/22 at 12:39 P.M. revealed Resident #36's lunch tray was delivered to her, while sitting in the television room, across from the nursing station. Resident #36 was served a regular texture meal which included marzetti, green beans, salad, and a piece of garlic bread. Resident #36 was observed to pick up the fork several times but was unable to put food on the fork and eat it. Resident #36 was observed to sit and stare at the plate of food, none of which was cut up. Resident #36 was observed to drink a small container of a chocolate shake and a glass of water. Resident #36's meal tray was removed without any assistance offered. Resident #36 had eaten no food. Observation of Resident #36 on 06/02/22 at 8:21 A.M. revealed she was in a wheelchair in the television (TV) room, across from the nursing station, with a bed side stand in front of her. Resident #36 was provided a breakfast tray which included two sausage patties, a piece of french toast and a cup of coffee. The meal tray was observed to have no items cut up for the resident and the container of syrup was sitting beside the plate unopened. The observation from 8:21 A.M. through 8:36 A.M. revealed no staff was offering to cut up Resident #36's food and/or assist her in any way. Resident #36 was observed sitting and staring at her food the entire time. Interview with State Tested Nursing Assistant (STNA) #215 on 06/02/22 at 8:37 A.M. STNA #215 was asked if she could cut up Resident #36's sausage and french toast. STNA #215 revealed today was her first day working at the facility and she asked if Resident #36 needed fed. STNA #215 revealedit was also the licensed nurse working on the units first day at the facility and she was unsure of Resident #36's needs. STNA #215 confirmed she was not aware if Resident #36 required assistance with her meals or not. STNA #215 cut up Resident #36's food at that time and assisted her with two bites of sausage patty, which Resident #36 ate. STNA #215 revealed she was going to finish passing meal trays to all the other residents and would return to help Resident #36. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 5 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Observation of Resident #36 on 06/02/22 at 8:58 A.M. revealed she remained in the TV room with her untouched meal tray and unopened supplements, and STNA #213 came to the area to remove her tray. Interview with STNA #213 confirmed Resident #36 had not eaten anything and the supplements were not opened or touched. STNA #213 then opened Resident #36's milkshake and placed a straw in the container, but continued to take the ice cream container, with the lid remaining, and stated she does not eat it. Resident #36 was observed to pick up the milk shake and started drinking it. STNA #213 identified she was not aware if Resident #36 needed assistance with the meal or not. STNA #213 identified she was new to the facility and worked through an agency. Event ID: Facility ID: 365577 If continuation sheet Page 6 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, resident interview, staff interview, and policy review, the facility failed to obtain physician orders prior to completing wound treatments. This affected one (Resident #427) out of two residents reviewed for skin concerns. The facility census was 71. Residents Affected - Few Findings include Review of the medical record for Resident #427 revealed an admission date of 05/27/22. Diagnoses included lumbar vertebra fracture, vascular disease, and absence of fingers. Review of Resident #427's care plan dated 05/27/22 revealed Resident #427 was at risk for skin breakdown with interventions including skin assessment as needed and provide supplements as ordered. Review of the progress note dated 06/01/22 revealed Resident #427 had wounds with dressings to bilateral arms. Review of Resident #427's physician orders dated 06/01/22 revealed an order for skin tear to left arm with instructions to pat dry and apply oil emulsion dressing and ABD pad wrap with bandage roll and change daily until healed. Review of Resident #427's physician order dated 06/01/22 revealed skin tear on right elbow with instructions to cleanse skin, pat dry, and apply TAO (triple antibiotic ointment), cover with bandage until healed and change daily. Observation and interview on 05/31/22 at 10:59 A.M. of Resident #427 revealed he had wound dressings on his bilateral arms with bandages dated 05/28/22. Resident #427 was unsure how frequent staff should be changing his wound bandages. Observation and interview on 06/01/22 at 10:30 A.M. of Resident #427 revealed he had wound dressings on his bilateral arms with bandages dated 05/31/22. Resident #427 revealed