Health inspection·July 5, 2022

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide adequate assistance with activities of daily living (ADL) to a resident who was dependent on staff for assistance. This affected one (Resident #5) of the six residents reviewed for ADL. The facility census was 82. Residents Affected - Few Findings include: Record review for Resident #5 revealed the resident was admitted to the facility on [DATE] and had diagnoses including rheumatoid arthritis, hypertension, migraines, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 08. This resident was assessed to be dependent upon two staff members for transfers and to require extensive assistance from two staff members for bed mobility, toileting, bed mobility, and personal hygiene. Observation on 06/26/22 at 11:03 A.M. revealed Resident #5 was lying in bed wearing a hospital gown. The resident was not observed to have eyeglasses on. Observation on 06/26/22 at 2:02 P.M. revealed Resident #5 continued to lie in bed wearing a hospital gown and did not have eyeglasses on. Observation on 06/27/22 at 10:30 A.M. revealed Resident #5 was lying in bed wearing a hospital gown and did not have eyeglasses on. Interview with Resident #5 on 06/27/22 at 10:30 A.M. revealed the resident wanted to get dressed in personal clothing and wanted to get up out of bed and required staff assistance to do so. Observation on 06/27/22 at 3:45 P.M. revealed Resident #5 remained in a hospital gown in bed and did not have eyeglasses on. Interview on 06/27/22 at 3:45 P.M. with Resident #5 revealed the resident continued to want to get dressed in personal clothing and get out of bed but was told by staff they did not have enough time to get the resident up. Observation on 06/28/22 at 10:50 A.M. revealed Resident #5 was lying in bed in a hospital gown and did not have eyeglasses on. Observation on 06/28/22 at 2:45 P.M. revealed Resident #5 was sitting up in a chair in the lobby and continued to wear a hospital gown. The resident was observed to have eyeglasses on. Interview with Resident #5 on 06/28/22 at 2:45 P.M. revealed the resident continued to prefer to be dressed in personal clothing rather than a hospital gown but was happy staff had the time to get her out of bed. Observation on 06/29/22 at 11:47 A.M. revealed Resident #5 was lying in bed in a hospital gown. The resident did not have eyeglasses on. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365585 If continuation sheet Page 2 of 21 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 365585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville I 10098 Big Bear Creek Rd Lucasville, OH 45648 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Resident #5 on 06/29/22 at 11:47 A.M. revealed the resident wanted staff to assist the resident to get up out of bed and dressed in personal clothing. The resident stated it was very hard to see without eyeglasses which were in the top bedside drawer out of the resident's reach. Interview with State Tested Nursing Assistant (STNA) #107 and STNA #131 on 06/29/22 at 11:52 A.M. verified Resident #5 had a large amount of personal clothing in which to be dressed in and required assistance from two staff members to get out of bed and dressed. STNA #127 and STNA #131 stated the two were working on the unit Resident #5 resided on and planned to get the resident up and dressed after lunch as they had not had sufficient time to yet. Interview with the Director of Nursing (DON) on 06/29/22 at 12:04 P.M. revealed residents were assisted to get up and dressed according to their personal preference. The DON stated if a resident wanted up, staff should provide requested assistance within a reasonable time. Observation on 06/29/22 at 1:53 P.M. revealed Resident #5 continued to remain in bed wearing a hospital gown and did not have eyeglasses on. Interview and observation with STNA #107 on 06/29/22 at 1:55 P.M. verified Resident #5 remained in bed wearing a hospital gown. STNA #107 verified Resident #5's eyeglasses continued to be in the top drawer of the bedside table out of the resident's reach. STNA #107 stated staff were preparing to get the resident out of bed as they had not had the time until now. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365585 If continuation sheet Page 3 of 21 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 365585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville I 10098 Big Bear Creek Rd Lucasville, OH 45648 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure appropriate administration of physician ordered medications. This affected two (Resident's #43 and #57) of the 82 residents who were administered their medications by facility staff. The facility census was 82. Residents Affected - Few Findings include: 1. Record review for Resident #43 revealed this resident was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparalysis affecting the right dominant side, dysphagia (difficulty swallowing), muscle weakness, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 09. This resident was assessed to require extensive assistance from one staff member for transfers, bed mobility, toileting, and eating. Review of the Medication Administration Record (MAR) for 06/26/22 revealed all ordered 6:00 A.M. medications had been documented as being administered as ordered by the physician to Resident #43. Observation on 06/26/22 at 11:35 A.M. revealed Resident #43 was observed to be sitting up on the side of the bed. There was a clear, plastic medication cup located on the bedside table which was labeled with the resident's name and contained multiple, unpackaged pills. There were no facility staff observed to be in the room. Observation and interview with Licensed Practical Nurse (LPN) #139 on 06/26/22 at 11:37 A.M. verified there was a medication cup labeled with Resident #43's name located on the bedside table in Resident #43's room which contained multiple, unpackaged pills. LPN #139 stated she had not administered any medications to Resident #43 since arriving for her shift at 7:00 A.M. and believed the medication cup contained the residents 6:00 A.M. scheduled medications. LPN #139 verified the resident should have been observed to take all medications before the nurse left the room as the resident was not allowed to self-administer medications. LPN #139 then gathered the medication cup containing the unpackaged medications and exited the room. Review of the facility policy titled Administering Oral Medications, revised 10/2010, revealed staff were to remain with resident until all medications had been taken. 2. Review of the medical record for Resident #57 revealed an admission date of 01/04/22 with diagnoses including chronic obstructive pulmonary disease, repeated falls, muscle weakness, gastro-esophageal reflux disease without esophagitis, heart failure, depression, chronic pain, and arthritis. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #57 had intact cognition. Review of the physical physician's orders for May 2022 revealed written in were orders for Oscal and Vitamin D tablet to be given by mouth twice a day starting 03/22/22 and a multivitamin tablet to be given once a day starting 02/23/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365585 If continuation sheet Page 4 of 21 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 365585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville I 10098 Big Bear Creek Rd Lucasville, OH 45648 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 Review of the electronic medical record revealed no orders for Oscal and Vitamin D or a multivitamin. Level of Harm - Minimal harm or potential for actual harm Review of the physical MAR for May 2022 revealed Oscal and Vitamin D and a multivitamin were given as ordered through 05/24/22. Residents Affected - Few Review of the electronic MAR for 05/25/22 through 05/31/22 and 06/01/22 through 06/28/22 revealed no administration records for Oscal and Vitamin D or a multivitamin. Interview on 06/28/22 at 4:46 P.M. with Regional Nurse #950 confirmed the two orders were missed when they began using electronic medical records and Resident #57 had not been receiving them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365585 If continuation sheet Page 5 of 21 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 365585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville I 10098 Big Bear Creek Rd Lucasville, OH 45648 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 record review, observation, and interviews the facility failed to provide appropriate supervision and implement appropriate fall interventions for residents who were a fall risk. This affected two (Resident #133 and Resident #60) of two residents reviewed for falls. The facility census was 82. Findings include: 1. Review of Resident #133's medical record revealed an initial admission date of 04/28/17 with diagnoses including bipolar disorder, registered sex offender, benign prostatic hyperplasia, hemiplegia and hemiparesis, anxiety, depression, dementia, hyperlipidemia, cataracts, muscle weakness, dysphagia, skull fractures, traumatic subdural hemorrhage, anemia, and cerebral infarction. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #133 was rarely/never understood as indicated by a Brief Interview for Mental Status (BIMS) score of 00. Review of nursing assessments and daily notes revealed Resident #133 was at risk for falls with his last fall in the facility dated on 05/20/22. This was documented as an unwitnessed fall. On assessment, Resident #133 sustained a hematoma to the forehead. All interventions were documented as being in place. On 05/21/22, Resident #133 was sent to the hospital for increased confusion. While in the hospital, Resident #133 sustained another fall, which resulted in him being transported to another hospital where an emergent left craniotomy was performed. Resident #133 returned to the facility on [DATE], with fall precautions in place including a helmet being in place at all times while out of bed. Resident #133 resides on the all-male secured unit (C Hall) that required supervision at all times. Observation of Resident #133 on 06/26/22 at 3:35 P.M. revealed this resident's head was hanging over the right side of the bed, approximately eight inches from the floor with the resident positioned crossways in the bed. Call light clipped on privacy curtain about two feet from the resident, and out of reach. The resident's feet were also hanging over the left side of the bed. This surveyor activated the call light system at 3:35 P.M. No staff response occurred. Observation of Resident #133 on 06/26/22 at 3:45 P.M. revealed resident remains in same position and has not moved as this surveyor remained in the room. Call light remained activated. No staff response observed. Observation of Resident #133 on 06/26/22 at 3:50 P.M. revealed Resident #133 remained in the same position with no visible injuries. Call light remained activated. No staff response observed. Observation of Resident #133 on 06/26/22 at 3:53 P.M. revealed a second surveyor was unable to find available staff members, and returned to the Resident #133's room at 3:53 P.M. with the Director of Nursing (DON). Resident #133's position had not changed, with no injuries sustained. The DON then left and returned with three staff members to reposition Resident #133 back in bed. The three staff members included Registered Nurse (RN) #200, Licensed Practical Nurse (LPN) #145, and State Tested (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365585 If continuation sheet Page 6 of 21 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 