he had a fall prior to his admission and had several large skin tears. Interview on 06/01/22 at 10:49 A.M. with Licensed Practical Nurse (LPN) #45 revealed Resident #427 had skin tears on the right elbow and left arm that were present upon admission. LPN #45 confirmed Resident #427 had his bilateral arm dressing changed on 06/01/22 and also confirmed no wound treatments were present in the residents medical record. LPN #45 revealed she was unsure what type of treatment and dressings were provided and confirmed neither treatment on 05/28/22 or 05/31/22 were documented anywhere in Resident #427's medical record. Interview on 06/01/22 at 4:10 P.M. with [NAME] President of Clinical Services (VPCS) #75 verified Resident #427 was admitted with skin tears from the hospital and also verified no orders for wound care were placed until 06/01/22. VPCS #75 verified nurses changed Resident #427's dressings without obtaining an order on 05/28/22 and 05/31/22, and verified the treatments were not documented anywhere in the medical record. Interview on 06/02/22 at 9:10 A.M. with LPN #76 revealed when a resident gets admitted with wounds or wound dressings, they should be assessed and the physician should be notified in order to obtain orders for wound care to be provided by facility staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 7 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 06/02/22 at 9:48 A.M. with Director of Clinical Services #70 confirmed Resident #427's treatments were provided without orders from the physician and without any documentation in the medical record. Review of policy titled Wound Care, dated 10/2010, revealed the facility should verify a physician order is present for the procedure or wound care. Once treatment was completed, information should be documented in the resident's medical record, including the type of wound care being provided, date and time wound care was provided, name and title of staff member(s) performing wound care, any changes in resident condition, all assessment data including wound color, size, and drainage ect. obtained when inspecting the wound. Event ID: Facility ID: 365577 If continuation sheet Page 8 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and medical record review, the facility failed to ensure residents received timely treatment and assistive devices to maintain vision. The affected one (Resident #18) out of one resident reviewed for vision services. The facility census was 71. Residents Affected - Few Findings include: Review of the medical record for Resident #18 revealed an admission date of 01/27/22. Diagnoses included end stage renal disease, diabetes type two, and chronic obstructive pulmonary disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had mild cognitive impairment. Review of the 360 eye visit schedule and resident list revealed Resident #18 was seen by the eye physician on 03/04/22. Review of the documents from 360 vision professionals revealed Resident #18 was assessed and provided a new eye prescription. Interview on 05/31/22 at 11:08 A.M. with Resident #18's wife revealed Resident #18 had seen the eye doctor at the facility about three months ago and had not heard of an update as to when his eye glasses would be delivered. Interview on 06/01/22 at 4:35 P.M. with Social Services Designee (SSD) #17 revealed Resident #18 had seen the eye professional in March 2022. SSD #17 revealed she had been in contact with the company about the status of the order but glasses take about three to four months to be delivered. Interview on 06/02/22 at 10:40 A.M. with SSD #17 revealed she spoke with a representative at 360 vision and was informed Resident #18's glasses would be shipped to the facility in seven to 14 days. SSD #17 revealed she had been following up with the provider through emails and phonecalls. Interview on 06/02/22 at 11:50 A.M. with Vision Provider #301 revealed once an order was placed by the facility, the glasses would be shipped within seven to 14 days. Vision Provider #301 revealed Resident #18's order for new glasses was not received by the facility until 06/02/22. Vision Provider #301 denied any previous orders having been submitted. He revealed he informed SSD #17, Resident #18's glasses would be shipped out in seven to 14 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 9 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, resident interview, observation, and policy review, the facility failed to complete weekly skin assessments, monitor wound progress, and timely implement interventions for pressure ulcers. This affected one (Resident #43) out of four residents reviewed for pressure ulcers. The facility census was 71. Residents Affected - Few Findings include: Review of the medical record for Resident #43 revealed an admission date of 03/13/22. Diagnoses included diabetes type two, COVID-19, lymphedema, and guillain-barre syndrome. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was cognitively intact and required extensive assist of two staff for bed mobility and transfers. Review of the care plan dated 04/01/22 revealed Resident #43 was at risk for skin breakdown due to decreased mobility with interventions including encourage resident to turn and reposition as tolerated, observe skin for signs and symptoms of breakdown and document and notify the physician, skin assessments to be completed weekly and as needed, and staff to identify signs and symptoms of skin breakdown and notify appropriate staff. The care plan revealed Resident #43 had the potential to develop pressure ulcers due to immobility with interventions including educate resident and family on causes of skin breakdown, follow policies for prevention of skin breakdown, inform resident of new areas of skin breakdown and weekly treatment documentation to include measurement of each area of skin breakdown including width, length, depth, and type of tissue and exudate. Review of Resident #43's progress note dated 03/13/22 revealed, upon admission, discoloration was noted to Resident #43's bilateral feet. Review of the physician order dated 03/13/22 revealed Resident #43 needed a body audit with instructions of one time a day every seven days for skin observation. Review of the history and physical for Resident #43 dated 03/17/22 revealed no mention of foot wounds. Review of Resident #43's weekly skin assessments dated 03/20/22 and 04/20/22 revealed neither mentioned any wounds on Resident #43's bilateral feet. No weekly skin assessments were provided for review since 04/20/22. Review of history and physical for Resident #43 dated 04/21/22 and again on 04/27/22 revealed Resident #43 had bilateral planter wounds with ruptured blisters. Review of the progress note on 05/02/22 from the nurse practitioner revealed Resident #43 was assessed and found to have ulcers on bilateral feet and an unstageable pressure wound on the left foot. Review of the wound note dated 05/27/22 revealed Resident #43 had a diabetic foot wound measuring 1.1 centimeters (cm) by 0.9 cm. The wound was described as dry intact scab with no drainage and a plan to paint with betadine and follow up in one week. The overall wound condition was listed as initial evaluation. Resident #43 also had an evaluation of a wound on the right lateral foot listed as a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 10 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few diabetic wound. The wound was described as a dry intact blister measuring 2.6 cm by 1.2 cm with no drainage and instructions for skin prep daily. Review of the progress note dated 05/30/22 revealed Resident #43 was reviewed in the weekly wound meeting and documentation from the wound care was reviewed along with the wound treatment plan and characteristics, and the initial evaluation from the wound team. Review of Resident #43's physician order dated 05/30/22 revealed an order for skin prep on area to right lateral foot daily and PRN. Review of Resident #43's physician order dated 05/30/22 revealed and order for the left plantar foot with instructions to paint the area with betadine daily. Review of Resident #43's physician order dated 06/01/22 revealed an order for skin prep each shift to the right foot lateral outer aspect redness. Interview on 05/31/22 at 2:20 P.M. with Resident #43 revealed she had wounds on her bilateral feet. Resident #43 revealed staff had informed her of these wounds and took a picture on Resident #43's phone so she could see the wound. Resident #43 described the wounds as pressure spots. Observation and interview on 06/01/22 at 10:49 A.M. with Licensed Practical Nurse (LPN) #45 revealed Resident #43 had wounds on her bilateral feet. LPN #45 revealed no knowledge of where the wounds came from and revealed staff recently started putting betadine treatment on the left foot and there was no treatment for the right foot. LPN #45 revealed Resident #43 had no monitoring or skin assessments for the wounds on either the right or left foot. LPN #45 revealed skin assessments should be done weekly and maintained in the resident's medical record. Interview on 06/01/22 at 2:00 P.M. with Assistant Director of Nursing (ADON) #57 confirmed the facility had no evidence of wound documentation and monitoring for Resident #43. Interview on 06/02/22 at 9:48 A.M. with Regional Director of Clinical Services #70 revealed the facility had no evidence