365585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville I 10098 Big Bear Creek Rd Lucasville, OH 45648 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 Nursing Assistant (STNA) #123. Level of Harm - Minimal harm or potential for actual harm Interview with the DON on 06/26/22 at 4:15 P.M. verified no staff members responded to the call light activated by the surveyor during an unsafe incident involving Resident #133, until eighteen minutes later. She verified this occurred due to surveyor intervention as one surveyor remained with the resident, while another alerted her. She stated there were four staff members assigned to C Hall at the time of the call light being activated, and no response was evident. Residents Affected - Few Interview with LPN #145 on 06/26/22 at 4:30 P.M. verified he was not aware the call light for Resident #133 had been activated until the DON had alerted him. He verified no other staff had notified him that any call lights were on. Review of the facility call light policy on 06/27/22 at 8:00 A.M. revealed a revision date in October 2010. The policy stated in general guidelines, if some residents are not able to use their call light to be sure to check on these residents frequently. Additionally, the resident's call is to be answered as soon as possible. Observation of Resident #133 on 06/27/22 at 10:30 A.M. revealed this resident in bed with 1:1 sitter in place to monitor resident. Observation of Resident #133 on 06/28/22 at 09:30 A.M. revealed this resident in bed with 1:1 sitter in place to monitor resident. Observation of Resident #133 on 06/29/22 at 02:30 P.M. revealed this resident in bed with 1:1 sitter in place to monitor resident. 2. Record review for Resident #60 revealed this resident was admitted to the facility on [DATE] with diagnoses including muscle weakness, unsteadiness on feet, and multiple falls. Review of the 5-day MDS 3.0 assessment dated [DATE] revealed Resident #60 had intact cognition evidenced by a BIMS assessment score of 15. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting. Review of the care plan, implemented on 01/05/20, revealed Resident #60 had the potential for injury. Interventions included non-skid socks while in bed and a perimeter mattress. Review of the active physician's orders revealed an order for a low bed with floor mat and a perimeter mattress. Observation on 06/26/22 at 12:25 P.M. revealed Resident #60 was observed to be lying in bed with the right side of the bed against the wall. There was not a perimeter mattress observed to be on the bed and there also was not a fall mat located on the floor by the left side of the bed. Observation on 06/27/22 at 9:20 A.M. revealed Resident #60 was observed to be lying in bed with the right side of the bed against the wall. There was not a perimeter mattress observed to be on the bed and there also was not a fall mat located on the floor by the left side of the bed. Observation on 06/28/22 at 11:53 A.M. revealed Resident #60 was observed to be lying in bed with the right side of the bed against the wall. There was not a perimeter mattress observed to be on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365585 If continuation sheet Page 7 of 21 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 365585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville I 10098 Big Bear Creek Rd Lucasville, OH 45648 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 bed and there also was not a fall mat located on the floor by the left side of the bed. Level of Harm - Minimal harm or potential for actual harm Observation and interview with STNA #128 on 06/28/22 at 11:55 A.M. verified there was not a perimeter mattress located on the bed of Resident #60 and there also was not a fall mat on the floor by the left side of the bed. Residents Affected - Few Observation and interview with Regional Nurse #950 on 06/28/22 at 12:51 P.M. verified there was not a fall mat or perimeter mattress in place for Resident #60 as ordered by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365585 If continuation sheet Page 8 of 21 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 365585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville I 10098 Big Bear Creek Rd Lucasville, OH 45648 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 observation, interview, and record review revealed the facility failed to provide therapeutic diet and supplements as ordered for Resident's #21, #34, #70, and #72. This affected four (Resident's #21, #34, #70, #72) of six residents reviewed for nutrition. The facility census was 82. Residents Affected - Some Findings include: 1. Review of the medical record revealed Resident #34 admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus, other schizophrenia, hypertension, adult failure to thrive, shortness of breath, depression, and unspecified protein-calorie malnutrition. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #34 had intact cognition. Review of the plan of care dated 04/21/22 revealed Resident #34 had potential fluid imbalance and imbalanced nutrition related to disease processes, behavioral problems, poor dentition, and weight change prior to admission. Interventions included weighing monthly and as needed, inviting to activities, administering medications as ordered, obtaining and monitoring lab work as ordered, monitoring for signs of dehydration, providing food preferences, providing supplements as ordered, and providing diet as ordered. Review of the signed physician's order dated 04/25/22 revealed an order to add Pro-Stat (protein supplement) 30 milliliters (ml) twice a day. Review of the electronic physician's orders for 05/25/22 through 05/31/22 and June 2022 revealed no order for Pro-Stat. Review of the physical Medication Administration Record (MAR) for May 2022 revealed Resident #34 was offered Pro-Stat from 05/01/22 through 05/24/22. Review of the electronic MAR revealed no documentation for Pro-Stat for 05/25/22 through 05/31/22 and for 06/01/22 through 06/28/22. Interview on 06/29/22 at 10:55 A.M. with Regional Nurse #950 confirmed Resident #34 had not been receiving Pro-Stat. 2. Review of the medical record for Resident #70 revealed an admission date of 02/13/20 with diagnoses including hemiplegia and hemiparesis of no-dominant side, vascular dementia, major depression, and hypertension. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #70 had intact cognition. He was not on any special diets and had no significant weight changes. Review of the physician order dated 05/24/22 revealed Resident #70 was to receive a regular diet with regular texture and fortified foods at meals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365585 If continuation sheet Page 9 of 21 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 365585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville I 10098 Big Bear Creek Rd Lucasville, OH 45648 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 Observation on 06/28/22 from 11:00 A.M. to 12:25 P.M. of the lunch meal revealed Resident #70 did not receive fortified food. Interview on 06/28/22 from 11:00 A.M. to 12:25 P.M. with [NAME] #801 and Dietary Aide #803 revealed residents who were ordered fortified foods were receiving fortified pudding. Residents Affected - Some Review of tray ticket for the lunch meal on 06/28/22 revealed no fortified foods were listed for Resident #70. Review of the diet requisition form dated 05/24/22, revealed the nurse completed a form indicating Resident #70 was to receive fortified foods with meals. Interview on 06/28/22 at 12:48 P.M. with Dietary Manager #800 confirmed Resident #70's tray ticket did not indicate he was to receive fortified foods and should have. 3. Review of the medical record for Resident #72 revealed an admission date of 11/09/18 with diagnoses including dementia, type two diabetes mellitus, hypertension, major depression, residual schizophrenia, and cognitive communication deficit. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #72 had severely impaired cognition. She weighed 125 pounds and had gained weight on a physician-prescribed regimen. Review of the diet requisition form dated 09/21/21, revealed the nurse completed a form indicating Resident #72 was to receive fortified foods with meals. Observation on 06/28/22 from 11:00 A.M. to 12:25 P.M. of the lunch meal revealed Resident #72 did not receive fortified food. Interview on 06/28/22 from 11:00 A.M. to 12:25 P.M. with [NAME] #801 and Dietary Aide #803 revealed residents who were ordered fortified foods were receiving fortified pudding. Review of the tray ticket for the lunch meal on 06/28/22 revealed no fortified foods were listed for Resident #72. Interview on 06/29/22 at 11:23 A.M. with Dietary Manager #800 confirmed Resident #72 did not have fortified foods on their tray ticket. She reported the order for fortified food was received before she was hired, and she was unsure if Resident #72 ever received fortified foods. 4. Review of the medical record for Resident #21 revealed an admission date of 12/09/20 with diagnoses including schizophrenia, cognitive communication deficit, hypertension, major depressive disorder, schizoaffective disorder, and dysphagia. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #21 had intact cognition. She was on a mechanically altered diet and had no significant weight changes. Review of the diet requisition form dated 12/09/20, revealed the nurse completed a form indicating Resident #21 was to receive fortified foods with lunch and dinner. Observation on 06/28/22 from 11:00 A.M. to 12:25 P.M. of the lunch meal revealed Resident #21 did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365585 If continuation sheet Page 10 of 21 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 365585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville I 10098 Big Bear Creek Rd Lucasville, OH 45648 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 not receive fortified food. Level of Harm - Minimal harm or potential for actual harm Interview on 06/28/22 from 11:00 A.M. to 12:25 P.M. with [NAME] #801 and Dietary Aide #803 revealed residents who were ordered fortified foods were receiving fortified pudding. Residents Affected - Some Review of the tray ticket for the lunch meal on 06/28/22 revealed no fortified foods were listed for Resident #21. Interview on 06/29/22 at 11:23 A.M. with Dietary Manager #800 confirmed Resident #21 did not have fortified foods on their tray ticket. She reported the order for fortified food was received before she was hired, and she was unsure if Resident #21 ever received fortified foods. Review of the undated policy Fortified Food Program revealed the goal of the fortified food program was to be able to provide a higher calorie and or higher protein food items to residents if the residents intake of regular food or beverages was not able to meet estimated nutritional needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365585 If continuation sheet Page 11 of 21 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 365585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville I 10098 Big Bear Creek Rd Lucasville, OH 45648 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review for Resident #69 revealed this resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia without behavioral disturbance, chronic obstructive pulmonary disease, hypertension, weakness, unsteadiness on feet, lack of coordination, and difficulty walking. Residents Affected - Few Review of the quarterly MDS 3.0 assessment, dated 05/23/22, revealed Resident #69 