of weekly skin assessments or wound monitoring having been completed for Resident #43 after the wounds were identified on her bilateral feet and categorized as pressure sores on or before 05/02/22 until a wound care provided was assigned and Resident #43 was assessed on 05/27/22. Review of policy titled Prevention of pressure ulcers/injuries, dated 07/2017, revealed the facility should complete a risk assessment weekly and upon changes in condition. The policy revealed skin should be inspected daily during care and identified for areas or signs of pressure injuries, moisturize skin and reposition resident. The policy revealed the facility should monitor skin by evaluating, reporting and documenting changes in the skin and review interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 11 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interviews, the facility failed to ensure nutritional supplements were provided as ordered. This affected one (Resident #36) out of four residents reviewed for nutrition. The facility census was 71. Residents Affected - Few Findings include: Review of Resident #36's medical record revealed admission to the facility occurred on 07/23/20. Resident #36 had medical diagnoses including dementia, high blood pressure, and coronary artery disease. Review of Resident #36's most recent quarterly assessment dated [DATE] revealed Resident #36 had severe cognitive impairment. The assessment revealed Resident #36 had unintended weight loss. Review of Resident #36's physician orders dated 09/15/20 revealed an order for house supplement (House Shake/Nutritional Shake) three times a day. Review of Resident #36's physician order dated 03/06/22 revealed an order for nutritional treat (ice cream nutritional supplement) two times a day. Review of Resident #36's Nutritional Notes dated 03/06/22 revealed a nutritional treat was added for Resident #36 two times a day which was to be provided by the kitchen. Review of Resident #36's medical record revealed the magic cup was noted as a weight loss intervention. Resident #36's record revealed on 12/21/21, Resident #36's weight was 120.6 pounds and on 03/01/22, Resident #36's weight had declined to 114 pounds, which was a non-significant weight loss. Review of Resident #36's meal ticket dated 06/02/22 revealed Resident #36 was to receive a House Shake and Magic Cup with her meal. Observation of Resident #36 on 06/02/22 at 8:21 A.M. revealed Resident #36 was in a wheelchair in the TV room, across from the nursing station, with a bed side stand in front of her. Resident #36 was provided a breakfast tray which included two sausage patties, a piece of french toast, and a cup of coffee. The meal tray was observed to have no items cut up for the resident and the container of syrup was sitting beside the plate unopened. The observation from 8:21 A.M. through 8:36 A.M. revealed no staff offered to cut up Resident #36's food and/or assist her in any way. Resident #36 was observed sitting and staring at her food the entire time. The observation revealed no nutritional snack or supplement was observed on the tray. Interview with State Tested Nursing Assistant (STNA) #215 on 06/02/22 at 8:37 A.M. revealed it was her first day working at the facility. STNA #215 revealed it was also the licensed nurse working on the unit first day at the facility and she was unsure of Resident #36's needs. Observation of Resident #36's meal tray on 06/02/22 at 8:45 A.M. revealed no supplements were observed on the tray. Observation and interview with Food Service Director #62 on 06/02/22 at 8:50 A.M. confirmed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 12 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 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 0692 Level of Harm - Minimal harm or potential for actual harm Resident #36's meal ticket identified Resident #36 should have received a house shake and magic cup on her meal tray. The observation of Resident #36 with the Food service Director #62 confirmed Resident #36 did not have the supplements on her meal tray, even though the items were listed on her meal ticket. Food Service Director #62 went to the kitchen, obtained the items for Resident #36 and placed both items unopened on her meal tray. Residents Affected - Few Observation of Resident #36 on 06/02/22 at 8:58 A.M. revealed she remained in the television room with her untouched meal tray and unopened supplements, and STNA #213 came to the area to remove her meal tray. Interview with STNA #213 confirmed Resident #36 had not eaten anything and the supplements were not opened or touched. STNA #213 then opened Resident #36 house shake and placed a straw in the