had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 05. This resident was assessed to require extensive assistance from one staff member for bed mobility, transfers, toileting, and supervision with set-up help only for eating. Resident #69 was assessed to use oxygen while a resident of the facility. Review of the care plan dated 03/02/22 revealed Resident #69 had an ineffective breathing pattern. Interventions included keep call bell within easy reach, monitor and report restlessness and agitation, change oxygen tubing according to facility policy, oxygen as ordered, diet as ordered, observe during meals, monitor lab reports as ordered, monitor lung sounds as ordered, elevate head of bed as ordered by physician, pulse oximetry as ordered, and diet as ordered. Observation on 06/26/22 at 12:25 P.M. revealed Resident #69 was lying in bed with oxygen running being administered by nasal cannula. The oxygen tubing and water humidification bottle were not observed to be labeled or dated. Observation and interview with Licensed Practical Nurse (LPN) #139 on 06/26/22 at 12:35 P.M. verified the oxygen tubing and humidification bottle were not labeled with the date changed. Review of the policy titled Departmental (Respiratory Therapy) Prevention of Infection, dated November 2011, revealed distilled water should be used for humidification per facility protocol. The bottle should be marked with the date and initials upon opening and discarded after 24 hours. The oxygen cannula and tubing were to be changed every seven days or as needed. Based on observation, interview, medical record review, and policy review the facility failed to ensure oxygen tubing and humidifier bottles were labeled and dated for Resident's #34 and #69 and failed to ensure Resident #34's humidifier bottle was filled. This effected two (Resident's #34 and #69) of two residents reviewed for oxygen. The facility census was 82. Findings include: 1. Review of the medical record revealed Resident #34 admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus, other schizophrenia, hypertension, adult failure to thrive, shortness of breath, depression, unspecified protein-calorie malnutrition. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #34 had intact cognition. During the lookback period he used oxygen. Review of Resident #34's respiratory plan of care dated 04/28/22 the resident had an ineffective breathing pattern related to diagnosis of chronic obstructive pulmonary disease. His interventions included reassuring the resident to decrease anxiety, monitoring and reporting restlessness, agitation, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365585 If continuation sheet Page 12 of 21 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 365585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville I 10098 Big Bear Creek Rd Lucasville, OH 45648 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few confusion, and increased or decreased heart rate, arranging activities of daily living to allow adequate rest, increasing activity of daily living and activities as tolerated, monitoring respiratory rate, depth, and quality, provide oxygen as ordered and change tubing per facility protocol, elevate head of bed as ordered, and provide medication as ordered. Review of the physician order dated 04/20/22 revealed oxygen tubing and nasal cannula was to be changed weekly or sooner as needed. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for June 2022 revealed no documented evidence of Resident #34's oxygen tubing or humidifier bottle being changed. Observation on 06/26/22 at 11:55 A.M. of Resident #34 revealed he had on a nasal cannula that was connected to an oxygen concentrator. Observation of the tubing revealed there was no date to indicate when it was changed. Additionally, observation of the humidifier bottle connected to the concentrator revealed it was empty and undated. Interview on 06/26/22 at 11:59 A.M. with Agency Registered Nurse #200 confirmed the observation. She reported oxygen tubing was to be changed weekly and then dated. She additionally reported the humidifier bottle should be dated and changed when empty. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365585 If continuation sheet Page 13 of 21 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 365585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville I 10098 Big Bear Creek Rd Lucasville, OH 45648 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of facility policy, the facility failed to ensure safe storage of medicated creams. This had the potential to affect six (Resident's #8, #12, #30, #35, #65, and #232) who were identified by the facility as being cognitively impaired and ambulatory and resided on the unlocked E, R, and S halls of the facility. The facility census was 82. Findings include: Observation on 06/26/22 at 12:32 P.M. revealed there was an open tube of Nystatin 100,000 unit per gram medicated cream located on the bathroom sink in room [ROOM NUMBER] of the facility. The cream was not labeled with a resident's name, or the date opened. Observation and interview with Licensed Practical Nurse (LPN) #139 on 06/26/22 at 12:32 P.M. verified the tube of Nystatin Cream was lying on the sink in room [ROOM NUMBER] and was not labeled with a resident's name or the date it was opened. LPN #139 verified the tube of cream should not be left in resident's rooms and removed the cream from the room. Observation on 06/26/22 at 12:45 P.M. revealed there was an open tube of Nystatin 100,000 unit per gram medicated cream located on a resident's bedside table in room [ROOM NUMBER]. The cream was not labeled with a resident's name or the date opened. Observation and interview with State Tested Nursing Assistant (STNA) #119 on 06/26/22 at 12:45 P.M. verified the tube of Nystatin cream was open and lying on the