container, but continued to take the ice cream container with the lid remaining, and stated she does not eat it. Resident #36 was observed to pick up the milk shake and started drinking it. STNA #213 identified she is new to the facility and worked through an agency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 13 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, review of manufacture instructions, and staff interview, the facility failed to ensure insulin was administered according to manufactures instructions. This affected one (Resident #281) of four residents observed for medication administration. The facility census was 71. Findings include: Observation of medication administration on 06/01/22 at 7:50 A.M. with Licensed Practical Nurse (LPN) #29 revealed LPN #29 obtained Resident #281's blood sugar which was found to be at 380 milligrams/deciliter. LPN #29 then obtained Resident #281's insulin pen, added a new needle and adjusted the dosage to 10 units. LPN #29 was then observed to administer the 10 units of Novolog insulin to Resident #281. Upon returning to the medication cart, LPN #29 was asked about priming the insulin pen prior to administration and LPN #29 confirmed she did not prime the insulin pen prior to administration and was not aware of the need to do so. Review of the Novolog flex pen (insulin pen) manufactures instructions revealed in the steps for administration; step seven priming, turn the dose selector to select two units, hold the pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top. Hold the pen with the needle pointing up and press and hold in the dose until the counter shows zero. The instructions revealed a drop of insulin should be seen at the needle tip, if not, repeat the steps. The instructions revealed small amounts of air may collect in the cartridge during normal use. The priming of the pen is completed to make sure you receive the prescribed dose of insulin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 14 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 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. Based on medical record review, review of pharmacy medication reviews, and staff interview, the facility failed to ensure the physician was aware and responded to pharmacy medication reviews/recommendations in a timely manner. This affected one (Resident #28) out of five residents reviewed for unnecessary medications. The facility census was 71. Findings include: Review of Resident #28's medical record revealed admission to the facility occurred on 07/23/21 with medical diagnoses including diabetes, depression, high blood pressure, dementia, and Covid-19 infection (03/17/22). Review of Resident #28's Medication Regimen revealed he was receiving Aricept (a medication used to treat dementia in people who have Alzheimer's disease) five milligrams (mg) daily for the diagnosis of dementia. Review of Resident #28's Medication Administration Record for May 2022 and June 2022 confirmed Resident #28 was receiving Aricept five mg daily. Review of a pharmacy review/recommendation dated 04/23/22, revealed on 03/20/22 a new order for Resident #28 to receive Aricept five mg at bedtime was written. The recommendation revealed the dose of Aricept thought to be most effective is 10 mg once a day and the pharmacist recommended to consider increasing the dose of Aricept to 10 mg once a day. Review of the recommendation form dated 04/23/22 revealed, as of 06/01/22, the recommendation was not addressed by the facility physician. Interview with the facility Corporate Registered Nurse (RN) #75 on 06/01/22 at 10:15 A.M. confirmed the facility changed pharmacy suppliers and when the April 2022 reviews/recommendations were completed, they were sent to a sister facility. The interview confirmed on 06/01/22, when the surveyors asked for the April 2022 reviews, it was determined the facility had not received any of Resident #28's reviews/recommendations for the month of April 2022. The interview confirmed Resident #28's pharmacy recommendation dated 04/23/22 had not been followed up on as of 06/01/22. The interview confirmed the facility should have identified the lack of the April 2022 reports coming to the proper facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 15 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview, the facility failed to obtain laboratory testing as ordered. This affected one (Resident #28) out of five residents reviewed for unnecessary medications. The facility census was 71. Residents Affected - Few Findings include: Review of Resident #28's medical record revealed admission to the facility occurred on 07/23/21 with medical diagnoses including