bedside table in room [ROOM NUMBER]. STNA #119 removed the tube of cream from the room. Observation on 06/29/22 at 1:53 P.M. revealed there was an open tube of Nystatin 100,000 unit per gram cream located in the top drawer of the bedside table in room [ROOM NUMBER]. The tube of Nystatin Cream was located in a box which contained a prescription label which contained the warning Keep out of reach of children. Observation and interview with STNA #107 on 06/29/22 at 1:53 P.M. verified the tube of Nystatin Cream was open and located in a box which contained a prescription label and was in the top bedside drawer in room [ROOM NUMBER]. Review of the facility policy titled Storage of Medications, revised 04/2007, revealed drugs should be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Compartments containing drugs and biologicals should be locked when not in use, and trays or carts used to transport such items should not be left unattended if open or otherwise potentially available to others. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365585 If continuation sheet Page 14 of 21 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 365585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville I 10098 Big Bear Creek Rd Lucasville, OH 45648 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review the facility failed to provide Resident's #35, #54, and #132 their diets as ordered. This affected three (Resident's #35, #54, and #132) of 81 residents who consumed food from the kitchen, the facility identified one (Resident #133) who consumed nothing by mouth. The facility census was 82. Findings include: 1. Review of the medical record revealed Resident #132 admitted on [DATE] with diagnoses including unspecified systolic heart failure, chronic kidney disease stage three, constipation, and atherosclerotic heart disease. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #132 had intact cognition. It was not indicated that he received a therapeutic diet. Review of the physician order dated 06/14/22 revealed Resident #132 was to receive a regular diet with regular texture. Observation on 06/28/22 from 11:00 A.M. to 12:25 P.M. of the lunch meal revealed Resident #132 was provided a two-gram sodium diet. Interview on 06/28/22 from 11:00 A.M. to 12:25 P.M. with [NAME] #801 and Dietary Aide #803 revealed the two-gram sodium diet was different than the regular diet. Residents on the two-gram diet were to receive glazed pork chop instead of ham. Review of the diet requisition form dated 06/13/22 revealed Resident #132 was to receive a cardiac diet. Review of the tray ticket for the lunch meal on 06/28/22 revealed Resident #132 received a two-gram sodium diet. Interview on 06/28/22 at 12:48 P.M. with Dietary Manager #800 confirmed the last diet requisition form she had received identified a cardiac diet which meant two-grams sodium diet for the kitchen. Interview on 06/29/22 at 1:59 P.M. with the Director of Nursing (DON) revealed Resident #132's diet changed to regular since 06/13/22 and the kitchen was not updated when it was determined Resident #132 could receive a regular diet. 2. Review of the medical record revealed Resident #35 admitted on [DATE] with diagnoses including atherosclerotic heart disease, chronic obstructive pulmonary disease, schizoaffective disorder, hypertension, dementia, and hypertension. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #35 had intact cognition and was not on a therapeutic diet. Review of the physician order dated 06/08/22 revealed Resident #35 was to receive a regular diet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365585 If continuation sheet Page 15 of 21 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 365585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville I 10098 Big Bear Creek Rd Lucasville, OH 45648 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 0808 with regular texture and fortified foods. Level of Harm - Minimal harm or potential for actual harm Review of the nutrition evaluation dated 06/13/22 revealed the dietitian had recommended Resident #35's diet be switched from therapeutic lifestyle changes to regular. Residents Affected - Few Observation on 06/28/22 from 11:00 A.M. to 12:25 P.M. of the lunch meal revealed Resident #35 received a therapeutic lifestyle changes diet. Interview on 06/28/22 from 11:00 A.M. to 12:25 P.M. with [NAME] #801 and Dietary Aide #803 revealed the therapeutic lifestyle change diet was different than the regular diet. Residents on this diet were to receive glazed pork chop instead of ham, which was what the regular diet called for. Review of the tray ticket for the lunch meal on 06/28/22 revealed Resident #35 received a therapeutic lifestyle change diet. Interview on 06/29/22 at 1:59 P.M. with the DON revealed Resident #35 was supposed to be on a regular diet and the kitchen had not been updated. 3. Review of the medical record for Resident #54 revealed an admission date of 10/21/16 with diagnoses including autistic disorder, unspecified psychosis, gastro-esophageal reflux disease, intellectual disabilities, and unspecified convulsions. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #54 had severely impaired cognition. The resident was received a mechanically altered diet. Review of the physician order dated 05/13/22 revealed Resident #54 had an order for a regular diet with dysphagia advanced texture. Observation on 06/28/22 from 11:00 A.M. to 12:25 P.M. of the lunch meal revealed Resident #54 received a carbohydrate controlled and dysphagia advanced diet. Review of the tray ticket for Resident #54 revealed she received a carbohydrate-controlled dysphagia advanced diet. Interview on 06/28/22 at 12:48 P.M. with Dietary Manager #800 revealed she was unable to find a diet requisition form for Resident #54. Interview on 06/29/22 at 1:59 P.M. with the DON revealed they had been unable to determine where the kitchen got the carbohydrate-controlled diet from, Resident #54 was not supposed to receive a therapeutic diet. Review of the policy titled Interdepartmental Notification of Diet, dated October 2008, revealed when a new resident was admitted or a diet had been changed the nurse supervisor was to ensure the food services department received a written notice of the diet order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365585 If continuation sheet Page 16 of 21 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 365585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville I 10098 Big Bear Creek Rd Lucasville, OH 45648 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 observation, interview, record review, and policy review the facility failed to keep an accurate electronic medical record for Resident #23 and Resident #34. This affected two (Resident's #23 and #34) of 29 resident records reviewed. The facility census was 82. Findings include: 1. Observation on 06/28/22 from 11:00 A.M. to 12:25 P.M. of the lunch meal revealed Resident #34 was provided a regular diet. Review of the medical record revealed Resident #34 admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus, other schizophrenia, hypertension, adult failure to thrive, shortness of breath, depression, unspecified protein-calorie malnutrition. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #34 had intact cognition; he was on a therapeutic diet. Review of the physician order dated 04/25/22 revealed Resident #34's diet was to be liberalized from carbohydrate controlled to regular. Review of the electronic physician's order dated 05/15/22 revealed an order for a carbohydrate-controlled diet (CCD). Review of the diet requisition form dated 4/25/22 revealed diet was to be liberalized from CCD to regular this was signed by a registered nurse. Review of the tray ticket for the lunch meal on 06/28/22 revealed Resident #34 was to receive a regular diet. Interview on 06/28/22 at 12:48 P.M. with Dietary Manager #800 confirmed she was given the diet requisition form to liberalize Resident #34's diet and had followed it. Interview on 06/29/22 at 11:08 A.M. with the Director of Nursing (DON) confirmed Resident #34's diet should have been regular had not been entered correctly in the electronic medical record. 2. Observation on 06/28/22 at 12:35 P.M. revealed Resident #23 received a dysphagia advanced diet. This was confirmed by Social Services #165 at that time. Review of the medical record revealed Resident #23 admitted on [DATE] with diagnoses including Alzheimer's disease, dementia, dysphagia, type two diabetes mellitus, atherosclerotic heart disease, and hyperlipidemia. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #23 had severely impaired cognition. She was not on a therapeutic or mechanically altered diet. Review of the physician order dated 04/21/22 revealed Resident #23 was ordered a regular diet with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365585 If continuation sheet Page 17 of 21 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 365585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville I 10098 Big Bear Creek Rd Lucasville, OH 45648 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 regular texture. Level of Harm - Minimal harm or potential for actual harm Review of the tray ticket for the lunch meal on 06/28/22 revealed Resident #23 was to receive a dysphagia advanced diet. Residents Affected - Few Review of the diet requisition form dated 03/21/22 revealed the speech language pathologist recommended a change to a dysphagia advanced diet. Interview on 06/28/22 at 12:48 P.M. with Dietary Manager #800 confirmed Resident #23 received a dysphagia advanced diet as the kitchen was told on 03/21/22. Interview on 06/29/22 at 11:08 A.M. with the DON confirmed Resident #23's diet was not correct in the electronic medical records, they were to receive a dysphagia advanced diet. Review of the policy titled Interdepartmental Notification of Diet, dated October 2008, revealed when a new resident was admitted or a diet had been changed the nurse supervisor was to ensure the food services department received a written notice of the diet order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365585 If continuation sheet Page 18 of 21 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 365585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville I 10098 Big Bear Creek Rd Lucasville, OH 45648 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, employee interview, and facility policy review the facility failed to ensure staff wore appropriate personal protective equipment in resident areas to prevent the potential spread of COVID-19. This had the potential to affect all 82 residents residing in the facility. Residents Affected - Many Findings Include: Observation on 06/26/22 at 9:00 A.M. Licensed Practical Nurse (LPN) #145 answered the front door of the facility and instructed the survey team who to speak to for direction. Observation on 06/26/22 at 9:02 A.M. Registered Nurse (RN) #200 was standing next to a medication cart without a mask, googles or face shield, and an unknown resident in a wheelchair was propelling away the medication cart. Interview on 06/26/22 at 9:03 A.M. with RN #200 verified she was not wearing a mask or googles. RN #200 stated she arrived at the facility at 7:45 A.M. and was administering medications to residents without appropriate PPE. Observation on 06/26/22 at 9:07 A.M. revealed LPN #139 sitting at the nurse's station with a face mask dangling from her left ear. Interview on 06/26/22 at 9:08 A.M. with LPN #139 verified she did not have her face mask on and was at the nurse's station. LPN #139 wore a face mask to administer medications to residents this morning. Interview on 06/26/22 at 12:45 P.M. with LPN #145 stated he was working on the men's lock down unit without a N-95 mask or surgical mask. LPN #145 stated he arrived at the facility at 7:00 A.M. and verified he did let the State Surveyors into the facility on [DATE] at 9:00 A.M. and did not have appropriate PPE on at that time or at the beginning of his shift. LPN #145 stated he should have been wearing a face mask. Observation on 06/27/22 at 10:45 A.M. revealed State Tested Nurse Aide (STNA) #120 had her goggles off and her N95 mask was at her chin while working in the women's lock down dining room. STNA #120's mouth and nose were exposed while sitting at a table across from Resident #25 who was in a wheelchair less than three feet away. STNA #120 was sitting at the table, with an open can of soda on the table within her reach. STNA #120 had her mask off but was not drinking. Interview on 06/27/22 at 10:45 A.M. with STNA #120 revealed she was sitting with Resident #25 and was having a drink which was why she did not have her mask on. STNA #120 stated she was allowed to have a drink with her. STNA #120 stated no supervisor gave her permission to drink while in resident care area. STNA #120 stated she had chronic obstructive pulmonary disease and was affected by wearing a N95 mask. Interview on 06/27/22 at 10:50 A.M. with LPN #132 that stated STNA #120 should have had her face mask and goggles on. LPN #132 stated she did not give STNA #120 permission to drink her soda while at the table with Resident #25. LPN #132 stated STNA #120 was one on one with Resident #25 as a fall precaution. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365585 If continuation sheet Page 19 of 21 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 365585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville I 10098 Big Bear Creek Rd Lucasville, OH 45648 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Observation on 06/29/22 at 9:00 A.M. revealed two new COVID-19 quarantine rooms with signs up and PPE at the doors. Interview on 06/29/22 at 10:00 A.M. with the Director of Nursing (DON) revealed an employee tested positive for COVID-19 yesterday and all the residents in the facility were tested. Two residents (Resident's #61 and #76) tested positive for COVID-19. The DON also stated the roommates of both COVID-19 positive residents were quarantined as well. Review of the facility policy titled Personal Protective Equipment, revised January 2012, revealed a supply of personal protective equipment was maintained at each nurses' station. Employees who fail to use personal protective equipment when indicated may be disciplined in accordance with our facility's personnel policy. Review of the facility policy titled Personal Protective Equipment Face Masks, revised September 2010, revealed the guide was to use masks to prevent transmission of infectious agents through the air, to protect the wearer from inhaling droplets, and to prevent transmission of some infections that are spread by direct contact with mucous membranes. When the use of mask was indicated to wear; appropriate eyewear must also be worn. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365585 If continuation sheet Page 20 of 21 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 365585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville I 10098 Big Bear Creek Rd Lucasville, OH 45648 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 0921 Level of Harm - Potential for minimal harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on record review, observation, and interviews the facility failed to provide a safe and functional environment with many of the walls in disrepair following previous work completed on the flooring throughout the building. This affected all residents residing in the facility. The facility census was 82. Findings include: Review of documents provided by the Administrator on 06/30/22 at 12:10 P.M. revealed flooring work was completed in March 2022, with all of the base boards not being installed. No other work was completed to either remove or replace wall carpeting which was in poor condition. Observation of the facility on 06/28/22 at 3:30 P.M. revealed each hall had newly laid flooring throughout the building but lacked a functional base board. With the exception of C hall, all other hallways have red carpeting that extends from the floor to the continuous handrail. This carpeting was flipped up or torn in many places, exposing the bare wall underneath. Observation of C hall on 06/28/22 at 03:56 P.M., the entire hall had the red wall carpet torn off with large areas of the wall unpainted and in poor repair. The wall below the handrails had large chunks of the wall missing as it had been ripped off when removing the red carpeting. Interview with State Tested Nursing Assistant (STNA) #123 on 06/29/22 at 10:20 A.M. revealed all of the walls had not been touched since the new flooring was completed. She stated the walls on C hall were ripped off approximately three months ago, and nothing else had been done. She stated none of the base boards had been installed. Interview with Resident #58 on 06/29/22 at 10:45 A.M. revealed the walls have been torn up for three to four months, ever since the flooring was installed. Resident #58 stated it was awful to look at. Interview with the Administrator on 06/30/22 at 12:15 P.M. verified none of the repairs had been made to the walls after the flooring was installed. He stated he had sent contracting bids to the corporate level and had not been issued an acceptance for any of the bids. The Administrator verified he was just waiting on approval to complete the work on the walls that was needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365585 If continuation sheet Page 21 of 21