diabetes, major depression, high blood pressure, and Covid-19 (03/17/22). Review of Resident #28's physician orders dated 11/14/21 revealed orders for blood laboratory testing of Complete Blood Count (CBC), Metabolic Panel (BMP), and Hemoglobin A1C (measures average blood glucose levels), to be completed every three months. Review of the Resident #28's medical record revealed no evidence of any blood laboratory testing having been conducted since November 2021. Interview with the Director of Nursing (DON) on 06/02/22 at 1:55 P.M., confirmed the facility did not obtain Resident #28's blood laboratory testing (CBC, BMP, Hemoglobin A1C), every three months, as ordered by the physician. The interview confirmed Resident #28 should have had laboratory testing completed in February 2022 and May 2022. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 16 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observations, interviews and record review, the facility failed to ensure meals were served using the correct serving size, and failed to ensure mechanical soft and pureed meals were prepared according to a recipe. This had the potential to affect all 69 residents who received meals from the kitchen. The facility identified two residents (Resident #16 and #276) who received nothing by mouth and did not receive food from the kitchen. The facility census was 71. Findings include Observation and interview on 06/01/22 at 11:01 A.M. with [NAME] #6 revealed the facility had four pureed meal orders and five mechanical soft meal orders. [NAME] #6 placed four four ounce (oz) scoops of green beans into the blender, with an unmeasured amount of water which appeared to be roughly a tablespoon, and blended them to a pureed consistency. [NAME] #6 then placed three breaded chicken tenders in the blender and blended them to a mechanical soft consistency. [NAME] #6 then scooped out an unmeasured amount of the blended chicken for the mechanical soft diets and placed the mechanical soft chicken in a metal dish. [NAME] #6 then added an unmeasured amount of water, which appeared to be roughly one tablespoon, to the remaining mechanical soft chicken in the blender and blended it to a pureed consistency. Then, [NAME] #6 placed one and a half four oz scoops of plain ziti pasta noodles in the blender with an unmeasured amount of water and blended it to a pureed consistency. Interview on 06/01/22 at 11:01 A.M. with [NAME] #6 revealed she just puts in a little and revealed it was about a tablespoon of water. [NAME] #6 revealed the facility does not have enough scoops and serving spoons so they have to make due with what they have. [NAME] #6 revealed the kitchen had no six oz scoops so they have just been using a four oz scoop and try to remember to do big scoops. Observation and interview on 06/01/22 at 11:22 A.M. with [NAME] #6 revealed staff were using a four oz scoop for the green beans and the baked ziti. The observation revealed [NAME] #6 used a spatula and cookie scooper to serve the pureed and mechanical soft meals. [NAME] #6 used the correct size scoop for the green beans but served the green beans after only filling the scoop to an average of half to three quarters full. Interview on 06/01/22 at 12:15 P.M. with [NAME] #6 revealed the facility does not have a guideline or recipe to use when making pureed food. [NAME] #6 revealed she does not like using water and would rather use sauce or broth but the facility does not have a guide in order to know how much to use. [NAME] #6 revealed residents should have received a six oz portion of the baked ziti according to the menu, but the facility does not have any six oz scoops. Interview on 06/01/22 at 12:20 P.M. with Kitchen Manager (KM) #62 confirmed there was no recipe or guides for staff to use in order to know how to make pureed and mechanical soft meals as well as provide adequate portion sizes. KM #62 confirmed the kitchen does not have all the scoop sizes for food service. Review of the menu and cooking instructions revealed residents should have been served four ounces of green beans and six ounces of baked ziti. Review of resident council minutes revealed residents expressed concerns about small and inconsistent serving sizes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 17 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews and record review, the facility failed to prepare food in a sanitary manner. This had the potential to affect all 69 residents who received meals from the kitchen. The facility identified two residents (Resident #16 and #276) who received nothing by mouth and did not receive food from the kitchen. The facility census was 71. Findings include 1. Observation on 06/01/22 at 11:01 A.M. of [NAME] #6 preparing the pureed meal items revealed [NAME] #6 placed four four ounce (oz) scoops of green beans in the blender then blended them to a pureed texture. [NAME] #6 then rinsed the blender with water only. [NAME] #6 did not use soap or sanitizer when cleaning the blender and the blender was not dried. [NAME] #6 then placed three breaded chicken tenders in the blender and blended them to a pureed consistency. [NAME] #6 then rinsed the blender with water only. [NAME] #6 did not use soap or sanitizer when cleaning the blender and the blender was not dried. [NAME] #6 then placed one and a half four oz scoops of plain ziti pasta noodles in the blender with an unmeasured amount of water and blended the noodles/water to a pureed consistency. Interview on 06/01/22 at 12:15 P.M. with [NAME] #6 confirmed she only rinsed the blender, did not use soap or sanitizer when cleaning the blender, and did not allow the blender to dry between uses. 2. Observation on 06/01/22 at 11:13 A.M. revealed [NAME] #6 took the lunch meal food temperatures for the burgers, plain ziti noodles, chicken tenders, two pans of baked ziti, green beans, hot dogs, mechanical chicken, pureed chicken noodles, and pureed green beans. [NAME] #6 sanitized the food thermometer using the same two alcohol wipes for all items. Observation on 06/01/22 at 11:38 A.M. revealed Kitchen Manager (KM) #62 was retaking the lunch meal food temperatures and used one alcohol wipe to sanitize the thermometer for all food items. Interviews on 06/01/22 at 11:15 A.M. and 11:20 A.M. with [NAME] #6 and KM #62 confirmed food temperatures were taken and the thermometer was being cleaned using the same alcohol wipes with potential for cross contamination. 3. Observation on 06/01/22 at 11:18 A.M. revealed [NAME] #6 knocked a set of tongs on the floor. [NAME] #6 then picked up the tongs and placed them on the prep table near other dirty dishes and trash that had not yet been thrown out. Wearing the same gloves, [NAME] #6 touched the hamburger buns and hamburgers, and reached into a bag on onions. Observation on 06/01/22 at 11:31 A.M. revealed [NAME] #6 had continued wearing the same gloves from the observation at 11:18 A.M., and grabbed all the pieces of garlic bread off the baking sheet, and placed them in a large metal container for service. With the same gloved hands, [NAME] #6 prepared a large mixed salad and used her hands to mix up the salad toppings in a large bowl. Observation on 06/01/22 at 11:37 A.M. revealed [NAME] #6 washed her hands and changed gloves, then did not have anymore clean tongs so she picked up two hotdog's with her hands and placed them in buns. Then, with the same gloves, [NAME] #6 opened the oven, touched the second tray of garlic bread, and placed all the pieces of bread into a serving container. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 18 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Interview on 06/01/22 from 12:15 P.M. and 12:20 P.M. with [NAME] #6 and Kitchen Manager #62, confirmed [NAME] #6 did not wash her hands and change gloves after each contamination which increased the risk for cross contamination throughout the meal service. [NAME] #6 stated she did not even think to change her gloves. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 19 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on review of the facility assessment and staff interview, the facility failed to ensure the facility assessment addressed the use of contract nursing staff to provide services. This had the potential to affect all 71 residents. The census was 71. Findings include: Review of the facility assessment, reviewed and revised on 03/17/22, revealed the facility assessment did not address the facilities use of contract (agency) nursing staff to provide services. Review of the daily assignment sheets provided by the facility during the survey week from 05/31/22 to 06/02/22 revealed the facility used agency nursing staff on 13 shifts. Interview with the Administrator on 06/01/22 at 11:30 A.M. verified the facility utilized agency nurses to provide services and confirmed the assessment does not include information regarding the facilities use of agency nursing staff even after it was reviewed and revised on 03/17/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 20 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 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, staff interview, and review of glucometer manufacture instructions, the facility failed to ensure the glucometer (machine used to test blood sugar level) was properly disinfected between residents. This affected four residents (Resident #45, #276, #277, and #281) out of 17 residents who resided on the 100 hall. The facility census was 71. Residents Affected - Some Findings include: Observation of medication administration on 06/01/22 at 7:50 A.M. with Licensed Practical Nurse (LPN) #29 revealed LPN #29 set out four alcohol pads and lancets to test blood sugars for multiple residents. LPN #29 was observed to obtain a blood sugar for Resident #277 with the glucometer. LPN #29 returned to the medication cart and cleaned the glucometer (which was a 100 hall community machine) with an alcohol pad. The nurse then obtained a blood sugar for Resident #276, using the same machine. LPN #29 was getting ready to test Resident #45 and Resident #281 and was stopped by the state surveyor. LPN #29 was asked if she cleaned the glucometer with anything other than an alcohol pad. LPN #29 identified no, then opened the medication cart and a bottle of sanitizing wipes with bleach was observed, which was an Environmental Protection Agency (EPA) approved disinfectant. LPN #29 stated maybe she should use the sanitizing wipes with bleach to clean the glucometer. LPN #29 was then observed to properly clean the machine before obtaining additional blood sugars. Review of the manufacture instructions for the facility glucometer revealed the meter should be cleaned and disinfected after use on each patient. The machine may only be used with multiple patients when standard precautions and the manufactures disinfection procedures are followed. The disinfection procedure is needed to prevent the transmission of blood-borne pathogens. The list of EPA approved disinfectant wipes included the sanitizing wipes with bleach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 21 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation and staff interview, the facility failed to ensure the stand up scale was properly maintained. This had the potential to affect all 24 residents (Resident #3, #4, #8, #9, #10, #16, #17, #18, #19, #21, #28, #29, #30, #32, #36, #40, #41, #46, #47, #53, #58, #60, #61, and #77) who could utilize the stand up scale and resided on the 300/400 hallway. The facility census was 71. Residents Affected - Some Findings include: Observation of Resident #36 being weighed on the stand up scale on 06/02/22 at 9:33 A.M. with State Tested Nurse Aide (STNA) #216 revealed Resident #36 was able to stand on the scale, however the scale was observed to tilt forward and was wobbling. STNA #216 confirmed the scale was broken and turned the scale over to discover there was a missing leg under the base of the scale. The scale was observed to have three loose legs and one leg was missing. Interview with Maintenance Director #64 was completed on 06/02/22 at 1:17 P.M. The interview confirmed he was notified the scale was not working properly on Monday 05/31/22 and placed it in the shower room on the 300/400 hallway. The interview confirmed the facility had to order new legs for the scale; however it was not tagged as out of service at that time. The interview confirmed he should have moved the scale to ensure staff would not be able to utilize the scale until it was repaired. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 22 of 23 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prestige Gardens Rehabilitation and Nursing Center 755 South Plum Street Marysville, OH 43040 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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, observation, resident interview, and staff interview, the facility failed to ensure resident call lights were in working order. This affected one (Resident #28) out of 24 reviewed for functioning call lights. The facility census was 71. Residents Affected - Few Findings include Review of the medical record for Resident #28 revealed an admission date of 07/23/21. Diagnoses included type two diabetes, depression, hyperlipidemia, acute embolism, and hyperlipidemia. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #28 was cognitively intact. Observation and interview on 05/31/22 at 9:27 A.M. with Resident #28 revealed Resident #28 was pressing his call light and reported staff were not responding. Resident #28 was observed to push the call light again and the light on the wall as well as the light outside door did not activate. Resident #28 revealed his call light had not been working for about a week and stated he had mentioned it to staff. Interview on 05/31/22 at 9:28 A.M. with Licensed Practical Nurse (LPN) #51 confirmed Resident #28's call light was not working properly and revealed a maintenance request would need to be placed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365577 If continuation sheet Page 23 of 23